A method for improving clearance of tumor targeted Anti-cancer drugs from a patient

Abstract

In accordance with at least one aspect of this disclosure, a method for improving clearance and elimination of tumor targeted anti-cancer drugs from a patient, comprises, administering to a patient an anti-cancer drug that is eliminated into urine, and administering to the patient one or more supplemental therapies at a predetermined time after administering the anti-cancer drug. The predetermined time can be determined as a function of at least one of: the anti-cancer drug, the supplemental therapy, a tumor type, and / or a current physiological condition of the patient.

Description

[0001] Docket No. 1515138.113WO2

[0002] A Method for Improving Clearance of Tumor Targeted Anti-Cancer Drugs from a Patient

[0003] CROSS-REFERENCE TO RELATED APPLICATIONS

[0004] This application claims priority to and the benefit of U.S. Provisional Patent Application No. 63 / 684,993, filed August 20, 2024, the entire content of which is incorporated by reference herein.

[0005] FIELD OF THE INVENTION

[0006] The present invention relates to methods of improving clearance of anti-cancer drugs from a patient. The anti-cancer drugs discussed in this application include small zwitterionic molecule anti-cancer drugs having more than one targeting ligand binding to at least one receptor on tumor cells, and thus addresses tumor heterogeneity and background reduction more effectively than traditional anti-cancer drugs.

[0007] BACKGROUND

[0008] Cancer heterogeneity or tumor heterogeneity describes the observation that different tumor cells can show distinct morphological and phenotypic profiles, including cellular morphology, gene expression, metabolism, motility, proliferation, and metastatic potential.

[0009] Cancer / tumor heterogeneity is a common characteristic of cancer that can make it difficult for cancer imaging and treatment drugs to be effective. It can refer to differences between tumors in different patients, between cancer cells in a single tumor of one patient, or between primary and metastatic tumors. Cancer heterogeneity can lead to drug resistance and therapeutic failure in several ways. First, cancer heterogeneity can directly affect therapeutic targets. Second, cancer heterogeneity can influence the tumor microenvironment (TME), which can then affect drug resistance. In addition, cancer heterogeneity can cause uneven distribution of genetic diversity within tumors, which can lead to drag resistance.

[0010] Moreover, cancer / tumor heterogeneity can occur over the life span of the tumor. For example, the cellular morphology and gene expression of the tumor may change over time through clonal evolution, and thus a drag which may be effective in treating the tumor at the beginning of treatment may lose its effectiveness after a treatment period. Docket No. 1515138.113WO2

[0011] Cancer / tumor heterogeneity may also affect the correct and efficient diagnosis of the cancer / tumor due to a lower binding rate of the imaging diagnosing agents to the surfaces of cancer / tumor cells.

[0012] Another problem of paramount importance but unaddressed is off-target, aka nonspecific binding and uptake of anti-cancer drugs. Most anti-cancer drugs are hydrophobic and / or sticky, and make weak but significant interactions with normal, non-cancerous cells and tissues. Off- target binding and uptake leads to a high background thus a low tumor-to- background ratio (TBR) when imaging cancer cells and a low therapeutic window when treating cancer cells.

[0013] Small zwitterionic molecule anti-cancer drugs having more than one targeting ligand binding to at least one receptor on tumor cells represent new and improved anti-cancer drugs which are capable of addressing the tumor heterogeneity and background reduction while greatly improving performance in both diagnosing and treating malignant tumors. A key feature of zwitterionic drugs is shifting of clearance, i.e., elimination from the body, from mostly hepatic (liver) to mostly or exclusive renal (kidney). Drugs exhibiting renal clearance are eliminated from the body in urine.

[0014] As with any targeted anti-cancer drug, a concern is raised regarding the clearance of the drug from the patient’s body, reducing overall toxicity of the drug. One must be cautious however, to address clearance concerns in a manner that preserves the efficacy of the drug with respect to the targeting and killing a tumor. Accordingly, there remains a need in the art for methods for improving clearance and elimination of the tumor targeted anti -cancer drag such that the drug improves cancer cell kill but reduces toxicity to the patient. Once a drug is eliminated from the body it no longer poses a threat.

[0015] 318494251 vl Docket No. 1515138.113WO2

[0016] Summary

[0017] In accordance with at least one aspect of this disclosure, a method for improving clearance and elimination of tumor targeted anti -cancer drags from a patient includes, administering to a patient an anti-cancer drag that is eliminated into urine and administering to the patient one or more supplemental therapies at a predetermined time after administering the anti-cancer drug. The predetermined time after administration of the anti-cancer drag can be determined as a function of at least one of: the anti-cancer drag, the supplemental therapy, a tumor type, and / or a physiological condition of the patient at the time of administration.

[0018] In certain embodiments, the anti-cancer drag includes a zwitterionic, heterotrimeric small molecule anti-cancer drug. In certain embodiments, the anti-cancer drug is a drug shown and described in U.S. Patent Application No. 19 / 209,293, filed May 15, 2025, the entire content of which is incorporated by reference herein.

[0019] In certain embodiments, the supplemental therapy is configured to cause the patient to rapidly clear the zwitterionic, heterotrimeric small molecule anti-cancer drag through urine to reduce toxicity of the zwitterionic, heterotrimeric small molecule anti-cancer drug to the patient. In certain embodiments, this is achieved by inducing one or more physiological conditions in the patient, the one or more physiological conditions including: hydration, dehydration, and / or increased urination.

[0020] In certain embodiments, the combination of the supplemental therapy and the predetermined time at which the supplemental therapy is administered reduces toxicity to the patient more than administering the supplemental therapy to the patient alone.

