Methods, systems, and compositions related to use of mu opioid receptor (MOR) antagonists

Abstract

The present disclosure relates to the use of mu opioid receptor (MOR) antagonists.

Description

[0001] Cross-reference to related applications

[0002] This application claims the benefit of U.S. Provisional Patent Application Serial No. 63 / 603,162, filed on December 21, 2023, the entire contents of which are incorporated herein by reference.

[0003] Government interests

[0004] This invention was made with government support under NIH grants R01DE033473, NIHS10OD032141, and P30CA047904. The government may enjoy certain rights in this invention. Technical Field

[0005] This disclosure relates to the use of μ-opioid receptor (MOR) antagonists, particularly axelopran. Background Technology

[0006] It is recognized that PD1 / PDL1 blockade can enhance antitumor effects in various solid tumors, including non-small cell lung cancer (NSCLC), melanoma, head and neck squamous cell carcinoma, renal cell carcinoma, urothelial carcinoma, high microsatellite instability colorectal cancer, cervical cancer, Hodgkin's lymphoma, hepatocellular carcinoma, and gastric cancer. However, clinical data on anti-PD1 / PDL1 therapy continue to show limited response rates, ranging from 20% to 50%. Previous studies have revealed a large cohort of patients with primary resistance who do not respond to PD1 / PDL1 blockade. Furthermore, some responders develop acquired resistance after initial response.

[0007] Furthermore, cancer treatment can be complicated by the use of opioids. Cancer and its treatment can cause pain for patients. Therefore, opioids are regularly prescribed to cancer patients to relieve pain. Recently, the results of clinical studies using anti-PD1 therapy have been analyzed based on opioid use (and / or opioid exposure levels), and this has also shown a correlation. Numerous observational studies across multiple tumor types have shown that opioids prescribed for pain are associated with worse outcomes in patients receiving anti-PD-1 / PD-L1 immunotherapy. Meta-analyses of these observational studies have shown that opioids reduce the expected ORR by approximately 50% and are associated with an increased hazard ratio for adverse outcomes in progression-free survival (HR 1.61; 95% CI 1.37–1.89) and overall survival (HR 1.67; 95% CI 1.30–2.14).

[0008] Therefore, there is a need to enhance the efficacy of PD1 / PDL1 anticancer therapies. Summary of the Invention

[0009] This disclosure relates to the use of μ-opioid receptor (MOR) antagonists.

[0010] The implementation includes a method involving diagnosing a patient suffering from cancer-related pain, administering an opioid to the patient to relieve the cancer-related pain, diagnosing the patient's cancer, administering a peripherally active μ-opioid receptor antagonist (PAMORA) to the patient, and treating the patient's cancer with a primary treatment, wherein the primary treatment is not the PAMORA, and wherein the PAMORA is maintained at a threshold level during the primary treatment.

[0011] Another implementation includes a method for treating cancer, which involves: administering acyclovir to establish a threshold concentration of acyclovir in a cancer patient, wherein the cancer patient is also receiving an opioid; after establishing the threshold concentration of acyclovir, treating the cancer patient with PD-1 / PD-L1 anticancer therapy; and maintaining the threshold concentration of acyclovir during the treatment.

[0012] Further embodiments of this disclosure include a method for treating immunosuppression secondary to opioid administration, which is performed by: diagnosing a patient suffering from pain; administering an opioid to the patient to relieve the pain; diagnosing an immune deficiency in the patient; administering a peripherally active μ-opioid receptor antagonist (PAMORA) to the patient; and treating the patient with a primary treatment, wherein the primary treatment is not the PAMORA, wherein the PAMORA is maintained at a threshold level during the primary treatment.

[0013] Brief description of the attached figures

[0014] Figure 1 The flowchart of the treatment of laboratory animals is shown.

[0015] Figure 2 A two-dimensional visualization of tumor volume changes relative to CD8+ T cell infiltration is shown. N=12 for each treatment condition.

[0016] Figure 3 Showing Figure 2 The two-dimensional plots showing tumor volume changes for each treatment relative to CD8+ T cell infiltration are differentiated based on the opioid status prior to immunotherapy.

[0017] Figure 4 The changes in tumor size with CD8+ T cell infiltration were shown in all treatment groups.

[0018] Figure 5This paper presents a summary of changes in tumor size with CD8+ T cell infiltration for three identified immune response categories, which depend on opioid status.

[0019] Figure 6 Results from a bioinformatics study are shown; Figure (AC) shows a computerized analysis of scRNA-seq from tumor-infiltrating leukocytes (TILs) in HNSCC patients, comparing those exposed to opioids with those not exposed to opioids. Opioid use reduced trans-TIL activity. OPRM1 Expression, including exhausted CD8+ T cells; Figure (DE) shows expression across multiple cell clusters. OPRM1 The proportions and mean expression levels were compared between the non-user and opioid exposure groups; Figure (F) shows the ratios and mean expression levels compared to the opioid exposure groups. OPRM1 Compared to CD8+ T cells, intratumoral... OPRM1 +CD8+ T cells overexpress several immune checkpoint markers TOX , ENTPD1 and receptors PDCD1 , HAVCR2 , LAG3 , CTLA4 Figure (G) shows a box plot comparing the overall tumor and normal tissue across multiple TCGA tumor types. OPRM1 Expression (log2 of TPM). Each pair of box plots represents a specific tumor type, with an asterisk indicating statistical significance. p≤ 0.05, p ≤ 0.01, (p ≤ 0.001). Head and neck tumors showed increased OPRM1 expression compared to normal tissues.

[0020] Figure 7 This showed that across multiple cell clusters, both in the solvent group and the opioid exposure group. OPRM1 Average expression ratio plot (A) and level plot (B). Data shows that opioid use in head and neck cancer patients leads to transtumor-infiltrating leukocytes. OPRM1 Lower expression was observed in exhausted CD8+ T cells (identified as Lag3+CTLA4+). Figure (C) shows that computational analysis of single-cell RNA sequencing from head and neck cancer patients who were not prescribed opioids revealed lower expression levels compared to... OPRM1 Compared to negative CD8+ T cells, intratumoral Oprm1 Positive CD8+ T cells strongly overexpress several immune checkpoint receptors ( PDCD1 , TIGIT , LAG3 , CTLA4Figure (D) shows that computer analysis of single-cell RNA sequencing of opioid-exposed head and neck tumors revealed that, compared with... OPRM1 Compared to negative CD8+ T cells, intratumoral expression OPRM1 CD8+ T cells do not strongly overexpress immune checkpoint receptors.

[0021] Figure 8 Figure (A) shows a heatmap illustrating the tumor types across different TCGA tumor types. OPRM1 Spearman correlation coefficients with various immune exhaustion and immune activation marker genes. Color gradients represent the strength and direction of the correlations, with solid squares highlighting significant correlations (p ≤ 0.05) and “X” marking insignificant correlations. Figure (B) shows the heatmap, which illustrates... OPRM1 Expressing the hazard ratio in determining outcomes across multiple TCGA tumor types. A positive hazard ratio indicates that with... OPRM1 Increased expression was associated with a higher risk of adverse outcomes, while negative hazard ratios indicated a protective effect. Solid squares represent significant hazard ratios (p ≤ 0.05), and “X” marks non-significant ratios. Figure (C) shows the gene module analysis, visualized across multiple TCGA cancer types. OPRM1 The correlation between gene expression and immune infiltration levels was investigated. Various computational methods were used to visualize the results, estimating the proportion of different immune cell types within tumor samples derived from overall gene expression data. Heatmap representations were also presented. OPRM1 The purity-adjusted partial Spearman correlation coefficient (rho) between expression and different immune cell types. The color gradient indicates the strength and direction of the correlation, with red indicating a positive correlation and blue indicating a negative correlation. Solid squares represent significant correlations (p ≤ 0.05), and "X" marks non-significant correlations.

