Application of benzimidazole compound drug combination in treatment and prevention of leukemia related diseases

Abstract

The invention relates to a combined application of a benzimidazole compound and a BCR-ABL1TKI inhibitor in preparation of a medicine for treating leukemia related diseases, and provides a combined application of the benzimidazole compound and the BCR-ABL1TKI inhibitor in preparation of a medicine for preventing or treating leukemia related diseases.

Description

[0001] This application claims priority to Chinese patent application CN202410774813.X, filed on June 14, 2024. This application incorporates the entire text of the aforementioned Chinese patent application. TECHNICAL FIELD

[0002] The present application belongs to the field of medicine, and relates to the use of a benzimidazole compound in combination with a BCR-ABL1 TKI inhibitor in the preparation of a medicament for preventing or treating leukemia-related diseases. BACKGROUND

[0003] The tyrosine kinase activity of ABL1 protein is normally tightly regulated, with the N-terminal cap region of the SH3 domain playing an important role. One regulatory mechanism involves the myristoylation of the N-terminal cap glycine-2 residue, which then interacts with the myristate binding site in the SH1 catalytic domain. A hallmark of chronic myeloid leukemia (CML) is the Philadelphia chromosome (Ph), formed by a t(9,22) chromosomal translocation in hematopoietic stem cells. This chromosome carries the BCR-ABL1 oncogene, which encodes a chimeric BCR-ABL1 protein that lacks the N-terminal cap and has a constitutively activated tyrosine kinase domain. Tyrosine kinase inhibitors (TKIs) against the BCR-ABL1 protein are the standard of care for CML patients, with imatinib, nilotinib, and dasatinib approved for the treatment of newly diagnosed CML patients.

[0004] However, some patients develop resistance due to the emergence of drug-resistant clones, in which mutations in the SHI domain impair inhibitor binding. While nilotinib and dasatinib retain potency against many BCR-ABL1 mutant forms resistant to imatinib, a mutation in which the threonine 315 residue is replaced by isoleucine (T315I) is insensitive to all three drugs and can lead to the development of resistance to treatment in CML patients. Therefore, there is still an unmet medical need to inhibit BCR-ABL1 mutations, such as T315I. Therefore, there is a clinical need to provide more methods to improve drug resistance. SUMMARY

[0005] BCR-ABL1 TKI inhibitors directly target the ATP binding site, while BCR-ABL1 allosteric inhibitors specifically target the BCR-ABL1 kinase myristoylation binding pocket, which makes them exert their inhibitory effect without being affected by point mutations that lead to resistance to ATP-competitive inhibitors, and also provides the possibility of combining allosteric inhibitors with ATP-competitive inhibitors. The combination of the two can inhibit the emergence of most drug-resistant mutations and avoid the continuous cloning of early low-abundance point mutations leading to drug resistance, which can amplify the clinical benefits of the subjects.

[0006] The combination of BCR-ABL1 allosteric inhibitor drug and Flumatinib mesylate can have additive or synergistic effect on cell inhibition of all BCR-ABL kinase domain mutations without kinase domain mutation and detected; because the mechanism of action of the two drugs is complementary, the combination of the two drugs will not produce drug resistance caused by kinase domain mutation, so that more patients can achieve deep molecular remission (DMR) faster, and after reaching the condition of drug withdrawal, longer TFR and lower relapse rate can be achieved.

[0007] The present application provides a use of a combination of BCR-ABL1 allosteric inhibitor and BCR-ABL1 TKI inhibitor in the preparation of a drug for treating leukemia-related diseases.

[0008] In some embodiments of the present application, the BCR-ABL1 allosteric inhibitor is selected from (R)-N-(4-(chlorodifluoromethoxy)phenyl)-2-(difluoromethyl)-1-(1-hydroxypropan-2-yl)-7-(pyrimidin-5-yl)-1H-benzo[d]imidazole-5-carboxamide or (3R)-N-(4-(chlorodifluoromethoxy)phenyl)-2-(difluoromethyl)-3-methyl-3,4,5a,6-tetrahydro-5-oxa-1,2a,6,8-tetraazabenzo[4,5]cycloocta[1,2,3-cd]indene-11-carboxamide or a pharmaceutically acceptable salt thereof.

[0009] In some embodiments of the present application, the BCR-ABL1 TKI is one or more of imatinib, dasatinib, nilotinib, flumatinib or bosutinib or a pharmaceutically acceptable salt thereof; preferably flumatinib or a pharmaceutically acceptable salt thereof.

[0010] In some embodiments of the present application, the pharmaceutically acceptable salt of the above-mentioned compound is selected from sulfate, hydrochloride, ethyl sulfonate, methanesulfonate, p-toluenesulfonate, benzenesulfonate, hydroxyethyl sulfonate or 1,5-naphthalenedisulfonate; preferably p-toluenesulfonate or methanesulfonate.

[0011] In some embodiments of the present application, the BCR-ABL1 allosteric inhibitor is (R)-N-(4-(chlorodifluoromethoxy)phenyl)-2-(difluoromethyl)-1-(1-hydroxypropan-2-yl)-7-(pyrimidin-5-yl)-1H-benzo[d]imidazole-5-carboxamide p-toluenesulfonate.

