Chimeric antigen receptor (CAR) T cell adjuvant therapy

Abstract

Methods, compositions, and kits that can be used to treat cytokine release syndrome, ICANS, or both associated with CAR T cell administration are described herein. For example, pharmaceutical compositions containing beraprost, beraprost isomers, or salts thereof may be used as adjuvant therapy using chimeric antigen receptor T cells (CAR T cells) to treat cancer while reducing or eliminating undesirable and potentially dangerous side effects.

Description

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS

[0002] This application claims priority to U.S. Provisional Application No. 63 / 347,221 and U.S. Provisional Application No. 63 / 482,448, filed on May 31, 2022, entitled Chimeric Antigen Receptor (CAR) T Cell Adjuvant Therapy, and U.S. Provisional Application No. 63 / 482,448 filed on January 31, 2023, entitled Chimeric Antigen Receptor (CAR) T Cell Adjuvant Therapy. The contents of U.S. Provisional Application No. 63 / 347,221 and U.S. Provisional Application No. 63 / 482,448 are incorporated herein by reference in their entirety.

[0003] background

[0004] Chimeric antigen receptor T cells (CAR T cells) are genetically engineered T cells that produce receptors with the ability to bind to specific proteins. CAR T cell therapies are attractive for use in immunotherapy because they can be designed and engineered to specifically target and recognize cancer cells.

[0005] T cells are harvested and genetically engineered before being infused back into the patient to attack their cancer cells. T cells can be obtained from the patient's blood ("autologous") or from another donor ("allogeneic"). Chimeric antigen receptors can target antigens present on the surface of cancer cells in a tumor and / or antigens present on non-cancerous cells (e.g., B cells).

[0006] A common but serious side effect of CAR T cell therapy is cytokine release syndrome ("CRS"). CAR T cells cause immune cell activation (T cells, macrophages and / or dendritic cells). CAR T cells and related cells cause large amounts of cytokines to be released into the blood. Due to the prolonged activation of cytokine signaling, the released cytokines can also cause immune overactivation. This can cause high fever, low blood pressure (hypotension), fatigue, headache, myalgia, nausea, capillary leakage, tachycardia, and potential multi-organ failure (e.g., liver failure and kidney loss) and even death. CRS occurs in 50-100% of patients. Discussion of side effects can be found in the NCCN Guidelines for Patients entitled "Immunotherapy Side Effects: CAR T-Cell Therapy–English (2020)" and the NCCN Guidelines Version 4.2021 entitled "Management of CAR T-Cell-Related Toxicities (2021)". Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) effects can occur in more than 25% of patients receiving CAR T-cell therapy. ICANS can present as headache, confusion, speech disorders, altered consciousness, seizures, cerebral edema. Almost all patients with ICANS may have had a prior CRS.

[0007] For example, using Novartis' Kymriah product (Kymriah is a registered trademark of Novartis; Basel, Switzerland), CRS occurs in 79% of acute lymphoblastic leukemia and 74% of patients with relapsed / refractory diffuse large B-cell lymphoma receiving Kymriah, including 49% of patients with relapsed / refractory acute lymphoblastic leukemia and 23% of patients with relapsed / refractory diffuse large B-cell lymphoma with a grade greater than or equal to 3 CRS. The median time of onset is 3 days, and the median time of remission is 8 days (ranging from 1-36 days). Similarly, using the Yescarta product from Kite / Gilead (Yescatta is a registered trademark of Kite Pharma, Inc.; Santa Monica, California, USA), CRS occurs in more than 90% of patients, of which 9% are greater than or equal to grade 3. Among the patients who died after receiving Yescarta, 4 patients suffered from persistent CRS at the time of death. The median time to onset was 2 days (range: 1-12 days), and the median duration was 7 days (range: 2-58 days).

[0008] From one perspective, the development of CRS is an indicator or diagnostic marker that the CAR T cells are working to attack cancer cells. CRS develops within a delay period after the initiation of CAR T cell administration. This delay period is very predictable and consistent, but the length of the delay is unpredictable. This inability to predict if and when a patient will develop CRS is challenging.

[0009] In the case of CRS or ICANS, currently approved treatments include supportive care, corticosteroids and the administration of tocilizumab (IL-6 antagonist). Although corticosteroids can effectively treat CRS and ICANS, there may be very serious adverse reactions, including severe hypertension, glucose intolerance, susceptibility to severe infection, delayed wound healing, gastrointestinal bleeding, sepsis and heart failure. There is also concern that corticosteroids may damage the function of infused CAR T cells. For this reason, corticosteroid use is generally limited to the most severe CRS and ICANS cases. Although tocilizumab is approved by the FDA for the treatment of CRS, it may have some disadvantages, because IL-6 has been clearly shown to promote the proliferation of T cells, and it is unclear whether IL-6 blocking may damage the in vivo proliferation of CAR T cells. In addition, after tocilizumab is administered, serum IL-6 levels may actually increase, and this increase in circulating cytokines may increase the risk of vascular leakage and BBB rupture, which is considered to contribute to the development of ICANS. Therefore, tocilizumab is generally not recommended for the treatment of ICANS, and some have hypothesized that its use may make the condition worse. Therefore, although helpful in a certain proportion of the population, the drug mechanism of action may be limited in addressing CRS and ICANS in this population. New treatment strategies are needed to prevent or reduce the use of tocilizumab and / or steroids.

[0010] CAR T-cell therapy is a powerful and effective “last resort” therapy, but new and improved treatments are needed to reduce or eliminate the undesirable and potentially fatal CRS side effect.

[0011] Overview

[0012] Disclosed herein are methods and compositions for administering CAR T cell therapy while reducing or eliminating cytokine release syndrome (CRS) side effects and / or immune effector cell-associated neurotoxicity syndrome (ICANS) effects. CAR T cell therapy can be used to treat cancer or other conditions.

[0013] The method for treating cytokine release syndrome, ICANS or both associated with CAR T cell administration can generally include administering CAR T cells and the first pharmaceutical composition to the subject as an adjuvant therapy / combination therapy method. The first pharmaceutical composition may include an effective amount of prostaglandin / prostaglandin analogs, such as analogs selected from the following groups: prostaglandin, beraprost, taprostene, niloprost, iloprost, cicarprost, ciprostene, treprostinil, bosentan, uoprost, eptaprost or its isomers and pharmaceutically acceptable salts thereof. In some embodiments, prostaglandin / prostaglandin analogs are beraprost or beraprost salts. Salts may be pharmaceutically acceptable salts of beraprost, such as beraprost sodium. Beraprost may be a beraprost isomer, such as beraprost CTO1681. The first pharmaceutical composition causes a negligible reduction in CAR T cell-mediated killing or no reduction in CAR T cell-mediated killing, for example, a reduction in CAR T cell-mediated killing of no more than about 5%.

[0014] Another method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject can include administering CAR T cells, a first pharmaceutical composition, and a second pharmaceutical composition to the subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and the second pharmaceutical composition includes at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof.

[0015] Additional methods of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration may comprise administering CAR T cells and a first pharmaceutical composition to a subject, wherein: the first pharmaceutical composition comprises at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and the subject experiences reduced ICANS effects, Parkinson's effects, or both relative to a similar subject who receives administered CAR T cells but does not receive the administered pharmaceutical composition.

[0016] A further method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject may comprise administering CAR T cells and a first pharmaceutical composition to the subject, wherein: the first pharmaceutical composition comprises at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and the subject experiences a reduced severity measurement relative to a similar subject receiving the administered CAR T cells but not receiving the administered pharmaceutical composition. In some embodiments, the subject experiences a reduced severity of CRS and / or ICANS effects.

[0017] Additional methods of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject may include administering CAR T cells and a first pharmaceutical composition to the subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and once the onset of CRS is detected by an increased level of one or more of the cytokines MIF, IL-5, IL-17A, IL-23, IFN-γ, CXCL9 / MIG, GCSF, VEGF-A, and TGF-β, the first pharmaceutical composition is administered. Alternatively or additionally, the onset of CRS may be detected by an increased level of one or more of the cytokines CCL2, IL-2, IL-6, IL-8, IL-10, IFN-γ, TNF-α, CXCL9, CXCL-10, VEGF, CCL3, GCSF, and GMCSF. Alternatively, the onset of CRS can be detected by detecting increased levels of one or more inflammatory markers associated with CRS, such as CRP (C-reactive protein) and ferritin. Alternatively, the onset of CRS can be detected by the manifestation of symptoms, such as one or more of fever, hypotension, and hypoxia.

[0018] Additional methods of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject may include administering CAR T cells and a first pharmaceutical composition to the subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; the subject experiences CRS, ICANS, a Parkinsonian effect, or a combination thereof; and the subject requires reduced treatment with at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof relative to a similar subject who received administered CAR T cells but did not receive administered the first pharmaceutical composition.

[0019] A kit for the treatment of cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject generally can include a first container (the first container contains a first pharmaceutical composition, the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof); a second container (the second container contains a second pharmaceutical composition, the second pharmaceutical composition includes at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof); and instructions for use for administering the first pharmaceutical composition, the second pharmaceutical composition, and CAR T cells to a subject.

[0020] The additional kit may include a first container (the first container contains a first pharmaceutical composition, the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer or a pharmaceutically acceptable salt thereof); a second container (the second container contains a second pharmaceutical composition, the second pharmaceutical composition includes at least one corticosteroid, tocilizumab, an IL-6 receptor blocker or a combination thereof); and instructions for administering the first pharmaceutical composition, the second pharmaceutical composition and CAR T cells to a subject.

[0021] BRIEF DESCRIPTION OF THE DRAWINGS

[0022] The above and other objects, features and advantages will become apparent from the following description of certain embodiments of the present disclosure, as illustrated in the accompanying drawings. The drawings are not necessarily drawn to scale, emphasis instead being placed upon illustrating the principles of various embodiments of the present disclosure.

[0023] Figure 1A It was shown that when CAR T cells and Raji cells were present at a ratio of 10:1, CTO1681 did not interfere with the tumor-killing efficacy of CD19-targeted CAR T cells in vitro (see the line connected by square points) and dose-dependently reduced the level of IL-6, a pro-inflammatory and CRS-induced cytokine (see the bar graph).

[0024] Figure 1B It was shown that when CAR T cells and Raji cells were present at a ratio of 10:1, CTO1681 did not interfere with the tumor-killing efficacy of CD19-targeted CAR T cells in vitro (see the line connected by square points) and dose-dependently reduced the level of TNF-α, a pro-inflammatory and CRS-induced cytokine (see the bar graph).

[0025] Figure 1C It was shown that when CAR T cells and Raji cells were present at a ratio of 10:1, CTO1681 did not interfere with the tumor-killing efficacy of CD19-targeted CAR T cells in vitro (see the line connected by square points) and dose-dependently reduced the level of TNF-γ, a pro-inflammatory and CRS-induced cytokine (see the bar graph).

[0026] Figure 1D The decrease in IL-6 upon treatment with increasing concentrations of CTO1681 was shown in three different concentrations of CAR-T cells and Raji cells.

[0027] Figure 1E The reduction of TNF-α upon treatment with increasing concentrations of CTO1681 was shown in three different concentrations of CAR-T cells and Raji cells.

[0028] Figure 1F The reduction of TNF-γ upon treatment with increasing concentrations of CTO1681 was shown in three different concentrations of CAR-T cells and Raji cells.

[0029] Figure 1G It showed that CTO1681 had no effect on the tumor killing efficacy of CAR-T.

[0030] Figure 2 CTO1681 was shown not to interfere with CAR T cell efficacy in the reduction of lymphoma tumor burden in vivo.

[0031] Figure 3 Depicted are the concentrations of TNF-α in cultured PBMCs as a function of the concentrations of beraprost (E; diamonds) or individual isomers of beraprostol (A = BPS-314d, circles; B = BPS-3151, squares; C = BPS-315d, upward triangles; D = BPS-3141, downward triangles).

[0032] Figure 4A Depicted are plasma concentrations of CTO1681 in African green monkeys following oral dosing at 0.008 mg / kg / day three times daily (TID).

[0033] Figure 4B Depicted are plasma concentrations of CTO1681 in African green monkeys following oral dosing at 0.04 mg / kg / day three times daily (TID).

[0034] Figure 4C Depicted are plasma concentrations of CTO1681 in African green monkeys following oral dosing at 0.2 mg / kg / day three times daily (TID).

[0035] Figure 4D Depicted are plasma concentrations of CTO1681 in African green monkeys following oral dosing at 0.008 mg / kg / day, 0.04 mg / kg / day, and at 0.2 mg / kg / day, three times a day (TID).

[0036] Figure 5A Shown are the mean maximum plasma concentrations (Cmax) in African green monkeys for each dose interval of CTO1681.

[0037] Figure 5B The area under the curve (AUC) for each dose of CTO1681 in African green monkeys is shown.

[0038] Figure 6 Depicted are TNF-α concentrations in serum samples from African green monkeys following treatment with CTO1681.

[0039] definition

[0040] Unless the context of the present disclosure indicates otherwise or is inconsistent with such an interpretation, as used herein, when immediately preceding a numerical value, the term "about" means a range of plus or minus 10% of that value, for example, "about 50" means 45 to 55, "about 25,000" means 22,500 to 27,500, etc.

[0041] As used herein, the term "analog" refers to a compound, the presence of which results in a biological activity of a receptor that is the same as that caused by the presence of the naturally occurring ligand of the receptor.

[0042]

[00136] As used herein, the terms "administer," "administering," or "administration" refer to the direct administration of a compound or composition to a subject.

[0043] As used herein, the term "effective amount" refers to an amount that causes a measurable inhibition of at least one symptom or parameter of a specific disorder or pathological process. As used herein, the term "therapeutically effective amount" of the composition of the present application is an amount that gives a therapeutic effect to the treated subject at a reasonable benefit / risk ratio applicable to any medical treatment. The therapeutic effect can be objective (i.e., measurable by some test or marker) or subjective (i.e., the subject gives a hint of the effect or feels the effect or the physician observes a change).

[0044] As used herein, the term "rapid release" refers to a pharmaceutical composition that releases the active ingredient over a short period of time.

[0045] As used herein, the term "modified release" refers to a pharmaceutical composition that does not otherwise release an active ingredient immediately, such as a pharmaceutical composition that can release an active ingredient at a sustained or controlled rate over an extended period of time, or can release a drug dose after a delayed time after administration, or can be used alternatively with a quick-release composition. Modified release includes extended release, sustained release, and delayed release. As used herein, the term "extended release" or "sustained release" is a dosage form that makes a drug available over an extended period of time after administration. As used herein, the term "delayed release" is a dosage form that does not release a drug quickly after administration.

[0046] As used herein, the phrase "pharmaceutically acceptable salt (one or more)" includes those salts of the compounds of the present application that are safe and effective for use in mammals and have the desired biological activity. Pharmaceutically acceptable salts include salts of acidic or basic groups present in the compounds of the present application or in the compounds identified according to the methods of the present application. Pharmaceutically acceptable acid addition salts include, but are not limited to, hydrochlorides, hydrobromides, hydroiodides, nitrates, sulfates, bisulfates, phosphates, acid phosphates, isonicotinates, acetates, lactates, salicylates, citrates, tartrates, pantothenates, bitartrates, ascorbates, succinates, maleates, gentisates, fumarates, gluconates, glucuronates, sugarates, formates, benzoates, glutamates, methanesulfonates, ethanesulfonates, benzenesulfonates, p-toluenesulfonates, and pamoates (i.e., 1,1'-methylene-bis-(2-hydroxy-3-naphthoate)). Certain compounds of the present application can form pharmaceutically acceptable salts with various amino acids. Suitable basic salts include, but are not limited to, aluminum, calcium, lithium, magnesium, potassium, sodium, zinc, iron and diethanolamine salts. Pharmaceutically acceptable base addition salts are also formed with amines (such as organic amines). Examples of suitable amines are N, N'-dibenzylethylenediamine, chloroprocaine, choline, diethanolamine, dicyclohexylamine, ethylenediamine, N-methylglucamine and procaine.

[0047] The term "prevent" or "preventing" may be understood to mean preventing a particular disorder, disease or condition and / or preventing the recurrence of a particular disorder, disease or condition.

[0048] The term "substantially pure isomer" refers to a preparation or composition wherein, among the various isomers of a compound, a single isomer is present in a proportion of about 70%, or more, or about 80% or more, or about 90% or more, or about 95% or more, or about 98% or more, or about 99% or more, or the compound or composition contains only a single isomer of the compound.

[0049] As used herein, the terms "treat," "treated," or "treating" refer to therapeutic treatment and prophylactic measures or preventive measures, wherein the goal is to protect against (partially or completely) or slow down (e.g., to reduce or delay the onset of an undesirable physiological condition, disorder, or disease), or to obtain a beneficial or desired clinical result, such as partial or complete restoration or inhibition of the decline of a parameter, value, function, or result that has or will become abnormal. For the purposes of this application, beneficial or desired clinical results include, but are not limited to, alleviation of symptoms; reduction in the extent or vitality or rate of the condition, disorder, or disease; stabilization of the state of the condition, disorder, or disease (i.e., not worsening); delay in the onset of the condition, disorder, or disease or slowing of the progression of the condition, disorder, or disease; alleviation of the state of the condition, disorder, or disease; and alleviation of the condition, disorder, or disease (whether partial or complete), whether translated into immediate alleviation of actual clinical symptoms, or enhancement or improvement. Treatment seeks to induce a clinically significant response without excessive levels of side effects.

[0050] The term "unit dosage forms" refers to physically discrete units suitable as unitary dosages for human subjects and other animals, each unit containing a predetermined quantity of active material calculated to produce the desired therapeutic effect, in association with a suitable pharmaceutical excipient.

[0051] The "mass percentage" disclosed herein may be a weight to weight percentage or a weight to volume percentage, depending on the composition.

[0052] As used herein, the term "disease" is intended to be generally synonymous with and used interchangeably with the terms "disorder," "symptom," and "condition" (in the medical context), as all reflect an abnormal condition of the human or animal body, or one of its parts, which impairs normal function, is usually manifested by distinctive signs and symptoms, and causes the human or animal to have a reduced lifespan or quality of life.

[0053] The term "combination therapy" means the administration of two or more therapeutic agents to treat a medical condition or disorder. Such administration encompasses the co-administration of these therapeutic agents in a substantially simultaneous manner, such as in a single capsule or dosage presentation with a fixed ratio of active ingredients, or in multiple separate capsules of each active ingredient. In addition, such administration also encompasses the use of each type of therapeutic agent in a continuous manner in the same patient, wherein the delivery interval of the individual therapeutic agent is about 1-24 hours, about 1-7 days, or about 1 week or longer. In either case, the treatment regimen will provide the beneficial effects of the drug combination in treating the condition or disorder described herein.

[0054] The present disclosure is not limited to the specific embodiments described in the present application, which are intended to be illustrations of various aspects. As will be apparent to those skilled in the art, many modifications and changes can be made without departing from its spirit and scope. Functionally equivalent methods and devices (except those listed herein) within the scope of the present disclosure will be apparent to those skilled in the art from the foregoing description. Such modifications and changes are intended to fall within the scope of the appended claims. The present disclosure is limited only by the terms of the appended claims and the full range of equivalents granted by such claims. It should be understood that the present disclosure is not limited to specific methods, reagents, compounds, compositions or biological systems, which can certainly vary. It should also be understood that the terms used herein are only for the purpose of describing specific embodiments and are not intended to be restrictive.

[0055] As used in this document, the singular forms "a", "an", and "the" include plural references unless the context clearly indicates otherwise. Unless otherwise defined, all technical and scientific terms used herein have the same meanings as those commonly understood by those of ordinary skill in the art. Nothing in this disclosure is to be construed as an admission that the embodiments described in this disclosure are not entitled to antedate such disclosure by virtue of prior invention. As used in this document, the term "comprising" means "including, but not limited to".

[0056] Although various compositions, methods, and apparatus are described in terms of "comprising" various components or steps (interpreted as "including, but not limited to"), these compositions, methods, apparatuses may also "consist essentially of" or "consist of" the various components and steps, and these terms should be interpreted as limiting substantially closed groups of members.

[0057] For the use of substantially any plural terms and / or singular terms herein, those skilled in the art can translate from plural to singular and / or from singular to plural in a manner appropriate to the context and / or the present application. For the sake of clarity, various singular substitutions / plural substitutions may be explicitly set forth herein.

[0058] Those skilled in the art will understand that, in general, the terms used herein (especially in the appended claims (e.g., the bodies of the appended claims)) are generally intended to be "open" terms (e.g., the term "including" should be interpreted as "including but not limited to", the term "having" should be interpreted as "having at least", the term "includes" should be interpreted as "includes but is not limited to", etc.). Those skilled in the art will also understand that if a specific number of an introduced claim limitation is intended, such intent will be expressly defined in the claim, and in the absence of such a limitation, no such intent is present. For example, as an aid to understanding, the following appended claims may contain the use of the introductory phrases "at least one" and "one or more" to introduce claim limitations. However, the use of such phrases should not be interpreted as implying that the introduction of a claim limitation by the indefinite article "a" or "an" limits any particular claim containing such introduced claim limitation to embodiments containing only one such limitation, even when the same claim contains the introductory phrases "one or more" or "at least one" and an indefinite article such as "a" or "an" (e.g., "a" and / or "an" should be interpreted as meaning "at least one" or "one or more"); the same applies to the use of the definite article used to introduce a claim limitation. In addition, even if a specific number of an introduced claim limitation is explicitly listed, a person skilled in the art will recognize that such a limitation should be interpreted to mean at least the listed number (e.g., the plain listing of "two limitations" (without other modifiers) means at least two limitations, or two or more limitations). In addition, in those cases where a convention similar to "at least one of A, B, and C, etc." is used, generally speaking, such construction is intended to be in the sense that a person skilled in the art would understand the convention (for example, "a system having at least one of A, B, and C" would include but not be limited to a system having only A, a system having only B, a system having only C, a system having both A and B, a system having both A and C, a system having both B and C, and / or a system having both A, B, and C, etc.).In those cases where a convention similar to "at least one of A, B, or C, etc." is used, generally speaking, such construction is intended to be in the sense that one skilled in the art would understand the convention (e.g., "a system having at least one of A, B, or C" would include, but is not limited to, a system having only A, a system having only B, a system having only C, a system having both A and B, a system having both A and C, a system having both B and C, and / or a system having both A, B, and C). One skilled in the art would also understand that virtually any transitional word and / or phrase presenting two or more alternative terms (whether in the specification, claims, or drawings) should be understood to contemplate the possibility of including one of the terms, either of the terms, or both of the terms. For example, the phrase "A or B" would be understood to include the possibility of "A" or "B" or "A and B."

[0059] In addition, where features or aspects of the disclosure are described in terms of Markush groups, those skilled in the art will recognize that the disclosure is also thereby described in terms of any individual member or subgroup of members of the Markush group.

[0060] As will be understood by those skilled in the art, for any and all purposes (such as in terms of providing a written description), the full range disclosed herein also includes any and all possible sub-ranges and combinations of sub-ranges.Any listed range can be easily understood to fully describe that the same range is decomposed into at least two equal parts, three equal parts, four equal parts, five equal parts, ten equal parts, etc., and the same range can be decomposed into at least two equal parts, three equal parts, four equal parts, five equal parts, ten equal parts, etc. As a non-limiting example, each scope discussed herein can be easily decomposed into lower third, middle third and upper third, etc. As will be understood by those skilled in the art, all languages ​​(such as "up to", "at least", etc.) include the numbers listed, and refer to the scope that can be subsequently decomposed into sub-ranges as described above.Finally, as will be understood by those skilled in the art, scope includes each individual member.Therefore, for example, a group with about 1-3 units refers to a group with about 1 unit, 2 units, or 3 units. Similarly, a group having about 1-5 cells refers to groups having about 1 cell, 2 cells, 3 cells, 4 cells, or 5 cells, etc.

[0061] Various above disclosed features and functions and other features and functions, or alternatives thereof, may be combined into many other different systems or applications. Those skilled in the art may subsequently make various currently unforeseen or unanticipated substitutions, modifications, changes or improvements therein, each of which is also intended to be covered by the disclosed embodiments.

[0062] Detailed description

[0063] The present disclosure is not limited to the particular systems, devices, and methods described, as these may vary. The terminology used in the specification is for the purpose of describing the particular versions or embodiments and is not intended to limit the scope.

[0064] Cytokine release syndrome ("CRS") and / or ICANS are common but serious side effects of CAR T cell therapy. CAR T cells can cause a large amount of pro-inflammatory cytokines to be released into the blood of subjects being treated with CAR T cells. This can cause high fever, low blood pressure (hypotension), fatigue, headache, myalgia, nausea, capillary leakage, tachycardia, and potential liver failure and kidney damage. CRS occurs in about 50-100% of patients. It is necessary to overcome the composition and method of CRS to enhance the therapeutic value of CAR T cell therapy. Various methods, compositions and kits are described herein for performing CAR T cell therapy with reduced or eliminated cytokine release syndrome (CRS) effects, immune effector cell-associated neurotoxicity syndrome (ICANS) effects, Parkinson's effects, or combinations thereof in subjects. The method may include administering CAR T cells and at least one pharmaceutical composition (such as a first pharmaceutical composition and / or a second pharmaceutical composition) to a subject. T cells and T cell therapy can be autologous or allogeneic.

[0065] In the present disclosure, the inventors have demonstrated that the first pharmaceutical composition including beraprost, beraprost isomers or a pharmaceutically acceptable salt of beraprost can alleviate the cytokine response associated with CRS. In particular, the inventors observed a reduction in proinflammatory cytokines (such as TNF-α and INF-γ). It is noteworthy that the inventors found that beraprost, beraprost isomers or a pharmaceutically acceptable salt of beraprost did not interfere with in vitro and in vivo CAR T cell killing.

[0066] In some embodiments, the use of beraprost, beraprost isomer or its pharmaceutically acceptable salt can alleviate the excessive release of proinflammatory cytokines, and thus reduce or eliminate the damage caused by CRS, and reduce or eliminate simultaneous or subsequent immune effector cell-related neurotoxicity syndrome (ICANS) effect or Parkinson's effect. ICANS usually occurs after CRS, but sometimes can occur simultaneously. When occurring after CRS, it can be many days later (for example, about 1 day, about 2 days, about 3 days, about 4 days, about 5 days or more) and sometimes even many weeks later. There are some differences between subjects, even between subjects with similar genetic backgrounds.

[0067] The current standard of care (SOC) for CRS includes the treatment of tocilizumab and the treatment of corticosteroids and supportive care based on observed CRS symptoms. The standard of care (SOC) for ICANS does not include the use of tocilizumab, but is a more intensive corticosteroid treatment and supportive care based on observed ICANS symptoms. Tocilizumab (for blocking IL-6 receptors) causes more IL-6 in circulation. Due to immunosuppression and other harmful downstream effects, the use of corticosteroids has significant limitations. Corticosteroids can be used prophylactically, although this is not typical or common. Individuals given corticosteroid treatment usually have to stay in the hospital for monitoring, thus extending their hospital stay and increasing related costs.

[0068] Due to the negative side effects of CAR T-cell therapy, hospital stays typically average about 7 to 14 days. In particular, patients with CRS and ICANS symptoms require lengthy hospital stays. The use of outpatient treatment is not recommended because the immunosuppressed patient population is at increased risk of infection.

[0069] The use of the first pharmaceutical compositions (such as those containing beraprost, an isomer or salt thereof) that are provided orally will allow more patients to seek life-saving CAR T cell therapy and bispecific antibody therapy.

[0070] The onset of CRS can be detected in a variety of ways. For example, the onset can be detected by measuring an increase in one or more cytokines or one or more inflammatory markers. Alternatively, the onset of CRS can be measured by the manifestation of clinical symptoms. Common symptoms include fever, hypotension and hypoxia.

[0071] Methods, compositions and kits can be used for therapies with reduced or eliminated effects from immune effector cell-associated neurotoxic syndrome (ICANS), Parkinson's or both. Methods, compositions and kits can also be used for therapies with reduced or eliminated severity measurements. Methods, compositions and kits can also be used for therapies with reduced or eliminated needs for corticosteroid treatment, IL-6 receptor blocker therapeutic agents and other biological treatments. Beraprost compound CTO1681 can potentially replace tocilizumab as an early treatment option.

[0072] CAR T-cell therapy

[0073] CAR T cell therapy can involve the infusion of T cells, which have been genetically engineered to express CAR to reprogram T cells to identify antigens expressed on the surface of target cells (e.g., tumor cells). CAR specificity can come from the extracellular domain of the engineered receptor, which can be derived from the antigen binding site of the antibody. The extracellular domain can be designed to reproduce a series of events in which T cells are thus activated and can be incorporated into stimulation and costimulatory domains (such as CD28 and / or 4-1BB or CD3z) to increase CAR T cell activation, survival and proliferation. In addition, CAR T cells can proliferate and differentiate into central or effector memory cells, and as a "living drug", it has been observed to continue in vivo for 30 days or even up to four years after administration. Once activated, the CAR T cells of clone expansion release cytokines and other soluble mediators that can directly kill target cells and normal cells expressing antigens.

[0074] CAR T cells can be any CAR T cells, such as (but not limited to) CD19 CAR T cells, BCMACAR T cells and / or CD19-CD3 bispecific CAR T cells.

[0075] Types of cancer

[0076] In some embodiments, CAR T cell therapy is administered to patients with cancer. Cancer can generally be any cancer suitable for the treatment of CAR T cell therapy. In some embodiments, cancer can be a hematological malignancy. For example, cancer can be B cell lymphoma, aggressive, relapsed or refractory diffuse large B cell lymphoma (DLBCL), primary mediastinal B cell lymphoma, high-grade B cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin's lymphoma, non-Hodgkin's lymphoma, acute myeloid leukemia or multiple myeloma. In some instances, cancer is B cell lymphoma. In some embodiments, cancer can be a solid tumor. Cancers suitable for treatment using CAR T cell therapy include brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal cancer, biliary tract cancer, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma, and liver metastases.

[0077] Methods of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration

[0078] The compounds and pharmaceutical compositions described herein may be administered at therapeutically effective dosage levels to treat the conditions, disorders and diseases described herein.