[0022] Figure 9 Figure (A) shows the results of using quantitative real-time PCR in mouse oral cancer cell lines and mouse trigeminal ganglion (nerve tissue, positive control). Oprm1 and Tlr4 Relative gene expression (2-ΔCT); housekeeping genes = Actb Figure (BC) shows a quantitative analysis of MOC1 cell proliferation and migration after continuous treatment with 1-100 μM morphine for 24 and 48 hours. The control for the scratch assay was 0.5% FBS in the culture medium. One-way ANOVA was performed at each time point. p<0.05. (D) Quantitative real-time PCR in human oral cancer cell lines. OPRM1 and TlLR4 Relative gene expression (2-ΔCT); housekeeping genes = ACTBFigure (E) shows the concentrations of CD8+ donor PBMCs cultured 48 hours after administration of CD3 / CD28 plus 0.1–10 μM morphine, 10 μM morphine + 10 μM MNTX, or 10 μM morphine + 1 μM acyclovir, relative to the solvent control. IL2 and IFNY The fold change of the gene (2-ΔΔCT), the solvent control was established by administering the same volume of saline and DMSO (n=4 healthy donors). Invention Details

[0024] Before describing certain embodiments in more detail, it should be understood that this disclosure is not limited to the described embodiments and therefore variations are possible. It should also be understood that the technical terms used herein are for descriptive purposes only and are not intended to be limiting, as the scope of this disclosure will be defined only by the appended claims.

[0025] This article describes several definitions. These definitions are intended to cover syntactic equivalents.

[0026] Unless otherwise stated, the use of "or" means "and / or". Furthermore, the terms "comprising", "having", "including", and other forms of use are intended to be inclusive and mean that additional elements may exist besides those listed.

[0027] As used herein, the term “about” is intended to cover variation when referring to measurable values ​​(e.g., quantity, duration, etc.). However, such variation depends on the specific component being referred to and the context as understood by one of ordinary skill in the art.

[0028] When a range of values ​​is provided, it should be understood that every intermediate value between the upper and lower limits of the range (unless otherwise explicitly stated by the context, up to one-tenth of the lower limit unit) and any other value or intermediate value within the range are included in this disclosure. The upper and lower limits of these smaller ranges may be independently included within those smaller ranges and are also included in this disclosure, subject to any explicit exclusions within the range. When the range includes one or two limits, the range excluding any one or both of the included limits is also included in this disclosure.

[0029] 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 disclosure pertains. Although any methods and materials similar to or equivalent to those described herein may be used in the practice or testing of this disclosure, representative exemplary methods and materials are described here.

[0030] Each individual embodiment described and illustrated herein has its own components and features, which can be readily separated from or combined with features of any other several embodiments without departing from the scope or spirit of this disclosure. Any of the enumerated methods may be carried out in the order of the enumerated events or in any other logically possible order.

[0031] The implementation scheme of this disclosure may be implemented without any components not specifically mentioned in this disclosure.

[0032] The opioids used in this article include tramadol, hydromorphone, methadone, morphine, oxycodone, hydrocodone, codeine, hydroxymorphone, fentanyl, buprenorphine, and tapentadol.

[0033] Peripherally active μ-opioid receptor antagonists (PAMORA) include at least one of the following: bevenopran, methylnaltrexone, acillolan, naloxixol, naldemedine, naloxone methiodide (NLXM).

[0034] The primary treatments used in this article include pembrolizumab, nivolumab, atezolizumab, durvalumab, avelumab, cimiprimab, sintilimab, dostarlimab, tislelizumab, riverimab, envolizumab, toripalimab, camrelizumab, spartazumab, sunitinib, regorafenib, sorafenib, pazopanib, cabozantinib, axitinib, lenvatinib, tevozanib, tesimolimus, everolimus, aflibercept, and bevacizumab.

[0035] The implementation scheme described herein may include, consist substantially of, or consist of elements therein.

[0036] Unless otherwise stated, percentages are given as a percentage of total weight, and all embodiments and preferred features may be combined in any combination.

[0037] As used herein, the term "asilolone" includes asilolone having the following structure:

[0038] ,

[0039] It also includes pharmaceutically acceptable salts of acyclovir and stereoisomers of acyclovir.

[0040] Many drug resistance mechanisms have been proposed and studied, including tumor immunogenicity deficiency, MHC dysfunction, irreversible T cell depletion, resistance to IFN-γ signaling, immunosuppressive microenvironment, classical oncogene mutations, and acquired resistance.

[0041] Emerging evidence also shows that the diversity and composition of the gut microbiota can influence anti-PD1 / PDL1 efficiency. Differences among tumor-bearing mice depend on variations in their symbiotic microbiota. Oral administration of Bifidobacterium spp. ( Bifidobacterium This can enhance the efficacy of anti-PDL1 antibodies in mice. In patients, symbiotic microbial composition was found to be associated with clinical anti-PD1 / PDL1 response rates, and transplantation of fecal microbiota from responders into germ-free or antibiotic-treated mice fully utilized the inhibitory effect of PD1 blockade.

[0042] Many strategies have been proposed to overcome drug resistance, including T cell sensitization, reversing T cell exhaustion, increasing T cell infiltration, and combinations with other therapies. The latter strategy has proven successful in some combinations; however, increased immunoreactivity due to multiple agents has also led to increased off-target immunoreactivity, resulting in dose-limiting side effects such as colitis, pneumonia, hypothyroidism, arthralgia, and vitiligo.

[0043] The presence of CD8+ T cells in the tumor mesenchymal junction (TME) is a prerequisite for anti-PD1 / PDL1 therapy. Therefore, TIL density is positively correlated with PD1 / PDL1 blockade efficacy. Consequently, primary ICI resistance is usually accompanied by a decrease in intratumoral CD8+ T cell density. Conversely, therapeutic strategies developed to overcome ICI resistance should lead to an increase in intratumoral CD8+ T cells.

[0044] In all solid tumor studies conducted to date, a previously overlooked mechanism of ICI resistance is the role of μ-opioid receptors (MORs) in tumor progression and immunosuppression. A significant proportion of patients with solid tumors experience cancer-related pain, which is overwhelmingly managed with prescription opioids. This ranges from 25% to as high as 90%, depending on the cancer type and stage of progression. When analyzed as subgroups, opioid use has been consistently associated with worse outcomes and reduced survival. It seems plausible that opioid use may be a marker of more pain associated with more aggressive disease. Some studies have attempted to partially control for this confounding by stratifying patients based on both baseline pain and opioid use and comparing outcomes with those received other non-opioid analgesics (e.g., NSAIDs and gabapentin). In each case, an independent association between opioids and adverse outcomes has still been observed. An association between opioids and outcomes has been observed in retrospective analyses of large-scale randomized controlled trials in which inclusion / exclusion criteria were partially standardized to the study population. In NSCLC patients receiving checkpoint inhibitors, the association between opioids and impaired survival persisted after propensity score matching.

