Combination therapy of tyrosine kinase inhibitors and activin type 2 receptor antagonists for treatment of pulmonary arterial hypertension (PAH)

Abstract

Disclosed herein are kits and methods for treating pulmonary arterial hypertension (PAH), the method comprising administering to a subject in need thereof: * a therapeutically effective amount of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and * a therapeutically effective amount of a dimeric fusion protein comprising: * an extracellular domain of activin type 2A (ACTR IIA) or activin type 2B receptor (ACTR IIB); and an Fc domain of human immunoglobulin G1 (IgG1). In some embodiments, the tyrosine kinase inhibitor is cellatinib or a pharmaceutically acceptable salt thereof, and the fusion protein is sotasercept.

Description

Technical Field

[0001] The present invention relates to tyrosine kinase inhibitors and dimeric fusion proteins, and their combined use in treating diseases. Background Art

[0002] Pulmonary hypertension (PH) is a chronic disease affecting the small arteries in the lungs, with high morbidity and mortality. The World Health Organization classifies PH into five categories based on underlying associated diseases:

[0003] Pulmonary arterial hypertension (PAH);

[0004] Pulmonary hypertension due to left heart disease;

[0005] Pulmonary hypertension due to lung disease and / or hypoxia;

[0006] Chronic thromboembolic pulmonary hypertension (CTEPH); or

[0007] Pulmonary hypertension with other multifactorial mechanisms.

[0008] Pulmonary arterial hypertension (PAH) is a progressive disease characterized by pulmonary vascular remodeling, leading to elevated pulmonary artery pressure and progressive right ventricular dysfunction. The pathological features of the disease include plexiform lesions with disordered angiogenesis and abnormal neointimal cell proliferation, which impede blood flow through the pulmonary arterioles. PAH may be associated with a variety of etiologies, including familial forms and predisposing genetic abnormalities, such as mutations in genes for bone morphogenetic protein receptor type 2 (BMPR2), endoglin, activin-like receptor kinase 1 (ALK1), maternal antitetraplegic homolog 9 (SMAD 9) and related pathways, autoimmune diseases (such as systemic sclerosis and scleroderma), congenital heart disease, liver disease with portal hypertension, and HIV infection.

[0009] Treatment of PAH has recently been reviewed ("Pulmonary arterial hypertension: tailoring treatment to risk in the current era", Gaine and M. Claughlin, European Respiratory Review, 2017, 26, 170095). For most patients, combination therapy is the standard of care. This involves dual combination therapy using agents that target the endothelin and nitric oxide pathways (e.g., a combination of an endothelin receptor antagonist (ERA) and a phosphodiesterase-5 (PDE-5) inhibitor). Triple combination therapy with agents targeting the endothelin pathway, the nitric oxide pathway, and the prostacyclin (PGI2) pathway has also been used.

[0010] Despite these advances, PAH ultimately remains a deadly disease and efforts to slow disease progression are critical. While current treatments are effective in slowing disease progression, the 5-year survival rate is only 60%. Therefore, treatments for this disease are urgently needed. Summary of the invention

[0011] Described herein are methods for treating disease, in particular pulmonary arterial hypertension (PAH), comprising administering to a subject in need thereof:

[0012] a therapeutically effective amount of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and

[0013] A therapeutically effective amount of a dimeric fusion protein, the dimeric fusion protein comprising:

[0014] The extracellular domain of activin type 2A (ACTR IIA) or activin type 2B receptor (ACTR IIB); and

[0015] The Fc domain of human immunoglobulin G1 (IgG1).

[0016] In some embodiments, the tyrosine kinase inhibitor is a PDGF receptor inhibitor, a CSF1R receptor inhibitor, a c-KIT kinase inhibitor, or a combination thereof. In some embodiments, the tyrosine kinase inhibitor is seratinib or a pharmaceutically acceptable salt thereof.

[0017] In some embodiments, the dimeric fusion protein comprises the extracellular domain of the activin type 2A receptor. In other embodiments, the dimeric fusion protein comprises the extracellular domain of the activin type 2B receptor. In yet other embodiments, the dimeric fusion protein is sotacept.

[0018] In other embodiments, is a method for treating pulmonary arterial hypertension (PAH), the method comprising administering to a subject in need thereof: a therapeutically effective amount of selatinib or a pharmaceutically acceptable salt thereof; and a therapeutically effective amount of sotacept. BRIEF DESCRIPTION OF THE DRAWINGS

[0019] Figure 1 shows that the combination of seratinib inhalation and sotacept injection showed more than additive efficacy in the SuHx model of PAH. PAH was induced in animals by giving a single injection of SU5416 (20 mg / kg) on ​​day 0 and then placing the animals in a hypoxic environment (10% oxygen) for 21 days. SuHx rats were divided into four groups and received the following treatments: i) control group: seratinib vehicle inhalation + sotacept vehicle injection (grey bars) or ii) seratinib 15 mg / kg, inhaled twice daily + sotacept vehicle, subcutaneously injected twice weekly (bars with horizontal patterns) or iii) sotacept 5 mg / kg, subcutaneously injected twice weekly + seratinib vehicle, inhaled twice daily (bars with vertical lines) or iv) seratinib 15 mg / kg, inhaled twice daily + sotacept 5 mg / kg, subcutaneously injected twice weekly (white bars); normoxic animals served as healthy controls. The bar graphs show individual normalized data points for: (A) right ventricular systolic pressure (RVSP) ( Figure 1A )、(B) mean pulmonary artery pressure (mPAP) ( Figure 1B ), (C) Right ventricular hypertrophy measured by Fulton index ( Figure 1C ) and PVR index ( Figure 1D ).

[0020] Figure 2 Representative images of lung histological changes by hematoxylin and eosin staining are shown. DETAILED DESCRIPTION

[0021] As described above, described herein is a method of treating pulmonary arterial hypertension (PAH), the method comprising administering to a subject in need thereof:

[0022] a therapeutically effective amount of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and

[0023] A therapeutically effective amount of a dimeric fusion protein, the dimeric fusion protein comprising:

[0024] Activin 2A receptor (ACTR IIA) or activin 2B receptor (ACTR

[0025] IIB) extracellular domain; and

[0026] The Fc domain of human immunoglobulin G1 (IgG1).

[0027] definition

[0028] Unless otherwise defined, all technical terms and scientific terms used herein have the same meanings as those generally understood by those of ordinary skill in the art to which the invention belongs. Although any methods and materials similar or equivalent to the methods and materials described herein can be used in the practice or testing of the present invention, preferred methods and materials are described herein. For purposes of the present invention, the following terms are defined below.

[0029] The articles "a" and "an" are used herein to refer to one or more than one (ie, at least one) of the grammatical object of the article. For example, "an element" means one element or more than one element.

[0030] As used herein, the term "about" refers to a quantity, level, value, size, size or amount that differs from a reference quantity, level, value, size, size or amount by up to 30%, 25%, 20%, 15%, 10% or 5%.

[0031] Throughout the specification, unless the context requires otherwise, the word "comprising" will be understood to imply the inclusion of stated steps or elements or groups of steps or elements but not the exclusion of any other steps or elements or groups of steps or elements.

[0032] As used herein, a "subject" is a mammal, a bird, an aquatic animal such as a fish or a reptile. In some embodiments, the subject is a human, a laboratory animal such as a mouse, a rat or a rabbit, a companion animal such as a dog or a cat, a working animal such as a horse, a donkey, etc., a livestock animal such as a cow, a bull, a pig, a sheep, a goat, a deer, a llama, an alpaca, etc., or a captive wild animal such as an animal in a zoo or a wildlife park, including a lion, a leopard, a cheetah, an elephant, a zebra, an antelope, a giraffe, a koala, a kangaroo, and a reptile such as a crocodile, a lizard, a snake, etc., a bird, particularly a captive bird, such as a budgie or a canary, a cockatoo, a parakeet, a macaw, a parrot, etc., or a fish, particularly a captive fish such as a tropical fish (zebrafish, guppy, Siamese fighting fish, clown fish, cardinal tetra, etc.), a dolphin, a whale, etc. In a specific embodiment, the subject is a human.

