(S,E)-N-(1-cyclopropyl-3-(methylsulfonyl)allyl)-2-(1,1-difluoroethyl)-4- phenoxy pyrimidine-5-carboxamide for use in the treatment of cancer

Abstract

This invention discloses a method for treating diseases associated with microsatellite instability (MSI-H) and / or treating cancer patients who have relapsed under previous immunotherapy (e.g., checkpoint inhibitor therapy) using a WRN ATP-dependent helicase inhibitor (WRNi).

Description

Technical Field

[0001] This invention discloses a covalent, irreversible WRN ATP-dependent helicase inhibitor (WRNi), a pharmaceutical composition comprising WRNi, and a method of using WRNi to treat diseases associated with microsatellite instability (MSI-H). Background Technology

[0002] Microsatellite instability (MSI-H) is a genetic characteristic of some tumors that exhibit defects in the mismatch repair pathway. MSI-H is common in a variety of cancers, including endometrial cancer, gastric cancer, and colorectal cancer. In recent years, the development of immunotherapy has revolutionized the management of several cancer indications, and these therapies have shown particularly high efficacy in tumors presenting with MSI-H, leading to clinical approval for these drugs in this patient population. Although checkpoint inhibitors (CPIs) have shown high efficacy in MSI-H tumors, approximately 50% of these patients do not respond to CPIs, which support the development of novel treatments for them.

[0003] In recent years, the standard of care for MSI and / or dMMR tumors has shifted with the approval of several checkpoint inhibitors. While the response to immune checkpoint blockade is generally durable in MSI and / or dMMR solid tumors, 40% to 70% of these cancers remain unresponsive to immune checkpoint blockade or develop secondary resistance, and the use of checkpoint inhibitors may be limited by toxicity. Therefore, new therapies are needed for patients with MSI and / or dMMR tumors.

[0004] Several checkpoint inhibitors have been approved for the treatment of refractory dMMR / MSI solid tumors, such as pembrolizumab, dostarlimab, and nivolumab with or without ipilimumab. Despite the high response rates and durable responses observed with these checkpoint inhibitors, a significant proportion of dMMR / MSI tumors remain unresponsive or develop resistance mechanisms (Schoenfeld, AJ, and Hellmann, MD, “Acquired Resistance to Immune Checkpoint Inhibitors,” Cancer Cell, 2020, 37, 443-455). Therefore, there is a need to develop methods for treating tumors that have developed resistance or are unresponsive to therapies such as checkpoint inhibitors. Summary of the Invention

[0005] This article provides a compound having the structure of formula (I): Or a pharmaceutically acceptable salt thereof, used to treat cancer in patients who have previously received checkpoint inhibitor therapy.

[0006] The present invention also provides a method for treating cancer in a subject, comprising administering to the subject a therapeutically effective amount of a compound having the structure of formula (I) or a pharmaceutically acceptable salt thereof.

[0007] Other aspects and advantages of the invention will become apparent to those skilled in the art upon reading the following detailed description in conjunction with the accompanying drawings. Although the compounds and methods disclosed herein can be implemented in various forms, the following description includes specific embodiments, and it should be understood that this disclosure is illustrative and not intended to limit the invention to the specific embodiments described herein. Attached Figure Description

[0008] Figure 1 Kaplan-Meier curves are shown for (1) tumor volume and (2) mice implanted with PDX2 and treated daily with compound (I) at the indicated dose.

[0009] Figure 2 Kaplan-Meier curves are shown for (1) tumor volume and (2) mice implanted with PDX3 and treated daily with compound (I) at the indicated dose. Detailed Implementation

[0010] This article provides methods and uses for WRN inhibitors in the treatment of cancers (e.g., microsatellite instability-H tumors), and / or in patients with relapse following prior therapy (e.g., immunotherapy), wherein the WRN inhibitor is a compound having the structure of formula (I): Or a pharmaceutically acceptable salt thereof. The IUPAC name for compound (I) is (S,E)-N-(1-cyclopropyl-3-(methanesulfonyl)allyl)-2-(1,1-difluoroethyl)-4-phenoxypyrimidine-5-carboxamide. WO2024 / 010782 discusses compound (I) and its synthetic methods, the entire contents of which are incorporated herein by reference. In some embodiments, compound (I) or a pharmaceutically acceptable salt or solvate thereof comprises at least one radioisotope. Specific examples of radioisotopes include 2 H, 3 H, 13 C 14 C and 18 F.

[0011] As described in this article, WRN inhibitors have been found to potentially help treat certain types of cancer, more specifically, tumors. In some cases, these tumors are MSI-H tumors.

[0012] A collection of patient-derived xenografts (PDXs) from multiple patients, including those with MSI-H colorectal cancer (CRC), was constructed. The clinical histories of these patients were annotated, and two PDX models from the same patient were selected. One model was derived from surgical material prior to immunotherapy, while the other PDX was obtained after tumor progression following multiple lines of therapy, including immune checkpoint inhibitors.