[0045] As mentioned above, the results of clinical studies using anti-PD1 therapy have also been analyzed based on opioid use (and / or opioid exposure levels), and this association has been shown. Numerous observational studies across multiple tumor types have demonstrated that opioids prescribed for pain are associated with worse outcomes in patients receiving anti-PD-1 / PD-L1 immunotherapy. Meta-analyses of these observational studies have shown that opioids reduce the expected ORR by approximately 50% and are associated with an increased hazard ratio for adverse outcomes in progression-free survival (HR 1.61; 95% CI 1.37–1.89) and overall survival (HR 1.67; 95% CI 1.30–2.14).

[0046] In any of these studies, the major mechanism of opioid-mediated adverse clinical outcomes has not been determined; however, some limited data have been reported in cases where ICI therapy has been investigated. A recent retrospective study reported immune function and outcomes in a cohort of 66 patients with recurrent or malignant neonatal angina (R / M HNSCC) who received anti-PD-1 monoclonal antibody therapy for R / M HNSCC, stratified according to prescribed opioid exposure. 63% of patients had taken opioids for pain prior to starting anti-PD-1 therapy; higher opioid use in this cohort was associated with lower intratumoral CD8 levels in tumor biopsy tissue prior to treatment. +T-cell density was correlated with significantly lower PFS and OS when using anti-PD-1 therapy. Notably, the objective response rate was 27.3% in 22 patients who did not use opioids for pain control, compared to 11.4% in 44 patients who did use opioids, and the only complete remission observed in this study occurred in a patient who did not use opioids for pain control.

[0047] Peripherally selective μ-opioid receptor antagonists can synergistically enhance the activity of anti-PD1 therapy in the absence of exogenous opioids. These agents are called PAMORA (peripherally active μ-opioid receptor antagonists) and do not cross the blood-brain barrier, preserving opioid-induced analgesia.

[0048] In an embryonic model (chicken embryo), PAMORA acillolam enhanced immune cell infiltration into transplanted tumors when administered in combination with anti-PD1 and bevacizumab (a VEGF inhibitor). In an syngeneic mouse model, PAMORA acillolam significantly reduced colon cancer tumor growth and increased survival when administered in combination with anti-PD1, even though anti-PD1 alone did not show significant activity. While the responsible mechanism is likely due to the inhibition of endogenous opioid activity of μ receptors at the tumor or immune system level, it remains unclear whether this activity would be replicated in subjects treated with exogenous opioids at levels used for cancer pain management.

[0049] Various MOR antagonists can be used in the methods of this disclosure. For example, in one embodiment, the μ-receptor opioid (MOR) antagonist is acillolan, naloxone, naldemeton-methyl, avimopan, or a combination thereof.

[0050]

[0051] In another embodiment, the MOR antagonist is acilolone, naloxone, or a combination thereof. In a preferred embodiment, the MOR antagonist is acilolone. In some embodiments, the MOR antagonist is a peripheral MOR antagonist. In one embodiment, the MOR antagonist does not include methylnaltrexone. In another embodiment, the MOR antagonist is a peripheral MOR antagonist that does not include methylnaltrexone. In another embodiment, the MOR antagonist does not include methylnaltrexone, naltrexone, and / or naloxone.

[0052] In some embodiments, the method requires the administration of a pharmaceutical composition containing a MOR antagonist (e.g., acillolan). Examples of suitable pharmaceutical compositions are described below. In one embodiment, the pharmaceutical composition is formulated for modified release. Alternatively, the pharmaceutical composition is formulated for modified release, local administration, or intravitreal injection. For example, the pharmaceutical composition is formulated for "modified release" when it is formulated for rapid / accelerated release, targeted release, controlled / pulsated release, delayed release to the lower intestine, or sustained release.

[0053] The method includes administering a MOR antagonist (e.g., asillolen) via various routes, including any of the administration routes described below. In one embodiment, the method includes oral administration of the MOR antagonist. In another embodiment, the method includes subcutaneous administration of the MOR antagonist. In yet another embodiment, the method includes intravitreal administration of the MOR antagonist. In an alternative embodiment, the method includes topical administration of the MOR antagonist.

[0054] In another embodiment, the method includes patient screening for the presence of cancer. These embodiments include collecting biological samples from patients and then testing the samples for the presence of cancer cells.

[0055] Other embodiments of this disclosure relate to the use of MOR antagonists (e.g., acillolam, naloxetine, or combinations thereof) in the preparation of medicaments for treating cancer. Further embodiments relate to the use of MOR antagonists (e.g., acillolam, naloxetine, or combinations thereof) for the treatment of cancer.

[0056] Furthermore, this disclosure provides combination therapies that include the use of a combination of a MOR antagonist with a checkpoint inhibitor and / or a VEGF antagonist. In some embodiments, the combination therapy is used to treat angiogenesis or cancer.

[0057] When two or three drugs are administered as part of the same course of treatment, these drugs are given to the subject in a “combination.” A course of treatment refers to the administration of a combination of drugs that a medical professional believes can act additively, complementaryly, synergistically, or otherwise in combination to produce a more beneficial outcome than would be expected from the administration of a single drug. A course of treatment can last one day or several days, but more commonly lasts several weeks.

[0058] When two drugs are administered in combination, various schedules can be used. In one case, for example and not limited to, drug 1 (e.g., a MOR antagonist) is administered first before drug 2 (e.g., a checkpoint inhibitor and / or a VEGF antagonist), and drug 1 is continued throughout the course of drug 2 administration; alternatively, drug 1 is administered after the start or completion of drug 2 therapy; alternatively, drug 1 is administered concurrently with the start of other cancer therapies. As used in this context, "concurrently" means administering the two drugs on the same day or over consecutive days.

[0059] Although some drugs can be formulated together in principle, they are usually administered as separate compositions. Similarly, although some drugs can be administered simultaneously, it is more common (especially for drugs administered by infusion) to administer them at different times of the same day, over several consecutive days, or according to an alternative schedule.

[0060] Therefore, one embodiment of this disclosure relates to a method of treating cancer, comprising administering to a cancer patient a MOR antagonist in combination with a checkpoint inhibitor and / or a VEGF inhibitor (e.g., a combination of a MOR antagonist and a checkpoint inhibitor and / or a VEGF inhibitor (e.g., bevacizumab)). In a preferred embodiment of these methods, the MOR antagonist is synergistically treated with the checkpoint inhibitor and / or the VEGF inhibitor. In one embodiment, the MOR antagonist is synergistically treated with a checkpoint inhibitor (an anti-PD1 antibody). One specific embodiment is a method of treating cancer using a synergistic combination of acyclovir and pembrolizumab (an anti-PD1 antibody). Another specific embodiment is a method of treating cancer using a synergistic combination of acyclovir, bevacizumab (an anti-VEGF antibody), and pembrolizumab (an anti-PD1 antibody). In other embodiments, the method comprises administering a combination of the MOR antagonist and the checkpoint inhibitor. In alternative embodiments, the method comprises administering a combination of the MOR antagonist and the VEGF antagonist.