[0033] The subject to be treated according to the methods described herein can be a subject that has been diagnosed with pulmonary hypertension, particularly arterial pulmonary hypertension. Diagnosis can be carried out by any method or technology known in the art. It will be appreciated by those skilled in the art that the subject to be treated according to the present disclosure may have been subjected to standard tests, or may be identified as being at risk due to the presence of one or more risk factors associated with a disease or condition without examination. In addition, it should be understood that the subject to be treated according to the present disclosure may have been subjected to previous standard of care treatment, including monotherapy, dual therapy, triple therapy or quadruple therapy. In a specific embodiment, the subject to be diagnosed with pulmonary hypertension, particularly arterial pulmonary hypertension is a person.

[0034] As used herein, the term "effective amount" or "therapeutically effective amount" refers to the amount of tyrosine kinase inhibitors and dimeric fusion proteins that is sufficient to achieve the desired effect in a subject treated with these agents. Ideally, an effective amount is an amount sufficient to prevent or treat a disease without causing significant toxicity in a subject. The effective amount required for the tyrosine kinase inhibitor to be used alone or in combination with other therapies that are not dimeric fusion proteins may be different from the effective amount required for the tyrosine kinase inhibitor to be used in combination with the dimeric fusion protein. Similarly, the effective amount required for the dimeric fusion protein to be used alone or in combination with other therapies that are not tyrosine kinase inhibitors may be different from the effective amount required for the dimeric fusion protein to be used in combination with the tyrosine kinase inhibitor. The effective amount will depend on the subject being treated, the severity of the disease, whether the subject has received previous treatment for the disease, and the mode of administration of the agent. Those skilled in the art will understand the method of determining the effective amount of the disclosed therapy sufficient to achieve the desired effect in the subject.

[0035] The term "combination" as used herein refers to the administration of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof and a dimeric fusion protein in a single composition, or separately, simultaneously or sequentially. The tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof and a dimeric fusion protein can be administered at different times with different frequencies, but in combination they exert biological effects at the same time or at overlapping times.

[0036] As used herein, "seratinib" refers to N-{3-[(1S)-1-{[6-(3,4-dimethoxyphenyl)pyrazin-2-yl]amino}ethyl]phenyl}-5-methylpyridine-3-carboxamide, also known as GB002 or PK10571, as shown below:

[0037]

[0038] Seratinib is a highly potent and selective inhibitor of PDGFRα and PDGFRβ, CSF1R and c-KIT. U.S. Patents 9,815,815 and 10,231,966 describe amorphous forms of seratinib. U.S. Patent 9,925,184 and published U.S. Patent Application US2021 / 0038510 describe formulations containing seratinib. U.S. Patents 10,231,966 and 11,364,238 describe combinations containing seratinib.

[0039] Inhaled seratinib has shown significant efficacy in the treatment of severe PAH in two animal models, improving cardiopulmonary hemodynamics, reducing NT-proBNP, reversing remodeling of pulmonary vascular pathology, and improving inflammatory biomarkers. In a preclinical study, seratinib showed superior efficacy compared with imatinib (see "Inhaled Seralutinib Exhibits Potent Efficacy in Models of Pulmonary Arterial Hypertension", Galkin et al., European Respiratory Journal, 2022). A phase 2 randomized, double-blind, placebo-controlled trial is currently underway to evaluate the efficacy and safety of inhaled seratinib in subjects with WHO Group 1 PAH.

[0040] As used herein, "sotacept" refers to a soluble fusion protein consisting of the extracellular domain of the activin receptor type IIA (ActR IIA) connected to the Fc portion of human IgG1 with anabolic bone activity. Sotacept captures multiple members of the TGF-β superfamily, including activins and growth differentiation factors. Bone morphogenetic protein receptor type 2 (BMPR2) is a member of the transforming growth factor β (TGF-β) superfamily, and its mutation is a major factor leading to hereditary PAH. BMPR2 plays an important role in maintaining the integrity of the pulmonary artery endothelium. Mutations that reduce signaling in the BMPR-II pathway promote endothelial dysfunction, increase cell proliferation, and pulmonary vascular remodeling. Sotacept restores the balance between the growth-promoting activin growth differentiation factor pathway and the growth-inhibiting BMP pathway.

[0041] Therapeutic treatment with a rodent analog of sotacept (RAP-011) reversed vascular remodeling in rats with PAH. In a Phase 2 clinical study, sotacept was reported to have beneficial effects in PAH patients treated with standard of care therapy. In 2019, the U.S. Food and Drug Administration (FDA) designated sotacept as an orphan drug for the treatment of pulmonary arterial hypertension (PAH). In 2020, sotacept received breakthrough therapy designation from the FDA and was granted priority medicines designation by the European Medicines Agency (EMA) for the same indication.

[0042] Treatment options for PAH

[0043] In one embodiment, a method of treating pulmonary arterial hypertension (PAH) is provided, the method comprising administering to a subject in need thereof:

[0044] a therapeutically effective amount of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and

[0045] A therapeutically effective amount of a dimeric fusion protein, the dimeric fusion protein comprising:

[0046] The extracellular domain of activin type 2A receptor (ACTR IIA) or activin type 2B receptor (ACTRIIB); and

[0047] The Fc domain of human immunoglobulin G1 (IgG1).

[0048] Receptor tyrosine kinase (RTK) or tyrosine kinase receptor (TKR) is a polypeptide that regulates cell regeneration, remodeling, development and differentiation. They are high-affinity cell surface receptors for many polypeptide growth factors, cytokines and hormones. Mutations in receptor tyrosine kinases lead to the activation of a series of signal cascades, which in turn affect protein expression. Receptor tyrosine kinases are part of a large family of protein tyrosine kinases, including receptor tyrosine kinase proteins containing transmembrane domains and non-receptor tyrosine kinases lacking transmembrane domains. About 20 different RTK species have been identified, including EGF (or ErbB), insulin, PDGF, VEGF, FGF, CCK, NGF, HGF, Eph, AXL, TIE, RYK, DDR, RET, ROS, LTK, ROR and MusK receptor families.

[0049] Platelet-derived growth factor receptor (PDGF-R) is a tyrosine kinase receptor for members of the platelet-derived growth factor (PDGF) family. PDGF subunits-A and -B are important factors in regulating cell proliferation, cell differentiation, cell growth and development. There are two forms of PDGF-R: α and β, each encoded by a different gene. The platelet-derived growth factor receptor (PDGFR) is associated with lung disease, tissue fibrosis and solid tumors.

