Methods of treating myeloproliferative tumors

Abstract

Therapeutic methods and pharmaceutical compositions for the treatment of myeloproliferative tumors (MPN) with a combination of an MDM2 inhibitor and a JAK inhibitor.

Description

Technical Field

[0001] Methods for treating myeloproliferative neoplasms (MPNs) using mouse double minute 2-homolog (MDM2) inhibitors and JAK inhibitors. Background Technology

[0002] p53 is a tumor suppressor and transcription factor that responds to cellular stress by activating the transcription of multiple genes involved in cell cycle arrest, apoptosis, senescence, and DNA repair. Unlike normal cells, which lack frequent causes of p53 activation, tumor cells are subjected to constant cellular stress from various forms of injury, including hypoxia and activation of pro-apoptotic oncogenes. Therefore, there is a strong selective advantage for inactivation of the p53 pathway in tumors, and it has been proposed that eliminating p53 function may be a prerequisite for tumor survival. To support this view, three research groups have used mouse models to demonstrate that the lack of p53 function is a persistent requirement for maintaining established tumors. When researchers restored p53 function in tumors with inactivated p53, tumor regression occurred.

[0003] In 50% of solid tumors and 10% of liquid tumors, p53 is inactivated by mutation and / or deletion. Other key members of the p53 pathway in cancer are also genetically or epigenetically altered. MDM2 (an oncoprotein) inhibits p53 function, and it is activated by gene amplification at a reported incidence of up to 10%. MDM2, in turn, is inhibited by another tumor suppressor, p14ARF. It has been shown that downstream changes of p53 in p53 WT tumors (p53 wild-type) may be the cause of at least partial inactivation of the p53 pathway. To support this view, some p53WT tumors appear to exhibit reduced apoptotic capacity, although their ability to undergo cell cycle arrest remains intact. One cancer treatment strategy involves using small molecules that bind to MDM2 and neutralize its interaction with p53. MDM2 inhibits p53 activity through three mechanisms: 1) acting as an E3 ubiquitin ligase to promote p53 degradation; 2) binding to and blocking the p53 transcriptional activation domain; and 3) exporting p53 from the nucleus to the cytoplasm. All three mechanisms are blocked by neutralizing the MDM2-p53 interaction. In particular, this therapeutic strategy can be applied to tumors with p53 WT, and studies with small-molecule MDM2 inhibitors have yielded promising reductions in tumor growth both in vitro and in vivo. Furthermore, in patients with p53-inactivated tumors, stabilizing wild-type p53 in normal tissues through MDM2 inhibition allows for selective protection of normal tissues from mitotic toxins. As used herein, MDM2 refers to the human MDM2 protein, and p53 refers to the human p53 protein. Note that human MDM2 may also be referred to as HDM2 or hMDM2. Several MDM2 inhibitors are currently in human clinical trials for the treatment of various cancers.

[0004] Myeloproliferative neoplasms (MPNs) (including, but not limited to, polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF)) are clonal hematopoietic stem cell (HSC) disorders characterized by the clonal proliferation of terminally differentiated bone marrow cells. Approximately 1%, 4%, and 20% of patients with ET, PV, and PMF, respectively, progress to a blast crisis (BP) known as MPN-BP within 10 years of diagnosis. Cervantes F et al., Acta Haematol. 1991; 85(3):124–127. MPN-BP and newly diagnosed acute myeloid leukemia (AML) each have distinct mutational patterns and clinical courses. Rampal R et al., ProcNatlAcadSci USA. 2014; 111(50):E5401-10. Patients with MPN-BP have a particularly poor prognosis, with a median survival of less than 6 months for currently available treatments. Summary of the Invention

[0005] The present invention relates to a method for inhibiting p21 expression levels in a person suffering from myeloproliferative neoplasm (MPN), the method comprising administering to the person a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein the administration inhibits p21 expression levels in the person compared to p21 expression levels in a person treated with the MDM2 inhibitor alone.

[0006] In one aspect, this disclosure provides a method for inhibiting p21 expression levels in a person suffering from myeloproliferative neoplasm (MPN), the method comprising administering to the person a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein the MDM2 inhibitor is a compound of formula (I): Or a pharmaceutically acceptable salt thereof, wherein the application inhibits p21 expression levels in humans compared to p21 expression levels in MDM2 inhibitor monotherapy. In one embodiment, the application inhibits p21 levels by at least 50%, optionally at least 60%, at least 70%, at least 80%, at least 90%, at least 95%, at least 96%, at least 97%, at least 98%, or at least 99%, compared to MDM2 inhibitor monotherapy.

[0007] In one embodiment, the application stimulates apoptosis of malignant bone marrow cells in a person with myeloproliferative neoplasm (MPN). In one embodiment, the malignant cells are CD34+ bone marrow cells or CD45+ myeloblasts.

[0008] In one implementation, MPN is polycythemia vera (PV). In one implementation, MPN is thrombocythemia. In one implementation, thrombocythemia is essential thrombocythemia (ET).

[0009] In one implementation, MPN is myelofibrosis. In one implementation, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia vera myelofibrosis (post-ET MF).

[0010] In one embodiment, MPN is chronic myeloid leukemia. In one embodiment, MPN is systemic mastocytosis (SM). In one embodiment, MPN is chronic neutrophilic leukemia (CNL). In one embodiment, MPN is myelodysplastic syndrome (MDS). In one embodiment, MPN is mast cell disease (SMCD). In one embodiment, MPN is chronic eosinophilic leukemia. In one embodiment, MPN is chronic myelomonocytic leukemia (CMML). In one embodiment, MPN is atypical chronic myeloid leukemia (aCML). In one embodiment, MPN is juvenile myelomonocytic leukemia (JMML). In one embodiment, MPN is eosinophilic syndrome (HES).

[0011] In one implementation, the MDM2 inhibitor is a pharmaceutically acceptable salt of a compound of formula (I).

[0012] In one embodiment, the compound of formula (I) is administered once daily at a dose selected from 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg. In another embodiment, the compound of formula (I) is administered twice daily at a dose selected from 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg. In one embodiment, the duration of treatment with the MDM2 inhibitor is selected from about 14 days, about 21 days, about 28 days, about 35 days, about 42 days, about 49 days, and about 56 days. In one embodiment, the compound of formula (I) is administered orally.

[0013] In one implementation, the JAK inhibitor is selected from AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, serdutinib, CHZ868, CYT387, decetinib, ENMD-2076, finzotinib, filogrinib, Ganettespib, INCB039110, INCB-047986, itatinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, and NSC42834. NVP-BSK805, Olapinib, Pacitinib, Pyrsitinib, Pyridone 6, R348, RGB-286638, Ruxolitinib, Ruxolitinib-S, SAR-20347, SB1317, Socitinib, TG101209, TG101348, Tofacitinib (3R, 4S), Tofacitinib (3S, 4R), Tofacitinib (3S, 4S), Tofacitinib, TYK2-IN-2, Upatinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and their pharmaceutically acceptable salts. In one embodiment, the JAK inhibitor is selected from baricitinib phosphate, CYT387 mesylate, CYT387 sulfate, NS-018 hydrochloride, NS-018 maleate, NVP-BSK805 dihydrochloride, olatinib maleate, ruxolitinib phosphate, ruxolitinib sulfate, tofacitinib citrate, and ZM39923 hydrochloride. In one embodiment, the JAK inhibitor is administered orally.

[0014] In one embodiment, the MDM2 inhibitor is administered before the JAK inhibitor. In another embodiment, the MDM2 inhibitor is administered after the JAK inhibitor. In yet another embodiment, the MDM2 inhibitor is administered concurrently with the JAK inhibitor.

[0015] In one implementation, the therapeutically effective dose of the MDM2 inhibitor is 100 mg.

[0016] In one implementation, the MPN in the human subject has the JAK2V617F mutation. Attached Figure Description

[0017] The foregoing overview and the following detailed description of the invention will be better understood when read in conjunction with the accompanying drawings.

[0018] Figure 1The effects of Navtemadilin (a compound of formula (I)) and ruxolitinib on p21 expression in ex vivo CD34+ bone marrow cells from patients with myelofibrosis are shown. Abbreviations: DMSO, dimethyl sulfoxide; μM, micromolar; MF, myelofibrosis; QD, once daily; RUX, ruxolitinib.

[0019] Figure 2 Figure A depicts the cytotoxicity of navtemadlin in combination with ruxolitinib in UKE-1 cells. Figure 2 B is a diagram depicting the synergistic effect of navmtadlin and ruxolitinib in driving apoptosis in UKE-1 cells (a JAK2 V617F cell line). Abbreviations: Nvtm, navtemadlin; Rux, ruxolitinib.

[0020] Figure 3 The effects of navtemadlin and ruxolitinib on apoptosis and p21 protein expression in progenitor cells derived from patients with myelofibrosis are shown. Abbreviations: MFI, median fluorescence intensity; NVTM, navtemadlin; Rux, ruxolitinib.

[0021] Figure 4 The effects of navtemadlin and ruxolitinib on MCL-1 protein expression in progenitor cells derived from patients with myelofibrosis are shown. Abbreviations: MFI, median fluorescence intensity; NVTM, navtemadlin; Rux, ruxolitinib. Detailed Implementation

[0022] While preferred embodiments of the invention have been shown and described herein, such embodiments are provided by way of example only and are not intended to otherwise limit the scope of the invention. Various alternatives to the described embodiments of the invention may be employed in carrying out the invention.

[0023] Unless otherwise specified, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains.

[0024] As used herein, the terms “combined administration” and “co-administration” cover the administration of two or more active pharmaceutical ingredients to a subject such that the two agents and / or their metabolites are present in the subject simultaneously. Co-administration includes simultaneous administration in separate compositions, administration in separate compositions at different times, or administration in a composition in which two or more agents are present.

[0025] The term "combination" or "drug combination" is defined herein as a fixed combination, non-fixed combination, or kit for combined administration of components in the form of a single dose unit, wherein the MDM2 and JAK inhibitors can be administered together, simultaneously and independently, or separately at time intervals, preferably such that the combination partners can exhibit synergistic (e.g., co-existing) effects. Therefore, the single compounds of the drug combinations of this disclosure can be administered simultaneously or sequentially.

[0026] Furthermore, the drug combinations disclosed herein may be in the form of a fixed combination or a non-fixed combination.

[0027] The term "effective amount" or "therapeutic effective amount" refers to an amount of active pharmaceutical ingredient or combination of active pharmaceutical ingredients as described herein that is sufficient to achieve the intended application (including, but not limited to, the treatment of a disease). Therapeutic effective amounts can vary depending on the intended application (in vitro or in vivo), or the subject being treated and the disease condition (e.g., the subject's weight, age, and sex), the severity of the disease condition, the route of administration, and other factors readily determined by a person skilled in the art. This term also applies to doses that will induce a specific response in target cells (e.g., a reduction in platelet adhesion and / or cell migration). Specific doses will vary depending on the specific compound selected, the dosing regimen followed, whether the compound is administered in combination with other compounds, the timing of administration, the tissue to which it is administered, and the physical delivery system carrying the compound.

[0028] The term "fixed combination" refers to the combination of MDM2 and JAK inhibitors (e.g., a single compound) as a single entity or dosage form.

[0029] "MPN-BP" refers to the blast crisis (BP) phase of myeloproliferative neoplasm (MPN) as described in this disclosure.

[0030] The term “non-fixed combination” refers to the simultaneous or sequential administration of MDM2 and JAK inhibitors (e.g., single compounds in combination) as separate entities or dosage forms to a patient, with no specific time limit, wherein such administration preferably provides therapeutically effective levels of two JAK inhibitors in a subject (e.g., a mammal or human) in need.

[0031] The term "pharmaceutically acceptable carrier" or "pharmaceutical acceptable excipient" is intended to include any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic agents, and absorption delay agents. The use of such media and reagents for the active pharmaceutical ingredient is well known in the art. The use of any conventional media or reagent in the therapeutic compositions of the present invention is contemplated unless any conventional media or reagent is incompatible with the active pharmaceutical ingredient. Additional active ingredients may also be incorporated into the compositions. Unless otherwise stated or explicitly indicated in the text, references to MDM2 and JAK inhibitors that may be used in pharmaceutical compositions of this disclosure include both the free acid and free base of the compound, as well as all pharmaceutically acceptable salts of the compound.

[0032] The term "pharmaceutically acceptable salt" refers to a salt derived from a variety of organic and inorganic counterions known in the art. Pharmaceutically acceptable acid addition salts can form with both inorganic and organic acids. Inorganic acids from which salts can be derived include, for example, hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, and phosphoric acid. Organic acids from which salts can be derived include, for example, acetic acid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, maleic acid, malonic acid, succinic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, and salicylic acid. Pharmaceutically acceptable base addition salts can form with both inorganic and organic bases. Inorganic bases from which salts can be derived include, for example, sodium, potassium, lithium, ammonium, calcium, magnesium, iron, zinc, copper, manganese, and aluminum. Organic bases from which salts can be derived include, for example, primary amines, secondary amines, and tertiary amines, substituted amines (including naturally occurring substituted amines), cyclic amines, and basic ion exchange resins. Specific examples include isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, and ethanolamine. In the selected embodiments, pharmaceutically acceptable base addition salts are selected from ammonium, potassium, sodium, calcium, and magnesium salts. The term "cocrystal" refers to a molecular complex derived from a variety of cocrystal formations known in the art. Unlike salts, cocrystals typically do not involve proton transfer between the cocrystal and the drug, and instead involve intermolecular interactions between the cocrystal formation and the drug within the crystal structure, such as hydrogen bonding, aromatic ring stacking, or dispersion forces.

[0033] As used herein, the term "therapeutic effect" encompasses the therapeutic benefits and / or preventive benefits described above. Preventive effects include delaying or eliminating the onset of a disease or condition, delaying or eliminating the onset of symptoms of a disease or condition, slowing, stopping, or reversing the progression of a disease or condition, or any combination thereof.