[0061] Another embodiment of this disclosure relates to a method for improving the immune response to tumors, comprising administering a MOR antagonist in combination with a checkpoint inhibitor and / or a VEGF inhibitor to a cancer patient. In some embodiments, the method comprises administering a combination of the MOR antagonist and the checkpoint inhibitor. In other embodiments, the method comprises administering a combination of the MOR antagonist and the VEGF antagonist. In some embodiments, the method increases the infiltration of immune cells into the tumor. In a specific embodiment, the method increases the infiltration of NK cells, lymphocytes, and / or monocytes / macrophages. Alternatively, the method increases the infiltration of CD3+, CD244+, and MMD+ immune cells. In some embodiments, the MOR antagonist and the checkpoint inhibitor synergistically improve the immune response to tumors.

[0062] In certain specific implementations of the combination therapy, the MOR antagonist does not include methylnaltrexone and / or naloxone.

[0063] Various checkpoint inhibitors can be used in combination with MOR antagonists (e.g., acillolan). In some embodiments, the checkpoint inhibitor is a PD-1 / PD-L1 pathway inhibitor (e.g., an antibody). In other embodiments, the checkpoint inhibitor is an inhibitor of: CTLA-4; LAG-3; TIM-3; B7-H3; B7-H4; A2aR; NKG21; PVRIG; PVRL2; CEACAM 1; CEACAM 5; CEACAM 6; FAK; CCL2 / CCR2; LIF; CD45; CSF-1; SEMA4D; CLEVER-1; OX-40; IL-1; IL-6; or IL-8. In some embodiments, the checkpoint inhibitor is an antibody. Other examples of suitable checkpoint inhibitors are disclosed in Marin Acevedo et al., J Hematol Oncol (2021) 14:45, the disclosure of which is incorporated herein by reference for its relation to checkpoint inhibitors. In some embodiments, the checkpoint inhibitor is an antibody that binds to PD-1, such as a humanized antibody. In one embodiment, the checkpoint inhibitor is pembrolizumab.

[0064] In some embodiments of the combination therapy, the method includes oral or subcutaneous administration of a MOR antagonist. In other embodiments, the method includes administration of a pharmaceutical composition comprising a MOR antagonist and a pharmaceutically acceptable carrier as described herein. For example, the method includes administration of a pharmaceutical composition formulated for modified release. For example, the pharmaceutical composition is formulated for "modified release" when it is formulated for rapid / accelerated release, site-directed release, controlled / pulsed release, delayed release to the lower intestine, or sustained release. When used, the checkpoint inhibitor is administered concurrently with, before, or after a MOR antagonist (e.g., acillolan).

[0065] In some embodiments, the method includes administering an angiogenesis inhibitor. The angiogenesis inhibitor may be used alone or in combination with a checkpoint inhibitor. In some embodiments, the angiogenesis inhibitor is a VEGF inhibitor. The VEGF inhibitor may be used alone or in combination with a checkpoint inhibitor (e.g., an antibody that binds to PD-1, such as pembrolizumab). In some embodiments, the VEGF inhibitor is an anti-VEGF antibody (e.g., an anti-VEGF-A antibody). In some embodiments, the VEGF inhibitor is a humanized antibody. The antibody is an anti-VEGF-A antibody. In other embodiments, the VEGF inhibitor is bevacizumab. Other suitable VEGF inhibitors include, but are not limited to, Ziv-aflibercept, aflibercept, ranibizumab, pegaptanib, or fareximab. In some embodiments of the method (combination therapy), the VEGF inhibitor is administered intravenously. When used, the VEGF inhibitor is administered concurrently with, before, or after a MOR antagonist. In other embodiments, when used in combination with a checkpoint inhibitor, the VEGF inhibitor is administered simultaneously with, before, or after the checkpoint inhibitor (e.g., a PD-1 / PD-L1 pathway inhibitor).

[0066] In some embodiments, this disclosure relates to the use of the MOR antagonists and PD-1 / PD-L1 pathway inhibitors as described above in the preparation of medicaments for treating cancer. This disclosure also relates to the use of the MOR antagonists and PD-1 / PD-L1 pathway inhibitors as described above in the preparation of kits for treating cancer. Furthermore, this disclosure relates to the use of the MOR antagonists and PD-1 / PD-L1 pathway inhibitors as described above for treating cancer.

[0067] In another embodiment, this disclosure relates to the use of the MOR antagonist and the VEGF inhibitor as described above in the preparation of a medicament for treating cancer. Alternatively, this disclosure relates to the use of the MOR antagonist and the VEGF inhibitor as described above for treating cancer. Furthermore, this disclosure relates to the use of the MOR antagonist and the VEGF inhibitor as described above in the preparation of a medicament for treating cancer. Additionally, this disclosure relates to the use of the MOR antagonist and the VEGF inhibitor as described above in the preparation of a kit for treating cancer.

[0068] Furthermore, this disclosure relates to the use of the MOR antagonists, PD-1 / PD-L1 pathway inhibitors, and VEGF inhibitors described above in the preparation of medicaments for the treatment of cancer.

[0069] Furthermore, in one embodiment, this disclosure relates to a method of treating cancer comprising a combination of a MOR antagonist (e.g., acillolan) as described above and a PD-1 / PD-L1 pathway inhibitor (e.g., pembrolizumab) as described above, the method comprising administering the combination to a subject in need. In some embodiments, the combination further comprises a VEGF inhibitor (e.g., bevacizumab) as described above.

[0070] In a specific embodiment of the above methods and uses, the MOR antagonist is acilololane, and the checkpoint inhibitor is an anti-PD1 antibody, such as pembrolizumab. In an alternative embodiment of the above methods and uses, acilololane and pembrolizumab act synergistically. In other embodiments of the above methods and uses, the MOR antagonist is acilololane, the checkpoint inhibitor is an anti-PD1 antibody, such as pembrolizumab, and the VEGF inhibitor is bevacizumab. In yet another embodiment of the above methods and uses, acilololane, pembrolizumab, and bevacizumab act synergistically.

[0071] One embodiment is a composition comprising a synergistic amount of a MOR antagonist and a PD-1 / PD-L1 pathway inhibitor. In some embodiments of this composition, the MOR antagonist comprises acillolan, naloxone, methylnaltrexone, or a combination thereof. In one embodiment, the MOR antagonist is acillolan. The PD-1 / PD-L1 pathway inhibitor is an antibody, such as an antibody that binds to PD-1 (e.g., pembrolizumab). The antibody may be humanized.

[0072] In some embodiments, the present invention relates to pharmaceutical compositions containing a MOR antagonist configured for use in the methods described herein. In a preferred embodiment, the MOR antagonist is acillolun.

[0073] In some embodiments, the present invention relates to pharmaceutical compositions comprising a MOR antagonist and a checkpoint inhibitor and / or a VEGF antagonist. In another embodiment, the present invention relates to pharmaceutical compositions comprising a MOR antagonist and separate pharmaceutical compositions comprising a checkpoint inhibitor and / or a VEGF antagonist.