[0050] In one embodiment, the tyrosine kinase inhibitor of the method for treating PAH is a PDGF receptor inhibitor or a pharmaceutically acceptable salt thereof, a CSF1R receptor inhibitor or a pharmaceutically acceptable salt thereof, a c-KIT kinase inhibitor or a pharmaceutically acceptable salt thereof, or a combination thereof. In some embodiments, the tyrosine kinase inhibitor is acalabrutinib or a pharmaceutically acceptable salt thereof, afatinib or a pharmaceutically acceptable salt thereof, alectinib or a pharmaceutically acceptable salt thereof, afatinib or a pharmaceutically acceptable salt thereof, axitinib or a pharmaceutically acceptable salt thereof, baricitinib or a pharmaceutically acceptable salt thereof, bimetinib or a pharmaceutically acceptable salt thereof, bosutinib or a pharmaceutically acceptable salt thereof, brigatinib or a pharmaceutically acceptable salt thereof, cabozantinib or a pharmaceutically acceptable salt thereof, capmatinib or a pharmaceutically acceptable salt thereof, ceritinib or a pharmaceutically acceptable salt thereof, cobimetinib or a pharmaceutically acceptable salt thereof, crizotinib or a pharmaceutically acceptable salt thereof, dacomitinib or a pharmaceutically acceptable salt thereof, entrectinib or a pharmaceutically acceptable salt thereof, erdafitinib or a pharmaceutically acceptable salt thereof, erlotinib or a pharmaceutically acceptable salt thereof, fuzotinib or a pharmaceutically acceptable salt thereof, fotantinib or a pharmaceutically acceptable salt thereof, gefitinib or a pharmaceutically acceptable salt thereof, gilteritinib or a pharmaceutically acceptable salt thereof, ibrutinib or a pharmaceutically acceptable salt thereof, imatinib or a pharmaceutically acceptable salt thereof, lapatinib or a pharmaceutically acceptable salt thereof, larotrectinib or a pharmaceutically acceptable salt thereof, lenvatinib or a pharmaceutically acceptable salt thereof, lorlatinib or a pharmaceutically acceptable salt thereof, midostaurin or a pharmaceutically acceptable salt thereof, neratinib or a pharmaceutically acceptable salt thereof, osimertinib or a pharmaceutically acceptable salt thereof, pazopanib or a pharmaceutically acceptable salt thereof, pemitinib or a pharmaceutically acceptable salt thereof, peicidinib or a pharmaceutically acceptable salt thereof, ponatinib or a pharmaceutically acceptable salt thereof, regorafenib or a pharmaceutically acceptable salt thereof, ripretinib or a pharmaceutically acceptable salt thereof, ruxolitinib or a pharmaceutically acceptable salt thereof, selpatinib or a pharmaceutically acceptable salt thereof, selumetinib or a pharmaceutically acceptable salt thereof, ceratinib or a pharmaceutically acceptable salt thereof, sorafenib or a pharmaceutically acceptable salt thereof, sunitinib or a pharmaceutically acceptable salt thereof, tofacitinib or a pharmaceutically acceptable salt thereof, trametinib or a pharmaceutically acceptable salt thereof, tucatinib or a pharmaceutically acceptable salt thereof, upadacitinib or a pharmaceutically acceptable salt thereof, vandetanib or a pharmaceutically acceptable salt thereof, zanubrutinib or a pharmaceutically acceptable salt thereof, or a combination thereof.

[0051] In some embodiments, the tyrosine kinase inhibitor is ceratinib or a pharmaceutically acceptable salt thereof. In some embodiments, the tyrosine kinase inhibitor is ceratinib. In some embodiments, the tyrosine kinase inhibitor is a pharmaceutically acceptable salt of ceratinib.

[0052] In some embodiments, the dimeric fusion protein comprises the extracellular domain of the activin type 2A receptor. In other embodiments, the dimeric fusion protein comprises the extracellular domain of the activin type 2B receptor. In other embodiments, the dimeric fusion protein is sotacept.

[0053] Further described herein is a method of treating pulmonary arterial hypertension (PAH), the method comprising administering to a subject in need thereof:

[0054] a therapeutically effective amount of seratinib or a pharmaceutically acceptable salt thereof; and

[0055] A therapeutically effective amount of sotacept.

[0056] The combination therapy described herein is intended to include the administration of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof and a dimeric fusion protein, either as an independent dual combination therapy or in combination with other biologically active ingredients and non-drug therapies (e.g., holistic therapies). In the case where the combination therapy also includes non-drug therapy, the non-drug therapy can be performed at any appropriate time as long as the combined action of the therapeutic agent and the non-drug therapy produces a beneficial effect. For example, in appropriate cases, when the non-drug therapy is temporarily removed from the administration of the therapeutic agent, it may be several days or even weeks, and a beneficial effect is still achieved.

[0057] In some embodiments, the subject is receiving a stable background therapy for arterial pulmonary hypertension. In some embodiments, the stable background therapy is a monotherapy, a dual therapy, or a triple therapy. In other embodiments, the stable background therapy is a monotherapy. In other embodiments, the stable background therapy is a dual therapy. In other embodiments, the stable background therapy is a triple therapy. In some embodiments, the stable background therapy comprises an endothelin-receptor antagonist, a phosphodiesterase-5 (PDE-5) inhibitor, a prostacyclin analog, a prostacyclin-receptor agonist, a soluble guanylate cyclase stimulator, or a combination thereof. In some embodiments, the stable background therapy comprises an endothelin-receptor antagonist. In some embodiments, the stable background therapy comprises a phosphodiesterase-5 (PDE-5) inhibitor. In some embodiments, the stable background therapy comprises a prostacyclin analog. In some embodiments, the stable background therapy comprises a soluble guanylate cyclase stimulator. In some embodiments, the stable background therapy comprises a combination of at least two therapies selected from endothelin-receptor antagonists, phosphodiesterase-5 (PDE-5) inhibitors, prostacyclin analogs, and prostacyclin-receptor agonists.

[0058] In some embodiments, the method further comprises administering to the subject an endothelin-receptor antagonist, a phosphodiesterase type 5 (PDE-5) inhibitor, a prostacyclin analog, a prostacyclin receptor agonist, a soluble guanylate cyclase stimulator, or a combination thereof.

[0059] In some embodiments, the method further comprises administering to the subject a therapeutically effective amount of an endothelin receptor agonist. In some embodiments, the endothelin receptor agonist is ambrisentan Macitentan Or bosentan.

[0060] In some embodiments, the method further comprises administering to the subject a therapeutically effective amount of a phosphodiesterase type 5 (PDE-5) inhibitor. In some embodiments, the phosphodiesterase type 5 (PDE-5) inhibitor is sildenafil, tadalafil, vardenafil, avanafil, or udenafil.

[0061] In some embodiments, the method further comprises administering to the subject a prostacyclin analog. In some embodiments, the prostacyclin receptor analog is epoprostenol, treprostinil, iloprost, or beraprost.

[0062] In some embodiments, the method further comprises administering to the subject a prostacyclin receptor agonist. In some embodiments, the prostacyclin receptor agonist is selexipag or lelipag.

[0063] In some embodiments, the method further comprises administering to the subject a soluble guanylate cyclase stimulator. In some embodiments, the soluble guanylate cyclase stimulator is riociguat or vericipirat.

[0064] In some embodiments, the method further comprises administering to the subject tadalafil, selexipag, lelipag, or a combination thereof. In other embodiments, the method further comprises administering to the subject tadalafil, selexipag, or a combination thereof.

[0065] In some embodiments of the method of treating PAH, the PAH is mild or moderate PAH. In some embodiments, the PAH is mild PAH. In some embodiments, the PAH is moderate PAH. In some embodiments, the method reduces the risk of developing and dying from PAH. In some embodiments, the method reduces the risk of developing PAH. In some embodiments, the method reduces the risk of dying from PAH. In some embodiments, the method reduces the risk of developing, dying from, or both PAH.

[0066] In some embodiments of the present invention, the tyrosine kinase inhibitor is administered by inhalation. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered by inhalation. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered by inhalation via a dry powder inhaler. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered once a day or twice a day. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered once. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered twice a day. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered three times a day.

[0067] In some embodiments, the dimeric fusion protein is administered by injection. In some embodiments, sotasip is administered by injection. In some embodiments, sotasip is administered by subcutaneous injection. In some embodiments, sotasip is administered once a week, once every two weeks, once every three weeks, or once a month. In other embodiments, sotasip is administered once a week. In some embodiments, sotasip is administered once every two weeks. In some embodiments, sotasip is administered every three weeks. In some embodiments, sotasip is administered once a month.