[0012] In some embodiments of the present application, the BCR-ABL1 TKI inhibitor is flumatinib mesylate.

[0013] In some embodiments of the present application, the BCR-ABL1 allosteric inhibitor and the BCR-ABL1 TKI inhibitor are in a weight ratio of 1:1-10, preferably 1:2-8, more preferably 1:3-6, based on free bases.

[0014] In certain embodiments of the application, the BCR-ABL1 allosteric inhibitor is administered at a dose ranging from 40 mg to 400 mg as a free base, preferably from 80 mg to 200 mg; more preferably from 120 mg to 160 mg; and the BCR-ABL1 TKI is administered at a dose ranging from 100 mg to 600 mg as a free base; preferably from 200 mg to 500 mg; more preferably from 300 mg to 400 mg. Exemplary doses are selected from 40 mg, 80 mg, 120 mg, 160 mg, 200 mg, 300 mg or 400 mg.

[0015] In certain embodiments of the application, the BCR-ABL1 allosteric inhibitor is administered at a dose ranging from 40 mg to 400 mg as a free base, preferably from 80 mg to 200 mg; more preferably from 120 mg to 160 mg; and the BCR-ABL1 TKI is administered at a dose ranging from 100 mg to 600 mg as a free base; preferably from 200 mg to 500 mg; more preferably from 300 mg to 400 mg. Exemplary doses are selected from 40 mg, 80 mg, 120 mg, 160 mg, 200 mg, 300 mg or 400 mg.

[0016] In certain embodiments of the application, the BCR-ABL1 allosteric inhibitor is administered twice a day, once a day or once every two days; preferably twice a day.

[0017] In certain embodiments of the application, the BCR-ABL1 TKI is dasatinib, and is administered at a dose ranging from 100 mg to 600 mg as a free base; preferably from 200 mg to 500 mg; more preferably from 300 mg to 400 mg. Exemplary doses are selected from 100 mg, 200 mg, 300 mg, 400 mg, 500 mg or 600 mg.

[0018] In certain embodiments of the application, the BCR-ABL1 TKI is dasatinib, and is administered twice a day, once a day or once every two days; preferably once a day.

[0019] In certain embodiments of the application, the BCR-ABL1 TKI is imatinib, and is administered at a dose ranging from 100 mg to 600 mg as a free base; preferably from 200 mg to 500 mg; more preferably from 300 mg to 400 mg. Exemplary doses are selected from 100 mg, 200 mg, 300 mg, 400 mg, 500 mg or 600 mg.

[0020] In certain embodiments of the application, the BCR-ABL1 TKI is imatinib, and is administered twice a day, once a day or once every two days; preferably once a day.

[0021] In certain embodiments of the application, the BCR-ABL1 TKI is dasatinib, the single administration dose ranges from 20 mg to 140 mg as free base; preferably from 50 mg to 100 mg; more preferably from 70 mg to 100 mg. Exemplary doses are selected from 20 mg, 50 mg, 70 mg, 100 mg or 140 mg.

[0022] In certain embodiments of the application, the BCR-ABL1 TKI is dasatinib, the administration frequency is twice a day, once a day or once every two days; preferably once a day.

[0023] In certain embodiments of the application, the BCR-ABL1 TKI is nilotinib, the single administration dose ranges from 150 mg to 400 mg as free base; preferably from 200 mg to 400 mg; more preferably from 300 mg to 400 mg. Exemplary doses are selected from 150 mg, 300 mg or 400 mg.

[0024] In certain embodiments of the application, the BCR-ABL1 TKI is nilotinib, the administration frequency is twice a day, once a day or once every two days; preferably once a day.

[0025] In certain embodiments of the application, the BCR-ABL1 TKI is bosutinib, the single administration dose ranges from 100 mg to 500 mg as free base; preferably from 200 mg to 400 mg; more preferably from 300 mg to 400 mg. Exemplary doses are selected from 100 mg, 200 mg, 300 mg, 400 mg or 500 mg.

[0026] In certain embodiments of the application, the BCR-ABL1 TKI is bosutinib, the administration frequency is twice a day, once a day or once every two days; preferably once a day.

[0027] In certain embodiments of the application, the BCR-ABL1 allosteric inhibitor drug and the BCR-ABL1 TKI inhibitor are applied simultaneously, concurrently, independently or sequentially.

[0028] The route of administration of the combination described in the present application is selected from oral administration.

[0029] The use of a BCR-ABL1 allosteric inhibitor in combination with a BCR-ABL1 TKI inhibitor for the preparation of a medicament for the treatment of a leukemia-related disease, wherein the leukemia-related disease is selected from chronic myelogenous leukemia, acute myelogenous leukemia or acute lymphoblastic leukemia

[0030] In some embodiments of the present application, the leukemia-related disease is selected from chronic myelogenous leukemia, acute myelogenous leukemia or acute lymphoblastic leukemia that is resistant or intolerant to at least one prior BCR-ABL1 TKI therapy.