[0079] The compounds and pharmaceutical compositions described herein may be administered at prophylactically effective dosage levels to alleviate or prevent the conditions, disorders and diseases described.

[0080] In some embodiments, beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof can be used to treat CRS, ICANS, or both. In some embodiments, CRS or ICANS can be associated with CAR T cell administration.

[0081] In some embodiments, beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof do not interfere with CART cell-mediated cell killing. When CAR T cells bind or interact with their corresponding antigens on cancer that can cause the death of cancer cells, cell killing can occur. In some embodiments, beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof do not reduce or inhibit CAR T cell-mediated cell killing. In some embodiments, beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof do not reduce CAR T cell-mediated killing by more than about 1%, about 2%, about 3%, about 4% about 5%, about 6%, about 7%, about 8%, about 9%, about 10%, about 0.01% to about 0.1%, about 0.1% to about 1%, about 1% to about 10%, about 10% to about 20%, about 0.5% to about 5%, about 5% to about 15%, about 15% to about 25% or more. In some embodiments, beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof does not inhibit or reduce CAR T cell activation or proliferation.

[0082] In some embodiments, beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof can be used to treat grade 1 CRS, grade 2 CRS, grade 3 CRS, or grade 4 CRS. Treatment with beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof can reduce the severity of CRS, so that treatment can cause a higher level of CRS, such as grade 4 CRS that becomes a lower level of CRS (e.g., grade 1). In some embodiments, treatment with beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof can eliminate or prevent CRS. In some embodiments, grade 1 CRS can include a fever of about 38°C or higher. In some embodiments, grade 1 can include nausea, fatigue, headache, and hospitalization may be required. In some embodiments, grade 2 CRS can include a fever of about 38°C or higher and hypotension that does not require vasopressors. Grade 2 CRS can also include hypoxia or reduced oxygen that requires a low-flow nasal cannula or blow-by oxygen. In some embodiments, grade 2 CRS may include hypotension and / or organ toxicity. In some embodiments, grade 3 may include fever of about 38°C or higher and hypotension requiring vasopressors (with or without vasopressin treatment). Grade 3 may also include hypoxia requiring high-flow nasal cannula, mask, non-rebreathing mask, or venturi mask. In some embodiments, grade 4 may include fever of about 38°C or higher and hypotension and / or organ toxicity requiring multiple vasopressors (excluding vasopressin). Grade 4 may also include hypoxia and / or organ toxicity requiring positive pressure (CPAP, BiPAP, intubation, mechanical ventilation).

[0083] In some embodiments, beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can be used to treat grade 1 ICANS, grade 2 ICANS, grade 3 ICANS or grade 4 ICANS. Treatment with beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can reduce the severity of CRS, so that treatment can cause higher-grade ICANS, such as grade 4 ICANS that become lower-grade ICANS (e.g., grade 1 ICANS). In some embodiments, treatment with beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can eliminate or prevent ICANS. In some embodiments, grade 1 ICANS can have an immune effector cell-related encephalopathy (ICE) score of about 7-9. In some embodiments, grade 1 ICANS can include the following: level of consciousness: spontaneous awakening; seizures: none; motor performance: none; elevated ICP / cerebral edema: none. In some embodiments, grade 2 ICANS can include an ICE score of about 3-6. In some embodiments, the 2nd level ICANS may include the following: level of consciousness: awakened by sound; seizures: none; motor manifestations: none; elevated ICP / cerebral edema: none. In some embodiments, the 3rd level ICANS may include an ICE score of about 0-2. In some embodiments, the 3rd level ICANS may include the following: level of consciousness: awakened by tactile stimulation only; seizures: any rapidly relieved clinical seizure, or non-convulsive seizures on EEG relieved with intervention; motor manifestations: none; elevated ICP / cerebral edema: focal / regional edema on neuroimaging. In some embodiments, the 4th level ICANS may include an ICE score of about 0 (i.e., the patient or subject is unable to perform ICE). Grade 4 ICANS may include the following parameters: Level of consciousness: subject cannot be aroused or requires vigorous or repeated tactile stimulation to arouse, stupor, or coma; Seizures: life-threatening prolonged seizures (>5 min); or repetitive clinical or electrical seizures without recovery to baseline; Motor manifestations: deep focal motor weakness such as hemiparesis or paraparesis; Elevated ICP / brain edema: diffuse brain edema on neuroimaging; decerebrate or decorticate posturing; or cranial nerve VI palsy; or papilledema; or Cushing's triad.

[0084] In some embodiments, beraprost, beraprost isomer or its pharmaceutically acceptable salt can reduce the level of one or more cytokines.The non-limiting examples of the cytokine that level can be reduced include IL-1 α, IL-1 β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES and / or GM-CSF.In some embodiments, the level of one or more cytokines can be reduced by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95% or more. In some embodiments, the level of one or more cytokines may be reduced by about 1-10%, about 5-15%, about 10-20%, about 15-25%, about 20-30%, about 25-35%, about 30-40%, about 35-45%, about 40-50%, about 45-55%, about 50-60%, about 55-65%, about 60-70%, about 65-75%, about 70-80%, about 75-85%, about 80-90%, about 85-95%, or about 90-100%.

[0085] Beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can be used to reduce the level of one or more cytokines known to increase in about 0-36 hours after CAR T cell therapy. For example, beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can be used to reduce the level of IL-2, IL-15 and / or MCP-1. In some embodiments, beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can be used to reduce the level of one or more cytokines known to increase from about 2 days to 5 days after CAR T cell therapy. For example, cytokines can be IL-6, IL-8, IL-10, IFN-γ or TNF-α.

[0086] In some methods, beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof can be used in combination therapy methods with other active pharmaceutical ingredients. For example, a method for treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject can include administering CAR T cells, a first pharmaceutical composition, and a second pharmaceutical composition to the subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and the second pharmaceutical composition includes at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof.

[0087] Treatment of cytokine release syndrome associated with CAR T cell administration, ICANS or both additional methods may include administering CAR T cells and a first pharmaceutical composition to a subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, beraprost isomers or a pharmaceutically acceptable salt thereof; and the subject is relative to receiving the CART cells administered, but similar subjects who do not receive the pharmaceutical composition administered, experience reduced ICANS effects, Parkinson's effects or both. ICANS can be evaluated and graded using a cognitive assessment tool called "immune effector cell-related encephalopathy (ICE) assessment" tool, a level of consciousness, the presence and severity of epileptic seizures, motor control disorders and the presence of cerebral edema. Parkinson's effects can be measured by a variety of metrics (including tremors, muscle stiffness, nervous system problems, psychomotor retardation, handwriting changes and gait changes).

[0088] A further method for treating cytokine release syndrome, ICANS or both associated with CAR T cell administration includes administering CAR T cells and a first pharmaceutical composition to a subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer or a pharmaceutically acceptable salt thereof; and the subject experiences a reduced severity measurement relative to a similar subject receiving the administered CAR T cells but not receiving the administered first pharmaceutical composition. The severity measurement may include event level, event duration, event rate, incidence of ICU or hospital stay, duration of ICU or hospital stay, onset time, mortality, interference with antibiotics or other supportive drugs, or a combination thereof. Additional severity measurements include the use of supportive therapy, the use of medical interventions, and the use of intensive medical interventions (such as intubation).

[0089] Treatment of cytokine release syndrome associated with CAR T cell administration, ICANS or both additional methods may include administering CAR T cells and a first pharmaceutical composition to a subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, beraprost isomers or pharmaceutically acceptable salts thereof; and once the onset of CRS is detected by one or more of the increased levels of cytokines MIF, IL-5, IL-17A, IL-23, IFN-γ, CXCL9 / MIG, GCSF, VEGF-A and TGF-β, the first pharmaceutical composition is administered. Alternatively or additionally, the onset of CRS can be detected by one or more of the increased levels of cytokines (such as CCL2, IL-2, IL-6, IL-8, IL-10, IFN-γ, TNF-α, CXCL9, CXCL-10, VEGF, CCL3, GCSF and GMCSF). The onset of CRS can be detected in a variety of ways. For example, the onset can be detected by measuring the increase in one or more cytokines or one or more inflammatory markers. Alternatively, the onset of CRS can be measured by the presentation of symptoms. Common symptoms include fever, hypotension, and hypoxia.

[0090] Additional methods of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject may include administering CAR T cells and a first pharmaceutical composition to the subject, wherein: the first pharmaceutical composition includes at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; the subject experiences CRS, ICANS, a Parkinsonian effect, or a combination thereof; and the subject requires reduced treatment with at least one corticosteroid relative to a similar subject who receives administered CAR T cells but does not receive the administered first pharmaceutical composition. In some instances, the subject does not require treatment with at least one corticosteroid.

[0091] The use of the described methods, kits and pharmaceutical compositions can cause reduction or elimination of CRS, ICANS, Parkinson's or a combination thereof. Reduction can be an improvement or alleviation of the undesirable physiological symptoms that the patient subject is experiencing, a quantifiable reduction of one or more cytokine concentrations or both. Reduction can generally reduce any amount. For example, reduction can be at least about 10%, at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, at least about 95%, at least about 96%, at least about 97%, at least about 98%, at least about 99%, and in ideal cases, about 100% reduction (complete elimination of disease, symptoms or other undesirable properties). Reduction can be relative to the administration of CAR T cells, but the effect observed when there is no administration of the first pharmaceutical composition.

[0092] CAR T cells are usually delivered by infusion in a single administration, although multiple administrations are also possible. Although CRS does not occur in all patients, about 50-100% of patients receiving CAR T cell therapy develop CRS. CRS usually occurs within the first week, and can usually occur within the first two weeks after CAR T cell administration. The first pharmaceutical composition can be administered at the same time as the CAR T cells (i.e., without a delay period), or after the delay period. In some instances, the first pharmaceutical composition can be additionally administered once or more before the administration of CAR T cells. The delay period can be a predetermined time period after the administration of CART cells (e.g., about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7 days, about 8 days, about 9 days, about 10 days, about 11 days, about 12 days, about 13 days, about 14 days or more, or any range between two of these values). Exemplary ranges for the delay period include about 3 to 7 days, about 2 to 5 days, about 3 to 5 days, about 2 to 5 days, about 4 to 8 days, etc. Alternatively, the delay may continue until the onset of CRS is detected.

[0093] Various times and sequences of administration of the first pharmaceutical composition are possible. For example, the first pharmaceutical composition can be administered before the administration of CAR T cells, on the same day as the administration of CAR T cells, after the administration of CAR T cells, and combinations thereof. For example, the first pharmaceutical composition can be administered before the administration of CAR T cells, on the same day as the administration of CAR T cells, and after the administration of CAR T cells. In a specific example, the first pharmaceutical composition can be administered one day before the administration of CAR T cells, and then continued for at least about 14 additional days.

[0094] The onset of CRS can be detected by any general method, such as detecting fever, headache, anorexia, nausea, fatigue, myalgia, hypoxia, low blood pressure (hypotension), impaired coagulation, capillary leakage, tachycardia, organ system failure, etc. For example, a simple method for detecting the onset of CRS is to detect fever. Alternatively, the onset of CRS can be detected by monitoring the increased level of one or more cytokines (such as IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES and GM-CSF). Alternatively or additionally, the onset of CRS can be detected by the increased level of one or more of cytokines CCL2, IL-2, IL-6, IL-8, IL-10, IFN-γ, TNF-α, CXCL9, CXCL-10, VEGF, CCL3, GCSF and GMCSF. In some instances, the onset of CRS can be detected by monitoring the increased levels of one or more cytokines (such as IL-6, IFN-γ, TNF-α and IL-10). Alternatively or additionally, the onset of CRS can be detected by monitoring the increased levels of one or more cytokines (such as MIF, IL-5, IL-17A, IL-23, IFN-γ, CXCL9 / MIG, GCSF, VEGF-A and TGF-β). The onset of CRS can be detected in a variety of ways. For example, the onset can be detected by measuring the increase of one or more cytokines or one or more inflammatory markers. Alternatively, the onset of CRS can be measured by the manifestation of symptoms. Common symptoms include fever, hypotension and hypoxia. In some embodiments, the first pharmaceutical composition can reduce the level of one or more cytokines (such as, but not limited to IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES and GM-CSF).

[0095] For example, after the delay period or when detecting the onset of CRS, the first pharmaceutical composition can be administered for about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7 days, about 8 days, about 9 days, about 10 days, about 11 days, about 12 days, about 13 days, about 14 days or longer or any range between two of these values.CRS usually disappears within about a week, but has been recorded to last for about 30 days or longer.In some instances, the first pharmaceutical composition can be administered for more than about 14 days, such as about 15 days, about 16 days, about 17 days, about 18 days, about 19 days, about 20 days, about 21 days, about 22 days, about 23 days, about 24 days, about 25 days, about 26 days, about 27 days, about 28 days, about 29 days, about 30 days or longer or any range between two of these values. Exemplary ranges include about 1 day to 7 days, about 1 day to about 14 days, about 1 day to about 21 days, about 1 day to about 30 days, about 7 days to about 14 days, about 7 days to about 21 days, about 7 days to about 30 days, about 14 days to about 21 days, and about 21 days to about 30 days. In a specific example, administration of the first pharmaceutical composition can be initiated one day prior to administration of the CAR T cells and continued for at least about 14 days.

[0096] Treatment can generally be carried out according to any effective arrangement. For example, the first pharmaceutical composition disclosed herein can be administered once, about once a day, about twice a day, about three times a day, about four times a day, about once a week, about twice a week, about three times a week, about four times a week, about five times a week, about six times a week, about seven times a week, every other week, every other day, etc., for one or more dosing cycles as needed. It will be understood that the specific dosage level and dosing frequency of any particular subject can vary and will depend on a variety of factors, including the subject's species, age, weight, general health, sex and diet, mode and time of administration, excretion rate, drug combination and severity of a particular condition.

[0097] Administration can be performed by generally any method. Exemplary delivery methods of administration include topical delivery, subcutaneous delivery, intravenous injection (IV) delivery, intramuscular injection (IM) delivery, intrathecal injection (IT) delivery, intraperitoneal injection (IP) delivery, transdermal delivery, subcutaneous delivery, oral delivery, oral delivery through mucosa, pulmonary delivery, inhalation delivery, intranasal delivery, buccal delivery, rectal delivery, vaginal delivery and combinations thereof. In some instances, administration includes oral delivery, subcutaneous, inhalation, IV or IM.

[0098] In some instances, relative to the CAR T cells for administration, but similar subjects who do not receive the first pharmaceutical composition for administration, at least an effective amount of beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can be used to reduce or eliminate the need for the treatment of using at least one corticosteroid, tocilizumab, IL-6 receptor blocker therapeutic agent or its combination. In an ideal example, the subject does not need to use at least one corticosteroid, tocilizumab or IL-6 receptor blocker therapeutic agent for treatment. In some instances, the subject experiences CRS, ICANS, Parkinson's effect or its combination, but requires a dose or administration of a reduction or elimination of a corticosteroid, tocilizumab, IL-6 receptor blocker therapeutic agent or its combination, to accept the CAR T cells for administration, but do not accept the first pharmaceutical composition for administration of similar subjects, to achieve similar (or more excellent) clinical effects.

[0099] CAR T cells can generally be any CAR T cells. Examples of currently commercialized CAR T cell preparations include Abecma (idecabtagene vicleucel), Breyanzi (isocabtagene maraleucel), Kymriah (tisagenlecleucel), Tecartus (brexucabtagene autoleucel), Yescarta (axicabtagene ciloleucel), and Carvykti (ciltacabtagene autoleucel).

[0100] In some embodiments, beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof can reduce or eliminate hospitalization associated with the development of CRS, ICANS, or a combination thereof. In some embodiments, the methods of the present disclosure using beraprost, beraprost isomers, or pharmaceutically acceptable salts thereof can convert CAR-T therapy from primarily inpatient treatment to outpatient treatment.

[0101] Pharmaceutical composition

[0102] The drug combination described herein can be a first pharmaceutical composition or a second pharmaceutical composition. The first pharmaceutical composition can include at least one prostacyclin / prostaglandin analog. The second pharmaceutical composition can include at least one corticosteroid, tocilizumab, IL-6 receptor blocker or a combination thereof.

[0103] Examples of prostaglandins or prostaglandin analogs include prostaglandin, beraprost, taprostene, niloprost, iloprost, cicaprost, ciprostene, treprostinil, bosentan, uoprost, eptaprost, or isomers thereof, and pharmaceutically acceptable salts thereof. In some embodiments, the first pharmaceutical composition includes an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof. Beraprost has the chemical formula C 24 H 30 O 5 and has a single carboxylic acid group. In some embodiments, the prostacyclin analog is a beraprost salt, such as beraprost sodium (C 24 H 29 NaO 5 ; 2,3,3a,8b-tetrahydro-2-hydroxy-1-(3-hydroxy-4-methyl-1-octen-6-ynyl)-1H-cyclopenta[b]benzofuran-5-butyric acid, sodium salt)). Beraprost sodium (BPS; GP1001) may be a mixture of four isomers (two diastereomers (BPS-314 and BPS-315) and their two enantiomers, each of which is BPS-314d (CTO1681; GP1681, (+)-[1R,2R,3aS,8bS]-2,3,3a,8b-tetrahydro-2-hydroxy-1-[(E)-(3S,4S)-3-hydroxy-4-methyl-1-octen-6-ynyl)-1H-cyclopenta[b]benzofuran-5-butyric acid, monosodium salt; also known as isoprost sodium salt) and BPS-314l (GP1684) as well as BPS-315d (GP1683) and BPS-315l (GP1682)). Beraprost isomers are also described in U.S. Patent Publication No. US2014-0275237 A1. In some examples, the first pharmaceutical composition may contain 1, 2, 3 or all 4 isomers of beraprost. In some embodiments, the beraprost isomer is BPS-314d (CTO1681; isoberaprost sodium salt).

[0104] Beraprost and its preparation method are shown in U.S. Patent No. 7,345,181 and PCT Publication No. WO 2004 / 026224 entitled "Process for preparing prostaglandin derivatives and starting materials for the same". Beraprost can be obtained commercially from Yonsung Fine Chemicals (Gyeonggi-do, South Korea). Beraprost, beraprost isomer or its pharmaceutically acceptable salt can be present in the first pharmaceutical composition with generally any effective amount or effective concentration. Different drug forms can have beraprost, beraprost isomer or its pharmaceutically acceptable salt with different amounts or concentrations.

[0105] In some embodiments, the first pharmaceutical composition may contain 1, 2, 3 or all 4 isomers of beraprost. A beraprost isomer refers to a beraprost molecule having the same molecular formula as another beraprost molecule, but its atoms have different arrangements in space. In some embodiments, the isomer of beraprost may be a structural isomer or a stereoisomer. In some embodiments, a structural isomer may include isomers in which the bonds between atoms are different but have the same molecular formula. In some embodiments, an isomer may be a stereoisomer of beraprost, in which the bonds between atoms are the same, but the relative positions of atoms are different. In some embodiments, a stereoisomer of beraprost may be a diastereomer of beraprost or an enantiomer of beraprost. An isomer may be a different stereoisomer produced by one or more chiral centers in its chemical structure. Different isomers of beraprost may have different biological activities, and may sometimes be inactive or even have undesirable activity compared to other desired isomers.

[0106] In some embodiments, the first pharmaceutical composition may include BPS-314d (CTO1681; GP1681, (+)-[1R,2R,3aS,8bS]-2,3,3a,8b-tetrahydro-2-hydroxy-1-[(E)-(3S,4S)-3-hydroxy-4-methyl-1-octen-6-ynyl)-1H cyclopenta[b]benzofuran-5-butyric acid, monosodium salt; also known as isubaprost sodium salt). In some embodiments, the first pharmaceutical composition may include BPS-314l (GP1684). In some embodiments, the first pharmaceutical composition may include BPS-315d (GP1683). In some embodiments, the first pharmaceutical composition may include BPS-315l (GP1682).

[0107] In some embodiments, the first pharmaceutical composition may include one or more enantiomers of beraprost. Commonly used purity measurements are "enantiomeric excess" or "ee". A racemic mixture has an ee of about 0%, while a completely pure enantiomer will have an ee value of about 100%. It is desirable that the ee value of the first pharmaceutical composition is at least about 80%, at least about 85%, at least about 90%, at least about 91%, at least about 92%, at least about 93%, at least about 94%, at least about 95%, at least about 96%, at least about 97%, at least about 98%, at least about 99% and an ideal 100%.

[0108] As an example, a first pharmaceutical composition including the beraprost isomer BPS-314d (CTO1681; GP1681; isoberaprost sodium salt) can have an ee value of at least about 80%, at least about 85%, at least about 90%, at least about 91%, at least about 92%, at least about 93%, at least about 94%, at least about 95%, at least about 96%, at least about 97%, at least about 98%, at least about 99%, and ideally 100%.

[0109] In some embodiments, one or more isomers of beraprost can be separated from other isomers so that only selected isomers are included in the first pharmaceutical composition. In one embodiment, BPS-314d (CTO1681) can be separated from other isomers in beraprost. Commercially available chiral chromatographic columns can be used to achieve separation of isomers from beraprost. Additional purification steps can be performed. In some embodiments, a single isomer can be obtained by a chiral synthesis method.

[0110] In some embodiments, synthetic methods can be used to prepare a desired isomer (eg, enantiomer or stereoisomer) in an increased concentration relative to an undesired enantiomer or stereoisomer.

[0111] In some embodiments, the first pharmaceutical composition can have high purity both at the time of manufacture and at a later time (such as when in use). In some embodiments, the first pharmaceutical composition can have low or no levels of degradation products of beraprost, beraprost isomers, or a pharmaceutically acceptable salt thereof.

[0112] Impurities are undesirable in the first pharmaceutical composition and can come from different sources.Impurities can be ingredients in raw materials, residual solvents or synthetics that are not completely removed or purified from the final desired product.Contaminants can be materials that are unintentionally included in the final desired product due to manufacturing environment or other sources.Impurities and contaminants may be harmful or may be harmless and may be identified or not identified.In some instances, the first pharmaceutical composition contains no more than about 0.1% by weight of impurities or contaminants, no more than about 0.2% by weight of impurities or contaminants or no more than about 0.5% by weight of impurities or contaminants.In an ideal example, the composition does not contain detectable impurities or contaminants.

[0113] One or more degradation products may come from various pathways, such as instability, degradation or oxidation of the first pharmaceutical composition itself, or incompatibility or reaction between the first pharmaceutical composition and another component of the composition (such as one or more excipients), moisture or composition packaging. In some examples, the first pharmaceutical composition contains no more than about 0.1% by weight of degradation products, no more than about 0.2% by weight of degradation products, or no more than about 0.5% by weight of degradation products. In one example, the composition does not contain detectable degradation products.

[0114] The daily dose (mass) of prostaglandin / prostaglandin analog or beraprost, beraprost isomer or its pharmaceutically acceptable salt can generally be any effective amount or effective dose.For example, the effective amount (in micrograms) for treatment can comprise about 0.1 μ g to about 100 μ g, about 10 μ g to about 90 μ g or about 15 μ g to about 90 μ g or about 0.1 μ g to about 5000 μ g.Mass value is the salt weight merged, i.e. anion and cation together.The specific example of effective amount for treatment comprises about 0.1 μ g, about 1 μ g, about 5 μ g, about 10 μ g, about 15 μ g, about 20 μ g, about 30 μ g, about 40 μ g, about 45 μ g, about 50 μ g, about 60 μ g, about 70 μ g, about 80 μ g, about 90 μ g, about 100 μ g and the scope between any two in these numerical values. When administered in two or more daily doses, the amounts in the individual doses may be added together to produce the total daily dose. For example, CTO1681 may be administered in a dose of about 15-90 μg / day (divided into about 3 doses, and each individual dose is about 5-30 μg).

[0115] In some embodiments, the effective amount of beraprost, beraprost isomers or pharmaceutically acceptable salts thereof present in a unit dose (mass) of the first pharmaceutical composition is at least about 1 microgram, about 1 microgram to about 100 micrograms, about 1 microgram to about 80 micrograms, about 1 microgram to about 60 micrograms, about 1 microgram to about 50 micrograms, about 1 microgram to about 40 micrograms, about 51 micrograms to about 30 micrograms, about 1 microgram to about 20 micrograms, about 1 mg to about 10 micrograms or about 1 microgram to about 5 micrograms, or any value between these ranges. Specific examples include about 1 microgram, about 5 micrograms, about 10 micrograms, about 25 micrograms, about 50 micrograms, about 75 micrograms, about 100 micrograms, about 60 micrograms to about 360 micrograms, or any range between these values.

[0116] In some embodiments, the amount of beraprost, beraprost isomers or pharmaceutically acceptable salts thereof can be calculated based on the presence of a single desired isomer. For example, if a single isomer (such as BPS-314d (CTO1681; also known as isoprost sodium salt) is desired in an amount of about 15 micrograms to about 90 micrograms, this is equivalent to an amount of about 60 micrograms to about 360 micrograms of a racemic mixture of four isomers (wherein the amount of a single isomer is one-fourth of the mass).

[0117] In some embodiments, the first pharmaceutical composition comprising beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof achieves a Cmax of about 0.01 nanomolar to about 10 nanomolar, about 0.01 nanomolar to about 5 nanomolar, about 0.01 nanomolar to about 3 nanomolar, about 0.01 nanomolar to about 2 nanomolar, about 0.01 nanomolar to about 1 nanomolar, about 0.01 nanomolar to about 0.5 nanomolar, or any value therebetween. Specific examples include about 0.01 nanomolar, about 0.05 nanomolar, about 0.075 nanomolar, about 0.1 nanomolar, about 0.5 nanomolar, about 1 nanomolar, about 2 nanomolar, about 5 nanomolar, or about 10 nanomolar.

[0118] In some embodiments, the first pharmaceutical composition comprising beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof achieves a T of about 0.1 hour to about 5 hours, about 0.1 hour to about 4 hours, about 0.1 hour to about 3 hours, about 0.1 hour to about 2 hours, about 0.1 hour to about 1 hour, or any specific value between these ranges. max Specific examples include about 0.1 hours, about 0.5 hours, about 1 hour, about 1.5 hours, about 1.7 hours, about 2 hours, or about 5 hours.

[0119] In some embodiments, the first pharmaceutical composition including beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof achieves an AUC of about 0.01 ng.hr / mL to about 30 ng.hr / mL over a 48 hour period, about 0.01 ng.hr / mL to about 20 ng.hr / mL over a 48 hour period, about 0.01 ng.hr / mL to about 10 ng.hr / mL over a 48 hour period, about 0.01 ng.hr / mL to about 5 ng.hr / mL over a 48 hour period, about 0.01 ng.hr / mL to about 3 ng.hr / mL over a 48 hour period, about 0.01 ng.hr / mL to about 2 ng.hr / mL over a 48 hour period, or about 0.01 ng.hr / mL to about 1 ng.hr / mL over a 48 hour period. Specific examples include about 0.01 ng.hr / mL, about 0.05 ng.hr / mL, about 0.1 ng.hr / mL, about 0.5 ng.hr / mL, about 1 ng.hr / mL, about 2 ng.hr / mL, about 5 ng.hr / mL, about 10 ng.hr / mL, or about 30 ng.hr / mL.

[0120] In some examples, the first pharmaceutical composition may further include at least one anti-inflammatory component, such as at least one corticosteroid or at least one therapeutic monoclonal antibody.

[0121] In some embodiments, the first pharmaceutical composition further comprises a pharmaceutically acceptable excipient. Examples of pharmaceutically acceptable excipients that may be present in the composition include, but are not limited to, fillers / solvents, solvents / co-solvents, preservatives, antioxidants, suspending agents, surfactants, defoamers, buffers, chelating agents, sweeteners, flavoring agents, binders, extenders, disintegrants, diluents, lubricants, fillers, wetting agents, glidants, and combinations thereof.

[0122] In some instances, the first pharmaceutical composition may also include one or more exemplary fillers. Examples of exemplary fillers include cellulose and cellulose derivatives, such as microcrystalline cellulose; starch (such as dry starch, hydrolyzed starch) and starch derivatives (such as corn starch); cyclodextrin; sugar (such as powdered sugar) and sugar alcohol (such as lactose, mannitol, sucrose and sorbitol); inorganic fillers (such as aluminum hydroxide gel, precipitated calcium carbonate, carbonate, aluminum magnesium silicate, dibasic calcium phosphate); sodium chloride, silicon dioxide, titanium dioxide, titanium oxide, dihydrated calcium phosphate, calcium sulfate, aluminum oxide, kaolin, talc or a combination thereof. Fillers can be present in the composition from about 20wt% to about 65wt%, about 20wt% to about 50wt%, about 20wt% to about 40wt%, about 45wt% to about 65wt%, about 50wt% to about 65wt% or about 55wt% to about 65wt% of the total weight of the composition, or any value between these ranges.

[0123] In some instances, the first pharmaceutical composition also includes one or more disintegrants. The example of disintegrant includes starch, alginic acid, cross-linked polymer (such as, for example, cross-linked polyvinyl pyrrolidone, cross-linked sodium carboxymethyl cellulose), potassium starch glycolate, sodium starch glycolate, clay, cellulose, starch, gum or its combination. Disintegrant can be present in the composition from about 1wt% to about 10wt%, about 1wt% to about 9wt%, about 1wt% to about 8wt%, about 1wt% to about 7wt%, about 1wt% to about 6wt% or about 1wt% to about 5wt% or any numerical value between these ranges from the gross weight of the composition.

[0124] In some examples, the first pharmaceutical composition further comprises one or more binders, one or more binders comprising (but not limited to) cellulose, such as hydroxypropyl cellulose, methyl cellulose and hydroxypropyl methyl cellulose; starch (such as corn starch, pregelatinized starch and hydroxypropyl starch); waxes and natural and synthetic gums (such as gum arabic, tragacanth, sodium alginate); synthetic polymers (such as polymethacrylate and polyvinyl pyrrolidone); and povidone, dextrin, pullulan, agar, gelatin, tragacanth, polyethylene glycol or a combination thereof. The binder can be present in the composition from about 0.5wt% to about 5wt%, about 0.5wt% to about 4wt%, about 0.5wt% to about 3wt%, about 0.5wt% to about 2wt% or about 0.5wt% to about 1wt%, or any value between these ranges, of the total weight of the composition.