[0068] Dosage regimen

[0069] The therapeutic agents described herein can be administered before, during or after the onset or diagnosis of a disease, and the timing of the administration of the agent can be different. For example, the agent can be used as a prophylactic and can be applied to a subject with a particular disease tendency in order to reduce the possibility of the disease. The agent can be applied to the subject as quickly as possible during or after the onset of symptoms. The initial administration can be carried out by any feasible route. After the onset of a disease or condition is detected or suspected, the therapeutic agent can be administered as soon as possible under feasible circumstances, and the time length required for the treatment of the disease can be continued. The length of the treatment time may vary from subject to subject.

[0070] In some embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered separately from the dimeric fusion protein to a subject in need thereof.

[0071] In some embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered by inhalation. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered by inhalation.

[0072] In some embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered once or twice daily. In some embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered once daily. In other embodiments, seratinib or a pharmaceutically acceptable salt thereof is administered twice daily.

[0073] In some embodiments, the dimeric fusion protein is administered by injection. In some embodiments, the dimeric fusion protein is administered by subcutaneous injection. In some embodiments, sotacept is administered by injection. In some embodiments, sotacept is administered by subcutaneous injection.

[0074] In some embodiments, the dimeric fusion protein is administered twice a week, once a week, once every two weeks, once every three weeks, or once a month. In some embodiments, sotasip is administered twice a week, once a week, once every two weeks, once every three weeks, or once a month. In some embodiments, sotasip is administered twice a week. In other embodiments, sotasip is administered once a week. In other embodiments, sotasip is administered once every two weeks. In other embodiments, sotasip is administered once every three weeks. In other embodiments, sotasip is administered once a month.

[0075] In some embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered at least once before, simultaneously or sequentially with the dimeric fusion protein. In a specific embodiment, multiple doses of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof are administered within a time period that begins before or simultaneously with the administration of the dimeric fusion protein and then continues after the administration of the dimeric fusion protein.

[0076] In some embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is regularly administered more than once before, simultaneously with, and after the administration of the dimeric fusion protein. In some embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered before the administration of the dimeric fusion protein. In other embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered simultaneously with or sequentially with the administration of the dimeric fusion protein, and is administered at least once after the administration of the dimeric fusion protein. The tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof may be administered 1 week to 1 day before the administration of the dimeric fusion protein, especially 1 day to 3 days before the administration of the dimeric fusion protein. The tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof may be administered simultaneously with or sequentially with the dimeric fusion protein, either immediately before the administration of the dimeric fusion protein or immediately after the administration of the dimeric fusion protein. The tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof can also be administered once or more within one month after the administration of the dimeric fusion protein, for example once a week, once every 5 days, once every 4 days, once every 3 days, once every 2 days, once a day, or twice a day, especially once a day or twice a day. The subsequent administration of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof can be continued, so that 1 to 10 doses of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof are administered after the administration of the dimeric fusion protein, especially 1 to 70 doses, 1 to 60 doses, 1 to 50 doses, 1 to 40 doses, 1 to 30 doses, 1 to 20 doses, 1 to 10 doses, 1 to 8 doses, 1 to 6 doses, 1 to 4 doses or 1 to 2 doses.

[0077] The dimeric fusion protein is administered in an effective amount. "Effective amount" refers to the amount necessary to achieve at least part of the desired therapeutic response. The amount varies depending on the health and physical condition of the individual to be treated, the pulmonary hypertension classification group of the individual to be treated, the preparation of the composition, the severity of pulmonary hypertension, the assessment of medical conditions and other relevant factors. It is expected that the amount will fall within a relatively wide range. For example, the effective amount can be in the range of about 0.1ng to 1g per kg of body weight per dose. The dose is preferably in the range of 1 μg to 0.5g per kg of body weight per dose, such as in the range of 0.1mg to 100mg per kg of body weight per dose, 1mg to 25mg per kg of body weight per dose or 5mg per kg of body weight per dose. In some embodiments, when the dimeric fusion protein dose is administered by subcutaneous injection, the dose is in the range of 0.1mg to 25mg per kg of body weight, for example 1mg to 10mg per kg of body weight, such as 1mg per kg of body weight, 2mg per kg of body weight, 3mg per kg of body weight, 4mg per kg of body weight or 5mg per kg of body weight per kg of body weight. The dosing regimen can be adjusted to provide the best therapeutic response. For example, in some embodiments, when the dimeric fusion protein is administered by subcutaneous injection, the dimeric fusion protein is administered once a month and the progress of treatment is monitored. In other embodiments, the dimeric fusion protein is administered once every three weeks and the progress of treatment is monitored. In other embodiments, the dimeric fusion protein is administered once every two weeks and the progress of treatment is monitored. In other embodiments, the dimeric fusion protein is administered once a week and the progress of treatment is monitored. In other embodiments, the dimeric fusion protein is administered twice a week and the progress of treatment is monitored.

[0078] The tyrosine kinase inhibitor or its pharmaceutically acceptable salt can also be administered in an effective amount. In addition, it is believed that the amount of an effective tyrosine kinase inhibitor or its pharmaceutically acceptable salt will depend on the health and physical condition of the individual to be treated, the pulmonary hypertension classification group of the individual to be treated, the formulation of the composition, the severity of pulmonary hypertension, the assessment of medical conditions and other relevant factors. It is expected that the amount of the tyrosine kinase inhibitor or its pharmaceutically acceptable salt will fall within the range of a fairly wide amount. The effective amount can be in the range of about 0.1 ng per kg of body weight to about 500 mg per kg of body weight per dose. The dosage is preferably in the range of 100 μg to 100 mg per kg of body weight per dose, 1 mg to 50 mg per kg of body weight per dose, 1 mg to 20 mg per kg of body weight per dose or 5 mg to 15 mg per kg of body weight per dose. In some embodiments, when the dose of the tyrosine kinase inhibitor or its pharmaceutically acceptable salt is administered by inhalation, the dose is in the range of 1 mg to 100 mg per kg of body weight, for example, 5 mg to 25 mg per kg of body weight, such as 5 mg per kg of body weight, 10 mg per kg of body weight, 15 mg per kg of body weight, 20 mg per kg of body weight, or 25 mg per kg of body weight. The dosage regimen can be adjusted to provide the best therapeutic response. For example, in some embodiments, when the tyrosine kinase inhibitor or its pharmaceutically acceptable salt is administered by inhalation, the tyrosine kinase inhibitor or its pharmaceutically acceptable salt is administered twice a day and the progress of treatment is monitored. In other embodiments, the tyrosine kinase inhibitor or its pharmaceutically acceptable salt is administered once a day and the progress of treatment is monitored. In other embodiments, the tyrosine kinase inhibitor or its pharmaceutically acceptable salt is administered once every 2 days and the progress of treatment is monitored. In other embodiments, the tyrosine kinase inhibitor or its pharmaceutically acceptable salt is administered once every 3 days and the progress of treatment is monitored. In other embodiments, the tyrosine kinase inhibitor or its pharmaceutically acceptable salt is administered once every 5 days and the progress of treatment is monitored. In other embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered once every 6 days and the progress of treatment is monitored. In other embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered once a week and the progress of treatment is monitored.

[0079] Reagent test kit

[0080] The composition of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof and the dimer fusion protein can be formulated separately and sold together in a kit or package. In one embodiment, each kit can contain one or more doses of each compound, which can be used to treat or prevent PAH. In another embodiment, each kit can contain one or more containers. In yet another embodiment, each container of the kit can contain one or more doses of one or more compounds, which are used to treat or prevent PAH. In one embodiment, each container of the kit contains one or more doses of different compounds, which can be used to treat or prevent PAH.

[0081] In one embodiment, a kit for treating or preventing pulmonary arterial hypertension (PAH) is provided, the kit comprising one or more containers containing:

[0082] A tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and

[0083] A dimeric fusion protein, the dimeric fusion protein comprising:

[0084] The extracellular domain of activin type 2A receptor (ACTR IIA) or activin type 2B receptor (ACTRIIB); and

[0085] The Fc domain of human immunoglobulin G1 (IgG1).