[0074] This document provides pharmaceutical compositions for treating cancer in subjects with this need. The pharmaceutical compositions comprise a MOR antagonist and a pharmaceutically acceptable carrier. In some embodiments, the pharmaceutical compositions comprise a checkpoint inhibitor and / or a VEGF antagonist.

[0075] In one embodiment, the pharmaceutical composition comprises acilolol, pembrolizumab, and / or bevacizumab. In another embodiment, the pharmaceutical composition comprises acilolol and pembrolizumab.

[0076] This pharmaceutical composition is in a form suitable for administration to a subject, or the pharmaceutical composition may further comprise one or more pharmaceutically acceptable carriers, one or more additional components, or combinations thereof. The various components of the pharmaceutical composition may be present in the form of physiologically acceptable salts, for example, in combination with physiologically acceptable cations or anions, as is well known in the art.

[0077] Pharmaceutical compositions that can be used in the methods of the present invention can be suitably developed for inhalation, oral administration, rectal administration, vaginal administration, parenteral administration, topical administration, transdermal administration, pulmonary administration, intranasal administration, buccal administration, ocular administration, intrathecal administration, intravenous administration, or other routes of administration. Other formulations considered include anticipated nanoparticles, liposome formulations, resealed red blood cells containing the active ingredient, and immunologically based formulations. One or more routes of administration will be apparent to those skilled in the art and will depend on any number of factors, including the type and severity of the disease being treated, the type and age of the veterinary or human patient being treated, etc.

[0078] The formulations of the pharmaceutical compositions described herein can be prepared by methods known or subsequently developed in any field of pharmacology. Typically, such preparation methods involve the step of combining the active ingredient with a carrier or one or more other auxiliary ingredients, and then, if desired or desired, shaping or packaging the product into the desired single-dose or multi-dose units.

[0079] The amount of active ingredient is typically equal to the dose of active ingredient to be administered to the subject, or a convenient fraction of that dose, such as half or one-third of the dose. The unit dosage form can be for a single daily dose or for multiple daily doses (e.g., about 1 to 4 or more times per day). When using multiple daily doses, the unit dosage form can be the same or different for each administration.

[0080] Although the description of the pharmaceutical compositions provided herein relates primarily to pharmaceutical compositions suitable for ethical administration to humans, those skilled in the art will understand that such compositions are generally suitable for administration to all species of animals. It is well understood that pharmaceutical compositions suitable for administration to humans can be modified to suit administration to a variety of animals, and that veterinary pharmacologists of ordinary skill can design and perform such modifications using only ordinary experiments (if any). Subjects contemplated for administration of the pharmaceutical compositions of the present invention include, but are not limited to, humans and other primates and mammals, including commercially relevant mammals such as cattle, pigs, horses, sheep, cats, and dogs. In one embodiment, the subject is a human or a non-human mammal, such as, but not limited to, horses, sheep, cattle, pigs, dogs, cats, and mice. In one embodiment, the subject is a human.

[0081] In one embodiment, the composition is formulated using one or more pharmaceutically acceptable excipients or carriers. In one aspect, a pharmaceutical composition for treating cancer in a subject is disclosed. The pharmaceutical composition contains a MOR antagonist. In another embodiment, the pharmaceutical composition further contains a checkpoint inhibitor, a VEGF antagonist, or a combination thereof. Available pharmaceutically acceptable carriers include, but are not limited to, glycerol, water, saline, ethanol, and other pharmaceutically acceptable salt solutions, such as salts of phosphates and organic acids. The carrier can be a solvent or dispersion medium containing, for example, water, ethanol, polyols (e.g., glycerol, propylene glycol, and liquid polyethylene glycol, etc.), suitable mixtures thereof, and vegetable oils. Proper flowability can be maintained, for example, by using a coating (e.g., lecithin), in the case of a dispersion, by maintaining the desired particle size, and by using a surfactant. Prevention of microbial action can be achieved by a variety of antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, ascorbic acid, thimerosal, etc. In many cases, it is preferred to include an isotonic agent in the composition, such as sugar, sodium chloride, or a polyol, such as mannitol and sorbitol. Long-term absorption of injectable compositions can be achieved by including a delayed absorption agent, such as aluminum monostearate or gelatin, in the composition.

[0082] The formulation can be mixed with conventional excipients, i.e., pharmaceutically acceptable organic or inorganic carrier substances suitable for oral, parenteral, nasal, intravenous, subcutaneous, enteral, or any other suitable mode of administration known in the art. The pharmaceutical formulation can be sterilized and, if desired, mixed with excipients such as lubricants, preservatives, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure buffers, coloring substances, flavoring substances, and / or aromatic substances. These can also be combined with other active agents (e.g., other analgesics) as needed.

[0083] The composition may contain about 0.005% to 2.0% of a preservative by weight of the total composition. The preservative is used to prevent spoilage upon exposure to environmental contaminants. Examples of preservatives that can be used according to the invention include, but are not limited to, those selected from benzyl alcohol, sorbic acid, parabens, imidazolidinyl urea, and combinations thereof. A particularly preferred preservative is a combination of about 0.5% to 2.0% benzyl alcohol and 0.05% to 0.5% sorbic acid.

[0084] The composition may contain antioxidants and chelating agents that inhibit the degradation of the compound. For some compounds, preferred antioxidants are BHT, BHA, α-tocopherol, and ascorbic acid, preferably in the range of about 0.01% to 0.3% by weight, and more preferably BHT in the range of 0.03% to 0.1% by weight, based on the total weight of the composition. Preferably, the chelating agent is present in an amount of 0.01% to 0.5% by weight, based on the total weight of the composition. Particularly preferred chelating agents include edetates (e.g., disodium edetate) and citric acid in the range of about 0.01% to 0.20% by weight, more preferably in the range of 0.02% to 0.10% by weight, based on the total weight of the composition. The chelating agent can be used to chelate metal ions in the composition that may be detrimental to the shelf life of the formulation. Although BHT and disodium edetate are particularly preferred antioxidants and chelating agents, respectively, for some compounds, other suitable and equivalent antioxidants and chelating agents, as known to those skilled in the art, can be substituted for them.

[0085] The pharmaceutical compositions disclosed herein can be used in combination with other therapeutic agents, such as antitumor agents, including but not limited to chemotherapeutic agents, antiproliferative agents, or any combination thereof. For example, the invention includes any of the following non-limiting exemplary categories of conventional chemotherapeutic agents: alkylating agents; nitrosoureas; antimetabolites; antitumor antibiotics; phytoalkaloids; taxanes; hormonal agents; and various other agents. In another aspect, the pharmaceutical compositions disclosed herein can be used in combination with radiotherapy.

[0086] In some embodiments of the invention, a MOR antagonist is administered simultaneously with a checkpoint inhibitor and / or a VEGF antagonist. In other embodiments, a checkpoint inhibitor and / or a VEGF antagonist are administered before the MOR antagonist is administered. In yet another embodiment, a checkpoint inhibitor and / or a VEGF antagonist are administered after the MOR antagonist is administered.

[0087] The administration regimen may affect factors constituting an effective dose. For example, the therapeutic agent may be administered to the patient subject before or after a cancer-related surgical intervention, or shortly after the patient is diagnosed with cancer. Furthermore, it may be administered daily or sequentially in several fractions and alternating doses, or the dose may be administered via continuous infusion or bolus injection. Additionally, the dose of the therapeutic agent may be increased or decreased proportionally as indicated by the emergency situation in the treatment or prevention.

