Pharmaceutical products and methods for alleviating cancer immunotherapy related cytokine release syndrome

Abstract

Disclosed is a p38 MAPK kinase inhibitor for use in preventing cancer immunotherapy associated cytokine release syndrome ("CRS") or reducing the severity of signs or symptoms thereof in a human patient wherein the p38 MAPK inhibitor is administered prior to the onset of CRS. Related methods, products, and uses thereof are also disclosed.

Description

[0001] This application claims the benefit of the following patent applications: UK patent application No. 2300510.1 filed on January 13, 2023; UK patent application No. 2300512.7 filed on January 13, 2023; UK patent application No. 2316713.3 filed on November 1, 2023; UK patent application No. 2316714.1 filed on November 1, 2023; and UK patent application No. 2316715.8 filed on November 1, 2023, all of which are incorporated herein by reference. Technical Field

[0002] Cytokine release syndrome ("CRS") is a common side effect of cancer immunotherapy. The present invention relates to products and methods for preventing CRS associated with cancer immunotherapy or reducing the severity of its signs or symptoms. More particularly, but not exclusively, the present invention relates to the use of a p38 MAP kinase inhibitor in human patients for preventing CRS associated with cancer immunotherapy or reducing the severity of its signs or symptoms, wherein the p38 MAPK inhibitor is administered before the onset of CRS. The present invention also relates to products including pharmaceutical compositions and kits and related methods. Background Art

[0003] In some cancer immunotherapies, effectiveness may depend on the survival rate, function and phenotype of one or more T cell populations in the patient's body. This is particularly important in the case of genetically engineered (or otherwise modified or cultured) modified T cells. This dependence is believed to involve, for example, tumor infiltrating lymphocytes ("TIL" therapy), T cell checkpoint regulator therapy and chimeric antigen receptor ("CAR") T cell therapy.

[0004] To illustrate, CAR T cell therapy relies on genetically modifying T cells so that they can recognize, target, and destroy cancer cells. T cells are collected (usually from the patient themselves, but T cells can also be obtained from healthy donors instead), genetically engineered to express CARs specific for cancer cell antigens (such as anti-CD19 or anti-BCMA CAR), and administered to cancer patients by infusion ("autologous transplantation"). CAR T cells then migrate through the blood circulation to cancer cells expressing antigens (such as CD19 or BCMA). Therefore, the survival, function, and phenotype of the infused CAR T cells drive the therapeutic effect.

[0005] At the same time, in other types of cancer immunotherapy, the survival rate and memory function of specific T cells are not considered to be necessary conditions for achieving the expected therapeutic effect, and the renewal of T cell populations is also expected not to lead to a complete loss of therapeutic effect. However, in order for the treatment to be effective, there must usually be a T cell population with sufficient function, and preferably with a phenotype that is beneficial to the relevant treatment. This is particularly important in T cell engagement therapies, such as bispecific T cell engager (BiTE) therapy, dual-function checkpoint inhibitory T cell engager (CiTE) therapy, simultaneous multi-interaction T cell engager (SMITe) therapy, other bispecific antibody therapies, trispecific killer engager (TriKE) therapy or other immunostimulatory molecule therapies that can induce cytokine release.

[0006] There are other cancer immunotherapies that, although not directly dependent on T cell survival, function, and phenotype, can still benefit from enhanced T cell activity. Examples include autologous immunotherapies using unmodified or non-engineered natural killer (NK) cells and cancer vaccines.

[0007] The survival rate, function and phenotype of T cells can be regulated by four different signals. The first of these (commonly referred to as "signal 1") involves antigen recognition. Signal 1 is antigen-specific and is produced by activation of the T cell receptor ("TCR") when the antigen peptide binds to the major histocompatibility complex ("MHC") complex, causing changes in the intracellular apparatus of the TCR. The second signal ("signal 2") involves co-stimulation and / or co-inhibition. That is, signal 2 is produced by co-stimulatory signaling between the co-stimulatory receptors on the T cell and the corresponding ligands of the receptor on antigen presenting cells (APC, i.e., monocytes and dendritic cells); and / or produced by co-inhibitory signaling between the co-inhibitory receptors on the T cell and the corresponding ligands of the receptor on APC.

[0008] Signal 2 can affect T cell polarization. It will be understood that the term "T cell polarization" as used herein refers to T cell differentiation into a T cell subset (phenotype) that is confined to producing a specific cytokine pattern (e.g., T1 pattern or T2 pattern). When initial or resting memory T cells differentiate into effector T cells, they can produce a wide range of cytokines of the T0 pattern. For example, when T cell polarization is confined to the T1 pattern or the T2 pattern, the cytokine of the T1 pattern may include interleukin (IL) -12 and interferon (IFN) γ, while the cytokine of the T2 pattern may include IL-4. If signal 2 is not provided after signal 1, the result may be that the T cell is unresponsive ("anergy").

[0009] During or after activation, several additional signals can further regulate T cell activity. Thus, "Signal 3" involves cytokines such as interferon-α, IFNγ, IL-4, IL-10, and IL-12, as well as other extracellular factors in the body. Signal 3 ensures that T cells can interact with their environment. Similar to Signal 2, Signal 3 may influence T cell polarization. Thus, Signal 3 may be involved in cytokine-mediated T cell differentiation and expansion.

[0010] At the same time, "Signal 4" may involve events after activation in vivo and may control the duration of T cell responses, affecting the phenotype, persistence, and function of activated T cells. Although "Signal 4" is a less conventional term (especially compared to Signals 1 or 2, it is not yet fully recognized in the art), the term was coined to recognize the important phenomena it involves. For example, Signal 4 may involve cytokines (such as IFN-I) inducing monocyte-derived cells to provide a survival checkpoint for T cell activation.

[0011] The function of T cells may depend, among other factors, on the environmental stimuli provided to them, such as the aforementioned signal 3 and signal 4. Signals 3 and 4 may contribute to the survival, expansion, and antigen-specific cell-mediated cell death of T cells.

[0012] Once cytotoxic T cells recognize specific antigens, they release perforins, granzymes, and inflammatory cytokines. For example, CAR T cells release such cytokines in CAR T cell therapy, which is thought to lead to high levels of apoptotic tumor cell death (Liu et al., 2020, Sci. Immunol. 5:43). As of the time of writing, CAR T cell therapy is approved by the U.S. Food and Drug Administration (FDA) as a standard treatment for certain aggressive, relapsed, or refractory non-Hodgkin lymphomas, including diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, and mantle cell lymphoma. CAR-T cell therapy is also approved for the treatment of B-cell acute lymphoblastic leukemia and multiple myeloma. Further CAR-T therapies for other cancers are under review, including hematological malignancies and solid tumors.

[0013] More measures have been taken to further enhance the function of CAR T cells. In one study (Gurusamy et al., 2020, Cancer Cell 37, 818-833), the Mapk14 gene encoding p38α kinase was knocked out in CAR T cells cultured in vitro. Mapk14 gene knockout cells showed increased cell proliferation and CD62L expression, as well as reduced accumulation of reactive oxygen species and γH2AX. The authors then attempted to mimic the phenotypic effects of Mapk14 gene knockout in a reversible manner, using the p38 MAP kinase inhibitor Doramapimod / BIRB796 to limit the p38 inhibition to the in vitro expansion stage. Similarly, this was found to promote the desired phenotype of CAR T cells in vitro. Doramapimod was eluted before autologous transplantation.

[0014] Cancer immunotherapy (e.g., CAR T cell therapy or infusion of T cell adaptors) can lead to significant toxicity, including CRS. CRS can manifest clinically within 1 day to several weeks after administration of cancer immunotherapy. CRS can manifest as a variety of symptoms, ranging from mild flu-like symptoms to severe, life-threatening, excessive systemic inflammatory responses. In severe cases, CRS can lead to death even with therapeutic intervention (Shimabukuro-Vornhagen et al., 2018, J. Immunother. Cancer, 15 6(1): 56).

[0015] CRS is believed to be derived from the hit effect of CAR T cell therapy (Morris et al., 2022, Nat. Rev. Immunol. 22, 85-96). Monocytes can be activated by cytokines (such as IL-6 and / or TNFα) produced by T cells that are involved in the elimination of cancer cells. Additionally or alternatively, monocytes can be activated by contact-dependent binding of CD40 ligands expressed by T cells to CD40 expressed by monocytes. Additionally or alternatively, monocytes can be activated by damage-associated molecular patterns ("DAMPs"), which are released by dying cancer cells and can be recognized by pattern recognition receptors ("PRRs") on the surface of monocytes.

[0016] Activated monocytes are the main source of cytokines in the body, such as interleukin-6 (IL-6). The cytokines secreted by monocytes can signal to a variety of non-immune cells, especially endothelial cells. Activation of endothelial cells can lead to vascular leakage, hypotension, and further secretion of cytokines such as interleukin-6 (IL-6) and interleukin-8 (IL-8), thereby amplifying the patient's inflammatory response.

[0017] Cytokines can attract circulating monocytes, leading to the accumulation of activated monocytes near where T cells interact with cancer cells, thereby amplifying the inflammatory cycle. In addition, T cells themselves can overflow or redistribute, exacerbating the uncontrolled immune response.

[0018] In one study, endothelial cells (HUVECs) were stimulated with supernatant of anti-CD19 CAR T cells / Nalm6-luc co-culture, and the p38 MAPK inhibitor SB203580 was applied to study the inhibition of endothelial cell activation (Chen et al., 2021, Front. Immunol., 12: 623610).

[0019] Meanwhile, WO 2021 / 022186 A1 and WO 2021 / 195475 A1 (both filed by Aclaris Therapeutics Inc.) disclose methods for modulating p38 MAP kinase-mediated functions in a patient, and it is speculated that in certain embodiments, the methods may be used to treat CRS.

[0020] Current treatments for CRS are reactive and require evidence of a CRS episode before treatment is started. For those who develop CRS, physicians have a variety of treatment options. For example, tocilizumab (an IL-6 receptor antagonist), optionally combined with corticosteroids, has been used to treat symptoms that occur after a CRS episode. For patients who are resistant to tocilizumab and corticosteroids, anakinra (an interleukin-1 receptor antagonist) can be used.

[0021] As of the time of this writing, prophylactic treatment of CRS has not become routine practice, and there remains a pressing need for treatments to prevent CRS associated with cancer immunotherapy.

[0022] For CRS treatment regimens, it is advantageous to have good clinical tolerance (i.e., no risk or low risk of side effects). Preferably, in cancer immunotherapy patients who already have a risk of viral and bacterial infection, it should not result in the loss of core immune function. Preferably, it should be provided in a form suitable for outpatient administration.

[0023] The present invention is directed to solving one or more of the above-identified problems and other related problems. Summary of the Invention

[0024] In a first aspect of the present invention, a p38 MAP kinase inhibitor is provided for preventing cancer immunotherapy-associated cytokine release syndrome or reducing the severity of its signs or symptoms in a human patient, wherein the p38 MAPK inhibitor is administered before the onset of CRS.

[0025] As supported by Examples 5 and 6 below (especially Example 6), administering a p38 MAPK inhibitor to a human patient before the onset of CRS can prevent or reduce the severity of CRS associated with cancer immunotherapy or its signs or symptoms. Relatedly, p38 MAPK inhibitors can inhibit the release of cytokines (especially IL-6 released by T cells, IL-6 released by monocytes, and IL-6 released by endothelial cells) by T cells, monocytes, and endothelial cells in the cancer cell environment; as supported by Examples 3, 4, and 6 below in this specification. Therefore, p38 MAPK inhibitors appropriately inhibit the release of IL-6 by T cells, inhibit the release of IL-6 by monocytes, and inhibit the release of IL-6 by endothelial cells.

[0026] Surprisingly, when p38 MAPK inhibitors are administered to patients before the onset of CRS, they can enhance T cell activity in the patient's body, and this effect can still be produced in the presence of cancer cells. p38 MAPK inhibitors can enhance the anti-cancer efficacy of T cells; or at least maintain the anti-cancer efficacy of T cells. In particular, p38 MAPK inhibitors can increase the number of circulating T cells (see Example 5 below); promote or maintain T cell-induced tumor cell death (see Example 6 below); and / or reduce exhaustion markers in T cells (especially TIM3 and / or LAG3) (see Example 3 below). The reduction in exhaustion markers can be interpreted as prolonging the anti-cancer efficacy of T cells; it can also be associated with T cell polarization, and thus with the above-mentioned "signal 2". At the same time, the maintenance (or improvement) of T cell proliferation and anti-cancer activity can each be associated with the regulation of the above-mentioned "signal 4". Therefore, in addition to preventing CRS associated with cancer immunotherapy or reducing the severity of its signs or symptoms, p38 MAPK inhibitors can also allow the maintenance or enhancement of the anti-cancer effect of immunotherapy. As claimed and mimicked by the present invention, p38 MAP kinase inhibitors can produce these effects when administered directly (in vivo) to a subject prior to the onset of CRS, such as shown in Example 6 described in this specification.

[0027] Therefore, p38 MAPK inhibitors can prolong (the duration of) the anti-cancer efficacy of T cells. p38 MAPK inhibitors can help maintain or enhance the strength of the anti-cancer efficacy of T cells. p38 MAPK inhibitors can prolong (the duration of) the anti-cancer efficacy of T cells and help maintain or enhance the strength of the anti-cancer efficacy of T cells.

[0028] Most suitably, p38 MAPK inhibitors can maintain or enhance the anti-cancer efficacy of T cells.

[0029] As used herein, the term "cancer immunotherapy" refers to therapeutic stimulation of the immune system for the treatment of cancer. Cancer immunotherapy is believed to enhance the immune system's natural ability to recognize and eliminate cancer cells and strengthen the memory function of immune cells, thereby preventing or reducing the risk of cancer recurrence.

[0030] Cancer immunotherapy as used herein may particularly include one or more of the following therapies: therapy using genetically engineered (or otherwise modified or cultured) modified T cells; immune cell engagement therapy (especially BiTEs and other bispecific antibodies); and other therapies, such as natural killer ("NK") cell therapy, cancer vaccines, and T cell checkpoint regulators (especially T cell checkpoint inhibitors). These therapies can benefit from regulating the survival, phenotype, and function of T cells by p38 MAPK inhibitors. In addition or alternatively, these therapies can benefit from regulating the activation of monocytes and / or endothelial cells by p38 MAPK inhibitors, particularly cells adjacent to cancer cells targeted by the immune system (especially cancer cells targeted by T cells).

[0031] According to the present invention, cancer immunotherapy may preferably comprise or consist of adoptive T cells, or otherwise involve T cells. It will be understood that so-called cancer immunotherapy "otherwise involving T cells" is not necessarily limited to T cell engagement therapy (such as BiTE, CiTE, SMITe or TriKE), but may encompass any cancer immunotherapy involving T cells. Therefore, cancer immunotherapy may be enhanced (or at least not significantly impaired) by one or more of the following effects:

[0032] (i) reducing the release of pro-inflammatory cytokines by T cells (especially reducing the release of IL-6 by T cells);

[0033] (ii) reducing the release of pro-inflammatory cytokines by monocytes (especially reducing the release of IL-6 by monocytes);

[0034] (iii) reducing the release of pro-inflammatory cytokines by endothelial cells (particularly reducing the release of IL-6 by endothelial cells; and, optionally, reducing the release of IL-8 by endothelial cells);

[0035] (iv) regulating T cell signal 3 and / or 4 (especially signal 4);

[0036] (v) regulating T cell polarization and / or reducing T cell exhaustion (particularly reducing the expression of TIM3 and / or LAG3 on the surface of T cells);

[0037] (vi) maintaining or enhancing the efficacy of T cells against tumor cells; and

[0038] (vii) maintaining or enhancing T cell proliferation,

[0039] In particular, the anti-tumor cell activity of T cells is maintained or enhanced, as demonstrated in the examples below. In particular, Example 2 provides the following evidence: TIM3 and LAG3 (exhaustion markers) on the surface of CAR T cells are reduced after p38 MAPK inhibitors are administered to CAR T cells in the presence of cancer cells (co-cultured with cancer cells). The reduction of exhaustion markers can be interpreted as extending the anti-cancer efficacy of T cells; in addition or alternatively, it can also be associated with T cell polarization, thereby being associated with the above-mentioned "signal 2". Three structurally different p38 MAPK inhibitors are shown to have this effect (all of these inhibitors are selective for p38, indicating that there is no or very little off-target effect). Example 2 also shows that p38 MAPK inhibition can reduce TNFα secretion of CAR T cells; Example 6 shows that p38 MAPK inhibition can reduce the secretion of a variety of cytokines known to cover T cell release and monocyte and endothelial cell release, including IL-6. Example 5 shows that the efficacy of CAR T cells is maintained after inhibition of p38 MAPK; on day 10 of the mouse study, twice-daily administration of 25 mg / kg of the p38 MAPK inhibitor UR-13870 significantly increased the number of circulating CAR T cells (see Table 5). Figure 18A In addition, Example 6 shows that after treatment with UR-13870 on days 9 and 10 (especially day 10) of the study, the average number of CD19+ cancer cells per ml showed a downward trend (compared to CD28 stimulation alone), which indicates that the strengthening / anti-cancer activity of T cells is increased (see Figure 30A ). At the same time, Examples 3 and 4 demonstrate that when treated with p38 MAPK inhibitors under stimulation of supernatant from cancer cells co-cultured with CAR T cells, IL-6 release from monocytes and endothelial cells is reduced; IL-8 release from endothelial cells is also reduced, indicating a beneficial effect on key mediators of CRS.

[0040] For some applications of the p38 MAP kinase inhibitors of the invention, cancer immunotherapy includes therapies mediated by effector T cell function and memory; in particular, therapies utilizing engineered T cells (e.g., CAR-T cell therapy and TCR therapy), utilizing other modified or cultured T cells (e.g., TIL therapy), or utilizing T cell checkpoint modulators.

[0041] For certain applications of the p38 MAP kinase inhibitors of the present invention, the cancer immunotherapy of the present invention can be a therapy mediated by effector T cell function (but in particular not dependent on T cell memory); for example, a T cell engagement therapy, such as a bispecific T cell engager (BiTE) therapy, other bispecific antibody therapy, a bifunctional checkpoint inhibitory T cell engager (CiTE) therapy, a simultaneous multi-interacting T cell engager (SMITe) therapy or a trispecific killer engager (TriKE) therapy, or other immunostimulatory molecule therapy capable of inducing cytokine release; in particular, a BiTE therapy.

[0042] Thus, the cancer immunotherapy of the present invention may suitably be a T cell engagement cancer immunotherapy (particularly BiTE therapy or therapy using other bispecific antibodies). This may be advantageous because, as described herein, p38 MAP kinase inhibitors may benefit T cells by, for example, increasing their level of anti-cancer efficacy and / or extending the period over which they exhibit anti-cancer efficacy. As required by the present invention and as simulated, for example, in Example 6 described herein, when a p38 MAP kinase inhibitor is administered directly (in vivo) to a subject before the subject develops CRS, it may surprisingly have these effects.

[0043] For certain applications of the p38 MAP kinase inhibitors of the present invention, the cancer immunotherapy of the present invention may be a therapy that does not significantly rely on effector T cell function or T cell memory. However, improvements in T cell function may be beneficial. For example, cancer immunotherapy may include CAR NK therapy or cancer vaccines.

[0044] For certain applications of the p38 MAP kinase inhibitors of the present invention, cancer immunotherapy can be a therapy that can benefit from modulation of signal 3 as described herein and elsewhere by a p38 MAP kinase inhibitor, such as T cell engagement therapy, particularly bispecific T cell engager (BiTE) therapy (or therapy using another bispecific antibody), CAR NK therapy, cancer vaccines, or T cell checkpoint modulators; or engineered T cell therapy (e.g., CAR T cell therapy and TCR therapy) or other modified or cultured T cell therapy (e.g., TIL therapy).

[0045] For certain applications of the p38 MAP kinase inhibitors of the present invention, the cancer immunotherapy of the present invention can be a therapy that can benefit from modulation of signal 4 described herein and elsewhere by a p38 MAP kinase inhibitor, such as a T cell engager therapy, particularly a bispecific T cell engager (BiTE) therapy (or a therapy using another bispecific antibody), a CAR NK therapy, a cancer vaccine, or a T cell checkpoint modulator; or an engineered T cell therapy (e.g., CAR T cell therapy and TCR therapy) or other modified or cultured T cell therapy (e.g., TIL therapy).

[0046] For certain applications of the p38 MAP kinase inhibitors of the present invention, cancer immunotherapy may particularly be a therapy comprising administering genetically engineered (or otherwise modified or cultured) modified T cells. As used herein, depending on the context, the term "therapy comprising administering genetically engineered T cells" may refer to one or both of CAR T cell therapy and TCR therapy; or to a broader group of therapies encompassing CAR T cell therapy and TCR therapy. At the same time, "therapy comprising administering otherwise modified or cultured T cells" may refer to tumor infiltrating lymphocyte ("TIL") therapy, or to a broader group of therapies encompassing TIL therapy.

