WO2018158225A1

WO2018158225A1 - Combination of a bcl-2 inhibitor and a mdm2 inhibitor, uses and pharmaceutical compositions thereof

Info

Publication number: WO2018158225A1
Application number: PCT/EP2018/054764
Authority: WO
Inventors: Ensar HALILOVIC; Youzhen Wang
Original assignee: Les Laboratoires Servier; Novartis Ag
Priority date: 2017-02-28
Filing date: 2018-02-27
Publication date: 2018-09-07

Abstract

A combination comprising a Bcl-2 inhibitor compound of formula (I): or an enantiomer, diastereoisomer, or addition salt thereof with a pharmaceutically acceptable acid or base, and a Mdm2inhibitor Compound 2: (S)-5-(5-Chloro-1-methyl-2- oxo-1,2-dihydro-pyridin-3-yl)-6-(4-chloro-phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-1isopropyl-5,6-dihydro-1H-pyrrolo[3,4-d]imidazol-4-one, or a pharmaceutically acceptable salt thereof,or a complex thereof, or a co-crystal thereof, or a solvate, including hydrate, thereof and compositions and uses of said combination.

Description

COMBINATION OF A BCL-2 INHIBITOR AND A MDM2 INHIBITOR, USES AND PHARMACEUTICAL COMPOSITIONS THEREOF

FIELD OF THE INVENTION

The present invention relates to a combination of a Bcl-2 inhibitor and a Mdm2 inhibitor, as defined below. The invention also relates to said combination for use in the treatment of cancer, in particular acute myeloid leukaemia, and a pharmaceutical formulation suitable for the administration of such combination.

BACKGROUND

In the present invention, the Bcl-2 inhibitor is a compound of formula (I) as described herein. Said compounds of formula (I), their synthesis, their use in the treatment of cancer and pharmaceutical formulations thereof, are described in WO 2013/110890, WO 2015/011397, WO 2015/011399 and WO 2015/011400, the content of which is incorporated by reference.

In particular, the Bcl-2 inhibitor is Compound 1 : N-(4-hydroxyphenyl)-3-{6-[((35)-3-(4- morpholinylmethyl)-3,4-dihydro-2(lH)-isoquinolinyl)carbonyl]-l,3-benzodioxol-5-yl}-N- phenyl-5,6,7,8-tetrahydro-l-indolizine carboxamide, or a pharmaceutically acceptable salt thereof. Said Compound 1, its synthesis, its use in the treatment of cancer and pharmaceutical formulations thereof, are described in WO 2013/110890. Compound 1 is a potent and selective Bcl-2 inhibitor which is specifically disclosed in Example 1 of WO 2013/110890, which is incorporated by reference.

The Mdm2 inhibitor of the combination of the invention is Compound 2: (S)-5-(5-Chloro- 1 -methyl-2-oxo- 1 ,2-dihydro-pyridin-3-yl)-6-(4-chloro-phenyl)-2-(2,4-dimethoxy- pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH-pyrrolo[3,4-(i]imidazol-4-one

Said Compound 2, its synthesis, its use in the treatment of cancer and pharmaceutical formulations thereof, are described in WO 2013/111105, the content of which is incorporated by reference. Compound 2 is specifically described in Example 102 of WO 2013/111105, incorporated by reference.

Apoptosis is a distinct cell death pathway that is highly regulated and initiated by various stimuli including DNA damage; however evasion of the programmed cell death is a hallmark of cancer. The efficacy of many chemotherapeutic agents is dependent upon the activation of the intrinsic mitochondrial pathway which is mainly regulated by B-cell like protein-2 (Bcl-2). Bcl-2 has been shown to be up-regulated in many cancers, particularly hematological malignancies such as mantle cell lymphoma (MCL) and follicular lymphoma/diffuse large B-cell lymphoma (FL/D) (Adams and Cory The Bcl-2 apoptotic switch in cancer development and therapy. Oncogene 2007 Vol 26: 1324-1337). Pharmacological inhibition of anti-apoptotic Bcl-2 family proteins has emerged as a therapeutic strategy to induce apoptosis and cause tumor regression in cancer (Zhang et al, Drug Resist Updat 2007 Vol 10(6):207-17). Nevertheless, mechanisms of resistance that develop to Bcl-2 therapy have been observed and investigated (Choudhary GS et al, Cell Death and Disease (2015) 6, el593; doi: 10.1038/cddis.2014.525).

Acute myeloid leukaemia (AML) is a rapidly fatal blood cancer arising from clonal transformation of hematopoietic stem cells resulting in paralysis of normal bone marrow function and deaths due to complications from profound pancytopenia. AML accounts for 25% of all adult leukaemias, with the highest incidence rates occurring in the United States, Australia and Europe (WHO. GLOBOCAN 2012. Estimated cancer incidence, mortality and prevalence worldwide in 2012. International Agency for Research on Cancer). Globally, there are approximately 88,000 new cases diagnosed annually. AML continues to have the lowest survival rate of all leukaemias, with expected 5-year survival of only 24%. Although the standard therapy for AML (cytarabine in combination with anthracyclines) was conceived over 4 decades ago, the introduction of successful targeted therapies for this disease has remained an elusive goal. The concept of targeted therapy in AML has been hampered by the realisation that this disease evolves as a multi-clonal hierarchy, with rapid outgrowth of leukaemic sub-clones as a major cause of drug resistance and disease relapse (Ding L et al, Nature 2012 481 :506-10).

There remains a need for new treatments and therapies for the treatment of cancer. It has unexpectedly been found that a Bcl-2 inhibitor as defined herein, in combination with the Mdm2 inhibitor as defined herein, interact in synergistic manner to strongly inhibit cell proliferation.