[0031] In some embodiments of the present application, the combination optionally further comprises other components, which include but are not limited to other drugs for treating leukemia-related diseases.

[0032] In some embodiments of the present application, when the combination of the BCR-ABL1 allosteric inhibitor drug and the BCR-ABL1 TKI inhibitor is in the form of a pharmaceutical composition, it further comprises one or more pharmaceutically acceptable carriers, excipients or diluents.

[0033] The present application also provides a method for preventing or treating leukemia-related diseases, comprising administering to a patient an effective dose of a BCR-ABL1 allosteric inhibitor and a BCR-ABL1 TKI inhibitor for 4-6 cycles of standard treatment or longer.

[0034] The 1 administration cycle is selected from 4 weeks, 3 weeks, 2 weeks, 1 week or 24 hours; preferably 4 weeks.

[0035] The "combination" described in the present application is an administration method, which refers to administering at least one dose of a BCR-ABL1 allosteric inhibitor and at least one dose of a BCR-ABL1 TKI inhibitor within a certain time period, wherein both substances show pharmacological effects. The BCR-ABL1 allosteric inhibitor and the BCR-ABL1 TKI inhibitor can be administered simultaneously or sequentially. Simultaneously includes the treatment by which the BCR-ABL1 allosteric inhibitor and the BCR-ABL1 TKI inhibitor are administered by the same administration route or different administration routes. BRIEF DESCRIPTION OF DRAWINGS

[0036] Figure 1 Results of the inhibitory effect of drug A and drug B alone and in combination on the proliferation of KCL22-s cells.

[0037] Figure 2 Results of the inhibitory effect of drug A and drug B alone and in combination on the proliferation of K562 cells.

[0038] Figure 3 Results of the inhibitory effect of drug A and drug B alone and in combination on the proliferation of KU812 cells. DETAILED DESCRIPTION

[0039] The present application will be explained in more detail below with reference to the examples, which are only used to illustrate the technical solutions of the present application and do not limit the essence and scope of the present application.

[0040] Example 1. Evaluation of the inhibitory effect of drug A in combination with deforolimus mesylate on the proliferation of human chronic myelogenous leukemia cells in vitro

[0041] 1.1 Experimental materials

[0042] 1.1.1 Test drugs

[0043] Drug A: p-toluenesulfonic acid salt of (R)-N-(4-(chlorodifluoromethoxy)phenyl)-2- (difluoromethyl)-1-(1-hydroxypropan-2-yl)-7-(pyrimidin-5-yl)-1H-benzo[d]imidazole-5- carboxamide, drug preparation using 0.5% HPMC;

[0044] Drug B: deforolimus mesylate.

[0045] 1.1.2 Cell lines

[0046] Table 1. Cell source and type

[0047]

[0048] 1.1.3 Reagent materials:

[0049] RPMI 1640, FBS, PBS, DMSO, Luminescent Cell Viability Assay, white 96-well plate, 96V bottom plate (PS), Cell Counting Chamber Slides1.1.4 Experimental instruments

[0050] Biological safety cabinet, CO2 incubator, electric pipette aspirator, cell counter, centrifuge, refrigerator, inverted fluorescence microscope, electric heating constant temperature water bath, vortex instrument, liquid nitrogen tank, centrifuge, microplate reader, refrigerator, single channel pipette, single channel pipette, single channel pipette, single channel pipette, 12-channel electric pipette.

[0051] 1.2 Experimental method

[0052] Application Luminescent Cell Viability Assay Kit The Luminescent Cell Viability Assay (LCA) was used to detect the inhibitory effect of drugs on tumor cell proliferation and growth. Overnight cultured cells in the logarithmic growth phase were directly collected, mixed by pipetting, and counted. Cell density was adjusted according to different density requirements, and cell suspensions were prepared and seeded into 96-well plates. The seeding density of KCL22-s cells was 5000 cells / well. Different concentrations of drugs were added, with three replicates for each concentration and corresponding solvent controls, and two replicates for each concentration, along with corresponding solvent controls and inter-plate calibration wells. The concentrations of drug A and drug B in KCL22-s cells were 25, 12.5, 6.25, 3.125, 1.5625, 0.78125, and 0.390625 nM, respectively. The concentrations of drug A and drug B in K562 and KU812 cells were 30, 10, 3.00, 1.11, 0.37, and 0.12 nM, respectively. An orthogonal design was used to combine the compound concentrations. After adding the compound, the cells were cultured for another 72 hours at 37°C and 5% CO2. The culture plate and its contents were then equilibrated to room temperature before adding the compound. The reagents were mixed on a shaker for 3 minutes to induce cell lysis. The culture plate was then incubated at room temperature in the dark for another 10 minutes. The chemiluminescence signal value was measured using a microplate reader (BioTek Synergy H1).