[0047] The T cells described herein can be T cells expressing PD-1, CTLA4, TIM-3, TIGIT, CD3 or CD28. CD28 can provide costimulatory signals for T cell activation and survival. CD28 can play a role in signals 1, 2, 3 and / or 4 described herein. CD28 can play a role in CRS described herein.

[0048] Optionally, the cancer immunotherapy can be a combination cancer immunotherapy, such as by combining CAR T cell therapy with one or more checkpoint inhibitors, such as one or more anti-PD-1 antibodies (e.g., nivolumab, pembrolizumab, or cemiplimab), or one or more anti-PD-L1 antibodies (e.g., atezolizumab, avelumab, or durvalumab), or one or more CTLA-4 antibodies (e.g., ipilimumab or tremelimumab).

[0049] “CAR T cell therapy” herein refers to a therapy for treating a cancer patient, wherein T cells have been harvested (optionally but not necessarily from the same cancer patient, as T cells can be harvested from a healthy donor) and genetically engineered in vitro to express a CAR specific for a relevant cancer cell antigen (and optionally but not necessarily proliferated in vitro), and the T cells are administered to the cancer patient by adoptive transfer. Suitably, CAR T cell therapy can be used to treat malignant tumors expressing CD19 or malignant tumors expressing BCMA. See, for example, Morris et al., Cytokine release syndrome and associated neurotoxicity in cancer immunotherapy, Nat. Rev. Immunol., 2022, (22) 85-96, which is incorporated herein by reference. Therefore, CAR T cell therapy can be autologous (wherein T cells are harvested from the same cancer patient). Alternatively, CAR T cell therapy can be allogeneic (“off-the-shelf”), using T cells harvested from a healthy donor and modified to express CAR. In allogeneic CAR T-cell therapy, T cells can optionally be further modified, for example by genome editing technologies such as CRISPR / Cas9 or base editing, to prevent graft-versus-host disease and host allogeneic rejection.

[0050] Similarly, TCR therapy involves genetic engineering of T cells, which are then adoptively transferred to patients in need. Although CAR T cells are able to recognize and bind to naturally occurring antigens on the surface of cancer cells, in TCR therapy, T cells are genetically engineered to express receptors that bind to major histocompatibility complex (MHC) proteins. However, the manufacturing process for TCR therapy can be similar to the process described above for CAR T cells in other respects.

[0051] Thus, TCR therapy herein may be used to refer to a therapy for treating a cancer patient wherein T cells that have been harvested (optionally, but not necessarily, from the same cancer patient, as T cells can be harvested from healthy donors) and genetically engineered in vitro to express an engineered T cell receptor configured to recognize an MHC-presented polypeptide fragment molecule (and optionally, but not necessarily, proliferated in vitro) are administered to the cancer patient by adoptive transfer.

[0052] In certain preferred embodiments, the cancer immunotherapy is CAR T cell therapy or TCR therapy.

[0053] As used herein, "tumor infiltrating lymphocytes" ("TILs") refer to white blood cells that leave the bloodstream and migrate to solid tumors. TILs can be found within the tumor and within the tumor stroma. The abundance and phenotype of TILs can vary with tumor type and stage. TILs can include, among other things, T cells.

[0054] "TIL therapy" herein refers to adoptive T cell transfer therapy performed on patients in need, wherein TILs (especially T cells) that can be derived from the patient or another individual are administered to the patient. Therefore, TILs obtained from resected tumors are usually expanded in vitro. Several TIL cultures can be established separately before the desired tumor recognition function is determined. Once selected, the desired TILs can be expanded over a period of several weeks; IL-2 is usually used as a general growth factor. After a further TIL cell selection step, the TIL cell line with the best tumor recognition ability can be further expanded in a "rapid expansion protocol" (REP), which uses anti-CD3 activation for several weeks. Finally, the REP-treated TILs are infused into the patient.

[0055] For certain applications of the p38 MAP kinase inhibitors of the present invention, cancer immunotherapy can be T cell engager therapy, such as bispecific T cell engager (BiTE) therapy or other bispecific antibody therapy, bifunctional checkpoint inhibitory T cell engager (CiTE) therapy, simultaneous multi-interacting T cell engager (SMITe) therapy, or trispecific killer engager (TriKE) therapy.

[0056] As used herein, the term "BiTE" refers to a bispecific monoclonal antibody used as an anticancer drug. In particular, a BiTE can be a fusion protein comprising single-chain variable fragments ("scFvs") of two different antibodies on a single peptide chain or comprise amino acid sequences from four different genes. One of the scFvs can be configured to bind to T cells (particularly through the CD3 receptor); the other can be configured to bind to tumor cells.

[0057] As used herein, the term "bispecific antibody" refers to an antibody that can simultaneously bind to two different types of antigens. Various bispecific antibodies are known in the art, including BiTEs.

[0058] For certain uses of the p38 MAP kinase inhibitors of the invention, the cancer immunotherapy can be natural killer ("NK") cell therapy, cancer vaccines, or T cell checkpoint modulation therapy.

[0059] The term "NK cell therapy" as used herein is used interchangeably with "CAR NK cell therapy." Similar to CAR T cells, CAR NK cells are genetically engineered to encode a CAR that recognizes tumor antigens. The manufacturing process for CAR NK cells is largely similar to the manufacturing process for CAR T cells described above.

[0060] "CAR NK cell therapy" herein refers to a therapy for treating a cancer patient in which natural killer cells have been harvested (optionally but not necessarily from the same cancer patient, as NK cells can be harvested from healthy donors) and genetically engineered in vitro to express a CAR (and optionally but not necessarily expanded in vitro), and the NK cells are administered to the cancer patient by adoptive transfer.

[0061] For certain applications of the p38 MAP kinase inhibitors of the invention, cancer immunotherapy can be a T cell engager therapy, such as a bispecific T cell engager (BiTE) therapy or a therapy using another bispecific antibody, a bifunctional checkpoint inhibitory T cell engager (CiTE) therapy, a synchronized multiply interacting T cell engager (SMITe) therapy, or a trispecific killer engager (TriKE) therapy.

[0062] As used herein, the term "cancer vaccine" refers to one or more tumor antigen vaccines, whether autologous or allogeneic. For example, a cancer vaccine may include: one or more cancer cell proteins and / or one or more fragments (peptides) thereof; one or more whole cells (e.g., tumor cells or dendritic cells); one or more nucleic acids; and / or one or more virus-based vaccines (including oncolytic viruses).

[0063] The term "T cell checkpoint modulator" as used herein has its conventional meaning in the medical field and refers to a T cell checkpoint inhibitor configured to block or otherwise antagonize the binding of tumor cell inhibitory immune checkpoint proteins to their partner proteins, or a T cell checkpoint stimulator configured to enhance the signaling or otherwise stimulate tumor cell co-stimulatory checkpoint proteins.

[0064] As used herein, the term "cancer immunotherapy-induced cytokine release syndrome" ("CRS") refers to an uncontrolled systemic inflammatory response triggered by cancer immunotherapy.

[0065] p38 MAP kinase inhibitors are believed to mitigate, rather than eliminate, the uncontrolled systemic inflammatory response that can result from cancer immunotherapy in some patients, with the goal of attenuating the damaging effects of uncontrolled inflammation while retaining its protective and pro-resolving effects, such as anti-cancer effects. Completely suppressing inflammation can be detrimental, whereas attenuating the onset of uncontrolled systemic inflammation should provide protection against the damaging effects of excessive inflammatory responses while preserving essential innate defense activities. Therefore, the p38 MAP kinase inhibitors used in the methods of the present invention are intended to mitigate, rather than completely eliminate, this component.

[0066] The patient population receiving cancer immunotherapy may be or include a particularly sensitive patient population for whom complete suppression of basic innate defense activities would be particularly harmful. They may be high-risk populations for whom elimination of core immune functions would make them particularly susceptible to viral and / or bacterial infections. For these patients, reducing or preventing susceptibility to viral and / or bacterial infections is an important concern. By reducing, rather than eliminating, the immune response, the risk of significant viral and / or bacterial complications resulting from suppression of the immune system may be reduced. Such infections may cause physicians to delay or discontinue cancer immunotherapy; therefore, by reducing the risk of significant viral and / or bacterial complications, the risk of delaying or discontinuing cancer immunotherapy is reduced; and the feasibility of anti-cancer efficacy is enhanced.

[0067] Cancer immunotherapy-induced CRS can present with a range of symptoms and signs. The symptoms and signs of CRS may vary, ranging from mild flu-like symptoms to life-threatening manifestations of excessive inflammatory responses. Examples 5 and 6 herein describe mouse experiments that record CRS symptoms in mice. In particular, in Example 6, a reduction in CRS scores can be demonstrated (see Figures 20A-20C ), found that administration of a p38 MAPK inhibitor before the onset of CRS could counteract CRS symptoms.

[0068] The onset of CRS can vary. CRS can occur within 5, 4, 3, 2, or 1 days after administering cancer immunotherapy. Symptoms or signs of CRS can be observed within 1 day after administering cancer immunotherapy.

[0069] As used herein, the term "onset of CRS" may refer to the onset of one or more detectable symptoms or signs of CRS. A detectable symptom or sign may refer to a symptom or sign that can be detected by a physician.

[0070] However, the onset of CRS can be later, for example, several weeks after administration of cancer immunotherapy. Thus, the onset of CRS can occur at least 10, 20, 30, 40, or 50 days after administration of cancer immunotherapy.

[0071] For example, TCR engineered cells, T cells, NK cells, or genetically engineered immune cells that can replicate can stay in the body for longer periods of time, for example, up to 6 months or up to 12 months or more. Therefore, these cells can trigger CRS even after several weeks of infusion. Therefore, the onset of CRS can occur about 1 week after the administration of cancer immunotherapy, for example, about 1 week to 6 weeks after the administration of cancer immunotherapy.

[0072] Mild symptoms or signs of CRS may first be observed, for example, within a few days after the onset of CRS (e.g., within 1 or 2 days after the onset of CRS).

[0073] Mild symptoms of CRS may include fever, fatigue, headache, rash, arthralgia and myalgia, especially fever. The term "fever" as used herein may refer to a core body temperature exceeding 38°C. Respiratory symptoms may be common in patients with CRS. Mild respiratory symptoms and signs may include cough and shortness of breath (respiratory rate ≥30 in patients aged ≥12 years, ≥40 in patients aged 6 to 12 years, ≥45 in patients aged 3 to 6 years, and ≥50 in patients aged 1 to 3 years).

[0074] The signs or symptoms of CRS to be prevented or alleviated may be signs or symptoms of Grade 1 CRS as graded according to the American Society for Transplantation and Cellular Therapy consensus guidelines (2019) as described below in Table 5. Thus, the patient may have symptoms including or consisting of fever.

[0075] Therefore, preventing the CRS related to cancer immunotherapy or reducing the severity of its signs or symptoms in human patients can be or include preventing (or reducing the severity of) the signs or symptoms of grade 1 CRS. Preventing the CRS related to cancer immunotherapy or reducing the severity of its signs or symptoms in human patients can be or include preventing (or reducing the risk of) the signs or symptoms of grade 1 CRS progressing to the signs or symptoms of grade 2 CRS. These effects are particularly beneficial when cancer immunotherapy is or includes T cell engagement cancer immunotherapy, especially BiTE therapy or therapy using one or more other bispecific antibodies. They are particularly beneficial in enabling cancer immunotherapy patients to be discharged as early as possible; and / or limiting their length of hospital stay to about 1-3 days. Therefore, it is particularly contemplated herein to prevent grade 1 CRS in patients receiving BiTE therapy or therapy using one or more other bispecific antibodies, or to prevent (or reducing the risk of) grade 1 CRS progressing to grade 2 CRS, such as enabling them to be discharged, or even enabling all their treatments to be performed outside a hospital environment.

[0076] Thus, preventing cancer immunotherapy-associated CRS or reducing the severity of its signs or symptoms in human patients can be or include primary prevention (by administering a p38 MAP kinase inhibitor before the onset of any form of CRS, e.g., before administering cancer immunotherapy) and / or secondary prevention (by administering a p38 MAP kinase inhibitor while the patient is already receiving cancer immunotherapy, e.g., when the patient exhibits symptoms or signs of Grade 1 CRS).

[0077] More severe symptoms or signs of CRS may be observed after the onset of mild symptoms or signs; however, more severe symptoms or signs may appear soon after the onset of CRS, such as within days or weeks after the onset of CRS (e.g., within 2, 3, 4, 5, 6, 15, or 25 days after the onset of CRS).

[0078] Preventing cancer immunotherapy-related CRS in human patients or reducing the severity of its signs or symptoms can be or include preventing (or reducing the severity of) the signs or symptoms of grade 2 CRS; or preventing (or reducing the risk of) the signs or symptoms of grade 2 CRS from progressing to the signs or symptoms of grade 3 (or grade 4) CRS. These effects can be particularly beneficial when cancer immunotherapy is or includes CAR T cell therapy.

[0079] Symptoms and signs of CRS, particularly without treatment, can persist for more than a week after the onset of CRS, for example, up to 10 days, up to 20 days, or up to 50 days after the onset of CRS.

[0080] Severe symptoms of CRS may include low blood pressure. As used herein, low blood pressure may refer to blood pressure below about 90 / 60 mmHg. Severe signs of CRS may include a high fever. As used herein, the term "high fever" may refer to a core body temperature exceeding 40°C. In particular, severe symptoms and signs of CRS may include both low blood pressure and a high fever.

[0081] Severe respiratory symptoms and signs of CRS may include one or more of the following: acute respiratory distress syndrome (ARDS) with dyspnea, hypoxemia (arterial oxygen saturation may be ≤92% on room air by transcutaneous means), and bilateral opacities on chest x-ray. ARDS due to CRS may require mechanical ventilation.

[0082] Severe symptoms and signs of CRS may include circulatory shock, particularly circulatory shock requiring vasopressors. Additionally or alternatively, symptoms and signs may include vascular leak, which may be accompanied by peripheral and pulmonary edema, and in some cases, disseminated intravascular coagulation.

[0083] Severe symptoms and signs of CRS may include dysfunction of one or more organs. Thus, severe symptoms and signs of CRS may include symptoms and signs of renal failure. Severe symptoms and signs of CRS may include symptoms and signs of cardiac dysfunction, such as a reduced ejection fraction as observed by echocardiography or multi-gated acquisition (MUGA) scan. The symptoms and signs of CRS may progress to symptoms and signs of multiple organ system failure.

[0084] Characteristics of CRS may include one or more of the following: cytopenias (lower than normal counts of one or more types of blood cells), elevated creatinine and liver enzymes, disturbances in coagulation parameters, and higher than normal levels of C-reactive protein.

[0085] In particularly severe cases, CRS can be fatal.

[0086] The symptoms and signs of CRS may vary from patient to patient. There may be a "first dose effect", that is, patients who receive multiple administrations of cancer immunotherapy over a period of time develop severe CRS symptoms and signs only after the first administration. A higher cancer burden may be a strong predictor of CRS (especially severe CRS). A higher dose of cancer immunotherapy may be a strong predictor of CRS (especially severe CRS). Children (the term used herein may refer to those aged 12 years or younger) may experience more severe CRS than adults.

[0087] It should be understood that in this context, the symptoms and signs of CRS can be considered to be primarily due to CRS-induced symptoms and signs rather than any other cause.

[0088] In particularly severe cases, CRS can be accompanied by clinical signs and laboratory abnormalities similar to hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS). However, CRS induced by cancer immunotherapy is different from HLH and MAS.

[0089] CRS is also different from other conditions. Thus, CRS (at least in terms of its triggers) is different from sepsis. CRS is also different from tumor lysis syndrome.

[0090] As used herein, "alleviating the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient" refers to alleviating one or more of the symptoms or signs of CRS described above. This may include, for example, preventing or reducing the severity of fever. This may include delaying the onset of fever. This may include preventing one or more severe CRS symptoms and signs described herein, particularly dysfunction of one or more organs. This may include preventing death.

[0091] As used herein, "preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may refer to avoiding one or more of the above-described signs and symptoms of CRS. This may include preventing fever. This may include preventing one or more of the severe signs and symptoms of CRS described herein, particularly dysfunction of one or more organs. This may include preventing death.

[0092] As used herein, "preventing signs or symptoms of cancer immunotherapy-related CRS in human patients" may refer to reducing the risk of a patient suffering from signs or symptoms of cancer immunotherapy-related CRS (e.g., one or more of the above signs or symptoms). It may include reducing the risk of fever. It may include reducing the risk of one or more severe CRS symptoms and signs described herein, particularly the risk of dysfunction of one or more organs. It may include reducing the risk of death.

[0093] As used herein, "preventing signs or symptoms of cancer immunotherapy-related CRS in human patients" may refer to reducing the risk of a patient suffering from signs or symptoms of cancer immunotherapy-related CRS (e.g., one or more of the above signs or symptoms) in a prophylactic manner. It may include reducing the risk of fever. It may include reducing the risk of one or more severe CRS symptoms and signs described herein, especially the risk of dysfunction of one or more organs. It may include reducing the risk of death.

[0094] In one aspect, the prevention of CRS associated with cancer immunotherapy or the alleviation of the severity of its signs or symptoms can be defined by reference to the mechanism of CRS induced by cancer immunotherapy. In the presence of cancer cells, cytokines produced by T cells (such as TNFα and / or IL-6, especially IL-6) and damage-associated molecular patterns (DAMPs) from dead cancer cells are thought to attract circulating monocytes. Monocytes then release proinflammatory mediators (such as IL-6). Furthermore, this is thought to trigger the release of proinflammatory mediators (such as IL-6 and IL-8, especially IL-6) by nearby endothelial cells. In addition, T cells can overflow or redistribute systemically, leading to activation of monocytes and endothelial cells in different regions. Therefore, one or more symptoms and signs of CRS mentioned above (including hypotension, hypoxia and / or organ dysfunction after fever) can be regarded as one or more sequelae of excessive induction of cytokines near the site of interaction between T cells and cancer cells, which may involve excessive release of proinflammatory mediators by nearby monocytes. This may also involve excessive release of proinflammatory mediators by adjacent endothelial cells. This activity of endothelial cells (also known as "endothelial cell activation") can lead to vascular leakage, which in turn causes hypotension (and further cytokine release).

[0095] Therefore, preventing or reducing excessive induction of cytokines near the site of T cell-cancer interaction is to prevent or reduce one or both of the following: (i) the release of proinflammatory mediators by monocytes; and (ii) the release of proinflammatory mediators by endothelial cells adjacent to monocytes, which can effectively prevent or at least reduce the symptoms and signs of CRS and the risk of death associated with cancer immunotherapy.

[0096] Therefore, according to the present invention, p38 MAP kinase inhibitors can appropriately inhibit the release of pro-inflammatory mediators by monocytes in vivo. In some embodiments, pro-inflammatory mediators include one or more of the following: IFNγ, IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12, IL-18, CCL2, CCL5, CXCL10, MCP-1, MIP-1β, GM-CSF, VEGF, and TNFα; most particularly IL-6.

[0097] Monocytes are responsible for releasing most of the cytokines (especially IL-6) produced near the site of cancer cell-T cell interaction. Therefore, by targeting monocyte-released cytokines (especially IL-6), p38 MAPK inhibitors could eliminate or weaken an important step in the cell signaling chain or cytokine feedback loop that would otherwise lead to CRS.

[0098] The terms monocytes and macrophages are used interchangeably herein. It will be understood by those skilled in the art that monocytes typically develop into macrophages when recruited from blood vessels to other tissues by extravasation. When monocytes are attracted to T cells and cancer cells interacting within the vascular lumen, they may exhibit characteristics and / or behaviors typically associated with macrophages; non-limiting examples include the release of one or more pro-inflammatory mediators including IFNγ, IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12, IL-18, CCL2, CCL5, CXCL10, MCP-1, MIP-1β, GM-CSF, VEGF, and TNFα; most particularly IL-6. It will also be understood that the terms "cytokines" and "pro-inflammatory mediators" are used interchangeably herein.

[0099] At the same time, the term "cancer" herein can generally be used to refer to blood cancers, such as leukemia, lymphoma or myeloma. For example, a blood cancer can be: acute myeloid leukemia (AML); chronic myeloid leukemia (CML); acute lymphocytic leukemia (ALL); chronic lymphocytic leukemia (CLL); non-Hodgkin's lymphoma (NHL); Hodgkin's lymphoma (HL); or myeloma. Therefore, in some embodiments, the cancer can be B-cell or T-cell acute lymphoblastic leukemia; or large cell lymphoma. In particular, the cancer can be an aggressive, relapsed or refractory non-Hodgkin's lymphoma, including: diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma and mantle cell lymphoma and peripheral T-cell lymphoma.