[0013] This study aims to investigate whether novel WRN inhibitors have antitumor activity in both immunotherapy-naïve and immunotherapy-treated patients.

[0014] If the activity in both models is confirmed, it indicates that WRN inhibitors are useful in patients who progress after immunotherapy as well as as first-line treatment (i.e., untreated patients), and in the latter case, they can be used in combination with immune checkpoint inhibitors to delay or reduce the development of resistance.

[0015] The investigated agent, (S,E)-N-(1-cyclopropyl-3-(methanesulfonyl)allyl)-2-(1,1-difluoroethyl)-4-phenoxypyrimidine-5-carboxamide, is a novel covalently irreversible WRN helicase inhibitor that induces DNA damage accumulation and exhibits selective antitumor activity in MSI cell lines and in vivo mouse models (including patient-derived models). Details of this compound and its synthesis can be found in WO2024 / 010782.

[0016] The following definitions of general terms used in this specification apply whether the term appears alone or in combination with other groups.

[0017] Unless otherwise defined, 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. Although similar or equivalent methods and materials described herein may be used in the implementation or testing of this invention, suitable methods and materials are described below.

[0018] The term "inhibitor" refers to a compound that competes for, reduces or prevents the binding of a specific ligand to a specific receptor, or that reduces or prevents the function of a specific protein.

[0019] The terms "pharmaceutically acceptable carrier" and "pharmaceuticalally acceptable excipient" refer to carriers and excipients that are compatible with other components in a formulation, such as diluents or excipients. Such formulations are pharmaceutically acceptable.

[0020] The term "pharmaceutical composition" encompasses products containing a specific ingredient in a predetermined amount or proportion, and any product resulting from a direct or indirect combination of a specific ingredient in a predetermined amount. In particular, it encompasses products containing one or more active ingredients and optionally a carrier containing an inert ingredient, and any product resulting directly or indirectly from a combination, complexation, or aggregation of any two or more ingredients, or from the dissociation of one or more ingredients, or from other types of reactions or interactions of one or more ingredients.

[0021] "Therapeutic effective amount" means the amount of compound that, when administered to a subject to treat a disease state, is sufficient to produce such a therapeutic effect on that disease state. The "therapeutic effective amount" will depend on the compound, the disease state being treated, the severity of the disease being treated, the subject's age and relative health condition, the route and form of administration, the judgment of the attending physician or veterinarian, and other factors.

[0022] The terms “as defined herein” and “as described herein”, when referring to variables, are used by incorporating the broad definition of the variable as well as (if any) the specific, more specific, and preferred definitions.

[0023] When referring to chemical reactions, terms such as "treatment," "contact," and "reaction" refer to the addition or mixing of two or more reagents under appropriate conditions to produce a specific and / or desired product. It should be understood that the reaction producing a specific and / or desired product is not necessarily a direct result of mixing the initially added two reagents; that is, the mixture may contain one or more intermediates that ultimately lead to the formation of the specific and / or desired product. Treatment includes preventative treatment and relief of acute symptoms.

[0024] The term "pharmaceuticalally acceptable excipient" refers to any non-therapeutic and non-toxic ingredient used in the formulation of a pharmaceutical product, such as disintegrants, binders, fillers, solvents, buffers, tension modifiers, stabilizers, antioxidants, surfactants, or lubricants. As used herein, "pharmaceuticalally acceptable carrier" or "pharmaceuticalally acceptable excipient" is intended to include any and all materials compatible with drug administration, including solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic agents and absorption delay agents, as well as other materials and compounds compatible with drug administration. Unless any conventional media or reagent is incompatible with the active compound, it is contemplated for use in the compositions of the present invention. Co-active compounds may also be incorporated into the compositions.

[0025] The corresponding pharmaceutically acceptable salts formed with acids can be obtained by standard methods known to those skilled in the art, for example, by dissolving the compound of formula (I) in a suitable solvent such as dioxane or THF and adding an appropriate amount of the corresponding acid. The product can usually be separated by filtration or chromatography. The conversion of the compound of formula (I) into a pharmaceutically acceptable salt formed with a base can be achieved by treating the compound with such a base. One feasible method for forming such a salt is, for example, by adding a 1 / n equivalent of a basic salt such as M(OH) n (where M = metal or ammonium cation, n = number of hydroxide anions) is added to a solution of the compound in a suitable solvent (e.g., ethanol, ethanol-water mixture, tetrahydrofuran-water mixture), and the solvent is removed by evaporation or freeze-drying.