[0053] 1.3 Experimental Results

[0054] The half-maximal inhibitory concentration (IC50) of drug A alone against KCL22-s cell proliferation was 3.28 nM, while the half-maximal inhibitory concentration (IC50) of drug B alone against cell proliferation was 4.73 nM. The inhibition rate when drug A and drug B were used in combination was significantly higher than the sum of the inhibition rates at their respective single concentrations. Figure 1 As shown, drug B and drug A at a concentration of 3.13 nM inhibited the proliferation of KCL22-s cells by 34% and 46%, respectively, both showing partial inhibition. However, when the two were used in combination, the inhibition rate of KCL22-s cell proliferation reached 91%. The concentration combination that achieved approximately half-maximal inhibition of KCL22-s cell proliferation was: drug B at 1.56 nM and drug A at 1.56 nM; or drug B at 3.13 nM and drug A at 0.78 nM.

[0055] The half-maximal inhibitory concentration (IC50) of drug A alone against K562 cell proliferation was 7.90 nM, and the half-maximal inhibitory concentration (IC50) of drug B alone against cell proliferation was 6.14 nM. The inhibition rate when drug A and drug B were used in combination was higher than the sum of the inhibition rates at their respective single concentrations. For example... Figure 2As shown, the inhibition rates of drug B and drug A on K562 cell proliferation at a concentration of 3.33 nM were 20.85% and 15.53%, respectively, both of which had a low inhibition on K562 cells, but when the two were used in combination, the inhibition of K562 cell proliferation reached half inhibition, with an inhibition rate of 54.63%.

[0056] The half-inhibitory concentration of drug A alone on KU812 cell proliferation inhibition was 3.00 nM, and the half-inhibitory concentration of drug B alone on cell proliferation inhibition was 2.45 nM. When drug A and drug B were used in combination, the inhibition rate was significantly higher than the sum of the inhibition rates at the corresponding single concentration. As shown, Figure 3 As shown, the inhibition rates of drug B and drug A on KU812 cell proliferation at a concentration of 3.33 nM were 63.21% and 51.36%, respectively, both of which had a partial inhibition on K562 cells, but when the two were used in combination, the inhibition rate of K562 cell proliferation reached 91.55%; the concentration combination when K562 cell proliferation reached about half inhibition was: drug B was 1.11 nM, and drug A was 1.11 nM.

[0057] 1.4 Experimental Conclusion:

[0058] Drug A combined with drug B had a good synergistic effect on the proliferation inhibition of KCL22-s cells, K562 cells and KU812 cells, and could achieve obvious inhibition effect at a lower drug concentration. Example 2. Ib phase clinical study of safety, tolerability, pharmacokinetics and effectiveness of drug A combination therapy in patients with chronic myeloid leukemia

[0059] This is a multicenter, open-label Ib phase clinical study to evaluate the safety, tolerability, effectiveness and PK characteristics of drug A combined with drug B in patients with chronic myeloid leukemia.

[0060] 2.1 Study Design

[0061] This study evaluates the safety, tolerability, pharmacokinetics and effectiveness of drug A combined with drug B in CML patients. This study is a dose exploration study of drug A combined with drug B, which is divided into two stages: the first stage (Part 1) is a joint dose escalation phase, and the second stage (Part 2) is a joint dose expansion phase

[0062] Part 1: In subjects with CML-CP / AP who were resistant or intolerant to at least one BCR-ABL1 TKI treatment, a dose escalation study of drug A combined with drug B was conducted by using a dose escalation design to evaluate the safety, tolerability, PK characteristics and preliminary effectiveness of combination therapy, and to determine the MTD (or MAD).

[0063] Part 2: An expansion study in CML first-line population (i.e. newly diagnosed Ph+ CML-CP subjects) at 1-2 safe and potentially effective doses determined in the combination dose escalation phase will be conducted to further evaluate the safety, PK and efficacy of Drug A in combination with Drug B and to determine the target dose of the combination regimen.

[0064] 2.2 Sample size determination

[0065] Part 1 - Combination dose escalation phase: 3 dose groups are planned, with 3-6 subjects per dose group according to the "Rolling 6" design principle, approximately 12-18 subjects in total;

[0066] Part 2 - Combination dose expansion phase: 1-2 safe and potentially effective dose groups are selected for dose expansion in the target population, with approximately 10-50 subjects per dose group, approximately 10-100 subjects in total in the expansion phase.

[0067] The study population can be adjusted according to the accumulation of clinical trial data, preclinical efficacy and research progress of similar drugs.

[0068] 2.2.1 Inclusion criteria for subjects:

[0069] Subjects must meet all of the following criteria to be enrolled in the study:

[0070] 1. Male or female subjects aged ≥ 18 years and < 75 years.

[0071] 2. Eastern Cooperative Oncology Group (ECOG) performance status (PS) score of 0-1 and no deterioration within 2 weeks prior to the first dose.

[0072] 3. Minimum expected survival of more than 12 weeks.

[0073] 4. Female subjects of childbearing potential are willing to take appropriate contraceptive measures from the time of signing the informed consent form until 6 months after the last dose and should not be breastfeeding; male subjects are willing to use barrier contraception (i.e. condom) from the time of signing the informed consent form until 6 months after the last dose.