[0100] The cancer can be a malignancy that expresses CD19 (e.g., a refractory or relapsed B-cell malignancy that expresses CD19). The cancer can be a malignancy that expresses BMCA (e.g., a myeloma that expresses BCMA). The cancer can be uveal melanoma.

[0101] It will be understood that the term "cancer" as used herein may also refer to solid tumors, in which case the term "cancer cell" may be used interchangeably with the term "tumor cell." Cancers having one or more solid tumors may include, for example, osteosarcomas; malignant epithelial tumors; carcinosarcoma; or lymphomas. Solid tumors may be present in, for example, the prostate, breast, lung, esophagus, stomach, small intestine, pancreas, colon and / or rectum, central nervous system, bladder, thyroid, kidney, uterine corpus, oral cavity, larynx, pharynx, or ovary.

[0102] In some embodiments, the cancer can be skin cancer.

[0103] In some embodiments, p38 MAP kinase inhibitors can inhibit the release of pro-inflammatory mediators from endothelial cells (another major source of cytokines) in vivo. Optionally, pro-inflammatory mediators may include one or more of the following: IL-1β, IL-2, IL-6, IL-8, IL-10, CCL2, CCL5, CXCL10, IL-18, TNFα, MCP-1, MIP-1β, IP10, and GM-CSF; particularly IL-6 and IL-8, most particularly IL-6.

[0104] In some embodiments, a p38 MAP kinase inhibitor can inhibit the upregulation of one or more proteins (eg, E-selectin, VCAM1, and / or ICAM1) on the surface of endothelial cells, particularly ICAM1.

[0105] p38 MAP kinase inhibitors can modestly inhibit the release of proinflammatory mediators from monocytes in vivo and also inhibit the release of proinflammatory mediators from endothelial cells in vivo.

[0106] p38 MAP kinase inhibitors can appropriately inhibit IL-6 release from monocytes and inhibit IL-6 release from endothelial cells in vivo. p38 MAP kinase inhibitors can most appropriately inhibit IL-6 release from T cells, inhibit IL-6 release from monocytes, and inhibit IL-6 release from endothelial cells (in vivo; therefore, it will be understood that this effect can occur when T cells, monocytes, and endothelial cells are all present; and that this effect is beneficial in the presence of cancer cells).

[0107] In particular, p38 MAP kinase inhibitors can prevent signaling from monocytes to endothelial cells by inhibiting the release of proinflammatory mediators from monocytes in vivo, which means that endothelial cell activation is reduced and the endothelial cells release fewer proinflammatory mediators (or even that the endothelial cells are never activated and do not release proinflammatory mediators themselves).

[0108] Any treatment for preventing CRS should ideally avoid significantly weakening the anti-cancer effect of cancer immunotherapy. As a representative but non-limiting example, T cells in genetically engineered T cell therapy should ideally retain their anti-cancer phenotype for a practical and useful duration. It is even more ideal that drug products for preventing CRS will also enhance cancer immunotherapy.

[0109] For example, in the presence of cancer cells, p38 MAPK inhibitors can appropriately inhibit the release of cytokines (e.g., TNFα, see Example 3 below; particularly IL-6, see Example 6 below) by T cells in vivo. p38 MAPK inhibitors can appropriately inhibit the release of cytokines by T cells after they undergo antigen recognition and, therefore, can alter signal 3 or signal 4 as described herein. Thus, p38 MAPK inhibitors can prevent or mitigate the risk of initiating a cytokine feedback loop by T cells and, therefore, can prevent or reduce the recruitment and activation of monocytes by T cells and cancer cells.

[0110] p38 MAPK inhibitors can effectively prevent or reduce CRS without eliminating the anti-cancer cell efficacy of cancer immunotherapy. Advantageously, in some embodiments, p38 MAPK inhibitors can effectively prevent or reduce CRS while also increasing the anti-cancer cell efficacy of cancer immunotherapy (e.g., in the presence of cancer cells). Example 2 provides the following evidence: After administering a p38 MAPK inhibitor to CAR T cells in the presence of cancer cells (co-cultured with cancer cells), TIM3 and LAG3 (exhaustion markers) on the surface of CAR T cells are reduced. The reduction in exhaustion markers can be interpreted as prolonging the anti-cancer efficacy of T cells; in addition or alternatively, it can also be associated with T cell polarization, and thus with "signal 2" as described above. Similarly, Example 5 shows that the efficacy of CAR T cells is not reduced after inhibiting p38 MAPK; on day 10 of the mouse study, twice-daily administration of 25 mg / kg of the p38 MAPK inhibitor UR-13870 significantly increased the number of circulating CAR T cells (participated in Figure 18A In addition, Example 6 shows that after treatment with UR-13870 on days 9 and 10 (especially day 10) of the study, the average number of CD19+ cancer cells per ml showed a downward trend (compared to CD28 stimulation alone), which indicates that the strengthening / anti-cancer activity of T cells is increased (see Figure 30A ). Maintenance (or improvement) of T cell proliferation and anti-cancer efficacy can each be associated with modulation of "Signal 4" as described above.

[0111] p38 MAPK inhibitors can effectively prevent or reduce the severity of the signs or symptoms of CRS in human patients. p38MAP kinase inhibitors can prevent or reduce the severity of the signs or symptoms of CRS while maintaining the anti-cancer cell efficacy of cancer immunotherapy (suitably, in the presence of cancer cells). p38 MAPK inhibitors can prevent or reduce the severity of the signs or symptoms of CRS in human patients without excessively weakening the anti-cancer cell efficacy of cancer immunotherapy in the presence of cancer cells.

[0112] Advantageously, p38 MAPK inhibitors can increase the anti-cancer cell efficacy of cancer immunotherapy (in vivo). Advantageously, p38 MAPK inhibitors can increase the anti-cancer cell efficacy of cancer immunotherapy in the presence of cancer cells. These effects can be suitably obtained by administering p38 MAPK inhibitors at the doses described herein.

[0113] As used herein, the term "anti-cancer cell efficacy" refers to the ability of cancer immunotherapy to help reduce the burden of cancer in patients. T cells can assist in achieving a reduction in the burden of cancer in patients. Thus, suitably, a p38 MAP kinase inhibitor can increase one or more of the following: cancer cell-directed cytotoxicity, in vivo expansion, IFNγ production, persistence of antigen-specific responses, viability, and memory phenotype (e.g., cell surface markers) of T cells; and / or reduce one or more of the following: oxidative stress markers (e.g., iNOS) and genomic stress markers (e.g., γH2AX) of T cells. A p38 MAPK inhibitor can increase one or more of the following: cancer cell-directed cytotoxicity, in vivo expansion, IFNγ production, persistence of antigen-specific responses, viability, and memory phenotype (e.g., cell surface markers) of CAR T cells; and / or reduce one or more of the following: oxidative stress markers (e.g., iNOS) and genomic stress markers (e.g., γH2AX) of CAR T cells.

[0114] Suitably, not unduly impairing the anti-cancer cell efficacy of the cancer immunotherapy in the presence of cancer cells is or includes not unduly impairing the anti-cancer cell efficacy of T cells in the presence of cancer cells. Suitably, increasing the anti-cancer cell efficacy of the cancer immunotherapy is or includes increasing the anti-cancer cell efficacy of T cells. Increasing the anti-cancer cell efficacy of the cancer immunotherapy in the presence of cancer cells may be or include increasing the anti-cancer cell efficacy of T cells in the presence of cancer cells.

[0115] p38 MAPK inhibitors can prevent or reduce T cell exhaustion (e.g., as evidenced by a reduction in TIM3 and LAG3 on the surface of T cells). Thus, suitably, p38 MAPK inhibitors can prevent or reduce T cell exhaustion. As used herein, "T cell exhaustion" can refer to T cells that are unable to cause cancer cell death; such T cells are non-functional and their transcriptional state may differ from that of functional T cells. Thus, p38 MAPK inhibitors can prolong the anti-cancer efficacy of T cells. It should be understood that p38 MAPK inhibitors can be administered to human patients at a dose effective to achieve this purpose. A reduction in exhaustion markers can be interpreted as prolonging the anti-cancer efficacy of T cells; it can be additionally or alternatively associated with T cell polarization, and thus with "signal 2" as described above. Thus, suitably, p38 MAPK inhibitors can modulate T cell polarization. Thus, p38 MAPK inhibitors can be administered at a dose effective to modulate T cell polarization and / or prevent or reduce T cell exhaustion.

[0116] Signal 3 and Signal 4, the T cell activation signals described herein, are believed to be modulated by external factors. p38 MAPK inhibitors are believed to modulate Signal 3 and Signal 4 without significantly detrimental effects on T cells and, in some embodiments, may have a beneficial effect on the anti-cancer efficacy of T cells.

[0117] In some embodiments, Signal 3 may be modulated, Signal 4 may be modulated, or both Signal 3 and Signal 4 may be modulated by reducing cytokine secretion (particularly IL-6) by monocytes and / or endothelial cells.

[0118] Thus, in some embodiments, p38 MAPK inhibitors can modulate T cell polarization. p38 MAPK inhibitors can modulate the specialization of T cells into T cell subsets that are restricted to produce a certain or multiple cytokine patterns.

[0119] p38 MAPK inhibitors can modulate the development of effector T cell functions, such as T cell-mediated tumor cell death. T cells may develop enhanced effector functions. Additionally or alternatively, inhibition of p38 MAPK may lead to the formation of a larger protective T cell memory population.

[0120] Also, in some embodiments, p38 MAPK inhibitors can modulate events following administration of cancer immunotherapy in vivo and can modulate the duration of T cell responses during therapy, thereby affecting subsequent T cell phenotype and function.

[0121] In some embodiments, the p38 MAPK inhibitor does not reduce the proliferation of non-anergic T cells in vivo. In some embodiments, the p38 MAPK inhibitor does not reduce the lifespan of non-anergic T cells in vivo. In some embodiments, the p38 MAPK inhibitor does not reduce the proliferation of non-anergic T cells in vivo and does not reduce the lifespan of non-anergic T cells in vivo.

[0122] In some embodiments, the p38 MAPK inhibitor increases the proliferation of non-anergic T cells in vivo. In some embodiments, the p38 MAPK inhibitor increases the lifespan of non-anergic T cells in vivo. In some embodiments, the p38 MAPK inhibitor increases the proliferation of non-anergic T cells in vivo and increases the lifespan of non-anergic T cells in vivo.

[0123] Smaller numbers of long-term surviving (eg, surviving for more than 3, 6, 9, or 12 months) but anergic T cells may be present.

[0124] At the same time, reducing cytokine secretion from monocytes and / or endothelial cells by p38 MAPK inhibitors can prevent or reduce the severity of signs or symptoms of CRS associated with cancer immunotherapy, despite the maintenance or increase in T cell proliferation, persistence, and / or lifespan. Thus, even when the anticancer cell efficacy of cancer immunotherapy remains the same or increases (which might otherwise be a predictor of CRS, similar to how higher doses of cancer immunotherapy are thought to be associated with a higher risk and / or more severe CRS), signs and symptoms of CRS can be prevented or their severity reduced.

[0125] Therefore, it may be advantageous to establish p38 MAPK inhibition in vivo at or during the early stages of cancer immunotherapy, for example, at or shortly after administration of cancer immunotherapy, for example, within 5, 4, 3, 2, or 1 day after administration of cancer immunotherapy. Thus, p38 MAPK inhibitors may shape initial factors in the process of T cell activation and / or expansion associated with the early stages of cancer immunotherapy, which may affect the effectiveness of anti-cancer therapy; in particular, signal 3 and signal 4.

[0126] In summary, in a broad sense, the beneficial effects associated with the use of the p38 MAPK inhibitors of the present invention may include, but are not limited to, one or more of the following:

[0127] (i) reducing the release of pro-inflammatory cytokines by T cells (especially reducing the release of TNFα by T cells);

[0128] (ii) reducing the release of pro-inflammatory cytokines by monocytes (especially reducing the release of IL-6 by monocytes);

[0129] (iii) reducing the release of pro-inflammatory cytokines by endothelial cells (particularly reducing the release of IL-6 by endothelial cells; and, optionally, reducing the release of IL-8 by endothelial cells);

[0130] (iv) regulating T cell signal 3 and / or 4 (especially signal 4);

[0131] (v) regulating T cell polarization and / or reducing T cell exhaustion (particularly reducing the expression of TIM3 and / or LAG3 on the surface of T cells);

[0132] (vi) maintaining or enhancing the efficacy of T cells against tumor cells; and

[0133] (vii) maintaining or enhancing T cell proliferation.

[0134] Most particularly, the beneficial effects may relate to maintaining or increasing the anti-cancer cell efficacy of T cells.

[0135] It will be understood that there are multiple isozymes of p38 MAP kinase, including the α isozyme, the β isozyme, the γ isozyme, and the δ isozyme. In some embodiments, the p38 MAP kinase inhibitor can be an inhibitor of one or more of p38α MAP kinase, p38β MAP kinase, p38γ MAP kinase, and p38δ MAP kinase; for example, as an inhibitor of p38α MAP kinase and / or an inhibitor of p38β MAP kinase.

[0136] Without prejudice to the generality of the present invention, references above and elsewhere herein to the use of p38 MAP kinase inhibitors specifically encompass the use of at least one of the following types of active agents.

[0137] Thus, suitably, the p38 MAP kinase inhibitor may have the following Formula I, or a pharmaceutically acceptable salt or solvate thereof:

[0138]

[0139] Formula I

[0140] Where R is C 1-3 Alkyl, optionally substituted by one or two halogen, NR 1 R 2 or hydroxyl-substituted, and R 1 and R 2 are each independently H, halogen or C 1-3 Alkyl, optionally substituted with one or two F.

[0141] For example, R may be optionally replaced by one, two or three halogens, NR 1 R 2or hydroxy; or optionally substituted by one or two halogen, NR 1 R 2 or hydroxy; or optionally substituted by a halogen, NR 1 R 2 When R is optionally substituted with more than one (e.g. two or three) halogen, NR 1 R 2 When substituted with hydroxy and / or hydroxy, these substituents may be independently selected from this list.

[0142] When R 1 and / or R 2 is C optionally substituted with one or more F 1-3 When alkyl, each C 1-3 Alkyl, for example, may be optionally substituted with one, two, or three Fs; may be optionally substituted with one or two Fs; may be optionally substituted with one or three Fs; may be optionally substituted with one F; or may be optionally substituted with three Fs.

[0143] In some embodiments, R is methyl or ethyl. In another embodiment, R may be propyl.

[0144] R may be substituted with one or more fluorine atoms.

[0145] In some embodiments, R may be substituted with a hydroxyl group. For example, R may be an ω-substituted alkyl group, i.e., an ω-hydroxyalkyl group. Thus, in one embodiment, R may be 3-propanol.

[0146] Appropriately, R 1 and R 2 May be independently selected from H and CH3.

[0147] R can be C 1-3 Alkyl, which is substituted by one, two or three halogens, NR1R2 or hydroxy.

[0148] In some embodiments, the p38 MAPK inhibitor can be represented by Formula II, or a pharmaceutically acceptable salt or solvate thereof:

[0149]

[0150] Formula II

[0151] Compounds of formula II and their synthesis are disclosed in WO 2004 / 076450 A1 (see Example 18). The contents of WO 2004 / 076450 A1 are incorporated herein by reference.

[0152] The contents of WO 2018 / 007788 A1 and WO 2019 / 122909 A1 are also incorporated herein by reference.

[0153] The compound of formula II may be particularly suitable for oral administration because of its advantage in ease of delivery (e.g., it can be easily delivered outside a hospital setting compared to other routes of administration such as intravenous administration, which generally require a hospital setting). In particular, it can be administered orally twice daily, for example, from about 5 mg to about 1000 mg twice daily, especially from about 5 mg to 200 mg twice daily, for example, about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg twice daily; in particular, about 70 mg or about 150 mg twice daily.

[0154] The compound of Formula II may be particularly suitably administered orally at a dose of about 5 mg to about 1000 mg twice daily (particularly about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg twice daily; most particularly about 70 mg or about 150 mg twice daily), starting about 4 days to about 2 hours before administration of the cancer immunotherapy (which may suitably be administered as a single dose, e.g., by infusion), until about 10 days after administration of the cancer immunotherapy.

[0155] Compounds of Formula II can be well tolerated (ie, have low or no side effects or toxicity), especially when administered acutely (eg, on a dosing regimen as described herein, e.g., over a period of days as opposed to months or years).

[0156] In summary, (i) reducing uncontrolled systemic inflammatory responses in at-risk patient populations without abolishing core immune function; (ii) convenient oral dosing regimen; and (iii) tolerability of the compound of Formula II can be particularly beneficial for patients receiving cancer immunotherapy because it is advantageous to provide them with a method for reducing or preventing the severity of signs or symptoms of cancer immunotherapy-associated CRS without abolishing core immune function, thereby without the risk of viral and / or bacterial complications; without the need for continuous monitoring and / or administration of the compound in a hospital setting (achieved by oral administration rather than, for example, intravenous administration); and without causing harmful side effects.