[0021] In certain embodiments, the physiological condition can be or include hydration, and administering to the patient one or more supplemental therapies can include administering, intravenously, a saline-containing solution. In certain such embodiments, the method can include administering to the patient the anti -cancer drag over a period of about 15 minutes, and administering to the patient about I L of saline containing solution over a period of about 1 to 4 hours about 1 hour after administering the anti-cancer drag.

[0022] In certain embodiments, the physiological condition can be or include hydration, and administering to the patient one or more supplemental therapies can include administering an isotonic solution. In certain such embodiments, the method can include administering to the patient the anti-cancer drug over a period of about 15 minutes and administering to the

[0023] 3

[0024] 318494251 vl Docket No. 1515138.113WO2 patient, via ingestion, about 2 L of isotonic solution over a period of about 6 to 8 hours about 1 hour after administering the anti-cancer drug.

[0025] In certain embodiments, the physiological condition can be or include hydration, and administering to the patient one or more supplemental therapies can include administering both of a saline-containing solution and an isotonic solution via different administration routes. In certain such embodiments, the method can include, administering to the patient the anti-cancer drug over a period of about 15 minutes, administering to the patient, intravenously, about 1 L of saline containing solution over a period of about 1 to 4 hours about 1 hour after administering the anti-cancer drug, administering to the patient, via ingestion (e.g., oral administration), about 1 L to 2 L of isotonic solution over a period of about 6 to 8 hours about 1 hour after administering the saline-containing solution.

[0026] In certain embodiments, the physiological condition can be or include increased urination and / or dehydration and administering to the patient one or more supplemental therapies can include administering a diuretic. In certain such embodiments, the method can include administering to the patient the anti -cancer drug over a period of about 15 minutes and administering to the patient the diuretic about 1 hour after administering the anti-cancer drug.

[0027] In certain embodiments, the physiological condition can be or include both hydration and increased urination, and administering to the patient one or more supplemental therapies includes administering both a saline -containing solution and a diuretic. In certain such embodiments, the method can include administering to the patient the anti-cancer drug over a period of about 15 minutes and administering to the patient about 1 L of saline-containing solution over a period of about 1 to 4 hours about 1 hour after administering the anti-cancer drug and administering the diuretic during administration of the saline-containing solution.

[0028] In certain embodiments, the diuretic can be or include a vasopressin inhibitor and / or the diuretic can be or include furosemide.

[0029] In certain embodiment, the physiological condition can be or include both hydration and increased urination, and administering to the patient one or more supplemental therapies can include administering a vasopressin inhibiting fluid. In certain such embodiments, the method can include administering to the patient the anti-cancer drag over a period of about 15 minutes and administering to the patient, via ingestion, about 1 L of the vasopressin inhibiting fluid over a period of about 6 to 8 hours about 1 hour after administering the anti- 4

[0030] 318494251 vl Docket No. 1515138.113WO2 cancer drug. In certain embodiments, the vasopressin inhibiting fluid can be or can include alcohol (e.g., an alcoholic beverage).

[0031] In certain embodiments, the physiological condition can be or include both hydration and dehydration, and administering to the patient one or more supplemental therapies can include administering a saline containing solution and a diuretic. In certain such embodiments, the method can include, administering to the patient the anti-cancer drug over a period of about 15 minutes, administering to the patient about 1 L of saline-containing solution about 1 hour after administering the anti-cancer drug, administering the diuretic to the patient during administration of the saline -containing solution, and modulating administration of the saline-containing solution and / or the diuretic. In certain such embodiments, the diuretic can be or include furosemide.

[0032] In certain embodiments, administering to the patient one or more supplemental therapies can include administering renal protective amino acids, such as, in certain embodiments, administering a co-infusion of at least two amino acids with administration of the anti-cancer drug. In certain such embodiment, the method can include administering to the patient the anti-cancer drug over a period of about 15 minutes and administering to the patient two or more renal protective amino acids as a co-infusion with the anti-cancer drug.

[0033] In certain embodiments, the supplemental therapy can be or include plasmapheresis (e.g., automated centrifugation). In certain such embodiments, the method can include administering to the patient the anti-cancer drug over a period of about 15 minutes, and administering to the patient plasmapheresis over a period of about 2.1 to 2.2 hours about 1 hour after administration of the anti-cancer drug.

[0034] 318494251 vl Docket No. 1515138.113WO2

[0035] Brief Description of the Drawings

[0036] So that those skilled in the art to which the subject disclosure appertains will readily understand how to make and use the devices and methods of the subject disclosure without undue experimentation, other embodiments thereof will be described in detail herein below with reference to certain figures, wherein:

[0037] Figure 1 shows an administration of the small zwitterionic multimeric targeted anticancer drug and the adjuvants within one day.

[0038] Figure 2 shows cycles of administration of the small zwitterionic multimeric targeted anti-cancer drug and the adjuvants in a period of 14 days as well as the tumor cells killing effects.

[0039] 318494251 vl Docket No. 1515138.113WO2

[0040] Detailed Description

[0041] It has now been found that one or more methods for eliminating unbound drug from the body will improve the therapeutic window, that is, maintain tumor cell killing while reducing toxicity to off-target tissues and organs.

[0042] Definitions

[0043] The following definitions will be useful in understanding the instant invention.

[0044] As used herein, the term “comprising” is intended to mean that the compositions and methods include the recited elements, but do not exclude other elements. “Consisting essentially of’, when used to define compositions and methods, shall mean excluding other elements of any essential significance to the combination. Thus, a composition consisting essentially of the elements as defined herein would not exclude trace contaminants from the isolation and purification method and pharmaceutically acceptable carriers, such as phosphate buffered saline, preservatives, and the like. “Consisting of’ shall mean excluding more than trace elements of other ingredients and substantial method steps for administering the compositions of this invention. Embodiments defined by each of these transition terms are within the scope of this invention.