[0086] In one embodiment, at least one container of the kit contains a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof. In a preferred embodiment, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is seratinib or a pharmaceutically acceptable salt thereof. In another embodiment, at least one container of the kit contains the dimeric fusion protein. In a preferred embodiment, the dimeric fusion protein is sotacept. In one embodiment, the kit comprises at least one container and at least one separate container, the at least one container containing seratinib or a pharmaceutically acceptable salt thereof, and the at least one separate container containing sotacept.

[0087] In one embodiment, a kit is provided, the kit comprising:

[0088] one or more doses of a therapeutically effective amount of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and

[0089] One or more doses of a therapeutically effective amount of a dimeric fusion protein, the dimeric fusion protein comprising:

[0091] The extracellular domain of activin type 2A (ACTR IIA) or activin type 2B receptor (ACTR IIB); and

[0092] The Fc domain of human immunoglobulin G1 (IgG1).

[0093] In some embodiments, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is formulated for administration by inhalation. In one embodiment, the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is formulated as a dry powder for administration by inhalation via a dry powder inhaler. In some embodiments, the kit comprises one or more doses of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof and a dry powder inhaler.

[0094] In some embodiments, the dimeric fusion protein is formulated for subcutaneous injection in a single large dose or multiple doses. For example, the kit may contain a dimeric fusion protein that is in a prefilled syringe as a liquid in a vial that can be immediately drawn into the syringe; or as a solid that can be dissolved before being absorbed into the syringe. The liquid or solid formulation can be a single-dose formulation or a multi-dose formulation. In other embodiments, the kit may contain multiple doses of the dimeric fusion protein, each dose being separately formulated in a prefilled syringe as a liquid in a vial that can be immediately drawn into the syringe; or as a solid that can be dissolved before being absorbed into the syringe.

[0095] The kit may also include one or more of the various pharmaceutical kit components, such as, for example, a container with one or more pharmaceutically acceptable carriers. The kit may also include an insert or label with instructions for use of each formulation. If desired, the insert or label may also include instructions on how to prepare each dosage form, including the amounts of the components to be administered and / or instructions on mixing the components, how to administer each dosage form, and / or when to administer each dosage form.

[0096] Example

[0097] The following examples are provided for illustrative purposes only, rather than to limit the scope of the claims provided herein. Although preferred embodiments of the present invention have been shown and described herein, it will be apparent to those skilled in the art that these embodiments are provided only as examples. Without departing from the present invention, those skilled in the art will now expect many variations, changes and substitutions. It should be understood that various alternatives to the embodiments of the present invention described herein can be used to implement the present invention. This means that the following claims define the scope of the present invention and therefore encompass methods and structures within the scope of these claims and their equivalents.

[0098] Example 1: PAH rat model

[0099] SuHx-mediated (SU5416 plus hypoxia) pulmonary hypertension was induced in male Sprague-Dawley rats (see "Inhibition of the VEGF receptor 2combined with chronic hypoxia causes cell death-dependent pulmonary endothelial cell proliferation and severe pulmonary hypertension", Taraseviciene-Stewart et al., J FASEB, 2001, 15, 427–438 and "TORREY, a Phase 2 study to evaluate the efficacy and safety of inhaled seralutinib for the treatment of pulmonary arterial hypertension", Frantz RP et al., Pulmonary Circulation, 2021;11(4), 1-7). Semaxanib (SU5416) was administered as a single subcutaneous injection (20 mg / kg) to rats weighing 200 g to 250 g. Rats were housed in 10% oxygen for 3 weeks and then re-exposed to normoxia during a 4-week treatment period.

[0100] Rats were divided into five treatment groups as summarized in Table 1 .

[0101] Table 1

[0102]

[0103] Rats were treated as described above starting on day 22 after disease induction for 4 weeks. After 4 weeks of treatment, the following parameters were evaluated: right ventricular systolic pressure (RVSP); Fulton index (ratio of right ventricle to left ventricle and septum weight); and mean pulmonary artery pressure (mPAP).

[0104] For each parameter measured (RVSP, Fulton Index, and mPAP), the combination of seratinib + sotacept (Group 5) resulted in a significant decrease compared to: control (Group 2, seratinib vehicle inhalation + sotacept vehicle, subcutaneous injection); seratinib treatment alone (Group 3); and sotacept treatment alone (Group 4).

[0105] In each case, the observed effects of the combination showed a synergistic effect that exceeded the additive effects of the individual agents. In addition, RVSP levels in 3 of 7 animals from the seratinib + sotacept combination treatment group (Group 5) decreased to the same level as healthy animals (Group 1). More specific details about this study are described below.

[0106] Induction of PAH

[0107] Animals from (Groups 2 to 5) received a single subcutaneous injection of SU5416 (20 mg / kg) on ​​day 0 and were exposed to hypoxia (10% O2) for 21 days and then to normoxia for 4 weeks. Group 1 animals (healthy group) stayed in cages exposed to ambient oxygen (normoxia) levels for 49 days. Food and water were provided ad libitum. On day 21, animals were randomly assigned to treatment groups based on their body weight and the results of transthoracic echocardiography.

[0108] Treatment with test article

[0109] Treatment with inhaled selatinib or vehicle, RAP-011, or mIgG2A was as described in Table 2 .

[0110] Table 2

[0111]

[0112] SER = seratinib; SOR = sotacept (administered as RAP-011, the rat analog of sotacept) Inh = administered by inhalation; SC = administered as a subcutaneous injection

[0113] Briefly, treatment with nebulized selatinib or vehicle was administered at an estimated dose of 15 mg / kg / dose twice daily for 45 minutes for 4 weeks starting on day 22 (as summarized in Table 1) using a Vilnius aerosol generator connected to an inhalation tower. Powder concentration was continuously monitored by a portable aerosol monitor. Aerodynamic particle size distribution measurements were performed using a Mercer-style cascade impactor. As described in Table 2, RAP-011 or mIgG was administered subcutaneously twice a week at a dose of 5 mg / kg starting on day 22 for 4 weeks.

[0114] Hemodynamic, RV hypertrophy, and echocardiographic measurements

[0115] All groups were monitored by echocardiography on day 21 (before treatment) and on the day of surgery (day 49) to observe disease progression. From day 21 onwards, echocardiographic results were used to randomize animals to ensure that only animals with sufficiently severe disease were selected and that disease stage was similar in all groups.

[0116] On day 49 after 4 weeks of treatment, the end of study procedures were performed: mean pulmonary artery pressure (mPAP) and right ventricular systolic pressure (RVSP) were measured by intraventricular fluid-filled catheters from AD instruments. Mean pulmonary artery pressure values ​​were obtained by using the formula mPAP = diastolic pressure + (systolic pressure - diastolic pressure) / 3. Pulmonary vascular resistance index (PVRI) was calculated using the following formula: PVRI = mPAP / CI, where mPAP is the mean pulmonary artery pressure (mm Hg) and CI is the cardiac index, defined as cardiac output (ml / min) normalized to 100 g body weight. As part of the Fulton index, the heart was dissected, the right ventricle was separated from the left ventricle with the septum, and then weighed separately, Fulton index = right ventricle weight / ventricular septum weight + left ventricle weight).