[0074] 5. Female subjects have a negative serum pregnancy test result within 7 days prior to the first dose, or meet one of the following criteria to demonstrate no risk of pregnancy:

[0075] a) Postmenopausal defined as age ≥ 60 years and amenorrhea for at least 12 months after cessation of all exogenous hormonal replacement therapies;

[0076] b) Women less than 60 years of age can be considered postmenopausal if they have been amenorrhoeic for 12 months or more following cessation of all exogenous hormonal replacement therapy, with documented serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in the postmenopausal range for the laboratory.

[0077] c) Has undergone irreversible sterilization surgery, including hysterectomy, bilateral oophorectomy, or bilateral salpingectomy, except for bilateral tubal ligation.

[0078] a) Has undergone irreversible sterilization surgery, including hysterectomy, bilateral oophorectomy or bilateral salpingectomy, except for bilateral tubal ligation.

[0079] 6. Voluntarily participate in this clinical trial, understand the research procedures, and be able to sign an informed consent form in writing before any protocol-related procedures are carried out.

[0080] 7. The subjects are willing and able to comply with the protocol to complete the corresponding visits, treatments and other research procedures.

[0081] 2.2.2 Subject-specific inclusion criteria:

[0082] In addition to the general inclusion criteria mentioned above, subjects must also meet all the criteria for the specific group to be enrolled in. Prat 1 (Combined Dose Escalation Phase)

[0083] 1. Patients diagnosed with CML-CP / AP by bone marrow cell morphology examination, molecular biological examination, or cytogenetic examination are required to provide a bone marrow cell morphology examination report within 8 weeks prior to the first dose of medication, and an examination report confirming the presence of the BCR-ABL1 fusion gene.

[0084] 2. Resistance or intolerance to at least one BCR-ABL1 TKI (such as imatinib, dasatinib, or nilotinib) after prior treatment*;

[0085] Part 2 (Combined Dosage Extension Phase):

[0086] 1. Ph+CML-CP subjects diagnosed for the first time within 1.6 months.

[0087] • Definition of a confirmed diagnosis: Positive Ph chromosome t(9;22) result in bone marrow cytogenetics and / or positive BCR / ABL result in molecular biological testing.

[0088] The fusion gene is positive.

[0089] • The date of the first confirmed diagnosis is defined as the sampling date on the report of the first confirmed diagnosis.

[0090] • Chronic phase (all of the following must be met):

[0091] a. Primitive cells in peripheral blood and bone marrow <15%.

[0092] b. The percentage of primitive cells plus promyelocytes in peripheral blood and bone marrow is less than 30%.

[0093] c. Basophils in peripheral blood < 20%.

[0094] d. Platelet count > 100 x 10 9 / L, or < 100 x 10 9 / L but related to prior medication received.

[0095] e. No extramedullary infiltration (except for hepatosplenomegaly).

[0096] 2.3 Study Medication

[0097] 2.3.1 Study Drug Information

[0098] Drug A Tablets

[0099] • Dosage form: Tablets

[0100] • Strength: 40 mg, 100 mg

[0101] • Route of administration: Oral

[0102] • Storage conditions: Protect from light, store in airtight container at room temperature below 25 °C

[0103] • Dosage and administration: Take orally twice daily

[0104] Drug B Tablets

[0105] • Trade name:

[0106] • Dosage form: Tablets

[0107] • Strength: 0.1 g, 0.2 g

[0108] • Route of administration: Oral

[0109] • Storage conditions: Protect from light, store in airtight container at room temperature below 25 °C

[0110] • Dosage and administration: Take orally once daily

[0111] 2.3.2 Dosing Regimen

[0112] Part 1 Dose Escalation Phase:

[0113] The starting dose is Drug B 400 mg once a day (QD) + Drug A 160 mg twice a day (BID), or other escalating doses.

[0114] From the first day of Cycle 1 (C1D1), subjects receive continuous treatment with Drug A and Drug B daily until treatment failure or other criteria for discontinuation of study treatment are met.

[0115] Part 2 Combination Dose Expansion Phase

[0116] An expansion study of newly diagnosed Ph+CML-CP subjects will be conducted at 1-2 safe and potentially effective doses determined in the combination dose escalation phase. The dosing regimen will be the same as in the combination dose escalation phase.

[0117] 2.4 Dose Adjustment

[0118] 2.4.1 Dose Adjustment for Drug A

[0119] Dose adjustment for Drug A is categorized as drug holiday, dose reduction, and permanent discontinuation.

[0120] Drug Holiday

[0121] The duration of study drug suspension should not exceed 28 days to ensure that the subject receives the intended strength of the drug. If the duration of the drug holiday exceeds the above criteria, the subject will be discontinued from the study unless the Investigator and Sponsor agree to continue the drug after discussion (e.g., non-drug related toxicity causes the drug holiday to exceed 28 days and no disease progression has occurred, etc.).

[0122] Dose Reduction:

[0123] The dose reduction allowed for the study drug is the lower dose that has been proven safe in the dose escalation phase. If the subject is still intolerant after reduction to the lowest dose, the drug will be discontinued and the subject will not receive further dose reduction unless the Investigator and Sponsor agree that further dose reduction is necessary after discussion.

[0124] Permanent Discontinuation:

[0125] In the combination treatment regimen, after a drug is judged to be permanently discontinued according to the dose adjustment principle, the remaining drugs can still be administered according to the original plan and do not need to be discontinued from the study.