[0045] As used in the specification and claims, the singular' form "a", "an" and "the" include plural references unless the context clearly dictates otherwise.

[0046] Ranges provided herein are understood to be shorthand for all of the values within the range. For example, a range of 1 to 50 is understood to include any number, combination of numbers, or sub-range from the group consisting of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50.

[0047] Unless specifically stated or obvious from context, as used herein, the term "or" is understood to be inclusive.

[0048] The recitation of a listing of chemical groups in any definition of a variable herein includes definitions of that variable as any single group or combination of listed groups. The recitation of an embodiment for a variable or aspect herein includes that embodiment as any single embodiment or in combination with any other embodiments or portions thereof.

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[0051] As used herein, the term “subject” or “patient” encompasses mammals and nonmammals. Examples of mammals include, but are not limited to, humans, chimpanzees, apes monkeys, cattle, horses, sheep, goats, swine; rabbits, dogs, cats, rats, mice, guinea pigs, and the like. Examples of non-mammals include, but are not limited to, birds, fish, parasites, microbes, and the like.

[0052] As used herein, the term “administration” or “administering” of the subject compound refers to providing a combination composition of the invention and / or prodrugs thereof to a subject in need of diagnosis or treatment.

[0053] As used herein, the term “ligand”, “targeting vector”, or “targeting ligand” refers to a moiety which is bound to or coordinated to the imaging agents or zwitterionic metal chelators of the combination compositions of the invention to provide enhanced binding to particular cell types or an increased concentration in the presence of particular cell types. In certain embodiments, the targeting vector can be bound to the imaging agents or zwitterionic metal chelators of the combination compositions in addition to the zwitterionic groups thereon. In still other embodiments, the targeting vector can be bound to the zwitterionic metal chelator in place of one or more zwitterionic groups provided that the zwitterionic metal chelator retains at least one zwitterionic group.

[0054] As used herein, the term “therapeutic window” or “therapeutic index” refers to the relationship between the therapeutic and toxic dose of a given drug and is calculated using the ED50 and TD50 (Therapeutic Index - TD50 / ED50). In certain embodiments of the invention, the zwitterionic metal chelators of the invention have a higher therapeutic index relative to other metal chelators. In certain other embodiments, the therapeutic window refers to a certainty safety factor (CSF) which is defined herein as the ratio of [TD1 / ED99]. A CSF > 1 indicates that the dose effective in 99% of the population is less than the dose that would be toxic in 1 % of the population. In certain embodiments of the invention, the combination compositions of the invention have a higher CSF relative individual active agents.

[0055] As used herein, the term “carrier” refers to chemical compounds or agents that facilitate the incorporation of a compound described herein into cells or tissues.

[0056] As used herein, the term “acceptable” with respect to a formulation, composition or ingredient, as used herein, means having no persistent detrimental effect on the general health

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[0058] 318494251 vl Docket No. 1515138.113WO2 of the subject being treated.

[0059] As used herein, the term “diluent” refers to chemical compounds that are used to dilute a compound described herein prior to delivery. Diluents can also be used to stabilize compounds described herein.

[0060] As used herein, the term “combination” refers to a mixture of more than one type of compounds.

[0061] As used herein, the term “contacting” refers to the bringing together of substances in physical contact such that the substances can interact with each other. For example, when an agent is “contacted” with tissue or cells, the tissue or cells can interact with the agent, for example, allowing the possibility of binding interactions between the agent and molecular components of the tissue or cells. “Contacting” is meant to include the administration of a substance such as an agent of the invention to an organism. Administration can be, for example, oral or parenteral.

[0062] As used herein, the term “ionic group” refers to a moiety comprising one or more charged substituents. The “charged substituent” is a functional group that is generally anionic or cationic when in substantially neutral aqueous conditions (e.g. a pH of about 6.5 to 8.0 or about physiological pH (7.4)). As recited above, examples of charged anionic substituents include anions of inorganic and organic acids such as sulfonate (-SO31), oxide, sulfinate, carboxylate, phosphinate, phosphonate, phosphate, and esters (such as alkyl esters) thereof. In some embodiments, the charged substituent is sulfonate or oxide. Examples of charged cationic substituents include quaternary ammonium ions (-NR3+) and phosphonium ions (-PR3+), where R is independently selected from C1-6 linear alkyl, C4-6 branched alkyl, C3-6 cycloalkyl, aryl, heteroaryl and arylalkyl or heteroarylalkyl. Other charged cationic substituents include protonated primary, secondary, and tertiary amines, and as well as guanidinium or amidinium or pyridinium or other protonated, alkylated or oxygenated nitrogen heterocycles. In some embodiments, the charged substituent is -N(CH3)3+.

[0063] As used herein, the phrase “non-ionic oligomeric or polymeric solubilizing groups” refers to soluble polymers such as, for example, polyethylene glycol, polypropylene glycol, polyethylene oxide and propylene oxide copolymer, a carbohydrate, a dextran, polyacrylamide, a peptide and the like. The solubilizing group can be attached by any

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[0065] 318494251 vl Docket No. 1515138.113WO2 desired mode. The point of attachment can be, e.g., a carbon-carbon bond, a carbon-oxygen bond, or a nitrogen-carbon bond. The attachment group can be, e.g., an ester group, a carbonate group, an urea group, an alcohol group, an ether group, a sulfide group, an amino group, an alkylene group, an alkyne group, an azide group, a tetrazine, an amide group, a carbonyl group, or a phosphate group.