[0117] Test product effectiveness (recovery rate)

[0118] The effect of the test article was calculated using the following formula:

[0119] ((Vehicle group value - Test article group value) / (Vehicle group value - Normoxia group value))

[0120] Statistical analysis

[0121] Data are presented as median with interquartile range. One-way ANOVA followed by Fisher's LSD test was performed for all experimental conditions in GraphPad Prism 10.0 to compare treatment groups with healthy animals (normoxic control) or diseased animals (SuHx+placebo and mIgG2A). Differences were considered significant when *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

[0122] data

[0123] Figures 1A to 1D The results showed that inhaled seratinib plus injected seratinib provided more than additive efficacy in this PAH model. Referring to Figure 1, the data show the changes in right ventricular systolic pressure (RVSP), mean pulmonary artery pressure (mPAP), right ventricular hypertrophy (Fulton index), and PVR index for each treatment group (i.e., Figure 1A , Figure 1B , Figure 1C and Figure 1D). The data presented were calculated by normalizing the median of each treatment to vehicle and normal control. Parameter value = (value - normal value) / (vehicle value - normal value). n = 5-7 per group. As shown in Figure 1, the seratinib + sotacept treatment group showed more than additive benefits in the four tested parameters (RVSP, mPAP, Fulton index and PVR index).

[0124] Figure 2 Representative images of pulmonary vessels from each treatment group are shown. Animals in the vehicle control group had significantly increased mPAP and RVSP, and pulmonary vessels appeared occlusive with neointimal hyperplasia and plexiform lesions, while pulmonary vessels in healthy animals were non-occlusive. The seratinib monotherapy group, sotacept monotherapy group, and seratinib + sotacept combination therapy group showed improved hemodynamic parameters and non-occlusive pulmonary vessels similar to healthy controls.

[0125] result

[0126] The Sugen-hypoxia rat model is a widely used and recognized model of severe PAH. Sugen 5416 (SU5416) is known to cause apoptosis of pulmonary endothelial cells and, when used at a working single dose of 20 mg / kg, combined with a three-week course of hypoxia (10% O2) in this study, resulted in severe PAH. Under hypoxic conditions, endothelial cell apoptosis triggers endothelial cell proliferation in precapillary arterioles and leads to the selection of a subpopulation of endothelial cells that are resistant to apoptosis. This occurs in addition to remodeling and contraction of vascular smooth muscle cells, promoting the development of PAH (Taraseviciene-Stewart, L, 2020). This occlusion of the pulmonary arterioles leads to slowed blood flow and significantly increases pulmonary artery pressure (PAP), right ventricular systolic pressure, and right ventricular hypertrophy.

[0127] In this study, vehicle-controlled animals that received SuHx with seratinib vehicle inhalation and sotacept control IgG2A for 49 days developed severe PAH. Vehicle-controlled (placebo inhalation + IgG2A) animals had statistically significant increases in RVSP (57.3 mmHg; IQR 65.7 mmHg to 55.7 mmHg) and mPAP (38.1 mmHg; IQR 43.3 mmHg to 34.2 mmHg) compared to normoxic controls (RVSP 23.8 mmHg; IQR 26.95 mmHg to 22.4 mmHg and mPAP 18.2 mmHg IQR 18.7 mmHg to 17.2 mmHg; p<0.0001). Likewise, RV hypertrophy measured using the Fulton index (0.62; IQR 0.66 to 0.56) was also significantly higher in vehicle control animals compared to healthy controls (0.26; IQR 0.26 to 0.24, p<0.0001).

[0128] The data presented are calculated after normalizing each data point to the vehicle (considered as 1 and normal control as 0). The RVSP, mPAP, Fulton index (RV hypertrophy measurement) and PVR index of animals treated with seratinib monotherapy decreased by 13%, 23%, 9% and 26%, respectively, and the RVSP, mPAP, Fulton index (RV hypertrophy measurement) and PVR index of animals treated with sotacept monotherapy decreased by 31%, 28%, 15% and 25%, respectively. The seratinib plus sotacept combination treatment group had a 77% decrease in RVSP, a 78% decrease in mPAP, a 55% decrease in Fulton index, and a 73% decrease in PVR index. The RVSP, mPAP, Fulton index, and PVR index were significantly decreased in the combination of selecitonib plus sotacept compared with selecitonib monotherapy (p<0.001 for RVSP and mPAP, and p<0.01 for Fulton index and PVR index), and significantly decreased in the RVSP, mPAP, and Fulton index compared with sotacept monotherapy (p<0.05 for RVSP, MPAP, and Fulton index).

[0129] The various embodiments described above can be combined to provide additional embodiments. All U.S. patents, U.S. patent application publications, U.S. patent applications, foreign patents, foreign patent applications, and non-patent publications mentioned in this specification and / or listed in the patent application data sheet are incorporated herein by reference in their entirety. If necessary, various aspects of the embodiments can be modified to provide additional embodiments using the concepts of each patent, patent application, and patent publication.

[0130] In light of the above detailed description, these and other changes may be made to the embodiments. In general, in the following claims, the terms used should not be construed to limit the claims to the specific embodiments disclosed in the specification and claims, but should be interpreted to include all possible embodiments and the full range of equivalents to which such claims are entitled. Therefore, the claims are not limited by the present disclosure.

[0131] This application claims the benefit of priority to U.S. Provisional Application No. 63 / 396,899, filed on August 10, 2022, which is hereby incorporated by reference in its entirety.

Claims

1. A method of treating pulmonary arterial hypertension (PAH), the method comprising administering to a subject in need thereof: a therapeutically effective amount of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and A therapeutically effective amount of a dimeric fusion protein, the dimeric fusion protein comprising: The extracellular domain of activin type 2A receptor (ACTR IIA) or activin type 2B receptor (ACTRIIB); and The Fc domain of human immunoglobulin G1 (IgG1). 2 . The method according to claim 1 , wherein the tyrosine kinase inhibitor is a PDGF receptor inhibitor or a pharmaceutically acceptable salt thereof, a CSF1R receptor inhibitor or a pharmaceutically acceptable salt thereof, a c-KIT kinase inhibitor or a pharmaceutically acceptable salt thereof, or a combination thereof.

3. The method according to claim 1 or 2, wherein the tyrosine kinase inhibitor is acalabrutinib or a pharmaceutically acceptable salt thereof, afatinib or a pharmaceutically acceptable salt thereof, alectinib or a pharmaceutically acceptable salt thereof, afatinib or a pharmaceutically acceptable salt thereof, axitinib or a pharmaceutically acceptable salt thereof, baricitinib or a pharmaceutically acceptable salt thereof, bimetinib or a pharmaceutically acceptable salt thereof, bosutinib or a pharmaceutically acceptable salt thereof, brigatinib or a pharmaceutically acceptable salt thereof, cabozantinib or a pharmaceutically acceptable salt thereof, capmatinib or a pharmaceutically acceptable salt thereof, ceritinib or a pharmaceutically acceptable salt thereof, cobimetinib or a pharmaceutically acceptable salt thereof, crizotinib or a pharmaceutically acceptable salt thereof, dacomitinib or a pharmaceutically acceptable salt thereof, entrectinib or a pharmaceutically acceptable salt thereof, erdafitinib or a pharmaceutically acceptable salt thereof, erlotinib or a pharmaceutically acceptable salt thereof, fuzotinib or a pharmaceutically acceptable salt thereof, fotantinib or a pharmaceutically acceptable salt thereof, gefitinib or a pharmaceutically acceptable salt thereof, gilteritinib or a pharmaceutically acceptable salt thereof, ibrutinib or a pharmaceutically acceptable salt thereof, imatinib or a pharmaceutically acceptable salt thereof, lapatinib or a pharmaceutically acceptable salt thereof, larotrectinib or a pharmaceutically acceptable salt thereof, lenvatinib or a pharmaceutically acceptable salt thereof, lorlatinib or a pharmaceutically acceptable salt thereof, midostaurin or a pharmaceutically acceptable salt thereof, neratinib or a pharmaceutically acceptable salt thereof, osimertinib or a pharmaceutically acceptable salt thereof, pazopanib or a pharmaceutically acceptable salt thereof, pemitinib or a pharmaceutically acceptable salt thereof, peicidinib or a pharmaceutically acceptable salt thereof, ponatinib or a pharmaceutically acceptable salt thereof, regorafenib or a pharmaceutically acceptable salt thereof, ripretinib or a pharmaceutically acceptable salt thereof, ruxolitinib or a pharmaceutically acceptable salt thereof, selpatinib or a pharmaceutically acceptable salt thereof, selumetinib or a pharmaceutically acceptable salt thereof, ceratinib or a pharmaceutically acceptable salt thereof, sorafenib or a pharmaceutically acceptable salt thereof, sunitinib or a pharmaceutically acceptable salt thereof, tofacitinib or a pharmaceutically acceptable salt thereof, trametinib or a pharmaceutically acceptable salt thereof, tucatinib or a pharmaceutically acceptable salt thereof, upadacitinib or a pharmaceutically acceptable salt thereof, vandetanib or a pharmaceutically acceptable salt thereof, zanubrutinib or a pharmaceutically acceptable salt thereof, or a combination thereof. 4 . The method according to any one of claims 1 to 3 , wherein the tyrosine kinase inhibitor is seratinib or a pharmaceutically acceptable salt thereof.