[0026] In various embodiments, the patient has received prior treatment prior to initiating treatment with a compound of formula (I) disclosed herein or a pharmaceutically acceptable salt thereof. In various cases, this prior treatment regimen is immunotherapy. In some embodiments, the immunotherapy of the prior treatment is a checkpoint inhibitor. In some embodiments, the checkpoint inhibitor is a CTLA-4 inhibitor, a PD-1 inhibitor, or a PD-L1 inhibitor. In some embodiments, the CTLA-4 inhibitor is ipilimumab (Yervoy). ® Or tremelimumab (GP-675,206). In some embodiments, the PD-1 inhibitor is selected from pembrolizumab (Keytruda). ® Nivolumab (Opdivo) ® ) and RN888. In some embodiments, the PD-L1 inhibitor is selected from atezolizumab (Tecentriq) and RN888. ® Avelumab (Bavencio) ® durvalumab (Imfinzi) TM In some embodiments, the PD-L1 inhibitor is atezolizumab (Tecentriq). ® ).

[0027] In various implementation schemes, the patient experiences a relapse that occurs during prior immunotherapy treatment.

[0028] In various embodiments, the cancer is thyroid cancer, colorectal cancer, melanoma, brain cancer, or non-small cell lung cancer. In some embodiments, the cancer is colorectal cancer.

[0029] In some implementation schemes, the patient has brain metastases.

[0030] Furthermore, this disclosure includes all optical isomers of the compound of formula (I), namely diastereomers, mixtures of diastereomers, racemic mixtures, all their respective enantiomers and / or tautomers, and, where applicable, their solvates.

[0031] If necessary, the racemic mixture of compounds of formula (I) can be separated to isolate individual enantiomers. This separation can be carried out by methods known in the art, such as coupling the racemic mixture of compounds with an enantiomerically pure compound to form a diastereomer mixture, followed by separation of the individual diastereomers by standard methods such as fractional crystallization or chromatography.

[0032] In embodiments providing optically pure enantiomers, optically pure enantiomers mean that the compound contains >90% by weight of the desired isomer, particularly >95% by weight, or more particularly >99% by weight of the desired isomer, said weight percentage based on the total weight of the compound's isomers. Chiral pure or chiral enriched compounds can be prepared by chiral selective synthesis or by enantiomer separation. Enantiomer separation can be performed on the final product or on a suitable intermediate.

[0033] Another embodiment provides a pharmaceutical composition comprising a compound of formula (I) or a pharmaceutically acceptable salt thereof, for the use described herein, and one or more therapeutically inert carriers, diluents, or excipients, and a method for preparing such a pharmaceutical composition. In one embodiment, the compound of formula (I) can be formulated into a galenally administered form by mixing it with a physiologically acceptable carrier (i.e., a carrier that is non-toxic to the recipient at the dose and concentration used) at ambient temperature, at an appropriate pH, and with the desired purity. The pH of the formulation depends primarily on the specific use and the concentration of the compound, but is preferably in the range of about 3 to about 8. In one embodiment, the compound of formula (I) is formulated in an acetate buffer at pH 5. In another embodiment, the compound of formula (I) is sterile. The compound can be stored, for example, as a solid or amorphous composition, a lyophilized formulation, or an aqueous solution.

[0034] The composition is formulated, dosage determined, and administered in accordance with good medical practice. Factors to be considered in this document include the specific condition being treated, the specific mammal being treated, the individual patient's clinical condition, the cause of the condition, the site of delivery of the drug, the method of administration, the timing of administration, and other factors known to the medical practitioner.

[0035] Pharmaceutical compositions can be obtained by processing a compound of formula (I) described herein with a pharmaceutically acceptable inorganic or organic carrier or excipient. For example, lactose, corn starch or derivatives thereof, talc, stearic acid or salts thereof can be used as carriers for tablets, coated tablets, sugar-coated pills, and hard gelatin capsules. Suitable carriers for soft gelatin capsules include, for example, vegetable oils, waxes, fats, semi-solid and liquid polyols. However, depending on the nature of the active ingredient, soft gelatin capsules generally do not require a carrier. Suitable carriers for preparing solutions and syrups include, for example, water, polyols, glycerin, and vegetable oils. Suitable carriers for suppositories include, for example, natural or hardened oils, waxes, fats, semi-liquid or liquid polyols.

[0036] In addition, pharmaceutical compositions may also contain preservatives, solubilizers, stabilizers, wetting agents, emulsifiers, sweeteners, colorants, flavoring agents, salts for regulating osmotic pressure, buffers, masking agents, or antioxidants. They may also contain other substances with therapeutic value.