[0157] In some embodiments, the p38 MAP kinase inhibitor can be or include: 2-(4-chlorophenyl)-4-(fluorophenyl)-5-pyridin-4-yl-1,2-dihydropyrazol-3-one; 4-[4-(4-fluorophenyl)-1-(3-phenylpropyl)-5-(4-pyridinyl)-1H-imidazol-2-yl]-3-butyn-1-ol; (2R)-2-[[(2R)-2-amino-5-(diaminomethyleneamino)pentanoyl]amino]-N-[(2R)-1-[[(2R)-1-[[(2R)-1-[[(2R)-1-[[(2R)-1-[[2-[[(2R)-1-amino-3-(4-hydroxyphenyl)-1-oxopropyl-2-yl]amino]-2-oxoethyl]amino]-1-oxohexan-2-yl]amino]-1-oxohexan-2-yl]amino]-1-oxohexan-2-yl]amino]-5-(diaminomethyleneamino)-1-oxopentan-2-yl]amino]-1-oxohexan-2-yl]amino]-1-oxohexan-2-yl]hexanamide; 2-[6-chloro-5-[(2R,5S)-4-[(4-fluorophenyl)methyl]-2,5-dimethylpiperazine-1-carbonyl]-1-methylindol-3-yl]-N,N-dimethyl-2-oxoacetamide; 6-[(6R)-2-(4-fluorophenyl)-6-(hydroxymethyl)-4,5,6,7-tetrahydropyrazolo[1,5-a]pyrimidin-3-yl]-2-(2-methylphenyl)pyridazin-3-one; 4-[3-[4-(4-fluorophenyl)-5-pyridin-4-ylimidazol-1-yl]propyl]morpholine; 4-[5-(4-fluorophenyl)-3-piperidin-4-ylimidazol-4-yl]pyrimidin-2-amine; 4-[5-(4-fluorophenyl)-3-piperidin-4-ylimidazol-4-yl]pyridine; 4-[4-(4-Fluorophenyl)-2-(4-methylsulfinylphenyl)-1H-imidazol-5-yl]pyridine; 4-[4-(4-Fluorophenyl)-5-(2-methoxypyrimidin-4-yl)imidazol-1-yl]cyclohexan-1-ol; 4-[5-(4-Fluorophenyl)-3-piperidin-4-ylimidazol-4-yl]-2-methoxypyrimidine; 6-(N-carbamoyl-2,6-difluoroanilino)-2-(2,4-difluorophenyl)pyridine-3-carboxamide; 5-(2,6-dichlorophenyl)-2-(2,4-difluorophenyl)thiopyrimido[1,6-b]pyridazin-6-one; 2-[[(2S)-2-amino-3-phenylpropyl]amino]-3-methyl-5-naphth-2-yl-6-pyridin-4-ylpyrimidin-4-one; 1-[5-tert-butyl-2-(4-methylphenyl)pyrazol-3-yl]-3-[4-(2-morpholin-4-ylethoxy)naphth-1-yl]urea; 6-(2,4-difluorophenoxy)-2-(1,5-dihydroxypentan-3-ylamino)-8-methylpyrido[2,3-d]pyrimidin-7-one;1-[7-(4-Fluorophenyl)-8-pyridin-4-yl-3,4-dihydro-1H-pyrazolo[5,1-c][1,2,4]triazin-2-yl]-2-phenylethane-1,2-dione; 8-(2,6-difluorophenyl)-2-(1,3-dihydroxypropan-2-ylamino)-4-(4-fluoro-2-methylphenyl)pyrido[2,3-d]pyrimidin-7-one; 2-[4-(4-fluorophenyl)-5-(2-phenoxypyrimidin-4-yl)imidazol-1-yl]propane-1,3-diol; N,N'-bis[3,5-bis[(E)-N-(diaminomethyleneamino)-C-methylcarbonimino]phenyl]decanediamine; [2-[4-(4-Fluorophenyl)-5-pyridin-4-yl-1H-imidazol-2-yl]-5-methyl-1,3-dioxan-5-yl]-morpholin-4-ylmethanone; methanesulfonic acid; [5-amino-1-(4-fluorophenyl)pyrazol-4-yl]-[3-[(2S)-2,3-dihydroxypropoxy]phenyl]methanone; 2-(2-chloro-6-fluorophenyl)-N-[3-(4-fluorophenyl)-4-pyrimidin-4-yl-1,2-oxazol-5-yl]acetamide; [(2R,3S,4R,5R,6R)-5-[[2-(aminomethyleneamino)acetyl]-methylamino]-3-hydroxy-2-(hydroxymethyl)-6-[(7-hydroxy-5-methyl-4-oxo-3a,6,7,7a-tetrahydro-1H-imidazo[4,5-c]pyridin-2-yl)amino]oxan-4-yl]carbamate; 1-[5-tert-butyl-2-(4-methylphenyl)pyrazol-3-yl]-3-[[5-fluoro-2-[1-(2-hydroxyethyl)indazol-5-yl]oxyphenyl]methyl]urea; 5-(2,4-Difluorophenoxy)-N-[2-(dimethylamino)ethyl]-1-(2-methylpropyl)indazole-6-carboxamide; N-cyclopropyl-3-fluoro-4-methyl-5-[3-[[1-[2-[2-(methylamino)ethoxy]phenyl]cyclopropyl]amino]-2-oxopyrazin-1-yl]benzamide; 3-[5-amino-4-(3-cyanobenzoyl)pyrazol-1-yl]-N-cyclopropyl-4-methylbenzamide; 4-[5-(cyclopropylcarbamoyl)-2-methylanilino]-5-methyl-N-propylpyrrolo[2,1-f][1,2,4]triazine-6-carboxamide; 4-[4-(4-fluorophenyl)-2-(4-methylsulfonylphenyl)-1H-imidazol-5-yl]pyridine; N-[4-[5-(4-Fluorophenyl)-3-methyl-2-methylsulfinylimidazol-4-yl]pyridin-2-yl]acetamide; 1-(5-tert-butyl-2-phenylpyrazol-3-yl)-3-[2-fluoro-4-[(3-oxo-4H-pyrido[2,3-b]pyrazin-8-yl)oxy]phenyl]urea;1-(5-tert-Butyl-2-phenylpyrazol-3-yl)-3-[2-methylthio-4-[(3-oxo-4H-pyrido[2,3-b]pyrazin-8-yl)oxy]phenyl]urea; 4-(3,4-dichlorophenyl)-5-(4-pyridyl)-2-thiazolamine dihydrochloride; 5-(2-chloroethyl)-4-methyl-1,3-thiazole; ethane-1,2-disulfonic acid; 2'-fluoro-N-(4-hydroxyphenyl)-[1,1'-biphenyl]-4-butyramide; [4-(2-amino-4-bromoanilino)-2-chlorophenyl]-(2-methylphenyl)methanone; (E)-3-[4-(imidazol-1-ylmethyl)phenyl]propen-2-enoic acid; 17α-ethynyl-5-androstene-3β,7β,17β-triol; (Z)-6-amino-2-(3',5'-dibromo-4'-hydroxybenzylidene)-2H-benzo[b][1,4]oxazin-3(4H)-one; (4-benzylpiperidin-1-yl)-(2-methoxy-4-methylthiophenyl)methanone; 6-[5-(cyclopropylcarbamoyl)-3-fluoro-2-methylphenyl]-N-(2,2-dimethylpropyl)pyridine-3-carboxamide; 5-[2-tert-butyl-4-(4-fluorophenyl)-1H-imidazol-5-yl]-3-(2,2-dimethylpropyl)imidazo[4,5-b]pyridin-2-amine; methanesulfonic acid; 4-[5-(4-fluorophenyl)-2-methylthio-1H-imidazol-4-yl]-N-(1-phenylethyl)pyridin-2-amine; 2-(3,4-dihydroxyphenyl)-3-hydroxychromen-4-one; 1-[5-tert-butyl-2-(3-chloro-4-hydroxyphenyl)pyrazol-3-yl]-3-[[2-[[3-[2-(2-hydroxyethylthio)phenyl]-[1,2,4]triazolo[4,3-a]pyridin-6-yl]thio]phenyl]methyl]urea; 3-[3-bromo-4-[(2,4-difluorophenyl)methoxy]-6-methyl-2-oxopyridin-1-yl]-N,4-dimethylbenzamide; 5-[2-tert-butyl-4-(4-fluorophenyl)-1H-imidazol-5-yl]-3-(2,2-dimethylpropyl)imidazo[4,5-b]pyridin-2-amine; 4-[4-[[4-chloro-3-(trifluoromethyl)phenyl]carbamoylamino]-3-fluorophenoxy]-N-methylpyridine-2-carboxamide; [5-amino-1-(4-fluorophenyl)pyrazol-4-yl]-[3-[(2S)-2,3-dihydroxypropoxy]phenyl]methanone; 4-[4-(4-fluorophenyl)-5-pyridin-4-yl-1H-imidazol-2-yl]phenol; 4-[4-(4-fluorophenyl)-2-(4-methylsulfinylphenyl)-1H-imidazol-5-yl]pyridine hydrochloride; 4-[4-(4-fluorophenyl)-5-pyridin-4-yl-1H-imidazol-2-yl]phenol hydrochloride;1-[4-[3-(4-chlorophenyl)-4-pyrimidin-4-yl-1H-pyrazol-5-yl]piperidin-1-yl]-2-hydroxyethanone; N,N'-bis[3,5-bis[(E)-N-(diaminomethyleneamino)-C-methylcarbonimino]phenyl]decanediamine; 6-(4-fluorophenyl)-5-pyridin-4-yl-2,3-dihydroimidazo[2,1-b][1,3]thiazole; 2-[6-chloro-5-[4-[(4-fluorophenyl)methyl]piperidine-1-carbonyl]-1-methylindol-3-yl]-N,N-dimethyl-2-oxoacetamide; [5-amino-1-(4-fluorophenyl)pyrazol-4-yl]-[3-(2,3-dihydroxypropyloxy)phenyl]methanone; N-[4-[2-ethyl-4-(3-methylphenyl)-1,3-thiazol-5-yl]pyridin-2-yl]benzamide; 4-[4-(6-methoxynaphthalen-2-yl)-2-(4-methylsulfinylphenyl)-1H-imidazol-5-yl]pyridine; 4,6-bis(p-fluorophenyl)-2-methyl-5-(4-pyridinyl)-1,2,7-triaza-2H-indene; and 2-(3-phenyl-4,5-dihydro-1,2-oxazol-5-yl)acetic acid.

[0158] In some embodiments, the p38 MAP kinase inhibitor can be or include: 8-(2,6-difluorophenyl)-2-(1,3-dihydroxypropan-2-ylamino)-4-(4-fluoro-2-methylphenyl)pyrido[2,3-d]pyrimidin-7-one; (E)-3-[4-(imidazol-1-ylmethyl)phenyl]propene-2-enoic acid; 6-[5-(cyclopropylcarbamoyl)-3-fluoro-2-methylphenyl]-N-(2,2-dimethylpropyl)pyridine-3-carboxamide; 5-[(2-chloro-6-fluorophenyl)acetamido]-3-(4-fluorophenyl)-4-(4-pyrimidinyl)isoxazole; 1-[5-tert-butyl-2-(3-chloro-4-hydroxyphenyl)pyrazol-3-yl]-3-[[2-[[3-[2-(2-hydroxyethylthio)phenyl]-[1,2,4]triazole [4,3-a]pyridin-6-yl]thio]phenyl]methyl]urea; 3-[3-bromo-4-[(2,4-difluorophenyl)methoxy]-6-methyl-2-oxopyridin-1-yl]-N,4-dimethylbenzamide; 2-methoxy-1-{4-[(4-{3-[5-(tert-butyl)-2-(p-tolyl)-2H-pyrazol-3-yl]urea}-1-naphthyloxy 1-[(4-[(tert-butyl)-2-(p-tolyl)-2H-pyrazol-3-yl]ureido}-1-naphthyloxy)-2-pyridinylamino]-1-ethanone; and 4,6-bis(p-fluorophenyl)-2-methyl-5-(4-pyridinyl)-1,2,7-triaza-2H-indene.

[0159] According to the present invention, a p38 MAPK inhibitor (optionally at least one of the above-mentioned active agents) is administered before the onset of CRS. It will be understood that this does not exclude the administration of a p38 MAPK inhibitor after the onset of CRS (e.g., continued administration). On the contrary, continued administration after the onset of CRS is preferred. Administration of the p38 MAPK inhibitor can be started from about 4 days to about 2 hours before the administration of cancer immunotherapy (suitably, cancer immunotherapy is administered in a single dose, e.g., by infusion); subsequently, the patient can continue to use the oral dosing regimen of the p38 MAPK inhibitor, the endpoint of which is up to about 10 days after the administration of cancer immunotherapy.

[0160] P38 MAPK inhibitors are administered to human patients before the onset of CRS. P38 MAPK inhibitors are directly administered to human patients before the onset of CRS (e.g., intravenously, orally, or both). For example, p38 MAPK inhibitors are not, for example, administered to T cell cultures in vitro and then administered to human patients. Preventing CRS related to cancer immunotherapy in human patients or alleviating the severity of their signs or symptoms is achieved by administering p38 MAPK inhibitors in vivo. Therefore, p38 MAPK inhibitors are administered in human patients before the onset of CRS.

[0161] The timing of administration of the p38 MAPK inhibitor prior to the onset of CRS can be mimicked as in the mouse experiments described in Examples 5 and 6 herein.

[0162] The p38 MAPK inhibitor can be administered orally, intravenously, intraperitoneally, topically, transdermally, intramuscularly, subcutaneously, intranasally, sublingually, intrathecally, intracerebroventricularly, intratumorally, or by any other suitable route. In a preferred embodiment, the p38 MAPK inhibitor can be administered intravenously, orally, or both (e.g., as disclosed herein, by an initial intravenous dose followed by several oral doses).

[0163] Oral administration of a p38 MAPK inhibitor (e.g., a compound of Formula II) is particularly preferred. Suitably, oral administration may be convenient in an outpatient setting. This may reduce the cost of treatment for patients by reducing the need for hospitalization or other inpatient monitoring. Suitably, the patient may start (e.g., in a hospital) an oral dosing regimen of the p38 MAPK inhibitor about 4 days to about 2 hours before the administration of the cancer immunotherapy (e.g., orally about 5 mg twice daily to about 1000 mg twice daily, particularly about 50 mg twice daily to about 200 mg twice daily, for example about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg twice daily, particularly about 70 mg twice daily or about 150 mg twice daily). mg); the patient can then continue the oral dosing regimen of the p38 MAPK inhibitor (e.g., after discharge from the hospital), with the endpoint of the oral dosing regimen being up to about 10 days after administration of the cancer immunotherapy.

[0164] The p38 MAPK inhibitor can be administered to a patient before cancer immunotherapy is administered to the patient. The p38 MAPK inhibitor can be administered to the patient simultaneously with cancer immunotherapy. The p38 MAPK inhibitor can be administered to the patient after cancer immunotherapy is administered to the patient but before the onset of CRS.

[0165] The p38 MAPK inhibitor can be administered prior to the administration of the cancer immunotherapy. Optionally, a dose of the p38 MAPK inhibitor can be administered (e.g., intravenously or orally) within a timeframe of about 1 minute to about 6 hours, or about 10 minutes to about 2 hours, or about 30 minutes to about 6 hours prior to the administration of the cancer immunotherapy. For example, a dose of the p38 MAPK inhibitor can be administered intravenously about 30 minutes prior to the administration of the cancer immunotherapy.

[0166] More preferably, the administration of the p38 MAPK inhibitor can be started within a time range of about 6 days to about 30 minutes, for example, about 5 days to about 1 hour, and especially about 4 days to about 2 hours before the administration of the cancer immunotherapy. Such administration of the p38 MAPK inhibitor is most suitably oral and twice daily, for example, 10 mg to 1000 mg orally twice daily. Such administration of the p38 MAPK inhibitor is suitably continued (orally twice daily) until an end point of up to 15 days, for example up to 10 days, and especially up to 7 days after the administration of the cancer immunotherapy (i.e., then stopped).

[0167] In this embodiment, p38 MAPK inhibitors can effectively prevent type 1 infusion-related hypersensitivity reactions or at least reduce the severity of type 1 infusion-related hypersensitivity reactions. The term "type 1 infusion-related hypersensitivity reaction" herein can be used to refer to acute immune-mediated reactions to intravenous administration of any cancer immunotherapy. In contrast to CRS induced by cancer immunotherapy, the classic mechanism of type 1 immune-mediated hypersensitivity reactions can involve the formation of immunoglobulin E (IgE) antibodies in response to the infusion. Subsequently, IgE binds to mast cells, which can lead to the release of various cytokines. Signs and symptoms can include itching, urticaria, fever, chills / chills, sweating, bronchospasm, and cardiovascular failure.

[0168] Optionally, one or more doses of the p38 MAPK inhibitor may be administered repeatedly (e.g., intravenously or orally), in particular orally twice daily; or the p38 MAPK inhibitor may be administered continuously, in particular by intravenous infusion; preferably, starting within a timeframe of about 4 days to about 2 hours, e.g., about 3 days to about 1 day, prior to the administration of the cancer immunotherapy, such that a steady-state plasma concentration of the p38 MAPK inhibitor is established upon administration of the cancer immunotherapy.

[0169] Establishing steady-state plasma concentrations of p38 MAPK inhibitors when administering cancer immunotherapy may enhance its prophylactic effects as described herein.

[0170] In order to establish a steady-state plasma concentration of a p38 MAPK inhibitor when administering cancer immunotherapy, the p38 MAPK inhibitor can be repeatedly administered orally at a dose of one or more doses per day (e.g., twice per day) starting within a time range of about 4 days to about 2 hours, for example, about 3 days to about 1 day before the administration of cancer immunotherapy. This dosing regimen can be sustained until an endpoint of up to about 15, 10, or especially 7 days after the administration of cancer immunotherapy. Advantageously, the patient can be relatively healthy, conscious, and able to receive the p38 MAPK inhibitor by oral administration at this stage of their personal treatment cycle. To date, treatment of CRS induced by cancer immunotherapy (e.g., by using tocilizumab and steroids as described above) has been reactive rather than preventive; however, reactive treatment of critically ill patients using oral medications may be difficult to achieve, requiring clinicians to resort to alternative modes of administration that are generally more laborious and / or invasive.

[0171] For some patients, in order to establish a steady-state plasma concentration of the p38 MAPK inhibitor while administering cancer immunotherapy, the p38 MAPK inhibitor can be administered by intravenous infusion; preferably, it can be started within a time range of about 3 days to about 1 day before the administration of cancer immunotherapy. The intravenous infusion can be continuous or can be performed periodically to establish a steady-state plasma concentration of the p38 MAPK inhibitor. Intravenous infusion may be particularly suitable when oral administration of the p38 MAPK inhibitor is not suitable for the patient (e.g., a patient under intensive care).

[0172] Those skilled in the art are familiar with appropriate calculations for determining when steady-state plasma concentrations of an active agent (e.g., a p38 MAP kinase inhibitor for use in accordance with the present invention) have been achieved. ss ) is defined as the period of time during which the concentration of an active agent remains stable or consistent when the active agent is given repeatedly or continuously (intravenously). The time to steady state is T 1 / 2 Css is a function of the active agent's rate of entry into the systemic circulation and is reached when the rate of elimination is equal to the active agent's rate of entry into the systemic circulation. For most active agents, Css is reached within approximately five half-lives. The time to steady state is independent of dose size, dosing interval, and number of doses. In the case of multiple dosing, when a fixed dose of an active agent is administered at fixed intervals, the plasma concentration increases exponentially to a plateau or steady state, with an incremental half-life equal to the agent's T 1 / 2 .

[0173] The steady-state plasma concentration of the p38 MAPK inhibitor can be about 1 μg / L to about 750 μg / L, about 5 μg / L to about 600 μg / L, about 10 μg / L to about 500 μg / L, about 25 μg / L to about 500 μg / L, about 50 μg / L to about 500 μg / L, or about 100 μg / L to about 400 μg / L.

[0174] Thus, the p38 MAPK inhibitor can be administered, in particular according to the present invention, starting about 4 days to about 2 hours (e.g., about 1 day to about 3 days) before the administration of the cancer immunotherapy, such that a steady-state plasma concentration of the p38 MAPK inhibitor of about 1 μg / L to about 750 μg / L is established when the cancer immunotherapy is administered. In particular, such administration of the p38 MAPK inhibitor can be repeated oral dosing (e.g., twice daily) or by intravenous infusion. Most particularly, the p38 MAPK inhibitor can be orally administered at a dose of 5 mg to 1000 mg twice daily starting about 4 days to about 2 hours before the administration of the cancer immunotherapy, until an endpoint of up to about 15, 10, or especially 7 days after the administration of the cancer immunotherapy; thereby establishing a steady-state plasma concentration of the p38 MAPK inhibitor for an appropriate time before, during, and after the administration of the cancer immunotherapy.

[0175] Additionally or alternatively, the p38 MAPK inhibitor may be administered concurrently with the administration of the cancer immunotherapy (e.g., intravenously). Optionally, the p38 MAPK inhibitor and the cancer immunotherapy may be administered concurrently, but in separate formulations and optionally by separate routes of administration. In some embodiments, the cancer immunotherapy and the p38 MAPK inhibitor may be administered concurrently with two separate intravenous injections in different formulations. In some embodiments, the cancer immunotherapy may be infused intravenously while the p38 MAPK inhibitor is administered orally. In some embodiments, the p38 MAPK inhibitor and the cancer immunotherapy may be administered in the same formulation, for example, both may be administered by the same intravenous injection.

[0176] Additionally or alternatively, the p38 MAPK inhibitor can be administered to the patient after cancer immunotherapy is administered but before the onset of CRS. The p38 MAPK inhibitor can be administered within 1, 2, or 3 days after cancer immunotherapy is administered (still before the onset of CRS). Since the risk of CRS is believed to be particularly high about 2 weeks after cancer immunotherapy is administered, the p38 MAPK inhibitor can be administered within 1 or 2 weeks after cancer immunotherapy is administered, before the onset of CRS.

[0177] The p38 MAPK inhibitor can be administered on a dosing schedule of once daily (OD), twice daily (BID), three times daily (TID), four times daily (QID), or more frequently. For example, the p38 MAPK inhibitor can be administered from about once daily to about six times daily. In particular, the p38 MAPK inhibitor can be administered twice daily. In some embodiments, the p38 MAPK inhibitor can be administered on a dosing schedule of every other day, three times a week, twice a week, weekly, or every two weeks. Examples 5 and 6 described herein simulate twice daily dosing. In particular, it can be administered orally twice daily, for example from about 5 mg to about 1000 mg twice daily, especially from about 5 mg to about 200 mg twice daily, for example about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg; in particular about 70 mg or about 150 mg twice daily.

[0178] The dosage schedule of the p38 MAPK inhibitor may include a "drug holiday," wherein, generally, one or more administration days are followed by one or more rest days, for example, the p38 MAPK inhibitor may be administered for one day, followed by one rest day; or for two days, followed by one rest day; or for three days, followed by one rest day, etc.; or it may be administered continuously without a drug holiday. Optionally, the p38 MAPK inhibitor may be administered as an initial dose prior to or concurrently with the administration of the cancer immunotherapy (it will be understood that this may be a single or one-time dose that does not form part of the above-described dosage schedule), followed by the initiation of the above-described dosage schedule. For example, an initial intravenous dose may be provided, followed by several oral doses administered according to the above-described dosage schedule (e.g., twice daily, for example, twice daily for about 1 to about 50 days).

[0179] Administration of the p38 MAPK inhibitor can be continued as needed. In some embodiments, the p38 MAPK inhibitor can be administered for less than about 28, about 14, about 7, about 6, about 5, about 4, about 3, or about 2 days. In some embodiments, the p38 MAPK inhibitor can be administered for more than about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 14, or about 28 days. In certain instances, continuous dosing can be achieved and maintained as needed. In some embodiments, the p38 MAPK inhibitor can be administered for about 1 to 50 days, preferably about 7 to 40 days, and more preferably about 14 to 28 days, following administration of the cancer immunotherapy. However, it is contemplated that administration of the p38 MAP kinase inhibitors of the present invention will be an acute treatment, lasting for a period of days or weeks. The treatments of the present invention are not intended to be long-term treatments lasting months or longer.

[0180] Thus, preferably, administration of the p38 MAPK inhibitor can begin from about 4 days to about 2 hours before the administration of the cancer immunotherapy; and such administration can continue until an end point of about 15 days after the administration of the cancer immunotherapy.