[0126] If a Grade 3 or higher non-study drug related adverse event occurs, or a Grade 2 laboratory abnormality that does not cause symptoms / signs of discomfort in the subject, or a non-fatal adverse event (hair loss, decreased appetite, etc.), the Investigator can consider whether to delay or resume study drug administration at his / her discretion.

[0127] Table 2 Dose Adjustment Plan for Drug A Tablets

[0128]

[0129] 2.4.2 Dose Adjustment for Drug B

[0130] Dose adjustment for Drug B is categorized as drug holiday, dose reduction, and permanent discontinuation.

[0131] Table 3 Dose Adjustment Plan for Drug B Tablets

[0132]

[0133] 2.5 Study Evaluation

[0134] 2.5.1 Safety Evaluation Criteria

[0135] Safety of the drug was evaluated according to CTCAE version 5.0 published by the U.S. Department of Health and Human Services / National Institutes of Health / National Cancer Institute. The relationship of adverse events to study drug was classified as definitely related, possibly related, probably unrelated, definitely unrelated, and indeterminate.

[0136] 2.5.2 Efficacy Evaluation Criteria

[0137] 2.5.2.1 Hematology Evaluation

[0138] Evaluation Method: Complete blood count with differential.

[0139] Evaluation Time: Screening, within the first 6 cycles after dosing, once every cycle. From cycle 7 to cycle 24, once every 3 cycles, and then once every 6 cycles thereafter. Suspected disease progression, the investigator can increase the examination at any time.

[0140] Definition of CHR, meeting all of the following criteria:

[0141] • Peripheral white blood cell count <10 x 10 9 / L;

[0142] • Peripheral platelet count <450 x 10 9 / L;

[0143] • No immature cells in peripheral blood, such as myeloblasts, promyelocytes, or blasts, immature cells,

[0144] and basophils <5%;

[0145] • No symptoms and signs of the disease in this study, and palpable splenomegaly has disappeared.

[0146] All CHR obtained need to be confirmed after ≥4 weeks.

[0147] Loss of CHR refers to any of the following:

[0148] • White blood cell count increased to >20 x 10 9 / L;

[0149] • Platelet count increased to >600 x 10 9 / L;

[0150] • Spleen enlargement to ≥5 cm below the costal margin;

[0151] • Peripheral blood myeloblasts + promyelocytes ≥5%.

[0152] • Presence of blast cells or promyelocytes in peripheral blood.

[0153] Loss of CHR must be confirmed after ≥4 weeks (unless accompanied by progression to AP or BP or CML-related death).

[0154] Elevated white blood cell count in subjects who do not achieve CHR is indicative of hematologic progression. Hematologic progression is defined as a doubling of the white blood cell count between two assessments at least 4 weeks apart with a white blood cell count >20.0 x 109 / L at the later assessment.

[0155] The presence of hematologic progression does not imply disease progression. Disease progression is considered to be progression of CML from chronic phase to AP / BP.

[0156] 2.5.2.2 Cytogenetic evaluation

[0157] Bone marrow fluid (to avoid bone marrow fluid dilution) or bone marrow tissue specimens are obtained by bone marrow aspiration / biopsy for chromosomal karyotype analysis and cytogenetic evaluation.

[0158] If bone marrow specimen collection is not optimal, multiple site aspirations are recommended.

[0159] Method of detection: Routine cytogenetic methods for bone marrow are used, with cell culture, G-banding / R-banding techniques, for bone marrow chromosomal karyotype analysis, observing at least 20 metaphase cells. If the results cannot be evaluated (e.g., fewer than 20 metaphase cells in the sample), a new bone marrow specimen is collected within 28 days for testing. Cytogenetic testing is performed in local laboratories at each center, and centers that are not able to perform cytogenetic testing will send the sample to a centralized laboratory for testing.

[0160] Timing of evaluation: Screening, C3, C6, every 6 cycles after C6, and as needed by the investigator at any time.

[0161] If a subject achieves CCyR at a visit and is confirmed (cytogenetic or molecular confirmation) within 4 weeks, cytogenetic testing can be performed every 12 cycles until the end of cycle 24. If a subject continues to achieve CCyR at the end of cycle 24 or continues to achieve MMR by molecular evaluation, no further testing is required until the investigator considers suspected disease progression. At any time a subject loses CCyR, return to evaluation every 3 cycles. Definition of cytogenetic response:

[0162] • Complete cytogenetic response (CCyR): 0% Ph+ by cytogenetic testing; BCR-ABL1IS <1% by molecular testing is equivalent to achieving CCyR;

[0163] Partial cytogenetic response (PCyR): 1-35% Ph+ by cytogenetics;

[0164] Minor cytogenetic response (mCyR): 36-65% Ph+ by cytogenetics;

[0165] Minimal cytogenetic response (miniCyR): 66-95% Ph+ by cytogenetics;

[0166] No cytogenetic response (NoCyR): >95% Ph+ by cytogenetics;

[0167] Major cytogenetic response (MCyR): 0-35% Ph+ by cytogenetics, i.e. CCyR and PCyR;

[0168] Loss of CCyR: increase in the proportion of Ph+ by cytogenetics from 0% to >0%; molecular detection of BCR::ABL1.