SUMMARY OF THE INVENTION

According to a first aspect of the invention, there is provided a novel combination of

♦ X and Y represent a carbon atom or a nitrogen atom, it being understood that they may not simultaneously represent two carbons atoms or two nitrogen atoms,

♦ Ai and A₂, together with the atoms carrying them, form an optionally substituted, aromatic or non-aromatic heterocycle Het composed of 5, 6 or 7 ring members which may contain, in addition to the nitrogen represented by X or by Y, from one to 3 hetero atoms selected independently from oxygen, sulphur and nitrogen, it being understood that the nitrogen in question may be substituted by a group representing a hydrogen atom, a linear or branched (Ci-C₆)alkyl group or a group -C(0)-0-Alk wherein Alk is a linear or branched (Ci-Ce)alkyl group,

or Ai and A₂ independently of one another represent a hydrogen atom, a linear or branched (Ci-C₆)polyhaloalkyl, a linear or branched (Ci-Ce)alkyl group or a cycloalkyl,

♦ T represents a hydrogen atom, a linear or branched (Ci-Ce)alkyl group optionally substituted by from one to three halogen atoms, a group (Ci-C₄)alkylene-NRiR₂, or a group (Ci-C4)alkylene-OR6,

♦ Ri and R₂ independently of one another represent a hydrogen atom or a linear or branched (Ci-Ce)alkyl group,

or Ri and R₂ form with the nitrogen atom carrying them a heterocycloalkyl,

♦ R₃ represents a linear or branched (Ci-Ce)alkyl group, a linear or branched (C₂-C₆)alkenyl group, a linear or branched (C₂-C₆)alkynyl group, a cycloalkyl group, a (C₃-Cio)cycloalkyl-(Ci-C₆)alkylene group wherein the alkyl moiety is linear or branched, a heterocycloalkyl group, an aryl group or a heteroaryl group, it being understood that one or more of the carbon atoms of the preceding groups, or of their possible substituents, may be deuterated,

♦ R4 represents an aryl group, a heteroaryl group, a cycloalkyl group or a linear or branched (Ci-Ce)alkyl group, it being understood that one or more of the carbon atoms of the preceding groups, or of their possible substituents, may be deuterated,

♦ R₅ represents a hydrogen or halogen atom, a linear or branched (Ci-Ce)alkyl group, or a linear or branched (Ci-Ce)alkoxy group,

♦ 5 represents a hydrogen atom or a linear or branched (Ci-Ce)alkyl group,

♦ R_a, R_b, R_c and Rj, each independently of the others, represent R₇, a halogen atom, a linear or branched (Ci-C₆)alkoxy group, a hydroxy group, a linear or branched (Ci-C₆)polyhaloalkyl group, a trifluoromethoxy group, -NR₇R₇', nitro, R₇-CO-(C₀-C₆)alkylene-, R₇-CO-NH-(C₀-C₆)alkylene-, NR₇R₇ ^*-CO-(C₀- C₆)alkylene-, NR₇R₇ ^*-CO-(C₀-C₆)alkylene-O-, R₇-SO₂-NH-(C₀-C₆)alkylene-, R₇-NH-CO-NH-(C₀-C₆)alkylene-, R₇-O-CO-NH-(C₀-C₆)alkylene-, a heterocycloalkyl group, or the substituents of one of the pairs (Ra,Rb), (Rb,Rc) or (Rc,R_d) form together with the carbon atoms carrying them a ring composed of from 5 to 7 ring members, which may contain from one to 2 hetero atoms selected from oxygen and sulphur, it also being understood that one or more carbon atoms of the ring defined hereinbefore may be deuterated or substituted by from one to 3 groups selected from halogen and linear or branched (Ci-Ce)alkyl,

♦ R₇ and R₇' independently of one another represent a hydrogen, a linear or branched

(Ci-C₆)alkyl, a linear or branched (C₂-C6)alkenyl, a linear or branched (C₂-C₆)alkynyl, an aryl or a heteroaryl, or R₇ and R₇' together with nitrogen atom carrying them form a heterocycle composed of from 5 to 7 ring members, it being understood that when the compound of formula (I) contains a hydroxy group, the latter may be optionally converted into one of the following groups: -OPO(OM)(OM'), -OPO(OM)(0^"Mi⁺), -OPO(0^"Mi⁺)(0^"M₂ ⁺), -OPO(0^")(0^")M₃ ²⁺,

-OPO(OM)(0[CH₂CH₂0]„CH₃), or -OPO(0^"Mi⁺)(0[CH₂CH₂0]„CH₃), wherein M and M' independently of one another represent a hydrogen atom, a linear or branched (Ci-Ce)alkyl group, a linear or branched (C₂-Ce)alkenyl group, a linear or branched (C₂-Ce)alkynyl group, a cycloalkyl or a heterocycloalkyl, both composed of from 5 to 6 ring members, while Mi⁺ and M₂ ⁺ independently of one another represent a pharmaceutically acceptable monovalent cation, M₃ ²⁺ represents a pharmaceutically acceptable divalent cation, and n is an integer from 1 to 5,

it being understood that:

- "aryl" means a phenyl, naphthyl, biphenyl or indenyl group,

"heteroaryl" means any mono- or bi-cyclic group composed of from 5 to 10 ring members, having at least one aromatic moiety and containing from 1 to 4 hetero atoms selected from oxygen, sulphur and nitrogen (including quaternary nitrogens), "cycloalkyl" means any mono- or bi-cyclic, non-aromatic, carbocyclic group containing from 3 to 10 ring members,

"heterocycloalkyl" means any mono- or bi-cyclic, non-aromatic, condensed or spiro group composed of 3 to 10 ring members and containing from 1 to 3 hetero atoms selected from oxygen, sulphur, SO, S0₂ and nitrogen,