[0034] When this document uses ranges to describe, for example, physical or chemical properties, such as molecular weight or chemical formula, it is intended to include all combinations and sub-combinations of the ranges, as well as specific embodiments thereof. When referring to numbers or numerical ranges, the use of the term “about” means that the number or range mentioned is an approximation within a range of experimental variability (or within a range of statistical experimental error), and therefore the number or range may vary, for example, between 1% and 15% of the stated number or range. The term “comprising” (and related terms such as “comprise”, “comprises”, “having”, or “including”) includes embodiments of any composition, method, or process of matter, such as those “consisting of” or “substantially composed of” the stated features.

[0035] This invention covers a method for regulating p21 expression in CD34+ bone marrow cells using a combination of MDM2 inhibitors and JAK inhibitors. p21, also known as cyclin-dependent kinase inhibitor 1 or CDK-interacting protein 1, is a cyclin-dependent kinase inhibitor (CKI) capable of inhibiting all cyclin / CDK complexes, although it is primarily associated with CDK2 inhibition. p21 represents a major target of p53 activity and is therefore associated with linking DNA damage to cell cycle arrest. This protein is encoded by the CDKN1A gene (6p21.2) located on human chromosome 6. The MDM2 / p53 inhibitory axis upregulates p21 expression, its function being to induce cell cycle arrest in damaged cells. MDM2 inhibitors must overcome this checkpoint to drive apoptosis. The fact that JAK inhibitors (i.e., ruxolitinib) do not regulate p21 is not surprising, as ruxolitinib is not expected to bioregulate p21. However, treatment of CD34+ bone marrow cells from patients with myelofibrosis using a combination of MDM2 inhibitors and JAK inhibitors resulted in suppression of p21 levels (i.e., they did not increase). Therefore, this invention is based on the unexpected finding that p21 expression is still upregulated in the presence of an MDM2 inhibitor, which does not occur when combined with a JAK inhibitor. Because the p21 checkpoint is no longer needed to be overcome, the apoptosis threshold is much lower in the presence of an MDM2 inhibitor, and more apoptosis occurs. This effect enhances the activity of the MDM2 inhibitor, making it more effective in the treatment of MPN. Co-application of compounds

[0036] This invention relates to pharmaceutical combinations or compositions that are particularly suitable as medicines. Specifically, the combinations or compositions of this disclosure can be used in the treatment of cancer. In one embodiment, the cancer is MPN. The invention also relates to the use of the pharmaceutical combinations or compositions of this disclosure in the preparation of a medicine for treating cancer, particularly MPN, and to a method for treating cancer in a subject in need, the method comprising administering to the subject a therapeutically effective amount of the pharmaceutical combination or composition according to this disclosure.

[0037] In one implementation, MPN is selected from polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mastocytosis (SMCD).

[0038] In one implementation, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF).

[0039] In one implementation, primary myelofibrosis (PMF) is selected from pre-fibrotic / early PMF and markedly fibrotic PMF.

[0040] In one implementation, the MPN is selected from chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia (aCML), juvenile myelomonocytic leukemia (JMML), eosinophilic syndrome (HES), and myelodysplastic dysplasia / myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T).

[0041] One embodiment of the invention is a composition, for example, a pharmaceutical composition comprising an MDM2 inhibitor in combination with a JAK inhibitor. Another embodiment is a kit comprising two components formulated as separate pharmaceutical compositions (formulated for co-administration).

[0042] Another embodiment of the present invention is a method for treating a subject with myeloproliferative neoplasm (MPN), wherein the MPN is selected from polycythemia vera (PV), myelofibrosis, thrombocythemia, idiopathic myelofibrosis, chronic myeloid leukemia, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mastocytosis (SMCD). The method comprises co-administering a therapeutically effective amount of a combination comprising an MDM2 inhibitor in combination with a JAK inhibitor to a subject in need. Both the pharmaceutical composition comprising this combination and the kit are used to treat such diseases or conditions.

[0043] In one embodiment, the MDM2 inhibitor is a compound of formula (I) or formula (II).

[0044] In one embodiment, the MDM2 inhibitor is selected from compounds of formula (I) and (II), RG7388, triptolide, HDM201, RG7112, CGM097A, CGM0970B, SJ-172550, SAR405838, MI-773, MX69, YH239-EE, RO8994, Nutlin-3, Nutlin-3a, Nutlin-3b, Serdemetan, NSC59984, CHEMBL2386350, MK-8242, DS-3032, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0045] In one embodiment, the MDM2 inhibitor is selected from compounds of formula (I) and (II), RG7388, HDM201, RG7112, CGM097A, CGM0970B, SAR405838, MK-8242, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0046] In one implementation, the JAK inhibitor is a JAK1 inhibitor.

[0047] In one implementation, the JAK inhibitor is a JAK2 inhibitor.

[0048] In one implementation, the JAK inhibitor is a JAK3 inhibitor.

[0049] In one implementation, the JAK inhibitor is a selective JAK inhibitor.

[0050] In one implementation, the JAK inhibitor is a pan JAK inhibitor.

[0051] In one implementation, the JAK inhibitor is selected from AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, serdutinib, CHZ868, CYT387, decetinib, ENMD-2076, finzotinib, filogrinib, Ganettespib, INCB039110, INCB-047986, itatinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, and NSC42834. NVP-BSK805, Olapinib, Pacitinib, Pyrsitinib, Pyridone 6, R348, RGB-286638, Ruxolitinib, Ruxolitinib-S, SAR-20347, SB1317, Socitinib, TG101209, TG101348, Tofacitinib (3R, 4S), Tofacitinib (3S, 4R), Tofacitinib (3S, 4S), Tofacitinib, TYK2-IN-2, Upatinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and their pharmaceutically acceptable salts.

[0052] In one embodiment, the JAK inhibitor is selected from baricitinib phosphate, CYT387 mesylate, CYT387 sulfate, NS-018 hydrochloride, NS-018 maleate, NVP-BSK805 dihydrochloride, olatinib maleate, ruxolitinib phosphate, ruxolitinib sulfate, tofacitinib citrate, and ZM39923 hydrochloride.

[0053] The combination can be administered via any route known in the art. In one exemplary embodiment, the MDM2 inhibitor and the JAK inhibitor are administered independently via oral, intravenous, intramuscular, intraperitoneal, subcutaneous, or percutaneous route. In one embodiment, the MDM2 inhibitor is administered orally.

[0054] In one exemplary implementation, the MDM2 inhibitor is in the form of a pharmaceutically acceptable salt.

[0055] In one exemplary implementation, an MDM2 inhibitor is administered to the subject prior to the administration of a JAK inhibitor.

[0056] In one exemplary implementation, an MDM2 inhibitor is administered to the subject after the administration of a JAK inhibitor.

[0057] In one exemplary implementation, an MDM2 inhibitor is administered to the subject concurrently with the administration of a JAK inhibitor.

[0058] In one embodiment, this disclosure provides a method for treating a subject with blast crisis myeloproliferative neoplasm (MPN-BP), the method comprising co-administering a therapeutically effective amount of a combination comprising an MDM2 inhibitor in combination with a JAK inhibitor to a subject in need. Both the pharmaceutical composition comprising the combination and the kit are used to treat such disease or condition. In one embodiment, MPN-BP is selected from blast crisis polycythemia vera (BP-PV), blast crisis myelofibrosis, blast crisis primary myelofibrosis, blast crisis thrombocythemia, blast crisis primary thrombocythemia (BP-ET), blast crisis idiopathic myelofibrosis, blast crisis systemic mast cell disease (BP-SM), blast crisis chronic neutrophilic leukemia (BP-CNL), blast crisis myelodysplastic syndrome (BP-MDS), and blast crisis systemic mast cell disease (BP-SMCD). In one implementation, blast crisis myelofibrosis is selected from blast crisis primary myelofibrosis (BP-PMF), blast crisis post-polycythemia vera myelofibrosis (BP-PV post-MF), and blast crisis post-thrombocythemia vera myelofibrosis (BP-ET post-MF). In another implementation, blast crisis primary myelofibrosis (BP-PMF) is selected from blast crisis pre-fibrotic / early fibrotic PMF and blast crisis markedly fibrotic PMF. In one embodiment, MPN-BP is selected from blast crisis chronic neutrophilic leukemia (BP-CNL), blast crisis chronic eosinophilic leukemia, blast crisis chronic myelomonocytic leukemia (BP-CMML), blast crisis atypical chronic myeloid leukemia (BP-aCML), blast crisis juvenile myelomonocytic leukemia (BP-JMML), blast crisis eosinophilic syndrome (BP-HES), and blast crisis myelodysplastic / myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (BP-MDS / MPN-RS-T). In one embodiment, the MDM2 inhibitor is a compound of formula (I) or formula (II). In one embodiment, the MDM2 inhibitor is selected from compounds of formula (I) and (II), RG7388, triptolide, HDM201, RG7112, CGM097A, CGM0970B, SJ-172550, SAR405838, MI-773, MX69, YH239-EE, RO8994, Nutlin-3, Nutlin-3a, Nutlin-3b, Serdemetan, NSC59984, CHEMBL2386350, MK-8242, DS-3032, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.In one embodiment, the MDM2 inhibitor is selected from compounds of formula (I) and (II), RG7388, HDM201, RG7112, CGM097A, CGM0970B, SAR405838, MK-8242, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0059] In one implementation, the MPN in the human subject is characterized by a CALR mutation (calreticulin, located on chromosome 19p13.2), as described in Massie, N. Engl. J. Med. (2013) 25: 2379-2390.

[0060] In one implementation, the MPN in the human subject is characterized by an MPL mutation (myeloproliferative leukemia virus oncogene; located on chromosome 1p34), as described in Pikman, Plos Med. (2006) 3(7):e270.

[0061] In one implementation, the MPN in the human subject is characterized by the JAK2V617F mutation. The JAK2V617F mutation is a functional mutation that promotes cytokine-independent growth of bone marrow cells and accounts for the majority of myeloproliferative neoplasms (MPNs), as described in N.Nakatake, Oncogene (2012) 31, 1323-1333.

[0062] In one implementation, the MPN in the human subject is characterized by having one or more mutations selected from JAK2V617F, MPL, CALR, and combinations thereof.

[0063] In one exemplary implementation, the subject is a mammal, such as a human. MDM2 inhibitors

[0064] The compound of formula (I) is known to be 2-((3R,5R,6S)-5-(3-chlorophenyl)-6-(4-chlorophenyl)-1-((S)-1-(isopropylsulfonyl)-3-methylbut-2-yl)-3-methyl-2-oxopiperidin-3-yl)acetic acid.

[0065] In one embodiment, the MDM2 inhibitor is a compound of formula (II), which is known as 4-(2-((3R,5R,6S)-1-((S)-2-(tert-butylsulfonyl)-1-cyclopropylethyl)-6-(4-chloro-3-fluorophenyl)-5-(3-chlorophenyl)-3-methyl-2-oxopiperidin-3-yl)acetamyl)-2-methoxybenzoic acid.

[0066] In one embodiment, the MDM2 inhibitor is RG7388. RG7388 is known as 4-[[(2R,3S,4R,5S)-3-(3-chloro-2-fluorophenyl)-4-(4-chloro-2-fluorophenyl)-4-cyano-5-(2,2-dimethylpropyl)pyrrolidine-2-carbonyl]amino]-3-methoxybenzoic acid.

[0067] In one embodiment, the MDM2 inhibitor is triptolide. Triptolide is known as (5bS,6aS,7aS,8R,8aR,9aS,9bS,10aS,10bS)-8-hydroxy-8a-isopropyl-10b-methyl-2,5,5b,6,6a,8,8a,9a,9b,10b-decahydrotris(oxacyclopropane)[2',3':4b,5;2”,3”:6,7;2”',3”':8a,9]phenanthro[1,2-c]furan-3(1H)-one.

[0068] In one embodiment, the MDM2 inhibitor is Nutlin-3a. Nutlin-3a is known as 4-[(4S,5R)-4,5-bis(4-chlorophenyl)-2-(4-methoxy-2-prop-2-yloxyphenyl)-4,5-dihydroimidazol-1-carbonyl]piperazin-2-one.

[0069] In one embodiment, the MDM2 inhibitor is HDM201. HDM201 is known as (4S)-5-(5-chloro-1-methyl-2-oxopyridin-3-yl)-4-(4-chlorophenyl)-2-(2,4-dimethoxypyrimidin-5-yl)-3-propyl-2-yl-4H-pyrrolo[3,4-d]imidazol-6-one.

[0070] In one embodiment, the MDM2 inhibitor is RG7112. RG7112 is known as [(4S,5R)-2-(4-tert-butyl-2-ethoxyphenyl)-4,5-bis(4-chlorophenyl)-4,5-dimethylimidazol-1-yl]-[4-(3-methylsulfonylpropyl)piperazin-1-yl] methyl ketone.

[0071] In one embodiment, the MDM2 inhibitor is CGM097A. CGM097A is known as (1S)-1-(4-chlorophenyl)-6-methoxy-2-[4-[methyl-[[4-(4-methyl-3-oxopirarin-1-yl)cyclohexyl]methyl]amino]phenyl]-7-propyl-2-yloxy-1,4-dihydroisoquinoline-3-one.

[0072] In one embodiment, the MDM2 inhibitor is nutlin-3. Nutlin-3 is known as 4-[4,5-bis(4-chlorophenyl)-2-(4-methoxy-2-prop-2-yloxyphenyl)-4,5-dihydroimidazole-1-carbonyl]piperazin-2-one.

[0073] In one embodiment, the MDM2 inhibitor is SJ-172550. SJ-172550 is known as methyl 2-[2-chloro-6-ethoxy-4-[(3-methyl-5-oxo-1-phenylpyrazole-4-ylidene)methyl]phenoxy]acetate.