5. The method according to any one of claims 1 to 4, wherein the dimeric fusion protein comprises the extracellular domain of the activin type 2A receptor.

6. The method according to any one of claims 1 to 5, wherein the dimeric fusion protein comprises the extracellular domain of the activin 2AF type c receptor.

7. The method according to any one of claims 1 to 4, wherein the dimeric fusion protein comprises the extracellular domain of the activin type 2B receptor.

8. The method according to any one of claims 1 to 6, wherein the dimeric fusion protein is sotacept.

9. The method according to any one of claims 1 to 6 or 8, wherein the tyrosine kinase inhibitor is seratinib or a pharmaceutically acceptable salt thereof, and the dimeric fusion protein is sotacept.

10. The method of any one of claims 1 to 9, wherein the subject is receiving stable background therapy for arterial pulmonary hypertension.

11. The method of claim 10, wherein the stable background therapy is a monotherapy, a dual therapy, a triple therapy, or a quadruple therapy.

12. The method of claim 10 or 11, wherein the stable background therapy comprises an endothelin-receptor antagonist, a phosphodiesterase-5 (PDE-5) inhibitor, a prostacyclin analog, a prostacyclin-receptor agonist, a soluble guanylate cyclase stimulator, or a combination thereof.

13. The method according to any one of claims 1 to 12, further comprising: An endothelin-receptor antagonist, a phosphodiesterase type 5 (PDE-5) inhibitor, a prostacyclin analog, a prostacyclin receptor agonist, a soluble guanylate cyclase stimulator, or a combination thereof is administered to the subject.

14. The method according to any one of claims 1 to 13, further comprising: A therapeutically effective amount of an endothelin receptor agonist is administered.

15. The method of claim 14, wherein the endothelin receptor agonist is ambrisentan Macitentan Or bosentan.

16. The method according to any one of claims 1 to 15, further comprising: A therapeutically effective amount of a phosphodiesterase type 5 (PDE-5) inhibitor is administered.

17. The method of claim 16, wherein the phosphodiesterase type 5 (PDE-5) inhibitor is sildenafil, tadalafil, vardenafil, avanafil, or udenafil.

18. The method according to any one of claims 1 to 17, further comprising: A prostacyclin analog is administered to the subject.

19. The method of claim 18, wherein the prostacyclin receptor analog is epoprostenol, treprostinil, iloprost, or beraprost.

20. The method according to any one of claims 1 to 19, further comprising: A prostacyclin receptor agonist is administered to the subject.

21. The method of claim 20, wherein the prostacyclin receptor agonist is selexipag or lelipag.

22. The method according to any one of claims 1 to 21, further comprising: A soluble guanylate cyclase stimulator is administered to the subject.

23. The method of claim 22, wherein the soluble guanylate cyclase stimulator is riociguat or vericipirat.

24. The method according to any one of claims 1 to 23, further comprising: The subject is administered tadalafil, selexipag, or a combination thereof.

25. The method according to any one of claims 1 to 24, further comprising: The subject is administered tadalafil, selexipag, lelipipag, or a combination thereof.

26. The method of any one of claims 1 to 25, wherein the PAH is a mild or moderate PAH.

27. The method according to any one of claims 1 to 26, wherein the PAH is a moderate PAH.

28. The method of any one of claims 1 to 27, wherein the method reduces the risk of morbidity, risk of mortality, or both from the PAH.

29. The method of any one of claims 1 to 28, wherein the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered by inhalation.

30. The method of any one of claims 1 to 29, wherein seratinib or a pharmaceutically acceptable salt thereof is administered by inhalation.

31. The method of any one of claims 1 to 30, wherein seratinib or a pharmaceutically acceptable salt thereof is administered once daily or twice daily.

32. The method according to any one of claims 1 to 31, wherein the dimeric fusion protein is administered by injection.

33. The method according to any one of claims 1 to 28, wherein sotacept is administered by injection.

34. The method according to any one of claims 1 to 33, wherein sotacept is administered by subcutaneous injection.

35. The method according to any one of claims 1 to 34, wherein sotacept is administered once a week, once every two weeks, once every three weeks, or once a month.

36. The method according to any one of claims 1 to 35, wherein the therapeutically effective amount of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered before, simultaneously with, and / or after the therapeutically effective amount of the dimeric fusion protein.

37. The method of claim 36, wherein the therapeutically effective amount of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered prior to administration of the therapeutically effective amount of the dimeric fusion protein.

38. The method of claim 36, wherein the therapeutically effective amount of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered simultaneously with the administration of the therapeutically effective amount of the dimeric fusion protein.

39. The method of claim 36, wherein the therapeutically effective amount of the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered after the therapeutically effective amount of the dimeric fusion protein is administered.

40. A method of treating pulmonary arterial hypertension (PAH), the method comprising administering to a subject in need thereof: a therapeutically effective amount of seratinib or a pharmaceutically acceptable salt thereof; and A therapeutically effective amount of sotacept.

41. A kit, comprising: one or more doses of a therapeutically effective amount of a tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof; and One or more therapeutically effective doses of a dimeric fusion protein, the dimeric fusion protein comprising: The extracellular domain of activin type 2A receptor (ACTR IIA) or activin type 2B receptor (ACTRIIB); and The Fc domain of human immunoglobulin G1 (IgG1).

42. The kit according to claim 41, wherein the tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is a PDGF receptor inhibitor or a pharmaceutically acceptable salt thereof, a CSF1R receptor inhibitor or a pharmaceutically acceptable salt thereof, a c-KIT kinase inhibitor or a pharmaceutically acceptable salt thereof, or a combination thereof.