[0125] In some examples, the first pharmaceutical composition further includes one or more wetting agents, including but not limited to oleic acid, glyceryl monostearate, sorbitan monooleate, sorbitan monolaurate, triethanolamine oleate, polyoxyethylene sorbitan monooleate, polyoxyethylene sorbitan monolaurate, sodium oleate, sodium lauryl sulfate, poloxamer, poloxamer 188, polyoxyethylene ether, polyoxyethylene sorbitan fatty acid ester, polyoxyethylene fatty acid ester, polyethylene glycol fatty acid ester, polyoxyethylene hardened castor oil, polyoxyethylene alkyl ether, polysorbate, cetyl alcohol, glycerol fatty acid ester (e.g., triacetin, glyceryl monostearate, etc.), polyoxymethylene stearate, sodium lauryl sulfate, sorbitan fatty acid ester, sucrose fatty acid ester, benzalkonium chloride, polyethoxylated castor oil, and combinations thereof. The wetting agent can be present in the composition from about 0.1 wt % to about 1 wt %, about 0.1 wt % to about 2 wt %, about 0.1 wt % to about 3 wt %, about 0.1 wt % to about 4 wt % or about 0.1 wt % to about 5 wt %, or any value therebetween, based on the total weight of the composition.

[0126] In some examples, the first pharmaceutical composition also includes one or more lubricants, one or more lubricants including, but not limited to, stearic acid, magnesium stearate, calcium hydroxide, talc, corn starch, sodium stearyl fumarate, alkali metal and alkaline earth metal salts, waxes, boric acid, sodium benzoate, sodium acetate, sodium chloride, leucine, polyethylene glycol (PEG), methoxypolyethylene glycol, propylene glycol, sodium oleate, glyceryl behenate, stearyl palmitin, benzoic acid glyceryl ester, magnesium lauryl sulfate, sodium lauryl sulfate and combinations thereof. The lubricant can be present in the composition from about 0.1wt% to about 5wt%, about 0.1wt% to about 4wt%, about 0.1wt% to about 3wt%, about 0.1wt% to about 2wt% or about 0.1wt% to about 1wt% of the total weight of the composition, or any value between these ranges.

[0127] In some examples, the first pharmaceutical composition further comprises one or more glidants, the one or more glidants comprising (but not limited to) colloidal silicon dioxide, talc, sodium lauryl sulfate, natural starch and combinations thereof. The glidant may be present in the composition from about 0.05wt% to about 1wt%, about 0.05wt% to about 0.9wt%, about 0.05wt% to about 0.8wt%, about 0.05wt% to about 0.5wt% or about 0.05wt% to about 0.1wt% of the total weight of the composition, or any value between these ranges.

[0128] In some examples, the first pharmaceutical composition is a tablet and further includes a top coating, such as a hydroxypropyl-methylcellulose coating or a polyvinyl alcohol coating, and is available under the trade name Opadry (e.g., Opadry White, Opadry II) (Opadry is a registered trademark of BPSI Holdings, LLC, Wilmington, USA). The top coating can be present in the composition from about 1 wt% to about 10 wt%, about 1 wt% to about 9 wt%, about 1 wt% to about 8 wt%, about 1 wt% to about 7 wt%, about 1 wt% to about 6 wt%, or about 1 wt% to about 5 wt%, or any value therebetween, of the total weight of the composition.

[0129] In some instances, the first pharmaceutical composition can also include one or more preservatives.The example of preservative includes sodium benzoate, parabens, methyl paraben, ethyl paraben, butyl paraben and propyl paraben, chlorobutanol, benzyl alcohol, phenylethyl alcohol, dehydroacetic acid, sorbic acid, benzalkonium chloride (BKC), benzethonium chloride, phenol, phenylmercuric nitrate, thimerosal or its combination.Preservative can be included in liquid dosage form.Preservative can be enough to extend the shelf life or storage stability of liquid dosage form or the amount of both.Preservative can be from about 0.05wt% to about 1wt% of the gross weight of composition, about 0.05wt% to about 0.9wt%, about 0.05wt% to about 0.8wt%, about 0.05wt% to about 0.5wt% or about 0.05wt% to about 0.1wt% or any numerical value between these scopes is present in composition.

[0130] In some instances, the first pharmaceutical composition can also include one or more flavoring agents. The example of flavoring agent includes extracts of synthetic flavor oils and flavor spices and / or natural oils, plant leaves, flowers, fruits, etc., etc., or any combination thereof. Additional examples include cinnamon oil (cinnamon oil), wintergreen oil, peppermint oil, clove oil, bay oil, anise oil, eucalyptus, thyme oil, cedar leaf oil, nutmeg oil, sage oil, bitter almond oil and cassia oil (cassia oil), etc., or any combination thereof. Also useful as flavoring agents are vanilla, citrus oil (including lemon, orange, grape, lime and grapefruit) and fruit essence (including apple, banana, pear, peach, strawberry, raspberry, cherry, plum, pineapple, apricot, strawberry flavor, candied fruit flavor (tutti-fruityflavor), mint flavor) or any combination thereof. The flavoring agent can be present in the composition from about 0.1 wt % to about 5 wt %, about 0.1 wt % to about 4 wt %, about 0.1 wt % to about 3 wt %, about 0.1 wt % to about 2 wt % or about 0.1 wt % to about 1 wt %, or any value therebetween, based on the total weight of the composition.

[0131] In some instances, the first pharmaceutical composition may also include one or more antioxidants. Examples of antioxidants include flavonoids, anthocyanidins, anthocyanidins, proanthocyanidins, or combinations thereof. The antioxidant may be present in the composition in an amount of about 0.05wt% to about 1wt%, about 0.05wt% to about 0.9wt%, about 0.05wt% to about 0.8wt%, about 0.05wt% to about 0.5wt%, or about 0.05wt% to about 0.1wt%, or any value between these ranges, of the total weight of the composition.

[0132] Physical form of the pharmaceutical composition

[0133] The first pharmaceutical composition and / or the second pharmaceutical composition can be generally any physical form suitable for the application of treating a subject. These forms can be referred to as unit dosage forms, such as single pills or tablets. In some instances, the first pharmaceutical composition and / or the second pharmaceutical composition can be formulated as tablets, capsules, granules, powders, liquids, suspensions, gels, syrups, syrups, suppositories, patches, nasal sprays, aerosols, injectable, implantable sustained release formulations or mucoadhesive films. In some instances, the first pharmaceutical composition and / or the second pharmaceutical composition can be formed into tablets, bilayer tablets, capsules, multi-granules, drug coated spheres, matrix tablets or multi-core tablets. Physical form can be selected according to the desired method of treatment. In some instances, the physical form can be a liquid, for example, for oral or IV, IP, IM or IT administration.

[0134] The first pharmaceutical composition and / or the second pharmaceutical composition can be manufactured by various conventional methods, such as conventional mixing, dissolving, granulating, making dragees, grinding, emulsifying, encapsulating, embedding or freeze-drying processes. The first pharmaceutical composition and / or the second pharmaceutical composition can be prepared in a conventional manner using one or more physiologically acceptable carriers, diluents, excipients or auxiliary agents that promote active agents to be processed into pharmaceutical preparations. According to the selected route of administration, appropriate formulations can be selected.

[0135] For topical administration, the first pharmaceutical composition and / or the second pharmaceutical composition described herein may be formulated as solutions, gels, ointments, creams, suspensions, etc., as known in the art. Systemic compositions include, but are not limited to, those designed for administration by injection (e.g., subcutaneous, intravenous (IV), intramuscular (IM), intrathecal (IT), intraperitoneal (IP)), and those designed for transdermal, subcutaneous, transmucosal oral or pulmonary administration. For injection, the first pharmaceutical composition and / or the second pharmaceutical composition may be formulated into an aqueous solution, preferably formulated into a physiologically compatible buffer, such as Hank's solution, Ringer's solution or saline buffer and / or certain emulsion preparations. The solution may contain one or more formulation agents, such as suspending agents, stabilizers and / or dispersants. In certain instances, the first pharmaceutical composition and / or the second pharmaceutical composition may be provided in powder form for reconstitution with a suitable solvent (e.g., sterile pyrogen-free water) prior to use. For transmucosal administration, one or more permeants suitable for the barrier to be permeated may be used in the formulation. Such penetrants are generally known in the art.

[0136] For oral administration, the first pharmaceutical composition and / or the second pharmaceutical composition can be combined with beraprost, its isomer or pharmaceutically acceptable salt and one or more pharmaceutically acceptable carriers known in the art. Such carriers are conveniently formulated into tablets, pills, dragees, capsules, liquids, gels, syrups, slurries, suspensions, etc., for oral ingestion by patients to be treated. For oral solid preparations (such as, for example, powders, capsules and tablets), suitable excipients include fillers, such as sugars, such as lactose, sucrose, mannitol and sorbitol; cellulose preparations, such as corn starch, wheat starch, rice starch, potato starch, gelatin, tragacanth gum, methylcellulose, hydroxypropyl methylcellulose, sodium carboxymethylcellulose and / or polyvinylpyrrolidone (PVP); granulating agents; and binding agents. If desired, disintegrants such as cross-linked polyvinylpyrrolidone, agar or alginic acid or its salt, such as sodium alginate, can be added. If desired, solid dosage forms can be sugar-coated or enteric-coated using standard techniques.

[0137] For oral liquid preparations, such as, for example, suspensions, elixirs and solutions, suitable carriers, excipients or diluents include water, glycols, oils, alcohols, etc. In addition, flavoring agents, preservatives, coloring agents, etc. may be added. For buccal administration, the composition may take the form of tablets, lozenges, etc. formulated in conventional manner.

[0138] For administration by inhalation, the first pharmaceutical composition and / or the second pharmaceutical composition may be delivered in the form of an aerosol spray from a pressurized package or nebulizer using a suitable propellant, for example, dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide or other suitable gas. In the case of a pressurized aerosol, the dosage unit may be determined by providing a valve to deliver a metered amount. For example, capsules and cartridges (e.g., made of gelatin) for use in an inhaler or insufflator may be formulated as a powder mix containing the compound and a suitable powder base (e.g., lactose or starch).

[0139] In some instances, the first pharmaceutical composition and / or the second pharmaceutical composition is a rapid release first pharmaceutical composition and / or the second pharmaceutical composition, a modified release first pharmaceutical composition and / or the second pharmaceutical composition, or a combination thereof. In some instances, the rapid release first pharmaceutical composition releases beraprost, beraprost isomers, or a pharmaceutically acceptable salt thereof within a short period of time (usually less than about 4 hours, less than about 3.5 hours, less than about 3 hours, less than about 2.5 hours, less than about 2 hours, less than about 90 minutes, less than about 60 minutes, less than about 45 minutes, less than about 30 minutes, less than about 20 minutes, or less than about 10 minutes) after administration.

[0140] In some embodiments, the first pharmaceutical composition is a rapid release first pharmaceutical composition comprising microcrystalline cellulose, hydroxypropyl cellulose, lactose monohydrate, pregelatinized starch, magnesium stearate and / or purified water. In some embodiments, the composition may comprise the use of Coating prepared by film coating process.

[0141] In some instances, the regulated release composition can release beraprost, beraprost isomer or its pharmaceutically acceptable salt with sustained rate or controlled rate in the extended time period or can release beraprost, beraprost isomer or its pharmaceutically acceptable salt after the lag time after application.For example, beraprost, beraprost isomer or its pharmaceutically acceptable salt can be applied after 4 hours, applied after 8 hours, applied after 12 hours, applied after 16 hours or applied after 24 hours release from composition.The regulated release composition comprises extended release composition, sustained release composition and delayed release composition. In some examples, a modified release composition may release about 10% in about 2 hours, about 20% in about 2 hours, about 40% in about 2 hours, about 50% in about 2 hours, about 10% in about 3 hours, about 20% in about 3 hours, about 40% in about 3 hours, about 50% in about 3 hours, about 10% in about 4 hours, about 20% in about 4 hours, about 40% in about 4 hours, about 50% in about 4 hours, about 10% in about 6 hours, about 20% in about 6 hours, about 40% in about 6 hours, or about 50% in about 6 hours.

[0142] In some examples, the modified release composition can include a matrix selected from microcrystalline cellulose, sodium carboxymethylcellulose, hydroxyalkyl cellulose (such as hydroxypropyl methylcellulose and hydroxypropyl cellulose), polyethylene oxide, alkyl cellulose (such as methyl cellulose and ethyl cellulose), polyethylene glycol, polyvinyl pyrrolidone, cellulose acetate, cellulose acetate butyrate, cellulose acetate phthalate, cellulose acetate trimellitate, polyvinyl acetate phthalate, polyalkyl methacrylate, polyvinyl acetate and mixtures thereof.

[0143] The regulated release composition can also be formulated into a depot preparation. Such a long-acting preparation can be used by implantation (for example, subcutaneously or intramuscularly) or by intramuscular injection. Therefore, for example, the compound can be formulated with a suitable polymeric material or a hydrophobic material (for example, as an emulsion in an acceptable oil) or an ion exchange resin, or is formulated into a slightly soluble derivative (for example, is formulated into a slightly soluble salt).

[0144] Subjects to be treated

[0145] The subject can generally be any mammal. Examples of subjects include non-human primates, humans, dogs, cats, mice, rats, cattle, goats, sheep, rabbits, horses, monkeys and pigs. In some instances, the subject is a human. The terms "subject," "individual" or "patient" are used interchangeably, and as used herein, are intended to include humans and non-human animals. Non-human animals include all vertebrates, for example, mammals and non-mammals, such as non-human primates, monkeys, sheep, dogs, rats, cats, cattle, horses, chickens, amphibians and reptiles. Examples of mammals include non-human primates, monkeys, sheep, dogs, cats, cattle and horses. In some instances, the subject is one or more people. The method is applicable to treating people with cancer. The subject can be symptomatic or asymptomatic.

[0146] Pill Box

[0147] In additional examples, the kit is provided for treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject. The kit may include a first container, the first container containing a first pharmaceutical composition, the first drug substance including at least an effective amount of prostaglandin / prostaglandin analog, or beraprost, beraprost isomer, or a pharmaceutically acceptable salt thereof; a second container, the second container containing a second pharmaceutical composition, the second pharmaceutical composition including at least one corticosteroid, tocilizumab, IL-6 receptor blocker, or a combination thereof; a third container, the third container containing CAR T cells; and instructions for use for administering the first pharmaceutical composition, the second pharmaceutical composition, and the CAR T cells to the subject. Any of the pharmaceutical compositions described above may be included in the kit. The kit may also include a fourth container containing additional pharmaceutical compositions or other active ingredients, etc. In some examples, the first container may contain a first pharmaceutical composition, the second container contains a second pharmaceutical composition, the third container contains CAR T cells, and the fourth container may contain at least one solvent or a plurality of solvents to be mixed with the first pharmaceutical composition before being administered to the subject according to the instructions for use. In one example, the kit may include a first container (the first container contains beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof), a second container (the second container contains a second pharmaceutical composition, the second pharmaceutical composition includes at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof), a third container (the third container contains CAR T cells), and a fourth container (the fourth container contains an aqueous solvent). In some examples, the beraprost isomer is BPS-314d (CTO1681).

[0148] In other examples, the kit may include: a first container, the first container containing a first pharmaceutical composition, the first pharmaceutical composition including at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; a second container, the second container containing a second pharmaceutical composition, the second pharmaceutical composition including at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof, and instructions for administering the first pharmaceutical composition, the second pharmaceutical composition, and CAR T cells to a subject. The kit may also contain a third container, the third container containing CAR T cells. The kit may also include a fourth container, the fourth container containing water or an aqueous solution.

[0149] Further aspects of the invention are also described in the following numbered clauses:

[0150] 1. A method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering to the subject CAR T cells, a first pharmaceutical composition, and a second pharmaceutical composition; wherein:

[0151] The first pharmaceutical composition comprises at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof; and

[0152] The second pharmaceutical composition includes at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof.

[0153] 2. The method according to clause 1, wherein the pharmaceutically acceptable salt is beraprost sodium salt.

[0154] 3. The method of clause 1, wherein the beraprost comprises at least one of BPS-314d, BPS-314l, BPS-315d and BPS-315l.

[0155] 4. The method according to clause 1, wherein beraprost is BPS-314d (isoberaprost sodium salt).

[0156] 5. The method of clause 1, wherein:

[0157] CAR T cell administration is performed to treat cancer; and

[0158] The cancer is B-cell lymphoma, aggressive, relapsed, or refractory diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia, or multiple myeloma.

[0159] 6. The method of clause 1, wherein

[0160] CAR T cell administration is performed to treat cancer; and

[0161] The cancer is brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal, biliary tract, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma or liver metastasis.

[0162] 7. The method as described in clause 1,

[0163] CAR T cell administration is performed to treat cancer; and

[0164] One of the cancers is B-cell lymphoma.

[0165] 8. The method of clause 1, wherein the subject is a mammal.

[0166] 9. The method of clause 1, wherein the subject is a non-human primate, monkey, cat, dog, pig, cow, goat, horse, sheep or rabbit.

[0167] 10. The method of clause 1, wherein the subject is a human.

[0168] 11. The method of clause 1, wherein:

[0169] Prior to administering the CAR T cells to the subject, administering a first pharmaceutical composition to the subject; and

[0170] After administering the CAR T cells to the subject, a second pharmaceutical composition is administered to the subject.

[0171] 12. The method of clause 1, wherein:

[0172] administering a first pharmaceutical composition to the subject before and after administering the CAR T cells to the subject; and

[0173] After administering the CAR T cells to the subject, a second pharmaceutical composition is administered to the subject.

[0174] 13. The method of clause 1, wherein the CAR T cells, the first pharmaceutical composition, and the second pharmaceutical composition are administered to the subject simultaneously.

[0175] 14. The method of clause 1, wherein the first pharmaceutical composition and the second pharmaceutical composition are administered to the subject after the CAR T cells are administered to the subject.

[0176] 15. The method of clause 1, wherein:

[0177] After administering the CAR T cells to the subject, administering the first pharmaceutical composition and the second pharmaceutical composition to the subject; and

[0178] The first pharmaceutical composition and the second pharmaceutical composition are administered simultaneously.

[0179] 16. The method of clause 1, wherein the first pharmaceutical composition and the second pharmaceutical composition are administered to the subject prior to administering the CAR T cells to the subject.

[0180] 17. The method of clause 1, wherein the first pharmaceutical composition is administered to the subject starting about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, or about 7 days after the CAR T cells are administered to the subject.

[0181] 18. The method of clause 1, wherein the first pharmaceutical composition is administered to the subject starting about 3 days to about 7 days after the CAR T cells are administered to the subject.

[0182] 19. The method of clause 1, wherein:

[0183] After administering the CAR T cells to the subject; and

[0184] Once the onset of CRS is detected,

[0185] The first pharmaceutical composition is then administered to the subject.

[0186] 20. The method of clause 1, wherein:

[0187] After administering the CAR T cells to the subject; and

[0188] Once the onset of CRS is detected by increased levels of one or more of the cytokines IL-1α, IL-β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES, and GM-CSF,

[0189] The first pharmaceutical composition is then administered to the subject.

[0190] 21. The method of clause 1, wherein:

[0191] After administering the CAR T cells to the subject; and

[0192] Once the onset of CRS is detected by increased levels of one or more of the cytokines IL-6, IL-10, IFN-γ, and TNF-α,

[0193] The first pharmaceutical composition is then administered to the subject.

[0194] 22. The method of Clause 1, wherein the first pharmaceutical composition is administered for a period of about 1 day to about 30 days.

[0195] 23. The method of Clause 1, wherein the first pharmaceutical composition is administered for a period of about 7 days to about 14 days.

[0196] 24. The method of clause 1, wherein the first drug composition is administered beginning one day prior to administration of the CAR T cells and continues to be administered for a period of at least about 14 days.

[0197] 25. The method of clause 1, further comprising administering a first pharmaceutical composition to the subject prior to administration of the CAR T cells.

[0198] 26. The method of clause 1, wherein the subject experiences reduced CRS relative to a similar subject who receives administered CAR T cells but does not receive administered the first pharmaceutical composition.

[0199] 27. The method of clause 1, wherein the subject does not experience CRS.

[0200] 28. The method of clause 1, wherein the CAR T cells are autologous.

[0201] 29. The method of clause 1, wherein the CAR T cells are allogeneic.

[0202] 30. The method of clause 1, wherein the first pharmaceutical composition further comprises at least one excipient, at least one filler, at least one disintegrant, at least one binder, at least one wetting agent, at least one lubricant, at least one glidant, at least one preservative, at least one flavoring agent, at least one antioxidant, or a combination thereof.

[0203] 31. The method of clause 1, wherein the first pharmaceutical composition is formulated as a tablet, capsule, granules, powder, liquid, suspension, gel, syrup, slurry, suppository, patch, nasal spray, aerosol, injectable, implantable sustained release formulation or mucoadhesive film.

[0204] 32. The method of clause 1, wherein the administration operation comprises local delivery, subcutaneous delivery, intravenous (IV) delivery, intramuscular (IM) delivery, intrathecal (IT) delivery, intraperitoneal (IP) delivery, transdermal delivery, subcutaneous delivery, oral delivery, transmucosal oral delivery, pulmonary delivery, inhalation delivery, intranasal delivery, buccal delivery, rectal delivery, vaginal delivery or a combination thereof.

[0205] 33. The method of Clause 1, wherein administering comprises oral delivery or intravenous (IV) delivery.

[0206] 34. The method of Clause 1, wherein the beraprost or a pharmaceutically acceptable salt thereof is present in the unit dose of the first pharmaceutical composition in an amount of about 1 microgram to about 100 micrograms.

[0207] 35. The method of Clause 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of at least about 0.1 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0208] 36. The method of Clause 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 0.1 micrograms to about 5000 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0209] 37. The method of Clause 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 15 micrograms to about 90 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0210] 38. The method of Clause 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 60 micrograms to about 360 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0211] 39. The method of clause 1, wherein the CAR T cells are Abecma (idecabtagene vicleucel), Breyanzi (Likimelanzi), Kymriah (tesalenzab), Tecartus (brexucabtagene autoleucel), Yescarta (Akirame), Carvykti (Cedaciclib), Belito (Belintoumab), or a combination thereof.

[0212] 40. A method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering to the subject CAR T cells and a first pharmaceutical composition, wherein:

[0213] The first pharmaceutical composition comprises at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof; and

[0214] The subject experiences reduced ICANS effects, Parkinsonian effects, or both relative to a similar subject who received the administered CAR T cells but did not receive the administered first pharmaceutical composition.

[0215] 41. The method of clause 40, wherein the pharmaceutically acceptable salt is beraprost sodium salt.

[0216] 42. The method of clause 40, wherein the beraprost comprises at least one of BPS-314d, BPS-3141, BPS-315d, and BPS-3151.

[0217] 43. The method of clause 40, wherein the beraprost is BPS-314d (isoberaprost sodium salt).

[0218] 44. The method of clause 40, wherein:

[0219] CAR T cell administration is performed to treat cancer; and

[0220] The cancer is B-cell lymphoma, aggressive, relapsed, or refractory diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia, or multiple myeloma.

[0221] 45. The method of clause 40, wherein:

[0222] CAR T cell administration is performed to treat cancer; and

[0223] The cancer is brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal, biliary tract, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma or liver metastasis.

[0224] 46. ​​The method of clause 40, wherein:

[0225] CAR T cell administration is performed to treat cancer; and

[0226] The cancer is B-cell lymphoma.

[0227] 47. The method of clause 40, wherein the subject is a mammal.

[0228] 48. The method of clause 40, wherein the subject is a non-human primate, monkey, cat, dog, pig, cow, goat, horse, sheep or rabbit.

[0229] 49. The method of clause 40, wherein the subject is a human.

[0230] 50. The method of clause 40, wherein a first pharmaceutical composition is administered to the subject prior to administering the CAR T cells to the subject.

[0231] 51. The method of clause 40, wherein:

[0232] Prior to administering the CAR T cells, administering a first pharmaceutical composition to the subject; and

[0233] After administering the CAR T cells to the subject, a first pharmaceutical composition is administered to the subject.

[0234] 52. The method of clause 40, wherein the CAR T cells and the first drug composition are administered to the subject simultaneously.

[0235] 53. The method of clause 40, wherein a first pharmaceutical composition is administered to the subject after the CAR T cells are administered to the subject.

[0236] 54. The method of clause 40, wherein the first pharmaceutical composition is administered to the subject starting about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, or about 7 days after the CAR T cells are administered to the subject.

[0237] 55. The method of clause 40, wherein administration of the first pharmaceutical composition to the subject begins about 3 days to about 7 days after administration of the CAR T cells to the subject.

[0238] 56. The method of clause 40, wherein:

[0239] After administering the CAR T cells to the subject; and

[0240] Once the onset of CRS is detected,

[0241] The first pharmaceutical composition is then administered to the subject.

[0242] 57. The method of clause 40, wherein:

[0243] After administering the CAR T cells to the subject; and

[0244] Once the onset of CRS is detected by increased levels of one or more of the cytokines IL-1α, IL-β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES, and GM-CSF,

[0245] The first pharmaceutical composition is then administered to the subject.

[0246] 58. The method of clause 40, wherein:

[0247] After administering the CAR T cells to the subject; and

[0248] Once the onset of CRS is detected by increased levels of one or more of the inflammatory markers CRP (C-reactive protein) and ferritin, which are associated with CRS,

[0249] The first pharmaceutical composition is then administered to the subject.

[0250] 59. The method of clause 40, wherein the first pharmaceutical composition is administered for a period of about 1 day to about 30 days.

[0251] 60. The method of Clause 40, wherein the first pharmaceutical composition is administered for a period of about 7 days to about 14 days.

[0252] 61. The method of clause 40, wherein the first drug composition is administered beginning one day prior to administration of the CAR T cells and continues to be administered for a period of at least about 14 days.

[0253] 62. The method of clause 40, further comprising administering a first pharmaceutical composition to the subject prior to administration of the CAR T cells.

[0254] 63. The method of clause 40, wherein the subject experiences a reduced ICANS effect relative to a similar subject who receives administered CAR T cells but does not receive administered the first pharmaceutical composition.

[0255] 64. The method of clause 40, wherein the subject does not experience an ICANS effect.

[0256] 65. The method of clause 40, wherein the subject experiences reduced Parkinsonian effects relative to a similar subject who receives administered CAR T cells but does not receive administered the first pharmaceutical composition.

[0257] 66. The method of clause 40, wherein the subject does not experience Parkinsonian effects.

[0258] 67. The method of clause 40, wherein the CAR T cells are autologous.

[0259] 68. The method of clause 40, wherein the CAR T cells are allogeneic.

[0260] 69. The method of clause 40, wherein the first pharmaceutical composition further comprises at least one excipient, at least one filler, at least one disintegrant, at least one binder, at least one wetting agent, at least one lubricant, at least one glidant, at least one preservative, at least one flavoring agent, at least one antioxidant, or a combination thereof.

[0261] 70. The method of clause 40, wherein the first pharmaceutical composition is formulated as a tablet, capsule, granules, powder, liquid, suspension, gel, syrup, slurry, suppository, patch, nasal spray, aerosol, injectable, implantable sustained release formulation or mucoadhesive film.

[0262] 71. A method as described in clause 40, wherein the administration operation includes local delivery, subcutaneous delivery, intravenous injection (IV) delivery, intramuscular injection (IM) delivery, intrathecal injection (IT) delivery, intraperitoneal injection (IP) delivery, transdermal delivery, subcutaneous delivery, oral delivery, transmucosal oral delivery, pulmonary delivery, inhalation delivery, intranasal delivery, buccal delivery, rectal delivery, vaginal delivery or a combination thereof.

[0263] 72. The method of clause 40, wherein administering comprises oral delivery or intravenous (IV) delivery.

[0264] 73. The method of Clause 40, wherein the beraprost or a pharmaceutically acceptable salt thereof is present in the unit dose of the first pharmaceutical composition in an amount of about 1 microgram to about 100 micrograms.

[0265] 74. The method of Clause 40, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of at least about 0.1 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0266] 75. The method of Clause 40, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 0.1 micrograms to about 5000 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0267] 76. The method of Clause 40, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 15 micrograms to about 90 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0268] 77. The method of Clause 40, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 60 micrograms to about 360 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0269] 78. The method of clause 40, wherein the CAR T cells are Abecma (idecabtagene vicleucel), Breyanzi (Likimelanzi), Kymriah (tesalenzab), Tecartus (brexucabtagene autoleucel), Yescarta (Akirame), Carvykti (Cedaciclib), Belito (Belintoumab), or a combination thereof.

[0270] 79. A method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering to the subject CAR T cells and a first pharmaceutical composition, wherein:

[0271] The first pharmaceutical composition comprises at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof; and

[0272] The subject experiences a reduced severity measure relative to a similar subject who received the administered CAR T cells but did not receive the administered first pharmaceutical composition.

[0273] 80. The method of Clause 79, wherein the pharmaceutically acceptable salt is beraprost sodium salt.

[0274] 81. The method of clause 79, wherein the beraprost comprises at least one of BPS-314d, BPS-3141, BPS-315d, and BPS-3151.

[0275] 82. The method of clause 79, wherein the beraprost is BPS-314d (isoberaprost sodium salt).

[0276] 83. The method of clause 79, wherein:

[0277] CAR T cell administration is performed to treat cancer; and

[0278] The cancer is B-cell lymphoma, aggressive, relapsed, or refractory diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia, or multiple myeloma.

[0279] 84. The method of clause 79, wherein:

[0280] CAR T cell administration is performed to treat cancer; and

[0281] The cancer is brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal, biliary tract, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma or liver metastasis.

[0282] 85. The method of clause 79, wherein:

[0283] CAR T cell administration is performed to treat cancer; and

[0284] The cancer is B-cell lymphoma.

[0285] 86. The method of clause 79, wherein the subject is a mammal.

[0286] 87. The method of clause 79, wherein the subject is a non-human primate, monkey, cat, dog, pig, cow, goat, horse, sheep or rabbit.