"-(Co-C₆)alkylene-" refers either to a covalent bond (-Coalkylene-) or to an alkylene group containing 1 , 2, 3, 4, 5 or 6 carbon atoms, it being possible for the aryl, heteroaryl, cycloalkyl and heterocycloalkyl groups so defined and the groups alkyl, alkenyl, alkynyl and alkoxy to be substituted by from 1 to 3 groups selected from: linear or branched (Ci-Ce)alkyl optionally substituted by a hydroxyl, a morpholine, 3-3-difluoropiperidine or a 3-3-difluoropyrrolidine; (C3-Ce)spiro; linear or branched (Ci-Ce)alkoxy optionally substituted by a morpholine; (Ci-C₆)alkyl-S-; hydroxyl; oxo; N-oxide; nitro; cyano; -COOR'; -OCOR; NR'R"; linear or branched (Ci-Ce)polyhaloalkyl; trifluoromethoxy; (Ci-C₆)alkylsulphonyl; halogen; aryl optionally substituted by one or more halogens; heteroaryl; aryloxy; arylthio; cycloalkyl; heterocycloalkyl optionally substituted by one or more halogen atoms or alkyl groups, wherein R and R" independently of one another represent a hydrogen atom or a linear or branched (Ci-Ce)alkyl group optionally substituted by a methoxy, it being possible for the Het group defined in formula (I) to be substituted by from one to three groups selected from linear or branched (Ci-C₆)alkyl, hydroxy, linear or branched (Ci-Ce)alkoxy, NRi'Ri" and halogen, it being understood that Ri' and Ri" are as defined for the groups R and R" mentioned hereinbefore, or an enantiomer, diastereoisomer, or addition salt thereof with a pharmaceutically acceptable acid or base, and (b) a Mdm2 inhibitor Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l ,2-dihydro-pyridin- 3-yl)-6-(4-chloro-phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH- pyrrolo[3,4-d]imidazol-4-one, or a pharmaceutically acceptable salt thereof, or a complex thereof, or a co-crystal thereof, or a solvate including hydrate thereof, for simultaneous, sequential or separate use.

In another aspect of the invention there is provided a combination comprising:

(a) A Bcl-2 inhibitor Compound 1 : N-(4-hydroxyphenyl)-3-{6-[((35)-3-(4- morpholinylmethyl)-3,4-dihydro-2(lH)-isoquinolinyl)carbonyl]-l,3-benzodioxol-5-yl}-N- phenyl-5,6,7,8-tetrahydro-l-indolizine carboxamide, or a pharmaceutically acceptable salt thereof,

and

(b) a Mdm2 inhibitor Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l,2-dihydro-pyridin- 3-yl)-6-(4-chloro-phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH- pyrrolo[3,4-d]imidazol-4-one, or a pharmaceutically acceptable salt or co-crystal thereof, for simultaneous, sequential or separate use.

In another aspect, the invention provides a combination as described herein, for use in the treatment of cancer, in particular acute myeloid leukaemia.

In a further aspect, the invention provides a pharmaceutical composition comprising the combination as described herein, and at least one pharmaceutically acceptable carrier.

BRIEF DESCRIPTION OF THE FIGURES

Figure 1 shows the anti-tumor effect in Acute Myeloid Leukaemia Xenograft Model 7781HAMLX5340-XEF.

Figure 2 shows the anti-tumor effect in Acute Myeloid Leukaemia Xenograft Model 7560HAMLX5343-XEF.

Figure 3 shows the body weight changes in Acute Myeloid Leukaemia Xenograft Model 7781HAMLX5340-XEF.

Figure 4 shows the body weight changes in Acute Myeloid Leukaemia Xenograft Model 7560HAMLX5343-XEF. DEFINITIONS

"Combination" refers to either a fixed dose combination in one unit dosage form (e.g., capsule, tablet, or sachet), non-fixed dose combination, or a kit of parts for the combined administration where a compound of the present invention and one or more combination partners (e.g. another drug as explained below, also referred to as "therapeutic agent" or "co-agent") may be administered independently at the same time or separately within time intervals, especially where these time intervals allow that the combination partners show a cooperative, e.g. synergistic effect.

The terms "co-administration" or "combined administration" or the like as utilized herein are meant to encompass administration of the selected combination partner to a single subject in need thereof (e.g. a patient), and are intended to include treatment regimens in which the agents are not necessarily administered by the same route of administration or at the same time.

The term "fixed dose combination" means that the active ingredients, e.g. a compound of formula (I) and one or more combination partners, are both administered to a patient simultaneously in the form of a single entity or dosage.

The term "non-fixed dose combination" means that the active ingredients, e.g. a compound of the present invention and one or more combination partners, are both administered to a patient as separate entities either simultaneously or sequentially, with no specific time limits, wherein such administration provides therapeutically effective levels of the two compounds in the body of the patient. The latter also applies to cocktail therapy, e.g. the administration of three or more active ingredients.

"Cancer" means a class of disease in which a group of cells display uncontrolled growth. Cancer types include haemato logical cancer (lymphoma and leukaemia). In particular "cancer" refers to haematological cancer, in particular acute myeloid leukaemia.

'AML' means acute myeloid leukaemia. The term "jointly therapeutically effective" means that the therapeutic agents may be given separately (in a chronologically staggered manner, especially a sequence-specific manner) in such time intervals that they prefer, in the warm-blooded animal, especially human, to be treated, still show a (preferably synergistic) interaction (joint therapeutic effect). Whether this is the case can, inter alia, be determined by following the blood levels, showing that both compounds are present in the blood of the human to be treated at least during certain time intervals.

"Synergistically effective" or "synergy" means that the therapeutic effect observed following administration of two or more agents is greater than the sum of the therapeutic effects observed following the administration of each single agent.

As used herein, the term "treat", "treating" or "treatment" of any disease or disorder refers in one embodiment, to ameliorating the disease or disorder (i.e., slowing or arresting or reducing the development of the disease or at least one of the clinical symptoms thereof). In another embodiment "treat", "treating" or "treatment" refers to alleviating or ameliorating at least one physical parameter including those which may not be discernible by the patient. In yet another embodiment, "treat", "treating" or "treatment" refers to modulating the disease or disorder, either physically, (e.g., stabilization of a discernible symptom), physiologically, (e.g., stabilization of a physical parameter), or both.

As used herein, a subject is "in need of a treatment if such subject would benefit biologically, medically or in quality of life from such treatment.

"Medicament" means a pharmaceutical composition, or a combination of several pharmaceutical compositions, which contains one or more active ingredients in the presence of one or more excipients.