[0181] Example 5 herein describes a mouse model with twice daily dosing for up to 11 days, while Example 6 herein describes a mouse model with twice daily dosing for up to 7 days.

[0182] The p38 MAPK inhibitor can be administered starting about 1 to about 5 days before the onset of CRS, particularly about 1 to about 4 days, for example about 1 to about 3 days. The p38 MAPK inhibitor can be administered until about 7 to about 28 days after the onset of CRS (ie, then stopped).

[0183] The dosage form and regimen selected will depend upon a variety of factors, including, for example, the activity of the p38 MAPK inhibitory compound being employed, the route of administration, the time of administration, the rate of clearance, rate and extent of absorption of the p38 MAPK inhibitory compound being employed, the duration of treatment, the formulation of the pharmaceutical product comprising the p38 MAP kinase inhibitor, the presence of other drugs, compounds and / or materials used in combination with the p38 MAPK inhibitor being employed, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and other such factors well known in the medical arts.

[0184] Generally, a suitable dose (eg, a twice daily dose) of a p38 MAPK inhibitor described herein is, in some embodiments, the lowest dose effective to produce a therapeutic and / or prophylactic effect.

[0185] In some embodiments, the dose may be the lowest dose effective to achieve one or more of the following:

[0186] (i) reducing the release of pro-inflammatory cytokines by T cells (especially reducing the release of TNFα by T cells);

[0187] (ii) reducing the release of pro-inflammatory cytokines by monocytes (especially reducing the release of IL-6 by monocytes);

[0188] (iii) reducing the release of pro-inflammatory cytokines by endothelial cells (particularly reducing the release of IL-6 by endothelial cells; and, optionally, reducing the release of IL-8 by endothelial cells);

[0189] (iv) regulating T cell signal 3 and / or 4 (especially signal 4);

[0190] (v) regulating T cell polarization and / or reducing T cell exhaustion (particularly reducing the expression of TIM3 and / or LAG3 on the surface of T cells);

[0191] (vi) maintaining or enhancing the efficacy of T cells against tumor cells; and

[0192] (vii) maintaining or enhancing the proliferation of non-anergic T cells.

[0193] Most particularly, it may be the lowest dose effective to maintain or increase the efficacy of T cells against cancer cells.

[0194] The effective dosage generally depends on the factors described herein. Typically, when a p38 MAPK inhibitor is used for the described effects, the dosage is from about 10 mg to about 1400 mg per day, or from about 10 mg to about 1300 mg per day, or from about 10 mg to about 1200 mg per day, or from about 20 mg to about 1120 mg per day.

[0195] Thus, the dosage of the p38 MAPK inhibitor can be about 10 mg to about 600 mg per day. For example, the dosage can be about 150 mg per day. For example, the dosage can be about 300 mg per day.

[0196] The p38 MAPK inhibitor can optionally be administered twice daily. When the p38 MAPK inhibitor is used for the described effects, the dosage range can be about 5 mg twice daily to about 1000 mg twice daily, or about 5 mg twice daily to about 700 mg twice daily (i.e., a total of about 10 mg to about 1400 mg per day), or about 5 mg twice daily to about 650 mg twice daily, or about 5 mg twice daily to about 600 mg twice daily, for example, about 10 mg to about 560 mg twice daily. In some embodiments, the dosage can be about 20 mg, about 80 mg, about 400 mg, about 600 mg, about 800 mg, or about 1120 mg per day. In some embodiments, the dosage can be about 10 mg, about 40 mg, about 200 mg, about 300 mg, about 400 mg, or about 560 mg twice daily. The dosage can especially be from about 5 to about 1000 mg twice daily, especially from about 5 to about 200 mg twice daily, for example about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg twice daily; in particular, about 70 or about 150 mg twice daily.

[0197] In some embodiments, for human patients, suitable dosages are from about 0.001 mg / kg / day to about 20 mg / kg / day, or from about 0.001 mg / kg / day to about 10 mg / kg / day, or from about 0.001 mg / kg / day to about 5 mg / kg / day.

[0198] As described above, when the p38 MAPK inhibitor is a compound of Formula II, 70 mg twice daily or 150 mg twice daily may be particularly preferred.

[0199] The actual dosage of the p38 MAPK inhibitor can be varied to obtain an amount of the p38 MAPK inhibitor that is effective to achieve the desired therapeutic response for a given patient, composition, and mode of administration, and that is non-toxic to the patient. In some cases, a dosage below the lower limit of the disclosed range may be sufficient, while in other cases, still higher dosages may be used without causing any adverse side effects.

[0200] In some embodiments, an initial intravenous dose of the p38 MAPK inhibitor (e.g., about 10 mg to about 1000 mg) can be administered, for example, but not limited to, concurrently with or prior to administration of the cancer immunotherapy (e.g., about 1 minute to 6 hours, e.g., about 20 to 60 minutes, before administration of the cancer immunotherapy); and subsequent doses of the p38 MAPK inhibitor can then be administered orally (e.g., about 10 mg to about 560 mg of the p38 MAPK inhibitor can be administered orally one to three times daily, e.g., twice daily, for about 1 to 50 days).

[0201] In another aspect, provided herein is a use of a p38 MAP kinase inhibitor of Formula II or a pharmaceutically acceptable salt or solvate thereof for preventing or treating cancer immunotherapy-associated CRS in a human patient. The p38 MAP kinase inhibitor, salt or solvate of Formula II may suitably be administered orally twice daily, for example 5-1000 mg twice daily, especially about 5 mg to about 200 mg twice daily, for example about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg twice daily; in particular about 70 mg or about 150 mg twice daily.

[0202] In a second aspect of the present invention, a pharmaceutical composition comprising a p38 MAP kinase inhibitor is provided for preventing cancer immunotherapy-associated CRS or reducing the severity of its signs or symptoms in human patients, wherein the pharmaceutical composition is administered in vivo before the onset of CRS.

[0203] Suitably, the pharmaceutical composition may comprise a p38 MAP kinase inhibitor as defined in the first aspect of the present invention comprising the above-mentioned specific active agents.

[0204] In some embodiments, the pharmaceutical composition can be a pharmaceutical composition suitable for oral administration. Pharmaceutical compositions suitable for oral administration can be in discrete dosage forms, such as capsules, cachets, or tablets, or in liquid or aerosol formulations, each containing a predetermined amount of a p38 MAPK inhibitor in the form of a powder or granules, a solution or suspension in an aqueous or non-aqueous liquid, an oil-in-water emulsion, or a water-in-oil liquid emulsion. These dosage forms can be prepared by any pharmaceutical method, but all methods include the step of combining the p38 MAP kinase inhibitor with a carrier composed of one or more ingredients. Generally, pharmaceutical compositions are prepared by uniformly and intimately mixing the p38 MAP kinase inhibitor with a liquid carrier, a finely divided solid carrier, or both, and then, if necessary, shaping the product into the desired form. For example, tablets can be prepared by compression or molding, optionally with one or more auxiliary ingredients. Compressed tablets can be prepared by compressing a free-flowing form of the p38 MAPK inhibitor (e.g., powder or granules), optionally mixed with excipients such as, but not limited to, binders, lubricants, inert diluents, and / or surfactants or dispersants, in a suitable machine. Molded tablets may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent.

[0205] The present invention also includes anhydrous pharmaceutical compositions and dosage forms comprising p38 MAPK inhibitors. Anhydrous pharmaceutical compositions and dosage forms can be prepared using anhydrous or low-moisture ingredients and low-moisture or low-humidity conditions. For example, pharmaceutical compositions and dosage forms containing lactose can be prepared in anhydrous form if substantial contact with moisture and / or humidity is expected during manufacturing, packaging, and / or storage. Anhydrous pharmaceutical compositions can be prepared and stored to maintain their anhydrous nature. Thus, anhydrous pharmaceutical compositions can be packaged using materials known to prevent contact with water, thereby allowing them to be included in suitable formulation kits. Examples of suitable packaging include, but are not limited to, sealed foils, plastics, etc., unit dose containers, blister packs, and strip packs.

[0206] The p38 MAPK inhibitor can be intimately mixed with a pharmaceutical carrier according to conventional pharmaceutical formulation techniques. Depending on the form of the preparation desired for administration, the carrier can take a variety of forms. When preparing a pharmaceutical composition for oral dosage form, any commonly used pharmaceutical medium can be used as a carrier. For example, in the case of oral liquid preparations (such as suspensions, solutions and elixirs) or aerosols, the carrier can be water, glycols, oils, alcohols, flavorings, preservatives, colorants, etc.; or in the case of oral solid preparations, carriers such as starch, sugar, microcrystalline cellulose, diluents, granulating agents, lubricants, binders and disintegrants can be used. In some embodiments, lactose is not used. For example, suitable carriers include solid oral preparations such as powders, capsules and tablets. In some embodiments, tablets can be coated by standard aqueous or non-aqueous techniques.

[0207] Binders suitable for use in pharmaceutical compositions and dosage forms include, but are not limited to, corn starch, potato starch or other starches, gelatin, natural and synthetic gums such as acacia, sodium alginate, alginic acid, other alginates, powdered tragacanth gum, guar gum, cellulose and its derivatives (e.g., ethylcellulose, cellulose acetate, carboxymethylcellulose calcium, sodium carboxymethylcellulose), polyvinylpyrrolidone, methylcellulose, pregelatinized starch, hydroxypropyl methylcellulose, microcrystalline cellulose, and mixtures thereof.

[0208] Examples of fillers suitable for use in the pharmaceutical compositions and dosage forms disclosed herein include, but are not limited to, talc, calcium carbonate (e.g., granules or powder), microcrystalline cellulose, powdered cellulose, dextrin, kaolin, mannitol, silicic acid, sorbitol, starch, pregelatinized starch, and mixtures thereof.

[0209] Disintegrants can be used in pharmaceutical compositions disclosed herein to provide tablets that disintegrate when exposed to an aqueous environment. The amount of disintegrant used can vary based on the type of formulation and mode of administration, and can be easily determined by one of ordinary skill in the art. For example, about 0.5 to about 15 weight percent of disintegrant can be used in the pharmaceutical composition, or about 1 to about 5 weight percent of disintegrant. Disintegrants that can be used to form pharmaceutical compositions and dosage forms include, but are not limited to, agar, alginic acid, calcium carbonate, microcrystalline cellulose, cross-linked sodium carboxymethyl cellulose, cross-linked polyvinylpyrrolidone, polycrilin potassium, sodium starch glycolate, potato or tapioca starch, other starches, pregelatinized starch, other starches, clays, other alginates, other celluloses, gums, or mixtures thereof.

[0210] Lubricants that can be used to form pharmaceutical compositions and dosage forms include, but are not limited to, calcium stearate, magnesium stearate, mineral oil, light mineral oil, glycerol, sorbitol, mannitol, polyethylene glycol, other glycols, stearic acid, sodium lauryl sulfate, talc, hydrogenated vegetable oils (e.g., peanut oil, cottonseed oil, sunflower oil, sesame oil, olive oil, corn oil, and soybean oil), zinc stearate, ethyl oleate, ethyl laurate, agar, or mixtures thereof. Additional lubricants include, for example, colloidal silicon dioxide, a condensed aerosol of synthetic silicon dioxide, or mixtures thereof. The amount of lubricant added can optionally be less than about 1 weight percent of the pharmaceutical composition.

[0211] When aqueous suspensions and / or elixirs are desired for oral administration, the p38 MAPK inhibitor therein may be combined with various sweetening or flavoring agents, colorants or dyes, and with emulsifying and / or suspending agents and diluents such as water, ethanol, propylene glycol, glycerol, and various combinations thereof.

[0212] The tablet dosage forms disclosed herein may be uncoated or coated by known techniques to delay disintegration and absorption in the gastrointestinal tract, thereby providing a sustained effect over a longer period of time. For example, a time-delaying agent such as glyceryl monostearate or glyceryl distearate may be used. Oral formulations may also be in the form of hard gelatin capsules in which the p38 MAPK inhibitor is mixed with an inert solid diluent such as calcium carbonate, calcium phosphate, or kaolin, or in the form of soft gelatin capsules in which the p38 MAPK inhibitor is mixed with an oil medium such as water or peanut oil, liquid paraffin, or olive oil.

[0213] In some embodiments, the pharmaceutical composition may include one or more surfactants. Surfactants that can be used to form the pharmaceutical composition include, but are not limited to, hydrophilic surfactants, lipophilic surfactants, and mixtures thereof. A mixture of hydrophilic surfactants, a mixture of lipophilic surfactants, or a mixture of at least one hydrophilic surfactant and at least one lipophilic surfactant can be used.

[0214] In some embodiments, the pharmaceutical composition may include a solubilizer to ensure good solubility and / or dissolution of the p38 MAPK inhibitor and to minimize precipitation of the p38 MAPK inhibitor. A solubilizer may also be added to increase the solubility of the p38 MAPK inhibitor and / or other components (e.g., surfactants) or to maintain the pharmaceutical composition as a stable or homogeneous solution or dispersion.

[0215] Examples of suitable solubilizers include, but are not limited to, alcohols and polyols such as ethanol, isopropanol, butanol, benzyl alcohol, ethylene glycol, propylene glycol, butanediol and isomers thereof, glycerol, pentaerythritol, sorbitol, mannitol, diethylene glycol monoethyl ether, dimethyl isosorbide, polyethylene glycol, polypropylene glycol, polyvinyl alcohol, hydroxypropyl methylcellulose and other cellulose derivatives, cyclodextrins and cyclodextrin derivatives; polyethylene glycol ethers having an average molecular weight of about 200 to about 6000, such as tetrahydrofurfuryl alcohol PEG ether (glycofurol) or methoxy PEG; amides and other nitrogen-containing compounds such as 2-pyrrolidone, 2-piperidone, ε-caprolactam, N-alkane alkylpyrrolidone, N-hydroxyalkylpyrrolidone, N-alkylpiperidone, N-alkylcaprolactam, dimethylacetamide and polyvinylpyrrolidone; esters such as ethyl propionate, tributyl citrate, acetyl triethyl citrate, acetyl tributyl citrate, triethyl citrate, ethyl oleate, ethyl caprylate, ethyl butyrate, glyceryl triacetate, propylene glycol monoacetate, propylene glycol diacetate, ε-caprolactone and its isomers, δ-valerolactone and its isomers, β-butyrolactone and its isomers; and other solubilizers known in the art, such as dimethylacetamide, dimethyl isosorbide, N-methylpyrrolidone, glyceryl monocaprylate, diethylene glycol monoethyl ether and water.

[0216] Mixtures of solubilizing agents can also be used. Examples include but are not limited to triacetin, triethyl citrate, ethyl oleate, ethyl caprylate, dimethylacetamide, N-methyl pyrrolidone, N-hydroxyethyl pyrrolidone, polyvinyl pyrrolidone, hydroxypropyl methylcellulose, hydroxypropyl cyclodextrin, ethanol, polyethylene glycol 200-100, polyethylene glycol tetrahydrofurfuryl ethyl ether, diethylene glycol monoethyl ether, propylene glycol and dimethyl isosorbide. In some embodiments, the solubilizing agent includes sorbitol, glycerol, triacetin, ethanol, PEG-400, polyethylene glycol tetrahydrofurfuryl ethyl ether and propylene glycol.

[0217] The content of solubilizing agent can not be particularly limited.The amount of given solubilizing agent can be limited to the acceptable amount of biology, and those skilled in the art can easily determine this amount.In some cases, it can be advantageous to comprise the solubilizing agent that far exceeds the acceptable amount of biology, for example, in order to maximize the concentration of medicine, and before using conventional techniques (such as distillation or evaporation) to provide pharmaceutical composition to the experimenter, remove excessive solubilizing agent.Therefore, if there is, based on the gross weight of medicine and other excipients, the weight ratio of solubilizing agent can be about 10%, 25%, 50%, 100% or up to about 200%.If desired, also can use a small amount of solubilizing agent, for example, about 5%, 2%, 1% or even less.Usually, the amount of solubilizing agent can be about 1 % by weight to about 100 % by weight, more generally about 5 % by weight to about 25 % by weight.

[0218] The pharmaceutical composition may further comprise one or more pharmaceutically acceptable additives and excipients. These additives and excipients include, but are not limited to, anti-adherents, defoaming agents, buffers, polymers, antioxidants, preservatives, chelating agents, viscosity modifiers, osmotic regulators, flavoring agents, colorants, oils, fragrances, opacifiers, suspending agents, adhesives, fillers, plasticizers, lubricants, and mixtures thereof.

[0219] Exemplary preservatives may include antioxidants, chelating agents, antimicrobial preservatives, antifungal preservatives, alcohol preservatives, acid preservatives and other preservatives. Exemplary antioxidants include but are not limited to alpha-tocopherol, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, monothioglycerol, potassium pyrosulfite, propionic acid, propyl gallate, sodium ascorbate, sodium bisulfite, sodium pyrosulfite and sodium sulfite. Exemplary chelating agents include ethylenediaminetetraacetic acid (EDTA), citric acid monohydrate, disodium edetate, dipotassium edetate, edetate, fumaric acid, malic acid, phosphoric acid, sodium edetate, tartaric acid and trisodium edetate. Exemplary antimicrobial preservatives include but are not limited to benzalkonium chloride, benzethonium chloride, benzyl alcohol, bronopol, cetrimide, cetylpyridinium chloride, chlorhexidine, chlorobutanol, chlorocresol, chloroxylenol, cresol, ethanol, glycerol, hexamidine, imidazole urea, phenol, phenoxyethanol, phenylethyl alcohol, phenylmercuric nitrate, propylene glycol and thimerosal. Exemplary antifungal preservatives include but are not limited to butylparaben, methylparaben, ethylparaben, propylparaben, benzoic acid, hydroxybenzoic acid, potassium benzoate, potassium sorbate, sodium benzoate, sodium propionate and sorbic acid. Exemplary alcohol preservatives include but are not limited to ethanol, polyethylene glycol, phenol, phenolic compounds, bisphenol, chlorobutanol, hydroxybenzoate and phenylethyl alcohol. Exemplary acid preservatives include but are not limited to vitamin A, vitamin C, vitamin E, beta-carotene, citric acid, acetic acid, dehydroacetic acid, ascorbic acid, sorbic acid and phytic acid.Other preservatives include but are not limited to tocopherol, tocopheryl acetate, mesylate deferoxime, cetrimonium bromide, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), ethylenediamine, sodium lauryl sulfate (SLS), sodium lauryl ether sulfate (SLES), sodium bisulfite, sodium metabisulfite, potassium sulfite, potassium metabisulfite, Glydant Plus, Phenonip, methyl paraben, Germall 115, Germaben II, Neolone, Kathon and Euxyl.In some embodiments, preservative is an antioxidant.In other embodiments, preservative is a chelating agent.

[0220] Exemplary oils include, but are not limited to, almond oil, apricot kernel oil, avocado oil, babassu oil, bergamot oil, black currant seed oil, borage oil, juniper oil, chamomile oil, rapeseed oil, caraway oil, carnauba wax, castor oil, cinnamon oil, cocoa butter, coconut oil, cod liver oil, coffee oil, corn oil, cottonseed oil, emu oil, eucalyptus oil, evening primrose oil, fish oil, linseed oil, geraniol, gourd oil, grape seed oil, hazelnut oil, hyssop oil, isopropyl myristate, jojoba oil, kukui nut oil, lavender oil Examples of the present invention include, but are not limited to, lavender oil, lemon oil, litsea cubeba oil, macadamia nut oil, mallow oil, mango seed oil, meadowfoam seed oil, mink oil, nutmeg oil, olive oil, orange oil, kalanchoe oil, palm oil, palm kernel oil, peach kernel oil, peanut oil, poppy seed oil, pumpkin seed oil, rapeseed oil, rice bran oil, rosemary oil, safflower oil, sandalwood oil, sasanqua oil, savory oil, sea buckthorn oil, sesame oil, shea butter, silicone oil, soybean oil, sunflower oil, tea tree oil, thistle oil, camellia oil, vetiver oil, walnut oil, and wheat germ oil. Exemplary oils include, but are not limited to, butyl stearate, caprylic triglyceride, capric triglyceride, cyclomethicone, diethyl sebacate, dimethicone 360, isopropyl myristate, mineral oil, octyldodecanol, oleyl alcohol, silicone oils, and combinations thereof.