[0287] 88. The method of clause 79, wherein the subject is a human.

[0288] 89. The method of clause 79, wherein a first pharmaceutical composition is administered to the subject prior to administering the CAR T cells to the subject.

[0289] 90. The method of clause 79, wherein:

[0290] Prior to administering the CAR T cells, administering a first pharmaceutical composition to the subject; and

[0291] After administering the CAR T cells to the subject, a first pharmaceutical composition is administered to the subject.

[0292] 91. The method of clause 79, wherein the CAR T cells and the first drug composition are administered to the subject simultaneously.

[0293] 92. The method of clause 79, wherein a first pharmaceutical composition is administered to the subject after the CAR T cells are administered to the subject.

[0294] 93. The method of clause 79, wherein the first pharmaceutical composition is administered to the subject starting about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, or about 7 days after the CAR T cells are administered to the subject.

[0295] 94. The method of clause 79, wherein the first pharmaceutical composition is administered to the subject beginning about 3 days to about 7 days after the CAR T cells are administered to the subject.

[0296] 95. The method of clause 79, wherein:

[0297] After administering the CAR T cells to the subject; and

[0298] Once the onset of CRS is detected,

[0299] administering a first pharmaceutical composition to the subject

[0300] 96. The method of clause 79, wherein:

[0301] After administering the CAR T cells to the subject; and

[0302] Once the onset of CRS is detected by increased levels of one or more of the cytokines IL-1α, IL-β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES, and GM-CSF,

[0303] The first pharmaceutical composition is then administered to the subject.

[0304] 97. The method of clause 79, wherein:

[0305] After administering the CAR T cells to the subject; and

[0306] Once the onset of CRS is detected by increased levels of one or more of the inflammatory markers CRP (C-reactive protein) and ferritin, which are associated with CRS,

[0307] The first pharmaceutical composition is then administered to the subject.

[0308] 98. The method of clause 79, wherein the first pharmaceutical composition is administered for a period of about 1 day to about 30 days.

[0309] 99. The method of clause 79, wherein the first pharmaceutical composition is administered for a period of about 7 days to about 14 days.

[0310] 100. The method of clause 79, wherein the first drug composition is administered beginning one day prior to administration of the CAR T cells and continues to be administered for a period of at least about 14 days.

[0311] 101. The method of clause 79, further comprising administering a first pharmaceutical composition to the subject prior to administration of the CAR T cells.

[0312] 102. A method as described in clause 79, wherein the severity measure is event level, event duration, event incidence, incidence of ICU or hospital stay, duration of ICU or hospital stay, time to onset, mortality, interference with antibiotics or other supportive medications, or a combination thereof.

[0313] 103. The method of clause 79, wherein the CAR T cells are autologous.

[0314] 104. The method of clause 79, wherein the CAR T cells are allogeneic.

[0315] 105. The method of clause 79, wherein the first pharmaceutical composition further comprises at least one excipient, at least one filler, at least one disintegrant, at least one binder, at least one wetting agent, at least one lubricant, at least one glidant, at least one preservative, at least one flavoring agent, at least one antioxidant, or a combination thereof.

[0316] 106. The method of clause 79, wherein the first pharmaceutical composition is formulated as a tablet, capsule, granules, powder, liquid, suspension, gel, syrup, slurry, suppository, patch, nasal spray, aerosol, injectable, implantable sustained release formulation or mucoadhesive film.

[0317] 107. A method as described in clause 79, wherein the administration operation includes local delivery, subcutaneous delivery, intravenous injection (IV) delivery, intramuscular injection (IM) delivery, intrathecal injection (IT) delivery, intraperitoneal injection (IP) delivery, transdermal delivery, subcutaneous delivery, oral delivery, transmucosal oral delivery, pulmonary delivery, inhalation delivery, intranasal delivery, buccal delivery, rectal delivery, vaginal delivery or a combination thereof.

[0318] 108. The method of clause 79, wherein administering comprises oral delivery or intravenous (IV) delivery.

[0319] 109. The method of Clause 79, wherein the beraprost or a pharmaceutically acceptable salt thereof is present in the unit dose of the first pharmaceutical composition in an amount of about 1 microgram to about 100 micrograms.

[0320] 110. The method of Clause 79, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of at least about 0.1 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0321] 111. The method of Clause 79, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 0.1 micrograms to about 5000 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0322] 112. The method of Clause 79, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 15 micrograms to about 90 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0323] 113. The method of Clause 79, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 60 micrograms to about 360 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0324] 114. The method of clause 79, wherein the CAR T cells are Abecma (idecabtagene vicleucel), Breyanzi (Likimelanzi), Kymriah (tesalenzab), Tecartus (brexucabtagene autoleucel), Yescarta (Akirame), Carvykti (Cedaciclib), Belinto (Belintoumab), or a combination thereof.

[0325] 115. A method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering to the subject CAR T cells and a first pharmaceutical composition, wherein:

[0326] The first pharmaceutical composition comprises at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof; and

[0327] Once the onset of CRS is detected by increased levels of one or more of the cytokines MIF, IL-5, IL-17A, IL-23, IFN-γ, CXCL9 / MIG, GCSF, VEGF-A, and TGF-β, or one or more of the inflammatory biomarkers C-reactive protein (CRP) and ferritin, the first pharmaceutical composition is administered.

[0328] 116. The method of clause 115, wherein the pharmaceutically acceptable salt is beraprost sodium salt.

[0329] 117. The method of clause 115, wherein the beraprost comprises at least one of BPS-314d, BPS-3141, BPS-315d, and BPS-3151.

[0330] 118. The method of clause 115, wherein the beraprost is BPS-314d (isoberaprost sodium salt).

[0331] 119. The method of clause 115, wherein:

[0332] CAR T cell administration is performed to treat cancer; and

[0333] The cancer is B-cell lymphoma, aggressive, relapsed, or refractory diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia, or multiple myeloma.

[0334] 120. The method of clause 115, wherein:

[0335] CAR T cell administration is performed to treat cancer; and

[0336] The cancer is brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal, biliary tract, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma or liver metastasis.

[0337] 121. The method of clause 115, wherein:

[0338] CAR T cell administration is performed to treat cancer; and

[0339] The cancer is B-cell lymphoma.

[0340] 122. The method of clause 115, wherein the subject is a mammal.

[0341] 123. The method of clause 115, wherein the subject is a non-human primate, monkey, cat, dog, pig, cow, goat, horse, sheep or rabbit.

[0342] 124. The method of clause 115, wherein the subject is a human.

[0343] 125. The method of clause 1, wherein the CAR T cells and the first drug composition are administered to the subject simultaneously.

[0344] 126. The method of clause 115, wherein a first pharmaceutical composition is administered to the subject after the CAR T cells are administered to the subject.

[0345] 127. The method of clause 115, wherein the first pharmaceutical composition is administered to the subject starting about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, or about 7 days after the CAR T cells are administered to the subject.

[0346] 128. The method of clause 115, wherein the first pharmaceutical composition is administered to the subject starting about 3 days to about 7 days after the CAR T cells are administered to the subject.

[0347] 129. The method of clause 115, wherein the first pharmaceutical composition is administered for a period of about 1 day to about 30 days.

[0348] 130. The method of clause 115, wherein the first pharmaceutical composition is administered for a period of about 7 days to about 14 days.

[0349] 131. The method of clause 115, wherein the first drug composition is administered beginning one day prior to administration of the CAR T cells and continues to be administered for a period of at least about 14 days.

[0350] 132. The method of clause 115, further comprising administering a first pharmaceutical composition to the subject prior to administration of the CAR T cells.

[0351] 133. The method of clause 115, wherein the CAR T cells are autologous.

[0352] 134. The method of clause 115, wherein the CAR T cells are allogeneic.

[0353] 135. The method of clause 115, wherein the first pharmaceutical composition further comprises at least one excipient, at least one filler, at least one disintegrant, at least one binder, at least one wetting agent, at least one lubricant, at least one glidant, at least one preservative, at least one flavoring agent, at least one antioxidant, or a combination thereof.

[0354] 136. The method of clause 115, wherein the first pharmaceutical composition is formulated as a tablet, capsule, granules, powder, liquid, suspension, gel, syrup, slurry, suppository, patch, nasal spray, aerosol, injectable, implantable sustained release formulation or mucoadhesive film.

[0355] 137. A method as described in claim 115, wherein the administration operation includes local delivery, subcutaneous delivery, intravenous (IV) delivery, intramuscular (IM) delivery, intrathecal (IT) delivery, intraperitoneal (IP) delivery, transdermal delivery, subcutaneous delivery, oral delivery, transmucosal oral delivery, pulmonary delivery, inhalation delivery, intranasal delivery, buccal delivery, rectal delivery, vaginal delivery or a combination thereof.

[0356] 138. The method of clause 115, wherein administering comprises oral delivery or intravenous (IV) delivery.

[0357] 139. The method of Clause 115, wherein the beraprost or a pharmaceutically acceptable salt thereof is present in the unit dose of the first pharmaceutical composition in an amount of about 1 microgram to about 100 micrograms.

[0358] 140. The method of clause 115, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of at least about 0.1 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0359] 141. The method of clause 115, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 0.1 micrograms to about 5000 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0360] 142. The method of clause 115, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 15 micrograms to about 90 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0361] 143. The method of clause 115, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 60 micrograms to about 360 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0362] 144. A method as described in clause 115, wherein the CAR T cells are Abecma (idecabtagene vicleucel), Breyanzi (Likimelanza), Kymriah (tesalenza), Tecartus (brexucabtagene autoleucel), Yescarta (Akiramza), Carvykti (Cedaciclib), Belito (Belinto Monomab), or a combination thereof.

[0363] 145. A method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering to the subject CAR T cells and a first pharmaceutical composition, wherein:

[0364] The first pharmaceutical composition includes at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof;

[0365] The subject experiences CRS, ICANS, Parkinsonian effects, or a combination thereof; and

[0366] The subject requires reduced treatment with at least one corticosteroid, tocilizumab, IL-6 receptor blocker, or a combination thereof relative to a similar subject who received the administered CAR T cells but did not receive the administered first pharmaceutical composition.

[0367] 146. The method of clause 145, wherein the pharmaceutically acceptable salt is beraprost sodium salt.

[0368] 147. The method of clause 145, wherein the beraprost comprises at least one of BPS-314d, BPS-3141, BPS-315d, and BPS-3151.

[0369] 148. The method of clause 145, wherein the beraprost is BPS-314d (isoberaprost sodium salt).

[0370] 149. The method of clause 145, wherein:

[0371] CAR T cell administration is performed to treat cancer; and

[0372] The cancer is B-cell lymphoma, aggressive, relapsed, or refractory diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia, or multiple myeloma.

[0373] 150. The method of clause 145, wherein:

[0374] CAR T cell administration is performed to treat cancer; and

[0375] The cancer is brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal, biliary tract, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma or liver metastasis.

[0376] 151. The method of clause 145, wherein:

[0377] CAR T cell administration is performed to treat cancer; and

[0378] The cancer is B-cell lymphoma.

[0379] 152. The method of clause 145, wherein the subject is a mammal.

[0380] 153. The method of clause 145, wherein the subject is a non-human primate, monkey, cat, dog, pig, cow, goat, horse, sheep or rabbit.

[0381] 154. The method of clause 145, wherein the subject is a human.

[0382] 155. The method of clause 145, further comprising administering a first pharmaceutical composition to the subject prior to administration of the CAR T cells.

[0383] 156. The method of clause 145, wherein:

[0384] Prior to administering the CAR T cells, administering a first pharmaceutical composition to the subject; and

[0385] After administering the CAR T cells to the subject, a first pharmaceutical composition is administered to the subject.

[0386] 157. The method of clause 145, wherein the CAR T cells and the first drug composition are administered to the subject simultaneously.

[0387] 158. The method of clause 145, wherein a first pharmaceutical composition is administered to the subject after the CAR T cells are administered to the subject.

[0388] 159. The method of clause 145, wherein the first pharmaceutical composition is administered to the subject starting about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, or about 7 days after the CAR T cells are administered to the subject.

[0389] 160. The method of clause 145, wherein the first pharmaceutical composition is administered to the subject beginning about 3 days to about 7 days after the CAR T cells are administered to the subject.

[0390] 161. The method of clause 145, wherein:

[0391] After administering the CAR T cells to the subject; and

[0392] Once the onset of CRS is detected,

[0393] The first pharmaceutical composition is then administered to the subject.

[0394] 162. The method of clause 145, wherein:

[0395] After administering the CAR T cells to the subject; and

[0396] Once the onset of CRS is detected by increased levels of one or more of the cytokines IL-1α, IL-β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES, and GM-CSF,

[0397] The first pharmaceutical composition is then administered to the subject.

[0398] 163. The method of clause 145, wherein:

[0399] After administering the CAR T cells to the subject; and

[0400] Once the onset of CRS is detected by increased levels of one or more of the cytokines IL-6, IL-10, IFN-γ, and TNF-α,

[0401] administering a first pharmaceutical composition to the subject

[0402] 164. The method of clause 145, wherein the first pharmaceutical composition is administered for a period of about 1 day to about 30 days.

[0403] 165. The method of clause 145, wherein the first pharmaceutical composition is administered for a period of about 7 days to about 14 days.

[0404] 166. The method of clause 145, wherein the first drug composition is administered beginning one day prior to administration of the CAR T cells and continues to be administered for a period of at least about 14 days.

[0405] 167. The method of clause 145, wherein the CAR T cells are autologous.

[0406] 168. The method of clause 145, wherein the CAR T cells are allogeneic.

[0407] 169. The method of clause 145, wherein the first pharmaceutical composition further comprises at least one excipient, at least one filler, at least one disintegrant, at least one binder, at least one wetting agent, at least one lubricant, at least one glidant, at least one preservative, at least one flavoring agent, at least one antioxidant, or a combination thereof.

[0408] 170. The method of clause 145, wherein the first pharmaceutical composition is formulated as a tablet, capsule, granules, powder, liquid, suspension, gel, syrup, slurry, suppository, patch, nasal spray, aerosol, injectable, implantable sustained release formulation or mucoadhesive film.

[0409] 171. A method as described in claim 145, wherein the administration operation includes local delivery, subcutaneous delivery, intravenous injection (IV) delivery, intramuscular injection (IM) delivery, intrathecal injection (IT) delivery, intraperitoneal injection (IP) delivery, transdermal delivery, subcutaneous delivery, oral delivery, transmucosal oral delivery, pulmonary delivery, inhalation delivery, intranasal delivery, buccal delivery, rectal delivery, vaginal delivery or a combination thereof.

[0410] 172. The method of clause 145, wherein administering comprises oral delivery or intravenous (IV) delivery.

[0411] 173. The method of clause 145, wherein the beraprost or a pharmaceutically acceptable salt thereof is present in the unit dose of the first pharmaceutical composition in an amount of about 1 microgram to about 100 micrograms.

[0412] 174. The method of clause 145, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of at least about 0.1 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0413] 175. The method of clause 145, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 0.1 micrograms to about 5000 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0414] 176. The method of clause 145, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 15 micrograms to about 90 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0415] 177. The method of clause 145, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 60 micrograms to about 360 micrograms of beraprost or a pharmaceutically acceptable salt thereof.

[0416] 178. The method of clause 145, wherein the subject does not require treatment with at least one corticosteroid.

[0417] 179. The method of clause 145, wherein the subject does not require treatment with tocilizumab.

[0418] 180. The method of clause 145, wherein the subject does not require treatment with an IL-6 receptor blocker.

[0419] 181. The method of clause 145, wherein the CAR T cells are Abecma (idecabtagene vicleucel), Breyanzi (Likimelanza), Kymriah (tesalenza), Tecartus (brexucabtagene autoleucel), Yescarta (Akiramza), Carvykti (Cedaciclib), Belito (Belinto Monomab), or a combination thereof.

[0420] 182. A medicine box, comprising:

[0421] a first container, the first container containing a first pharmaceutical composition, the first pharmaceutical composition comprising at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof;

[0422] a second container containing a second pharmaceutical composition comprising at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof; and

[0423] Instructions for administering the first pharmaceutical composition, the second pharmaceutical composition, and the CAR T cells to a subject.

[0424] 183. The drug kit of clause 182, further comprising a third container containing CAR T cells.

[0425] 184. The kit of clause 182, further comprising a fourth container comprising water or an aqueous solution.

[0426] 185. The method or kit of any of the preceding clauses, wherein the beraprost is BPS-314d.

[0427] Further aspects of the invention are also described in the following numbered clauses:

[0428] 1A. A method of treating cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), or both associated with CAR T cell administration in a subject, the method comprising administering to the subject a population of CAR T cells and a first pharmaceutical composition, wherein:

[0429] The first pharmaceutical composition comprises at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and

[0430] The first pharmaceutical composition does not reduce cell killing mediated by the CAR T cell population by more than about 5%.

[0431] 2A. A method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering to the subject CAR T cells, a first pharmaceutical composition, and a second pharmaceutical composition, wherein:

[0432] The first pharmaceutical composition comprises at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof; and

[0433] The second pharmaceutical composition includes at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof.

[0434] 3A. The method of clause 2A, wherein the corticosteroid is dexamethasone.

[0435] 4A. The method of clauses 2A-3A, wherein the subject requires reduced treatment with the second pharmaceutical composition relative to subjects not receiving the first pharmaceutical composition.

[0436] 5A. A method for treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering CAR T cells and a first pharmaceutical composition to the subject, wherein: the first pharmaceutical composition comprises at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and the first pharmaceutical composition is administered once the onset of CRS is detected by increased levels of one or more of the cytokines MIF, IL-5, IL-17A, IL-23, CXCL9 / MIG, GCSF, VEGF-A and TGF-β, CCL2, CXCL9, CXCL-10, VEGF, CCL3, GCSF, CRP (C-reactive protein), and ferritin.

[0437] 6A. A method for treating cytokine release syndrome and ICANS or ICANS associated with CAR T cell administration in a subject, the method may include administering CAR T cells and a first pharmaceutical composition to the subject, wherein: the first pharmaceutical composition comprises at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; and once the onset of CRS is detected by increased levels of one or more of the cytokines MIF, IL-5, IL-17A, IL-23, IFN-γ, CXCL9 / MIG, GCSF, VEGF-A, and TGF-β, CCL2, IL-2, IL-6, IL-8, IL-10, IFN-γ, TNF-α, CXCL9, CXCL-10, VEGF, CCL3, GCSF and GMCSF, CRP (C-reactive protein), and ferritin, the first pharmaceutical composition is administered.

[0438] 7A. A method of treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering to the subject CAR T cells and a first pharmaceutical composition, wherein:

[0439] The first pharmaceutical composition comprises at least an effective amount of beraprost or a pharmaceutically acceptable salt thereof; and

[0440] The subject experiences reduced ICANS effects, Parkinsonian effects, or both relative to a similar subject who received the administered CAR T cells but did not receive the administered first pharmaceutical composition.

[0441] 8A. The method of any of clauses 1A-7A, wherein the beraprost is BPS-314d (isoberaprost sodium salt).

[0442] 9A. A method for treating cytokine release syndrome, ICANS, or both associated with CAR T cell administration in a subject, the method comprising administering CAR T cells and a first pharmaceutical composition to the subject, wherein: the first pharmaceutical composition comprises at least an effective amount of BPS-314d (isubprost sodium salt) or a pharmaceutically acceptable salt thereof; and the first pharmaceutical composition is administered once the onset of CRS is detected by increased levels of one or more of the cytokines Il-6, IFN-γ, and TNF-α.

[0443] 10A. The method of any of clauses 1A-9A, wherein CAR T cell administration is performed to treat cancer; and

[0444] The cancer is B-cell lymphoma, aggressive, relapsed, or refractory diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia, or multiple myeloma, brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal, biliary tract, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma, or liver metastasis.

[0445] 11A. The method of any of clauses 1A-10A, wherein the CAR T cells are autologous CAR T cells or allogeneic CAR T cells. Example

[0446] Example 1: Evaluation of mouse model of CRS

[0447] The study will contain 3 groups - placebo control, positive control (tocilizumab or dexamethasone) and CTO1681-treated. The CTO1681-treated group will have multiple arms for dose-response determinations in a murine model of CRS. These doses will provide the information needed for a secondary in vivo model of CAR-T therapy associated with CRS treatment.

[0448] Before CRS induction, humanized mice (expressing human PBMCs-HU-PBMC NSG TM; Commercially available from The Jackson Laboratory; Bar Harbor, ME, USA) will be given control treatment or 1 of 5 doses of CTO1681. To induce CRS, treated mice will be administered the antibody OKT3 (anti-CD3 monoclonal antibody) intraperitoneally (IP) to induce CRS. Mice will be sacrificed 24-28 hours after CRS induction, and cytokine production will be quantified (peripherally and in tissues).

[0449] The results will show that mice that received CTO1681 prior to CRS induction had lower production of undesirable cytokines than mice in the control group. The results will also show a reduction in the rapid acute symptoms that occur in the mouse model within the first 48 hours. Longer models will show a survival benefit, but this particular example will not proceed to that point.

[0450] Example 2: Mouse Model of CRS Induced by CAR T Cell Therapy

[0451] The study will contain 3 groups - placebo control, dexamethasone control and the dose of CTO1681 determined from the preliminary CRS mouse study in Example 1. SCID or humanized mice (expressing human PBMCs-HU-PBMC NSG TM ) will be injected (IP) with Raji-luc tumor cells and tumor growth will be observed for approximately three weeks. Tumor burden will be assessed via bioluminescence technology.

[0452] CAR-T cell therapy (IP) will be performed to induce CRS (occurring approximately 2-3 days after CAR-T infusion). Control and CTO1681 treatment (IP, BID for 7 days) will start approximately 5 hours before CAR-T cell transfer. At the end of the 7-day treatment regimen, tumor burden will be assessed via bioluminescence technology, and mice will be sacrificed for gross histopathology and peripheral and tissue cytokine concentration determination.

[0453] The results will show that mice receiving dexamethasone or CTO1681 have lower production of undesirable cytokines than mice in the control group, and that CTO1681 is superior to dexamethasone. Although the dexamethasone control and CTO1681 will demonstrate a reduction in cytokine levels, it is expected that there will be a greater survival benefit for CTO1681 compared to dexamethasone.

[0454] Example 3: Human treatment without a delay period

[0455] A group of 50-100 human subjects with B-cell lymphoma will be divided into two groups—a control group and a CTO1681 treatment group. Both groups will receive an infusion of CAR T cells. The CTO1681 treatment group will begin receiving CTO1681 one day before the administration of CAR T cells and continue daily for 7-15 days, or the CTO1681 treatment group will receive co-administration of CTO1681 and CAR T cells and continue daily for 7-15 days. For both groups, clinical signs and cytokines of CRS will be monitored daily. The results will show that subjects receiving CTO1681 have reduced CRS symptoms and lower undesirable cytokine production compared to subjects in the control group.

[0456] Example 4: Treatment with a predetermined delay period

[0457] A group of 80 human subjects with mantle cell lymphoma will be divided into two groups - a control group and a CTO1681 treatment group. Both groups will receive an infusion of CAR T cells. The CTO1681 treatment group will receive CTO1681 starting 3 days after the administration of CAR T cells and continue daily for eleven days. For both groups, cytokines will be monitored daily. The results will show that subjects receiving CTO1681 have reduced CRS symptoms and lower undesirable cytokine production compared to subjects in the control group.

[0458] Example 5: Treatment with a monitoring delay period

[0459] A group of 40 human subjects with acute myeloid leukemia will be divided into two groups - a control group and a CTO1681 treatment group. Both groups will receive CAR T cell infusions. Cytokines will be monitored daily for both groups. Once an increase in any of the cytokines IL-6, IFN-γ, and IL10 is detected, the CTO1681 treatment group will begin receiving CTO1681. Treatment with CTO1681 will continue daily for ten days. The results will show that subjects receiving CTO1681 have reduced CRS symptoms and lower production of undesirable cytokines compared to subjects in the control group.

[0460] Example 6: Kit for the treatment of cancer

[0461] The box will be constructed with a first container and written instructions for administering a first pharmaceutical composition and CAR T cells to a subject, the first container containing an effective amount of beraprost, beraprost isomers, or a pharmaceutically acceptable salt thereof. The instructions for use may be printed on paper and placed in the box, or may be a hyperlinked website with written instructions for use. The box is combined with a second container containing autologous or allogeneic CAR T cells. The box may optionally contain a third container containing water or an aqueous solution to dissolve beraprost, beraprost isomers, or a pharmaceutically acceptable salt thereof.

[0462] Example 7: Ex vivo assessment of cytokine release after CTO1681 treatment

[0463] Based on the parameters evaluated in earlier pilot work, a cytokine release assay in normal human PBMCs was developed and performed for analysis of CTO1681 downregulation of cytokine production.For the current assay, PBMCs from 5 healthy donors were obtained.

[0464] The assay began with pretreatment of resting cells with a positive control drug (dexamethasone) or CTO1681. After pretreatment, cells were stimulated with LPS or poly (I:C). Twenty-four to forty-eight hours after stimulation, supernatants were collected and tested for viability (48 hours) and the concentrations of 29 different cytokines (24 hours). Viability assessment confirmed the lack of cellular cytotoxicity associated with CTO1681. Statistical comparisons of single donor results were performed between all test groups within each donor group (between single stimulant-treatment pairs) to determine the efficacy of stimulation and any potential CTO1681 effects on cytokine production. In addition, statistical analysis was performed on the combined donor data for each cytokine stimulator-treatment pair to comprehensively determine the cytokine inhibitory effect of CTO1681 on each cytokine.

[0465] Both LPS and poly(I:C) stimulated PBMCs from all five donors, but with some notable variability. Neither stimulator induced significant stimulation (stimulated cells compared to unstimulated control cells) in various cytokines from different donors. Likewise, there was donor-specific variability in the level of stimulation, especially more common in donor 5, which had lower levels of stimulation of all cytokines.

[0466] Although these apparent changes in cytokine responses are unpredictable and unintended consequences, they do adequately represent naturally observed variations in human immune responses. Considering both individual donor and pooled responses, CTO1681 treatment demonstrated significant reductions in 21 different cytokines, as detailed in Table 1 below, where the ** symbol indicates the 21 cytokines.

[0467] Table 1: Cytokine responses

[0468]

[0469] These 21 include 10 cytokines that were not previously identified by Gemmus Pharma, Inc. research. Further, this work shows that in this in vitro assay, IL-2, IL-6, IL-8 and IL-10 signals are not significantly reduced. It is important to note that in Gemmus Pharma's in vivo influenza (H5N1) therapeutic study, these four cytokines are identified as being reduced by CTO1681 treatment. In addition, in current CytoAgents in vivo influenza (HINI) research, IL-2, IL-6 and IL-10 are reduced by CTO1681 treatment. The difference in the reduction observed in the in vivo work and in vitro work emphasizes an important aspect of the inherent differences in the assay, and it is worth noting that in vitro negative results are not always equivalent to in vivo negative results. These results can be surprising and unpredictable sometimes.

[0470] The final cytokine measured in these assays, which was not analyzed in previous Gemmus Pharma, Inc work, is IFN-α. IFN-α is a type I interferon that is closely related to the antiviral response of the immune system, which is not usually associated with inhibition induced by inhibiting NFkB. CTO1681 has a significant reduction in the very low levels of IFN-α produced in this ex vivo system. This is not directly related to the inhibition of IFN-α antiviral activity (in early in vivo CTO1681 influenza treatment studies, IFN-α was not inhibited). In summary, data from Gemmus Pharma, Inc studies and current work herein confirm that the production of approximately 25 different cytokines is downregulated by treatment with CTO1681.

[0471] Example 8: Cell Target—Normal Human PBMC

[0472] Cytokine release assays were performed in normal human PBMC from five donors of different age, race, and gender. Normal human PBMC were obtained from Lonza's extensive cell reagent catalog. Cells were thawed according to the manufacturer's instructions, washed in complete growth medium, and viability was assessed using trypan blue staining. 2×10 6 Cells were suspended in complete growth medium and then dispensed into wells of black-walled plates (2 × 10 5 The cells were cultured at 37°C and 5% CO 2 Rest for 1 hour.

[0473] Treatment, stimulation, cell harvesting, and cell viability measurement

[0474] After resting the cells, 100 μl of CTO1681 was added to the appropriate wells at a final dosing concentration of 750 μM. Vehicle and dexamethasone (final dosing concentration of 1 μM) were also added to their appropriate wells at 100 μl, respectively, and all were incubated at 37°C and 5% CO. 2 Incubate for 15 minutes. For cell stimulation, 20 μL of 1.0 ng / mL LPS solution or 250 μg / mL poly (I: C) solution was added to the appropriate wells according to the group name. Twenty-four hours later, 100 μL of supernatant was collected from all wells and stored for cytokine analysis. About four hours before the final harvest, Alamar Blue dye was added to all wells. Forty-eight hours after stimulation, all samples were collected and the cell viability of the supernatant was tested. When added to cells, Alamar Blue is modified by the reducing environment of living cells and becomes highly fluorescent. Therefore, increased fluorescence after cell staining indicates increased viability. Alamar Blue viability assessment demonstrated that there was no cytotoxicity when cells were treated with CTO1681 in donors 1-5. Similarly, no signs of cytotoxicity were observed when cells were stimulated with LPS or poly (I: C).

[0475] Cytokine Readings, Final Results, and Conclusions

[0476] Via multiple kits from Millipore, samples collected 24 hours after stimulation were evaluated for cytokines using Luminex multiplex technology on MAGPIX instruments. The concentration of each cytokine was evaluated based on standard curves. The sample values ​​below the detection limit collected by multiple analysis were not included in the final determination. Undiluted donor IL-6 concentration exceeded the linear range of determination, and therefore for typical standard curves, the valuation was too high. Therefore, IL-6 samples were rerun with a dilution of 1:5. The determined cytokine concentration (pg / ml) results of each cytokine were plotted as single donor stimulator-treatment pairs. Via one-way ANOVA and multiple comparisons, all cytokine individual donor results were statistically compared between control groups. ANOVIA analysis was performed between the stimulated groups (only LPS, only poly (I:C)) and controls (only culture medium, dexamethasone and vehicle), to determine the effectiveness of stimulation and dexamethasone positive controls, and any potential vehicle effects. The common one-way t-test was then used to compare the vehicle group with CTO1681 stimulation to determine whether the test item had an effect. The combined stimulus-treatment pairs of all five donors were plotted, and a single means was used to evaluate the overall efficacy of CTO1681 cytokine inhibition. Statistical analysis was also performed for the combined donor results for each cytokine plotted (Wilcoxon matched-pairs signed rank test). The final results for cytokine inhibition were determined by evaluating the combined results as well as the individual donor results. CTO1681 reduced 21 of the 29 cytokines analyzed in this study.