DETAILED DESCRIPTION OF THE INVENTION Described below are a number of embodiments of the invention, where for convenience El is identical to the first aspect of the invention hereinabove. Further enumerated embodiments (E) of the invention are described herein. It will be recognized that features specified in each embodiment may be combined with other specified features to provide further embodiments of the present invention.

E2. A combination according to El , wherein Compound 2 is (5)-5-(5-Chloro-l-methyl-2- oxo- 1 ,2-dihydro-pyridin-3-yl)-6-(4-chloro-phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)- 1 - isopropyl-5,6-dihydro-lH-pyrrolo[3,4-(i]imidazol-4-one, or a pharmaceutically acceptable salt or co-crystal thereof, or a solvate (including hydrate), thereof. E3. A combination according to El or E2, comprising

(a) Compound 1 : N-(4-hydroxyphenyl)-3-{6-[((35)-3-(4-morpholinylmethyl)-3,4-dihydro- 2(lH)-isoquinolinyl)carbonyl]-l,3-benzodioxol-5-yl}-N-phenyl-5,6,7,8-tetrahydro-l- indolizine carboxamide, or a pharmaceutically acceptable salt thereof, and

(b) Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l,2-dihydro-pyridin-3-yl)-6-(4-chloro- phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH-pyrrolo[3,4- ]imidazol-4-one, or a pharmaceutically acceptable salt or co-crystal thereof, or a solvate

(including hydrate), thereof,

for simultaneous, sequential or separate use.

E4. The combination according to any of El to E3, wherein Compound 1 : N-(4- hydroxyphenyl)-3-{6-[((35)-3-(4-morpholinylmethyl)-3,4-dihydro-2(lH)- isoquinolinyl)carbonyl]- 1 ,3-benzodioxol-5-yl} -N-phenyl-5,6,7,8-tetrahydro- 1 -indolizine carboxamide is in the form of the hydrochloride salt.

E5. The combination according to any of El to E4, wherein Compound 2 is the succinate.

E6. The combination according to any of El to E4, wherein Compound 2 is in the form of the succinic acid co-crystal. E7. The combination according to any of El to E6, wherein Compound 1 and Compound 2 are administered orally.

E8. The combination according to any of El to E7, further comprising at least one additional anti-cancer agent. E9. The combination according to any of El to E8, in the form of a non- fixed dose combination.

E10. The combination according to any of El to E8, in the form of a fixed dose combination.

El l . The combination according to any of El to El 0, for use in medicine. El 2. The combination for use according to El l, wherein said use is in the treatment of cancer.

E13. The combination for use according to El 2, wherein the cancer is haemato logical cancer.

El 4. The combination for use according to El 3, wherein the cancer is acute myeloid leukaemia.

E15. The combination for use according to El 4, wherein the acute myeloid leukaemia comprises one or more of FLT3-ITD mutation.

E16. The combination for use according to E14, wherein the acute myeloid leukaemia carries one or more of KRAS mutation and wild type FLT3. El 7. The combination for use according to any of El l to El 6, wherein Compound 1 and Compound 2 are provided in amounts which are jointly therapeutically effective for the treatment of cancer. El 8. The combination for use according to any of El l to El 6, wherein Compound 1 and Compound 2 are provided in amounts which are synergistically effective for the treatment of cancer.

El 9. The combination for use according to any of El l to El 6, wherein Compound 1 and Compound 2 are provided in synergistically effective amounts which enable a reduction of the dose required for each compound in the treatment of cancer, whilst providing an efficacious cancer treatment, with a reduction in side effects.

E20. A pharmaceutical composition comprising the combination according to any of El to E8, and at least one pharmaceutically acceptable carrier. E21. The use of a combination according to any of El to E10, in the manufacture of a medicament for the treatment of cancer.

E22. The use according to E21, wherein the cancer is acute myeloid leukaemia.

E23. The use according to E22, wherein the acute myeloid leukaemia comprises one or more of FLT3-ITD mutation. E24. The use according to E22, wherein the acute myeloid leukaemia carries one or more of KRAS mutation and wild type FLT3.

E25. A medicament containing, separately or together,

(b) Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l,2-dihydro-pyridin-3-yl)-6-(4-chloro- phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH-pyrrolo[3,4- ]imidazol-4-one, or a pharmaceutically acceptable salt thereof, or a complex thereof, or a co-crystal thereof, or a solvate, including hydrate, thereof, for simultaneous, sequential or separate administration, and wherein Compound 1 and Compound 2 are provided in effective amounts for the treatment of cancer.

E26. A method of treating cancer, comprising administering a jointly therapeutically effective amount of

(b) Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l,2-dihydro-pyridin-3-yl)-6-(4-chloro- phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH-pyrrolo[3,4- ]imidazol-4-one, or a pharmaceutically acceptable salt thereof, or a complex thereof, or a co-crystal thereof, or a solvate, including hydrate, thereof,to a subject in need thereof.

Compound 2 as disclosed herein can be in the form of a pharmaceutically acceptable salt, a complex, a co-crystal, a solvate (including hydrate), or a mixture of such forms. In particular, Compound 2 can be in the form of a pharmaceutically acceptable salt, a solvate (including hydrate), or co-crystal thereof. Co-crystals of Compound 2 may be formed with acids such as succinic acid, lactic acid, tartaric acid and malonic acid. Solvates may be formed with solvents such as ethanol, propanol, butanol or water. In particular, the solvate of Compound 2 is ethanolate or hydrate. Solvate, hydrate and co-crystal forms of Compound 2 are disclosed in WO 2013/111105, the content of which is incorporated by reference. In one embodiment, Compound 2 is the free molecule. In another embodiment, Compound 2 is a co-crystal. In a particular embodiment, Compound 2 is the succinic acid. In particular, when Compound 2 is the succinic acid, it is the succinic acid co-crystal. In a further embodiment, Compound 2 is the hydrate.

In the pharmaceutical compositions according to the invention, the proportion of active ingredients by weight (weight of active ingredients over the total weight of the composition) is from 5 to 50 %.