[0221] In addition, acid or base can be added to the pharmaceutical composition to facilitate processing, enhance stability or for other purposes. Examples of pharmaceutically acceptable bases include amino acids, amino acid esters, ammonium hydroxide, potassium hydroxide, sodium hydroxide, sodium bicarbonate, aluminum hydroxide, calcium carbonate, magnesium hydroxide, magnesium aluminum silicate, synthetic aluminum silicate, synthetic portlandite, magnesium aluminum hydroxide, diisopropylethylamine, ethanolamine, ethylenediamine, triethanolamine, triethylamine, triisopropanolamine, trimethylamine, tris(hydroxymethyl)aminomethane (TRIS) and the like. The salt of pharmaceutically acceptable acid is also suitable, for example the salt of following acid: acetic acid, acrylic acid, adipic acid, alginic acid, alkanesulfonic acid, amino acid, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid, citric acid, fatty acid, formic acid, fumaric acid, gluconic acid, hydroquinonesulfonic acid, isoascorbic acid, lactic acid, maleic acid, oxalic acid, p-bromobenzenesulfonic acid, propionic acid, p-toluenesulfonic acid, salicylic acid, stearic acid, succinic acid, tannic acid, tartaric acid, thioglycolic acid, toluenesulfonic acid, uric acid etc. Also can use the salt of polyacid, for example sodium phosphate, disodium hydrogen phosphate and sodium dihydrogen phosphate.When alkali is salt, cation can be any convenient and pharmaceutically acceptable cation, for example ammonium, alkali metal, alkaline earth metal etc.Example can include but not limited to sodium, potassium, lithium, magnesium, calcium and ammonium.

[0222] Suitable acids are pharmaceutically acceptable organic or inorganic acids. Examples of suitable inorganic acids include hydrochloric acid, hydrobromic acid, hydroiodic acid, sulfuric acid, nitric acid, boric acid, phosphoric acid, etc. Examples of suitable organic acids include acetic acid, acrylic acid, adipic acid, alginic acid, alkanesulfonic acid, amino acids, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid, citric acid, fatty acids, formic acid, fumaric acid, gluconic acid, hydroquinonesulfonic acid, isoascorbic acid, lactic acid, maleic acid, methanesulfonic acid, oxalic acid, p-bromobenzenesulfonic acid, propionic acid, p-toluenesulfonic acid, salicylic acid, stearic acid, succinic acid, tannic acid, tartaric acid, thioglycolic acid, toluenesulfonic acid, uric acid, etc.

[0223] In some embodiments, provided herein are pharmaceutical compositions for parenteral administration (eg, intravenous administration) comprising a p38 MAPK inhibitor disclosed herein and a pharmaceutical excipient suitable for parenteral administration.

[0224] The disclosed pharmaceutical compositions are available in the form of aqueous or oily suspensions or emulsions (including sesame oil, corn oil, cottonseed oil or peanut oil), as well as elixirs, mannitol, glucose or sterile aqueous solutions, and similar pharmaceutical carriers for administration by injection.

[0225] Saline solutions are also commonly used for injection. Ethanol, glycerol, propylene glycol, liquid polyethylene glycols, etc. (and suitable mixtures thereof), cyclodextrin derivatives, and vegetable oils may also be used. For example, appropriate fluidity may be maintained by using a coating (e.g., lecithin) and by using a surfactant to maintain the desired particle size in the case of a dispersion. The effects of microorganisms may be prevented or reduced by various antibacterial and antifungal agents (e.g., parabens, chlorobutanol, phenol, sorbic acid, thimerosal, etc.).

[0226] The preferred mode of administration of the present invention may be or involve intravenous infusion of a solution or dispersion of a p38 MAPK inhibitor, especially starting about 1 to about 3 days before the administration of cancer immunotherapy or before the onset of CRS, so as to achieve a steady-state plasma concentration of the p38 MAPK inhibitor when the cancer immunotherapy is administered or when CRS strikes. Therefore, the present invention particularly includes a pharmaceutical composition, wherein the p38 MAPK inhibitor is added to a powder used to prepare such a solution or dispersion. The powder may be a vacuum-dried or freeze-dried (lyophilized) powder comprising the p38 MAPK inhibitor and, optionally, suitable excipients and / or additives. Suitably, the powder may comprise a sufficient amount of at least one p38 MAP kinase inhibitor such that, when formulated into a solution for infusion, the concentration of the active agent in the solution is suitable for achieving the desired dose per hour at an infusion rate of about 500-3000 mL / 24h.

[0227] Sterile injectable solutions can be prepared by adding the p38 MAPK inhibitor disclosed herein in the required amount to an appropriate solvent and, if appropriate, various other ingredients as described above, followed by filtered sterilization. Typically, dispersions are prepared by adding the sterilized p38 MAPK inhibitor to a sterile vehicle containing a basic dispersion medium and the appropriate other ingredients as described above. In the case of sterile powders for the preparation of sterile injectable solutions, certain preparation methods include vacuum drying and freeze drying techniques, which produce a powder of the p38 MAPK inhibitor plus any additional ingredients from a previously sterile-filtered solution.

[0228] Injectable formulations can be sterilized, for example, by filtration through a bacteria-retaining filter, or by incorporating a sterilizing agent in the form of a sterile solid composition that can be dissolved or dispersed in sterile water or other sterile injectable medium prior to use. The injectable composition can contain from about 0.1% to about 5% by weight of a p38 MAPK inhibitor disclosed herein.

[0229] In some embodiments, provided herein are pharmaceutical compositions for controlled-release administration, comprising a p38 MAPK inhibitor disclosed herein and a pharmaceutical excipient suitable for controlled-release administration.

[0230] The p38 MAPK inhibitors can be administered by controlled release means or by delivery devices known to those of ordinary skill in the art. Such dosage forms can be used to provide slow or controlled release of the p38 MAPK inhibitors, for example, using hydroxypropyl methylcellulose, other polymer matrices, gels, permeable membranes, osmotic systems, multilayer coatings, microparticles, liposomes, microspheres, or combinations thereof to provide the desired release profile in varying proportions. Suitable controlled-release formulations known to those of ordinary skill in the art (including those described herein) can be readily selected for use in combination with the p38 MAPK inhibitors disclosed herein. Thus, the pharmaceutical compositions provided include single unit dosage forms suitable for oral administration, such as, but not limited to, tablets, capsules, gel capsules, and caplets suitable for controlled release.

[0231] The common goal of all controlled-release pharmaceutical products is to improve drug therapy, exceed the effect achieved by its non-controlled counterpart. In some embodiments, the feature of using controlled-release formulations in medical treatment is to cure or control disease, disorder or illness in the shortest time with minimum drug substance. The advantages of controlled-release formulations include extended activity of medicine, reduction in dosing frequency and increase in subject compliance. In addition, controlled-release formulations can be used for affecting the onset time of effect or other features such as blood drug concentration, and therefore can affect the generation of side effect (such as adverse reaction).

[0232] In some embodiments, a controlled-release formulation is designed to initially release a certain amount of a p38 MAPK inhibitor disclosed herein to rapidly produce the desired therapeutic effect, and then gradually and continuously release additional amounts of the p38 MAPK inhibitor to maintain the level of therapeutic or prophylactic effect over a longer period of time. To maintain a constant level of the compound in the body, the p38 MAPK inhibitor should be released from the dosage form at a rate that will replace the amount of drug that is metabolized and excreted from the body. Controlled release of the p38 MAPK inhibitor can be stimulated by various conditions, including but not limited to pH, temperature, enzymes, water, or other physiological conditions or compounds.

[0233] In certain embodiments, the pharmaceutical composition can be administered using intravenous infusion, an implantable osmotic pump, a transdermal patch, or other modes of administration. In one embodiment, a pump can be used. In another embodiment, a polymeric material can be used. In another embodiment, a controlled release system can be placed in an appropriate location on a subject as determined by a healthcare professional, e.g., so that only a fraction of the systemic dose is required.

[0234] In a third aspect of the present invention, a method for preventing or reducing the severity of cancer immunotherapy-associated CRS in a human patient is provided, comprising administering a prophylactically effective amount of a p38 MAPK inhibitor to the patient before the onset of CRS.

[0235] Suitably, the method may comprise administering to the patient a prophylactically effective amount of a p38 MAPK inhibitor comprising the above-mentioned specific active agent as defined in the first aspect of the invention.

[0236] In a fourth aspect of the present invention, a kit is provided, comprising: (i) a pharmaceutical composition as defined in the second aspect of the present invention; and (ii) instructions for use of the pharmaceutical composition for preventing cancer immunotherapy-associated CRS or reducing the severity of its signs or symptoms in human patients; wherein the p38 MAPK inhibitor should be administered before the onset of CRS.

[0237] The preferred mode of administration of the present invention can be intravenous infusion of a solution or dispersion of a p38 MAPK inhibitor, especially starting about 1 to about 3 days before the administration of cancer immunotherapy or before the onset of CRS, so as to achieve a steady-state plasma concentration of the p38 MAPK inhibitor when the cancer immunotherapy is administered or when CRS strikes. Therefore, the present invention particularly includes a kit comprising a pharmaceutical composition (wherein the p38 MAPK inhibitor is added to a powder for preparing such a solution or dispersion) and instructions printed with instructions for using the powder according to the methods disclosed herein. The powder can be a vacuum-dried or freeze-dried (lyophilized) powder comprising a p38 MAPK inhibitor and optionally suitable excipients and / or additives.

[0238] Another preferred mode of administration of the present invention may be repeated oral administration of a p38 MAPK inhibitor, particularly twice daily, particularly starting about 1 to about 3 days before the administration of cancer immunotherapy or before the onset of CRS, thereby achieving a steady-state plasma concentration of the p38 MAPK inhibitor when the cancer immunotherapy is administered or when CRS occurs. Thus, the present invention particularly includes a kit comprising a plurality of oral dosage forms of a p38 MAPK inhibitor for such administration and instructions printed with instructions for using the dosage form according to the methods disclosed herein.

[0239] In addition to the instructions, the kit may also contain additional printed materials, such as discussions of clinical studies, lists of side effects, etc. Such kits may also include information such as scientific literature references, package inserts, clinical trial results and / or summaries of these that indicate or confirm the activity and / or advantages of the pharmaceutical composition and / or describe dosage, administration, side effects, drug interactions, or other information useful to healthcare providers.

[0240] In some embodiments, the kit may be provided with a memory aid, such as numbers next to each dosage form (e.g., a tablet or capsule disclosed herein), which correspond to the days in the dosage schedule when the corresponding dosage form should be taken. Another example of such a memory aid is a calendar printed on a card, such as "Week 1, Monday, Tuesday... etc.... Week 2, Monday, Tuesday..." etc. Other forms of memory aids are also apparent. A "daily dose" can be a single dosage form or multiple dosage forms to be taken on a given day (e.g., a dose specified to be taken twice daily).

[0241] Suitable packaging and additional items for use (e.g., measuring cups for liquid preparations, aluminum foil packaging to reduce air contact, etc.) are known in the art and may be included in the kit. In other embodiments, the kit may also include a device for administering the pharmaceutical composition. Examples of such devices include, but are not limited to, syringes, infusion bags, patches, and inhalers. The kits described herein may be provided, sold, and / or promoted to healthcare providers, including physicians, nurses, pharmacists, formulary managers, and the like. In some embodiments, the kits may also be sold directly to consumers.

[0242] An example of such a test kit is a so-called blister pack. Blister packs are well known in the packaging industry and are widely used for packaging pharmaceutical unit dosage forms (tablets, capsules, etc.). Blister packs typically consist of a relatively hard material covered with a preferably transparent plastic foil. During the packaging process, recesses are formed in the plastic foil. The size and shape of these recesses match the tablets or capsules to be packaged. Next, the tablets or capsules are placed in the recesses, and a relatively hard sheet of material is sealed onto the side of the plastic foil opposite to the direction in which the recesses are formed. As a result, the tablets or capsules are sealed in the recesses between the plastic foil and the sheet. The strength of the sheet allows the tablets or capsules to be removed from the blister pack by manually applying pressure to the recesses, thereby forming an opening on the sheet at the recess. The tablets or capsules can then be removed through the opening.

[0243] The kit may also contain a pharmaceutically acceptable carrier that can be used to administer the pharmaceutical composition. For example, if the pharmaceutical composition is provided as a solid form that must be reconstituted for parenteral administration, the kit may contain a sealed container of a suitable vehicle in which the p38 MAPK inhibitor can be dissolved to form a particle-free sterile solution suitable for parenteral administration.

[0244] In a fifth aspect of the present invention, there is provided a use of a p38 MAP kinase inhibitor in the preparation of a medicament for preventing CRS associated with cancer immunotherapy in a human patient or reducing the severity of its signs or symptoms, wherein the pharmaceutical composition is administered in vivo prior to the onset of CRS. Suitably, the p38 MAP kinase inhibitor may be defined according to the first aspect of the present invention, comprising the above-mentioned specific active agent.

[0245] In a sixth aspect of the present invention, there is provided a use of a pharmaceutical composition comprising a p38 MAP kinase inhibitor for the preparation of a medicament for preventing or reducing the severity of signs or symptoms of CRS associated with cancer immunotherapy in a human patient, wherein the pharmaceutical composition is administered in vivo prior to the onset of CRS. Suitably, the pharmaceutical composition may be defined according to the third aspect of the present invention.

[0246] In a seventh aspect of the present invention, a method is provided for reducing the release of cytokines (particularly IL-6) by monocytes caused by the administration of cancer immunotherapy to a human patient, while maintaining or increasing the anti-cancer efficacy of the cancer immunotherapy, by administering a therapeutically or prophylactically effective amount of a p38 MAPK inhibitor to the patient. It will be understood that in the method of the seventh aspect of the present invention, the reduction in cytokine release by monocytes is carried out in the presence of cancer cells. Suitably, the p38 MAPK inhibitor may be defined according to the first aspect of the present invention, comprising the above-mentioned specific active agents.

[0247] Optionally, the method further comprises reducing the release of cytokines (especially TNFα) by T cells. Additionally or alternatively, the method comprises reducing the release of cytokines (especially IL-6) by endothelial cells. Additionally or alternatively, the method comprises regulating T cell signal 3 and / or 4. Additionally or alternatively, the method comprises maintaining or increasing T cell proliferation.

[0248] The method may suitably include prolonging the anti-cancer efficacy of the T cells. The p38 MAP kinase inhibitor may modulate T cell polarization. The p38 MAP kinase inhibitor may prevent or reduce T cell exhaustion. The p38 MAP kinase inhibitor may reduce one or more of TIM3 and LAG3 in T cells.

[0249] It will be appreciated that features described in relation to one aspect of the invention may be incorporated into other aspects of the invention. BRIEF DESCRIPTION OF THE DRAWINGS

[0250] Embodiments of the invention will now be described, by way of example only, and with reference to the accompanying drawings, in which:

[0251] Figure 1 The structures of CD19CAR and blank control CAR vectors used to transfect T293 cells are shown (see Example 1);

[0252] Figure 2A and Figure 2B Flow cytometric confirmation of blank control CAR T cell transduction and CD19 CAR T cell transduction is shown (see Example 1);

[0253] Figure 3 mCherry fluorescence in stably transfected Raji (cancer) cells is shown (see Example 1);

[0254] Figure 4 The tumor cell clearance rate of CD19 CAR T and blank control CAR T cells is shown as determined by the ratio of cancer cells in culture after 28 hours and 48 hours at a range of CD19 CAR T (or blank control CAR T) to tumor cell ratios (see Example 1);

[0255] Figure 5 The proliferation of CD19 CAR T cells and blank control CAR T cells after incubation with tumor cells for 24 hours, 48 ​​hours, and 96 hours is shown when the ratio of CD19 CAR T cells (or blank control CAR T cells) to tumor cells is 1:1 (see Example 1);

[0256] Figure 6 The effect of p38 inhibitors on CAR T cell proliferation in CAR T: tumor cell co-cultures is shown (see Example 2);

[0257] Figure 7 The effect of p38 inhibition on tumor cell killing by CAR T cells (only at the "high" dose) is shown in a 24-hour co-culture with a 1:1 ratio of CAR T to cancer cells (see Example 2);

[0258] Figure 8A and Figure 8B CAR T cell activation and exhaustion conditions investigated in the experiment described in Example 2 are shown;

[0259] Figure 9 The effect of p38 inhibition on TNFα levels in supernatants of CAR T:tumor cell co-cultures is shown (see Example 2);

[0260] Figure 10 Shown is the effect of p38 inhibition on IL-6 levels in the supernatant of THP-1 (monocyte) cells treated with "sCAR T" for 24 hours (see Example 3);

[0261] Figure 11A and Figure 11B Shown is the effect of p38 inhibition on IL-6 and IL-8 levels in the supernatant of HUVEC (endothelial) cells treated with "sCAR T" for 24 hours (see Example 3);

[0262] Figure 12A -C shows the effect of p38 inhibition on the RNA levels of IL-6, ICAM1 and VCAM1 in HUVEC cells treated with "sCAR T" for 24 hours (see Example 3);

[0263] Figure 13 is a schematic diagram of the co-culture device for the experiment described in Example 4;

[0264] Figure 14A and Figure 14B Shown is the effect of p38 inhibition on IL-6 and IL-8 levels in the supernatant of HUVEC cells treated with "sCAR T-mono" supernatant for 24 hours (see Example 4);

[0265] Figure 15 Shown is the effect of p38 inhibition on ICAM1 RNA levels in HUVEC cells treated with "sCAR T-mono" supernatant for 24 hours (see Example 4);

[0266] Figure 16 is a schematic timeline of the mouse experiment described in Example 5;

[0267] Figure 17A and Figure 17BThe IVIS imaging results of tumor cell fluorescence in the mouse experiment described in Example 5 are shown;

[0268] Figure 18A and Figure 18B Mouse CRS scores and the number of CAR T cells per mL are shown (see Example 5);

[0269] Figure 19 is a schematic timeline of the mouse experiment described in Example 6;

[0270] Figure 20A -C shows the mouse CRS score in the mouse experiment described in Example 6;

[0271] Figure 21 The figure shows the proliferation of tumor cells during the mouse experiment described in Example 6;

[0272] Figure 22-29 It is shown that during the mouse experiment described in Example 6, IFNγ ( Figure 22 ), TNFα( Figure 23 )、IL-10( Figure 24 ), IL-6( Figure 25 ), IL-2( Figure 26 ), IL-4( Figure 27 )、IL-8( Figure 28 ) and MIP-1α( Figure 29 ) level;

[0273] Figure 30A The average number of CD19+ cancer cells per mL on days 9 and 10 in the mouse experiment described in Example 6 is shown; and

[0274] Figures 30B-30D The results of the mouse experiment described in Example 6 on days 9 and 10 ( Figure 30D Average number of hCD45+ cells, hCD3+ cells, and hCD4+ cells per µl (day 9 only). DETAILED DESCRIPTION

[0275] Although the subject matter of the present invention is described and illustrated below with reference to specific embodiments, it will be understood by those skilled in the art that the subject matter is applicable to many different variations not specifically described herein. Some possible variations will now be described by way of example only.

[0276] Example

[0277] The following examples are provided to aid in understanding the subject matter of the present invention and to assist in practicing the subject matter. In particular, these examples are intended to aid in understanding the effects that p38 MAP kinase inhibitors may have on cellular responses to cancer immunotherapy associated with CRS.

[0278] In this embodiment, CRS was studied based on CRS induced by CAR T therapy or anti-CD28 antibodies (the latter being T cell superagonists, thereby providing an excellent model for CRS induced by T cell activity); for these models, there is relatively easy access to research materials. The common mechanism means that it is reasonable to expect that the effects of p38 MAP kinase inhibitors observed in the context of CRS induced by CAR T cell therapy or CRS induced by T cell responses to anti-CD28 antibodies will extend to other cancer immunotherapies; in particular, other cancer immunotherapies that include adoptive T cell use or otherwise combine with T cells as described herein. Such cancer immunotherapies can trigger signaling between T cells, monocytes, and endothelial cells, which is observed in CRS induced by CAR T cells or CRS induced by anti-CD28 antibodies and can be modulated by the p38 MAPK inhibitors of the present invention. Additionally or alternatively, it is reasonable to expect that the effects of p38 MAPK inhibitors on T cell signal 3 and / or signal 4, and hence on T cell survival, phenotype, and memory (beneficial in the context of CAR T or anti-CD28 antibodies), will benefit other cancer immunotherapies involving T cells.

[0279] In general, where applicable in the following examples, statistical analyses were performed using GraphPad Prism version 10.1.2. Figure 4 and Figure 5 The data in the table were analyzed using a two-way ANOVA. For all other figures, a one-way ANOVA was fitted to the data and the Bonferroni test was used to adjust for multiple testing for the comparisons of interest, using a 5% significance interval; p values ​​less than 0.05 were considered significant and are indicated in the relevant figures as follows: * = p < 0.05, ** = p < 0.01, *** = p < 0.001, **** = p < 0.0001. Where not specified by a figure, the significance value is compared with the sCAR-T or CAR T-only control.