[0066] Some examples of solubilizing groups include polyethylene glycols, such as -(CH2CH2O)a-H, -OC(=O)O(CH2CH2O)aH, -OC(=O)O(CH2CH2O)aCH3, - O(CH2CH2O)aCH3, and -S(CH2CH2O)2CH3, “a” being an integer between about 2 and about 250. In some embodiments, “a” is 4 to 12 or 5 to 10. In further embodiments, “a” is 6, 7, or 8. Other examples of solubilizing groups include dextrans such as -OC(=O)O(dextran).

[0067] The solubilizing moiety can have an absolute molecular weight of from about 500 amu to about 100,000 amu, e.g., from about 1 ,000 amu to about 50,000 amu or from about 1,500 to about 25,000 amu.

[0068] Further examples of solubilizing groups include: -(CH2)c-(OCH2CH2)d-ORa, wherein “c” is 0 to 6, “d” is 1 to 200, and Rais H or Ci-6 alkyl. In some embodiments, “c” is 1 to 4, “d” is 1 to 10, and Rais H. In some embodiments, “d” is 6 or 7.

[0069] See WO 2008 / 017074, U.S. Ser. No. 12 / 376,243 (filed February 3, 2009), and U.S. Ser. No. 12 / 376,225 (filed February 3, 2009), each of which is incorporated herein by reference in its entirety, for a further description of suitable non-ionic oligomeric or polymeric solubilizing groups, and method for incorporating them into dyes.

[0070] It is further appreciated that certain features of the invention, which are, for clarity, described in the context of separate embodiments, can also be provided in combination in a single embodiment. Conversely, various features of the invention which are, for brevity, described in the context of a single embodiment, can also be provided separately or in any suitable subcombination.

[0071] Compounds of the invention can also include all isotopes of atoms occurring in the intermediates or final compounds. Isotopes include those atoms having the same atomic number but different mass numbers. For example, isotopes of hydrogen include tritium and deuterium.

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[0074] The chemical substances represented herein by name, chemical formula, or structure are meant to include all stereoisomers, geometric isomers, tautomers, resonance structures, and isotopes of the same, unless otherwise specified.

[0075] The chemical substances described herein may be charged or include substituents with formal charges. When such chemical substances are represented as charged, it is understood that, unless otherwise specified, the charges are generally countered with an appropriate counterion. For example, chemical substances or functional groups having a charge of -I are understood to be countered with an ion have a +1 charge. Suitable counterions with +1 charge include Na+, K+, tetraalkylammonium ions, and the like. Conversely chemical substances or functional groups having a charge of +1 are understood to be countered with an ion having a -1 charge. Suitable counterions with -1 charge include F-, C1-, Br-, I-, perchlorate, acetate, trifluoroacetate, and the like.

[0076] As used herein, the term “zwitterionic group,” “zwitterionic ligand,” or “zwitterion” refer to one or more charged moieties with balanced (electrically neutral) polyionicity. The zwitterionic feature could be part of the linker and / or payload and / or targeting ligand. The zwitterionic trimeric drugs of the claimed invention are decorated by one or more zwitterionic groups.. In the case of a pay load that is a metal chelator, these zwitterionic groups are distinct from metal chelator cores, which typically has negative charges to chelate positively-charged metals. For example, a zwitterionic metal chelator with a chelator core of - 4 that binds a +4 metal would have a total net charge of zero. Although a total net charge of zero is considered ideal, a zwitterionic metal chelator with a chelator core of -4 that binds a +2 metal, resulting in an overall charge of -2, would still be expected to exhibit improved properties in vivo because of shielding of the chelator core / metal complex by one or more zwitterionic groups. In the absence of zwitterionic groups, the molecule would have no such shielding or expanded water of hydration and would be more likely to bind non-specifically.

[0077] A particular active agent molecule may have several attached "zwitterionic groups” or charge pairs. In general, the anion portion and the cation portion of the zwitterionic group (charge pair) will be part of the same moiety, though it is possible for two ionic groups to be used as separate moieties to form a zwitterionic group. In particular embodiments, the zwitterionic group is covalently bound to the base structure via a carbon-carbon bond, a carbon-oxygen bond, or a nitrogen-carbon bond. Examples of zwitterionic groups (charge

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[0079] 318494251 vl Docket No. 1515138.113WO2 pairs) that can be included in the compounds and complexes of the claimed invention include, but are not limited to, ammoniophosphates, ammoniophosphonates, ammoniophosphinates, ammoniosulfonates, ammoniosulfates, ammoniocarboxylates, ammoniosulfonamides, ammonio-sulfon-imides, guanidiniocarboxylates, pyridiniocarboxylates, pyridiniosulfonates, ammonio(alkoxy)dicyanoethenolates, ammonioboronates, sulfo niocarboxylates, phophoniosulfonates, and phosphoniocarboxylates. The charged groups in these zwitterions can be separated by suitable spacer groups like linear or branched alkyl chains, aryl or heteroaryl moieties. In certain embodiments, the zwitterionic groups can be derivatives of amino acids, such as amino carboxylic acids, amino phosphonic acids, amino phosphinic acids or amino sulfonic acids, furthermore, aminoalkyl substituted sulfates or phosphates. Zwitterions can also be derivatives of betaines, such as carboxy betaines, sulfobetaines, sulfabetaines, phosphobetaines or phosphabetaines or N-oxides or derivatives of sulfamic acid. Particular examples of zwitterionic groups include ammonium sulfobetaines or N- oxides. A simple example of a zwitterionic group at physiological pH is the charge pair of a carboxylic acid (deprotonated at physiological pH) and an amine (protonated at physiological pH).