[0088] The composition can be of any volume and can be used for single or multiple doses, including, but not limited to, from or from about 0.01 mL to 100 mL, 0.1 mL to 100 mL, 1 mL to 100 mL, 10 mL to 100 mL, 0.01 mL to 10 mL, 0.1 mL to 10 mL, 1 mL to 10 mL, 0.02 mL to 20 mL, 0.05 mL to 5 mL, 0.5 mL to 50 mL, or 0.5 mL to 5 mL, each including an endpoint.

[0089] The composition of the invention may be administered to a patient subject, preferably a mammal, more preferably a human, using known procedures to achieve a dosage and duration appropriate for the treatment of the subject's cancer. The effective amount of the therapeutic compound necessary to achieve a therapeutic effect may vary depending on factors such as: the activity of the particular compound used; the time of administration; the rate of excretion of the compound; the duration of treatment; other drugs, compounds, or materials used in combination with said compound; the state of disease or disorder; the age, sex, weight, condition, general health, and medical history of the patient being treated; and similar factors well known in the medical field. Dosing regimens may be adjusted to provide an optimal therapeutic response. For example, several fractional doses may be administered daily, or the dose may be reduced proportionally as indicated by the urgency of the treatment situation. A non-limiting example of an effective dose range of the therapeutic compound is about 0.01 to about 50 mg / kg body weight / day.

[0090] MOR antagonists can be administered to subjects frequently, such as several times a day, along with checkpoint inhibitors and / or VEGF receptor antagonists, or less frequently, such as once daily, once weekly, once every two weeks, once monthly, or even less frequently, such as once every few months or even once a year or less. It should be understood that, in non-limiting instances, the daily dose of the compound can be administered daily, every other day, every two days, every three days, every four days, or every five days. For example, for every other day administration, a 5 mg daily dose can be started on Monday, followed by the first subsequent 5 mg daily dose on Wednesday, the second subsequent 5 mg daily dose on Friday, and so on. The frequency of dosage will be apparent to those skilled in the art and depends on any number of factors, such as, but not limited to, the type and severity of the disease being treated, and the type and age of the animal. The actual dose level of the active ingredient in the pharmaceutical compositions of the present invention can be varied to obtain an amount of active ingredient that effectively achieves the therapeutic response required for a particular patient, composition, and administration mode without toxicity to the patient. Physicians or veterinarians with common skills in the art can readily determine and prescribe an effective amount of the desired pharmaceutical composition. For example, a physician or veterinarian may start with a dose of the compound of the present invention in the pharmaceutical composition at a level below that required to achieve the desired therapeutic effect, and gradually increase the dose until the desired effect is achieved.

[0091] In specific embodiments, it is particularly advantageous to formulate the compound in dosage units to facilitate administration and uniformity of dosage. As used herein, dosage units refer to physically discrete units suitable as a unit dose for treating a patient; each unit contains a predetermined amount of the therapeutic compound, calculated to produce the desired therapeutic effect when combined with a desired pharmaceutical solvent. The dosage unit form of the present invention is influenced by and directly depends on (a) the unique characteristics of the therapeutic compound and the specific therapeutic effect to be achieved, and (b) the inherent limitations in the field of formulating / preparing such therapeutic compounds for treating patients with cancer or other conditions.

[0092] Those skilled in the art will recognize that, although more than one route of administration may be used, a particular route may provide a more immediate and effective response than another. In some embodiments of the invention, the MOR antagonist is administered along with a checkpoint inhibitor and / or a VEGF antagonist via the same route of administration. In other embodiments, the MOR antagonist is administered along with a checkpoint inhibitor and / or a VEGF antagonist via different routes of administration.

[0093] The disclosed compositions (containing a MOR antagonist or a MOR antagonist combined with a checkpoint inhibitor and / or a VEGF antagonist) can be administered via inhalation, oral, nasal, rectal, parenteral, sublingual, transdermal, transmucosal (e.g., sublingual, tongue, buccal, urethral, ​​vaginal (e.g., vaginal and perivallary), nasal (internal) and (internal) rectal), intravesical, intrapulmonary, intraduodenal, intragastric, intrathecal, subcutaneous, intramuscular, intradermal, intraarterial, intravenous, intrabronchial, inhalation, and topical application. Suitable compositions and dosage forms include, for example, tablets, capsules, pouches, pills, gelatin capsules, troch, dispersants, suspensions, solutions, syrups, granules, beads, transdermal patches, gels, powders, microtablets, emulsions, lozenges, creams, pastes, plasters, lotions, discs, suppositories, liquid sprays for nasal or oral administration, dry powder or nebulized formulations for inhalation, and compositions and formulations for intravesical administration. It should be understood that the formulations and compositions used in this invention are not limited to the specific formulations and compositions described herein. In one embodiment, treatment with a MOR antagonist and / or treatment with checkpoint inhibitors and / or VEGF antagonists includes administration via routes selected from: inhalation, oral, rectal, vaginal, parenteral, topical, transdermal, pulmonary, intranasal, buccal, ocular, intrahepatic artery, intrapleural, intrathecal, intratumoral, intravenous, and any combination thereof.

[0094] The present invention also includes kits containing MOR antagonists, checkpoint inhibitors, and / or VEGF antagonists, wherein said kits are used to treat cancer. In one embodiment, the kit comprises a pharmaceutical composition containing a MOR antagonist and a pharmaceutically acceptable carrier. In one embodiment, the kit comprises a pharmaceutical composition containing a μ-receptor (e.g., acillolan) antagonist and a checkpoint inhibitor (e.g., pembrolizumab). In some embodiments, the pharmaceutical composition further comprises a VEGF inhibitor. The pharmaceutical composition may be formulated for modified release, local administration, or intravitreal injection.

[0095] In one embodiment, the kit comprises a pharmaceutical composition containing a μ-receptor (e.g., acillolan) antagonist and a checkpoint inhibitor (e.g., pembrolizumab). The kit also includes a separate pharmaceutical composition containing a VEGF inhibitor (e.g., pembrolizumab).

[0096] Example

[0097] The syngeneic mouse model of orthotopic oral cancer using the MOC1 cell line was used as the experimental model. MOC1 is the best preclinical model for studying the effect of morphine on immunotherapy response because, in the absence of exogenous opioids, most (80%) MOC1 tumors showed a complete response to anti-PD-1 therapy, as measured by tumor volume reduction and an increase of up to 20% in total CD8+ TILs and granzyme B-producing CD8+ TILs relative to the control (Zhou et al., 2022).

[0098] In this study, three drugs and their respective controls were used: solvent (saline) vs. morphine (10 mg / kg ip, twice daily); solvent (pH 7 PBS) vs. acillolam (1 mg / kg ip, co-injected with morphine or aPD-1); and allotype IgG vs. antiPD-1 (250 μg / injection, three times every other day). In previous studies relating morphine-induced immunosuppression or antiPD-1 immunotherapy responses in MOC1 transplantation models, no sex differences were identified; therefore, mice were evenly assigned to sex groups (total 48 mice).