[0074] In one embodiment, the MDM2 inhibitor is SAR405838. SAR405838 is known as (2'R,3R,3'S,5'S)-6-chloro-3'-(3-chloro-2-fluorophenyl)-5'-(2,2-dimethylpropyl)-N-(4-hydroxycyclohexyl)-2-oxospiro[1H-indole-3,4'-pyrrolidine]-2'-carboxamide.

[0075] In one embodiment, the MDM2 inhibitor is MI-773. MI-773 is known as (2'R,3S,3'S,5'R)-6-chloro-3'-(3-chloro-2-fluorophenyl)-5'-(2,2-dimethylpropyl)-N-(4-hydroxycyclohexyl)-2-oxospiro[1H-indole-3,4'-pyrrolidine]-2'-carboxamide.

[0076] In one implementation, the MDM2 inhibitor is MX69. MX69 is known as 4-[8-[(3,4-dimethylphenyl)aminosulfonyl]-3a,4,5,9b-tetrahydro-3H-cyclopentadieno[c]quinoline-4-yl]benzoic acid.

[0077] In one embodiment, the MDM2 inhibitor is YH239-EE. YH239-EE is known as ethyl 3-[2-(tert-butylamino)-1-[(4-chlorophenyl)methylformylamino]-2-oxoethyl]-6-chloro-1H-indole-2-carboxylate.

[0078] In one embodiment, the MDM2 inhibitor is RO8994. RO8994 is known as (2'R,3R,3'S,5'S)-N-(4-carbamoyl-2-methoxyphenyl)-6-chloro-3'-(3-chloro-2-fluorophenyl)-5'-(2,2-dimethylpropyl)-2-oxospiro[1H-indole-3,4'-pyrrolidine]-2'-carboxamide.

[0079] In one embodiment, the MDM2 inhibitor is nutlin-3b. Nutlin-3b is known as 4-[(4R,5S)-4,5-bis(4-chlorophenyl)-2-(4-methoxy-2-prop-2-yloxyphenyl)-4,5-dihydroimidazol-1-carbonyl]piperazin-2-one.

[0080] In one embodiment, the MDM2 inhibitor is Serdemetan. Serdemetan is known as 1-N-[2-(1H-indol-3-yl)ethyl]-4-N-pyridin-4-ylphenyl-1,4-diamine.

[0081] In one embodiment, the MDM2 inhibitor is NSC59984. NSC59984 is known as (E)-1-(4-methylpiperazin-1-yl)-3-(5-nitrofuran-2-yl)prop-2-en-1-one.

[0082] In one embodiment, the MDM2 inhibitor is CHEMBL2386350. CHEMBL2386350 is known as 2-[4-[(4S,5R)-2-(4-tert-butyl-2-ethoxyphenyl)-4,5-bis(4-chlorophenyl)-4,5-dimethylimidazol-1-carbonyl]piperazin-1-yl]-1-morpholin-4-yl ethyl ketone.

[0083] In one embodiment, the MDM2 inhibitor is CGM0970B. CGM0970B is known as (1R)-1-(4-chlorophenyl)-6-methoxy-2-[4-[methyl-[[4-(4-methyl-3-oxopirarin-1-yl)cyclohexyl]methyl]amino]phenyl]-7-propyl-2-yloxy-1,4-dihydroisoquinoline-3-one.

[0084] In one embodiment, the MDM2 inhibitor is MK-8242. MK-8242 is known as 4-amino-1-[(2R,3S,4S,5R)-3,4-dihydroxy-5-(hydroxymethyl)oxacyclopentan-2-yl]pyrimidin-2-one.

[0085] In one embodiment, the MDM2 inhibitor is DS-3032. DS-3032 is known as (3'R,4'S,5'R)-N-((3R,6S)-6-carbamoyltetrahydro-2H-pyran-3-yl)-6”-chloro-4'-(2-chloro-3-fluoropyridin-4-yl)-4,4-dimethyl-2”-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3”-indoline]-5'-carboxamide.

[0086] In one embodiment, the MDM2 inhibitor is DS-3032B. DS-3032B is known as (3'R,4'S,5'R)-N-((3R,6S)-6-carbamoyltetrahydro-2H-pyran-3-yl)-6”-chloro-4'-(2-chloro-3-fluoropyridin-4-yl)-4,4-dimethyl-2”-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3”-indoline]-5'-carboxamide 4-methylbenzenesulfonate.

[0087] In one embodiment, the MDM2 inhibitor is HDM201. HDM201 is known as (4S)-5-(5-chloro-1-methyl-2-oxopyridin-3-yl)-4-(4-chlorophenyl)-2-(2,4-dimethoxypyrimidin-5-yl)-3-propyl-2-yl-4H-pyrrolo[3,4-d]imidazol-6-one.

[0088] In one embodiment, the MDM2 inhibitor is APG-115. APG-115 is known as 4-((3'R,4'S,5'R)-6”-chloro-4'-(3-chloro-2-fluorophenyl)-1'-ethyl-2”-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3”-indoline]-5'-carboxamido)bicyclo[2.2.2]octane-1-carboxylic acid.

[0089] In one embodiment, the MDM2 inhibitor is APG-115. APG-115 is known as 4-((3'R,4'S,5'R)-6”-chloro-4'-(3-chloro-2-fluorophenyl)-2”-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3”-indoline]-5'-carbamate)benzoic acid. JAK inhibitors

[0090] In one implementation, the JAK inhibitor is ruxolitinib (available from Incyte Corp. and Novartis AG). Ruxolitinib is known as (R)-3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-3-cyclopentylpropionitrile.

[0091] In one embodiment, the JAK inhibitor is ruxolitinib phosphate (available from Incyte Corp. and Novartis AG). In another embodiment, the JAK inhibitor is (R)-3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-3-cyclopentylpropionitrile phosphate.

[0092] In one embodiment, the JAK inhibitor is baricitinib (available from Incyte Corp. and Eli Lilly & Co.). Baricitinib is known as 2-(3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-1-(ethylsulfonyl)azacyclobutane-3-yl)acetonitrile.

[0093] In one implementation, the JAK inhibitor is molotinib (Gilead Sciences). Molotinib is also known as CYT-387. Molotinib is known as N-(cyanomethyl)-4-(2-((4-morpholinophenyl)amino)pyrimidin-4-yl)benzamide.

[0094] In one implementation, the JAK inhibitor is Ganetespib. Ganetespib is known as 5-(2,4-dihydroxy-5-isopropylphenyl)-4-(1-methyl-1H-indol-5-yl)-2,4-dihydro-3H-1,2,4-triazol-3-one.

[0095] In one implementation, the JAK inhibitor is NS-018. NS-018 is known as (S)-N 2 -(1-(4-fluorophenyl)ethyl)-6-(1-methyl-1H-pyrazole-4-yl)-N 4 -(pyrazin-2-yl)pyrimidine-2,4-diamine.

[0096] In one embodiment, the JAK inhibitor is BMS-911543. BMS-911543 is known as N,N-dicyclopropyl-4-((1,5-dimethyl-1H-pyrazol-3-yl)amino)-6-ethyl-1-methyl-1,6-dihydroimidazo[4,5-d]pyrrolo[2,3-b]pyridine-7-carboxamide.

[0097] In one implementation, the JAK inhibitor is Gandotinib. Gandotinib is known as 3-(4-chloro-2-fluorobenzyl)-2-methyl-N-(5-methyl-1H-pyrazol-3-yl)-8-(morpholinomethyl)imidazo[1,2-b]pyridazin-6-amine.

[0098] In one embodiment, the JAK inhibitor is ENMD-2076. ENMD-2076 is known as (E)-N-(5-methyl-1H-pyrazol-3-yl)-6-(4-methylpiperazin-1-yl)-2-styrylpyrimidine-4-amine.

[0099] In one implementation, the JAK inhibitor is AT-9283. AT-9283 is known to be 1-cyclopropyl-3-(3-(5-) In one implementation, the JAK inhibitor is pactinib. Pactinib is known as 11-(2-pyrrolidone-1-ylethoxy)-14,19-dioxa-5,7,26-triaza-tetracyclo[19.3.1.1(2,6).1(8,12)]hepta-1(25),2(26),3,5,8,10,12(27),16,21,23-decane.

[0100] In one implementation, the JAK inhibitor is AC-410 (available from Ambit Biosciences). AC-410 is known as (S)-(4-fluorophenyl)(4-((5-methyl-1H-pyrazol-3-yl)amino)quinazolin-2-yl)methanol.

[0101] In one implementation, the JAK inhibitor is AZD-1480. AZD-1480 is known as ((S)-5-chloro-N 2 -(1-(5-Fluoropyrimidin-2-yl)ethyl)-N 4 -(5-methyl-1H-pyrazol-3-yl)pyrimidine-2,4-diamine.

[0102] In one implementation, the JAK inhibitor is CYT387. CYT387 is known as N-(cyanomethyl)-4-(2-(4-morpholinophenylamino)pyrimidin-4-yl)benzamide.

[0103] In one embodiment, the JAK inhibitor is TYK2-IN-2. TYK2-IN-2 is known as 6-((3,5-dimethylphenyl)amino)-8-(methylamino)imidazo[1,2-b]pyridazine-3-carboxamide.

[0104] In one embodiment, the JAK inhibitor is SAR-20347. SAR-20347 is known as 2-(2-chloro-6-fluorophenyl)-5-[4-(morpholin-4-carbonyl)anilino]-1,3-oxazol-4-carboxamide.

[0105] In one implementation, the JAK inhibitor is utpatinib (ABT-494). Upatinib is known as (3S,4R)-3-ethyl-4-(3H-imidazo[1,2-a]pyrrolo[2,3-e]pyrazin-8-yl)-N-(2,2,2-trifluoroethyl)pyrrolidine-1-carboxamide.

[0106] In one embodiment, the JAK inhibitor is WP1066. WP1066 is known as (E)-3-(6-bromopyridin-2-yl)-2-cyano-N-[(1S)-1-phenylethyl]prop-2-enamide.

[0107] In one implementation, the JAK inhibitor is GLPG0634 (fegotinib). GLPG0634 is known as N-[5-[4-[(1,1-dioxo-1,4-thiazin-4-yl)methyl]phenyl]-[1,2,4]triazolo[1,5-a]pyridin-2-yl]cyclopropanecarboxamide.

[0108] In one embodiment, the JAK inhibitor is TG101348 (fenzotinib; SAR 302503). TG101348 is known as N-tert-butyl-3-[[5-methyl-2-[4-(2-pyrrolidone-1-ylethoxy)anilino]pyrimidin-4-yl]amino]benzenesulfonamide.

[0109] In one embodiment, the JAK inhibitor is cedutinib (PRT062070; PRT2070). Cedutinib is known as 4-(cyclopropylamino)-2-[4-(4-ethylsulfonylpiperazin-1-yl)anilino]pyrimidine-5-carboxamide.

[0110] In one implementation, the JAK inhibitor is tofacitinib. Tofacitinib is known as 3-[(3R,4R)-4-methyl-3-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]piperidin-1-yl]-3-oxopropionitrile.

[0111] In one embodiment, the JAK inhibitor is itatinib. Iatinib is known as 2-[1-[1-[3-fluoro-2-(trifluoromethyl)pyridin-4-carbonyl]piperidin-4-yl]-3-[4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)pyrazol-1-yl]azacyclobutane-3-yl]acetonitrile.

[0112] In one implementation, the JAK inhibitor is decetinib. Decetinib is known as (2R)-2-methyl-2-[[2-(1H-pyrrolo[2,3-b]pyridin-3-yl)pyrimidin-4-yl]amino]-N-(2,2,2-trifluoroethyl)butyramide.

[0113] In one embodiment, the JAK inhibitor is CHZ868. CHZ868 is known as N-[4-[2-(2,4-difluoroanilino)-1,4-dimethylbenzimidazol-5-yl]oxypyridin-2-yl]acetamide.

[0114] In one embodiment, the JAK inhibitor is SB1317. SB1317 is known as (E)-6-methyl-12-oxa-3,6-diaza-2(4,2)-pyrimidin-1,4(1,3)-diphenylheterocyclic dodecyl-8-ene.

[0115] In one implementation, the JAK inhibitor is soxitinib. Soxitinib is known as N-[5-[4-(3,3-dimethylazacyclobutane-1-carbonyl)phenyl]-[1,2,4]triazolo[1,5-a]pyridin-2-yl]cyclopropanecarboxamide.

[0116] In one implementation, the JAK inhibitor is piracetinib. Piracetinib is known as 4-[[(1R,3S)-5-hydroxy-2-adamantyl]amino]-1H-pyrrolo[2,3-b]pyridine-5-carboxamide.

[0117] In one embodiment, the JAK inhibitor is CEP-33779. CEP-33779 is known as N-[3-(4-methylpiperazin-1-yl)phenyl]-8-(4-methylsulfonylphenyl)-[1,2,4]triazolo[1,5-a]pyridine-2-amine.

[0118] In one embodiment, the JAK inhibitor is pyridone 6. Pyridone 6 is known as 2-(tert-butyl)-9-fluoro-3H-benzo[h]imidazo[4,5-f]isoquinoline-7-ol.

[0119] In one implementation, the JAK inhibitor is LFM-A13. LFM-A13 is known as (Z)-2-cyano-N-(2,5-dibromophenyl)-3-hydroxybut-2-enamide.

[0120] In one embodiment, the JAK inhibitor is BMS-911543. BMS-911543 is known as (Z)-N,N-dicyclopropyl-4-((1,5-dimethyl-1,2-dihydro-3H-pyrazole-3-ylidene)amino)-6-ethyl-1-methyl-1,6-dihydroimidazo[4,5-d]pyrrolo[2,3-b]pyridine-7-carboxamide.