[0477] Observations from in vitro treatment results

[0478] Effective stimulation of PBMCs by LPS or poly(I:C) was determined by comparing the media control group and the stimulated group (non-treatment). Both mitogens successfully stimulated most cytokines, but there was variability between donors and between cytokines. VEGF and IL-7 failed to be continuously stimulated with LPS or poly(I:C) to levels above the lower limit of the standard curve and were therefore not calculated in the combined analysis. Failure to stimulate may be an artifact of ex vivo assays, which must be performed within a relatively short observation window and lack the complexity of a complete in vivo system. Successfully stimulated additional cytokines did not achieve significant levels of stimulation compared to unstimulated media wells. Statistically significant increases in LPS or poly(I:C) were detected in a few donors in the TGF-β, IL-2 results. In the poly(I:C) group, no statistical significance was achieved for GM-CSF, IL-8, IL-17A, CXCL10 / IP-10, or CCL5 / RANTES. The variability between the general stimulation levels of the donors was also a noteworthy observation. In general, when treated with both poly (I: C) and LPS, donor 5 had much lower stimulation levels for all cytokines. Due to this lack of stimulation, donor 5 data was not included in the merge and final analysis for IL-2, IL-4, IL-5, IL-9, IL-15, IL-12, IL-13, IL-17, IL-18, GM-CSF and PDGF. Donor 5's stimulation of cytokines IL-10 and CXCL10 / IP-10 was above the minimum limit of detection, but these values ​​were orders of magnitude (1-3 logs) lower than the other 4 donors, so although donor 5 data was not included in the merge analysis for these two cytokines, individual results were still considered in the final determination of CTO1681 efficacy. Similarly, donor 1 TGF-β results were all below the lower threshold from the standard curve, so the data from this donor for this cytokine was not included in the overall merge analysis of CTO1681 efficacy. Donor 4 did have significantly lower levels of overall stimulation in several cytokines (but not below the thresholds included in the calculations). Overall, these differences highlight the natural variation seen in the prevalent immune response to mitogens within a population, which may be attributable to genetic differences between subjects.

[0479] Very similar to the observations for the differences in successful stimulation seen between groups and donors, similar unpredictability was observed in the stimulation methods and treatment group results within donors. CTO1681 was able to reduce the concentrations of several cytokines that dexamethasone had no effect on. Overall, CTO1681 inhibited the production of 21 of the 29 cytokines evaluated. Despite successful stimulation in LPS and poly(I:C)-induced cells, only three cytokines (GCSF, TGF-β, and IL-8) did not experience suppression under CTO1681 and dexamethasone treatment. Similarly, in some cases, dexamethasone failed to inhibit cytokine production, while CTO1681 successfully reduced the concentration of cytokines produced (poly(I:C)-stimulated cells—IL-4, CCL2 / MCP1), and vice versa, CTO-1681 failed to inhibit cytokine production, while dexamethasone successfully reduced cytokine concentrations (poly(I:C)-stimulated cells—IL-17, IL-9). Furthermore, in some cases, both dexamethasone and CTO1681 demonstrated significant reductions in cytokine production in one stimulus mitogen (LPS) but not in the other (poly(I:C)), as observed with FGF and CCL3 / MIP1a. Admittedly, the complexity of evaluating the entire study (control vs. CTO1681 in two different stimuli, 5 donors, and 29 different cytokines) was quite daunting. Ultimately, the conclusions based on the evaluation of the pooled and individual donor data indicated that CTO1681 inhibited cytokine production in both stimulation methods for the following cytokines—IL-1α, IL-1β, IL-4, IL-5, IL-12, p70, IL-13, IL-15, IL-18, TNF-α, CCL2 / MCP-1, CCL5 / RANTES, CXCL9 / MIG, CXCL10 / IP-10, IFN-γ, IFN-α, and PDGF; and inhibition of cytokines from LPS stimulation alone was observed—IL-9, IL-17, CCL3 / MIP1a, GM-CSF, and FGF.

[0480] There are a number of operational factors to consider in the interpretation of the mechanisms and actions behind these tabulated results. Each stimulus triggers a response through a different cellular receptor, which can then have different timing in the subsequent cellular cascade of events. In addition, the analysis window for this study—24 hours, while necessary for the nature of this ex vivo study, may not have provided sufficient time for the production of all evaluated cytokines to initiate or reach significant expression levels. Furthermore, in the absence of an intact biological system, the recruitment of immune factors that can play a role in the different cytokine responses is not all present in an intact physiological system. Therefore, negative results should be viewed with this knowledge, and it needs to be recognized that in vivo results may be different. For example, in this ex vivo study, inhibition of CTO1681 by IL-2, IL-6, IL-8, and IL-10 was negative. However, in concurrent data from an in vivo lethal influenza H1N1 study (and a previous GemmusPharma Inc H5N1 in vivo study), CTO1681 significantly inhibited the production of these cytokines.

[0481] The CTO1681 inhibition of ex vivo IFN-α activity is surprising and unexpected. IFN-α is a type 1 interferon, which is usually not associated with the same pathway or pattern (or more precisely, with the activity induced by NFκB) as standard proinflammatory cytokines. Type 1 interferon is an important part of the antiviral immune response. In addition, type I interferons are usually not associated with the production of NFκB because IFN-α is produced by promoters and transcription elements different from standard proinflammatory cytokines. The pathway of IFN-α, from cell receptors to feedback loops, is completely different from that of proinflammatory cytokines. The inclusion of IFN-α in this study was originally incorporated as a safety measure rather than an efficacy measure. The results seen here are opposite to the ex vivo / in vivo phenomena mentioned above for IL-2, IL-6, etc. Although the IFN-α inhibition of CTO1681 is obvious in the data of these ex vivo studies, our in vivo data show the opposite, or during lethal H1N1 influenza infection, CTO1681 treatment has no significant inhibition of IFN-α concentrations. In evaluating these two contrasting results, it is important to recognize that the amount of INF-α produced in ex vivo stimulated PBMCs differs substantially from that induced by active viral replication in vivo. LPS-stimulated INF-α production in PBMCs was <101 pg / ml, whereas poly(I:C)-stimulated levels were approximately 101 pg / ml. Mice lethally infected with H1N1 had approximately 103 pg / ml of INF-α detected in BALF fluid. The nominal reduction in ex vivo production of INF-α, although statistically significant, was less than 2-fold. This minor reduction would not be a significant alteration in BALF INF-α production in the levels of INF-α produced during active viral replication. INF-α production occurs in two phases, early and late, with late production being associated with high levels of INF-α associated with viral infection. One of the transcription factors responsible for a significant portion of INF-α production in the early phase is IRF7. IRF7 has an NFkB response element in its promoter. Mechanistically, this may mean that CTO1681 indirectly affects INF-α production, thereby having a significant but minimal effect on type 1 interferon production as observed in the ex vivo assay.

[0482] In summary, this data and information demonstrates the broad potency of CTO1681 cytokine inhibition across 25 different cytokines, identifying novel cytokines affected by ex vivo treatment of stimulated PBMCs using the molecule (compared to 10 in previous Gemmus Pharma, Inc. data).

[0483] Example 9: Kit containing beraprost and tocilizumab

[0484] The box will be constructed with a first container (the first container contains a first pharmaceutical composition, the first pharmaceutical composition contains an effective amount of beraprost, a beraprost isomer or a pharmaceutically acceptable salt thereof), a second container (the second container contains a second pharmaceutical composition, the second pharmaceutical composition contains an effective amount of tocilizumab) and written instructions for administering the first pharmaceutical composition, the second drug combination and CAR T cells to the subject. The instructions for use can be printed on paper and placed in the box, or can be a hyperlinked website with written instructions for use. The box can be combined with a third container (the third container contains autologous or allogeneic CAR T cells). The box may optionally contain a fourth container (the fourth container contains water or an aqueous solution to dissolve beraprost, a beraprost isomer or a pharmaceutically acceptable salt thereof and tocilizumab).

[0485] Example 10: Use of a combination of beraprost and tocilizumab

[0486] The day before CAR T cells are administered, subjects with cancer will be treated with orally administered beraprost, beraprost isomers or their pharmaceutically acceptable salts. Beraprost, beraprost isomers or their pharmaceutically acceptable salts will be continued for at least 14 days of attachment. Tocilizumab and / or corticosteroids can be added according to the doctor's instructions, but need to be lower in amount relative to similar subjects who do not receive beraprost, beraprost isomers or their pharmaceutically acceptable salts. Compared with other subjects, improved clinical results will be observed from the combination. Subjects will be observed to have a reduced ICANS effect and a lower average incidence of hospital stay and a shorter average duration of hospital stay.

[0487] Example 11: Phase 1b study to prevent or reduce CAR T cell-induced toxicity

[0488] Phase 1b of the study is a multicenter, open-label, dose-escalation, safety and pharmacokinetics (PK) study of multiple ascending doses (MAD) of CTO1681 in patients with B-NHL receiving commercially available CD19-directed CAR T cell therapy. This part of the study will be conducted using a Bayesian optimal interval (BOIN) design to inform dose escalation in a cohort of patients with B-NHL. It will include the following sequential steps for each patient in each cohort: screening, recruitment, pretreatment with lymphocyte depletion (LD) chemotherapy, initiation of study drug (CTO1681), CAR T cell infusion, continued treatment with CTO1681 (for a total of 15 days), and safety follow-up. Patients with CRS or ICANS who have not resolved before day 15 may continue to receive treatment for up to an additional 13 days (a total of 28 days) at the discretion of the investigator, subject to medical supervision and approval by the sponsor. The timing of CTO1681 treatment will be based on the following schedule relative to LD and CAR T cell infusions:

[0489] Day -12 to Day -3: LD chemotherapy (if necessary per CAR T cell manufacturer's package insert [PI])

[0490] Day -1: Approximately 24 hours prior to CAR T cell infusion, study drug (CTO1681) will be started. Study drug will be continued orally (PO) 3 times daily (TID) for 15 days.

[0491] The total daily dose of CTO1681 will be 30 μg, 60 μg or 90 μg, depending on the cohort each patient is enrolled in. The study drug must be taken within 30 minutes after a meal or snack.

[0492] Day 1: CAR T cell infusion (per CAR T cell manufacturer's PI). Patients will be monitored to record tumor response for up to 6 months.

[0493] The BOIN algorithm will be implemented to provide recommendations for dose escalation. The algorithm will target the identification of the maximum tolerated dose (MTD) with a probability of toxicity of less than 33%. The dose-limiting toxicity (DLT) observation period is defined as 42 days after the first dose of study drug.

[0494] Three dose cohorts will be considered, with a maximum of 27 patients. The first dose level (30 μg) will enroll a cohort of 3 patients. The 60 μg and 90 μg dose levels will initially enroll 6 patients. The total enrollment for each dose level cohort will be a maximum of 9 patients.

[0495] The MTD is defined as the maximum dose achieved before a toxicity rate of >33% is observed. The recommended phase 2 dose (RP2D) is the MTD or the highest dose at which no MTD discontinuation occurs. The target toxicity rate is ≤33%. See Table 2.

[0496] Table 2: Dose escalation and stopping rules

[0497]

[0498] Abbreviations: DLT = dose-limiting toxicity; MTD = maximum tolerated dose.

[0499] Example 12: Phase 2a Study

[0500] Phase 2a: Phase 2a of the study will be conducted as a double-blind, randomized, placebo-controlled study and will recruit approximately 104 patients. Patients will be treated with CTO1681 at the RP2D established during Phase 1b, or with placebo. Patients will be randomized between the CTO1681 arm and the placebo arm in a 1:1 ratio before receiving LD chemotherapy. If more than 1 commercially available CAR T cell product from the Phase 1b portion of the study is continued, an attempt will be made to balance multiple CAR T cell products where feasible. Each patient will follow the same study steps as described above for the Phase 1b portion. The duration of treatment will be determined based on the findings and recommendations of the Phase 1b study after the Phase 1b interim analysis is stopped (e.g., the average number of treatment days, the number of extension requests initiated by clinicians, and the recommendations of the Safety Review Committee [SRC]). This part of the study will include a PK substudy at selected sites. Patients recruited in this part of the study will be monitored for tumor response for up to 12 months after CAR T cell infusion.

[0501] For both the Phase 1b study and the Phase 2a study, safety, efficacy, and biomarker assessments will be conducted according to an event schedule and at intervals specified in the study protocol.

[0502] Study patients will be hospitalized for observation and management of CAR T cell-related toxicity based on institutional guidelines. All CRS and ICANS grading will be based on the American Society for Transplantation and Cellular Therapy (ASTCT) standards. Detailed management guidelines for CRS and ICANS will be provided in the complete study protocol and will be consistent with the standards of care management.

[0503] The currently commercially available CD19-directed CAR T-cell therapy for B-NHL, Akilumab, Tisaron Leakey Myron will be included in the Phase 1b portion of the study. Based on the interim analysis of the Phase 1b results, 1 or more of these CAR T-cell therapies will continue in the Phase 2a study.

[0504] Example 13: Management of CRS and ICANS

[0505] CTO1681 should be continued in patients who develop CRS unless otherwise specified under the study protocol section for the management of DLTs. Detailed management guidelines for CRS and ICANS will be provided to the investigator to standardize care at participating study sites. These guidelines will be consistent with the standard of care outlined in the CAR T-cell product package insert, with the exception of the use of prophylactic steroids or tocilizumab.

[0506] Example 14: Critical Dose Limiting Toxicity

[0507] The key DLT standards are:

[0508] Hypotension not attributed to CAR T-cell therapy, defined as documented prolonged (≥2 hours) systolic blood pressure <90 mmHg that is unresponsive to primary medical therapy (ie, fluid challenge, vasopressors).

[0509] Bleeding: Any clinically significant bleeding event (ie, excluding accidental lacerations, periodontal, menstrual, or hemorrhoidal bleeding, or easily controlled epistaxis) (including any episode of hemoptysis).

[0510] Liver function abnormalities: Any occurrence of transaminase elevations >5× upper limit of normal (ULN; Common Terminology Criteria for Adverse Events [CTCAE] grade 3).

[0511] QTc prolongation: Development of a QT interval corrected using the Fridericia formula (QTcF) ≥501 msec or a change from baseline of 60 msec persisting for ≥5 minutes confirmed by repeated 12-lead electrocardiogram (ECG) / telemetry.

[0512] Ventricular tachycardia requiring urgent medical intervention (CTCAE grade 3).

[0513] Example 15: Management of Dose-Limiting Toxicity

[0514] DLT of hypotension or abnormal liver function: CTO1681 will be interrupted until DLT resolves. If DLT recurs, CTO1681 will be stopped.

[0515] DLT of bleeding: CTO1681 will be discontinued.

[0516] DLTs of QTc prolongation or ventricular tachycardia: CTO1681 will be interrupted if a patient develops Grade 3 or 4 CRS.

[0517] Example 16: Target

[0518] Phase 1b:

[0519] Determine the RP2D and (if applicable) MTD of CTO1681 in patients with B-NHL receiving CAR T-cell therapy

[0520] To determine the preliminary safety profile of CTO1681 in patients with B-NHL receiving CAR T-cell therapy

[0521] Phase 2a:

[0522] Determine preliminary CTO1681 effectiveness in preventing or reducing CRS compared to placebo

[0523] To determine the preliminary effectiveness of CTO1681 in preventing or reducing ICANS compared to placebo

[0524] Determining the expanded safety profile of CTO1681 in patients with B-NHL receiving CAR T-cell therapy

[0525] To investigate the potential effect of CTO1681 on the anti-tumor activity of CAR T-cell therapy compared with historical data and placebo.

[0526] Example 17: Endpoint

[0527] Phase 1b:

[0528] main:

[0529] Adverse events (AEs) characterized by type, frequency, timing, severity (according to CTCAE v5.0 grading), severity, and relationship to CTO1681, including DLTs and laboratory abnormalities

[0530] Exploratory:

[0531] The incidence (rate), severity, onset, and duration of CRS (as measured by the area under the CRS grading curve (AUC) between the initiation of CAR T-cell therapy and 30 days after the initiation of CAR T-cell therapy)

[0532] Incidence, severity, onset, and duration of ICANS (as measured by ICANS grade AUC between CAR T-cell therapy initiation and 30 days after CAR T-cell therapy initiation)

[0533] Number of days of treatment with CTO1681

[0534] Incidence of grade ≥3 CRS and grade ≥3 ICANS

[0535] Antitumor activity (including overall response rate (ORR), duration of response (DOR), progression-free survival (PFS) based on investigator assessment, and overall survival (OS))

[0536] Frequency and duration of hospitalizations and intensive care unit (ICU) admissions attributable to CRS or ICANS

[0537] Levels and persistence of CAR T cells

[0538] Use of tocilizumab, steroids, and other anticytokine therapies for the treatment of CRS or ICANS

[0539] PK concentration characteristics of CTO1681

[0540] Biomarkers associated with CTO1681’s mechanism of action (MOA) and immune response

[0541] Immune reconstitution

[0542] Phase 2a:

[0543] main:

[0544] Incidence, severity, onset, and duration of CRS (as measured by the AUC of CRS grade between the initiation of CAR T-cell therapy and 30 days after the initiation of CAR T-cell therapy)

[0545] secondary:

[0546] Additional Assessment of CRS Incidence and Severity:

[0547] Maximum level CRS

[0548] Incidence of grade ≥2 CRS

[0549] Incidence of grade ≥3 CRS

[0550] Duration of CRS level ≥ 1

[0551] Incidence, severity, onset, and duration of ICANS (as measured by ICANS grade AUC between CAR T-cell therapy initiation and 30 days after CAR T-cell therapy initiation)

[0552] Additional Assessment of ICANS Incidence and Severity:

[0553] Maximum Level ICANS

[0554] Incidence of ICANS Grade ≥ 2

[0555] Incidence of ICANS Grade ≥ 3

[0556] Duration of ICANS at Level ≥ 1

[0557] Frequency and duration of hospitalizations and ICU admissions attributable to CRS or ICANS

[0558] Use of tocilizumab, steroids, and other anticytokine therapies for the treatment of CRS or ICANS

[0559] Antitumor activity (including ORR, DOR, PFS and OS assessed by investigator)

[0560] Exploratory:

[0561] Levels and persistence of CAR T cells

[0562] PK concentration characteristics of CTO1681

[0563] Biomarkers associated with MOA and immune response to CTO1681

[0564] Immune reconstitution

[0565] Example 18: Number of patients (planned)

[0566] Phase 1b: 15 to 27

[0567] Phase 2a: 104

[0568] Example 19: Inclusion criteria

[0569] 1. Aged 18 or above.

[0570] 2. Underwent leukapheresis and was scheduled to receive commercially available CD19-directed CAR T-cell therapy for B NHL as specified in the study protocol without corticosteroid prophylaxis for CRS. Eligible patients must have relapsed or refractory DLBCL after at least two prior lines of systemic therapy.

[0571] 3. Meet all inclusion criteria for CAR T-cell therapy according to institutional guidelines.

[0572] 4. Adequate organ function is defined as:

[0573] A. Serum creatinine ≤1.5×ULN or estimated glomerular filtration rate (eGFR) according to the Cockroft-Gault formula ≥60mL / min / 1.73m2.

[0574] B. Serum alanine aminotransferase (ALT) / aspartate aminotransferase (AST) ≤ 2.5×ULN.

[0575] C. Bilirubin ≤ 2.0 mg / dL, except for patients with Gilbert's syndrome with total bilirubin ≥ 3.0 × ULN and indirect bilirubin ≤ 1.5 × ULN.

[0576] D. Left ventricular ejection fraction (LVEF) ≥ 40% on echocardiography (ECHO) or multi-gated acquisition (MUGA) and no clinically significant pericardial effusion.

[0577] E. Platelet count ≥50,000 / mm3.

[0578] F. Absolute neutrophil count>1000 / μL

[0579] G. Absolute lymphocyte count> 100 / μL

[0580] 5. Documented, measurable disease sufficient to be assessed by the Lugano criteria.

[0581] 6. Eastern Cooperative Oncology Group (ECOG) performance status is 0 to 1.

[0582] 7. Female participants of childbearing potential and all male participants must agree to use investigator-approved contraceptive methods during the study drug period and within 30 days thereafter.

[0583] 8. Patients who are able to provide written informed consent prior to pre-drug procedures, or who have a legal representative who can provide informed consent on their behalf.

[0584] Example 20: Exclusion criteria

[0585] 1. Any cytotoxic chemotherapy within 14 days of leukapheresis.

[0586] 2. Clinically significant malabsorption syndrome and dysphagia (e.g., odynophagia, dysphagia, gastroesophageal reflux disease) as assessed by the investigator.

[0587] 3. Clinically significant electrolyte imbalance (e.g., hypokalemia, hypomagnesemia) as assessed by the investigator.

[0588] 4. Abnormal or clinically significant ECG abnormalities at Screening and Baseline (Day 1), including (but not limited to), confirmed QTcF values ​​>450 msec (for males) and >470 msec (for females). Patients with borderline or difficult to interpret QTcF readings due to conditions such as bundle branch block or those in which T and U waves are superimposed will be excluded.

[0589] 5. History of cardiac arrhythmias (e.g., bradycardia, congenital long QT syndrome, atrial fibrillation) and / or requiring therapeutic doses of anticoagulant / antiplatelet therapy.

[0590] 6. Any clinically significant (i.e., active) cardiovascular disease, including cerebrovascular accident / stroke (<6 months before recruitment), myocardial infarction (<6 months before recruitment), or unstable angina, and congestive heart failure ≥ New York Heart Association grade III.

[0591] 7. Uncontrolled thromboembolic events or recent severe bleeding.

[0592] 8. Requires continuous therapeutic doses of anticoagulant therapy, antiplatelet agents, or fibrinolytic agents.

[0593] 9. Patients who, in the opinion of the investigator, will be unlikely to comply with study procedures or are not suitable for recruitment.

[0594] Example 21: Study Product, Dosage and Mode of Administration

[0595] Phase 1b: CTO1681 will be administered as a 10-μg tablet. In Cohort 1, CTO1681 tablets will be administered PO TID at a total daily dose of 30 μg for a minimum of 15 days, but no more than 28 days. Cohorts 2 and 3 will receive CTO1681 PO TID at a total daily dose of 60 μg and 90 μg, respectively, for a minimum of 15 days, but no more than 28 days. Neither intra-patient nor intra-cohort dose modifications will be allowed.

[0596] Phase 2a: CTO1681 will be administered as a 10-μg tablet, with multiple tablets possible per dose, based on the dose determined by the Phase 1b results. The duration of treatment will also be determined by the Phase 1b results.

[0597] Note: Since CTO1681 has a positive food effect, it should be administered within 30 minutes after a meal or snack.

[0598] Example 22: Duration of the study (per patient)

[0599] Phase 1b: approximately 7 months (including screening)

[0600] Phase 2a: About 13 months (including screening)

[0601] Example 23: Reference Therapy, Dosage and Mode of Administration

[0602] Phase 1b: None.

[0603] Phase 2a: Placebo tablets will be administered PO TID in the same manner as active treatment. Placebo tablets will be identical to CTO1681 10-μg tablets in size, shape, color, and packaging.

[0604] Example 24: Security Review

[0605] The SRC will be composed of the study's investigators, the sponsor's medical representative (or qualified delegate), and special committee members as appropriate (e.g., statisticians, PK experts). The SRC will monitor the progress and safety of patients throughout the Phase 1b study. Regular systematic reviews of AEs will serve as the basis for suspending or stopping the study early. Unexpected SAEs related to CTO1681 will be the main criterion for suspending or stopping the study. If CTO1681-related DLTs occur in >33% of patients in the cohort (excluding fever, hematological toxicity, CRS or ICANS, or events unrelated to underlying disease or CAR T-cell therapy), this will indicate that the MTD has been reached and the study will be stopped.

[0606] During the Phase 1b portion of the study, the SRC will review safety data after the DLT assessment period is stopped (42 days after the first dose of CTO1681). To determine whether dose escalation may occur for each dose level cohort based on the BOIN algorithm, the SRC will decide whether to proceed to the next cohort based on safety data (the earlier of the following two: 42 days from the first dose of study drug for the last patient treated in the current cohort if patients have been treated for a maximum of 28 days; or 14 days after the last dose for the last patient treated in the current cohort if the last patient has been treated for less than 28 days). The dose may be escalated, additional subjects may be recruited (up to 9 per dose level), or the study may be stopped. Cumulative safety data will be reviewed at each SRC meeting. If any suspension or stopping rules are met, the cohort will be suspended or stopped, and the SRC will review and determine the relationship of the AE to CTO1681.

[0607] After completion of at least 1 month of follow-up after the first dose of CTO1681 administered in Phase 1b, or after all patients enrolled in Phase 1b have prematurely discontinued the study, an interim analysis will be performed to summarize the Phase 1b results. The SRC will make recommendations on progression of the study to the Phase 2a portion and the selection of an RP2D based on safety (including available anti-tumor response data). The SRC will also make recommendations on the dose regimen and recommended CAR T-cell product to be included in Phase 2a.

[0608] Throughout the Phase 1b portion of the study, the SRC can also make recommendations on any necessary study protocol modifications focused on patient safety.

[0609] An Independent Data Monitoring Committee (IDMC), consisting of 2 CAR T / hematological oncology experts and 1 independent biostatistician, will be established to monitor safety data during the Phase 2a portion of the study. The IDMC will conduct planned safety data reviews after approximately 20, 40, 60, 80, and 104 patients have been followed for at least 1 month since first exposure to study drug or have stopped the study early. The study will be paused or stopped if any pre-specified pause or stop rules are met. If the investigator believes and the sponsor's death is consistent with a known adverse reaction of CTO1681, such as a DLT identified as a suspension criterion during the Phase 1b portion of the study, a special meeting of the IDMC will be held. In addition, the IDMC will meet more frequently, if necessary, to review serious AEs (SAEs) and provide recommendations on when to pause recruitment or terminate the study.

[0610] The IDMC will review the complete response (CR) rate based on a set of pre-specified non-binding anti-tumor response impact assessments planned for the 40, 60, and 80 patient safety data reviews. Assessments will include patients who have achieved a CR (based on the Lugano response criteria), best anti-tumor response with progressive disease, have stopped the study early, or have had follow-up of at least 3 months since the first dose of CAR T-cell therapy. At each anti-tumor response impact assessment, the CR rate and exact Clopper-Pearson 95% CI will be calculated for patients randomized to CTO1681, comparing the upper limit of the CI to a benchmark rate derived from the lower limit of the 95% CI for 6-month CR rates in the previous literature. At the time of Phase 1b stop, the lower limit will be selected after the sponsor selects the CAR T-cell therapy to be included in the Phase 2a portion of the study. Study recruitment will not be paused for planned safety data reviews or anti-tumor response impact analyses unless necessary based on safety stopping rules.

[0611] A formal charter will be drawn up to clarify the rules and responsibilities of the SRC and IDMC.

[0612] Example 25: Criteria for Suspending or Stopping a Study

[0613] If any of the following events occur within 42 days of the first dose of study drug and the investigator believes that they are not related to the underlying disease, CAR T-cell therapy, or events or factors unrelated to study participation, the SRC (in Phase 1b) or IDMC (in Phase 2a) should be informed immediately and a special meeting should be scheduled to review all available safety data. The committee will then provide recommendations on how to proceed.

[0614] Suspension Standard

[0615] Phase 1b:

[0616] CTO1681 DLT rate exceeds 33%:

[0617] Bleeding: Any clinically significant bleeding event (excluding accidental lacerations, periodontal, menstrual or hemorrhoidal bleeding, or easily controlled epistaxis).

[0618] Hypotension: Prolonged and symptomatic (≥2 hours) systolic blood pressure <90 mm Hg that is unresponsive to basic medical therapy.

[0619] QTc prolongation: QTcF ≥ 501 msec or a change from baseline of 60 msec that persists for ≥ 5 minutes.

[0620] Ventricular tachycardia (CTCAE grade 3)

[0621] Transaminase elevation > 5×ULN (CTCAE grade 3)

[0622] Two or more patients in the assigned cohort experienced CTCAE grade 4 toxicity (excluding events that could be attributed to disease progression / underlying disease or CAR T-cell therapy (e.g., pyrexia, hematologic toxicity, and CRS / ICANS)).

[0623] Deaths that are related to the study but not related to the underlying disease or CAR T-cell therapy.

[0624] Phase 2a:

[0625] Deaths that are considered by the investigator and confirmed by the sponsor representative to be consistent with a known adverse reaction to CTO1681, such as DLTs identified as holding criteria during Phase 1b.

[0626] Following the safety review, if the cohort and / or study is deemed safe to proceed, recruitment and treatment will proceed as planned. If there are unresolved issues, the study may proceed as recommended by the SRC or IDMC.

[0627] Stop criteria

[0628] Phase 1b:

[0629] CTO1681 DLT rate exceeds 33%

[0630] CTCAE grade 4 toxicities (refractory, unexpected) that are possibly, probably, or definitely related to CTO1681 as assessed by the investigator and confirmed by the SRC and the sponsor (excluding CAR T-cell therapy-related toxicities such as pyrexia, hematologic toxicity, and CRS / ICANS).

[0631] Death caused by CTO1681-related DLT not related to the underlying disease, CAR T-cell therapy, or external events (not related to the investigational product or investigational procedures). Specifically:

[0632] Fatal bleeding events.

[0633] Refractory hypotension resulting in death.

[0634] Refractory ventricular tachycardia resulting in death.

[0635] Phase 2a:

[0636] CTCAE grade 4 toxicities (refractory, unexpected) possibly, probably, or definitely related to CTO1681 occurred in >33% of dosed patients (excluding pyrexia, hematologic toxicity, and CRS / ICANS).