[0080] In some embodiments, the targeting ligands of the zwitterionic trimer drugs of the invention can also comprise a targeting vector for an agricultural process, chemical process, disease, or tissue-specific epitope, such as the cyclic peptide cRGDyK (aka cRGD). cRGD is a cyclic derivative of the tripeptide Arg-Gly-Asp which can be conjugated to one or more arms of the metal chelators of the invention. In still other embodiments, the targeting vector is octreotide or bombesin. In other embodiments, the targeting vector is KUE or dPSMA- 617, a small molecule capable of targeting Fibroblast Activation Protein (FAP) also called FAP-inhibitor or FAPI, an amino acid or combination of amino acids, or derivatives thereof. In such embodiments, the targeting vector-conjugates can be formed in place of one or more zwitterionic groups.

[0081] An ideal active agent conjugated to a targeting vector would adopt the total net charge of the targeting vector, which is purposeful because in most cases the charges on the targeting vector are crucial for the ability to bind its target. Targeted zwitterionic trimer drugs thus retain the major advantage of minimizing non-specific binding while maximizing specific binding. It should be apparent to those skilled in the art that additional charges can be added to the zwitterionic trimer drugs, if needed, to balance overall surface charge to zero.

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[0083] 318494251 vl Docket No. 1515138.113WO2

[0084] In certain embodiments, the zwitterionic trimeric drugs comprise a reactive conjugation group. Such reactive conjugation groups are typically an activated derivative of a carboxylic acid, such as an n-hydroxy succinimide (NHS) ester, a sulfo-NHS ester, a pentafluorophenyl (PFP) ester, a hydroxybenzotriazole (HOBt) ester, a hydroxyazabenzotriazole (HO At) ester, a tetrafluorophenyl (TFP) ester, an acid anhydride, an acid azide or an acid halide. Such reactive conjugation groups can be bound or substituted onto the chelator at any suitable structural location as would be understood by one of ordinary skill in the synthesis of such compounds. Reactive conjugation groups also include, but are not limited to, alkynes, azides, maleimides, thiols, amines, alkohols, phenols, carbonyls, phosphanes, alkenes and tetrazines.

[0085] As used herein, the phrase “core” or “central core” refers to a chemical structure which is located at the center of the drug with four substituents for binding zwitterionic linkers and / or targeting ligands.

[0086] As used herein, the phrase “linker” refers to a chemical structure connects two or more functional groups.

[0087] As used herein, the phrase “payload” refers to a diagnosis or a treatment functional group. When being used as a treatment functional group, the payload refers to, for example, a potent cytotoxin drug that kills cancer cells. Another example would be a payload that radiosensitizes the malignant cell to radiation. When being used as a diagnosis functional group, the payload refers to an imaging agent that provides a signal facilitating the identification of cancer cells.

[0088] Other definitions appear in context throughout the disclosure.

[0089] Small Zwitterionic Multimeric Targeted Anti-Cancer Drugs

[0090] The structure of the anti-cancer drugs discussed herein can include small zwitterionic multimeric targeted anti-cancer drug. These drugs can include a central core, more than one targeting ligands (e.g., three or more) conjugated to the central core, linkers, and a payload for imaging or treating the tumors (e.g., flexible linkers connecting each of the three different targeting ligands and the pay load to the central core). Specific embodiments of said drugs and their specific structures are described in further detail in U.S. Provisional Patent Application

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[0093] No. 63 / 648,305, filed May 16, 2024, and further in U.S. Patent Application No.19 / 209,293 filed May 15, 2025, both of which are incorporated herein by reference in their entirety.

[0094] The central core, the payload of the zwitterionic diagnostic or therapeutic agent, and zwitterionic flexible linkers of the small zwitterionic multimeric targeted anti-cancer drug can form a “force field” of charge-balanced polyionicity and water of hydration such that only the targeting ligands are exposed out of the force field.

[0095] These small zwitterionic multimeric targeted anti-cancer drugs of the have significant advantages over traditional Antibody-Drug Conjugates (ADCs). First, with respect to the pharmacokinetic profile, the small zwitterionic multimeric targeted anti-cancer drugs of the present invention have a rapid effect and can be applied in a form of multiple re-treatment to prevent resistance to the drugs. Moreover, the small zwitterionic multimeric targeted anticancer drugs of the present invention are hetero tri meric monovalent molecules which addresses the tumor heterogeneity more efficiently. In addition, the small zwitterionic multimeric targeted anti-cancer drugs of the present invention can be synthesized more easily and at a lower cost than ADCs.

[0096] Methods for Improving Clearance and Reducing Toxicity of Zwitterionic, Heterotrimeric Small Molecule Anti- Cancer Drugs

[0097] Zwitterionic, heteromultimeric small molecule anti-cancer drugs (hereinafter “Core Multimers”) have good binding affinity to tumors, and zwitterionicity will effectively shield the drug from non-specific / off-target uptake, thus redirecting the drug to the kidney for elimination from the body via urine. The behavior of these anti-cancer drugs under various physiological conditions, for example, excess hydration, diuretics, renal-protect amino acids, plasmapheresis, and combinations thereof, or in the presence of supplemental therapy, can be mathematically modeled. Using this model, one or more supplemental and / or physiological conditions can be combined with administration of the anti -cancer drug to improve the clearance of the drug from the patient. Improving clearance not only reduces toxicity to the patient, but allows for more rapid re-treatment, improving cancer cell kill.