[0121] In one embodiment, the JAK inhibitor is NS-018. NS-018 is known as 6-N-[(1S)-1-(4-fluorophenyl)ethyl]-4-(1-methylpyrazol-4-yl)-2-N-pyrazin-2-ylpyridine-2,6-diamine.

[0122] In one embodiment, the JAK inhibitor is JANEX-1. JANEX-1 is known as 4-[(6,7-dimethoxyquinazoline-4-yl)amino]phenol.

[0123] In one embodiment, the JAK inhibitor is TG101209. TG101209 is known as N-tert-butyl-3-[[5-methyl-2-[4-(4-methylpiperazin-1-yl)anilino]pyrimidin-4-yl]amino]benzenesulfonamide.

[0124] In one embodiment, the JAK inhibitor is WHI-P154. WHI-P154 is known as 2-bromo-4-[(6,7-dimethoxyquinazoline-4-yl)amino]phenol.

[0125] In one implementation, the JAK inhibitor is NVP-BSK805. NVP-BSK805 is known as 4-[[2,6-difluoro-4-[3-(1-piperidin-4-ylpyrazol-4-yl)quinoxaline-5-yl]phenyl]methyl]morpholine.

[0126] In one embodiment, the JAK inhibitor is ZM39923. ZM39923 is known as 3-[benzyl(propyl-2-yl)amino]-1-naphth-2-ylpropyl-1-one.

[0127] In one implementation, the JAK inhibitor is ruxolitinib-S. Ruxolitinib-S is known as (3S)-3-cyclopentyl-3-[4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)pyrazol-1-yl]propionitrile.

[0128] In one implementation, the JAK inhibitor is XL019. XL019 is known as (2S)-N-[4-[2-(4-morpholin-4-ylaniline)pyrimidin-4-yl]phenyl]pyrrolidine-2-carboxamide.

[0129] In one embodiment, the JAK inhibitor is AZ960. AZ960 is known as 5-fluoro-2-[[(1S)-1-(4-fluorophenyl)ethyl]amino]-6-[(5-methyl-1H-pyrazol-3-yl)amino]pyridine-3-carboxynitrile.

[0130] In one embodiment, the JAK inhibitor is JAK3-IN-1. JAK3-IN-1 is known as N-[3-[[[5-chloro-2-[2-methoxy-4-(4-methylpiperazin-1-yl)anilino]pyrimidin-4-yl]amino]methyl]phenyl]prop-2-enamide.

[0131] In one implementation, the JAK inhibitor is WHI-P97. WHI-P97 is known as 2,6-dibromo-4-[(6,7-dimethoxyquinazoline-4-yl)amino]phenol.

[0132] In one embodiment, the JAK inhibitor is RGB-286638. RGB-286638 is known as 1-[3-[4-[[4-(2-methoxyethyl)piperazin-1-yl]methyl]phenyl]-4-oxo-1H-indo[1,2-c]pyrazol-5-yl]-3-morpholin-4-ylurea, dihydrochloride.

[0133] In one implementation, the JAK inhibitor is tofacitinib (3R,4S). Tofacitinib (3R,4S) is known as 3-[(3R,4S)-4-methyl-3-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]piperidin-1-yl]-3-oxopropionitrile.

[0134] In one embodiment, the JAK inhibitor is NSC42834. NSC42834 is known as 2-methyl-1-phenyl-4-pyridin-2-yl-2-(2-pyridin-2-ylethyl)but-1-one.

[0135] In one embodiment, the JAK inhibitor is PF-06651600. PF-06651600 is known as benzyl 2-(hydroxymethyl)-5-[(2-methylprop-2-yl)oxycarbonylamino]piperidine-1-carboxylate.

[0136] In one implementation, the JAK inhibitor is tofacitinib (3S,4S). Tofacitinib (3S,4S) is known as 3-[(3S,4S)-4-methyl-3-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]piperidin-1-yl]-3-oxopropionitrile.

[0137] In one implementation, the JAK inhibitor is tofacitinib (3S,4R). Tofacitinib (3S,4R) is known as 3-[(3S,4R)-4-methyl-3-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]piperidin-1-yl]-3-oxopropionitrile.

[0138] In one implementation, the JAK inhibitor is AEG3482. AEG3482 is known as 6-phenylimidozolo[2,1-b][1,3,4]thiadiazole-2-sulfonamide.

[0139] In one implementation, the JAK inhibitor is lintatinib (CEP-701). Lintatinib is known as (5R,7S,8S)-7-hydroxy-7-(hydroxymethyl)-8-methyl-5,6,7,8,13,14-hexahydro-15H-16-oxa-4b,8a,14-triaza-5,8-bridged methylene dibenzo[b,h]cycloocttrien[jkl]cyclopentadien[e]-as-indenotetraen-15-one.

[0140] In one implementation, the JAK inhibitor is olatinib. Olatinib is known as N-methyl-1-[4-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]cyclohexyl]methanesulfonamide.

[0141] In one embodiment, the JAK inhibitor is (E)-4-(2-(pyrrolidone-1-yl)ethoxy)-6,11-dioxa-3-aza-2(4,2)-pyrimidin-1(2,5)furanza-4(1,3)benzylcyclododecyl-8-ene.

[0142] In one embodiment, the JAK inhibitor is (9E)-15-(2-(pyrrolidone-1-yl)ethoxy)-7,12,25-trioxa-19,21,24-triaza-tetracyclo[18.3.1.1(2,5).1(14,18)]hexadecyl-1(24),2,4,9,14(26),15,17,20,22-nonaene.

[0143] In one embodiment, the JAK inhibitor is (R)-(4-fluorophenyl)(4-((5-methyl-1H-pyrazol-3-yl)amino)quinazoline-2-yl)methanol, which is also known in the art to be active as a JAK inhibitor. In another embodiment, the JAK inhibitor is racemic (4-fluorophenyl)(4-((5-methyl-1H-pyrazol-3-yl)amino)quinazoline-2-yl)methanol, which is also known in the art to be active as a JAK inhibitor.

[0144] In one embodiment, the JAK inhibitor is (S)-5-fluoro-2-((1-(4-fluorophenyl)ethyl)amino)-6-((5-methyl-1H-pyrazol-3-yl)amino)nicotinonitrile.

[0145] In one embodiment, the JAK inhibitor is ((R)-7-(2-aminopyrimidin-5-yl)-1-((1-cyclopropyl-2,2,2-trifluoroethyl)amino)-5H-pyrido[4,3-b]indole-4-carboxamide, also known as 7-(2-aminopyrimidin-5-yl)-1-{[(1R)-1-cyclopropyl-2,2,2-trifluoroethyl]amino}-5H-pyrido[4,3-b]indole-4-carboxamide. Pharmaceutical Composition

[0146] In some embodiments, the present invention provides a pharmaceutical composition comprising a combination of an MDM2 inhibitor and a JAK inhibitor. In one embodiment, MPN is selected from polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mastocytosis (SMCD). In one embodiment, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (PV-MF), and post-essential thrombocytosis myelofibrosis (ET-MF). In one embodiment, primary myelofibrosis (PMF) is selected from pre-fibrotic / early PMF and markedly fibrotic PMF. In one implementation, the MPN is selected from chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia (aCML), juvenile myelomonocytic leukemia (JMML), eosinophilic syndrome (HES), and myelodysplastic dysplasia / myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T).

[0147] In one implementation, the MDM2 inhibitor is a compound of formula (I) or formula (II) or a pharmaceutically acceptable salt thereof.

[0148] In one embodiment, the MDM2 inhibitor is selected from compounds of formula (I) and (II), RG7388, triptolide, HDM201, RG7112, CGM097A, CGM0970B, SJ-172550, SAR405838, MI-773, MX69, YH239-EE, RO8994, Nutlin-3, Nutlin-3a, Nutlin-3b, Serdemetan, NSC59984, CHEMBL2386350, MK-8242, DS-3032, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0149] In one embodiment, the MDM2 inhibitor is selected from compounds of formula (I) and (II), RG7388, HDM201, RG7112, CGM097A, CGM0970B, SAR405838, MK-8242, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0150] In one implementation, the JAK inhibitor is selected from AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, serdutinib, CHZ868, CYT387, decetinib, ENMD-2076, finzotinib, filogrinib, Ganettespib, INCB039110, INCB-047986, itatinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, and NSC42834. NVP-BSK805, Olapinib, Pacitinib, Pyrsitinib, Pyridone 6, R348, RGB-286638, Ruxolitinib, Ruxolitinib-S, SAR-20347, SB1317, Socitinib, TG101209, TG101348, Tofacitinib (3R, 4S), Tofacitinib (3S, 4R), Tofacitinib (3S, 4S), Tofacitinib, TYK2-IN-2, Upatinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and their pharmaceutically acceptable salts.

[0151] In one embodiment, the JAK inhibitor is selected from baricitinib phosphate, CYT387 mesylate, CYT387 sulfate, NS-018 hydrochloride, NS-018 maleate, NVP-BSK805 dihydrochloride, olatinib maleate, ruxolitinib phosphate, ruxolitinib sulfate, tofacitinib citrate, and ZM39923 hydrochloride.

[0152] In one implementation, thrombocytosis is primary thrombocytosis (ET).

[0153] In one implementation, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia vera myelofibrosis (post-ET MF). Polycythemia vera

[0154] In some embodiments, the present invention provides pharmaceutical compositions comprising a compound of formula (I) or formula (II) or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor; wherein the JAK inhibitor is selected from AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cedutinib, CHZ868, CYT387, decetinib, ENMD-2076, finzotinib, filogrinib, Ganettespib, INCB039110, INCB-047986, itatinib, JAK3-IN-1, JANEX-1, LFM-A13 LY2784544, NS-018, NSC42834, NVP-BSK805, Oratinib, Pacitinib, Pixitinib, Pyridone 6, R348, RGB-286638, Ruxolitinib, Ruxolitinib-S, SAR-20347, SB1317, Soxitinib, TG101209, TG101348, Tofacitinib (3R,4S), Tofacitinib (3S,4R), Tofacitinib (3S,4S), Tofacitinib, TYK2-IN-2, Upatinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and their pharmaceutically acceptable salts. Essential thrombocythemia (ET)

[0155] In some embodiments, the present invention provides pharmaceutical compositions comprising a compound of formula (I) or formula (II) or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor; wherein the JAK inhibitor is selected from AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cedutinib, CHZ868, CYT387, decetinib, ENMD-2076, filgortinib, Ganetspib, INCB039110, INCB-047986, itatinib, JAK3-IN-1, JANEX-1, LFM-A13, L Y2784544, NS-018, NSC42834, NVP-BSK805, Oratinib, Pacitinib, Pixitinib, Pyridone 6, R348, RGB-286638, Ruxolitinib, Ruxolitinib-S, SAR-20347, SB1317, Soxitinib, TG101209, TG101348, Tofacitinib (3R,4S), Tofacitinib (3S,4R), Tofacitinib (3S,4S), Tofacitinib, TYK2-IN-2, Upatinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and their pharmaceutically acceptable salts. Myelofibrosis

[0156] In some embodiments, the present invention provides pharmaceutical compositions comprising a compound of formula (I) or formula (II) or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor; wherein the JAK inhibitor is selected from AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cedutinib, CHZ868, CYT387, decetinib, ENMD-2076, filgortinib, Ganetspib, INCB039110, INCB-047986, itatinib, JAK3-IN-1, JANEX-1, LFM-A13, L Y2784544, NS-018, NSC42834, NVP-BSK805, Oratinib, Pacitinib, Pixitinib, Pyridone 6, R348, RGB-286638, Ruxolitinib, Ruxolitinib-S, SAR-20347, SB1317, Soxitinib, TG101209, TG101348, Tofacitinib (3R,4S), Tofacitinib (3S,4R), Tofacitinib (3S,4S), Tofacitinib, TYK2-IN-2, Upatinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and their pharmaceutically acceptable salts.

[0157] In one implementation, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF).

[0158] Pharmaceutical compositions are typically formulated to provide therapeutically effective amounts of MDM2 inhibitors and JAK inhibitors. If desired, the pharmaceutical composition contains pharmaceutically acceptable salts and / or coordination complexes thereof, as well as one or more pharmaceutically acceptable excipients, carriers (including inert solid diluents and fillers), diluents (including sterile aqueous solutions and various organic solvents), permeation enhancers, solubilizers, and adjuvants.

[0159] In the selected embodiments, the concentrations of the MDM2 inhibitor and JAK inhibitor provided in the pharmaceutical composition of the present invention are independently less than, for example, 100%, 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19%, 18%, 17%, 16%, 15%, 14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03%, 0.02%, 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002% or 0.0001% w / w, w / v or v / v.

[0160] In the selected embodiments, the concentrations of the MDM2 inhibitor and JAK inhibitor provided in the pharmaceutical composition of the present invention are independently greater than 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19.75%, 19.50%, 19.25%, 19%, 18.75%, 18.50%, 18.25%, 18%, 17.75%, 17.50%, 17.25%, 17%, 16.75%, 16.50%, 16.25%, 16%, 15.75%, 15.50%, 15.25%, 15%, 14.75%, 14.50%, 14.25%, 14%, 13.75%, 13.50%, 13.25%, 13%, 12.75%, 12.50%, 12.25%, 12%, 11.75%, 11.50%, 11.25%, 11%, 10.75%, 10.50%, 10.25%, 10%, 9.75%, 9.50%, 9.25%, 9%, 8.75%, 8.50%, 8.25%, 8%, 7.75%, 7.50%, 7.25%, 7%, 6.75%, 6.50%, 6.25%, 6%, 5.75%, 5.50%, 5.25%, 5%, 4.75%, 4.50%, 4.25%, 4%, 3.75%, 3.50%, 3.25%, 3%, 2.75%, 2.50%, 2.25%, 2%, 1.75%, 1.50%, 125%, 1%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0. 0.07%, 0.06%, 0.05%, 0.04%, 0.03%, 0.02%, 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002% or 0.0001% w / w, w / v or v / v.