Among the pharmaceutical compositions according to the invention there will be more especially used those which are suitable for administration by the oral, parenteral and especially intravenous, per- or trans-cutaneous, nasal, rectal, perlingual, ocular or respiratory route, more specifically tablets, dragees, sublingual tablets, hard gelatin capsules, glossettes, capsules, lozenges, injectable preparations, aerosols, eye or nose drops, suppositories, creams, ointments, dermal gels etc. The pharmaceutical compositions according to the invention comprise one or more excipients or carriers selected from diluents, lubricants, binders, disintegration agents, stabilisers, preservatives, absorbents, colourants, sweeteners, flavourings etc.

By way of non-limiting example there may be mentioned:

♦ as diluents: lactose, dextrose, sucrose, mannitol, sorbitol, cellulose, glycerol, ^♦ as lubricants: silica, talc, stearic acid and its magnesium and calcium salts, polyethylene glycol,

♦ as binders: magnesium aluminium silicate, starch, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose and polyvinylpyrrolidone,

♦ as disintegrants: agar, alginic acid and its sodium salt, effervescent mixtures. The compounds of the combination may be administered simultaneously, separately or sequentially. The administration route is preferably the oral route, and the corresponding pharmaceutical compositions may allow the instantaneous or delayed release of the active ingredients. The compounds of the combination may moreover be administered in the form of two separate pharmaceutical compositions, each containing one of the active ingredients, or in the form of a single pharmaceutical composition, in which the active ingredients are in admixture. Preferably, the pharmaceutical composition of Compound 1 is a tablet.

The dose of N-(4-hydroxyphenyl)-3-{6-[((35)-3-(4-morpholinylmethyl)-3,4-dihydro- 2(lH)-isoquinolinyl)carbonyl]-l,3-benzodioxol-5-yl}-N-phenyl-5,6,7,8-tetrahydro-l- indolizine carboxamide during the combination treatment is from 50 mg to 1500 mg. Preferably, N-(4-hydroxyphenyl)-3-{6-[((35)-3-(4-morpholinylmethyl)-3,4-dihydro-2(lH)- isoquinolinyl)carbonyl]- 1 ,3-benzodioxol-5-yl} -N-phenyl-5,6,7,8-tetrahydro- 1 -indolizine carboxamide is administered during the combination treatment once a day. Compound 2 may be administered orally. In one embodiment, oral administration is by solid form. In particular, the oral administration may use a high-dose intermittent regimen [e.g. Regimen A (50 mg - 400 mg Compound 2 administered on day 1 of a 3-week cycle or Regimen B (50 mg - 150 mg Compound 2 administered on days 1 and 8 of a 4-wk cycle) or regimen C (50 mg - 500 mg Compound 2 administered on day 1 of a 4-week cycle], or a low-dose extended regimen [e.g. Regimen D (10 mg - 30 mg Compound 2 once daily for the first 2 weeks of a 4-week cycle) or Regimen E (15 mg - 50 mg Compound 2 once daily for the first week of a 4-week cycle)].

Pharmaceutical composition of Compound 1 HCl salt film-coated tablet containing 50 mg and 100 mg of drug substance

Amount (mg) Function

50 mg

Tablet strength 100 mg strength

Compound 1 HCl salt 52,58 105,16 Drug Substance equivalent in base to 50 100

Lactose monohydrate 178,51 357,02 Diluent

Maize starch 66,6 133,2 Disintegrant

Povidone 23,31 46,62 Binder

Magnesium stearate 3,33 6,66 Lubricant

Silica, colloidal anhydrous 0,67 1,34 Flow agent

Sodium starch glycolate (Type A) 10 20 Disintegrant

For an uncoated tablet with a mass of 335 670

Film-Coating

Glycerol 0,507 1,014 Plasticizing agent hypromellose 8,419 16,838 Film-coating agent

Macrogol 6000 0,538 1,076 Smoothing agent Magnesium stearate 0,507 1,014 Lubricant

Titanium dioxide 1,621 3,242 Pigment

Intermediary Vehicule

Water, purified qs. qs. Solvent

For a film-coated tablet with a mass of 346,6 693,2

Drug product containing compound 2 succinic acid:

The drug product may consist of the drug substance compound 2 succinic acid filled directly into hard gelatin capsules (HGC), and may not need to contain any other excipients. The capsule filling may be done manually. The drug product may be provided in four dosage strengths: 1 mg, 2.5 mg, 10 mg and 100 mg (based on the weight of the free form), intended for oral use. The 1 mg strength capsule may be a "Size 3" yellow HGC, the 2.5 mg strength capsule may be a "Size 3" Swedish Orange HGC, the 10 mg strength capsule may be a "Size 1" Grey HGC, and the 100 mg may be a "Size 0" Swedish Orange HGC. The drug product may be packaged in child resistant, induction sealed High Density Polyethylene (HDPE) bottles.

Example 1: Anti Tumor effect in Acute Myeloid Leukaemia Xenograft Models Animals

NOD scid gamma (NSG) female mice weighing 17-27 grams (Jackson Laboratories) were allowed to acclimate in an animal facility with access to food and water ad libitum for 3 days prior to manipulation.

Primary tumor models

Patient-derived primary AML model HAMLX5340 harboring FLT3-ITD, and Patient- derived primary AML model HAMLX5343 carrying KRAS mutation and wild type FLT3 were obtained from Dana Farber Cancer Institute. Test compounds, formulations

Compound 2 succinic acid was formulated in 0.5% methylcellulose. Compound 1 HC1 salt was formulated in PEG300/EtOH/water (40/10/50). Vehicle and compound dosing solutions were prepared as needed. All animals were dosed at 10 mL/kg. Methods

Study design

Four treatment groups were used in both studies as summarized in Table 1 and Table 2. All treatments were initiated when the average tumor burden (%CD-45 positive cells) was between 5% and 30%.

In the 7560HAMLX5343-XEF study, Compound 2 and Compound 1 were administered by oral gavage (po) at 40 mg/kg with 3 consecutive doses (3 hour interval between each dose) once a week and 200 mg/kg once a week, respectively, for 14 days.