[0169] ABL1 / ABLIS≥1% is equivalent to loss of CCyR.

[0170] Loss of PCyR: increase in the proportion of Ph+ by cytogenetics from 1-35% to >35%.

[0171] Note: In this study, if cytogenetic examination is performed, bone marrow dry aspiration or bone marrow dilution occurs, or observation of less than 20 metaphase cells is not sufficient to evaluate, it can be evaluated by BCR-ABL1IS value. When cytogenetic evaluation is performed, if there are standard cytogenetic detection results and molecular detection results at the same time, the cytogenetic evaluation is based on the cytogenetic detection results. If the achievement of CCyR is supported by BCR-ABL1 IS , the evaluation of Ph+ metaphase can not be performed.

[0172] 2.5.2.3 Molecular evaluation

[0173] Detection method: Take the peripheral blood of the subject, and detect BCR-ABL1 / ABLIS by real-time quantitative polymerase chain reaction (RQ-PCR). Molecular detection is performed by collecting samples from each center and sending them to a unified central laboratory for detection and analysis.

[0174] Evaluation time: within 24 hours before the first administration, C1-C24, every 3 cycles (i.e. C3, C6, C9…C24), every 6 cycles (i.e. C30, C36, C42…) since C25. Suspected disease progression can be checked at any time.

[0175] Definition of molecular response (MR):

[0176] • MR1.0: BCR-ABL1 / ABL IS ≤ 10%;

[0177] • MR2.0: BCR-ABL1 / ABL IS ≤ 1%;

[0178] • MR3.0: BCR-ABL1 / ABL IS ≤ 0.1%;

[0179] • MR4.0: BCR-ABL1 / ABL IS ≤ 0.01%;

[0180] • MR4.5: BCR-ABL1 / ABL IS ≤ 0.0032%;

[0181] • Molecularly undetectable: BCR-ABL1 transcripts are not detectable at the level of amplifiable ABL transcripts.

[0182] Loss of major molecular response (MMR) is defined as confirmed BCR-ABL1 / ABL IS > 0.1%,

[0183] with a ≥ 5-fold increase from the lowest value obtained during the study (confirmed by duplicate analysis of the same sample).

[0184] Loss of MR4.0 is defined as confirmed BCR-ABL / ABL IS > 0.01% with a ≥ 5-fold increase from the lowest value obtained during the study (confirmed by duplicate analysis of the same sample).

[0185] Loss of MR4.5 is defined as confirmed BCR-ABL / ABL IS > 0.0032% with a ≥ 5-fold increase from the lowest value obtained during the study (confirmed by duplicate analysis of the same sample).

[0186] Loss of MMR / MR4.0 / MR4.5 must be confirmed by repeat testing 4-6 weeks after the date of the test sample, and the confirmation must be performed within 6 weeks. If the loss of MMR / MR4.0 / MR4.5 is confirmed and the patient has also lost a previously achieved CHR, or has lost a previously achieved CCyR, or has progressed to AP or BP, or has died from CML-related causes, no further molecular testing is required.

[0187] Regarding gene mutation detection: peripheral blood samples need to be collected for gene mutation detection in this study. Gene mutation detection can be performed when the following situations occur in the subjects:

[0188] 1 Screening period or before first dose (Part 1 subjects);

[0189] 2 Not reaching MMR after 12 months of treatment;

[0190] 3 Loss of MMR;

[0191] 4 Disease progression to accelerated phase or blast phase at any time.

[0192] 2.6 Study Conclusion

[0193] The BCR-ABL1 allosteric inhibitor combined with the BCR-ABL1 TKI inhibitor treatment regimen for the treatment of leukemia-related diseases can meet the current clinical treatment needs of such tumor patients, so as to improve the treatment effect of such tumor population, prolong the survival and improve the quality of life.

Claims

1. Use of a BCR-ABL1 allosteric inhibitor in combination with a BCR-ABL1 TKI inhibitor for the manufacture of a medicament for the treatment of a leukemia-related disease, wherein the BCR-ABL1 allosteric inhibitor is selected from (R)-N-(4-(chlorodifluoromethoxy)phenyl)-2-(difluoromethyl)-1-(1- hydroxypropan-2-yl)-7-(pyrimidin-5-yl)-1 H-benzo[d]imidazole-5-carboxamide or (3R)-N-(4-(chlorodifluoromethoxy)phenyl)-2-(difluoromethyl)-3-methyl-3,4,5a,6- tetrahydro-5-oxa-1,2a,6,8-tetraazabenzo[4,5]cycloocta[1,2,3-cd]indene-11 -carboxamide or a pharmaceutically acceptable salt thereof; the BCR-ABL1 TKI inhibitor is selected from one or more of imatinib, dasatinib, nilotinib, f oratinib or bosutinib or a pharmaceutically acceptable salt thereof; preferably f oratinib or a pharmaceutically acceptable salt thereof.