[0161] In the selected embodiments, the concentrations of the MDM2 inhibitor and the JAK inhibitor are independently ranging from about 0.0001% to about 50%, from about 0.001% to about 40%, from about 0.01% to about 30%, from about 0.02% to about 29%, from about 0.03% to about 28%, from about 0.04% to about 27%, from about 0.05% to about 26%, from about 0.06% to about 25%, from about 0.07% to about 24%, and from about 0. The range of 0.08% to about 23%, about 0.09% to about 22%, about 0.1% to about 21%, about 0.2% to about 20%, about 0.3% to about 19%, about 0.4% to about 18%, about 0.5% to about 17%, about 0.6% to about 16%, about 0.7% to about 15%, about 0.8% to about 14%, about 0.9% to about 12%, or about 1% to about 10% w / w, w / v, or v / v.

[0162] In the selected embodiments, the concentrations of the MDM2 inhibitor and the JAK inhibitor are independently in the range of about 0.001% to about 10%, about 0.01% to about 5%, about 0.02% to about 4.5%, about 0.03% to about 4%, about 0.04% to about 3.5%, about 0.05% to about 3%, about 0.06% to about 2.5%, about 0.07% to about 2%, about 0.08% to about 1.5%, about 0.09% to about 1%, about 0.1% to about 0.9% w / w, w / v, or v / v.

[0163] In the selected implementation scheme, the amounts of the MDM2 inhibitor and the JAK inhibitor are independently equal to or less than 10g, 9.5g, 9.0g, 8.5g, 8.0g, 7.5g, 7.0g, 6.5g, 6.0g, 5.5g, 5.0g, 4.5g, 4.0g, 3.5g, 3.0g, 2.5g, 2.0g, 1.5g, 1.0g, 0.95g, 0.9g, 0.85g, 0.8g, 0.75g, 0.7g, 0.65g, 0.6g, 0.55g, 0.5g, 0.45g, 0.4g, 0.35g, 0.3g, 0.2g. 5g, 0.2g, 0.15g, 0.1g, 0.09g, 0.08g, 0.07g, 0.06g, 0.05g, 0.04g, 0.03g, 0.02g, 0.01g, 0.009g, 0.008g, 0.007g, 0.006g, 0.005g, 0.004g, 0.003g, 0.002g, 0.001g, 0.0009g, 0.0008g, 0.0007g, 0.0006g, 0.0005g, 0.0004g, 0.0003g, 0.0002g, or 0.0001g.

[0164] In the selected implementation scheme, the amounts of the MDM2 inhibitor and the JAK inhibitor are independently greater than 0.0001g, 0.0002g, 0.0003g, 0.0004g, 0.0005g, 0.0006g, 0.0007g, 0.0008g, 0.0009g, 0.001g, 0.0015g, 0.002g, and 0.0025g. , 0.003g, 0.0035g, 0.004g, 0.0045g, 0.005g, 0.0055g, 0.006g, 0.0065g, 0.007 g, 0.0075g, 0.008g, 0.0085g, 0.009g, 0.0095g, 0.01g, 0.015g, 0.02g, 0.025g, 0.03g, 0.035g, 0.04g, 0.045g, 0.05g, 0.055g, 0.06g, 0.065g, 0.07g, 0.075g, 0 .08g, 0.085g, 0.09g, 0.095g, 0.1g, 0.15g, 0.2g, 0.25g, 0.3g, 0.35g, 0.4g, 0.4 5g, 0.5g, 0.55g, 0.6g, 0.65g, 0.7g, 0.75g, 0.8g, 0.85g, 0.9g, 0.95g, 1g, 1.5g, 2g, 2.5, 3g, 3.5, 4g, 4.5g, 5g, 5.5g, 6g, 6.5g, 7g, 7.5g, 8g, 8.5g, 9g, 9.5g or 10g.

[0165] MDM2 inhibitors are effective over a wide dose range. For example, in adult treatment, doses ranging independently from 0.01 to 1000 mg daily, 0.5 to 100 mg, 1 to 50 mg daily, and 5 to 40 mg daily are examples of doses that can be used. The exact dose will depend on the route of administration, the form of the compound administered, the sex and age of the subject to be treated, the weight of the subject to be treated, and the preferences and experience of the attending physician. Pharmaceutical compositions for oral administration

[0166] In selected embodiments, the present invention provides a pharmaceutical composition for oral administration comprising an MDM2 inhibitor and a JAK inhibitor, and a pharmaceutical excipient suitable for oral administration.

[0167] In selected embodiments, the present invention provides a solid pharmaceutical composition for oral administration comprising: (i) a combination comprising an effective amount of an MDM2 inhibitor and a JAK inhibitor, combined with (ii) a pharmaceutical excipient suitable for oral administration. In selected embodiments, the composition further comprises (iii) an effective amount of at least one additional active ingredient.

[0168] In selected embodiments, the pharmaceutical composition may be a liquid pharmaceutical composition suitable for oral consumption. Pharmaceutical compositions of the present invention suitable for oral administration may exist as discrete dosage forms, such as capsules, flat capsules or tablets, or liquids or sprays, each containing a predetermined amount of active ingredient as a powder or granules, solution, or suspension in an aqueous or non-aqueous liquid, oil-in-water emulsion, or water-in-oil liquid emulsion. Such dosage forms may be prepared by any method, but all methods include the step of associating the active ingredient with a carrier, which constitutes one or more essential components. Typically, a composition is prepared by uniformly and tightly mixing the active ingredient with a liquid carrier or a finely chopped solid carrier, or both, and then shaping the product into the desired appearance (if desired). For example, tablets may be prepared by compression or molding, optionally with one or more excipients. Compressed tablets may be prepared by compressing the active ingredient in a free-flowing form (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 can be prepared by molding a mixture of powdered compounds wetted with an inert liquid diluent in a suitable machine.

[0169] This invention further covers anhydrous pharmaceutical compositions and dosage forms because water can promote the degradation of some compounds. For example, in the pharmaceutical field, water (e.g., 5%) can be added as a means of simulating long-term storage in order to determine properties such as the shelf life or stability of the formulation over time. The anhydrous pharmaceutical compositions and dosage forms of this invention can be prepared using anhydrous or low-moisture components and low-moisture or low-humidity conditions. If significant contact with moisture and / or humidity is anticipated during manufacturing, packaging, and / or storage, the pharmaceutical compositions and dosage forms of this invention containing lactose can be made anhydrous. Anhydrous pharmaceutical compositions can be prepared and stored such that their anhydrous properties are maintained. Therefore, anhydrous compositions can be packaged using materials known to prevent exposure to water, so that they can be included in suitable formulation kits. Examples of suitable packaging include, but are not limited to, hermetically sealed foil, plastics, etc., unit-dose containers, blister packs, and strip packs.

[0170] The combination of an MDM2 inhibitor and a JAK inhibitor can be further combined with a drug carrier in a close mixture using conventional drug mixing techniques. The carrier can take various forms, depending on the desired formulation for administration. In compositions preparing oral dosage forms, any conventional drug medium can be used as a carrier, such as water, glycols, oils, alcohols, flavoring agents, preservatives, coloring agents, etc., in the case of oral liquid formulations (e.g., suspensions, solutions, and elixirs) or aerosols; or in some embodiments where lactose is not used, carriers such as starch, sugar, microcrystalline cellulose, diluents, granulating agents, lubricants, binders, and disintegrants can be used in the case of oral solid dosage forms. Suitable carriers include powders, capsules, and tablets, as well as solid oral dosage forms. Tablets can be coated using standard aqueous or non-aqueous techniques if desired.

[0171] Binders suitable for 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 gum arabic, sodium alginate, alginic acid, other alginates, powdered tragacanth gum, guar gum, cellulose and its derivatives (e.g., ethyl cellulose, cellulose acetate, calcium carboxymethyl cellulose, sodium carboxymethyl cellulose), polyvinylpyrrolidone, methyl cellulose, pregelatinized starch, hydroxypropyl methyl cellulose, microcrystalline cellulose, and combinations thereof.

[0172] Examples of suitable fillers for 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, glucose binders, kaolin, mannitol, silicic acid, sorbitol, starch, pregelatinized starch, and combinations thereof.

[0173] Disintegrants can be used in the compositions of the present invention to provide tablets that disintegrate upon exposure to an aqueous environment. Excessive disintegrants can result in tablets that disintegrate in the bottle. Insufficient disintegrants may be insufficient to cause disintegration, thereby altering the rate and extent of release of the active ingredient from the dosage form. Therefore, dosage forms of the compounds disclosed herein can be formed using a sufficient amount of disintegrant that is neither too little nor too much, so as not to adversely alter the release of the active ingredient. The amount of disintegrant used can vary depending on the type of formulation and the administration method, and can be readily identified by those skilled in the art. About 0.5 to about 15% by weight of disintegrant, or about 1 to about 5% by weight of disintegrant, can be used in pharmaceutical compositions. Disintegrants that can be used to form the pharmaceutical compositions and dosage forms of the present invention include, but are not limited to, agar, alginate, calcium carbonate, microcrystalline cellulose, croscarmellose sodium, crospovidone, polacolin potassium, sodium glycolate starch, potato or cassava starch, other starches, pregelatinized starch, other starches, clay, other alginates, other celluloses, gums, or combinations thereof.

[0174] Lubricants that can be used to form the pharmaceutical compositions and dosage forms of the present invention include, but are not limited to, calcium stearate, magnesium stearate, mineral oil, light mineral oil, glycerin, 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 laurylate, agar, or combinations thereof. Additional lubricants include, for example, syloid silica gel, condensed aerosols of synthetic silica, or combinations thereof. Lubricants may optionally be added in an amount less than about 1% by weight of the pharmaceutical composition.

[0175] When an aqueous suspension and / or elixir is required for oral administration, the basic active ingredient may be combined with various sweeteners or flavorings, colorings or dyes, and emulsifiers and / or suspending agents (if desired), as well as diluents such as water, ethanol, propylene glycol, glycerin, and various combinations thereof.

[0176] Tablets may be uncoated or coated using known techniques to delay disintegration and absorption in the gastrointestinal tract, thereby providing a sustained effect over a longer period. For example, time-delaying materials such as glyceryl monostearate or glyceryl distearate may be used. Formulations for oral use may also be available as hard gelatin capsules (where the active ingredient is mixed with an inert solid diluent such as calcium carbonate, calcium phosphate, or kaolin) or as soft gelatin capsules (where the active ingredient is mixed with an aqueous or oily medium such as peanut oil, liquid paraffin, or olive oil).

[0177] Surfactants that can be used to form the pharmaceutical compositions and dosage forms of the present invention include, but are not limited to, hydrophilic surfactants, lipophilic surfactants, and combinations thereof. That is to say, mixtures of hydrophilic surfactants, mixtures of lipophilic surfactants, or mixtures of at least one hydrophilic surfactant and at least one lipophilic surfactant can be used.

[0178] Suitable hydrophilic surfactants typically have an HLB value of at least 10, while suitable lipophilic surfactants typically have an HLB value of about 10 or less. The empirical parameter used to characterize the relative hydrophilicity and hydrophobicity of nonionic amphiphilic compounds is the hydrophilic-lipophilic balance (“HLB” value). Surfactants with lower HLB values ​​are more lipophilic or more hydrophobic and have greater solubility in oils, while surfactants with higher HLB values ​​are more hydrophilic and have greater solubility in aqueous solutions. Hydrophilic surfactants are generally considered to be those compounds with HLB values ​​greater than about 10, as well as anionic, cationic, or zwitterionic compounds for which HLB grading is generally not applicable. Similarly, lipophilic (i.e., hydrophobic) surfactants are compounds with HLB values ​​equal to or less than about 10. However, the HLB value of a surfactant is only a rough guideline commonly used to enable the formulation of industrial, pharmaceutical, and cosmetic emulsions.

[0179] Hydrophilic surfactants can be ionic or nonionic. Suitable ionic surfactants include, but are not limited to, alkylammonium salts; fusidates; fatty acid derivatives of amino acids, oligopeptides, and polypeptides; glycerol ester derivatives of amino acids, oligopeptides, and polypeptides; lecithin and hydrogenated lecithin; lysophosphatidylcholine and hydrogenated lysophosphatidylcholine; phospholipids and their derivatives; lysophosphatidylcholine and its derivatives; carnitine fatty acid ester salts; salts of alkyl sulfates; fatty acid salts; sodium docusate; acyl acrylates; monoacetylated and diacetylated tartrate esters of monoglycerides and diglycerides; succinylated monoglycerides and diglycerides; citrate esters of monoglycerides and diglycerides; and combinations thereof.

[0180] For example, in the above group, ionic surfactants include: lecithin, lysophosphatidylcholine, phospholipids, lysophosphatidylcholine and their derivatives; carnitine fatty acid ester salts; salts of alkyl sulfates; fatty acid salts; sodium docusate; acyl acrylates; monoacetylated and diacetylated tartrate esters of monoglycerides and diglycerides; succinylated monoglycerides and diglycerides; citrate esters of monoglycerides and diglycerides; and combinations thereof.

[0181] Ionic surfactants can be lecithin, lysophosphatidylcholine, phosphatidylethanolamine, phosphatidylglycerol, phosphatidic acid, phosphatidylserine, lysophosphatidylcholine, lysophosphatidylethanolamine, lysophosphatidylglycerol, lysophosphatidic acid, lysophosphatidylserine, PEG-phosphatidylethanolamine, PVP-phosphatidylethanolamine, lactates of fatty acids, stearoyl-2-lactate, stearoyllactate, succinylated monoglycerides, mono / diglycerides of mono / diglycerides, citrates of mono / diglycerides, cholycylsarcosine, hexanoate, caprylate, caprate, laurate, myristate, palmitate, oleate, ricinoleate, linoleate, linolenic acid ester, stearate, lauryl sulfate, teracecyl sulfate, docusate, lauroylcarnitine, palmitoylcarnitine, myristoylcarnitine, and their salts and combinations thereof in ionized forms.