In study 7781HAMLX5340-XEF, Compound 2 and Compound 1 were administered by oral gavage (po) at 20mg/kg once a week with 3 consecutive doses (3 hour interval between each dose) and lOOmg/kg once a week, respectively, for 22 days.

Both drugs were administered at 10 mL/kg. Animals were weighed daily and the dose was body weight adjusted. Bodyweights were recorded twice/week and tumor burden was recorded once/week.

Table 1 Dose and dose schedules for 7560HAMLX5343-XEF

Treatment groups Number of animals Dosing regimen

Vehicle (10 mL/kg) 5 QW

Compound 2 (40mg/kg po) 5 Q3hx3/wk

Compound 1 (200mg/kg po) 5 QW

Compound 2 + Compound 1 (40mg/kg + 5 Q3hx3/wk + QW 200 mg/kg) Table 2 Dose and dose schedules for 7781HAMLX5340-XEF

Treatment groups Number of animals Dosing regimen

Vehicle (10 mL/kg) 4 QW

Compound 2 (20mg/kg po) 4 Q3hx3/wk

Compound 1 (lOOmg/kg po) 4 QW

Compound 2 + Compound 1 (20mg/kg + 4 Q3hx3/wk + QW lOO mg/kg)

Table 3 Study design

Study number Tumor model Start Day Duration (Days)

7560HAMLX5343-XEF HAMLX5343 21 14

7781HAMLX5340-XEF HAMLX5340 37 22

Primary AML model

For each experiment, 20 mice were implanted with primary AML line HAMLX5340 or HAMLX5343. Mice were injected intravenously with 2.0 million leukemia cells. When the tumor burden was between 5%-30%, animals were randomized into four groups of four or five mice each for vehicle, Compound 2, Compound 1, or combination treatment. After 14-22 days of treatment, the study was terminated when the tumor burden reached 80- 100% or when excessive bodyweight loss would result in the loss of the majority of the animals in one group. Tumor burden was measured by FACS analysis.

Animal monitoring

Animal well-being and behavior, including grooming and ambulation were monitored twice daily. General health of mice was monitored and mortality recorded daily. Any moribund animals were sacrificed.

Tumor measurement

Mice were bled via tail snip once per week. Blood was split into an IgG control well and a CD33/CD45 well of a 96-well plate. Blood was lysed with 200μ1 RBC lysis buffer (eBioscience # 00-4333-57) twice at RT, then washed once with FACS buffer (5% FBS in PBS). Samples were then incubated for 10-30 minutes at 4C in ΙΟΟμΙ blocking buffer (5% mouse Fc Block [Miltenyi #130-092-575] + 5% human Fc Block [Miltenyi #130-059-091] + 90% FACS buffer). 20μ1 IgG control mix (2.5μ1 Mouse igGl K isotype control-PE [eBioscience #12-4714-42] + 2.5μ1 Mouse igGl K isotype control-APC [eBioscience #17- 4714-42] + 15μ1 FACS buffer) were added to the IgG control wells and 20ul CD33/CD45 mix (2.5μ1 Mouse anti-human CD33-PE [eBioscience #12-0339-42] + 2.5μ1 Mouse anti- human CD45-APC [eBioscience #17-9459-42] + 15μ1 FACS buffer). Samples were incubated for 30-60 minutes at 4C then washed twice prior to analysis. Samples were run on Canto with FACSDiva software. Analysis was performed with FloJo software. The percent of CD45 -positive, live, single cells was reported as the tumor burden.

Data analysis

Percent treatment/control (T/C) values were calculated using the following formula:

%T/C = 100 x ΑΎ/ C if ΔΤ >0

%Regression = 100 ^χ ΔΤ/Τ_ίηΜαι if ΔΤ <0

where:

T = mean tumor burden of the drug-treated group on the final day of the study;

ΔΤ = mean tumor burden of the drug-treated group on the final day of the study - mean tumor burden of the drug-treated group on initial day of dosing;

i_bi_al = mean tumor burden of the drug-treated group on initial day of dosing;

C = mean tumor burden of the control group on the final day of the study; and

AC = mean tumor burden of the control group on the final day of the study - mean tumor burden of the control group on initial day of dosing.

All data were expressed as Mean ± SEM. Delta tumor burden and body weight were used for statistical analysis. Between-groups comparisons for final measurements were performed using ANOVA with Tukey's test. Statistical analysis was carried out using GraphPad Prism.

Statistical analysis

All data were expressed as mean ± standard error of the mean (SEM). Delta tumor volume and body weight were used for statistical analysis. Between-group comparisons were carried out using the Kruskal-Wallis ANOVA followed by a post hoc Dunn's test or Tukey's test. For all statistical evaluations, the level of significance was set at p < 0.05. Significance compared to the vehicle control group is reported unless otherwise stated. The standard protocols used in pharmacology studies are not pre-powered to demonstrate statistically significant superiority of a combination over the respective single agent treatment. The statistical power is often limited by potent single agent response and/or model variability. The p-values for combination vs single agent treatments are, however, provided.

Results

Synergistic anti-tumor effect of combined MDM2 and BCL2 inhibition

In the 7781HAMLX5340-XEF study, Compound 2 alone did not show anti-tumor activity in the HAMLX5340 model carrying the FLT3-ITD mutation, when administered at 20mg/kg with 3 consecutive doses (3-hour interval between each does) once a week (%T/C of 92%, p>0.05). Compound 1 alone only led to a moderate anti-tumor activity when orally administered at 100 mg/kg once a week (%T/C of 32%, p<0.05) in this model. On the other hand, the combination of Compound 2 + Compound 1 treatment resulted in near complete tumor regression (%Regression of 96%>), which is significantly different from either single agent (p<0.05). The mean tumor burden for each treatment group is plotted against time for the 22 day treatment period, as shown in Figure 1. The change in tumor burden, %T/C or %Regression is presented in Table 4. In addition, the mean body weight (BW) change is shown in Figure 3. All treatments were well tolerated. Mice treated with Compound 1 and Compound 2 exhibited body weight gain (1.27% and 2.81%, respectively). A minimal body weight loss was observed with combination treatment (- 1.52%).