[0037] Pharmaceutical compositions of compounds of formula (I) may be prepared and stored, alone or in combination with a second anticancer agent, by mixing the active ingredient having the desired purity with an optional pharmaceutically acceptable carrier, excipient, or stabilizer (Remington's Pharmaceutical Sciences, 16th edition, Osol, A. (ed.) (1980)), in the form of a lyophilized preparation or an aqueous solution. Acceptable carriers, excipients, or stabilizers are non-toxic to the recipient at the doses and concentrations used and include buffers such as phosphates, citrates, and other organic acids; antioxidants including ascorbic acid and methionine; preservatives (such as octadecyl dimethyl benzyl ammonium chloride; hexamethyl chloride; benzalkonium chloride, benzyl chloride; phenol, butanol, or benzyl alcohol; alkyl esters of p-hydroxybenzoate such as methylparaben or propylparaben; catechol; resorcinol; cyclohexanol; 3-pentanol; m-cresol); low molecular weight (less than) (Approximately 10 residues) polypeptides; proteins, such as serum albumin, gelatin, or immunoglobulins; hydrophilic polymers such as polyvinylpyrrolidone; amino acids such as glycine, glutamine, asparagine, histidine, arginine, or lysine; monosaccharides, disaccharides, and other carbohydrates including glucose, mannose, or dextrin; chelating agents such as EDTA; sugars such as sucrose, mannitol, trehalose, or sorbitol; salt-forming counterions such as sodium; metal complexes (e.g., zinc-protein complexes); and / or nonionic surfactants such as TWEEN. TM PLURONICS TM Or polyethylene glycol (PEG).

[0038] Pharmaceutical compositions of formula (I) include those suitable for oral, nasal, topical (including buccal and sublingual), rectal, vaginal, and / or parenteral administration. The compositions are readily available in unit dosage forms and can be prepared by any method known in the pharmaceutical field. The amount of active ingredient that can be combined with a carrier material to produce a single dosage form will vary depending on the host being treated and the specific route of administration. The amount of active ingredient that can be combined with a carrier material to produce a single dosage form is typically the amount of formula (I) compound that produces a therapeutic effect. Typically, this amount, in percentage terms, will be in the range of about 1% to about 90% of the active ingredient, preferably about 5% to about 70%, and most preferably about 10% to about 30%. Methods for preparing these compositions include the step of combining a formula (I) compound with a carrier and optionally one or more auxiliary components. Typically, pharmaceutical compositions are prepared by uniformly and tightly combining a formula (I) compound with a liquid carrier, or a finely dispersed solid carrier, or both, and then, if desired, shaping the product. Pharmaceutical compositions suitable for oral administration may be capsules, sachets, pouches, pills, tablets, lozenges (using a flavored base, typically sucrose and gum arabic or tragacanth), powders, granules, or solutions or suspensions in aqueous or non-aqueous liquids, or oil-in-water or water-in-oil liquid emulsions, or elixirs or syrups, or soft lozenges (using an inert base, such as gelatin and glycerin, or sucrose and gum arabic), and / or mouthwashes, etc., each containing a predetermined amount of a compound of formula (I) as an active ingredient.

[0039] The active ingredient can also be encapsulated in microcapsules, which are prepared, for example, by coagulation techniques or interfacial polymerization, such as preparing hydroxymethyl cellulose or gelatin microcapsules and poly(methyl methacrylate) microcapsules, for use in colloidal drug delivery systems (e.g., liposomes, albumin microspheres, microemulsions, nanoparticles, and nanocapsules) or in crude emulsions. Such techniques are disclosed in Remington's Pharmaceutical Sciences, 16th edition, Osol, A. (ed.) (1980).

[0040] Formulations intended for internal administration must be sterile. This can be easily achieved through filtration using sterile filter membranes.

[0041] Dosage can vary within a wide range and must, of course, be adjusted according to the individual needs of each specific case. In the case of oral administration, the adult dose can be approximately 0.01 mg to approximately 1000 mg daily of a compound of general formula (I) or a pharmaceutically acceptable solvate thereof. The daily dose can be administered as a single dose or in divided doses, and may be exceeded if deemed necessary. In the case of oral administration, administration can be performed after a high-fat meal or after a 10-hour fast.

[0042] Embodiments of the present invention All the individual implementation schemes described below can be combined together.

[0043] 1. Compounds of formula (I) Or a pharmaceutically acceptable salt thereof, for the treatment of cancer patients who have previously received checkpoint inhibitor therapy.

[0044] 2. Compounds of formula (I) Or a pharmaceutically acceptable salt thereof, for the treatment of patients with recurrent cancer who have previously received checkpoint inhibitor therapy.

[0045] 3. Compounds of formula (I) Or a pharmaceutically acceptable salt thereof, used to prevent the formation of treatment resistance, especially when such resistance has been observed in patients who have already received checkpoint inhibitor therapy.

[0046] 4. Compounds of formula (I) Or its pharmaceutically acceptable salts, used to reduce treatment resistance in cancer.

[0047] 5. Compounds of formula (I) Or a pharmaceutically acceptable salt thereof, for the treatment of recurrent cancers that have been treated with checkpoint inhibitors.

[0048] 6. A method for treating cancer, the method comprising administering an effective amount of a compound of formula (I). Or a pharmaceutically acceptable salt thereof, given to patients in need, wherein the patient with said cancer has previously received checkpoint inhibitor therapy.