[0182] Hydrophilic nonionic surfactants may include, but are not limited to, alkyl glucosides; alkyl maltodextrins; alkyl thioglucosides; lauryl polyethylene glycol glycerol esters; polyoxyethylene alkyl ethers, such as polyethylene glycol alkyl ethers; polyoxyethylene alkylphenols, such as polyethylene glycol alkylphenols; polyoxyethylene alkylphenol fatty acid esters, such as polyethylene glycol fatty acid monoesters and polyethylene glycol fatty acid diesters; polyethylene glycol glycerol fatty acid esters; polyglycerol fatty acid esters; polyoxyethylene sorbitan fatty acid esters, such as polyethylene glycol sorbitan fatty acid esters; hydrophilic transesterification products of polyols with at least one of glycerides, vegetable oils, hydrogenated vegetable oils, fatty acids, and sterols; polyoxyethylene sterols, their derivatives, and analogs; polyoxyethyleneized vitamins and their derivatives; polyoxyethylene-polyoxypropylene block copolymers; combinations thereof; polyethylene glycol sorbitan fatty acid esters and hydrophilic transesterification products of polyols with at least one of triglycerides, vegetable oils, and hydrogenated vegetable oils. Polyols can be glycerol, ethylene glycol, polyethylene glycol, sorbitol, propylene glycol, pentaerythritol, or sugars.

[0183] Other hydrophilic nonionic surfactants include, but are not limited to, PEG-10 laurate, PEG-12 laurate, PEG-20 laurate, PEG-32 laurate, PEG-32 dilaurate, PEG-12 oleate, PEG-15 oleate, PEG-20 oleate, PEG-20 dioleate, PEG-32 oleate, PEG-200 oleate, PEG-400 oleate, PEG-15 stearate, PEG-32 distearate, PEG-40 stearate, PEG-100 stearate, PEG-20 dilaurate, PEG-25 glyceryl trioleate, PEG-32 dioleate, PEG-20 glyceryl laurate, PEG-30 glyceryl laurate, PEG-20 glyceryl stearate, PEG-20 glyceryl oleate, PEG-30 glyceryl oleate, PEG-30 glyceryl laurate, PEG-40 glyceryl laurate, and PEG-40 palm kernel oil. PEG-50 hydrogenated castor oil, PEG-40 castor oil, PEG-35 castor oil, PEG-60 castor oil, PEG-40 hydrogenated castor oil, PEG-60 hydrogenated castor oil, PEG-60 corn oil, PEG-6 caprylic / caprylic glyceryl ester, PEG-8 caprylic / caprylic glyceryl ester, polyglycerol 10 laurate, PEG-30 cholesterol, PEG-25 phytosterols, PEG-30 soybean sterols, PEG-20 trioleate, PEG-40 Sorbitol oleate, PEG-80 sorbitol lauryl ester, polysorbate 20, polysorbate 80, POE-9 lauryl ether, POE-23 lauryl ether, POE-10 oleyl ether, POE-20 oleyl ether, POE-20 stearyl ether, tocopheryl PEG-100 succinate, PEG-24 cholesterol, polyglycerol 10 oleate, Tween 40, Tween 60, sucrose monostearate, sucrose monolaurate, sucrose monopalmitate, PEG 10-100 nonylphenol series, PEG 15-100 octylphenol series, and poloxamer.

[0184] For example, suitable lipophilic surfactants include: fatty alcohols; glycerol fatty acid esters; acetylated glycerol fatty acid esters; lower alcohol fatty acid esters; propylene glycol fatty acid esters; sorbitol fatty acid esters; polyethylene glycol sorbitol fatty acid esters; sterols and sterol derivatives; polyoxyethyleneized sterols and sterol derivatives; polyethylene glycol alkyl ethers; sugar esters; sugar ethers; lactic acid derivatives of monoglycerides and diglycerides; hydrophobic transesterification products of polyols with at least one of glycerides, vegetable oils, hydrogenated vegetable oils, fatty acids, and sterols; oil-soluble vitamins / vitamin derivatives; and combinations thereof. Among these, preferred lipophilic surfactants include glycerol fatty acid esters, propylene glycol fatty acid esters, and combinations thereof, or hydrophobic transesterification products of polyols with at least one of vegetable oils, hydrogenated vegetable oils, and triglycerides.

[0185] In one embodiment, the composition may include a solubilizer to ensure good solubilization and / or dissolution of the compounds of the present invention and to minimize precipitation of the compounds of the present invention. This may be particularly important for compositions intended for non-oral use, such as compositions intended for injection. Solubilizers may also be added to increase the solubility of hydrophilic drugs and / or other components, such as surfactants, or to maintain the composition as a stable or homogeneous solution or dispersion.

[0186] Examples of suitable solubilizers include, but are not limited to, the following: alcohols and polyols, such as ethanol, isopropanol, butanol, benzyl alcohol, ethylene glycol, propylene glycol, butanediol and its isomers, 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; ethers of polyethylene glycol having an average molecular weight of about 200 to about 6000, such as tetrahydrofurfuryl PEG ether (tetrahydrofuran polyethylene glycol ether (glycofurol)) or methoxyPEG; amides and other nitrogen-containing compounds, such as 2-pyrrolidone, 2-piperidine. Ketones, ε-caprolactam, N-alkylpyrrolidone, N-hydroxyalkylpyrrolidone, N-alkylpiperidinone, N-alkylcaprolactam, dimethylacetamide, and polyvinylpyrrolidone; esters, such as ethyl propionate, tributyl citrate, acetylacetic acid triethyl citrate, acetylacetic acid tributyl citrate, triethyl citrate, ethyl oleate, ethyl octanoate, ethyl butyrate, triacetin, 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, dimethylisosorbide, N-methylpyrrolidone, monooctanoic acid, diethylene glycol monoethyl ether, and water.

[0187] Mixtures of solubilizers may also be used. Examples include, but are not limited to, triacetyl citrate, triethyl oleate, ethyl octanoate, dimethylacetamide, N-methylpyrrolidone, N-hydroxyethylpyrrolidone, polyvinylpyrrolidone, hydroxypropyl methylcellulose, hydroxypropyl cyclodextrin, ethanol, polyethylene glycol 200-100, tetrahydrofuran polyethylene glycol ether, diethylene glycol monoethyl ether, propylene glycol, and dimethyl isosorbide. Particularly preferred solubilizers include sorbitol, glycerol, triacetyl citrate, ethanol, PEG-400, tetrahydrofuran polyethylene glycol ether, and propylene glycol.

[0188] There are no particular limitations on the amount of solubilizer that may be included. The amount of a given solubilizer may be limited to a bioacceptable amount, which can be readily determined by those skilled in the art. In some cases, including an amount of solubilizer far exceeding the bioacceptable amount may be advantageous, for example, to maximize the concentration of the drug, wherein excess solubilizer is removed using conventional techniques, such as distillation or evaporation, before the composition is administered to the patient. Thus, if present, the solubilizer may be present in weight percentages of 10%, 25%, 50%, 100%, or up to about 200% by weight, based on the total weight of the drug and other excipients. Very small amounts of solubilizer may also be used, such as 5%, 2%, 1%, or even less, if desired. Typically, the solubilizer may be present in amounts from about 1% to about 100% by weight, and more typically from about 5% to about 25% by weight.

[0189] The composition may further include one or more pharmaceutically acceptable additives and excipients. Such additives and excipients include, but are not limited to, anti-sticking agents, defoamers, buffers, polymers, antioxidants, preservatives, chelating agents, viscosity modifiers, tension modifiers, flavoring agents, coloring agents, fragrances, opacifiers, suspending agents, binders, fillers, plasticizers, lubricants, and combinations thereof.

[0190] In addition, acids or bases may be incorporated into the composition to facilitate processing, enhance stability, or for other reasons. 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 calcite dihydrate, magnesium aluminum hydroxide, diisopropylethylamine, ethanolamine, ethylenediamine, triethanolamine, triethylamine, triisopropanolamine, trimethylamine, tri(hydroxymethyl)aminomethane (TRIS), etc. Suitable bases are also salts of pharmaceutically acceptable acids, such as acetic acid, acrylic acid, adipic acid, alginic acid, alkyl sulfonic acid, amino acids, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid, citric acid, fatty acids, formic acid, fumaric acid, gluconic acid, hydroquinone sulfonic 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, mercaptoacetic acid, toluenesulfonic acid, uric acid, etc. Salts of polybasic acids, such as sodium phosphate, disodium hydrogen phosphate, and sodium dihydrogen phosphate, can also be used. When the base is a salt, the cation can be any convenient and pharmaceutically acceptable cation, such as ammonium, alkali metals, and alkaline earth metals. Examples may include, but are not limited to, sodium, potassium, lithium, magnesium, calcium, and ammonium.

[0191] 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, and phosphoric acid. Examples of suitable organic acids include acetic acid, acrylic acid, adipic acid, alginic acid, alkyl sulfonic acid, amino acids, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid, citric acid, fatty acids, formic acid, fumaric acid, gluconic acid, hydroquinone sulfonic 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, and uric acid. Pharmaceutical composition for injection

[0192] In selected embodiments, the present invention provides a pharmaceutical composition for injection comprising a combination of an MDM2 inhibitor and a JAK inhibitor and an injectable pharmaceutical excipient.

[0193] The compositions of the present invention can be incorporated into aqueous or oily suspensions or emulsions for administration by injection, having sesame oil, corn oil, cottonseed oil or peanut oil, as well as elixirs, mannitol, dextrose or sterile aqueous solutions and similar pharmaceutical solvents.

[0194] Aqueous solutions in saline solutions are also commonly used for injection. Ethanol, glycerol, propylene glycol, and liquid polyethylene glycol (and suitable combinations thereof), cyclodextrin derivatives, and vegetable oils can also be used. For example, appropriate flowability can be maintained by using coatings (e.g., lecithin) to maintain the desired particle size in the case of dispersions, and by using surfactants. Prevention of microbial action can be achieved with various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, sorbic acid, and thimerosal.

[0195] Sterile injectable solutions are prepared by incorporating MDM2 inhibitors and JAK inhibitors in desired amounts, along with various other ingredients listed above as required, into a suitable solvent, followed by filtration and sterilization. Typically, dispersions are prepared by incorporating various sterilized active ingredients into a sterile solvent containing a basic dispersion medium and desired other ingredients from those listed above. In the case of sterile powders used to prepare sterile injectable solutions, certain desirable preparation methods include vacuum drying and freeze-drying techniques, which produce powders of the active ingredient plus any other desired ingredients from their previously sterile filtered solutions.

[0196] Administration of a combination containing an MDM2 inhibitor and a JAK inhibitor can be achieved by any method that enables the compound to be delivered to the site of action. These methods include oral administration, duodenal administration, parenteral injection (including intravenous, intra-arterial, subcutaneous, intramuscular, intravascular, or infusion), local administration (e.g., percutaneous application), and local delivery via catheter or stent.

[0197] Exemplary parenteral formulations include solutions or suspensions of the active compound in sterile aqueous solutions, such as aqueous propylene glycol or dextrose solution. Such formulations may be appropriately buffered if necessary.

[0198] This invention also provides kits. Kits include, in suitable packaging, individual or combined MDM2 inhibitors and JAK inhibitors, along with written materials that may include instructions for use, discussions of clinical studies, and a list of side effects. Such kits may also include information such as scientific literature references, package insert materials, clinical trial results, and / or summaries of these, indicating or determining the activity and / or benefits of the composition, and / or describing dosage, administration, side effects, drug interactions, or other information useful to healthcare providers. Such information may be based on the results of various studies, such as studies involving the use of laboratory animals in in vivo models and studies based on human clinical trials. Kits may further include another active pharmaceutical ingredient. Suitable packaging and other items used (e.g., measuring cups for liquid formulations, foil packaging for minimizing air exposure, etc.) are known in the art and may be included in the kit. The kits described herein are available, marketed, and / or promoted to healthcare providers, including physicians, nurses, pharmacists, prescribing officers, etc. In selected embodiments, the kits may also be sold directly to consumers. In one embodiment, the invention provides a kit for treating MPN comprising a combination of an MDM2 inhibitor and a JAK inhibitor. In one embodiment, MPN is selected from polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mastocytosis (SMCD). In one embodiment, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (PV-MF), and post-essential thrombocytosis myelofibrosis (ET-MF). In one embodiment, primary myelofibrosis (PMF) is selected from pre-fibrotic / early PMF and markedly fibrotic PMF. In one implementation, the MPN is selected from chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia (aCML), juvenile myelomonocytic leukemia (JMML), eosinophilic syndrome (HES), and myelodysplastic dysplasia / myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T). Dosage and administration regimen

[0199] The dosage of MDM2 inhibitors and JAK inhibitors administered will depend independently on the person being treated, the severity of the condition or illness, the rate of administration, the disposal of the compounds, and the prescribing physician's judgment. However, in a single dose or fractions, the effective dose is in the range of about 0.001 to about 100 mg per kilogram of body weight per day, for example, about 1 to about 35 mg / kg / day. For a 70 kg person, this would be equivalent to about 0.05 to 7 g / day, for example, about 0.05 to about 2.5 g / day. In some cases, dose levels below the lower limit of the above range may be sufficient, while in other cases, such larger doses can be used without causing any harmful side effects by dividing a larger dose into several smaller doses to be administered throughout the day.