Table 4 Summary of anti-tumor effect in 7781HAMLX5340-XEF study

♦ * p < 0.05 versus Vehicle (ANOVA, Tukey's test)

♦ ** p < 0.05 versus Vehicle and single agents (ANOVA, Tukey's test) Figure 1 shows anti-tumor activity in 7781HAMLX5340-XEF study.

In the 7560HAMLX5343-XEF study, Compound 2 (40 mg/kg, po q3hx3/wk) or Compound 1 (200mg/kg po qw) alone did not exhibit anti-tumor activities in the HAMLX5343 model with wt FLT3 (%T/C of 83% or 81%, p>0.05, respectively), while the combination of Compound 2 + Compound 1 treatment resulted in complete tumor regression (%>Regression of 100%), which is statistically significant as compared to either single agent (p<0.05). The mean tumor burden for each treatment group is plotted against time for the 14 day treatment period as shown in Figure 2. The change in tumor burden, %T/C or %>Regression is presented in Table 5. In addition, the mean body weight (BW) change is shown in Figure 4. All treatments were well tolerated. Body weight gain was observed in Compound 1, Compound 2 and combination treated groups (1.83%, 6.43%> and 1.27%), respectively).

Table 5 Summary of anti-tumor effect in 7560HAMLX5343-XEF study

♦ * p < 0.05 versus Vehicle and single agents (ANOVA, Tukey's test)

Figure 2 shows anti-tumor activity in 7560HAMLX5343-XEF study. Conclusion

In testing the effect of the combination of Compound 2 and Compound 1 inhibition in two AML xenograft models, with either FLT3-ITD mutation or KRAS mutation {wt FLT3), we show that the combination of Compound 2 and Compound 1 has a dramatic synergistic effect in treating AML. The results indicate that Compound 2 and Compound 1 combination would be an effective therapy for AML. In addition, the combination treatment is well tolerated as indicated by body weight gain or minimal body weight loss in both studies.

Claims

1. A combination comprising:

(a) a compound of formula (I):

wherein:

♦ Ai and A₂, together with the atoms carrying them, form an optionally substituted, aromatic or non-aromatic heterocycle Het composed of 5, 6 or 7 ring members which may contain, in addition to the nitrogen represented by X or by Y, from one to 3 hetero atoms selected independently from oxygen, sulphur and nitrogen, it being understood that the nitrogen in question may be substituted by a group representing a hydrogen atom, a linear or branched (Ci-C₆)alkyl group or a group -C(0)-0-Alk wherein Alk is a linear or branched (Ci-C₆)alkyl group,

or Ai and A₂ independently of one another represent a hydrogen atom, a linear or branched (Ci-Ce)polyhaloalkyl, a linear or branched (Ci-Ce)alkyl group or a cycloalkyl, ♦ T represents a hydrogen atom, a linear or branched (Ci-Ce)alkyl group optionally substituted by from one to three halogen atoms, a group (Ci-C₄)alkylene-NRiR₂, or a group (Ci-C4)alkylene-OR6,

or Ri and R₂ form with the nitrogen atom carrying them a heterocycloalkyl,

♦ R₃ represents a linear or branched (Ci-Ce)alkyl group, a linear or branched (C₂-C₆)alkenyl group, a linear or branched (C₂-C₆)alkynyl group, a cycloalkyl group, a (C3-Cio)cycloalkyl-(Ci-C₆)alkylene group wherein the alkyl moiety is linear or branched, a heterocycloalkyl group, an aryl group or a heteroaryl group, it being understood that one or more of the carbon atoms of the preceding groups, or of their possible substituents, may be deuterated,

♦ 5 represents a hydrogen atom or a linear or branched (Ci-Ce)alkyl group,

♦ R_a, Rb, R_c and Rj, each independently of the others, represent R₇, a halogen atom, a linear or branched (Ci-C₆)alkoxy group, a hydroxy group, a linear or branched (Ci-C₆)polyhaloalkyl group, a trifluoromethoxy group, -NR₇R₇', nitro, R₇-CO-(C₀-C₆)alkylene-, R₇-CO-NH-(C₀-C₆)alkylene-, NR₇R₇ ^*-CO-(C₀- C₆)alkylene-, NR₇R₇ ^*-CO-(C₀-C₆)alkylene-O-, R₇-SO₂-NH-(C₀-C₆)alkylene-, R₇-NH-CO-NH-(C₀-C₆)alkylene-, R₇-O-CO-NH-(C₀-C₆)alkylene-, a heterocycloalkyl group, or the substituents of one of the pairs (R_a,Rb), (Rb,R_c) or (R_c,R_d) form together with the carbon atoms carrying them a ring composed of from 5 to 7 ring members, which may contain from one to 2 hetero atoms selected from oxygen and sulphur, it also being understood that one or more carbon atoms of the ring defined hereinbefore may be deuterated or substituted by from one to 3 groups selected from halogen and linear or branched (Ci-Ce)alkyl,

♦ R₇ and R₇' independently of one another represent a hydrogen, a linear or branched (Ci-C₆)alkyl, a linear or branched (C₂-Ce)alkenyl, a linear or branched (C₂-C₆)alkynyl, an aryl or a heteroaryl, or R₇ and R₇' together with nitrogen atom carrying them form a heterocycle composed of from 5 to 7 ring members, it being understood that when the compound of formula (I) contains a hydroxy group, the latter may be optionally converted into one of the following groups: -OPO(OM)(OM'), -OPO(OM)(0^"Mi⁺), -OPO(0^"Mi⁺)(0^"M₂ ⁺), -OPO(0^")(0^")M₃ ²⁺,