[0049] 7. A method for reducing the recurrence and growth of cancer cells, comprising administering a therapeutically effective amount of a compound of formula (I), Or a pharmaceutically acceptable salt thereof, especially wherein the administration of said drug reduces the recurrent growth of cancer cells, more specifically, wherein recurrence is observed after prior administration of at least one checkpoint inhibitor.

[0050] 8. Use of a compound of formula (I) or a pharmaceutically acceptable salt thereof in the preparation of a medicament for treating cancer. Patients with the aforementioned cancer had previously received checkpoint inhibitor treatment.

[0051] 9. A compound, method, or use according to any one of embodiments 1 to 8, wherein the previously treated checkpoint inhibitor is selected from CTLA-4 inhibitors, PD-1 inhibitors, or PD-L1 inhibitors, optionally wherein the CTLA-4 inhibitor is ipilimumab (Yervoy). ® ) or trimelimumab (GP-675,206), optionally wherein the PD-1 inhibitor is selected from pembrolizumab (Keytruda). ® Nivolumab (Opdivo) ® ) and RN888, optionally wherein the PD-L1 inhibitor is selected from atezolizumab (Tecentriq) ® ), Bavencio ® ) and durvalumab (Imfinzi TM Alternatively, the PD-L1 inhibitor may be atezolizumab (Tecentriq®).

[0052] 10. A compound, method, or use according to any one of embodiments 1 to 9, wherein tumor recurrence occurs following prior treatment.

[0053] 11. A compound, method, or use according to any one of embodiments 1 to 10, wherein the cancer is thyroid cancer, colorectal cancer, melanoma, brain cancer, or non-small cell lung cancer.

[0054] 12. A compound, method, or use according to any one of embodiments 1 to 11, wherein the cancer is colorectal cancer.

[0055] 13. The compound, method, or use according to any one of embodiments 1 to 12, wherein the cancer is non-small cell lung cancer.

[0056] 14. The use, method or use of the compound according to any one of embodiments 1 to 13, wherein the patient has brain metastases.

[0057] 15. A compound, method, or use according to any one of embodiments 1 to 14, wherein the cancer is associated with microsatellite instability (MSI).

[0058] 16. A combination of a compound of formula (I) and a checkpoint inhibitor, for use in any one of embodiments 1-15.

[0059] 17. The method according to any one of embodiments 1-16, wherein a checkpoint inhibitor is also administered to the patient.

[0060] 18. The method of claim 17, wherein the checkpoint inhibitor is a CTLA-4 inhibitor, a PD-1 inhibitor, or a PD-L1 inhibitor, optionally wherein the CTLA-4 inhibitor is ipilimumab (Yervoy). ® ) or trimelimumab (GP-675,206), or optionally said PD-1 inhibitor is selected from pembrolizumab (Keytruda). ® Nivolumab (Opdivo) ® ) and RN888, optionally wherein the PD-L1 inhibitor is selected from atezolizumab (Tecentriq) ® ), Bavencio ® ) and durvalumab (Imfinzi TM Alternatively, the PD-L1 inhibitor may be atezolizumab (Tecentriq®).

[0061] 19. The method according to embodiment 18, wherein the checkpoint inhibitor is atezolizumab (Tecentriq). ® ).

[0062] 20. Use of a compound of formula (I) or a pharmaceutically acceptable salt thereof, according to any one of embodiments 1-19, in combination with a checkpoint inhibitor.

[0063] 21. The use described in Implementation Scheme 20, wherein the checkpoint inhibitor is atezolizumab (Tecentriq) ® ).

[0064] 22. A method of treating a patient with microsatellite instability-H (MSI-H) cancer, comprising administering the patient a therapeutically effective amount of a compound of formula (I): Or its pharmaceutically acceptable salt.

[0065] 23. The method of implementation scheme 22, wherein the patient is given immunotherapy before the administration of compound (I) is initiated.

[0066] 24. A method of treating a patient with cancer, comprising administering the patient a therapeutically effective amount of a compound of formula (I): Or its pharmaceutically acceptable salt. Immunotherapy was administered before starting the administration of compound (I).

[0067] 25. The method of implementation scheme 24, wherein the cancer is a microsatellite instability (MSI-H) cancer.

[0068] 26. The method of any one of implementations 23 to 25, wherein the immunotherapy is a checkpoint inhibitor.

[0069] 27. The method of embodiment 26, wherein the checkpoint inhibitor is a CTLA-4 inhibitor, a PD-1 inhibitor, or a PD-L1 inhibitor.

[0070] 28. The method of embodiment 27, wherein the CTLA-4 inhibitor is ipilimumab (Yervoy®) or trimemumab (GP-675,206).

[0071] 29. The method of embodiment 27, wherein the PD-1 inhibitor is pembrolizumab (Keytruda®), nivolumab (Opdivo®), or RN888.