2. Use according to claim 1, characterized in that, the pharmaceutically acceptable salt is selected from a sulfate, a hydrochloride, an ethylsulfonate, a methanesulfonate, a p-toluenesulfonate, a benzenesulfonate, a hydroxyethylsulfonate or a 1,5-naphthalenedisulfonate; preferably a p-toluenesulfonate or a methanesulfonate.

3. Use according to claim 1, characterized in that, the BCR-ABL1 allosteric inhibitor is (R)-N-(4-(chlorodifluoromethoxy)phenyl)-2- (difluoromethyl)-1-(1-hydroxypropan-2-yl)-7-(pyrimidin-5-yl)-1 H-benzo[d]imidazole-5- carboxamide p-toluenesulfonate; the BCR-ABL1 TKI inhibitor is f oratinib mesylate.

4. Use according to claim 1, characterized in that, the weight ratio of the BCR-ABL1 allosteric inhibitor to the BCR-ABL1 TKI inhibitor is 1 :1 to 10, preferably 1 :2 to 8, more preferably 1 :3 to 6.

5. Use according to claim 1, characterized in that, the dose of the BCR-ABL1 allosteric inhibitor is 40 mg to 400 mg; preferably 80 mg to 200 mg; more preferably 120 mg to 160 mg; the dose of the BCR-ABL1 TKI inhibitor is 100 mg to 600 mg; preferably 200 mg to 500 mg; more preferably 300 mg to 400 mg.

6. Use according to claim 1, characterized in that, the BCR-ABL1 TKI is f oratinib mesylate, the single dose is in the range of 100 mg to 600 mg; preferably 200 mg to 500 mg; more preferably 300 mg to 400 mg; preferably, the dosing frequency is twice a day, once a day or once every two days; preferably once a day; more preferably, f oratinib mesylate is administered orally once a day at a dose of 300 mg to 400 mg; or, the BCR-ABL1 TKI is imatinib, the single dose is in the range of 100 mg to 600 mg; preferably 200 mg to 500 mg; more preferably 300 mg to 400 mg, preferably, the dosing frequency is twice a day, once a day or once every two days; preferably once a day; more preferably, imatinib is administered orally once a day at a dose of 300 mg to 400 mg; Alternatively, the BCR-ABL1 TKI is dasatinib, administered in a single dose ranging from 20 mg to 140 mg; preferably from 50 mg to 100 mg; more preferably from 70 mg to 100 mg; Preferably, the administration frequency is twice a day, once a day or once every two days; preferably once a day. More preferably, dasatinib is administered orally once a day in a dose ranging from 70 mg to 100 mg. Alternatively, the BCR-ABL1 TKI is nilotinib, administered in a single dose ranging from 150 mg to 400 mg; preferably from 200 mg to 400 mg; more preferably from 300 mg to 400 mg. Preferably, the administration frequency is twice a day, once a day or once every two days; preferably once a day. More preferably, nilotinib is administered orally once a day in a dose of 300 mg. Alternatively, the BCR-ABL1 TKI is bosutinib, administered in a single dose ranging from 100 mg to 500 mg; preferably from 200 mg to 400 mg; more preferably from 300 mg to 400 mg. Preferably, the administration frequency is twice a day, once a day or once every two days; preferably once a day. More preferably, bosutinib is administered orally once a day in a dose ranging from 300 mg to 400 mg.

7. Use according to claim 1, characterized in that, The BCR-ABL1 allosteric inhibitor is administered in a single dose ranging from 40 mg to 400 mg, preferably from 80 mg to 200 mg; more preferably from 120 mg to 160 mg. Alternatively, the BCR-ABL1 allosteric inhibitor is administered twice a day, once a day or once every two days; preferably twice a day. Preferably, the BCR-ABL1 allosteric inhibitor is administered orally twice a day in a single dose ranging from 120 mg to 160 mg.

8. Use according to any one of claims 1 to 7, characterized in that, The BCR-ABL1 allosteric inhibitor drug and the BCR-ABL1 TKI inhibitor are administered simultaneously, concurrently, independently or sequentially.

9. Use according to any one of claims 1 to 7, characterized in that, When the combination of the BCR-ABL1 allosteric inhibitor drug and the BCR-ABL1 TKI inhibitor is a pharmaceutical composition, it further comprises one or more pharmaceutically acceptable carriers, excipients or diluents.

10. Use according to any one of claims 1 to 8, or a pharmaceutical composition according to claim 9, for the manufacture of a medicament for the prevention or treatment of a leukemia-related disease, wherein The leukemia-related disease is selected from chronic myeloid leukemia, acute myeloid leukemia or acute lymphoblastic leukemia, preferably chronic myeloid leukemia, acute myeloid leukemia or acute lymphoblastic leukemia resistant or intolerant to at least one previous treatment with a BCR-ABL1 TKI. The leukemia-related disease is selected from chronic myeloid leukemia, acute myeloid leukemia or acute lymphoblastic leukemia, preferably chronic myeloid leukemia, acute myeloid leukemia or acute lymphoblastic leukemia resistant or intolerant to at least one previous treatment with a BCR-ABL1 TKI.

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