[0637] Death caused by CTO1681-related DLT not related to the underlying disease, CAR T-cell therapy, or external events (not related to the investigational product or investigational procedures). Specifically:

[0638] Fatal bleeding events.

[0639] Refractory hypotension resulting in death.

[0640] Refractory ventricular tachycardia resulting in death.

[0641] The sponsor may decide to stop the study or make modifications to the study based on the SRC / IDMC's recommendations and the totality of evidence. The SRC may recommend stopping the study if it is determined that continuing the study may endanger patient safety. The IDMC may recommend stopping the study based on safety or futility grounds.

[0642] Example 26: Statistical methods

[0643] Sample size considerations:

[0644] Phase 1b: Based on the BOIN algorithm, a maximum sample size of 27 (maximum 9 per dose level) will be selected to support dose escalation and RP2D selection of CTO1681 dose levels. Phase 1b safety results will help determine continued treatment and duration of CAR T-cell therapy in Phase 2a.

[0645] Phase 2a: This study was designed with a sample size selected to provide adequate power for the primary endpoint as well as selection of secondary endpoints. Although CRS grade AUC was identified as the primary endpoint, there is also interest in evaluating the effect of CTO1681 on other measures of CRS severity to better understand the sensitivity of capturing treatment effects.

[0646] The CRS grade AUC for each patient was calculated as the sum of the maximum (non-zero) grade CRS per day over the duration of the efficacy observation period (30 days after initiation of CAR T-cell therapy), and a sample size of 104 patients (52 in each of the CTO1681 and placebo groups) provided more than 85% power with a one-sided type I error rate of 0.05 using a difference in means T test to detect a between-group difference in mean AUC of 4.5 days with a standard deviation of 8.

[0647] A sample size of 104 patients (52 in each group) provided more than 85% power with a one-sided type I error rate of 0.05 using the Wilcoxon-Mann-Whitney test to establish differences in ordinal variables, assuming no treatment, that 35% of CAR T-cell patients experienced a maximum of grade 1 CRS, 20% experienced a maximum of grade 2, 12% experienced a maximum of grade 3, and 8% experienced a maximum of grade 4, compared with a reduction in severity such that when treated with CTO1681, 30% of patients experienced a maximum of grade 1, 10% experienced a maximum of grade 2, and 10% experienced a maximum of grade 3.

[0648] With a sample size of 104 patients (52 in each group), there was over 65% power with a one-sided type I error rate of 0.05 to detect a difference in the proportion of 40% of control patients experiencing grade ≥2 CRS versus 20% of CTO1681 patients.

[0649] Analyzed groups:

[0650] The modified intention-to-treat (mITT) population will include all patients who receive both CAR T-cell therapy and at least 1 dose of study drug (CTO1681 or placebo). Patients will be randomized. The standard ITT population containing all randomized patients can be analyzed as a test of the robustness of the mITT.

[0651] The safety population will include all patients who received at least 1 dose of study drug (CTO1681 or placebo). Patients will be grouped by treatment.

[0652] The per-protocol (PP) population will include all patients in the mITT population who have received at least 5 doses of study treatment, CAR T cell therapy, and without any major protocol deviations. Patients will be grouped by treatment.

[0653] The dose-limiting toxicity (DLT) population will include all patients in Phase 1b who receive both CAR T-cell therapy and at least 1 dose of CTO1681. Patients who withdraw for reasons unrelated to study procedures, behavior, or treatment before experiencing a DLT and before completing the DLT observation period (42 days after the first dose of study drug) will not be included in this population.

[0654] Data presentation / descriptive statistics:

[0655] All statistical analyses will be described in a detailed statistical analysis plan (SAP) that will be performed prior to unblinding of the Phase 2a data. If there is a discrepancy between the study protocol and the SAP, the SAP will be used to determine the correct analysis and methodology.

[0656] Demographics, safety, PK, and efficacy parameters will be summarized by study phase, presented overall for Phase 1b and by treatment group for Phase 2a, and assisted by graphical presentations as appropriate. Descriptive summaries will include n, mean, standard deviation, minimum, and maximum values ​​for continuous parameters, and frequencies and percentages for categorical parameters. Longitudinal data will be presented at appropriate time intervals based on the summarized endpoints.

[0657] Phase 1b: In keeping with the exploratory nature of the Phase 1 study, no inferential hypothesis testing will be performed. All endpoint summaries will be presented with descriptive statistics. Tables will be summarized by dose level and overall. The mITT and DLT populations will be summarized. The end-of-Phase 1b analysis will be performed after the completion of Phase 1b and before the initiation of Phase 2a. This analysis will inform the SRC recommendations and sponsor decisions on the RP2D, CTO1681 dosing approach, and CAR T-cell product to be included in Phase 2a.

[0658] Phase 2a: Primary and secondary endpoints will be analyzed in the mITT and PP populations. Safety parameters will be analyzed in the safety population.

[0659] The Phase 2a endpoints, incidence, severity, onset, and duration of CRS will be measured by the AUC of CRS grade within 30 days immediately following the initiation of CAR T-cell therapy. The AUC provides a single numerical value to represent the occurrence, duration, and severity of CRS. Analysis of covariance (ANCOVA) will be used to compare the mean AUCs between treatment groups, taking into account the randomization stratification. The difference in mean comparison will be applied, and a one-sided p-value for the AUC difference will be calculated. Further details of this method will be provided in SAP.

[0660] The incidence, severity, onset, and duration of ICANS will be measured by the AUC of the ICANS class within the first 30 days after the initiation of CAR T-cell therapy. Other secondary endpoints, including the AUC of the ICANS class, will be analyzed using the Cochran-Mantel-Haenszel chi-square statistic for categorical variables and ANCOVA for continuous variables, taking into account the randomization stratification. Ordinal variables, including the maximum severity of CRS, will be analyzed using the Wilcoxon-Mann-Whitney test overall and by stratification (as appropriate). Time-to-event endpoints will be compared using the stratified logrank test.

[0661] The robustness of the CRS-level AUC will be established by assessing the correlation of the CRS-level AUC with each component. Specifically, a graphical representation of duration and severity with the AUC will be displayed. The association test will contain differences in mean t-tests and receiver operating curves to determine, for example, whether there are appropriate criteria for establishing the possibility of grade 3 or higher CRS events using the AUC. In addition, the AUC will be evaluated for the frequency and duration of hospitalization and ICU admission attributed to CRS, as well as the use of concomitant medication and anti-cytokine therapy for the treatment of CRS, to determine its relative association with healthcare use. A similar analysis will be performed on the ICANS-level AUC. Additional information will be provided in SAP.

[0662] The analysis of safety parameters will include a summary of AEs, clinical laboratory measurements, vital signs, electrocardiogram results, and concomitant medications.

[0663] Example 27: Phase 1b / 2a Study Methodology:

[0664] The Phase 1b / 2a study is designed to explore the safety and efficacy of CTO1681 in preventing or reducing CAR T cell-induced toxicities. The study will be divided into 2 different parts (named Phase 1b and Phase 2a). Patients are considered enrolled after providing written informed consent for either Phase 1b or Phase 2a of the study. Study participants will be evaluated for inclusion during the screening period. For all participants, the 19-day screening period will end 2 days prior to baseline (Day -3).

[0665] Phase 1b: The Phase 1b portion of the study is a multicenter, open-label, dose-escalation, safety, and pharmacokinetics (PK) study of multiple ascending doses of CTO1681 in patients with DLBCL who are receiving commercially available Akivac CD19-directed CAR T-cell therapy. This portion of the study will be conducted using a rolling 6 design to inform dose escalation in cohorts of patients with DLBCL. The Phase 1b portion of the study will contain the following sequential steps for each patient in each cohort: screening, treatment recruitment, conditioning with lymphodepletion (LD) chemotherapy, initiation of study drug (CTO1681), CAR T-cell infusion, continued treatment with CTO1681 (for a total of 15 days), and safety follow-up. Study eligibility will be determined after leukapheresis and before LD chemotherapy. The duration of treatment with CTO1681 will be based on the following schedule relative to CAR T-cell infusion (CAR T-cell infusion on "Day 0"):

[0666] Day -12 to Day -3: LD chemotherapy (if necessary per the YESCARTA package insert [PI]).

[0667] Day -1: Approximately 24 hours prior to CAR T cell infusion, study drug (CTO1681) was initiated.

[0668] Study drug will continue to be taken orally (PO) 3 times a day (TID) for a total of 15 days. Depending on the cohort each patient is enrolled into, the total daily dose of CTO1681 will be 30μg, 60μg, or 90μg (administered in TID increments of 10μg / dose, 20μg / dose, or 30μg / dose, respectively). Study drug must be taken within 30 minutes after a meal or snack.

[0669] Day 0: CAR T cell infusion (as per YESCARTA PI).

[0670] Patients will be monitored to record tumor responses for up to 6 months (using the Lugano criteria for malignant lymphoma). In addition, patients will be monitored for efficacy and safety throughout the study. A rolling 6 design will be implemented to make recommendations for dose escalation. The dose-limiting toxicity (DLT) observation period is defined as 43 days after the first dose of study drug (Day -1), 42 days after the start of CAR T-cell therapy (Day 0), i.e. Day +41. During the rolling 6 dose escalation program, up to 3 dose cohorts will be considered, with a maximum of 18 patients enrolled. A minimum of 3 patients and a maximum of 6 patients will be enrolled at each dose level.

[0671] Prior to the review of the data for dose escalation, at least 3 patients must complete the DLT observation period (to day +41). Up to 0 / 3, 0 / 4, 0 / 5 or 1 / 6 DLTs may be recorded to allow escalation to the next higher dose level. According to the rolling 6 design, the Safety Review Committee (SRC) will make recommendations for the next dose level based on the safety, laboratory and any PK and pharmacodynamic (PD) data available at the time of the review. If sufficient safety data is not obtained from 1 or more patients in a given cohort, additional patients will be recruited to the cohort, and only patients with sufficient safety data can be included in the safety assessment. If 1 DLT is observed, any new patient will be enrolled at the same dose level until 6 patients are recruited and the DLT observation period has been completed, or at least 2 DLTs are observed and the maximum tolerated dose (MTD) has therefore been exceeded. MTD is defined as the maximum CTO1681 dose reached when the patient is safely treated. If no more than 0 DLTs are observed in 3-5 patients or 1 DLT is observed in 6 patients, the dose can be escalated to the next dose level. If a dose level is too toxic (2 or more DLTs observed in 3-6 patients), the MTD stopping rule for that cohort / dose level may apply. At the discretion of medical monitoring and the sponsor, any or all cohorts deemed safe by the SRC after the dose escalation procedure may be backfilled with up to 12 patients. Backfill samples will allow further safety, anti-tumor response, PK and PD information to better select a recommended Phase 2 dose (RP2D) that is at or below the MTD in Phase 2a. The maximum sample size for Phase 1b is 36 patients. Table 3 below shows the dose escalation and stopping rules.

[0672] Table 3: Dose escalation and stopping rules

[0673]

[0674]

[0675] Abbreviations: DLT = dose-limiting toxicity; MTD = maximum tolerated dose; SRC = safety review committee; a If the dose level is determined to be safe based on the MTD stopping rule and the SRC's recommendations, backfill patients will be recruited at the discretion of the medical monitor and the sponsor. Up to 12 patients can be treated at each dose level. The SRC will monitor the progress and safety of patients throughout the Phase 1b portion of the study and will decide whether dose escalation can occur for each dose level cohort based on a rolling 6 design. In addition, the SRC will make recommendations on the progression of Phase 1b to the Phase 2a portion of the study and the selection of an RP2D based on safety (including available anti-tumor response data). The SRC will also make recommendations on dosing regimens and recommended CAR T-cell products included in Phase 2a.

[0676] Phase 2a: The Phase 2a part of the study will be conducted as a randomized double-blind placebo-controlled study, and approximately 100 patients will be recruited. During Phase 2a, patients will be treated with CTO1681 (which is established in Phase 1b) of RP2D or treated with placebo. Patients will be randomly assigned between the CTO1681 arm and the placebo arm at a ratio of 1:1. Patients will receive commercially available Akirensai CD19-guided CAR T cell therapy. Each patient will follow the same research steps as described above for Phase 1b. Patients recruited in this Phase 2a part of the study will be monitored for tumor response for up to 12 months (using the Lugano criteria for malignant lymphoma) after CAR T cell infusion. Sparse PK samples will be collected in all patients in Phase 2a for population PK and exploratory exposure-response analysis.

[0677] For both the Phase 1b and Phase 2a parts of the study, safety, efficacy, PK and PD evaluations will be performed at intervals specified in the study protocol. Study patients will be hospitalized for observation and management of CAR T cell-related toxicity based on institutional guidelines. All CRS and ICANS grading will be based on the American Society for Transplantation and Cellular Therapy (ASTCT) standards. Detailed management guidelines for CRS and ICANS will be provided in a complete study protocol and will be consistent with the standards for care (SOC) management.

[0678] An Independent Data Monitoring Committee (IDMC), consisting of at least 2 CAR T / hematological oncology experts and an independent biostatistician, will be established to monitor safety data during the Phase 2a portion of the study. The IDMC will conduct planned safety data reviews after approximately 20, 40, 60, and 80 patients have been followed to Day +41 or after the study has been stopped early. Available data from Phase 1b will be included in each review. The study will be paused or stopped if any pre-specified pause or stop rules are met.

[0679] Phase 1b and Phase 2a

[0680] Safety, efficacy, PK, and PD assessments were conducted for both the Phase 1b and Phase 2a portions of the study at the intervals specified in the study protocol for Phase 1b and Phase 2a.

[0681] Patients are planned to be treated as inpatients at least from Baseline / Day -1 to Day +6 to allow for appropriate monitoring. During the period of Day +7 to Day +13, patients may be discharged without CRS / ICANS at the discretion of the Investigator, with approval.

[0682] Example 28: Medical Monitoring and Sponsors.

[0683] If the patient is discharged, they must return to the clinic for a minimum of two visits during the week (day +7 to day +13), which must include a visit on day +13 for AE collection and status assessment during treatment. In addition, study patients will be hospitalized for observation and management of CAR T cell-related toxicity based on institutional guidelines. Currently commercially available CD19-directed CAR T cell therapy (YESCARTA) for B-NHL (which includes DLBCL) will be used in the Phase 1b and Phase 2a portions of this study.

[0684] Example 29: Phase 1b - Safety Review Committee

[0685] The SRC will consist of 1 or more study investigators, study medical monitors and the sponsor's medical representative(s) (or qualified delegate(s)), and special committee members, as appropriate (e.g., statisticians, PK, and regulatory affairs experts). The SRC will monitor the progress and safety of patients throughout the Phase 1b portion of the study. Regular systematic review of AEs will serve as the basis for pausing or stopping the study early. Dose-limiting toxicity will be the primary criterion for pausing or stopping the study consistent with the rolling 6 design operating characteristics. The SRC will carefully review any observed AE that may be considered a DLT that occurs more than 5 half-lives after study drug cessation and evaluate whether the AE can reasonably be considered related to the study drug; recommendations will appropriately reflect this consideration. The SRC will review available safety, laboratory, electrocardiogram (ECG), and PK data through the end of the DLT assessment period (i.e., Day +41, 43 days after the first dose of CTO1681). The SRC may recommend that the dose be escalated, or additional patients may be recruited (up to 6 per dose level), or the SRC may determine that the MTD has been reached and no further dose escalation is appropriate. Cumulative safety data will be reviewed at each SRC meeting. After the dose level is determined to be safe based on the dose escalation program and the SRC review of safety and PK data (if available), additional backfill patients may be recruited (up to a maximum of 12 patients per cohort). If any suspension or stopping rules are met (according to the DLT criteria), the cohort will be suspended or stopped. The SRC makes recommendations on the selection of the Phase 2a portion of the study and the RP2D based on available safety, anti-tumor response data, PK and PD results. An interim analysis will be conducted to summarize the completed Phase 1b results. The SRC may also make recommendations on any necessary study protocol amendments for patient safety throughout the Phase 1b phase of the study. Further details will be recorded in a separate Safety Review Committee Charter.

[0686] Example 30: Phase 2a - Independent Data Monitoring Committee

[0687] An IDMC consisting of a minimum of 2 CAR T / hematologic oncology experts and 1 independent biostatistician will be established to monitor safety data during the Phase 2a portion of the study. The IDMC will conduct planned safety data reviews after approximately 20, 40, 60, and 80 patients have been followed to Day +41 or after the study has been stopped early. The study will be paused or stopped if any pre-specified pause or stopping rules are met. The IDMC will carefully review any observed AE that may be considered a DLT that first occurred more than 5 half-lives after study drug discontinuation and evaluate whether it can reasonably be considered related to study drug; recommendations will appropriately reflect this consideration. In the event of a patient death, a special meeting of the IDMC will be held. In addition, the IDMC will meet more frequently, as necessary, to review SAEs and provide recommendations on when to pause recruitment or terminate the study. The IDMC will also review available data on CR rates based on a set of pre-specified non-binding anti-tumor response impact assessments planned to be performed during the safety data reviews of 40, 60, and 80 patients (20, 30, and 40 per treatment arm). Patients treated with R2PD in Phase 1b will be included in these assessments. Tumor response assessments will include patients who have achieved a CR (according to the Lugano response criteria), have a best anti-tumor response with progressive disease, have discontinued the study early, or have been followed for at least 3 months since the first dose of study drug. Patients who have not achieved a CR, have not had progressive disease, and have not been followed for a minimum of 3 months after treatment initiation will not be included in the analysis. This distinction is made to ensure adequate follow-up to allow for possible responses or disease progression after treatment initiation to avoid artificial underreporting of response rates.

[0688] At each anti-tumor response impact assessment, the CR rate and exact Clopper-Pearson 95% CI will be calculated for patients randomized to CTO1681, comparing the upper limit of the CI to the 41% benchmark minimum rate derived from the lower limit of the 95% CI for CR rate from the YESCARTA label. The first anti-tumor response assessment is expected to be performed after 20 patients have been enrolled and treated with CTO1681; however, a minimum of 12 eligible patients will be analyzed. If necessary, study enrollment may be paused for anti-tumor response data review.

[0689] Example 31: Management of CRS and ICANS

[0690] CTO1681 should be continued in patients who develop CRS and / or ICANS unless otherwise stated under the section for the management of DLTs. Detailed management guidelines for CRS and ICANS will be provided to the investigator to standardize care at participating study sites. These guidelines will be consistent with the SOC outlined in the PI for the selected CAR T-cell therapy, except that self-administration of corticosteroids or tocilizumab to prevent Grade 1 CRS or ICANS will not be permitted. For Grade 2 or higher CRS and ICANS, treatment with corticosteroids and tocilizumab may be considered, along with other supportive therapies.

[0691] Example 32: Critical Dose Limiting Toxicity

[0692] A DLT was defined as a drug-related AE that was considered serious, intolerable, or, in the opinion of the SRC / IDMC, would place the patient at medical risk if a higher dose of CT01681 was administered.

[0693] The key DLT standards are:

[0694] Hypotension: defined as documented prolonged (≥2 hours) systolic blood pressure <80 mm Hg that is unresponsive to primary medical therapy (ie, fluid challenge).

[0695] Bleeding: Any clinically significant bleeding event (grade ≥3 according to the Common Terminology Criteria for Adverse Events v5.0 [CTCAE]) (ie, excluding accidental lacerations, periodontal, menstrual, or hemorrhoidal bleeding, or easily controlled epistaxis) (including any episode of hemoptysis).

[0696] Abnormal liver function: Any occurrence of transaminase elevation >5× upper limit of normal (ULN; CTCAE grade ≥3).

[0697] QTc prolongation: development of a QT interval corrected using the Fridericia formula (QTcF) ≥550 msec or a change from baseline of >60 msec confirmed by repeated 12-lead electrocardiogram (ECG).

[0698] Ventricular tachycardia: CTCAE grade ≥3, requiring urgent medical intervention.

[0699] Other: Safety data for other CTCAE grade ≥3 non-hematologic toxicities in the treatment population will be evaluated, which may be dose-limiting and will include (but are not limited to):

[0700] Any Grade 3 or 4 toxicity and / or laboratory values ​​involving a vital organ (e.g., heart or lung) resulting in significant and irreversible organ damage.

[0701] Any other non-hematologic toxicity of CTCAE grade ≥3 that does not improve to CTCAE grade ≤2 within 72 hours.

[0702] Any death not attributable to the underlying malignancy (Note: All CTCAE Grade 5 events will trigger a study pause to collect and evaluate events for DLT determination. Expedited safety reports submitted to the U.S. Food and Drug Administration [FDA] will be included).

[0703] Waiver of DLT criteria is based on the expected high prevalence of confounding in the specific study patient population and will include

[0704] Grade 3 or 4 anemia, lymphopenia, or thrombocytopenia.

[0705] Grade 3 or 4 fever or febrile neutropenia lasting ≤ 14 days.

[0706] Grade 3 or 4 tumor lysis syndrome lasting ≤ 14 days.

[0707] Any other laboratory finding that is not clinically significant and rapidly reversible to ≤ Grade 2 at baseline within 14 days.

[0708] In subjects with a prior history of peripheral sensory neuropathy, Grade 3 peripheral sensory neuropathy will not be considered a DLT.

[0709] Grade 3 renal and hepatic toxicity improved to ≤ 2 within 7 days.

[0710] Grade 3 fatigue and anorexia not resulting in hospitalization, tube feeding, or total parenteral nutrition.

[0711] Example 33: Target

[0712] Phase 1b:

[0713] To determine the preliminary safety profile of CTO1681 in patients with DLBCL receiving CAR T-cell therapy.

[0714] Determine the RP2D and, as appropriate, MTD of CTO1681 in patients with DLBCL receiving CAR T-cell therapy.

[0715] Phase 2a:

[0716] To determine the preliminary effectiveness of CTO1681 in preventing CRS or reducing the severity and duration of CRS compared to placebo.

[0717] To determine the preliminary effectiveness of CTO1681 in preventing ICANS or reducing the severity and duration of ICANS compared with placebo.

[0718] To determine the expanded safety profile of CTO1681 in patients with DLBCL receiving CAR T-cell therapy.

[0719] To investigate the potential effect of CTO1381 on the anti-tumor activity of CAR T-cell therapy compared with historical data and placebo.

[0720] Example 34: End point:

[0721] Phase 1b

[0722] main:

[0723] Adverse events (AEs) characterized by type, frequency, timing, severity (according to CTCAE v5.0 grading), severity, and relationship to CTO1681, including DLTs as well as laboratory and ECG abnormalities.

[0724] Exploratory:

[0725] The incidence of CRS (any grade).

[0726] Relief time of CRS (any level).

[0727] The incidence of ICANS (any grade).

[0728] Mitigation time for ICANS (any level).

[0729] Biomarkers associated with the mechanism of action (MOA) and immune response of CTO1681.

[0730] Frequency and duration of hospitalizations and intensive care unit (ICU) admissions attributable to CRS or ICANS.

[0731] Use (dosage and duration) of tocilizumab, steroids, and other anti-cytokine therapies for the treatment of CRS or ICANS.

[0732] PK concentration profile of CTO1681.

[0733] Levels and persistence of CAR T cells.

[0734] Immune reconstitution (ie, B-cell aplasia).

[0735] Antitumor activity (including complete response (CR), overall response rate (ORR), duration of response (DOR), and progression-free survival (PFS) based on investigator assessment, and overall survival (OS)).

[0736] Phase 2a (active vs. placebo):

[0737] main:

[0738] Incidence of grade ≥2 CRS.

[0739] secondary:

[0740] Additional Assessment of CRS Incidence and Severity:

[0741] The incidence of CRS (any grade).

[0742] Incidence of grade ≥3 CRS.

[0743] CRS relief time.

[0744] Additional Assessment of ICANS Incidence and Severity:

[0745] The incidence of ICANS (any grade).

[0746] The incidence of ICANS of grade ≥2.

[0747] The incidence of grade ≥3 ICANS.

[0748] ICANS relief time.

[0749] AEs and laboratory abnormalities, and ECG abnormalities were characterized by type, frequency, timing, severity (according to CTCAE v5.0 grading), severity, and relationship to CTO1681.

[0750] Frequency and duration of hospitalizations and ICU admissions attributable to CRS or ICANS.

[0751] Use of tocilizumab, steroids, and other anti-cytokine therapies for the treatment of CRS or ICANS.

[0752] Antitumor activity (including CR rate, ORR, DOR, PFS according to investigator assessment, and OS).

[0753] Exploratory:

[0754] Levels and persistence of CAR T cells.

[0755] PK concentration profile of CTO1681.

[0756] Biomarkers associated with MOA and immune response to CTO1681.

[0757] Immune reconstitution.

[0758] Example 35: End of Study and Study Termination

[0759] The end of the study was defined as the time when all patients had completed or discontinued treatment with CTO1681 (or placebo for the Phase 2a portion of the study) and had been followed up for assessment of CAR T efficacy for 6 or 12 months (Phase 1b or Phase 2a, respectively), or had died, been lost to follow-up, or withdrawn consent.

[0760] The Sponsor may, at its sole discretion, terminate the study if there is good and reasonable cause. If this occurs, each Investigator will be provided with a written notice documenting the reasons for termination.

[0761] Circumstances that may require early termination of the study include (but are not limited to):

[0762] Determination of unexpected, significant, or unacceptable risk to the patient.

[0763] Inadequate compliance with study protocol requirements.

[0764] Plan to revise, suspend, or terminate development of an investigational drug.

[0765] Despite every effort to increase recruitment, patients could not be recruited at an acceptable rate.

[0766] Other administrative reasons.

[0767] If the study is terminated prematurely, all study materials must be returned to the sponsor or the sponsor's designee.

[0768] Example 36: Inclusion criteria

[0769] 1. Aged 18 or above.

[0770] 2. Underwent leukapheresis and planned to receive commercially available Akivacet CD19-directed CAR T-cell therapy for DLBCL as specified in the study protocol without corticosteroid prophylaxis for CRS and / or ICANS. Eligible patients must have relapsed or refractory DLBCL after at least two prior lines of systemic therapy.

[0771] 3. Meet all inclusion criteria for CAR T-cell therapy according to institutional guidelines.

[0772] 4. Adequate organ function is defined as: serum creatinine ≤1.5×ULN, and estimated glomerular filtration rate (eGFR) according to the Cockroft-Gault formula ≥60mL / min×BSAm2 / 1.73m2. Serum alanine aminotransferase / aspartate aminotransferase ≤2.5×ULN. Total bilirubin ≤1.5×ULN. Left ventricular ejection fraction ≥40% on echocardiography or multi-gated circuit acquisition scan, and no clinically significant pericardial effusion. Platelets ≥50,000 / mm3. Absolute neutrophil count>1000 / μL. Absolute lymphocyte count>100 / μL.

[0773] 5. Documented measurable lymphoma sufficient to be judged by the Lugano criteria.

[0774] 6. Eastern Cooperative Oncology Group (ECOG) performance status is 0 to 1.

[0775] 7. Female participants of childbearing potential and all male participants must agree to use investigator-approved contraceptive methods during the study drug period and within 30 days thereafter.

[0776] 8. Patients who are willing to provide written informed consent prior to pre-drug procedures, or who have a legal representative who can provide informed consent on their behalf.

[0777] Example 37: Exclusion criteria

[0778] Patients who meet any of the following criteria will be excluded from the study:

[0779] 1. Any cytotoxic chemotherapy within 14 days before leukapheresis.

[0780] 2. Clinically significant malabsorption syndrome and dysphagia (e.g., odynophagia, dysphagia, gastroesophageal reflux disease) that is inadequately controlled with medication as assessed by the investigator.

[0781] 3. Electrolyte imbalance that is unstable or unresponsive to therapy.

[0782] 4. Clinically significant ECG abnormalities at screening or baseline (Day 1), including (but not limited to), confirmed QTcF values ​​> 470 msec. Patients to be excluded include those with borderline or difficult to interpret QTcF readings due to conditions such as bundle branch block or those conditions in which the end of the T wave is difficult to measure.

[0783] 5. History of clinically significant arrhythmias and / or requiring therapeutic doses of anticoagulant / antiplatelet therapy.

[0784] 6. Any clinically significant (i.e., active) cardiovascular disease, including cerebrovascular accident / stroke (<6 months before recruitment), myocardial infarction (<6 months before recruitment), or unstable angina, and congestive heart failure ≥ New York Heart Association grade III.

[0785] 7. Uncontrolled thromboembolic events or recent severe bleeding in the past 6 months.

[0786] 8. Known history of any bleeding disorder.

[0787] 9. Requires continuous therapeutic doses of anticoagulant therapy, antiplatelet agents, or fibrinolytic agents (low molecular weight heparin prophylaxis is permitted).

[0788] 10. Baseline systolic blood pressure <100 mm Hg.

[0789] 11. History of autoimmune disease / graft-versus-host disease requiring immunosuppressive therapy within the past 2 years. However, physiologic steroids (prednisone equivalents) may be administered at doses of 5 mg or less.

[0790] 12. Patients who, in the opinion of the investigator, will be unlikely to comply with study procedures or are not suitable for recruitment.

[0791] Example 38: Study Treatment

[0792] Lymphodepleting chemotherapy

[0793] Lymphodepleting chemotherapy will be administered according to the CAR T-cell manufacturer's PI and institutional guidelines. For patients with a white blood cell count of ≤1000 cells / μL within 1 week prior to the planned CAR T-cell infusion, lymphodepleting chemotherapy is not required (but may be performed at the investigator's discretion).

[0794] Unless otherwise specified, lymphodepleting chemotherapy will be supplied by the study center. Instructions for packaging, storage, preparation, administration, and management of toxicities associated with the administration of LD chemotherapy as documented on the current product label should be followed.

[0795] Study Drug

[0796] For the Phase 1b portion of the study, study drug will consist of CTO1681-IR-OSD-10 μg rapid-release tablets.