[0200] In some implementations, the MDM2 inhibitor and JAK inhibitor are administered independently as a single dose. Typically, such administration is performed by injection, such as intravenous injection, to allow for rapid delivery of the medication. However, other routes may be used as appropriate. Single doses of the MDM2 inhibitor and JAK inhibitor can also be used to treat acute conditions.

[0201] In some embodiments, the MDM2 inhibitor and the JAK inhibitor are administered independently in multiple doses to treat MPN. In one embodiment, the MDM2 inhibitor and the JAK inhibitor are administered independently in multiple oral doses. In one embodiment, the administration may be once, twice, three times, four times, five times, six times, or more than six times daily. In one embodiment, the administration may be selected from once daily, twice daily, three times daily, four times daily, five times daily, six times daily, every two days, once weekly, twice weekly, three times weekly, four times weekly, once every two weeks, and once monthly. In some embodiments, the MDM2 inhibitor and the JAK inhibitor are administered independently three times weekly, including Mondays, Wednesdays, and Fridays.

[0202] MDM2 inhibitors and JAK inhibitors can be administered independently and continuously as needed. In some embodiments, MDM2 inhibitors and JAK inhibitors are administered independently for more than 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 days or more. In some embodiments, MDM2 inhibitors and JAK inhibitors are administered independently for less than 28, 14, 7, 6, 5, 4, 3, 2 or 1 day. In some embodiments, MDM2 inhibitors and JAK inhibitors are administered independently for about 14 days, about 21 days, about 28 days, about 35 days, about 42 days, about 49 days or about 56 days. In some embodiments, MDM2 inhibitors and JAK inhibitors are administered independently and long-term on a continuous basis for the treatment of chronic effects. In another implementation, the administration of the MDM2 inhibitor and the JAK inhibitor is independently sustained for less than about 7 days. In yet another implementation, administration is sustained for more than about 6, 10, 14, 28 days, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, or one year. In some implementations, administration is sustained for more than about one year, two years, three years, four years, or five years. In some implementations, continuous dosing is achieved and maintained as long as necessary.

[0203] In some embodiments, the effective doses of the MDM2 inhibitor and the JAK inhibitor are independently from 1 mg to about 500 mg, about 10 mg to about 300 mg, about 20 mg to about 250 mg, about 25 mg to about 200 mg, about 10 mg to about 200 mg, about 20 mg to about 150 mg, about 30 mg to about 120 mg, about 10 mg to about 90 mg, about 20 mg to about 80 mg, about 30 mg to about 70 mg, about 40 mg to about 60 mg, about 45 mg to about 55 mg, and about 48 mg. The range is approximately 52 mg, approximately 50 mg to approximately 150 mg, approximately 60 mg to approximately 140 mg, approximately 70 mg to approximately 130 mg, approximately 80 mg to approximately 120 mg, approximately 90 mg to approximately 110 mg, approximately 95 mg to approximately 105 mg, approximately 150 mg to approximately 250 mg, approximately 160 mg to approximately 240 mg, approximately 170 mg to approximately 230 mg, approximately 180 mg to approximately 220 mg, approximately 190 mg to approximately 210 mg, approximately 195 mg to approximately 205 mg, or approximately 198 mg to approximately 202 mg. In some embodiments, the effective dose of the MDM2 inhibitor and JAK inhibitor is about 25 mg, about 50 mg, about 75 mg, about 100 mg, about 125 mg, about 150 mg, about 175 mg, about 200 mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about 325 mg, about 350 mg, about 375 mg, about 400 mg, about 425 mg, about 450 mg, about 475 mg, or about 500 mg. In some embodiments, the effective dose of the MDM2 inhibitor or JAK inhibitor is 25 mg, 50 mg, 75 mg, 100 mg, 125 mg, 150 mg, 175 mg, 200 mg, 225 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 375 mg, 400 mg, 425 mg, 450 mg, 475 mg, or 500 mg.

[0204] In some embodiments, the effective dose of the MDM2 inhibitor or JAK inhibitor is independently from about 0.01 mg / kg to about 4.3 mg / kg, about 0.15 mg / kg to about 3.6 mg / kg, about 0.3 mg / kg to about 3.2 mg / kg, about 0.35 mg / kg to about 2.85 mg / kg, about 0.15 mg / kg to about 2.85 mg / kg, about 0.3 mg / kg to about 2.15 mg / kg, about 0.45 mg / kg to about 1.7 mg / kg, about 0.15 mg / kg to about 1.3 mg / kg. kg, about 0.3 mg / kg to about 1.15 mg / kg, about 0.45 mg / kg to about 1 mg / kg, about 0.55 mg / kg to about 0.85 mg / kg, about 0.65 mg / kg to about 0.8 mg / kg, about 0.7 mg / kg to about 0.75 mg / kg, about 0.7 mg / kg to about 2.15 mg / kg, about 0.85 mg / kg to about 2 mg / kg, about 1 mg / kg to about 1.85 mg / kg, about 1.15 mg / kg to about 1.7 mg / kg, about 1.3 mg / kg The effective dose of the MDM2 inhibitor or JAK inhibitor is in the range of about 1.6 mg / kg, about 1.35 mg / kg to about 1.5 mg / kg, about 2.15 mg / kg to about 3.6 mg / kg, about 2.3 mg / kg to about 3.4 mg / kg, about 2.4 mg / kg to about 3.3 mg / kg, about 2.6 mg / kg to about 3.15 mg / kg, about 2.7 mg / kg to about 3 mg / kg, about 2.8 mg / kg to about 3 mg / kg, or about 2.85 mg / kg to about 2.95 mg / kg. In some embodiments, the effective dose of the MDM2 inhibitor or JAK inhibitor is about 0.35 mg / kg, about 0.7 mg / kg, about 1 mg / kg, about 1.4 mg / kg, about 1.8 mg / kg, about 2.1 mg / kg, about 2.5 mg / kg, about 2.85 mg / kg, about 3.2 mg / kg, or about 3.6 mg / kg.

[0205] In some implementations, the MDM2 inhibitor or a pharmaceutically acceptable salt thereof is administered at doses from 10 to 500 mg BID, including doses of 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg BID.

[0206] In some implementations, the MDM2 inhibitor or a pharmaceutically acceptable salt thereof is administered at doses of 10 to 500 mg QD, including doses of 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg QD.

[0207] Effective amounts of MDM2 inhibitors or JAK inhibitors can be administered in single or multiple doses via any acceptable mode of administration (including sublingual, sublingual, and transdermal routes) of a drug with similar efficacy, through intra-arterial injection, intravenous, parenteral, intramuscular, subcutaneous, or oral administration.

[0208] In some implementations, the MDM2 inhibitor and JAK inhibitor are administered to the subject independently and intermittently, referred to as intermittent administration. "Intermittent administration" refers to a period of administration of a therapeutically effective dose of the MDM2 inhibitor and / or JAK inhibitor, followed by a period of discontinuation, then another administration period, and so on. Within each administration period, the dosing frequency may be independently selected from three times daily, twice daily, once daily, once weekly, twice weekly, three times weekly, four times weekly, five times weekly, six times weekly, or once monthly. In one implementation, the MDM2 inhibitor is a compound of formula (I) or formula (II). In one implementation, the JAK inhibitor is selected from ruxolitinib, ruxolitinib-S, and finzotinib.

[0209] The term "withdrawal period" or "rest period" refers to the length of time during which the administration of an MDM2 inhibitor and / or a JAK inhibitor is discontinued. The withdrawal period can be longer or shorter than the administration period, or the same as the administration period. For example, when the administration period includes dosing three times daily, twice daily, once daily, once weekly, twice weekly, three times weekly, four times weekly, five times weekly, six times weekly, or once monthly, the withdrawal period can be at least approximately 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, one month, two months, three months, four months, or more days. During the withdrawal period, other JAK inhibitors besides MDM2 inhibitors and JAK inhibitors can be administered.

[0210] In one embodiment, the MDM2 inhibitor and the JAK inhibitor are administered independently to a subject in need for the treatment of myeloproliferative neoplasm (MPN), with a first administration period, a subsequent discontinuation period, a subsequent second administration period, and so on. In one embodiment, MPN is selected from polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mastocytosis (SMCD). In one embodiment, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (PV-MF), and post-essential thrombocytosis myelofibrosis (ET-MF). In one embodiment, primary myelofibrosis (PMF) is selected from pre-fibrotic / early PMF and markedly fibrotic PMF. In one implementation, the MPN is selected from chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia (aCML), juvenile myelomonocytic leukemia (JMML), eosinophilic syndrome (HES), and myelodysplastic dysplasia / myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T). The first administration period, the second administration period, and the withdrawal period are independently selected from more than 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, one month, two months, three months, four months, and more days, wherein the MDM2 inhibitor and the JAK inhibitor are independently administered to the subject three times daily, twice daily, once daily, once weekly, twice weekly, three times weekly, four times weekly, five times weekly, six times weekly, or once monthly. In one implementation, the first administration period is the same length as the second administration period. In one implementation, the first administration period is shorter than the second administration period. In one implementation, the first administration period is longer than the second administration period. In one implementation, the first and second administration periods are approximately three weeks, wherein the MDM2 inhibitor and the JAK inhibitor are independently administered to the subject once daily; and the withdrawal period is approximately two weeks. In one implementation scheme, the first and second administration periods are approximately three weeks, during which the MDM2 inhibitor and the JAK inhibitor are administered to the subject independently once weekly; and the withdrawal period is approximately two weeks. In another implementation scheme, the first and second administration periods are approximately four weeks, during which the MDM2 inhibitor and the JAK inhibitor are administered to the subject independently once daily; and the withdrawal period is approximately two weeks.In one implementation, the first and second administration periods are approximately four weeks, wherein the MDM2 inhibitor and the JAK inhibitor are administered to the subject independently once weekly; and the discontinuation period is approximately two weeks. In one implementation, the MDM2 inhibitor is a compound of formula (I) or formula (II). In one implementation, the JAK inhibitor is selected from ruxolitinib, ruxolitinib-S, and finzotinib.

[0211] In one embodiment, the MDM2 inhibitor is administered to a person intermittently, while the JAK inhibitor is administered to a person non-intermittently. In another embodiment, the JAK inhibitor is administered to a person intermittently, while the MDM2 inhibitor is administered to a person non-intermittently. In another embodiment, both the MDM2 inhibitor and the JAK inhibitor are administered to a person intermittently. In yet another embodiment, both the MDM2 inhibitor and the JAK inhibitor are administered to a person non-intermittently. Treatment methods for myeloproliferative neoplasms (MPN)

[0212] In one embodiment, the present invention covers a method for inhibiting p21 expression levels in a person suffering from myeloproliferative neoplasm (MPN), the method comprising administering to the person a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein the MDM2 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof, wherein the administration inhibits p21 expression levels in the person compared to p21 expression levels in a single treatment with the MDM2 inhibitor. In one embodiment, the present invention relates to a method of treating MPN in a person, comprising the steps of: administering to the person an independently selected dose of 15 mg QD, 25 mg QD, 30 mg QD, 50 mg QD, 60 mg QD, 75 mg QD, 100 mg QD, 120 mg QD, 150 mg QD, 175 mg QD, 200 mg QD, 225 mg QD, 240 mg QD, 250 mg QD, 275 mg QD, 300 mg QD, 325 mg QD, 350 mg QD, 360 mg QD, 375 mg QD, 480 mg QD, 15 mg BID, 25 mg BID, 30 mg BID, 50 mg BID, 60 mg BID, 75 mg BID, 100 mg BID, 120 mg BID, 150 mg BID, 175 mg BID, 200 mg BID, 225 mg BID, 240 mg BID, etc. Administer therapeutically effective doses of MDM2 inhibitors and JAK inhibitors at doses of 250 mg BID, 275 mg BID, 300 mg BID, 325 mg BID, 350 mg BID, 360 mg BID, 375 mg BID, and 480 mg BID. In one embodiment, MPN is selected from polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mastocytosis (SMCD). In one embodiment, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (PV-MF), and post-essential thrombocytosis myelofibrosis (ET-MF). In one embodiment, primary myelofibrosis (PMF) is selected from pre-fibrotic / early PMF and markedly fibrotic PMF.In one embodiment, the MPN is selected from chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia (aCML), juvenile myelomonocytic leukemia (JMML), eosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasms with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T). In one embodiment, the MDM2 inhibitor is a compound of formula (I) or (II). In one embodiment, the JAK inhibitor is selected from ruxolitinib, ruxolitinib-S, and finzotinib.

[0213] In one embodiment, the present invention relates to a combination of a therapeutically effective amount of an MDM2 inhibitor and a JAK inhibitor for treating MPN in humans, wherein the MDM2 inhibitor and the JAK inhibitor are independently selected from 15 mg QD, 25 mg QD, 30 mg QD, 50 mg QD, 60 mg QD, 75 mg QD, 100 mg QD, 120 mg QD, 150 mg QD, 175 mg QD, 200 mg QD, 225 mg QD, 240 mg QD, 250 mg QD, 275 mg QD, 300 mg QD, 325 mg QD, 350 mg QD, 360 mg QD, 375 mg QD, 480 mg QD, 15 mg BID, 25 mg BID, 30 mg BID, 50 mg BID, 60 mg BID, 75 mg BID, 100 mg BID, 120 mg BID, 150 mg BID, 175 mg BID, 200 mg BID, etc. Administered at doses of 225 mg BID, 240 mg BID, 250 mg BID, 275 mg BID, 300 mg BID, 325 mg BID, 350 mg BID, 360 mg BID, 375 mg BID, and 480 mg BID. In one embodiment, MPN is selected from polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mastocytosis (SMCD). In one embodiment, myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (PV-MF), and post-essential thrombocytosis myelofibrosis (ET-MF). In one embodiment, primary myelofibrosis (PMF) is selected from pre-fibrotic / early PMF and markedly fibrotic PMF. In one embodiment, MPN is selected from chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia (aCML), juvenile myelomonocytic leukemia (JMML), eosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T). In one embodiment, the MDM2 inhibitor is a compound of formula (I) or formula (II). In one embodiment, ruxolitinib, ruxolitinib-S, and finzotinib are also mentioned.