[0280] Example 1 - Optimization of CAR T cell:cancer cell co-culture ratio

[0281] The purpose of Example 1 was to prepare a co-culture of CAR T cells and cancer cells with an optimized CAR T cell to cancer cell ratio and co-culture duration for use in subsequent examples. In summary, an optimal ratio of 1:1 and a duration of 24 hours for co-culture were selected based on the CAR T cell expansion and cancer cell death relative to the control.

[0282] T cells are engineered to express a CAR specific for the B lymphocyte antigen CD19 ("CD19"; also referred to in the art as: CD19 molecule; B lymphocyte surface antigen B4; T cell surface antigen Leu-12; or CVID3). Transduction is confirmed by flow cytometry to demonstrate cell surface CAR expression (in this example, flow cytometry is suitably performed using an Agilent NovoCyte 3 flow cytometer, available from Agilent, 5301 Stevens Creek Boulevard, Santa Clara, California, USA).

[0283] The CAR sequence encodes a fusion protein consisting of a leader sequence, a CD19-specific single-chain variable fragment, a CD8α hinge, a CD8α spacer and a transmembrane domain, a 4-1BB internal domain, a CD3ζ internal domain and a T2A tag. Enhanced green fluorescent protein (EGFP) sequence is added to allow CAR expression to be detected by fluorescence. The resulting cDNA is subcloned into a replication-defective lentivirus or retroviral vector. In order to produce viral particles, a triple transfection of vector, envelope and gag-pol genes is performed in 293T cells (an immortalized cell line derived from human embryonic kidney cells carrying the SV40 replication origin, available from the American Type Culture Collection). Therefore, 293T cells are cultured and transfected. Viral particles encoding CAR are harvested from their supernatant and concentrated. Viral titer is measured; and activated T cells derived from human peripheral blood mononuclear cells (PBMCs) harvested from healthy donor peripheral blood are transduced using viral transduction. T cells were expanded from PBMCs in medium containing IL-7 and IL-15 and treated with CD3- and CD28-coupled magnetic beads. T cells were then incubated in the presence of the viral vector, and CAR expression was confirmed using flow cytometry.

[0284] "Blank control" CART cells with irrelevant extracellular domains (ie, no antigen specificity for any cell in culture) were used as negative controls.

[0285] Schematic diagram of CD19 and blank control CAR vectors. Figure 1 Shown in.

[0286] The cells were washed with phosphate buffered saline (pH 7.2) to confirm transduction. To confirm transduction, the co-expressed reporter gene, enhanced green fluorescent protein (EGFP), was detected by fluorescence emission in flow cytometry; and the expression of CD19-specific CAR was confirmed by staining the cells with anti-CD19 antibodies.

[0287] Figure 2A and Figure 2B Flow cytometry and staining results of the cells are shown, respectively, confirming successful transduction.

[0288] (This process is repeated according to the purpose of subsequent experiments. With each new transduction, gene transfer is confirmed using the described method and recorded in the laboratory notebook so that the relevant batch analysis can be associated with each subsequent experiment. In this context, a batch refers to CAR T cells derived from the same donor and transduced as a single sample, which is then subdivided into further experiments as needed.)

[0289] Raji immortalized human B cell line CD19-expressing cancer cells were obtained (available from the American Type Culture Collection) and stably transfected with the mCherry reporter protein to facilitate identification of cancer cells in co-culture by detecting mCherry protein fluorescence by flow cytometry.

[0290] Figure 3 Shown is the fluorescence of the mCherry tag in stably transfected Raji cells.

[0291] Co-culture of CAR T cells (or blank control CAR T cells for control) with cancer cells expressing mCherry+CD19 was then established in liquid culture medium with a pH of 7.2 supplemented with nutrients and growth factors including L-arginine, L-glutamine, and fetal bovine serum.

[0292] As shown in Table 1 below, CAR T cells and cancer cells were incubated for 24 to 96 hours at 37°C in a humidified atmosphere with 5% CO2, and then cancer cell clearance was measured by flow cytometry. In this case, cancer cells can be detected as mCherry+ events and CAR T cells can be detected as EGFR+ events.

[0293] CO2 levels were managed using a controlled pump system, and the air was filtered through a high-efficiency particulate adsorption (HEPA) filtration system. CAR T cell (also called effector cell) to tumor cell ratios of 1:2, 1:1, 2:1, and 5:1 were studied.

[0294] Table 1 - CAR T cell:cancer cell ratio

[0295]

[0296] Incubation time was 24-96 hours at 37°C, 5% CO2 and physiological pH.

[0297] CAR T cell proliferation through CAR T cell Cell Trace TM Violet staining is performed before adding T cells to the co-culture with tumor cells. After co-culture, staining can be visualized by flow cytometry.

[0298] therefore, Figure 4Shown are tumor cell killing by CD19 CAR T (and vehicle control CAR T) cells over a range of effector cell to tumor cell ratios, as determined by the proportion of cancer cells in culture after 24 and 48 hours.

[0299] The ratio of CAR T cells to tumor cells was 1:1 and was used for the study at different time points. Figure 5 The proliferation of CD19 CAR T cells and blank control CAR T cells after incubation with tumor cells at a ratio of 1:1 for 24, 48, and 96 hours (Figure 2) Figure 5 As shown, the decrease in fluorescence correlates with the number of replication rounds each cell or progeny cell undergoes during the co-culture.

[0300] By balancing two factors (according to Figure 4 and Figure 5 ), the ratio of CAR T cells to cancer cells was selected to be 1:1, and co-cultured for 24 hours for subsequent experiments:

[0301] 1. First, through Cell Trace TM Violet staining was used to determine the optimal expansion ratio of T cells.

[0302] 2. Secondly, compared with the blank control CAR T and tumor cell co-culture control, a significantly higher frequency of tumor cell death occurred in the CD19 CAR T cell and tumor co-culture.

[0303] CAR T cells were co-cultured with cancer cells at a 1:1 ratio for 24 h, which is expected to mimic successful CAR T therapy (or other cancer immunotherapies) in the clinical setting and thus provide an optimal background for evaluating CRS induction.

[0304] Supernatant isolated from a 1:1 co-culture of preferred CAR T cells and tumor cells (sCAR), co-cultured for 24 hours, was used for subsequent analysis and experiments.

[0305] The supernatant (referred to as sCAR or sCAR T) was harvested by separating the culture medium into a new container and pelleting the cells and debris by applying a centripetal force of 400 G. The cell- and debris-free supernatant was collected using a micropipette (volume 0.01-2 ml) or a Pasteur pipette (volume greater than 2 ml).

[0306] All experiments using sCAR used supernatant from the same 1:1 ratio of blank control CAR T cells to tumor cells as a negative control, also cultured for 24 hours (referred to as smCAR or smCAR T).

[0307] In Example 3 below, sCAR (or smCAR) was added to an in vitro culture of monocytes of the human monocytic cell line THP-1 using a micropipette, which is available from the American Type Culture Collection. The culture was incubated in a closed incubator at 37°C, 5% CO2 and a suitably humidified atmosphere for about 24 hours, after which cytokine release was observed. The activation of p38 MAPK and the release of cytokines were confirmed by assessing the presence of IL-6 in THP-1 cells using an enzyme-linked immunosorbent assay (ELISA; kits for ELISA are available from Thermo Fisher Scientific, Kingfisher Dr, Swindon, UK, SN3 5BZ).

[0308] In a similar manner and also shown in Example 3 below, sCAR (or smCAR) is added to endothelial cells (HUVEC), which can be obtained from the American Type Culture Collection, and a protocol equivalent to that for treating THP-1 cells is used (but with individually optimized conditions, such as the concentration of sCAR used), after which IL-6 release and IL-8 release are observed. Proinflammatory cytokines IL-6 and IL-8 are measured using enzyme-linked immunosorbent assay (ELISA), and IL-6, ICAM1, and VCAM1 are measured by quantitative PCR (QPCR; kits for QPCR are appropriately available from Thermo Fisher Scientific, Kingfisher Dr, Swindon, UK, zip code SN3 5BZ).

[0309] Example 2 - Addition of p38 MAP kinase inhibitors to CAR T cell / cancer cell co-cultures

[0310] Example 2 studies the effects of several p38 MAPK inhibitors (i.e., UR-13870, Ralimetinib, and Acumapimod) on CAR T cells in co-cultures of cancer cells and CAR T cells; in particular, their effects on features that contribute to the efficacy of CAR T cells against cancer cells and on features that contribute to the onset of CRS, such as the secretion of cytokines. As shown in Table 2, several concentrations of p38 MAPK inhibitors were tested. Each of UR-13870, Ralimetinib, and Acumapimod is highly selective for p38, ensuring no (or minimal) off-target effects.

[0311] Table 2 - p38 MAPK inhibitors

[0312]

[0313] UR-13870, Ralimetinib, or Acumapimod were added to CD19+ cancer cell cultures (using a micropipette to transfer the correct volume to achieve the desired final concentration in Table 2).

[0314] After 5-10 minutes, CAR T cells were added to the same culture. Briefly, the CAR T cell concentration per mL was determined and used to aliquot the required number of CAR T cells into the culture to achieve the desired 1:1 CAR T cell to cancer cell ratio.

[0315] The co-culture containing CAR T cells and tumor cells was gently vortexed to ensure that the cells were evenly dispersed throughout the vessel. The resulting co-culture was incubated in a closed incubator at 37°C, 5% CO2, and an appropriately humidified atmosphere for 24 to 96 hours.

[0316] Cell Trace observation by flow cytometry TM Violet staining confirmed the proliferation of CAR T cells. Figure 6 shown. Figure 6 CD19 CAR T cells (and control CAR T cells) are shown to induce tumor cell death across a range of CAR T cell to tumor cell ratios, as determined by the proportion of cancer cells remaining in the culture after 28 and 48 hours. Advantageously, UR-13870, Ralimetinib, and Acumapimod all maintained CAR T cell proliferation. These results suggest that p38 MAP kinase inhibitors can modulate the post-activation events involved, particularly in signal 4; impacting the phenotype, persistence, and function of activated T cells.

[0317] Tumor cell death was observed by flow cytometry to measure the relative CAR T cell:tumor cell numbers after 24 hours of co-culture. Figure 7 Therefore, Figure 7 The effect of p38 inhibition (high dose only) on tumor cell killing by CAR T cells in a 24-hour co-culture at a 1:1 ratio of CAR T cells to cancer cells is shown. Advantageously, UR-13870, Ralimetinib, and Acumapimod sustained CAR T cell-induced cancer cell death, as determined by the percentage of residual tumor cells in the co-culture.

[0318] like Figure 8A and Figure 8BAs shown, T cell markers were observed by flow cytometry. The T cell surface markers T cell immunoglobulin and mucin domain-containing protein 3 (TIM3 / CD366) and lymphocyte activation gene 3 (LAG3 / CD223) are both associated with T cell exhaustion and disease progression during immunotherapy. Advantageously, UR-13870, Ralimetinib, and Acumapimod all reduced the number of TIM3+CAR T cells and LAG3+CAR T cells. The reduction in TIM3 and LAG3 suggests that UR-13870, Ralimetinib, and Acumapimod each regulate T cell polarization by preventing the induction of an exhausted T cell phenotype (signal 2). For LAG3+, the results for Ralimetinib at a concentration of 5 µM appear to be affected by experimental failure, so these results can be discarded.

[0319] Cytokine release by T cells was also quantified by TNFα enzyme-based immunosorbent assay of co-culture supernatants, as Figure 9 Ralimetinib and Acumapimod reduced TNF-α secretion after treatment. Data for UR-13870 were discarded due to experimental procedural failure.

[0320] Example 3 - Addition of p38 MAP kinase inhibitors to (i) THP-1 monocytes and (ii) HUVEC endothelial cells and sCAR T

[0321] This study investigated the effects of UR-13870, Acumapimod, and Ralimetinib on (i) monocytes and (ii) endothelial cells, which were stimulated with supernatant obtained from a co-culture of cancer cells and CAR T cells (sCAR; or smCAR in the control case), thereby mimicking the in vivo environment of (i) monocytes and (ii) endothelial cells in patients undergoing CAR T therapy (see Example 1 for details).

[0322] (i) Monocytes

[0323] At 37°C, 5% CO2 and a properly humidified environment, sCAR (or smCAR) produced as described in Example 1 above was added to a monoculture of THP-1 monocytes at the concentrations shown in Table 2, and UR-13870, Ralimetinib or Acumapimod were added at the same time and cultured for 24 hours.

[0324] The IL-6 levels in the supernatants of THP-1 monocytes monocultured with sCAR (or smCAR) were determined by ELISA. Figure 10Figure 5 shows that UR-13870, Ralimetinib, and Acumapimod each significantly reduced IL-6 secretion from THP-1 monocytes.

[0325] (ii) Endothelial cells

[0326] At 37°C, 5% CO2 and a properly humidified environment, sCAR (or smCAR) produced as described in Example 1 above was added to a monoculture of HUVEC endothelial cells at the concentrations shown in Table 2, and UR-13870, Ralimetinib or Acumapimod were added at the same time and cultured for 24 hours.

[0327] The levels of IL-6 and IL-8 in the supernatants of HUVEC endothelial cells monocultured with sCAR (or smCAR) were determined by ELISA. Figure 11A As shown in Figure 2, UR-13870, Ralimetinib, and Acumapimod each significantly reduced IL-6 secretion from HUVEC cells, and IL-8 was also reduced. Figure 11B shown.

[0328] Endothelial cell activation was also assessed by QPCR analysis of VCAM1, ICAM1, and IL-6. Figure 12A As shown in Figure 3C, UR-13870, Ralimetinib, and Acumapimod each significantly reduced IL-6 and ICAM1 mRNA levels. Although not significantly, they also reduced VCAM1 mRNA levels.

[0329] Example 4 - Co-culture of monocytes with CAR T cells and cancer cells in the presence of a p38 MAP kinase inhibitor Effects of the supernatant obtained from the culture medium on endothelial cells

[0330] This study investigated the effects of UR-13870, Acumapimod, and Ralimetinib on endothelial cells stimulated with supernatant from an in vitro co-culture of cancer cells, CAR T cells, and monocytes to further mimic the in vivo endothelial cell environment in patients receiving CAR T therapy, as well as the effects of p38 MAPK inhibitors.

[0331] With reference to the accompanying drawings Figure 13 Co-cultures (100) were established using standard cell culture Transwell dishes, comprising a first compartment (101) containing CAR T cells and cancer cells (at a 1:1 ratio), separated from a second compartment (102) containing monocytes by a 0.4 μm pore size semipermeable membrane (103) made of tissue culture treated polyethylene terephthalate. This membrane is permeable to soluble factors but does not allow cells to cross from one compartment to the other.

[0332] Each of UR-13870, Acumapimod, and Ralimetinib was administered to the co-cultures following a similar procedure as described above in Example 2 (at the concentrations shown in Table 2).

[0333] The co-culture was incubated for 24 hours at 37°C, 5% CO2, and an appropriately humidified atmosphere. Upon completion, the Transwell insert was removed and the supernatant was separated. The container was centrifuged at 400G and the supernatant was gently pipetted into a new container without disturbing the cell pellet at the bottom of the previous container to remove cells and debris.

[0334] The resulting supernatant from the co-culture (referred to as sCAR T-mono) was then added to the HUVEC endothelial cell monoculture using a micropipette 30 minutes after the addition of the p38 MAPK inhibitor in the presence of UR-13870, Acumapimod, or Ralimetinib at the corresponding concentrations shown in Table 2. Prior to the addition of the p38 inhibitor and sCAR T-mono, the endothelial cells were incubated overnight in an appropriately humidified atmosphere at 37°C and 5% CO2 to allow the cells to fully attach to the tissue culture plate.

[0335] The levels of IL-6 and IL-8 in the supernatants were determined by ELISA after 24 h of treatment with sCAR T-mono and p38 MAPK inhibitor. Figure 14A and Figure 14B UR-13870, Acumapimod, and Ralimetinib reduced IL-6 levels in the supernatant, and IL-8 levels in the supernatant showed a (although not significant) downward trend.

[0336] Endothelial cell activation was also assessed by QPCR analysis of ICAM1. Figure 15 In response to treatment with UR-13870, Acumapimod, and Ralimetinib, decreased ICAM1 expression demonstrated reduced endothelial cell activation.

[0337] Example 5 - In vivo (mouse) model of CRS induction using CAR T

[0338] Example 5 investigated the effect of p38 MAPK inhibition on CAR T-induced CRS in tumor-bearing mice, as well as the effect of p38 MAPK inhibition on CAR T cells themselves.

[0339] The timeline of the model is outlined in Figure 16 Shown in ; starting from day -5 of the study and ending on day 10 of the study.

[0340] The timing of this model was designed to evaluate the effect of administering the p38 MAPK inhibitor UR-13870 (which is highly selective for p38 and therefore has no or minimal off-target effects) before the onset of CRS in the PBMC-humanized NSG-MHCI / II double knockout mice studied.

[0341] Therefore, 30 female NSG-(KbDb)null (IA)null mice aged 6 to 8 weeks were irradiated with 100 cGy on day -5 of the study. Four hours later on the same day (day -5 of the study), each mouse was injected with 0.25 × 10 6 Cancer cells expressing Raji-LucCD19 (a wild-type Raji cell line that stably and highly expresses luciferase, allowing for fluorescence-based detection of cancer burden).

[0342] On day -2 of the study, clinical observation (including weight monitoring) was initiated for all 30 mice, and all 30 mice were imaged using in vivo fluorescence imaging (IVIS). For IVIS, 150 mg / kg of D-luciferin was injected intraperitoneally into the mice. Ten minutes after the injection of D-luciferin, the dorsal and ventral sides of the mice were imaged (automatic exposure) using the IVIS Lumina system (available from PerkinElmer, Chalfont Road, Hill Green, Buckinghamshire, UK, postal code HP9 2FX). A region of interest (ROI) was drawn for each mouse to capture its entire body, and the total flux (p / s) was reported. Throughout the study, all 30 mice were imaged with IVIS every two weeks to monitor cancer cell burden. Daily clinical observations, including CRS observations, were continued throughout the study, and CRS scores were scored as follows:

[0343] 0 = Normal activity

[0344] 1 = Normal activity, arched back + / - piloerection

[0345] 2 = Arched back and decreased activity, but will still move around the cage without continued stimulation

[0346] 3 = Does not move unless stimulated; moves when touched but stops quickly when hand is removed

[0347] 4 = Near death (no response to touch)

[0348] On day 0 of the study, 25 mice were injected intraperitoneally with 5 × 10 6 Anti-CD19 CAR T cells in phosphate-buffered saline.

[0349] As a control, a group of 5 mice ("Group 1") was not administered CAR T cells. From day -1 of the study to day 9 of the study, Group 1 was treated twice daily with 5 mL / kg of a 0.5% (w:v) HPMC, 0.1% (w:v) Tween 80 solution in sWFI (vehicle / control).

[0350] The 25 mice administered CAR T cells were divided into groups of 5 mice each. Administration of control drug (Humira), vehicle, or UR-13870 was performed according to the following schedule:

[0351] Group 2: 5 mL / kg of 0.5% (w:v) HPMC, 0.1% (w:v) Tween 80 in sWFI (hereinafter referred to as "vehicle") solution twice daily from Day -1 to Day 9 of the study;

[0352] Group 3 - UR-13870 (formulated with vehicle) at 2 mg / kg twice daily (BID) starting on Study Day -1 and ending on Study Day 9;

[0353] Group 4 - UR-13870 (formulated with vehicle) at 10 mg / kg twice daily (BID) starting on Study Day -1 and ending on Study Day 9;

[0354] Group 5 - UR-13870 (formulated with vehicle) at 25 mg / kg twice daily (BID) starting on Study Day -1 and ending on Study Day 9;

[0355] Group 6 - Humira 5 mg / kg (formulated in PBS pH 7.2) administered once on day 1 of the study (further positive control).

[0356] UR-13870 or vehicle was administered by subcutaneous injection. The subcutaneous injection site was rotated between each dose (alternating between the right flank, left flank, right inguinal area, and left inguinal area). For UR-13870 and vehicle, the morning and afternoon (twice daily) doses were separated by at least 6 hours. Humira was administered by intraperitoneal injection approximately 24 hours after CAR T administration.

[0357] On day -1 of the study, 10 × 10 6 Human peripheral blood mononuclear cells (PBMCs) were used to humanize mice from groups 1-6.

[0358] On days 2, 6, and 10 of the study, blood was collected from each of the 30 mice in Groups 1-6 (50-300 µl blood samples per mouse) for flow cytometric analysis, including analysis of the number of CAR T cells per µl. Of note, for the twice-daily dosing groups, blood was collected between the morning and afternoon dosing.

[0359] On day 10 of the study, all mice in Groups 1-6 were euthanized by CO2 asphyxiation.

[0360] CAR T cell therapy remained effective in the presence of UR-13870, as shown by tumor burden on days 7 and 9 (measured by IVIS). Figure 17A and Figure 17B (The same is true for Humira).