[0098] Using conventional modeling techniques, the blood half-life of the Core Multimer can be calculated, for example by treating it as an “ideal” small molecule that is injected into the bloodstream, equilibrates with the extracellular space, and is simultaneously cleared via the kidney. For this example, 13 L is used as the expected intravascular / extracellular volume, 100

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[0100] 318494251 vl Docket No. 1515138.113WO2 mL / min / 1.73 m2 is used as a typical glomerular filtration rate (GFR), and the hydrodynamic diameter is assumed to be below the glomerular slit size of 5 nm. The blood half-life is thus calculated as:

[0101] Blood Half-Life = (13,000 mL I 100 mL / min ) * ln(2) = 90 min

[0102] In 4 half-lives (6 hours), blood half-life will be reduced to 6.25% of its peak value immediately after intravenous injection. It has been observed that target binding of the Core Multimers will peak in the first hour after injection, and endocytosis will often lock the drug inside the tumor cell. The radioactive decay half-life of Pb-212 (10.6 h) is preferable for extended cell killing without residual medical waste.

[0103] While this result appears to have great success, it is noted that over the first 6 h after injection, 94% of the radioactive a particle radiation, that is the non-tumor-bound dose, will end up in the bladder and kidney, which can be the dose-limiting tissues for re-treatment. In addition, the linear energy transfer (LET) of a particles is extremely high, however, some cancer cells will be able to recover from the damage and therefore grow through the treatment. For this reason, radiosensitizers, which amplify the cell killing ability of a particles should be administered at an optimal time point relative to the radiation dose.

[0104] However, using mathematical modeling of the behavior of the Core Multimer in combination with various supplemental (i.e., concomitant therapies) and / or physiological conditions will greatly improve cancer cell kill while reducing toxicity by quickly clearing the Core Multimer from the patient, allowing for rapid re-treatment and minimal regrowth between treatments.

[0105] Methods to Reduce Toxicity of Zwitterionic Trimers by Improving Elimination from the Body

[0106] In order to avoid, for the anti-cancer drugs, the absorbed dose to kidney and bladder being dose-limiting, a number of strategies to lower the absorbed dose to the kidney and bladder are presented below. The following strategies show promise in reducing toxicity and allow for much quicker retreatment, supplemental therapy and the predetermined time at which the supplemental therapy is administered reduces toxicity to the patient more than administering the supplemental therapy to the patient alone.

[0107] Hydration

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[0109] 318494251 vl Docket No. 1515138.113WO2

[0110] After administration of the radiopharmaceutical or chemotherapeutic over 15 minutes, administer 1 L of a saline-based or saline-containing solution over 1-2 hours, which in an average-sided adult should result in almost 1 L of fluid clearance (20% of blood volume) through the kidney and bladder, effectively flushing the highest dose levels from the body through frequent voiding. Any suitable saline-based or saline-containing solution is contemplated herein, for example, normal saline, half normal saline, lactated ringers, dextrose, or the like. Other examples of hydrating fluids can include certain commercially available isotonic beverages, such as sports drinks.

[0111] In certain cases, hydrating supplemental therapies may be administered in multiple forms, for example, administering the saline-based or saline-containing solution to the patient 1 hour after administration of the anti-cancer drug, and then further having the patient ingest about 1 L to 2 L of the isotonic fluids (e.g., a sports drink) over a period of about 6-8 hours, after the saline-based solution was administered. The hydration dose can be adjusted as needed with weight-based administration.

[0112] Diuretics

[0113] With or without hydration, administration of a diuretic, such as furosemide, can be used to increase the flux of fluid clearance through the kidneys and bladder. In certain cases, the diuretic itself can be a hydrating fluid. For example, alcohol and certain alcoholic beverages consumed by the patient to provide fluids while also inhibiting release of vasopressin, thus acting as a diuretic. Administration of a hydrating diuretic, or a diuretic tablet may also be used with one or more of the hydrating supplemental therapies discussed above to achieve optimal elimination of the anti-cancer drug, for example depending on the anti-cancer drug, a tumor or cancer type, and / or a physiological condition of the patient at the time of administering the supplemental therapy.

[0114] In certain treatment options, the administration of hydration and diuretics can be administered together but in a modulated manner.

[0115] Renal-Protective Amino Acids

[0116] Basic amino acids, typically a mixture of lysine and arginine, can be used to protect the kidneys from radiation damage. Thus, renal-protective amino acids co-infused with the anti-cancer drug can be used to block reuptake of certain compounds (e.g., DTP A) in renal tubules of the kidneys.

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[0118] 318494251 vl Docket No. 1515138.113WO2

[0119] Plasmapheresis

[0120] . Performing plasmapheresis can remove the unwanted, unbound radiation dose while bypassing the kidneys and bladder altogether. There are two types of plasmapheresis, automated centrifugation and filtration using semipermeable membranes. The preferred method of plasmapheresis in most centers worldwide is automated centrifugation, where filtered plasma is discarded and replacement fluid (donor plasma or colloids) is returned. The common term for this procedure is “therapeutic plasma exchange’" or TPE. The second method is membrane plasma separation, which is typically only useful for selective removal of undesired macromolecules (not small molecules) and filtered, processed plasma is returned to the patient, eliminating the need for replacement fluids. Therefore, for the removal of radioactive small molecule trimers from blood, automated centrifugation and TPE is preferred because the goal of the plasmapheresis is to completely remove unbound dose.