[0797] For the Phase 2a portion of the study, study drug will consist of CTO1681-IR-OSD-10μg rapid-release tablets or matching placebo tablets. In Phase 1b of the study, CTO1681 will be administered PO as a 10-μg tablet. In Cohort 1, CTO1681 tablets will be administered PO TID at a total daily dose of 30μg for 15 days. Cohorts 2 and 3 will receive CTO1681 PO TID at a total daily dose of 60μg and 90μg, respectively, for 15 days. During Phase 2a of the study, CTO1681 will be administered orally as a 10-μg tablet, with the possibility of multiple tablets per dose based on the RP2D dose determined by Phase 1b results. Placebo tablets are identical to CTO1681 10-μg tablets in size, shape, color, and packaging.

[0798] Example 39: Study Product, Dosage and Mode of Administration:

[0799] CTO1681 dosing must be initiated at the baseline visit (Day -1), approximately 24 hours (±1 hour) prior to CAR T cell infusion, and administered every TID within 30 minutes of the start of a meal or snack; ideally 5 hours (±30 minutes) between meals from Days -1 to +13. Treatment adherence will be measured on all dosing days (Day -1 to +13). For Days +7 to +13, non-hospitalized patients will receive a dosing diary to record any relevant information regarding study medication, and during hospital visits, site staff will review the diary for compliance and record the required date in the patient eCRF.

[0800] Phase 1b: CTO1681 will be administered orally as a 10-μg tablet. In Cohort 1, CTO1681 tablets will be administered POTID at a total daily dose of 30 μg for 15 days. Cohorts 2 and 3 will receive CTO1681 POTID at a total daily dose of 60 μg and 90 μg, respectively, for 15 days. Neither intra-patient nor intra-cohort dose modifications will be allowed unless specified in the management of DLTs.

[0801] Phase 2a: CTO1681 will be administered orally as a 10-μg tablet, with the potential for multiple tablets per dose based on the RP2D dose determined by Phase 1b results.

[0802] Note: Since CTO1681 has a positive food effect, it should be administered within 30 minutes after a meal or snack.

[0803] Duration of study (per patient)

[0804] Phase 1b: Approximately 9 months (including screening).

[0805] Phase 2a: Approximately 15 months (including screening).

[0806] Example 40: Reference therapy, dosage and mode of administration:

[0807] Phase 1b: None.

[0808] Phase 2a: Placebo tablets will be administered PO TID in the same manner as active treatment. Placebo tablets will be identical to CTO1681 10-μg tablets in size, shape, color, and packaging.

[0809] Example 41: CAR T cell therapy

[0810] Patients will receive commercially available Akirensen CD19-directed CAR T-cell therapy (which will be administered according to the manufacturer's PI and institutional guidelines).

[0811] Example 42: Packaging and labeling

[0812] CTO1681-IR-OSD-10μg rapid-release tablets and placebo tablets will be provided in plastic bottles containing 45 tablets each. The study number will be printed on each individual medication label. The label for Phase 1b will contain identification of the contents, as only CTO1681-IR-OSD-10μg rapid-release tablets will be dispensed to patients during this open-label portion of the study. During the randomized portion of the study, Phase 2a, the contents of the drug or placebo bottles will be appropriately masked.

[0813] The patient identification number, initials, and date the bottle was dispensed for each patient will be completed by site staff or a pharmacist. Packaging will meet all regulatory requirements.

[0814] Example 43: Storage

[0815] According to the package label, study drug tablets will be stored in their original container at room temperature (20°C to 25°C ([68°F to 77°F]).

[0816] All investigational drug products will be stored in a secure, limited access location and may only be distributed by the investigator or staff specifically authorized by the investigator.

[0817] Example 44: Duration of Patient Participation

[0818] Patient participation during the Phase 1b portion of the study will be approximately 9 months, including screening. Patient participation during the Phase 2a portion of the study will be approximately 15 months, including screening.

[0819] Example 45: Treatment Compliance

[0820] Patients enrolled in Phase 1b of the study will be assigned 1, 2, or 3 bottles of CTO1681 10 μg tablets (for the 30 μg / day dose, 60 μg / day dose, or 90 μg / day dose). In the Phase 2a portion, patients assigned CTO1681 or placebo will receive 1, 2, or 3 bottles of CTO1681 10 μg tablets or placebo, depending on randomization assignment and the RP2D for continuation of that portion of the study. Each bottle will contain 45 tablets of CTO1681 10 μg tablets or placebo (Phase 2a only).

[0821] Example 46: Previous medication and concurrent medication and treatment

[0822] Previous and concurrent medications and procedures

[0823] All medications administered and procedures performed at study entry should be recorded on the eCRF within 20 days prior to the first day of study drug administration (Day -1) and until the end-of-study visit (6 months or 12 months for Phase 1b and Phase 2a, respectively). In addition, all previous treatments for DLBCL should be recorded.

[0824] During the study, LD chemotherapy and CAR T-cell therapy are recorded on the designated eCRF pages. All other medications taken since the signing of the informed consent form should be recorded as concomitant medications on the appropriate eCRF pages.

[0825] Prohibited combination therapy

[0826] The following concomitant therapies were prohibited during study participation:

[0827] Bridging chemotherapy was allowed, however, no additional therapy should be given within 7 days of initiation of LD chemotherapy.

[0828] After leukapheresis, additional steroids exceeding physiologic doses should not be given.

[0829] Unless used to manage CAR T-cell-related toxicities, systemic steroids and other immunosuppressive drugs should be continued for 3 months after CAR T-cell infusion.

[0830] Systemic steroids or tocilizumab are used for the prevention of CRS / ICANS (prophylactic steroids or tocilizumab) or for the treatment of grade 1 CRS / ICANS. Steroids and / or tocilizumab should only be given for grade 2 or higher CRS / ICANS.

[0831] The study protocol does not allow for chemotherapy, immunotherapy, targeted agents, radiation therapy, high-dose corticosteroids, and investigational agents other than LD chemotherapy unless required for treatment of disease progression following CAR T-cell therapy.

[0832] Granulocyte macrophage colony-stimulating factor (GM-CSF) can potentially exacerbate CRS symptoms and should be avoided.

[0833] Short-acting granulocyte colony-stimulating factor within 3 days of CAR T-cell infusion or long-acting granulocyte colony-stimulating factor within 10 days of CAR T-cell infusion.

[0834] Central nervous system prophylaxis (eg, intrathecal methotrexate) must be discontinued more than 1 week before CAR T-cell infusion.

[0835] Herbal and natural remedies.

[0836] Potential drugs that may interact with CTO1681 (CTO1681 [Investigator's Brochure]).

[0837] Example 47: Permitted Combination Therapies

[0838] Any medication or inactivated vaccine (including over-the-counter or prescription medications, and excluding vitamins) received at enrollment or during the study that is considered for supportive care and patient safety must be recorded in the eCRF along with the reason for use, date of administration (including start and end dates), and dosing information (including dose and frequency). This may include (but is not limited to) the following:

[0839] Routine prophylactic medications (eg, diphenhydramine, acetaminophen / paracetamol) are administered during CAR T-cell infusion.

[0840] Systemic steroids: dexamethasone, prednisone, or other corticosteroids for the treatment of CRS or ICANS as per study guidelines.

[0841] Physiologic steroid replacement (≤5 mg / day prednisone or equivalent) topical and inhaled steroids.

[0842] Symptomatic treatment of tumor-related symptoms (e.g., pain and nausea).

[0843] Oxygen therapy and blood products or transfusions.

[0844] Medicines to treat chronic conditions (for example, high blood pressure and high cholesterol).

[0845] If necessary, the investigator, in consultation with the sponsor or designee, may consider any concomitant medication not listed in the study protocol on a case-by-case basis.

[0846] Example 48: Management of Critical Dose-Limiting Toxicity

[0847] DLTs of hypotension, abnormal liver function, bleeding, QTc prolongation, and ventricular tachycardia will be managed as follows:

[0848] DLT of hypotension or abnormal liver function: CTO1681 will be interrupted until DLT resolves. If DLT recurs, CTO1681 will be stopped for that patient.

[0849] DLT of bleeding: CTO1681 will be interrupted until DLT resolves. If DLT recurs, CTO1681 will be stopped for that patient.

[0850] DLT of QTc prolongation or ventricular tachycardia: In the case of QTc prolongation, CTO1681 will be interrupted until the DLT resolves. If the DLT recurs, CTO1681 will be stopped for that patient.

[0851] In the event of ventricular tachycardia, CTO1681 should be permanently discontinued for that patient. All other DLTs will be managed according to the institutional SOC.

[0852] Example 49: Infection Prophylactic Treatment

[0853] Patients should receive prophylactic treatment for Pneumocystis pneumonia infection, herpes virus, and fungal infections according to standard institutional practice or National Comprehensive Cancer Network guidelines.

[0854] Tumor lysis syndrome

[0855] All patients with significant malignancy burden and without paradoxicals such as allergies should begin prophylactic therapy (e.g., allopurinol) according to institutional guidelines prior to CAR T-cell infusion. Prophylactic therapy should be discontinued once the risk of tumor lysis has passed.

[0856] B cell depletion

[0857] Due to the effects of CAR T cell therapy on normal B cells, B cell depletion and hypogammaglobulinemia may occur. According to institutional guidelines, immunoglobulin will be administered for hypogammaglobulinemia. At a minimum, trough immunoglobulin G (IgG) levels should be maintained above 400 mg / dL, especially in the case of infection (Hill, JA, et al. (2019). Blood Rev 38: 100596.).

[0858] Example 50: Cytokine Release Syndrome

[0859] The goal of CRS management is to prevent life-threatening conditions while retaining the benefits of antitumor effects. The CRS grading system and treatment guidelines for CRS created by ASTCT and published by Lee et al. (Lee, et al. 2019 Biol Blood Marrow Transplant 25(4): 625-638) are detailed in Table 4. General recommendations and monitoring for CRS are as follows:

[0860] Patients should be adequately hydrated prior to and while receiving CTO1681.

[0861] CTO16181 should be administered according to the study schedule and dosing instructions.

[0862] Patients should be monitored as inpatients during CTO1681 administration from Day -1 to Day +13, unless discharged from the hospital without CRS / ICANS at the investigator's discretion on Day +7 to Day +13 with medical supervision and sponsor approval.

[0863] If symptoms (fever, hypotension, hypoxia) develop, the patient will be evaluated for other causes (e.g., infection) / the patient will be evaluated to exclude other causes (e.g., infection). Other causes of symptoms should be treated as appropriate.

[0864] Neither steroids nor tocilizumab should be administered prophylactically. Table 4 shows the management of CRS.

[0865] Table 4: Management of cytokine release syndrome

[0866]

[0867]

[0868] In Table 4:

[0869] Fever was defined as a temperature ≥ 38°C that could not be attributed to any other cause. In patients who had CRS and then received antipyretic or anticytokine therapy (such as tocilizumab or steroids), fever was no longer required to grade the subsequent severity of CRS. In this setting, CRS grading was advanced by hypotension and / or hypoxia.

[0870] In Table 4, ASTCT=American Society for Transplantation and Cellular Therapy; BiPAP=bilevel positive airway pressure; C=degrees Celsius; CPAP=continuous positive airway pressure; CRS=cytokine release syndrome; h=hour; IV=intravenous; PRN=as needed.

[0871] CRS grade is determined by more severe events: hypotension or hypoxia not attributed to any other cause. For example, a patient with a temperature of 39.5°C, hypotension requiring 1 vasopressor, and hypoxia requiring a low-flow nasal cannula is classified as grade 3 CRS.

[0872] Low-flow nasal cannula is defined as delivering oxygen at ≤6 L / min. Low flow also includes blow-through oxygen delivery, which is sometimes used in pediatrics. High-flow nasal cannula is defined as delivering oxygen at >6 L / min.

[0873] Example 51: Immune Effector Cell-Associated Neurotoxicity Syndrome

[0874] Like CRS, ICANS is a potentially life-threatening toxic syndrome that is often caused by CAR T-cell therapy and often occurs within the first week after CAR T-cell therapy. ICANS can progress through increasingly severe manifestations. The ICANS grading system developed by ASTCT and ICANS treatment guidelines are detailed in Table 5. If concurrent CRS is suspected, treat CRS according to the recommendations in Table 4.

[0875] Table 5: ICANS Management

[0876]

[0877]

[0878] In Table 5, ASTCT = American Society for Transplantation and Cellular Therapy; CT = computed tomography; EEG = electroencephalogram; h = hour; ICANS = immune effector cell-associated neurotoxicity syndrome; ICE = immune effector cell-associated encephalopathy; ICP = intracranial pressure; IV = intravenous; MRI = magnetic resonance imaging; VI = six.

[0879] In Table 5:

[0880] The ICANS grade is determined by the most severe event (ICE score, level of consciousness, seizure, motor manifestations, elevated ICP / cerebral edema) that is not attributable to any other cause; for example, a patient with an ICE score of 3 who has a generalized seizure is classified as a grade 3 ICANS.

[0881] Patients with an ICE score of 0 may be classified as Grade 3 ICANS if they have complete aphasia when awake, but may be classified as Grade 4 ICANS if they cannot be awakened.

[0882] The decreased level of consciousness should not be attributed to other causes (eg, absence of sedative medications).

[0883] Tremor and myoclonus associated with immune effector cell therapy can be graded according to CTCAE v5.0, but they do not affect the ICANS grade.

[0884] Intracranial hemorrhage with or without associated edema is not considered a neurotoxic feature and is excluded from the ICANS classification. Grading can be performed according to CTCAE v5.0.

[0885] Grading of CRS and ICANS will be performed daily starting on day 0 (and according to ASTCT criteria as clinically indicated).

[0886] For Days +7 to +13, if the patient was not hospitalized, CRS / ICANS assessments were performed only during the outpatient visit, regardless of the CTO1681 dose timing.

[0887] CRS consensus grading: In grading CRS, researchers from the National Cancer Institute published a CRS severity scale associated with antibody therapy. Understanding the need to adapt the scale to other therapies to define mild, moderate, severe, and life-threatening events; explain overlapping symptoms; and guide treatment recommendations, a revised CRS grading system was created during an ASTCT-supported meeting and published by Lee et al. (Table 4).

[0888] ICANS grading: Immune effector cell-associated neurotoxicity syndrome is a clinical neuropsychiatric syndrome that can occur after immunotherapy, especially associated with T cell-involved therapies, and can often occur simultaneously with or immediately after CRS. ASTCT created and published the ICANS grading system (Table 5).

[0889] Example 52: Fever and Neutropenia

[0890] Evaluation for infectious sources should be performed according to institutional guidelines. Fever should be treated with acetaminophen and comfort measures. Nonsteroidal anti-inflammatory drugs and corticosteroids should be avoided. Patients with neutropenia and fever should receive broad-spectrum antibiotics. Most febrile patients should be started on maintenance intravenous fluids (normal saline), particularly if oral intake is inadequate or if the patient is tachycardic. In patients who are not hypotensive and not experiencing active tumor lysis syndrome, an even daily fluid balance should be sought.

[0891] Filgrastim should be used according to published guidelines (eg, Infectious Diseases Society of America).

[0892] Example 53: Blood Product Support for Anemia and Thrombocytopenia

[0893] Treatment of anemia and thrombocytopeniaShould be provided according to institutional guidelines. All blood products should be irradiated. Using a complete blood count as a guide, patients should receive platelets and packed red blood cells as needed. Attempts should be made to maintain hemoglobin levels >8.0 gm / dL and platelet counts >20,000 / mm3. Leukocyte filters should be used for all blood and platelet transfusions to reduce sensitivity to the transfused white blood cells and reduce the risk of cytomegalovirus infection.

[0894] Example 54: Prophylactic Treatment of Deep Vein Thrombosis

[0895] Prevention of deep vein thrombosis should be administered according to institutional guidelines. According to institutional guidelines, prophylactic treatment of deep vein thrombosis should be administered to all patients with reduced mobility during hospitalization. Based on benefit / risk, if there are no contraindications (e.g., recent surgery, bleeding tendency, platelet count <50,000 / μL), the use of low molecular weight heparin is encouraged. Non-invasive mechanical intermittent pneumatic compression devices for prophylactic treatment of deep vein thrombosis should be used in patients who cannot receive anticoagulants due to increased risk of bleeding or other concerns (Lyman, Carrier et al. 2021 Blood Adv 5 (4): 927-974).

[0896] Example 55: Criteria for pausing or stopping a study:

[0897] If any of the events mentioned below as suspension or stopping criteria occur within 43 days of the first exposure to study drug (i.e., Day +41), the SRC (in Phase 1b) or IDMC (in Phase 2a) will be notified immediately and a special meeting will be scheduled to review all available safety data. Study recruitment will be suspended at that time. The committee will then provide recommendations on how to proceed.

[0898] Suspension Standard

[0899] The emergence of any DLT standard will prompt a special meeting of the SRC (Phase 1b) or IDMC (Phase 2a).

[0900] Stop criteria

[0901] The SRC (Phase 1b) or IDMC (Phase 2a) will recommend stopping the study if:

[0902] CTCAE grade 4 toxicities (refractory, unexpected) possibly, probably, or definitely related to CTO1681 occurring in >25% of dosed patients (excluding pyrexia, hematologic toxicity, and CRS / ICANS).

[0903] Death caused by CTO1681-related DLT not related to the underlying disease, CAR T-cell therapy, or external events (not related to the investigational product or investigational procedures). Specifically:

[0904] Fatal bleeding events.

[0905] Refractory hypotension resulting in death.

[0906] Refractory ventricular tachycardia resulting in death.

[0907] NOTE: Safety stopping criteria for Phase 2a may also consider data from Phase 1b subjects treated at the RP2D and lower doses.

[0908] The sponsor may decide to suspend, stop, or modify the study based on the SRC / IDMC's recommendations and the completeness of the chain of evidence. If it is determined that continuing the study may endanger patient safety, the SRC may recommend suspending or stopping the study. The IDMC may recommend stopping the study based on safety or reduced anti-tumor response.

[0909] The occurrence of the following will prompt a special meeting of the SRC (Phase 1b) or IDMC (Phase 2a):

[0910] Hypotension: defined as documented prolonged (>2 hours) systolic blood pressure <80 mm Hg that is unresponsive to basic medical therapy (ie, fluid challenge).

[0911] Bleeding: Any clinically significant bleeding event of grade > 3 (according to CTCAE v5.0) (ie, excluding accidental lacerations, periodontal, menstrual or hemorrhoidal bleeding, or easily controlled epistaxis) (including any episode of hemoptysis).

[0912] Abnormal liver function: Any occurrence of transaminase elevation >5× upper limit of normal (ULN; CTCAE grade ≥3).

[0913] QTc prolongation: development of a QTcF >550 msec or a change from baseline >60 msec confirmed by repeated 12-lead electrocardiogram (ECG).

[0914] Ventricular tachycardia: (CTCAE grade > 3) requires urgent medical intervention.

[0915] Other: Safety data for other CTCAE grade >3 non-hematologic toxicities in the treatment population will be evaluated, which may be dose-limiting and will include (but not limited to):

[0916] Any Grade 3 or 4 toxicity and / or laboratory values ​​involving a vital organ (e.g., heart or lung) resulting in significant and irreversible organ damage.

[0917] Any other grade 3 non-hematologic toxicity that does not improve to ≤ grade 2 within 72 hours.

[0918] Any death not attributable to the underlying malignancy (Note: All Grade 5 events will trigger a study pause to collect and evaluate events for DLT determination. Expedited reporting to the FDA will be included). The SRC (Phase 1b) or IDMC (Phase 2a) will recommend stopping the study if:

[0919] CTCAE grade 4 toxicities (refractory, unexpected) possibly, probably, or definitely related to CTO1681 occurring in >25% of dosed patients (excluding pyrexia, hematologic toxicity, and CRS / ICANS).

[0920] Death caused by CTO1681-related DLT not related to the underlying disease, CAR T-cell therapy, or external events (not related to the investigational product or investigational procedures). Specifically:

[0921] Fatal bleeding events

[0922] Refractory hypotension leading to death

[0923] Refractory ventricular tachycardia causing death

[0924] Note: The safety stopping criteria for Phase 2a may also consider data from subjects treated at the RP2D and lower doses in Phase 1b. Sponsors may decide to suspend, stop, or modify the study based on the recommendations of the SRC / IDMC and the completeness of the chain of evidence. The SRC may recommend suspending or stopping the study if it is determined that continuing the study may endanger patient safety. The IDMC may recommend stopping the study based on safety or reduced anti-tumor response.

[0925] Example 56: Statistical methods:

[0926] Sample size considerations:

[0927] Phase 1b: A maximum sample size of 36 (maximum 12 per dose level) was selected to support dose escalation and RP2D selection of CTO1681 dose levels based on a rolling 6-dose escalation process and backfill expansion to ensure adequate safety data for Phase 2a dose selection.

[0928] Phase 2a: The study was designed with a sample size selected to provide adequate power for the primary endpoint. The sample size was 100 patients (50 in each group) with 80% power with a one-sided type I error rate of 0.05 to detect a difference in the proportion of 40% of control patients experiencing grade ≥2 CRS versus 16% of CTO1681 patients.

[0929] Analyzed groups:

[0930] Modified Intent-to-Treat (mITT) Population: The mITT population will include all patients who received both CAR T-cell therapy and at least 1 dose of study drug (CTO1681 / placebo). Patients will be stratified by dose group for Phase 1b analysis and randomized for Phase 2a analysis.

[0931] Safety population: The safety population will include all patients who received at least 1 dose of study drug (CTO1681). Patients will be grouped by treatment.

[0932] DLT population: The DLT population will include all patients who receive both CAR T cell therapy and at least 1 dose of CTO1681 in Phase 1b. Patients who withdraw from the study due to reasons unrelated to the study procedure, behavior, or treatment before experiencing a DLT and completing the DLT observation period (until Day + 41, 43 days after the first dose of CTO1681 or placebo) will not be included in this population. Additional analysis populations can be defined in the statistical analysis plan (SAP). The standard intention-to-treat (ITT) population containing all randomized patients can be analyzed as an evaluation of the robustness of the mITT.

[0933] Example 57: Research Theory Foundation

[0934] CTO1681 has a broad effect on multiple (20+) cytokines to alleviate hypercytokinemia (CTO1681). Early administration of CTO1681 (before the initial release of pro-inflammatory cytokines (e.g., IFN-γ, TNF-α, IL-1, IL-2, and IL-6)) can mitigate the risk of CRS associated with CAR T cell therapy. Through excessive cytokine inhibition, CTO1681 can potentially prevent the onset or progression of CAR T cell-induced immune-mediated toxicity, thereby reducing associated morbidity and hospitalization. The purpose of this study is to evaluate the safety and tolerability of CTO1681, as well as to determine the preliminary effectiveness of CTO1681 (primarily measured by the reduction of CAR T cell-induced toxicity, including CRS and ICANS and other efficacy measurements). This Phase 1b / 2a study will recruit adult patients with B-NHL (DLBCL subtype) who are scheduled to receive akirafenib (i.e. )CD19-directed CAR T-cell therapy to manage the potential variability in response and adverse reaction rates between CAR T-cell therapies. However, CRS and ICANS are not unique to Akiram, and future studies of CTO1681 may involve additional CAR T-cell therapy. The Phase 1b portion will contain an initial open-label, dose-finding, safety, and toxicity assessment of a small sample of patients (n=9 to 36). The Phase 2a portion (n=100) will be a randomized proof-of-concept evaluation to investigate the potential benefit of CTO1681 versus placebo initiated prior to CAR T-cell therapy in mitigating or reducing CAR T-cell-induced toxicities.

[0935] There is a medical need for an alternative treatment option to tocilizumab and steroids in B-NHL for CRS and / or ICANS caused by CAR T-cell therapy. CTO1681 has demonstrated a tolerable safety profile in healthy volunteers, consistent with that reported for beretrostenol sodium. Results from the Phase 1a study in healthy volunteers support further investigation of CTO1681 to mitigate CAR T-cell therapy toxicity in the DLBCL patient population.

[0936] Rationale for dose selection and scheduling

[0937] The proposed doses for the Phase 1b multiple ascending dose portion of the study will be 10 μg, 20 μg and 30 μg three times daily (TID) (30 μg, 60 μg and 90 μg daily). The dose for the proposed Phase 2a portion of the study will be selected based on the findings of the Phase 1b portion of the study.

[0938] There is substantial evidence from the nonclinical and clinical use history of rapid-release formulations of beraprost sodium and the same active isomer as CTO1681 that these doses will be well tolerated and potentially effective in the prevention and treatment of CRS. Beraprost sodium contains 4 stereoisomers, one of which (314d) contains nearly all of the biological activity and is chemically identical to CTO1681. There is extensive clinical experience worldwide with beraprost sodium, and its safe and effective doses for non-CRS indications have been well described. In Japan, the approved dose range for rapid-release formulations of beraprost sodium is 60 μg / day to 180 μg / day (corresponding to 15 μg / day to 45 μg / day CTO1681), divided into 3 or 4 doses administered with food and generally titrated upward to tolerance. In studies of patients with pulmonary hypertension, the safety of long-term administration of high levels of beraprost sodium up to 480 μg / day (120 μg / day CTO1681) for up to 36 months has been reported (Vizza, Sciomer et al. 2001 Heart 86(6):661-665, Galie, Humbert et al. 2002 J Am Coll Cardiol 39(9):1496-1502, Nagaya, Shimizu et al. 2002 Heart 87(4):340-345, Barst, McGoon et al. 2003 J Am Coll Cardiol 41(12):2119-2125, Ono, Nagaya et al. 2003 Circ J 67(5):375-378, Ono, Nagaya et al. 2003 Chest 123(5):1583-1588, Durongpisitkul, Laoprasitiporn et al.2005Circ J 69(1):61-64., Park,Moon etal.2006Pulm Pharmacol Ther 19(4):264-271, Vizza,Badagliacca etal.2006Cardiology 106(3):168-173.).

[0939] Findings from the recently completed Phase 1 multiple ascending repeat dosing study of CTO1681, which evaluated doses of 15 μg / day to 60 μg / day in healthy volunteers over a 7-day period, have confirmed this generally mild safety profile. No SAEs, treatment-emergent AEs (TEAEs) of special interest (defined as clinically significant changes in coagulation parameters or platelets, or persistent / recurrent symptomatic orthostatic hypotension), or TEAEs leading to study discontinuation or dose reduction occurred. Treatment-emergent AEs were only mild (62 AEs) or moderate (4 AEs) in severity and were fully consistent with the previously reported safety profiles of beraprost sodium and 314d.

[0940] Doses of beraprost sodium within the dose equivalent of CTO1681 for multiple ascending dose studies have been shown to cause a significant reduction in TNF-α in patients with diabetes (Fujiwara, Nagasaka et al. 2004 Exp Clin Endocrinol Diabetes 112 (7): 390-394, Xu, Pan et al. 2020 Exp Ther Med 19 (1): 639-645). It is assumed that similar reductions in TNF-α and other pro-inflammatory cytokines may alleviate the CRS frequently observed in CAR T cell therapy. Importantly, in healthy volunteers treated with CTO1681, no clinically significant decrease in cytokine levels (panel of 27 cytokines) was seen, indicating that CTO1681 did not completely eliminate the cytokine response, but rather alleviated the excessive response, further supporting the safety of CTO1681 and justifying continued clinical evaluation.

[0941] Example 58: Potency Measurement

[0942] The primary phase 2a endpoint, the incidence of grade ≥2 CRS, will be summarized as the frequency and proportion of patients experiencing this event, and the treatment groups will be compared using Fisher's exact test evaluated at a one-sided type I error rate of 0.05. Exact 90% CIs will be presented.

[0943] The incidence of CRS (any grade), CRS grade ≥ 3, ICANS (any grade), ICANS grade ≥ 2, and ICANS grade ≥ 3 will be summarized in a similar manner as CRS grade ≥ 2. For exploratory purposes, comparisons between treatment groups will be performed using Fisher's exact test.

[0944] The ordinal variables (including the maximum severity of CRS) will be analyzed using the Wilcoxon-Mann-Whitney test as appropriate. The CRS regression time and ICANS regression time will be analyzed using the Kaplan-Meier method, and the logrank test will be used to compare between treatment groups. The frequency and duration of hospitalization and ICU admission due to CRS or ICANS will be summarized using descriptive statistics, as well as the use of tocilizumab, steroids, and anti-cytokine therapy for the treatment of CRS or ICANS.

[0945] Example 59: Pharmacokinetic Measurements

[0946] During the Phase 1b and Phase 2a portions of the study, serial blood samples will be drawn from patients for PK assessments. These samples will be used to determine the PK concentration profile of CTO1681.

[0947] In the Phase 1b portion, blood samples for plasma preparation will be collected for analysis at the following times:

[0948] Day -1 (1st [morning] dose): At time = 0 (before food and within 1 hour before morning dose) hour and 0.5 (±10 minutes) hour, 1 (±10 minutes) hour, 1.5 (±10 minutes) hour, 2 (±10 minutes) hour, 3 (±10 minutes) hour and 4 (±10 minutes) hour after the first (morning) dose of CTO1681.

[0949] Day -1 (second and third doses): 0.5 hours (±10 minutes) before and 1 hour before the second and third doses of CTO1681. Day 0, Day +2, Day +4, Day +6, and Day +13: 1 hour (±10 minutes) after the first morning dose of CTO1681.

[0950] In the Phase 2a portion, sparse blood samples will be collected from all patients for the preparation of plasma for population PK and exploratory exposure-response analyses. Samples should be collected approximately 1 hour (±10 minutes) after the first morning dose. If PK samples are scheduled at the same time as ECG assessments and cytokine extractions, the assessments should be performed in the following order: (1) ECG measurement, (2) PK extraction, (3) cytokine extraction.

[0951] Pharmacokinetic samples should be processed within 1 hour of collection and frozen at -80°C until shipping. Further details on the collection, handling and processing of PK samples will be included in a separate study brochure.

[0952] Example 60: Biomarker and Immune Reconstitution Measurements

[0953] Biomarkers related to the mechanism of action (MOA) of CTO1681 and immune response, as well as immune reconstitution will be collected via blood sampling for patients in both the Phase 1b and Phase 2a portions of the study.

[0954] Biomarkers associated with the MOA and immune response to CTO1681 include: cytokines (IFN-γ, TNF-α, IL-1, IL-2, IL-6, and GM-CSF), C-reactive protein (CRP), and ferritin. In addition, blood sampling for IgG, lymphocyte subset count (TBNK) panel, and immunophenotyping to determine immune reconstitution will be obtained.