[0072] 30. The method of embodiment 27, wherein the PD-L1 inhibitor is atezolizumab (Tecentriq®), avelumab (Bavencio®), or durvalumab (Imfinzi™).

[0073] 31. The method of embodiment 30, wherein the PD-L1 inhibitor is atezolizumab.

[0074] 32. The method of any one of implementations 23 to 31, wherein the patient has a relapse response to immunotherapy.

[0075] 33. The method of any one of Implementation 22 to 32, wherein the cancer is thyroid cancer, colorectal cancer, melanoma, brain cancer or non-small cell lung cancer.

[0076] 34. The method of implementation scheme 33, wherein the cancer is colorectal cancer.

[0077] 35. The method of any one of embodiments 22 to 33, wherein the patient has brain metastases.

[0078] 36. The method of any one of implementation schemes 22 to 35 further includes administering immunotherapy to the patient.

[0079] 37. The method of implementation scheme 36, wherein the immunotherapy is a checkpoint inhibitor.

[0080] 38. The method of embodiment 37, wherein the checkpoint inhibitor is a CTLA-4 inhibitor, a PD-1 inhibitor, or a PD-L1 inhibitor.

[0081] 39. The method of embodiment 37, wherein the CTLA-4 inhibitor is ipilimumab (Yervoy®) or trimemumab (GP-675,206).

[0082] 40. The method of embodiment 37, wherein the PD-1 inhibitor is pembrolizumab (Keytruda®), nivolumab (Opdivo®), or RN888.

[0083] 41. The method of embodiment 37, wherein the PD-L1 inhibitor is atezolizumab (Tecentriq®), avelumab (Bavencio®), or durvalumab (Imfinzi™).

[0084] 42. The method of embodiment 41, wherein the PD-L1 inhibitor is atezolizumab.

[0085] Example The following examples illustrate the contents of this disclosure, but do not limit it, and are merely representative.

[0086] Materials and Methods A collection of patient-derived xenografts (PDXs) from multiple patients has been established, including CRCs presenting as MSI-H.

[0087] For these patients, their clinical history was annotated, and two PDX models derived from the same patient were selected. One model was derived from surgical materials of the patient before receiving immunotherapy, and the second PDX was derived from surgical materials of the patient after tumor progression following multiple lines of therapy, including immune checkpoint inhibitors.

[0088] The aim of this study was to investigate whether a novel WRN inhibitor has antitumor activity in both immunotherapy-naïve and immunotherapy-treated patients.

[0089] If the activity can be confirmed in both models, it would indicate that WRN inhibitors (used in combination with immune checkpoint inhibitors) have practical value for patients undergoing immunotherapy as well as first-line patients.

[0090] Experimental setup: Two-mm × two-mm tumor fragments of PDX2 and PDX3 were subcutaneously implanted into the right flank of NSG mice (NSG mice (NOD scidgamma mice) are an immunodeficient laboratory mouse strain). When the tumor grew to 100-300 mm... 3 At that time, based on tumor volume (mm) 3The mice were randomly assigned to four groups, as described below: For each PDX, a total of 52 NSG mice were randomly divided into 4 groups, with 13 animals in each group. The oral medication treatments for each group of mice were as follows: (1)- Vector group: 13 NSG mice; (2) - Compound of formula (I) 5 mg / kg: 13 NSG mice; (3) - Compound of formula (I) 20 mg / kg: 13 NSG mice; (4) Compound of formula (I) 75 mg / kg: 13 NSG mice.

[0091] The compound of formula (I) was administered orally to mice in groups 2, 3, and 4 at doses of 5, 20, and 75 mg / kg, respectively, daily via gavage.

[0092] Animals underwent surgery and were subcutaneously inoculated with 100,000 cells per mouse. Measurements were taken after the tumor began to grow. Tumor volume was measured twice weekly using calipers, and mice were euthanized when the tumor diameter reached 1500 mm.

[0093] Treatment began after randomization (four weeks post-surgery). Each mouse received 0.1 mL of the appropriate dose of the compound or carrier daily.

[0094] Twenty-four hours after the first administration, three animals in each group were sacrificed, and the tumors were collected into two test tubes, immediately frozen in liquid nitrogen, and stored at -80ºC.

[0095] A carrier (500 mL) was prepared using reverse osmosis treated drinking water as a solvent: HPMC: 1.25% (w / v), 6.25 g in 500 mL of water DOSS: 0.1% (w / v), which is 0.5 g in 500 mL of water. Parabens: 0.2% (w / v) (9 / 1): Methylhydroxparabenzoate: 900 mg in 500 mL of water; Propylene hydrobenzoate: 100 mg dissolved in 500 mL of water Preparation of compound formulations: 75 mg / kg: 750 mg of compound (I) was dissolved in 40 mL of carrier (0.1 mL / mouse, containing 1.875 mg of compound).