[0121] While TPE plasmapheresis appears a suitable method for improving clearance, there are certain contraindications to the procedure, for example, non-availability of central line access or large bore peripheral lines, hemodynamic instability or septicemia, known allergy to fresh frozen plasma or replacement colloid / albumin, and known allergy to heparin. Hypocalcemia (restricts the use of citrate as an anticoagulant during the procedure) and Angiotensin-converting enzyme (ACE) inhibitor used in last 24 hours are also relative contraindications. However, as plasmapheresis is only one of the proposed methods for improving clearance, these contraindications may addressed by administering a different, more appropriate supplemental therapy.

[0122] Plasmapheresis Example

[0123] In general, the formula for plasma volume is:

[0124] Body weight (kg) x 0.065 x (1 - Hematocrit)

[0125] Therefore, for a 70 kg adult with normal hematocrit, PV = 2. -2.7 L. To remove 95% of a substance from the blood, 3 PV volumes = 7.5-7.9 L is required. Modern TPE devices can exchange 60 mL of plasma per minute. Therefore:

[0126] 7900 mL / 60 mL / min = 131 minutes = 2.2 hours.

[0127] 7500 mL / 60 mL / min = 125 minutes = 2.1 hours.

[0128] Prophylaxis may need to be administered to prevent hypocalcemia.

[0129] 17

[0130] 318494251 vl Docket No. 1515138.113WO2

[0131] Dehydration

[0132] The more dehydrated a patient is, the less renal clearance there will be due to the body’s desire to preserve water. After initial injection, this is the preferred state because blood concentration of the anti-cancer drug will be very high and renal flux low. On the other hand, the flux that does go through the kidneys will be highly concentrated. Using the mathematical modeling of the Core Multimer behavior will help determine the temporal combination of dehydration and hydration to improve clearance.

[0133] Combinations of Supplemental Therapies and Optimal Timing

[0134] As detailed above, five strategies to improve tumor kill and reduce toxicity are presented. Certain strategies, like plasmapheresis for example, suggest that improvements of 2- to 100-fold in therapeutic window might be attainable. Thus, combining these improved clearance strategies with optimal timing suggest significant and unexpected results with respect to clearing anti-cancer drugs, including zwitterionic Core Multimers, from the patient’s blood.

[0135] Any one or more of the strategies outlined above can be combined with additional technologies that lead to improved patient outcome.

[0136] Combination Therapy Treatment Example

[0137] Fig. 1 shows an example of a combination of a Core Multimer (e.g., Pb-212 multimer) with radiosensitization, and plasmapheresis strategy so that repetitive dosing can occur. The repetitive dosing under normal administration would be precluded by radiation dose to kidney and bladder.

[0138] An example treatment protocol for the combination therapy discussed herein is shown in Fig. 2, and assumes a starting tumor size of 1012cells (« 1 kg; near-death), 2 logs of tumor cell kill per cycle, and rapid re-treatment to prevent regrowth (1 day rest between cycles). Since the clearance of the drug occurs on the level of hours, rather than days, the rapid redosing can occur every other day, for example, rather than weeks. This can significantly reduce tumor regrowth between doses. Accordingly, using this model, a responsive tumor could be cured within 2 weeks with such a strategy.

[0139] The Core Multimer behavioral mathematical modeling can be used to determine the optimal treatment regimen. This is shown for example, in Figs. 1 and 2.

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[0141] 318494251 vl Docket No. 1515138.113WO2

[0142] Those having ordinary skill in the art understand that any numerical values disclosed herein can be exact values or can be values within a range. Further, any terms of approximation (e.g., “about”, “approximately”, “around”) used in this disclosure can mean the stated value within a range. For example, in certain embodiments, the range can be within (plus or minus) 20%, or within 10%, or within 5%, or within 2%, or within any other suitable percentage or number as appreciated by those having ordinary skill in the art (e.g., for known tolerance limits or error ranges).

[0143] The articles “a”, “an”, and “the” as used herein and in the appended claims are used herein to refer to one or to more than one (i.e., to at least one) of the grammatical object of the article unless the context clearly indicates otherwise. By way of example, “an element” means one element or more than one element.

[0144] The phrase “and / or,” as used herein in the specification and in the claims, should be understood to mean “either or both” of the elements so conjoined, i.e., elements that are conjunctively present in some cases and disjunctively present in other cases. Multiple elements listed with “and / or” should be construed in the same fashion, i.e., “one or more” of the elements so conjoined. Other elements may optionally be present other than the elements specifically identified by the “and / or” clause, whether related or unrelated to those elements specifically identified. Thus, as a non-limiting example, a reference to “A and / or B”, when used in conjunction with open-ended language such as “comprising” can refer, in one embodiment, to A only (optionally including elements other than B); in another embodiment, to B only (optionally including elements other than A); in yet another embodiment, to both A and B (optionally including other elements); etc.

[0145] As used herein in the specification and in the claims, “or” should be understood to have the same meaning as “and / or” as defined above. For example, when separating items in a list, ”or” or “and / or” shall be interpreted as being inclusive, i.e., the inclusion of at least one, but also including more than one, of a number or list of elements, and, optionally, additional unlisted items. Only terms clearly indicated to the contrary, such as “only one of” or “exactly one of,” or, when used in the claims, “consisting of,” will refer to the inclusion of exactly one element of a number or list of elements. In general, the term “or” as used herein shall only be interpreted as indicating exclusive alternatives (i.e., “one or the other but not both”) when preceded by terms of exclusivity, such as “either,” “one of,” “only one of,” or “exactly one of.”

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[0147] 318494251 vl Docket No. 1515138.113WO2

[0148] Any suitable combination(s) of any disclosed embodiments and / or any suitable portion(s) thereof are contemplated herein as appreciated by those having ordinary skill in the art in view of this disclosure.