43. The kit according to claim 41 or 42, wherein the tyrosine kinase inhibitor is acalabrutinib or a pharmaceutically acceptable salt thereof, afatinib or a pharmaceutically acceptable salt thereof, alectinib or a pharmaceutically acceptable salt thereof, afatinib or a pharmaceutically acceptable salt thereof, axitinib or a pharmaceutically acceptable salt thereof, baricitinib or a pharmaceutically acceptable salt thereof, bimetinib or a pharmaceutically acceptable salt thereof, bosutinib or a pharmaceutically acceptable salt thereof, brigatinib or a pharmaceutically acceptable salt thereof, cabozantinib or a pharmaceutically acceptable salt thereof, capmatinib or a pharmaceutically acceptable salt thereof, ceritinib or a pharmaceutically acceptable salt thereof, cobimetinib or a pharmaceutically acceptable salt thereof, crizotinib or a pharmaceutically acceptable salt thereof, dacomitinib or a pharmaceutically acceptable salt thereof, entrectinib or a pharmaceutically acceptable salt thereof, erdafitinib or a pharmaceutically acceptable salt thereof, erlotinib or a pharmaceutically acceptable salt thereof, fuzotinib or a pharmaceutically acceptable salt thereof, fotantinib or a pharmaceutically acceptable salt thereof, gefitinib or a pharmaceutically acceptable salt thereof, gilteritinib or a pharmaceutically acceptable salt thereof, ibrutinib or a pharmaceutically acceptable salt thereof, imatinib or a pharmaceutically acceptable salt thereof, lapatinib or a pharmaceutically acceptable salt thereof, larotrectinib or a pharmaceutically acceptable salt thereof, lenvatinib or a pharmaceutically acceptable salt thereof, lorlatinib or a pharmaceutically acceptable salt thereof, midostaurin or a pharmaceutically acceptable salt thereof, neratinib or a pharmaceutically acceptable salt thereof, osimertinib or a pharmaceutically acceptable salt thereof, pazopanib or a pharmaceutically acceptable salt thereof, pemitinib or a pharmaceutically acceptable salt thereof, peicidinib or a pharmaceutically acceptable salt thereof, ponatinib or a pharmaceutically acceptable salt thereof, regorafenib or a pharmaceutically acceptable salt thereof, ripretinib or a pharmaceutically acceptable salt thereof, ruxolitinib or a pharmaceutically acceptable salt thereof, selpatinib or a pharmaceutically acceptable salt thereof, selumetinib or a pharmaceutically acceptable salt thereof, ceratinib or a pharmaceutically acceptable salt thereof, sorafenib or a pharmaceutically acceptable salt thereof, sunitinib or a pharmaceutically acceptable salt thereof, tofacitinib or a pharmaceutically acceptable salt thereof, trametinib or a pharmaceutically acceptable salt thereof, tucatinib or a pharmaceutically acceptable salt thereof, upadacitinib or a pharmaceutically acceptable salt thereof, vandetanib or a pharmaceutically acceptable salt thereof, zanubrutinib or a pharmaceutically acceptable salt thereof, or a combination thereof.

44. The kit according to any one of claims 41 to 43, wherein the tyrosine kinase inhibitor is seratinib or a pharmaceutically acceptable salt thereof.

45. The kit of any one of claims 41 to 44, wherein the dimeric fusion protein comprises the extracellular domain of the activin type 2A receptor.

46. ​​The kit of any one of claims 41 to 45, wherein the dimeric fusion protein comprises the extracellular domain of the activin 2AF type c receptor.

47. The kit of any one of claims 41 to 44, wherein the dimeric fusion protein comprises the extracellular domain of the activin type 2B receptor.

48. The kit according to any one of claims 41 to 46, wherein the dimeric fusion protein is sotacept.

49. The kit according to any one of claims 41 to 46 or 48, wherein the tyrosine kinase inhibitor is seratinib or a pharmaceutically acceptable salt thereof, and the dimeric fusion protein is sotacept.

50. The kit of any one of claims 41 to 49, further comprising one or more therapeutically effective amounts of an endothelin-receptor antagonist, a phosphodiesterase-5 (PDE-5) inhibitor, a prostacyclin analog, a prostacyclin-receptor agonist, a soluble guanylate cyclase stimulator, or a combination thereof.

51. The kit of any one of claims 41 to 50, further comprising one or more doses of a therapeutically effective amount of an endothelin receptor agonist.

52. The kit of claim 51, wherein the endothelin receptor agonist is ambrisentan Macitentan Or bosentan.

53. The kit of any one of claims 41 to 52, further comprising one or more doses of a therapeutically effective amount of a phosphodiesterase type 5 (PDE-5) inhibitor.

54. The kit of claim 53, wherein the phosphodiesterase type 5 (PDE-5) inhibitor is sildenafil, tadalafil, vardenafil, avanafil, or udenafil.

55. The kit of any one of claims 41 to 54, further comprising one or more doses of a therapeutically effective amount of a prostacyclin analogue.

56. The kit of claim 55, wherein the prostacyclin receptor analog is epoprostenol, treprostinil, iloprost or beraprost.

57. The kit of any one of claims 41 to 56, further comprising one or more doses of a therapeutically effective amount of a prostacyclin receptor agonist.

58. The kit of claim 57, wherein the prostacyclin receptor agonist is selexipag or lelipag.

59. The kit of any one of claims 41 to 58, further comprising one or more doses of a therapeutically effective amount of a soluble guanylate cyclase stimulator.

60. The kit of claim 59, wherein the soluble guanylate cyclase stimulator is riociguat or vericipirat.

61. The kit of any one of claims 41 to 60, further comprising one or more doses of a therapeutically effective amount of tadalafil, selexipag, lelipag, or a combination thereof.

62. The kit of any one of claims 41 to 61, wherein the one or more doses of the therapeutically effective amount of the tyrosine kinase inhibitor are formulated for administration by inhalation.

63. The kit according to any one of claims 41 to 62, wherein the one or more doses of the therapeutically effective amount of selatinib or a pharmaceutically acceptable salt thereof is formulated for administration by inhalation.

64. The kit according to any one of claims 41 to 63, wherein the one or more doses of the therapeutically effective amount of selatinib or a pharmaceutically acceptable salt thereof are formulated as a dry powder for administration by inhalation via a dry powder inhaler.

65. A kit according to any one of claims 41 to 64, further comprising a dry powder inhaler.

66. The kit of any one of claims 41 to 65, wherein the one or more doses of the therapeutically effective amount of the dimeric fusion protein are formulated for administration by injection.

67. The kit according to any one of claims 41 to 66, wherein the one or more doses of the therapeutically effective amount of sotacept are formulated for administration by injection.

68. The kit according to any one of claims 41 to 67, wherein the one or more doses of the therapeutically effective amount of sotacept are formulated for administration by subcutaneous injection.

69. The kit according to any one of claims 41 to 68, wherein the one or more doses of the therapeutically effective amount of sotacept are formulated for subcutaneous injection in the form of a single bolus or multiple doses.

70. The kit according to any one of claims 41 to 69, wherein the one or more doses of the therapeutically effective amount of sotacept are formulated for subcutaneous injection in one or more pre-filled syringes.

71. The kit according to any one of claims 41 to 69, wherein the one or more doses of the therapeutically effective amount of sotacept are formulated as a liquid in a vial for subcutaneous injection that can be immediately drawn into a syringe.

72. The kit of claim 71, wherein the liquid in the vial is a single-dose formulation of a therapeutically effective amount of sotacept.

73. The kit of claim 71, wherein the liquid in the vial is a multiple-dose formulation of a therapeutically effective amount of sotacept.

74. The kit according to any one of claims 41 to 69, wherein the one or more doses of the therapeutically effective amount of sotacept are formulated as a solid for subcutaneous injection that dissolves prior to being drawn into a syringe.

75. The kit of claim 74, wherein the solid that dissolves prior to being drawn into a syringe is a single-dose formulation of a therapeutically effective amount of sotacept.

76. The kit of claim 74, wherein the solid that dissolves prior to being drawn into a syringe is a multiple-dose formulation of a therapeutically effective amount of sotacept.

77. A kit according to any one of claims 41 to 76, comprising one or more containers.

78. The kit according to any one of claims 41 to 77, comprising at least one container containing seratinib or a pharmaceutically acceptable salt thereof.

79. The kit according to any one of claims 41 to 77, comprising at least one container containing sotacept.

80. The kit according to any one of claims 41 to 79, comprising at least one container containing sotacept and at least one other container containing sotacept.

81. The kit of any one of claims 41 to 80, further comprising an insert or label with instructions for use.

82. The kit of claim 81, wherein the insert or label with instructions for use includes instructions on how to prepare each dosage form.

83. The kit of claim 81, wherein the insert or label with instructions for use includes instructions regarding the amounts of the components to be administered, directions regarding mixing the components, how to administer each dosage form, or when to administer each dosage form.

84. A kit comprising: one or more doses of a therapeutically effective amount of selatinib or a pharmaceutically acceptable salt thereof; and One or more doses of a therapeutically effective amount of sotacept.

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