[0096] 20 mg / kg: Diluted in 75 mg / kg test tubes (dilution ratio 1:3, 75) 5 mg / kg: Diluted in 20 mg / kg test tubes (dilution ratio 1:4) Shake overnight at 4°C.

[0097] result Figure 1 The top figure shows the tumor volume of mice implanted with PDX2 and treated daily with the compound of formula (I) at the indicated dose, and the bottom figure shows the Kaplan-Meier curve.

[0098] Figure 2 The top figure shows the tumor volume of mice implanted with PDX3 and treated daily with the compound of formula (I) at the indicated dose, while the bottom figure shows the Kaplan-Meier curves.

[0099] Conclusion: Compound (I) showed activity in both PDXs. These data suggest that compound (I) could be used for treatment after immunotherapy relapse, or as a first-line combination immunotherapy for MSI-H patients.

[0100] The pharmaceutical composition may conveniently contain about 1-500 mg, particularly 5-250 mg, of a compound of formula (I), such as 5, 25, 100, or 500 mg of a compound of formula (I). In some embodiments, the pharmaceutical composition containing a compound of formula (I) further contains about 1-500 mg, particularly 5-80 mg, of a MEK inhibitor, said MEK inhibitor being present in a fixed-dose conjugate form.

[0101] Non-limiting embodiments of the compositions disclosed herein include: Example A-1 Prepare tablets with the following composition using conventional methods: Table 1 - Tablet Composition Table 1 Tablet preparation process 1. Mix ingredients 1, 2, 3 and 4 and granulate with purified water.

[0102] 2. Dry the granules at 50°C.

[0103] 3. Pass the particles through a suitable grinding device.

[0104] 4. Add ingredient 5 and mix for 3 minutes; then press on a suitable press.

[0105] Example A-2 A film-coated tablet for oral administration may comprise a compound of formula (I) and the following excipients: sodium dodecyl sulfate, microcrystalline cellulose, lactose monohydrate, magnesium oxide, colloidal silica, croscarmellose sodium, and magnesium stearate. The coating mixture may comprise polyvinyl alcohol, polyethylene glycol, talc, titanium dioxide, iron oxide red, and iron oxide yellow. These tablets may be administered QD or BID and conveniently contain about 5–500 mg, particularly 25 mg or 200 mg, of the compound of formula (I).

[0106] Example B-1 Prepare capsules with the following composition: Table 2 – Capsules of Compounds of Formula (I) Table 2. Capsule preparation process 1. Place ingredients 1, 2 and 3 into a suitable mixer and mix for 30 minutes.

[0107] 2. Add ingredients 4 and 5, and stir for 3 minutes.

[0108] 3. Fill into suitable capsules.

[0109] First, the compound of formula (I), lactose, and corn starch are mixed in a mixer, and then further pulverized in a grinder. The mixture is returned to the mixer, talc is added, and it is thoroughly mixed. Finally, the mixture is filled into suitable capsules, such as hard gelatin capsules, using a machine.

[0110] Example B-2 Prepare soft gelatin capsules with the following composition using the components listed in Table 3 or Table 4: Table 3 -- Soft Gelatin Capsules Table 4 -- Soft Gelatin Capsules Preparation process The compound of formula (I) is dissolved in a warm melt of the other ingredients listed in Table 3 or Table 4, and the mixture is filled into soft gelatin capsules of appropriate size. The filled soft capsules are then processed using conventional methods.

[0111] Example C Suppositories with the composition shown in Table 5 were prepared. Table 5 - Suppository Composition Preparation process Melt the suppository base in a glass or steel container, stir thoroughly, and cool to 45°C. Then, add the finely powdered compound of type (I) and stir until completely dispersed. Pour the mixture into suppository molds of appropriate size and allow them to cool; then remove the suppositories from the molds and package them individually in waxed paper or metal foil.

[0112] Example D Prepare the injection solution with the composition shown in Table 6: Table 6 - Composition of Injection Solution Preparation process Dissolve the compound of formula (I) in a mixture of polyethylene glycol 400 and water for injection (partially). Adjust the pH to 5.0 with acetic acid. Adjust the volume to 1.0 ml by adding the remaining water. Filter the solution, fill vials with the appropriate excess, and sterilize.

[0113] Example E Prepare sachet with the following composition: Table 7 - Composition of Small Bags Preparation process The compound of formula (I) was mixed with lactose, microcrystalline cellulose, and sodium carboxymethyl cellulose, and granulated with an aqueous solution of polyvinylpyrrolidone. The granules were then mixed with magnesium stearate and flavoring agents and filled into small bags.

[0114] All features of WRN inhibitors disclosed in this specification (including any appended claims, abstracts, and drawings) and / or all steps of any disclosed methods or processes can be combined arbitrarily, except for combinations of at least some features and / or steps that are mutually exclusive. This invention is not limited to the detailed description of any embodiments of WRN inhibitors explicitly disclosed herein. Any embodiment of a WRN inhibitor described in this application can be combined with any other embodiment. This invention extends to any new feature disclosed in this specification (including any appended claims and abstracts) or any novel combination thereof, or any novel combination applicable to any WRN inhibitor embodiment, or any step applicable to any disclosed method or process.