[0099] Figure 1 This is a flowchart of the experimental treatment time. MOC1 cancer cells (7.5 x 10⁻⁶ cells) were used, diluted 1:1 with Matrigel in cell culture medium (total 30 µl). 5 Mice were inoculated onto the anterolateral aspect of the tongue, and the tumors grew to 200 mm. 3 Or larger (approximately 4 weeks). Measure tumor size using calipers and calculate tumor volume (mm). 3 Mice were then treated with morphine or morphine plus acyclovir for 4 days. On day 5, mice began treatment with either anti-PD1 immunotherapy alone or with acyclovir co-injection for 3 doses (days 5, 7, and 9). On day 10, tumor diameter was measured using calipers, and the relative change in tumor volume (RCTV) between treatment groups was calculated, which was the change in tumor volume (TV) (TV0) from the start of treatment to the endpoint (TVn) divided by TV0 (RCTV = [TVn - TV0] / TV0). Following measurements, tongue tissue was collected on day 10 for flow cytometry analysis of tumor-infiltrating lymphocytes (TILs).

[0100] This study aimed to replicate a common clinical cohort of HNC patients, where 50% of participants were receiving opioid therapy for pain control prior to their first cycle of anti-PD-1 therapy, while 50% were not using opioids. Therapeutic treatment options included 1) no treatment, 2) acillolan, 3) anti-PD-1 therapy, and 4) anti-PD-1 therapy plus acillolan. Results showed... Figure 2 In the study, tumor size showed changes with CD8+ lymphocyte infiltration.

[0101] In this cohort of participants, 50% had prior exposure to exogenous opioids before anti-PD1 therapy, and anti-PD1 alone did not significantly inhibit tumor growth (approximately 20% reduction). The modest effect of anti-PD1 therapy in this model study is similar to the 20% clinical response seen in a previously published cohort of HNC patients comprising 63% opioid-treated and 37% non-opioid-treated patients (25).

[0102] Compared with anti-PD1 therapy, both acilolol (44% reduction, P=0.0204) and acilolol plus anti-PD1 (75% reduction, P=0.001) significantly slowed tumor growth. The combination of the two agents produced synergistic activity, meaning that the therapeutic effect of the combination was greater than the additive effect of each agent alone.

[0103] With 50% of animals pretreated with morphine, neither anti-PD1 alone nor acilloren alone significantly altered CD8+ T cell infiltration into the tumor stroma. Figure 2 However, when both drugs were used together, CD8+ T cells increased significantly, by more than 250% relative to the solvent control (P=0.001).

[0104] A surprising finding was that the efficacy of acillolun as a single agent in reducing tumor growth appeared to occur without a significant increase in CD8+ T cell infiltration into the tumor stroma. In contrast, the combination therapy of acillolun and anti-PD1 significantly increased CD8+ T cell infiltration into the tumor while significantly reducing tumor growth. This suggests that acillolun may reduce tumor growth in part through one or more mechanisms different from anti-PD1.

[0105] Further research will be conducted by analyzing each subgroup based on opioid status (endogenous or endogenous plus exogenous (morphine) during the four days prior to the immunotherapy regimen). Figure 2 The data is displayed visually. Figure 3 In the study, tumor size was shown to vary with the percentage of CD8+ lymphocytes infiltrating the tumor matrix.

[0106] When anti-PD1 therapy is used alone, opioid status is a decisive factor in treatment outcome. Animals treated with anti-PD1 alone clearly split into two distinct groups. Those animals pretreated with morphine exhibited the largest tumors and lacked significant CD8+ lymphocyte infiltration. Therefore, morphine led to the complete failure of the anti-PD1 treatment regimen.

[0107] In contrast, under endogenous opioid conditions, animals treated with anti-PD1 showed the highest percentage of CD8+ TILs (p=0.005) and a significant reduction in tumor size (p=0.001). Under the other three treatment conditions, there was little difference in tumor size or CD8+ T cell infiltration between the morphine-treated and non-morphine-treated groups.

[0108] Tables 1 and 2 show... Figure 3 The data show tumor growth and T cell infiltration for each of the eight treatment conditions. Tumor growth in animals not previously treated with morphine was significantly inhibited by anti-PD1 (p=0.0238), accompanied by CD8+ T cell influx into the tumor (P=0.021). Although acilloren alone had no significant effect on tumor growth (P=0.4398) or CD8+ T cell infiltration (0.9699), when combined with anti-PD1, a more than additive reduction in tumor volume was observed (P=0.008), without accompanying CD8+ T cell infiltration. + The corresponding increase in T cell infiltration (P=0.9184) indicates the effectiveness of PAMORA.

[0109] Table 1

[0110]

[0111] Compared to the control without morphine solvent, tumor growth was slightly increased in the presence of morphine, but CD8+ T cell infiltration was significantly suppressed (p=0.001). Acilloren partially restored the blocked CD8+ T cell infiltration, but not to the levels seen in the absence of morphine. In the presence of morphine, anti-PD1 failed to induce CD8+ T cell infiltration into the tumor stroma, and this was accompanied by a further increase in tumor growth.

[0112] If acilolol is started during morphine treatment and continued along with anti-PD1 therapy, the failure of morphine-induced anti-PD1-induced CD8+ T cell infiltration can be completely prevented. When administered with morphine, the combination of acilolol and anti-PD1 showed similar levels of infiltration as seen with anti-PD1 alone in the absence of morphine.

[0113] Table 2

[0114]

[0115] Compared to morphine-free solvents

[0116] The presence of CD8+ T cells in the tumor microenvironment is not the only requirement for successful immunotherapy outcomes. The expression of exhaustion markers such as PD1 and TIM3 is also a determinant of the outcome. Therefore, the levels of exhaustion markers were also determined.

[0117] Under endogenous opioid conditions, PD1-expressing T cells decreased by approximately one-third with anti-PD1 treatment and increased with acilolol alone. However, when acilolol and anti-PD1 were administered together, PD1-expressing T cells decreased by 5-fold. In the presence of morphine, the number of cells positive for the exhaustion marker PD1 increased compared to that seen under endogenous opioid conditions. Both acilolol and anti-PD1 reduced the exhaustion marker by approximately 50%. However, when administered together, the exhaustion marker PD1 decreased by 10-fold, as shown in Table 3.

[0118] Table 3

[0119]

[0120] Under endogenous opioid conditions, no treatment significantly altered TIM3 expression. However, in the presence of morphine, compared to that seen under endogenous opioid conditions, there was an increase in TIM3-positive cells, a depletion marker, and both acyclovir and anti-PD1 reduced this depletion marker by approximately 40%. However, when administered together, the depletion marker TIM3 was reduced 10-fold, as shown in Table 4.

[0121] Table 4

[0122]

[0123] The results presented in this paper describe three different cases that define PD1-resistant responses. These overviews are in... Figure 4 , Figure 5 And in Table 5.

[0124] Table 5

[0125]

[0126] In the presence of elevated opioids (morphine), the tumor exhibited the highest growth rate across all test conditions, CD8+ T cells were unable to enter the tumor microenvironment, and those that did enter showed the highest percentage of T cells positive for exhaustion markers PD1 and TIM3.

[0127] In the presence of endogenous opioids, or in the presence of acyclovir (with or without morphine), tumors were of intermediate size and CD8+ T cell infiltration was increased compared to animals treated with morphine. This intermediate category is considered immune-permitted because significant antitumor responses were observed when anti-PD1 was added to the treatment regimen.