[0214] The above methods can be used as first-line cancer treatment or after treatment with conventional chemotherapy active ingredients (including cyclophosphamide, fludarabine (FC chemotherapy) and chlorambucil).

[0215] The combination of MDM2 inhibitors and JAK inhibitors can also be used in conjunction with radiotherapy, hormone therapy, surgery, and immunotherapy, treatments that are well known to those skilled in the art. Example

[0216] The embodiments covered herein are now described with reference to the following examples. These examples are provided for illustrative purposes only, and the disclosure covered herein should in no way be construed as limiting to these examples, but rather as covering any and all variations that become apparent from the teachings provided herein. Example 1: Effect of the combination of compound (I) and JAK inhibitor on CD34+ bone marrow cells from patients with myelofibrosis

[0217] The procedure for the effect of the compound of test formula (I) in combination with a JAK inhibitor on CD34+ bone marrow cells followed the procedure described in Lu, Blood (2012) 120(15); 3098-3105. The procedure is briefly described below.

[0218] Peripheral blood was obtained from patients with myelofibrosis (MF). Peripheral blood samples were plated onto a Ficoll-Hypaque (1.077 g / mL; GE Healthcare) and low-density monocytes were separated by centrifugation. CD34+ cells were isolated using a human CD34+ cell selection kit (StemCell Technologies) according to the manufacturer's instructions. The purity of the CD34+ cell population was analyzed using a FACSCalibur flow cytometer (BD Biosciences); and it was required to be at least 85% for all experiments. Fresh normal human bone marrow CD34+ cells from ALLCELLS were used as controls.

[0219] The effects of compounds of formula (I) in combination with ruxolitinib on MF patients were assessed by an HPC assay described in Lu, Blood (2012) 3098-3105. Briefly, CD34+ cells were cultured in serum-free medium (StemCell Technologies) containing 50 ng / mL stem cell factor (SCF), 50 ng / mL thrombopoietin (TPO), 50 ng / mL fms-like tyrosine kinase 3 (Flt-3) ligand, and 50 ng / mL IL-3, and treated for 4 days with various doses of compounds of formula (I) and / or ruxolitinib. After 4 days of treatment, CD34+ cells were measured in a semi-solid medium as described in Bruno, Blood, 2006, 3128-3134 (the entirety of which is incorporated herein by reference). Briefly, 5 × 10⁶ cells were plated per culture dish. 2 Two copies of CD34+ cells were cultured, each containing 1 mL of IMDM, 1.1% methylcellulose, and 20% FBS. SCF, TPO, Flt-3 ligand, IL-3, and GM-CSF (50 ng / mL each) and 2 U / mL erythropoietin (EPO) were added. After 14 days of incubation, colonies were counted, and individual colonies were isolated and genotyped for JAK2V617F.

[0220] Genomic DNA was isolated from randomly collected colonies using Extract-N-Amp Blood PCR Kits (Sigma-Aldrich). JAK2V617F was detected using nested allele-specific PCR as described in Bruno, Blood, 2006, 3128-3134. The final PCR products were analyzed on a 2.0% agarose gel. A 279-bp product indicated allele-specific JAK2V617F positivity, while a 229-bp product indicated JAK2V617F negativity. Colonies containing only a 279-bp band were classified as homozygous for JAK2V617F, while heterozygous colonies were identified based on the presence of both 279-bp and 229-bp bands.

[0221] Collect processed cells and wash with PBS for staining with annexin-V (BD Biosciences); the staining procedure was performed according to the manufacturer's protocol. Data were acquired on a FACSCalibur flow cytometer (BD Biosciences), with at least 10,000 live cells acquired for each analysis (BD FACSDiva software; BD Biosciences).

[0222] CD34+ cells were purified from peripheral blood of patients with myocardial infarction (MF) and cultured in serum-free medium containing SCF, FL-3 ligand, IL-3, and TPO. Cells were treated with various doses of compounds of formula (I) for 4 hours. Cells were harvested and whole-cell protein extracts were prepared using RIPA lysis buffer (Boston BioProducts) for Western blotting.

[0223] To prepare cytoplasmic and nucleoprotein fractions from cells of patients with myocardial infarction (MF), CD34+ cells were expanded for 10 days in serum-free medium containing SCF, FL-3 ligand, and IL-3. The CD34+ cells were then repurified and treated for 48 hours with various doses of compounds of formula (I) and / or ruxolitinib in the presence of SCF, FL-3 ligand, IL-3, and TPO. Protein extracts were prepared using the NE-PER nuclear and cytoplasmic extraction reagent (Thermo Scientific) according to the manufacturer's instructions.

[0224] Prior to Western blotting, all samples were denatured using Laemmli SDS sample buffer (Boston BioProducts) by heating at 95°C for 5 minutes. The samples were then separated on SDS-PAGE gels and transferred to polyvinylidene fluoride membranes (Bio-Rad). Phosphorylated p53, p53, MDM2, p21, p-STAT1, PUMA, and Bak were visualized using antibodies (Cell Signaling Technologies) and ECL Western blotting reagents (Denville Scientific).

[0225] The MDM2 / p53 inhibitory axis upregulates p21 expression, which functions to cause damaged cells to enter cell cycle arrest. MDM2 inhibitors must overcome this checkpoint to drive apoptosis. It is not surprising that the JAK inhibitor (i.e., ruxolitinib) does not regulate p21 expression, as ruxolitinib is not expected to biomodulate p21 expression. However, treatment of CD34+ bone marrow cells from patients with myelofibrosis with a combination of ruxolitinib and compounds of formula (I) did not result in an increase in p21 expression levels, despite the inclusion of treatment with an MDM2 inhibitor (compound of formula (I)). Upregulation of p21 expression in the presence of an MDM2 inhibitor was expected, but it was not. Because the p21 checkpoint was no longer required to be overcome, the apoptosis threshold was much lower, and more in vitro apoptosis was observed (see [link to relevant documentation]). Figure 1 ).like Figure 1 As shown, single-treatment with navtemadlin increased p21 levels (a precursor apoptosis checkpoint), while adding ruxolitinib to navtemadlin inhibited p21-mediated cell cycle arrest.

[0226] Example 2: Cytotoxicity of the combination of the compound of formula (I) with the JAK inhibitor in the UKE-1 cell line.

[0227] Cell viability was assessed following the procedure described in Canon et al., Mol Cancer Ther (2015) 14(3):649–658. The procedure is briefly described below.

[0228] UKE-1 cells were seeded at the optimal initial seeding density in 96 or 384-well plates to ensure that cells did not reach confluence at the end of the assay. Cells were treated with DMSO control or various concentrations of navtemadlin and ruxolitinib for 24 hours and incubated. The number of viable cells was determined using a commercial cell viability assay kit. Growth inhibition (GI) was calculated on a 200-point scale according to the following equation, where V 24 The luminescence of DMSO control over 24 hours, and T 24 Emission of the sample treated with the compound: if T 24 If V > 0, then GI = 100 × (1 - ((T)) 24 -V0) / (V 24 -V0)));If T 24 <V0, then GI=100×(1-((T) 24 -V0) / V0)). GI values ​​of 0, 100, and 200 represent uninhibited cell growth (i.e., DMSO control), cell arrest, and complete cell killing, respectively. Results showed... Figure 2 In A.

[0229] The HSA model (Combenefit software) was used to perform collaborative analysis on this data, and the results are shown in... Figure 2 In section B, the y-axis shows the percentage of baseline cell proliferation under control conditions (i.e., without navtemadlin and ruxolitinib). A decrease in y-axis values ​​corresponds to an increase in apoptosis. Dark blue / blue indicates drug combinations that induce synergistic apoptosis, exceeding the total cell death induced by the drugs alone.

[0230] Example 3: Apoptosis and protein expression after 24 and 72 hours of exposure to navtemadlin and ruxolitinib.

[0231] The effects of navtemadlin in combination with ruxolitinib on apoptosis and protein expression in progenitor cells derived from myelofibrosis subjects were evaluated. Figure 3As shown, navtemadlin, in combination with ruxolitinib, enhances apoptosis in progenitor cells derived from myelofibrosis subjects, and complete inhibition of p21 was observed in the presence of ruxolitinib. Viable cells were defined as CD45+ moderate, SSC low, CD14-, cPARP-. Figure 4 As shown, navtemadlin in combination with ruxolitinib reduced pro-survival MCL-1 levels.

[0232] The foregoing description is intended to teach those skilled in the art how to practice the invention and is not intended to detail all obvious modifications and variations that will become apparent to those skilled in the art upon reading the description. However, all such obvious modifications and variations are intended to be included within the scope of the invention as defined by the appended claims. Unless the context clearly indicates otherwise, the claims are intended to cover any order of components and steps that effectively fulfill their intended purpose.

Claims

1. A method for inhibiting p21 expression levels in a person suffering from myeloproliferative neoplasm (MPN), the method comprising administering to the person a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein the MDM2 inhibitor is a compound of formula (I): Or a pharmaceutically acceptable salt thereof, wherein the administration inhibits the p21 expression level in the person compared to the p21 expression level in MDM2 inhibitor monotherapy.

2. The method of claim 1, wherein the administration inhibits p21 levels by at least 50%, optionally at least 60%, at least 70%, at least 80%, at least 90%, at least 95%, at least 96%, at least 97%, at least 98%, or at least 99%, compared to MDM2 inhibitor monotherapy.

3. The method of claim 1, wherein the administration stimulates apoptosis of malignant bone marrow cells in the person suffering from myeloproliferative neoplasm (MPN).

4. The method of claim 3, wherein the malignant cells are CD34+ bone marrow cells or CD45+ myeloblasts.

5. The method of any one of claims 1 to 4, wherein the MPN is polycythemia vera (PV).

6. The method of any one of claims 1 to 4, wherein the MPN is thrombocytosis.

7. The method of claim 6, wherein the thrombocytosis is essential thrombocytosis (ET).

8. The method of any one of claims 1 to 4, wherein the MPN is myelofibrosis.

9. The method of claim 8, wherein the myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia vera myelofibrosis (post-ET MF).

10. The method of any one of claims 1 to 4, wherein the MPN is chronic myeloid leukemia.

11. The method of any one of claims 1 to 4, wherein the MPN is systemic mastocytosis (SM).

12. The method of any one of claims 1 to 4, wherein the MPN is chronic neutrophilic leukemia (CNL).

13. The method of any one of claims 1 to 4, wherein the MPN is myelodysplastic syndrome (MDS).

14. The method of any one of claims 1 to 4, wherein the MPN is mast cell disease (SMCD).

15. The method of any one of claims 1 to 4, wherein the MPN is chronic eosinophilic leukemia.

16. The method of any one of claims 1 to 4, wherein the MPN is chronic myelomonocytic leukemia (CMML).

17. The method of any one of claims 1 to 4, wherein the MPN is atypical chronic myeloid leukemia (aCML).

18. The method of any one of claims 1 to 4, wherein the MPN is juvenile myelomonocytic leukemia (JMML).

19. The method of any one of claims 1 to 4, wherein the MPN is eosinophilic syndrome (HES).

20. The method of any one of claims 1 to 19, wherein the MDM2 inhibitor is a pharmaceutically acceptable salt of a compound of formula (I).

21. The method of any one of claims 1 to 20, wherein the compound of formula (I) is administered once daily at a dose selected from 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg and 480 mg.

22. The method of any one of claims 1 to 20, wherein the compound of formula (I) is administered twice daily at a dose selected from 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg and 480 mg.

23. The method of any one of claims 1 to 22, wherein the duration of treatment of the person with the MDM2 inhibitor is selected from about 14 days, about 21 days, about 28 days, about 35 days, about 42 days, about 49 days, and about 56 days.

24. The method of any one of claims 1 to 23, wherein the compound of formula (I) is administered orally.

25. The method of any one of claims 1 to 24, wherein the JAK inhibitor is selected from AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cedutinib, CHZ868, CYT387, decetinib, ENMD-2076, finzotinib, filogrinib, Ganettespib, INCB039110, INCB-047986, itatinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, NSC42834, NVP-BSK805, Olapinib, Pacitinib, Pixitinib, Pyridone 6, R348, RGB-286638, Ruxolitinib, Ruxolitinib-S, SAR-20347, SB1317, Soxitinib, TG101209, TG101348, Tofacitinib (3R,4S), Tofacitinib (3S,4R), Tofacitinib (3S,4S), Tofacitinib, TYK2-IN-2, Upatinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and their pharmaceutically acceptable salts.

26. The method of any one of claims 1 to 24, wherein the JAK inhibitor is selected from baricitinib phosphate, CYT387 mesylate, CYT387 sulfate, NS-018 hydrochloride, NS-018 maleate, NVP-BSK805 dihydrochloride, olatinib maleate, ruxolitinib phosphate, ruxolitinib sulfate, tofacitinib citrate, and ZM39923 hydrochloride.

27. The method of claim 25 or 26, wherein the JAK inhibitor is administered orally.

28. The method of any one of claims 1 to 4, wherein the MDM2 inhibitor is administered prior to the administration of the JAK inhibitor.

29. The method of any one of claims 1 to 4, wherein the MDM2 inhibitor is administered after the JAK inhibitor is administered.

30. The method of any one of claims 1 to 4, wherein the MDM2 inhibitor is administered simultaneously with the administration of the JAK inhibitor.

31. The method of any one of claims 1 to 30, wherein the therapeutically effective amount of the MDM2 inhibitor is 100 mg.

32. The method of any one of claims 1 to 31, wherein the MPN in the human subject has a JAK2V617F mutation.

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