[0955] The objectives, assessments, and analysis criteria for biomarker and reconstruction analyses are defined below (Table 6).

[0956] Table 6: Objectives, assessments, and analysis criteria for biomarker and reconstruction analyses

[0957]

[0958] Example 61: Cytokine sampling

[0959] In the first 24 hours of cytokine collection, patients should avoid vigorous physical exercise. For both 1b phase and 2a phase, the blood sampling of cytokines will occur in the morning before CTO1681 dosage and in the morning after CTO1681 dosage for about 1 hour from the +1st day to the +6th day. For screening, LD chemotherapy, -1st day, 0th day, +7th day to +13th day, the 1st follow-up, 1st month, 3rd month, 6th month and 12th month (only 2a phase), sampling should occur in the time of the roughly same number of days that the number of days that CTO1681 sampling will occur in the morning (post-morning) during the hospitalization period. The number of days (0th day, +2nd day, +4th day, +6th day and +13th day) of PK sampling are also arranged for this time point, and the cytokine sample should be extracted immediately after PK sampling. Sample should be processed within 1 hour after collection, and frozen at -80 ℃ until transportation. Further details on the collection, handling and processing of PK samples will be included in a separate study brochure.

[0960] Example 62: Disease Assessment

[0961] Disease assessment will be performed by computed tomography (CT) scan or positron emission tomography-CT scan. Screening scans are acceptable if performed within 30 days prior to the screening visit. Magnetic resonance imaging will be performed as additional imaging only if deemed necessary per the investigator's assessment or institutional guidelines. If bridging therapy is administered, imaging will need to be repeated prior to LD chemotherapy.

[0962] Example 63: Lugano Criteria for Malignant Lymphoma

[0963] The Lugano criteria are the standard response criteria currently used for lymphoma. These criteria are based on two-dimensional tumor measurements on positron emission tomography (PET) or CT for non-fluorodeoxyglucose (FDG)avid lymphoma or when PET imaging is not available (Cheson, Fisher et al. 2014 J Clin Oncol 32 (27): 3059-3068). These criteria represent a revised version of the Cheson criteria published in 2014 (Barrington, Mikhaeel et al. 2014 J Clin Oncol 32 (27): 3048-3058). The most important changes in the classification criteria for imaging (Barrington, Mikhaeel et al. 2014, Cheson, Fisher et al. 2014) are:

[0964] The Deauville 5-point scale (5-PS) was used instead of the dichotomous PET assessment.

[0965] Introduce interim PET scans during treatment.

[0966] 5-PS is a purely visual qualitative assessment that allows for a more differentiated classification than previous methods of evaluating FDG uptake. The criteria for 5-PS are summarized in Table 6.

[0967] In some cases, interim PET examinations can make it possible to adjust treatment earlier. This allows the problem of lack of treatment response to be resolved more quickly, so that corresponding treatment upgrades can be initiated, or in the case of early treatment response, the scale of treatment can be reduced to minimize toxicity and secondary diseases (Spaepen, Stroobants et al. 2002 Ann Oncol 13 (9): 1356-1363, Hutchings, Mikhaeel et al. 2005 Ann Oncol 16 (7): 1160-1168, Hutchings, Loft et al. 2006 Blood 107 (1): 52-59, Cerci, Pracchia et al. 2010 J Nucl Med 51 (9): 1337-1343). These response criteria will be used to evaluate the patient's response to CAR T cell therapy (Table 7).

[0968] Table 6: Lugano criteria for malignant lymphoma

[0969]

[0970]

[0971] Abbreviations: 5-PS = 5-point scale; CR = complete response; CT = computed tomography; FDG = fluorodeoxyglucose; GTD = large transverse diameter; PET = positron emission tomography; PPD = product of perpendicular diameters; PR = partial response; SAD = short-axis diameter; SD = stable disease; SPD = sum of the products of diameters. a Deauville 5-PS

[0972] Overall response rate

[0973] The overall response rate was defined as the proportion of patients who achieved a confirmed best response of CR or partial response (PR) as their best response as assessed by the Lugano criteria (Table 7).

[0974] Reaction duration

[0975] Duration of response was determined for patients with an objective response and was measured from the time the response criteria were first met until the first day of disease recurrence or progression or death attributable to any cause.

[0976] Progression-free survival

[0977] Progression-free survival was measured from the start of treatment (Phase 1b) or the date of randomization (Phase 2a) until the first day of disease recurrence or progression or death attributable to any cause.

[0978] Overall survival

[0979] Overall survival was defined as the time from the start of treatment to the date of death attributed to any cause.

[0980] Levels and persistence of CAR T cells

[0981] Levels of CAR+ T cells in serum after CAR T cell infusion will be measured from day 0 to day 180 in the Phase 1b portion of the study and from day 0 to day 360 in the Phase 2a portion of the study.

[0982] Example 64: In vitro analysis of CTO1681 activity in CAR T cell assays

[0983] The effect of CTO1681 on the potency of CD19-targeted CAR T cells in vitro and its ability to reduce CRS-induced pro-inflammatory cytokine levels in the presence of CAR T cells and tumor cells in vitro were explored. The aim of the study was to determine whether CTO1681 exhibits an anti-CRS phenotype while retaining the anti-tumor function of CAR T cells. CD3 T cells were sorted from PBMCs of a healthy donor, stimulated for a short period of time and transduced with CD19 CAR-T lentivirus (LV) containing CD28 and CD3ζ domains. CD19 CAR T cells were expanded for 6 days and used in the assay.

[0984] CD19-targeted CD3 T cells were treated with 5 increasing concentrations of CTO1681 (0.36nM, 1.8nM, 9nM, 45nM, and 225nM) or vehicle for 30 minutes before and during co-culture with CD19+Raji lymphoma target cells. Wells containing culture medium, vehicle, and positive control (dexamethasone) alone. After initial treatment, CAR T cells (Effector) were co-cultured with fluorescently labeled CD19+Raji tumor cells (target cells) at 3 different effector:target cell ratios (10:1, 5:1, and 1:1) and treated with 5 different concentrations of CTO1681 or vehicle for 24 hours. Before co-culture, CPD (eBioscience TM Cell proliferation dye eFluor TM ) target cells (Raji cells) were fluorescently labeled to distinguish Raji cells from effector cells, and target cell viability was analyzed by flow cytometry. After incubation, the supernatant was collected, and the levels of pro-inflammatory cytokines IL-6 and TNF-α were measured by multiple Luminex assays, and INF-γ was measured via time-resolved fluorescence resonance energy transfer (TR-FRET) assays. These cytokines were selected for quantification because they are early cytokines that cause excessive activation of the immune system after infusion of CAR T cells in vivo, resulting in acute systemic inflammation, CRS, multiple organ failure, and possible death. In addition, flow cytometry was used to measure the level of Raji tumor / target cell death after CAR T treatment under CTO1681 conditions to measure the effect of CTO1681 on CAR T cell efficacy. The co-culture was stained with the viability dye 7-AAD to measure viability.

[0985] The result of a 10:1 ratio of effector to target cells is Figure 1A , Figure 1B and Figure 1CAs shown in the figure. The maximum reductions in TNF-α, IFN-γ, and IL-6 reached approximately 50%, 26%, and 23%, respectively. The study found that CTO1681 did not affect or interfere with the tumor / target cell killing effect of CD19-directed CAR T cells in vitro (e.g., CTO1681 did not interfere with CAR T cell efficacy). All concentrations of CTO1681 showed target cell killing. As expected, CTO1681 dose-dependently reduced pro-inflammatory and CRS-induced cytokine levels IL-6, TNF-α, and INF-γ. Similar results were obtained at effector-to-target cell ratios of 5:1 and 1:1 ( Figure 1D , Figure 1E , Figure 1F and Figure 1G ). After CAR T cell infusion in patients, more than a dozen cytokines have been shown to be elevated, and CTO1681 has been shown to reduce the level of each cytokine in non-CAR T models. The results here show that CTO1681 can significantly reduce the levels of IL-6, TNF-α, and IFN-γ, which is consistent with previous findings (i.e., CTO1681 can reduce each of these cytokine levels in infectious disease models in vitro and in vivo). The results also provide additional validation (i.e., CTO1681 targets potential sources of proinflammatory cytokine release from immune cells). Therefore, CTO1681 is the best candidate therapeutic drug for CAR T cell therapy. In general, the results of this study show that CTO1681 does not interfere with CAR T cell efficacy in vitro. It also provides strong evidence that CTO1681 acts on CAR T cells to significantly reduce the release of proinflammatory cytokines that are critical for triggering overactive immune responses and life-threatening conditions (including CRS).

[0986] Example 65: In vivo effect of CTO1681 on CAR T cell efficacy in NSG tumor-bearing mice

[0987] The effects, if any, of CTO1681 on in vivo CAR T cell activity were measured. Human T cells expressing a CD19-CD28-CD3Z CAR construct were used in this experiment.

[0988] On day 1, 6-7 week old NSG TM (NOD SCIDγ) mice were implanted with 1×10 6 luciferase (luc)-expressing Raji tumor cells (referred to herein as "Raji-luc" tumor cells) were injected into the lateral tail vein to allow tumor growth over a 7-day period before treatment began. 6The NSG mice were severely immunodeficient, which facilitated rapid tumor engraftment, and subsequent clearance of the CAR T cells could be measured.

[0989] Tumor growth and subsequent removal after implantation were monitored once a week (starting from the 7th day) using IVIS imaging to detect luciferase signals in live mice. CTO1681 administration began on the 8th day (two days before CAR T cell infusion), injected twice a day for 14 days. Mice received a total daily dose of CTO1681 of 0.3mg / kg / d, 0.2mg / kg / d or 0.15mg / kg / d via two injections (BID). CTO1681 doses were selected based on the pharmacokinetic properties of the drug in mice. The control group included mice that received Raji-luc tumor cells but did not receive CAR T cell therapy, mice that received Raji-luc tumor cells and CAR T cell infusions, and mice that received Raji-ruc tumor cells and vehicle treatment. Throughout the study, the body temperature and health assessment (weight, movement, posture, hair condition, etc.) of the mice were monitored.

[0990] Tumor burden was confirmed before treatment began, with the CTO1681 treatment group starting BID dosing 48 hours before CAR T cell administration. Two-way ANOVA measured on day 15 found statistical differences between group 1 (no CAR-T treatment) and all other groups (p=<0.0001). CD19 CAR T cells significantly inhibited the growth of Raji tumor cells. All animals given CD19 CAR T cells (including those co-administered with CTO1681) had significantly reduced tumor burden (an increase between 3.9 and 9.5 times). Therefore, at any dose tested, treatment with CTO1681 did not affect CD19 CART cell activity. There was no statistical difference (p=0.17 to 0.99) between the groups given CAR-T cells alone (Groups 2 and 3) and the animals given CAR-T cells and CTO1681 at any dose level. IVIS images and quantification of luciferin signal are shown on days 7 and 15 after allowing adequate tumor growth following transplantation, with the day 7 values ​​representing the baseline before treatment ( Figure 2 On day 6 of CAR T-cell treatment (day 15 of the study), tumor burden was significantly reduced, with no disruption in the CAR-T-cell therapy-associated reductions at all three CTO1681 doses ( Figure 2). Follow-up observations at later time points showed that disease progression in all experimental groups (including those without CTO1681 treatment) indicated that Raji-luc cells that were not eliminated by CAR-T treatment re-replicated and grew, a phenomenon that is occasionally seen in the NSG tumor model. These data clearly show that the administration of CTO1681 together with CAR T cell therapy does not interfere with the efficacy of in vivo treatment. In addition, CTO1681 did not cause any increase in clinical morbidity (including weight loss or limb movement). In summary, CAR T cell therapy with or without CTO1681 caused a significant reduction in tumor burden compared to mice that did not receive any treatment.

[0991] Example 66: CTO1681 Cytokine Regulation

[0992] Peripheral blood mononuclear cells (PBMCs) from five donors obtained from AllCells (Emeryville, CA, catalog number: PB001) were activated by TLR-3 using poly r(I:C) expression. The cells were then incubated with beraprost (a mixture of four isomers) or with isomers BPS-314d (CTO1681, or isomer A in this example), BPS-3151 (isomer B in this example), BPS-315d (isomer C in this example), BPS-3141 (isomer D in this example) at concentrations ranging from 0.3 nM to 750 nM. The samples were analyzed for TNFα production using a commercially available TNFα sandwich ELISA, and the EC of each isomer was calculated. 50 The following data clearly show that isomer BPS-314d (Isomer A) outperforms the other three isomers tested.

[0993] In triplicate experiments, CTO1681 (BPS-314d or isoform A) reduced TNFα production in activated PBMCs more than isoform B, isoform C, isoform D, or the parent mixture of the four isoforms ( Figure 3 The EC50 of CTO1681 (BPS-314d or isomer A) was significantly lower than that of other isomers, among which EC 50 was 5.7 nM (compared to 33.59 nM for isoform C in the first replicate) (Table 7).

[0994] Table 7: EC50 values ​​for replicate 1

[0995]

[0996] Second replication of EC 50 Value and EC of the first replication 50 The values ​​correspond to the EC values ​​of isomer A.50 was 4.141 nM (compared to 21.71 nM for isomer C) (Table 8).

[0997] Table 8: EC50 values ​​for replicate 2

[0998]

[0999] The third replication of EC 50 The values ​​also show the EC of isomer A. 50 Lower than other isomers (Table 9).

[1000] Table 9: EC50 values ​​for replicate 3

[1001]

[1002] Example 67: Pharmacokinetics in African Green Monkeys

[1003] This example presents plasma concentrations of CTO1681 in African green monkeys (AGM) after three times daily (TID) dosing at different drug concentrations. Here, the increased dose concentrations of CTO1681 are associated with increased plasma CTO1681 concentrations over multiple dose intervals. The results from this study collectively establish oral administration of CTO1681 in AGM as a viable method for systemic delivery of CTO1681. In addition, the results from this study provide support for the tolerability of oral administration of CTO1681, which is critical for testing the efficacy of CTO1681 in reducing cytokine levels and ARDS in this non-human primate model.

[1004] The data collected from this study demonstrated that the plasma concentration of CTO1681 in AGM was increased relative to the concentration / dose of CTO1681 administered TID via oral gavage. Overall, the maximum observed concentration (Cmax) measured after dosing and the area under the concentration-time curve (AUC0-t) calculated from the start of dosing to the last observed concentration increased with increasing CTO1681 doses in rounds 1-3 (0.008 mg / kg / day, 0.04 mg / kg / day, and 0.2 mg / kg / day, TID administration, respectively).

[1005] Study Design- A CTO1681 PK murine (BALB / C) study in a single-dose PK study design demonstrated that T1 / 2 was approximately 1-2 hours. Similarly, a murine (NSG) PK study in a twice-daily (BID) dose study design (CAS-2201) demonstrated that T1 / 2 for BID exposure was approximately 5 hours, while calculations of the elimination half-life using the first daily dose and measured exposure indicated a range of 1.8 h (Rsq=0.40) using 6-12 h. Therefore, the estimated half-life values ​​for the BID and single-dose studies were consistent PK parameters across studies. With the understanding of this short half-life of CTO1681, a study design with more frequent blood draws early after injection was implemented in the study plan. Therefore, due to the number and frequency of blood draws within the overall planned sampling schedule, as well as the limitation on the number of blood draws allowed within a 24-h window, a “nine for three” animal sampling design (i.e., three sampling cohorts, three in each cohort) was used within the time frame of blood draws to maximize the amount of blood drawn within the 24-h observation period.

[1006] Individual animal indicators —Nine African green monkeys (approximately 16 years old, wild-caught) were used in this PK study. In accordance with CDC requirements, all animals were isolated in CDC facilities for 30 days before the start of the study, followed by a 90-day isolation / adaptation period at TNPRC. In three separate rounds of the study, animals were dosed three times a day (TID) by oral gavage (increasing dose concentration). Individual animal weights were tracked throughout the study. Changes in individual animal weights during the study period are reported in Table 10. On average, all cohorts lost 5.5% of their body weight, and no individual animal lost more than 8.7% of its initial body weight during the study. No difference in average weight change was observed between male and female monkeys. Overall, the individual weights of the animals indicated that TID oral administration of CTO1681 did not cause significant weight loss. Ultimately, the animals handled the arrangement well, all animals remained healthy, and weight loss did not exceed the veterinary staff's expectations of the intensity of the arrangement. CTO1681 was shown to be generally tolerable to all animals in the study.

[1007] Table 10: Body weight of individual African green monkeys during the entire observation period

[1008] Animal ID gender Dosage interval Starting weight (kg) Ending weight (kg) Weight change (%) PI47 female 1 4.55 4.36 -4.2 PI51 male 1 7.21 6.79 -5.8 PI54 male 1 8.24 7.85 -4.7 PI46 female 2 4.83 4.45 -7.9 PI52 male 2 6.52 6.37 -2.3 PI55 male 2 6.22 5.68 -8.7 PI44 female 3 4.65 4.35 -6.5 PI53 male 3 5.97 5.73 -4.0 PI56 male 3 7.16 6.8 -5.0

[1009] Pharmacokinetics of CTO1681 in AGM- Pharmacokinetic parameters were determined using a continuous sampling design based on individual plasma concentrations for each animal. On a single day of dosing, individual animal characteristics were assessed after each dose. After a minimum of 7 days of washout between rounds of increasing dose levels, the same animals were used for single-day TID dosing, with round 1 being TID 0.008 mg / kg / day (0.00267 mg / kg / dose), round 2 being TID 0.04 mg / kg / day (0.0133 mg / kg / dose), and round 3 being TID 0.2 mg / kg / day (0.0667 mg / kg / dose). Confirm the eluted (negative) plasma levels of CTO1681 between dose rounds. Blood samples from monkeys were collected for determination of active pharmaceutical ingredient exposure of CTO1681 via femoral vein puncture sampling under anesthesia. Samples were collected at the following target time points relative to the first TID dose of the day: 0.25 hours, 0.5 hours, 1 hour, 2 hours, 4 hours and 8 hours (before the second daily dose), 8.25 hours, 8.5 hours, 9 hours, 10 hours, 12 hours and 16 hours (before the third daily dose), 16.25 hours, 16.5 hours, 17 hours, 18 hours, 20 hours, 24 hours, 28 hours and 40 hours after TID test item administration by oral gavage (where three daily doses were administered at 0 hours, 8 hours and 16 hours in 9 animals), staggered n = 3 collections after each daily dose administration. Plasma concentrations of CTO1681 were measured during a 40 hour period starting from the first TID dose administered at t = 0 hours. In all dosing rounds, plasma CTO1681 was below the monitored lower level at t = 0 for any animal. Figure 4 reports the plasma concentrations of CTO1681 for independent dosing rounds 1, 2 and 3 ( Figure 4A , Figure 4B , Figure 4C ) and combined dosing rounds ( Figure 4D) over time, corresponding to the 0.008 mg / kg / day dose, the 0.04 mg / kg / day dose, and the 0.2 mg / kg / day dose. The plasma levels at the lowest dose level (0.008 mg / kg / day) significantly pushed the edge of the lower limit of CTO1681 quantification. However, the concentrations over time indicated that the plasma CTO1681 concentration increased after each oral administration of the drug (as indicated by the arrows in Figure 4). Although inter-animal variability in CTO1681 concentrations was observed, the level of variability was within the expected normative range of the study design, particularly in wild-caught animals, where there was a clear dose-dependent increase in plasma drug concentrations (indicated by increased plasma CTO1881 levels from round 1 to round 3). During the third dosing period (t=16-40 hours), greater variability between individual animals was observed, assuming that this was due to differences in the administration of the drug by gavage by different technicians during the evening shift (11:00 p.m.).

[1010] As part of this study, standard PK parameters were measured, including Cmax and AUC0-t (Figure 5). The increase in mean Cmax was measured at each dose interval in all dosing rounds, except for dose interval 2 in round 3 ( Figure 5A ). The mean Cmax level at the lowest dose was more consistent with the Cmax level detected in the human PK analysis of CTA-1901 and increased with increasing dose level. Although there was variability between individual animals within the dosing group in each round, a dose-dependent increase in both Cmax and AUC0-t was calculated in the last dosing interval (dose interval 3; Figure 5B ). The highest CTO1681 dose (0.2 mg / kg / day) resulted in a maximum plasma Cmax of approximately 3 ng / mL after TID dosing. In addition, the mean time to reach maximum plasma CTO1681 concentration (Tmax) was positively correlated with the dose concentration. The Tmax for rounds 1, 2, and 3 was calculated to be 1.5 hours, 2.0 hours, and 2.1 hours, respectively. Regardless of the dose administered, there was no correlation in Tmax within the dosing interval.

[1011] These data together demonstrate that oral administration of CTO1681 in African green monkeys results in detectable and quantifiable dose-dependent CTO1681 measurements, and that, on average, the maximum plasma concentration of CTO1681 reaches approximately 3 ng / mL after TID dosing at 0.2 mg / kg / day. In addition, the average time to reach maximum plasma CTO1681 concentration is positively correlated with drug dose.

[1012] Summarize—This work demonstrates that oral administration of CTO1681 via oral gavage allows for detectable and quantifiable plasma CTO1681. The study demonstrated that plasma CTO1681 increased in a dose-dependent manner with increasing concentrations of the administered drug. Following TID administration of 0.2 mg / kg / day CTO1681 (the highest dose tested), an average Cmax of approximately 3 ng / mL of plasma CTO1681 was measured, while the lowest dose was comparable to the dose tested in 60 ug administration in normal healthy humans. Importantly, no toxicity or negative health effects from CTO1681 administration were observed, including significant weight loss. Overall, this study demonstrates that oral administration of CTO1681 in African green monkeys is a viable model for studying the efficacy of CTO1681 in non-human primate models in subsequent studies.

[1013] Example 68: Cytokine Measurements Following CTO1681 Treatment in African Green Monkeys

[1014] Longitudinal serum samples were collected throughout the observation period. At the end of all three cohorts, serum samples were used to determine circulating concentrations of 12 different cytokines. Representative data for TNFα, a key hub cytokine in CRS, are shown below ( Figure 6 ). AGMs treated with the highest dose of CTO1681 showed significant and consistent reductions in cytokine levels compared to the other two cohorts. Overall, cytokine reductions appeared to be dose-dependent.

[1015] In the above detailed description, reference is made to the accompanying drawings which form a part of this document. In the drawings, similar symbols generally identify similar components unless the context dictates otherwise. The illustrative embodiments described in the detailed description, drawings, and claims are not meant to be limiting. Other embodiments may be used, and other changes may be made, without departing from the spirit or scope of the subject matter presented herein. It should be readily understood that aspects of the present disclosure, as generally described herein and illustrated in the accompanying drawings, may be arranged, substituted, combined, separated, and designed in a wide variety of different configurations, all of which are expressly contemplated herein.

Claims

1. A method of treating cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), or both associated with CAR T cell administration in a subject, the method comprising administering to the subject a population of CAR T cells and a first pharmaceutical composition; wherein: The first pharmaceutical composition comprises at least an effective amount of beraprost, a beraprost isomer or a pharmaceutically acceptable salt thereof; and The first pharmaceutical composition does not reduce cell killing mediated by the CAR T cell population by more than about 5%.

2. The method of claim 1, wherein the CRS is a level 1 CRS, a level 2 CRS, a level 3 CRS, or a level 4 CRS.

3. The method of claim 1, wherein the ICANS is a level 1 ICANS, a level 2 ICANS, a level 3 ICANS, or a level 4 ICANS.

4. The method of claim 1, wherein the first pharmaceutical composition reduces the level of one or more cytokines of IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IFN-γ, TNF-α, IP-10, MCP-1, MIP-1, RANTES, and GM-CSF in the subject.

5. The method of claim 1, further comprising administering a second pharmaceutical composition comprising at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof.

6. The method of claim 5, wherein the subject requires reduced treatment with the second pharmaceutical composition relative to a subject not receiving the first pharmaceutical composition.

7. The method of claim 1, wherein the subject experiences reduced Parkinsonian effects when receiving the first pharmaceutical composition relative to a subject not receiving the first pharmaceutical composition.

8. The method of claim 1, wherein the subject experiences a reduced severity measure associated with CRS, ICANS, or both while receiving the first pharmaceutical composition relative to a subject not receiving the first pharmaceutical composition.

9. The method of claim 1, wherein the first pharmaceutical composition is administered once the onset of CRS is detected by increased levels of one or more cytokines of IL-6, IL-10, IFN-γ, TNF-α, MIF, IL-5, IL-17A, IL-23, CXCL9 / MIG, GCSF, VEGF-A, and TGF-β, or one or more of the inflammatory biomarkers C-reactive protein (CRP) and ferritin.

10. The method of claim 1, wherein the pharmaceutically acceptable salt is beraprost sodium.

11. The method of claim 1, wherein the beraprost comprises at least one of BPS-314d, BPS-3141, BPS-315d, and BPS-3151.

12. The method of claim 1, wherein the isomer is BPS-314d (Isubraprost sodium salt).

13. The method of claim 1, wherein: The CAR T cell administration is performed to treat cancer; and The cancer is B-cell lymphoma, aggressive, relapsed or refractory diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, relapsed or refractory mantle cell lymphoma, acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia or multiple myeloma.

14. The method of claim 1, wherein The CAR T cell administration is performed to treat cancer; and The cancer is brain cancer, breast cancer, glioblastoma, lung cancer, non-small cell lung cancer, multiple myeloma, ovarian cancer, neuroblastoma, colorectal, biliary tract, pancreatic mesothelioma, hepatoblastoma, embryonal sarcoma, prostate sarcoma or liver metastasis.

15. The method of claim 1, wherein: The CAR T cell administration is performed to treat cancer; and The cancer is B-cell lymphoma.

16. The method of claim 1, wherein the subject is a mammal.

17. The method of claim 1, wherein the subject is a non-human primate, monkey, cat, dog, pig, cow, goat, horse, sheep, or rabbit.

18. The method of claim 1, wherein the subject is a human.

19. The method of claim 1, wherein the first pharmaceutical composition is administered to the subject prior to administering the CAR T cell population to the subject.

20. The method of claim 5, wherein the second pharmaceutical composition is administered to the subject after the CAR T cell population is administered to the subject.

21. The method of claim 5, wherein the first pharmaceutical composition and the second pharmaceutical composition are administered to the subject after the CAR T cell population is administered to the subject.

22. The method of claim 21, wherein the first pharmaceutical composition and the second pharmaceutical composition are administered simultaneously.

23. The method of claim 5, wherein the first pharmaceutical composition and the second pharmaceutical composition are administered to the subject prior to administering the CAR T cell population to the subject.

24. The method of claim 1, wherein the first pharmaceutical composition is administered to the subject beginning about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, or about 7 days after the CAR T cell population is administered to the subject.

25. The method of claim 1, wherein the first pharmaceutical composition is administered to the subject beginning about 3 days to about 7 days after the CAR T cell population is administered to the subject.

26. The method of claim 1, wherein the first pharmaceutical composition is administered for a period of about 1 day to about 30 days.

27. The method of claim 1, wherein the first pharmaceutical composition is administered for a period of about 7 days to about 14 days.

28. The method of claim 1, wherein the first drug composition is administered beginning one day prior to administration of the CAR T cells and continues to be administered for a period of at least about 14 days.

29. The method of claim 1, wherein the CAR T cells are autologous CAR T cells.

30. The method of claim 1, wherein the CAR T cells are allogeneic CAR T cells.

31. The method of claim 1, wherein the first pharmaceutical composition further comprises at least one excipient, at least one filler, at least one disintegrant, at least one binder, at least one wetting agent, at least one lubricant, at least one glidant, at least one preservative, at least one flavoring agent, at least one antioxidant, or a combination thereof.

32. The method of claim 1, wherein the first pharmaceutical composition is formulated as a tablet, capsule, granules, powder, liquid, suspension, gel, syrup, slurry, suppository, patch, nasal spray, aerosol, injectable, implantable sustained release formulation, or mucoadhesive film.

33. The method of claim 1, wherein the administration operation comprises local delivery, subcutaneous delivery, intravenous (IV) delivery, intramuscular (IM) delivery, intrathecal (IT) delivery, intraperitoneal (IP) delivery, transdermal delivery, subcutaneous delivery, oral delivery, transmucosal oral delivery, pulmonary delivery, inhalation delivery, intranasal delivery, buccal delivery, rectal delivery, vaginal delivery, or a combination thereof.

34. The method of claim 1, wherein administering comprises oral delivery or intravenous (IV) delivery.

35. The method of claim 1, wherein the beraprost, beraprost isomer, or pharmaceutically acceptable salt thereof is present in the unit dose of the first pharmaceutical composition in an amount of about 1 microgram to about 100 micrograms.

36. The method of claim 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of at least about 0.1 micrograms of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof.

37. The method of claim 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 0.1 micrograms to about 5000 micrograms of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof.

38. The method of claim 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 15 micrograms to about 90 micrograms of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof.

39. The method of claim 1, wherein administering comprises delivering the first pharmaceutical composition to the subject in an amount of about 60 micrograms to about 360 micrograms of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof.

40. The method of claim 1, wherein the CAR T cell population comprises a BCMA CAR-T cell population, a CD19 CAR-T cell population, a CD19-CD3 bispecific CAR-T cell population, or a combination thereof.

41. A kit for treating a subject using CAR T cells, the kit comprising: a first container, the first container containing a first pharmaceutical composition, the first pharmaceutical composition comprising at least an effective amount of beraprost, a beraprost isomer, or a pharmaceutically acceptable salt thereof; a second container containing a second pharmaceutical composition comprising at least one corticosteroid, tocilizumab, an IL-6 receptor blocker, or a combination thereof; as well as Instructions for administering the first pharmaceutical composition, the second pharmaceutical composition, and CAR T cells to a subject.

42. The drug kit of claim 41, further comprising a third container containing CAR T cells.

43. The kit of claim 41, further comprising a fourth container comprising water or an aqueous solution.

44. The method or kit of any of the preceding claims, wherein the beraprost is BPS-314d (isoberaprost sodium salt).

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