[0128] When anti-PD1 was administered under immunocompetent conditions, the tumor size was minimized, CD8+ T cell infiltration was maximized, and the expression of exhaustion markers was significantly reduced.

[0129] The expression of the OPRM1 receptor on tumor-infiltrating immune cells in patients with head and neck squamous cell carcinoma (HNSCC) was assessed using computational bioinformatics.

[0130] Computerized analysis of scRNA-Seq data from tumor-infiltrating leukocytes in head and neck cancer patients revealed that... OPRM1 Primarily expressed by CD8+ cells. Patients were then stratified based on opioid use, with the active opioid prescription at the time of resection as the boundary, demonstrating that opioid use reduced immune infiltration and OPRM1 Overall expression ( Figure 6 AE, Figure 7 We found that, particularly in patients who had not been prescribed opioids prior to resection, OPRM1+CD8+ T cells exhibited increased markers of exhaustion (e.g., PDCD1 , CTLA4 , LAG3 , TIGIT ) expression, and reduced cytokine (e.g. TGFB1 , IFNG , TNF )Express( Figure 6 F, Figure 7 Using the Cancer Genome Atlas (TCGA) database, cross-cancer types... OPRM1 Expression was compared with that in normal tissues matched to the tumor site; the results showed statistically significant expression in a variety of tumors, including squamous cells of the head and neck. Figure 6 G; Figure 8 ). OPRM1 Expression is associated with worsening survival across tumor types, as well as with immune exhaustion and impaired immune infiltration (e.g., TIMER, xCell, EPIC); Figure 8 Related to this. We were unable to detect it using quantitative PCR in nine human oral squamous cell carcinoma (oSCC) cell lines and five mouse oSCC cell lines. OPRM1 mRNA, and no proliferation or migration changes were found in response to morphine treatment. Figure 9 Another example of CD8+ T cells as a target of PAMORA to reverse opioid-induced immunosuppression is... Figure 9 The data shown in E clearly indicate that morphine treatment significantly reduces cytokine expression (a marker of T cell activation) on CD8+ T cells, and this suppression can be overcome by treatment with PAMORA agents (methylnaltrexone and acillolam). In summary, these data suggest that expression... OPRM1 CD8+ T cells may be target cells of opioid-induced immunosuppression and may exhibit reduced anti-tumor capabilities.

[0131] In bioinformatics analysis, single-cell RNA sequencing data from tumor-infiltrating lymphocytes (TILs) of patients with head and neck squamous cell carcinoma (HNSCC) were derived from GSE139324, which contained scRNA-Seq data from 16 opioid-free patients and 10 opioid-exposed patients. These data were processed using the 10X Genomics Cell Ranger pipeline. Seurat objects were created from the available raw gene expression matrices for each patient and normalized and integrated using R with the Seurat package. Principal component analysis (PCA) was performed, followed by clustering using 20 principal components at a resolution of 0.5. Immune cell clusters were visualized using UMAP and annotated based on gene markers from PanglaoDB. Features and violin plots visualized using the Plotly package were used to evaluate cross-immune cell clusters. OPRM1 Express.

[0132] The Gene_DE module of the Tumor Immunological Estimation Resource version 2 (TIMER2.0) (timer.cistrome.org / ) was used to assess the interaction between tumors and adjacent normal tissues. OPRM1 This module analyzes differential gene expression levels across all cancer types included in the Trans-Cancer Genome Atlas (TCGA). It visualizes these levels using box plots. OPRM1 Expression distribution in tumor and normal tissues. The statistical significance of differential expression was calculated using the Wilcoxon test.

[0133] Many features and advantages of this disclosure will be apparent from the detailed description, and therefore the appended claims are intended to cover all such features and advantages of this disclosure that fall within the true spirit and scope of this disclosure. Furthermore, since many modifications and variations will readily occur to those skilled in the art, it is not intended to limit this disclosure to the exact constructions and operations shown and described, and therefore all suitable modifications and equivalents falling within the scope of this disclosure may be used.

[0134] The following references are incorporated herein by reference in their entirety.

[0135]

[0136]

[0137]

[0138]

[0139]

[0140]

Claims

1. A method comprising: Patients diagnosed with cancer-related pain; Administering opioids to the patient to relieve the cancer-related pain; Diagnose the patient with cancer; The patient was administered a peripherally active μ-opioid receptor antagonist (PAMORA); and The patient’s cancer is treated with a primary treatment, wherein the primary treatment is not PAMORA; During the primary treatment, PAMORA is maintained at a threshold level.

2. The method of claim 1, wherein the opioid is selected from at least one of the following: tramadol, hydromorphone, methadone, morphine, oxycodone, hydrocodone, codeine, oxymorphone, fentanyl, buprenorphine, and tapentadol.

3. The method of claim 2, wherein the opioid substance is at least selected from morphine.

4. The method of any one of the preceding claims, wherein the PAMORA is selected from at least one of the following: bevinoplan, methylnaltrexone, asillolen, naloxetine, naldemetonine, avimopan or naloxone methyl iodide (NLXM).

5. The method of claim 1, wherein PAMORA is asilloran.

6. The method of claim 1, wherein PAMORA is methylnaltrexone.

7. The method of any one of claims 1-2 or 5-6, wherein the primary treatment comprises a checkpoint inhibitor and / or a VEGF inhibitor.

8. The method of claim 7, wherein the checkpoint inhibitor is a PD-1 / PD-L1 pathway inhibitor.

9. The method of claim 8, wherein the PD-1 / PD-L1 pathway inhibitor is an antibody.

10. The method of claim 9, wherein the antibody is an antibody that binds to PD-1.

11. The method of claim 10, wherein the antibody is a humanized antibody.

12. The method of claim 11, wherein the primary treatment comprises at least one of the following: pembrolizumab, nivolumab, atezolizumab, durvalumab, avelumab, cimiprimab, sintilimab, dostalimab, tislelizumab, rivaril, envorimab, toripalimab, camrelizumab, spartazumab, sunitinib, regorafenib, sorafenib, pazopanib, cabozantinib, axitinib, lenvatinib, tevozanib, tesimolimus, everolimus, aflibercept, and bevacizumab.

13. A method for treating cancer, comprising: Acyclovir was administered to establish a threshold concentration of acyclovir in cancer patients who were also receiving opioids. After establishing the threshold concentration of the acyclovir, the cancer patients were treated with PD-1 / PD-L1 anticancer therapy; and Maintain the threshold concentration of acyclovir during the treatment.

14. The method of claim 13, wherein the threshold concentration of acyclovir synergistically enhances the PD-1 / PD-L1 anticancer therapy.

15. The method of claim 1 or 13, further comprising maintaining the administration of acillolan while discontinuing the opioid in the patient.

16. A method for treating immunosuppression secondary to opioid administration, comprising: Diagnosing patients with pain; Administering opioids to the patient to relieve the pain; Diagnose the patient's immune dysfunction; The patient was administered a peripherally active μ-opioid receptor antagonist (PAMORA); and The patient was treated with a primary treatment, wherein the primary treatment was not PAMORA. During the primary treatment, PAMORA is maintained at a threshold level.

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