[0149] The embodiments of the present disclosure, as described above and shown in the drawings, provide for improvement in the art to which they pertain. While the apparatus and methods of the subject disclosure have been shown and described, those skilled in the art will readily appreciate that changes and / or modifications may be made thereto without departing from the scope of the subject disclosure.

[0150] 318494251 vl

Claims

Docket No. 1515138.113WO2What is claimed is:

1. A method for improving clearance and elimination of tumor targeted anti-cancer drugs from a patient, comprising: administering to a patient an anti-cancer drug that is eliminated into urine; administering to the patient one or more supplemental therapies at a predetermined time after administering the anti-cancer drug, wherein the predetermined time is determined as a function of at least one of: the anti-cancer drug, the supplemental therapy, a tumor type, and / or a physiological condition of the patient at the time of administration.

2. The method of claim 1, wherein the anti-cancer drug includes a zwitterionic, heterotrimeric small molecule anti-cancer drug.

3. The method of claim 1, wherein a combination of the supplemental therapy and the predetermined time at which the supplemental therapy is administered reduces toxicity more than administering the supplemental therapy to the patient alone.

4. The method of claim 1 , wherein the supplemental therapy is configured to induce one or more physiological conditions in the patient, the one or more physiological conditions including: hydration, dehydration, and / or increased urination.

5. The method of claim 4, wherein the physiological condition is hydration, and wherein administering to the patient one or more supplemental therapies includes administering, intravenously, a saline-containing solution.

6. The method of claim5, wherein the method includes, administering to the patient the anti-cancer drug over a period of about 15 minutes; and administering to the patient about 1 L of saline containing solution over a period of about 1 to 4 hours about 1 hour after administering the anti -cancer drug.

7. The method of claim 4, wherein the physiological condition is hydration, and wherein administering to the patient one or more supplemental therapies includes administering an isotonic solution.21318494251 vlDocket No. 1515138.113WO28. The method of claim 7, wherein the method includes, administering to the patient the anti-cancer drug over a period of about 15 minutes; and administering to the patient, via ingestion, about 2 L of isotonic solution over a period of about 6 to 8 hours about 1 hour after administering the anti-cancer drug.

9. The method of claim 4, wherein the physiological condition is hydration, and wherein administering to the patient one or more supplemental therapies includes administering a saline-containing solution and an isotonic solution.

10. The method of claim 9, wherein the method includes, administering to the patient the anti-cancer drug over a period of about 15 minutes; administering to the patient, intravenously, about 1 L of saline containing solution over a period of about 1 to 4 hours about 1 hour after administering the anti-cancer drug; and administering to the patient, via ingestion, about 1 L to 2 L of isotonic solution over a period of about 6 to 8 hours about 1 hour after administering the saline-containing solution.

11. The method of claim 4, wherein the physiological condition is increased urination or dehydration, and administering to the patient one or more supplemental therapies includes administering a diuretic.

12. The method of claim 11 , wherein the method includes, administering to the patient the anti-cancer drug over a period of about 15 minutes; and administering to the patient a diuretic about 1 hour after administering the anti-cancer drug.

13. The method of claim 12, wherein the physiological condition includes both hydration and increased urination, wherein administering to the patient one or more supplemental therapies includes administering both a saline-containing solution and the diuretic, wherein the method further comprises: administering to the patient about 1 L of saline-containing solution over a period of about 1 to 4 hours about 1 hour after administering the anti -cancer drug and administering the diuretic during administration of the saline-containing solution.22318494251 vlDocket No. 1515138.113WO214. The method of any of claims 11-13, wherein the diuretic is a vasopressin inhibitor.

15. The method of claim 12, wherein the physiological condition includes both hydration and increased urination, wherein administering to the patient one or more supplemental therapies includes administering a vasopressin inhibiting fluid, wherein the method further comprises: administering to the patient the anti-cancer drug over a period of about 1 minutes; administering to the patient, via ingestion, about 1 L of the vasopressin inhibiting fluid over a period of about 6 to 8 hours about 1 hour after administering the anti-cancer drug.

16. The method of claim 15, wherein the vasopressin inhibiting fluid includes alcohol.

17. The method of claim 14, wherein physiological condition includes both hydration and dehydration, wherein administering to the patient one or more supplemental therapies includes administering a saline containing solution and a diuretic, wherein the method includes: administering to the patient the anti-cancer drug over a period of about 15 minutes; administering to the patient about 1 L of saline-containing solution about 1 hour after administering the anti-cancer drug; administering the diuretic to the patient during administration of the saline-containing solution, wherein the diuretic includes furosemide; and modulating administration of the saline-containing solution and / or the furosemide.

18. The method of claim 1, wherein administering to the patient one or more supplemental therapies includes administering renal protective amino acids.

19. The method of claim 18, wherein administering to the patient one or more supplemental therapies includes co-infusion of at least two amino acids with administration of the anti-cancer drug.

20. The method of claim 19, wherein the method includes, administering to the patient the anti-cancer drug over a period of about 15 minutes; and23318494251 vlDocket No. 1515138.113WO2 administering to the patient two or more renal protective amino acids as a co-infusion with the anti-cancer drug.

21. The method of claim 1, wherein the supplemental therapy includes plasmapheresis.

22. The method of claim 21 , wherein plasmapheresis includes automated centrifugation.

23. The method of claim 21 , wherein the method includes: administering to the patient the anti-cancer drug over a period of about 15 minutes; and administering to the patient plasmapheresis over a period of about 2. 1 to 2.2 hours about 1 hour after administration of the anti-cancer drug.24318494251 vl

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