Claims

1. Compound of formula (I): Or its pharmaceutically acceptable salts, for the treatment of patients with microsatellite instability (MSI-H) cancer.

2. The compound of claim 1, wherein the patient has received immunotherapy prior to initiating administration of the compound of formula (I).

3. Compound of formula (I): Or a pharmaceutically acceptable salt thereof, for the treatment of a patient with cancer, wherein the patient has received immunotherapy prior to the initiation of administration of compound (I).

4. The compound of claim 3, wherein the cancer is a microsatellite instability (MSI-H) cancer.

5. The compound used in any one of claims 2 to 4, wherein the immunotherapy is a checkpoint inhibitor.

6. The compound of claim 5, wherein the checkpoint inhibitor is a CTLA-4 inhibitor, a PD-1 inhibitor, or a PD-L1 inhibitor.

7. The compound of claim 6, wherein the CTLA-4 inhibitor is Yervoy (ipilimumab). ® ) or trimelimumab (GP-675,206).

8. The compound of claim 6, wherein the PD-1 inhibitor is pembrolizumab (Keytruda). ® Nivolumab (Opdivo) ® ) or RN888.

9. The compound of claim 6, wherein the PD-L1 inhibitor is atezolizumab (Tecentriq). ® ), Bavencio ® or durvalumab (Imfinzi) TM ).

10. The compound of claim 9, wherein the PD-L1 inhibitor is atezolizumab (Tecentriq). ® ).

11. The compound used in any one of claims 2 to 10, wherein the patient has relapsed from immunotherapy.

12. The compound used in any one of claims 1 to 11, wherein the cancer is thyroid cancer, colorectal cancer, melanoma, brain cancer, or non-small cell lung cancer.

13. The compound of claim 12, wherein the cancer is colorectal cancer.

14. The compound used in any one of claims 1 to 13, wherein the patient has brain metastases.

15. The compound used in any one of claims 1 to 14, wherein the patient is further given a checkpoint inhibitor, wherein the checkpoint inhibitor is selected from ipilimumab (Yervoy). ® ) and trimetumab (GP-675,206) are CTLA-4 inhibitors derived from pembrolizumab (Keytruda). ® Nivolumab (Opdivo) ® PD-1 inhibitors of RN888 and RN888, or those selected from atezolizumab (Tecentriq) ® ), Bavencio ® ) and durvalumab (Imfinzi TM PD-L1 inhibitors, preferably atezolizumab (Tecentriq) ® ).

16. A method of treating a patient with microsatellite instability-H (MSI-H) cancer, comprising administering to the patient a therapeutically effective amount of a compound of formula (I): Or its pharmaceutically acceptable salt.

17. The method of claim 16, wherein the MSI-H cancer is thyroid cancer, colorectal cancer, melanoma, brain cancer, or non-small cell lung cancer.

18. The method of claim 16 or 17, wherein the patient has previously been given immunotherapy to treat MSI-H cancer (or relapsed by said immunotherapy) (i.e., the compound of formula (I) is a second-line or higher-level therapy).

19. The method of claim 18, wherein the immunotherapy is a checkpoint inhibitor therapy.

20. The method of claim 19, wherein the checkpoint inhibitor is a CTLA-4 inhibitor, a PD-1 inhibitor, or a PD-L1 inhibitor.

21. The method of claim 20, wherein the CTLA-4 inhibitor is ipilimumab (Yervoy). ® ) or trimelimumab (GP-675,206).

22. The method of claim 20, wherein the PD-1 inhibitor is pembrolizumab (Keytruda). ® Nivolumab (Opdivo) ® ) or RN888.

23. The method of claim 20, wherein the PD-L1 inhibitor is atezolizumab (Tecentriq). ® ), Bavencio ® or durvalumab (Imfinzi) TM ).

24. The method of claim 23, wherein the PD-L1 inhibitor is atezolizumab (Tecentriq). ® ).

25. The method of claim 16 or 17, wherein the patient has not received treatment for MSI-H cancer (i.e., the compound of formula (I) is a first-line therapy).

26. The method of any one of claims 16 to 25, further comprising administering a checkpoint inhibitor to the patient.

27. The method of claim 26, wherein the checkpoint inhibitor is selected from ipilimumab (Yervoy). ® ) and trimetumab (GP-675,206) are CTLA-4 inhibitors derived from pembrolizumab (Keytruda). ® Nivolumab (Opdivo) ® PD-1 inhibitors of RN888 and RN888, or those selected from atezolizumab (Tecentriq) ® ), Bavencio ® ) and durvalumab (Imfinzi TM PD-L1 inhibitors, preferably atezolizumab (Tecentriq) ® ).

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