-OPO(OM)(0[CH₂CH₂0]„CH₃), or -OPO(0^"Mi⁺)(0[CH₂CH₂0]„CH₃), wherein M and M' independently of one another represent a hydrogen atom, a linear or branched (Ci-Ce)alkyl group, a linear or branched (C₂-C₆)alkenyl group, a linear or branched (C₂-C₆)alkynyl group, a cycloalkyl or a heterocycloalkyl, both composed of from 5 to 6 ring members, while Mi⁺ and M₂ ⁺ independently of one another represent a pharmaceutically acceptable monovalent cation, M₃ ²⁺ represents a pharmaceutically acceptable divalent cation, and n is an integer from 1 to 5, it being understood that:

"aryl" means a phenyl, naphthyl, biphenyl or indenyl group,

"-(Co-C₆)alkylene-" refers either to a covalent bond (-Coalkylene-) or to an alkylene group containing 1, 2, 3, 4, 5 or 6 carbon atoms, it being possible for the aryl, heteroaryl, cycloalkyl and heterocycloalkyl groups so defined and the groups alkyl, alkenyl, alkynyl and alkoxy to be substituted by from 1 to 3 groups selected from: linear or branched (Ci-Ce)alkyl optionally substituted by a hydroxyl, a morpholine, 3-3-difluoropiperidine or a 3-3-difluoropyrrolidine; (C₃-C₆)spiro; linear or branched (Ci-Ce)alkoxy optionally substituted by a morpholine; (Ci-C₆)alkyl-S-; hydroxyl; oxo; N-oxide; nitro; cyano; -COOR'; -OCOR; NR'R"; linear or branched (Ci-Ce)polyhaloalkyl; trifluoromethoxy; (Ci-C6)alkylsulphonyl; halogen; aryl optionally substituted by one or more halogens; heteroaryl; aryloxy; arylthio; cycloalkyl; heterocycloalkyl optionally substituted by one or more halogen atoms or alkyl groups, wherein R and R" independently of one another represent a hydrogen atom or a linear or branched (Ci-Ce)alkyl group optionally substituted by a methoxy, it being possible for the Het group defined in formula (I) to be substituted by from one to three groups selected from linear or branched (Ci-C₆)alkyl, hydroxy, linear or branched (Ci-C₆)alkoxy, NRi'Ri" and halogen, it being understood that Ri' and Ri" are as defined for the groups R and R" mentioned hereinbefore, or an enantiomer, diastereoisomer, or addition salt thereof with a pharmaceutically acceptable acid or base,

and

(b) Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l ,2-dihydro-pyridin-3-yl)-6-(4-chloro- phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH-pyrrolo[3,4- ]imidazol-4-one, or a pharmaceutically acceptable salt thereof, or a complex thereof, or a co-crystal thereof, or a solvate, including hydrate, thereof, for simultaneous, sequential or separate use.

2. A combination according to claim 1 , comprising:

(a) Compound 1 : N-(4-hydroxyphenyl)-3- {6-[((35)-3-(4-morpholinylmethyl)-3,4-dihydro- 2(lH)-isoquinolinyl)carbonyl]-l ,3-benzodioxol-5-yl}-N-phenyl-5,6,7,8-tetrahydro-l- indolizine carboxamide, or a pharmaceutically acceptable salt thereof and

(b) Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l ,2-dihydro-pyridin-3-yl)-6-(4-chloro- phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH-pyrrolo[3,4- ]imidazol-4-one, or a pharmaceutically acceptable salt or co-crystal thereof, or a solvate, including hydrate, thereof,

for simultaneous, sequential or separate use.

3. The combination according to claim 2, wherein Compound 1 : N-(4-hydroxyphenyl)-3- {6-[((35)-3-(4-morpholinylmethyl)-3,4-dihydro-2(lH)-isoquinolinyl)carbonyl]-l,3- benzodioxol-5-yl}-N-phenyl-5,6,7,8-tetrahydro-l-indolizine carboxamide is in the form of the hydrochloride salt.

4. The combination according to any of claims 1, 2 and 3, wherein Compound 2 is the succinate.

5. The combination according to any of claims 1, 2 and 3, wherein Compound 2 is in the form of the succinic acid co-crystal.

6. The combination according to any of claims 1 to 5, wherein Compound 1 and Compound 2 are administered orally.

7. The combination according to any of claims 1 to 6, further comprising at least one additional anti-cancer agent.

8. The combination according to any of claims 1 to 7, in the form of a non-fixed dose combination.

9. The combination according to any of claims 1 to 7, in the form of a fixed dose combination.

10. The combination according to any of claims 1 to 9, for use in medicine.

11. The combination for use according to claim 10, wherein said use is in the treatment of cancer.

12. The combination for use according to claim 1 1, wherein the cancer is haemato logical cancer.

13. The combination for use according to claim 12, wherein the cancer is acute myeloid leukaemia.

14. The combination for use according to any of claims 10 to 13, wherein Compound 1 and Compound 2 are provided in amounts which are jointly therapeutically effective for the treatment of cancer.

15. The combination for use according to any of claims 10 to 13, wherein Compound 1 and Compound 2 are provided in amounts which are synergistically effective for the treatment of cancer.

16. The combination for use according to any of claims 10 to 13, wherein Compound 1 and Compound 2 are provided in synergistically effective amounts which enable a reduction of the dose required for each compound in the treatment of cancer, whilst providing an efficacious cancer treatment, with a reduction in side effects.

17. A pharmaceutical composition comprising the combination according to any of claims 1 to 7, and at least one pharmaceutically acceptable carrier.

18. The use of a combination according to any of claims 1 to 9, in the manufacture of a medicament for the treatment of cancer.

19. The use according to claim 18 wherein the cancer is acute myeloid leukaemia.

20. A medicament containing, separately or together,

21. A method of treating cancer, comprising administering a jointly therapeutically effective amount of

(b) Compound 2: (5)-5-(5-Chloro-l-methyl-2-oxo-l,2-dihydro-pyridin-3-yl)-6-(4-chloro- phenyl)-2-(2,4-dimethoxy-pyrimidin-5-yl)-l-isopropyl-5,6-dihydro-lH-pyrrolo[3,4- ]imidazol-4-one, or a pharmaceutically acceptable salt thereof, or a complex thereof, or a co-crystal thereof, or a solvate, including hydrate, thereof.