[0361] See also Figure 18A In the presence of UR-13870 (as well as in the presence of the positive control Humira), CAR T cells successfully expanded and CAR T cell expansion was successfully maintained (as measured by flow cytometry). In fact, at day 10, high-dose UR-13870 significantly increased the number of circulating CAR T cells, see Figure 18A .

[0362] See also Figure 18B During the experiment, CRS scores were mild (even in Group 2, the CRS score was 1), so for this model, the anti-inflammatory effects of UR-13870 and Humira could not be quantified by CRS scores or effects on peripheral blood cytokine levels.

[0363] Example 6 - In vivo (mouse) model of CRS induction using anti-CD28 antibodies

[0364] Example 6 investigated the effects of p38 MAPK inhibition on CRS induced by activation of naive T cells in cancerous mice by anti-CD28 antibodies (T cell superagonist), as well as on the T cells themselves.

[0365] The timeline of the model is outlined as follows Figure 19 As shown; starting from day 0 of the study and ending on day 10 of the study. This experiment evaluated the effect of anti-CD28 toxicity in PBMC humanized NSG-MHCI / II double knockout mice when the p38 MAPK inhibitor UR-13870 (which has high selectivity for p38 and therefore has no or minimal off-target effects) was administered before anti-CD28 antibody activation of natural T cells. Therefore, it mimics the effect of the present invention of administering a p38 MAP kinase inhibitor before the onset of CRS.

[0366] Anti-CD28 antibodies act as T cell superagonists (i.e., strongly activate T cells), leading to T cell-mediated tumor cell death, followed by rapid release of cytokines and chain reactions on monocytes and endothelial cells; thus mimicking CRS induced by various types of cancer immunotherapies involving T cells.

[0367] Therefore, on day 0 of the study, 30 female NSG-(KbDb)null (IA)null mice aged 6 to 8 weeks were irradiated with 100 cGy. Approximately 4 hours later on the same day (day 0 of the study), 15×10 6 All mice were humanized with human peripheral blood mononuclear cells (PBMCs).

[0368] On day 5 of the study, all mice were intravenously injected with 0.25 × 10 6 Cancer cells expressing Raji-LucCD19 (a Raji wild-type cell line that is stable and highly expresses luciferase, and cancer burden can be detected by fluorescence). Approximately 4 hours later, the mice were imaged using in vivo fluorescence imaging (IVIS). For IVIS, 150 mg / kg D-luciferin was injected intraperitoneally into the mice. Ten minutes after the D-luciferin injection, the dorsal and ventral sides of the mice were imaged (automatic exposure) using the IVIS Lumina system (available from PerkinElmer, Chalfont Road, Hill Green, Buckinghamshire, HP9 2FX, UK). A region of interest (ROI) was drawn for each mouse to capture its entire body, and the total flux (p / s) was reported. Starting on day 5 of the study, tumor burden was monitored twice a week by IVIS, and daily clinical observations, including CRS observations, were continued throughout the study. The CRS score was as follows:

[0369] 0 = Normal activity

[0370] 1 = Normal activity, arched back + / - piloerection

[0371] 2 = Arched back and decreased activity, but will still move around the cage without continued stimulation

[0372] 3 = Does not move unless stimulated; moves when touched but stops quickly when hand is removed

[0373] 4 = Near death (no response to touch)

[0374] On day 6 of the study, 25 of the 30 mice received 1 mg / kg anti-CD28 treatment.

[0375] As a control, the remaining group of 5 mice ("Group 1") was not administered anti-CD28. From day 4 of the study until day 10 of the study, Group 1 was treated twice daily with 5 mL / kg of a 0.5% (w:v) HPMC, 0.1% (w:v) Tween 80 solution in sWFI (vehicle / control).

[0376] The 25 mice administered anti-CD28 were divided into groups of 5 mice each. Administration of control drug (Humira), vehicle, or UR-13870 was performed according to the following schedule:

[0377] Group 2 - Vehicle only, twice daily, starting on study day 4 and ending on study day 10;

[0378] Group 3 - UR-13870 (formulated with vehicle) at 2 mg / kg twice daily (BID) starting on study day 4 and ending on study day 10;

[0379] Group 4 - UR-13870 (formulated with vehicle) at 10 mg / kg twice daily (BID) starting on study day 4 and ending on study day 10;

[0380] Group 5 - UR-13870 (formulated with vehicle) at 25 mg / kg twice daily (BID) starting on study day 4 and ending on study day 10; and

[0381] Group 6 - Humira 5 mg / kg (formulated in PBS pH 7.2) once daily starting on study day 4 and ending on study day 10 (further positive control).

[0382] UR-13870 or vehicle was administered by subcutaneous injection. The subcutaneous injection site was rotated between each dose (right flank, left flank, right inguinal area, left inguinal area). For UR-13870 and vehicle, the morning and afternoon (twice daily) doses were separated by at least 6 hours. Humira was administered by intraperitoneal injection.

[0383] On days 6, 9, and 10 of the study, blood was collected from each of the 30 mice in groups 1-6 (50-200 μl blood samples per mouse per time) for flow cytometry analysis, including analysis of the number of CD19+ cancer cells per ml; and cytokine measurements. It should be noted that for the twice-daily dosing groups, blood was collected between the morning and afternoon dosing.

[0384] On day 10 of the study, all mice in Groups 1-6 were euthanized by CO2 asphyxiation.

[0385] UR-13870 significantly reduced CRS scores (as did Humira, confirming the positive control). Figure 20A The scores on the 9th and 10th days are shown in Figure 20B and Figure 20C Shown in.

[0386] All experimental groups showed consistent tumor burden as measured on days 5 to 7 (mid-point dosing for UR-13870 and Humira), indicating that UR-13870 does not increase tumor cell proliferation and sustain T cell-mediated cancer cell death (nor does Humira). Figure 21 This suggests that p38 MAP kinase inhibitors can effectively prevent CRS in the presence of cancer cells without excessively impairing the anti-cancer efficacy of T cells.

[0387] Proinflammatory cytokines were measured from serum samples using Luminex cytokine assays (Millipore Sigma Cat# HCYTA-60k, human IFNγ, TNF, IL-10, IL-6, IL-4, IL-2, MIP-1α, and IL-8) according to the manufacturer's guidelines and analyzed on a BioRad BioPlex 200 Luminex microplate reader (kits available from Sigma Aldrich / Merck Life Science UK Limited of The Old Brickyard, Gillingham New Road, SP8 4XT, UK).

[0388] T cell phenotype was observed from blood samples using flow cytometry to measure cytotoxicity and polarization (by observing hCD45, hCD3, and hCD4). All cytokines tested peaked on day 9, except for IL-8, which continued to rise on day 10.

[0389] UR-13870 (and Humira) mitigates the effects of various inflammatory cytokines including IFNγ ( Figure 22 ), TNFα( Figure 23 )、IL-10( Figure 24 ), IL-6( Figure 25 ), IL-2( Figure 26 ), IL-4( Figure 27 )、IL-8( Figure 28 ) and MIP-1α( Figure 29 This includes all cytokines released by T cells, monocytes, and endothelial cells.

[0390] The observation that neither UR-13870 nor Humira increased tumor cell proliferation was supported by the CD19+ cancer cell counts per ml. Furthermore, there was a trend toward a decrease in the mean number of CD19+ cancer cells per ml after treatment with UR-13870 on days 9 and 10 (particularly on day 10; a similar trend was observed with Humira only on day 10) compared to CD28 stimulation alone. Figure 30A ).

[0391] UR-13870 or Humira had no significant effect on hCD45+ cells / µl, hCD45+hCD3+ cells / µl, or hCD45+CD3+hCD4+ cells / µl ( Figure 30B -D; data were serially gated in this order). This suggests that p38 MAP kinase inhibition may increase the anti-cancer efficacy of T cells.

[0392] One animal in Group 2 was euthanized on day 8, and one animal each in Groups 2, 3, and 6 was euthanized on day 9 due to acute effects of the CD28 antibody and tumor burden.

[0393] As shown in Examples 2 to 6, various effects on T cells in the presence of cancer cells (including in vivo administration of a p38 MAP kinase inhibitor starting before administration of an anti-CD28 antibody in mice, mimicking administration prior to the onset of CRS in humans) can be summarized in the following non-limiting Table 3:

[0394] Table 3

[0395]

[0396] Meanwhile, the beneficial effects on monocytes and endothelial cells (which may help alleviate or prevent CRS) can be summarized in the following non-limiting Table 4:

[0397] Table 4

[0398]

[0399] Example 7 - Administration to Patients

[0400] About 4 days to about 2 hours before cancer immunotherapy (e.g., adoptive transfer of CAR T cells) is administered to a patient in need thereof, the patient is started on an oral dosing regimen of about 5 mg twice daily to about 1000 mg twice daily of a p38 MAPK inhibitor, such as UR-13870 (a compound of Formula II); for example, about 70 mg or about 150 mg of UR-13870 (a compound of Formula II) is administered twice daily, depending on the age, sex, weight, condition, general health, and past medical history of the patient being treated.

[0401] For up to about 15 days after administration of a cancer immunotherapy (administered as a single dose, such as adoptive transfer of CAR T cells), the patient continues a twice-daily oral dosing regimen of a p38 MAPK inhibitor (e.g., UR-13870). For example, an oral dose containing about 70 mg or about 150 mg of UR-13870 is administered twice daily.

[0402] Healthcare providers monitored patients for fever, hypotension, and hypoxia throughout the course of the study. Supportive care, including analgesics and / or antipyretics, was provided as needed. CRS grading during monitoring was consistent with the American Society for Transplantation and Cellular Therapy consensus guidelines (2019) as described in Table 5.

[0403] Table 5

[0404]

[0405] †Not attributed to any other cause.

[0406] *CRS grade is determined by the more severe event.

[0407] By observing the alleviation or prevention of one or more symptoms and signs listed in Table 5, it is possible to determine that CAR T cell therapy is associated with the prevention of CRS in the patient or its signs or symptoms are alleviated. Reduction or elimination of fever can be observed. A delay in the onset of fever (e.g., a delay of 1, 2, 3, 4, or 5 days) can be observed. For example, it can be observed that the rectal, ear, or temporal artery temperature is maintained at less than about 38°C within 1 week, 2 weeks, 3 weeks, or longer after administration of CAR T cell therapy. Hypotension, hypoxia, and / or organ dysfunction can be avoided or at least alleviated. Death can be avoided. The time period for observing the above-mentioned ideal effects can last for 1 week, 2 weeks, or more than 3 weeks. It should be understood that although patient discomfort caused by CRS can be alleviated or avoided, there is no guarantee that patient discomfort caused by other causes (e.g., potential cancer) can be alleviated or avoided.

[0408] In the above description, if reference is made to equivalent features or limitations that are known, obvious or foreseeable to those skilled in the art based on the present invention, then these equivalents are incorporated herein as if specifically set forth. The scope of the subject matter of the present invention should be determined primarily with reference to the claims. The scope of protection claimed in this application also covers any such equivalents. It will also be understood by those skilled in the art that features or limitations of the disclosed subject matter described as preferred, suitable, advantageous, convenient, etc. may be optional and may not limit the scope of the independent claims or the protection claimed, unless expressly stated otherwise. Furthermore, it will be understood that these optional features or limitations, while beneficial in certain embodiments of the disclosed subject matter, may be undesirable and, therefore, may be absent or omitted in other embodiments.

Claims

1. A p38 MAP kinase inhibitor for use in preventing cancer immunotherapy-associated cytokine release syndrome ("CRS") or reducing the severity of its signs or symptoms in human patients, wherein: The p38 MAPK inhibitor was administered before the onset of CRS.

2. The p38 MAP kinase inhibitor for use according to claim 1, wherein: The p38 MAP kinase inhibitor prevents CRS or reduces the severity of signs or symptoms of CRS while maintaining the anti-cancer cell efficacy of the cancer immunotherapy.

3. The p38 MAP kinase inhibitor for use according to claim 2, wherein: The maintenance of the anti-cancer cell efficacy of the cancer immunotherapy is or includes maintaining the anti-cancer cell efficacy of T cells in the presence of cancer cells.

4. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor increases the anti-cancer cell efficacy of the cancer immunotherapy.

5. The p38 MAP kinase inhibitor for use according to claim 4, wherein: Increasing the anti-cancer cell efficacy of cancer immunotherapy is or includes increasing the anti-cancer cell efficacy of T cells.

6. The p38 MAP kinase inhibitor for use according to claim 4 or 5, wherein: The p38 MAP kinase inhibitor increases the anti-cancer cell efficacy of the cancer immunotherapy in the presence of cancer cells.

7. The p38 MAP kinase inhibitor for use according to claim 6, wherein: Increasing the anti-cancer cell efficacy of the cancer immunotherapy in the presence of cancer cells is or includes increasing the anti-cancer cell efficacy of T cells in the presence of cancer cells.

8. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor prolongs the anti-cancer efficacy of T cells.

9. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor modulates T cell polarization; and / or prevents or reduces T cell exhaustion.

10. The p38 MAP kinase inhibitor for use according to claim 8 or 9, wherein: The p38 MAP kinase inhibitor reduces one or more of TIM3 and LAG3 in T cells.

11. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein Preventing cancer immunotherapy-associated CRS or reducing the severity of its signs or symptoms in a human patient is or includes preventing fever or reducing the severity of fever.

12. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The cancer immunotherapy is: T cell engagement therapy (such as BiTE therapy, therapy using another bispecific antibody, CiTE therapy, SMITe therapy or TriKE therapy); TIL therapy; CAR NK cell therapy; cancer vaccine; T cell checkpoint modulator therapy; or CAR T cell therapy.

13. The p38 MAP kinase inhibitor for use according to claim 12, wherein: The cancer immunotherapy is CAR T therapy.

14. The p38 MAP kinase inhibitor for use according to claim 12, wherein: The cancer immunotherapy is BiTE therapy or therapy using another bispecific antibody.

15. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor inhibits the release of pro-inflammatory mediators from monocytes.

16. The p38 MAP kinase inhibitor for use according to claim 15, wherein The proinflammatory mediators include one or more of the following: IFNγ, IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12, IL-18, CCL2, CCL5, CXCL10, MCP-1, MIP-1β, GM-CSF, VEGF and TNFα.

17. The p38 MAP kinase inhibitor for use according to claim 16, wherein The pro-inflammatory mediators include or are IL-6.

18. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor inhibits the release of pro-inflammatory mediators from endothelial cells.

19. The p38 MAP kinase inhibitor for use according to claim 18, wherein The pro-inflammatory mediators include one or more of the following: IL-1β, IL-2, IL-6, IL-8, IL-10, CCL2, CCL5, CXCL10, IL-18, TNFα, MCP-1, MIP-1β, IP10 and GM-CSF.

20. The p38 MAP kinase inhibitor for use according to claim 19, wherein The pro-inflammatory mediators include or are IL-6.

21. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor inhibits the upregulation of E-selectin, VCAM1 and / or ICAM1 on the surface of endothelial cells.

22. The p38 MAP kinase inhibitor for use according to claim 21, wherein The p38 MAP kinase inhibitor inhibits the upregulation of ICAM1 on the surface of endothelial cells.

23. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor is an inhibitor of p38α MAP kinase and / or p38β MAP kinase.

24. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAP kinase inhibitor is represented by Formula I, or a pharmaceutically acceptable salt or solvate thereof: Formula I wherein R is C1-3 alkyl, optionally substituted with one or more halogen, NR1R2 or hydroxy, and R1 and R2 are independently H, halogen or C1-3 alkyl, optionally substituted with one or more F.

25. The p38 MAP kinase inhibitor for use according to claim 24, wherein The p38 MAP kinase inhibitor is of formula II: Formula II.

26. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAPK inhibitor is administered prior to the cancer immunotherapy.

27. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein Administration of the p38 MAPK inhibitor is initiated from about 4 days to about 2 hours prior to administration of the cancer immunotherapy, or from about 1 to about 3 days prior to the onset of CRS.

28. The p38 MAP kinase inhibitor for use according to claim 27, wherein A steady-state plasma concentration of the p38 MAPK inhibitor is achieved upon administration of the cancer immunotherapy or by the onset of CRS.

29. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAPK inhibitor is administered acutely over a period of days or weeks, for example, wherein the p38 MAPK inhibitor is administered over a period of about 7 to about 28 days.

30. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAPK inhibitor prevents or reduces the severity of infusion-related hypersensitivity reactions.

31. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein The p38 MAPK inhibitor was administered orally twice daily.

32. The p38 MAP kinase inhibitor for use according to claim 31, wherein The p38 MAP kinase inhibitor is administered at about 5 mg twice daily to about 1000 mg twice daily.

33. A p38 MAP kinase inhibitor for use according to any one of the preceding claims, wherein Administration of the p38 MAP kinase inhibitor begins about 4 days to about 2 hours before administration of the cancer immunotherapy and ends about 15 days after administration of the cancer immunotherapy.

34. The p38 MAP kinase inhibitor for use according to claim 32 or 33, wherein The p38 MAP kinase inhibitor is of Formula II.

35. A p38 MAP kinase inhibitor of formula II or a pharmaceutically acceptable salt or solvate thereof for use in preventing or treating cancer immunotherapy-associated CRS in human patients.

36. The p38 MAP kinase inhibitor of formula II, or a salt or solvate thereof for use as claimed in claim 35, wherein: The p38 MAP kinase inhibitor, salt or solvate of Formula II is administered orally twice daily.

37. The p38 MAP kinase inhibitor of formula II, or a salt or solvate thereof for use as claimed in claim 36, wherein: The p38 MAP kinase inhibitor of Formula II, salt or solvate is administered at 5-1000 mg twice daily.

38. A pharmaceutical composition comprising a p38 MAP kinase inhibitor or a pharmaceutically acceptable salt or solvate thereof for preventing cancer immunotherapy-associated cytokine release syndrome ("CRS") or reducing the severity of its signs or symptoms in a human patient, wherein: The pharmaceutical composition is administered in vivo before the onset of CRS.

39. The pharmaceutical composition for use as claimed in claim 38, wherein The p38 MAP kinase inhibitor is as defined in any one of claims 2 to 37.

40. A method for preventing cancer immunotherapy-associated cytokine release syndrome ("CRS") in a human patient, comprising administering to the patient a therapeutically effective amount or a prophylactically effective amount of a p38 MAPK inhibitor, or a pharmaceutically acceptable salt or solvate thereof, prior to the onset of CRS.

41. The method of claim 40, wherein: The p38 MAP kinase inhibitor is as defined in any one of claims 2 to 37.

42. A kit comprising: (i) the pharmaceutical composition as defined in claim 38 or 39; and (ii) instructions comprising instructions for use of the pharmaceutical composition for preventing cancer immunotherapy-associated cytokine release syndrome ("CRS") or reducing the severity of its signs or symptoms in a human patient, wherein the p38 MAPK inhibitor is administered prior to the onset of CRS.

43. Use of a p38 MAP kinase inhibitor in the preparation of a medicament for preventing cancer immunotherapy-associated cytokine release syndrome ("CRS") or reducing the severity of its signs or symptoms in human patients, wherein: The pharmaceutical composition is administered in vivo before the onset of CRS.

44. The use according to claim 43, wherein The p38 MAPK inhibitor is as defined in any one of claims 2 to 37.

45. Use of a pharmaceutical composition comprising a p38 MAP kinase inhibitor for the preparation of a medicament for preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome ("CRS") in a human patient, wherein: The pharmaceutical composition is administered in vivo before the onset of CRS.

46. ​​The use according to claim 45, wherein The pharmaceutical composition is as defined in claim 38 or 39.

47. A method for reducing cytokine release by monocytes resulting from administration of a cancer immunotherapy to a human patient while maintaining or increasing the anti-cancer cell efficacy of the cancer immunotherapy, by administering to the human patient a therapeutically effective amount or a prophylactically effective amount of a p38 MAPK inhibitor.

48. The method of claim 47, comprising reducing the release of IL-6 by monocytes.

49. The method of claim 47 or 48, further comprising reducing cytokine release by T cells.

50. The method of any one of claims 47 to 49, further comprising reducing the release of cytokines by endothelial cells.

51. The method of claim 50, comprising reducing IL-6 release by endothelial cells.

52. The method of any one of claims 47 to 51 , further comprising maintaining or increasing T cell proliferation.

53. The method of any one of claims 47 to 52, further comprising prolonging the anti-cancer cell efficacy of the T cells.

54. The method of any one of claims 47 to 53, further comprising modulating T cell polarization; and / or preventing or reducing T cell exhaustion.

55. The method of claim 53 or 54, wherein The p38 MAP kinase inhibitor reduces one or more of TIM3 and LAG3 in T cells.

56. The method of any one of claims 47 to 55, wherein The p38 MAP kinase inhibitor is as defined in any one of claims 2 to 37.

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