Methods of treatment of myelodysplastic syndrome

Abstract

To provide methods for monitoring therapeutic efficacy in subjects with myelodysplastic syndrome (MDS), to provide methods for identifying subjects with MDS for treatment with telomerase inhibitors, and to provide methods for treating MDS.SOLUTION: A method may include administering to a subject an effective amount of a telomerase inhibitor and assessing hTERT expression levels in a biological sample obtained from the subject. In some cases, a 50% or greater decrease in hTERT expression levels identifies a subject that is likely to benefit from treatment with a telomerase inhibitor. The subject may be naive to treatment with HMA, lenalidomide, or both.SELECTED DRAWING: None

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of priority to U.S. Provisional Application No. 62 / 772,861, filed November 29, 2018, U.S. Provisional Application No. 62 / 811,271, filed February 27, 2019, and U.S. Provisional Application No. 62 / 860,557, filed June 12, 2019, each of which is incorporated by reference in its entirety. [Background technology]

[0002] Myelodysplastic syndromes (MDS) are a group of conditions that include cancers of the blood and bone marrow. MDS also includes diseases such as refractory anemia, refractory anemia with blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia. MDS is a collection of hematological conditions involving ineffective production of myeloid class blood cells. In MDS, immature blood stem cells (blasts) never develop into normal red blood cells, white blood cells, or platelets. The blasts either die in the bone marrow or move into the blood, leaving less room in the bone marrow for healthy white blood cells, red blood cells, and / or platelets to form.

[0003] MDS primarily affects older adults and is characterized by anemia and other cytopenias, as well as a high risk of leukemic transformation (Cheson et al., Blood 2006;108:419-425). In clinical practice, MDS is suspected when anemia that is otherwise unexplained is associated with other cytopenias, elevated mean corpuscular volume, or elevated red cell distribution width. Diagnosis includes bone marrow and cytogenetic testing. The bone marrow is typically hyperproliferative. Diagnosis is based on demonstrating erythroid, granulocytic, or megakaryocytic dysplasia in 10% or more of the beneficial cells (Vardiman,et al., Blood 2009;114(5):937-951). MDS may progress over time. For example, MDS patients often develop severe anemia, requiring frequent blood transfusions. They also suffer from bleeding and infection risks, resulting from decreased or dysfunctional platelets and neutrophils, respectively. In some cases, the disease worsens and patients develop cytopenias (low blood cell counts) due to progressive bone marrow failure. In other cases, the disease transforms into acute myeloid leukemia (AML). Transformation to AML is said to occur when the overall percentage of myeloblasts in the bone marrow exceeds certain cutoffs (World Health Organization (WHO) 20% and French-American-British (FAB) 30%). Treatment options for patients with relapsed or erythropoietin-stimulating agent (ESA)-refractory lower-risk MDS are limited.

[0004] The standard prognostic tool for assessing MDS is the International Prognostic Scoring System (IPSS), which classifies patients into low-risk, intermediate-1, intermediate-2, and high-risk categories based on several prognostic variables, including bone marrow blasts, cytogenetic findings, and the presence or absence of cytopenias. The median survival times for these four groups are estimated to be 5.7, 3.5, 1.2, and 0.4 years, respectively. The median time to 25% of patients developing AML in these groups was 9.4, 3.3, 1.1, and 0.2 years, respectively (Greenberg et al., Blood 1997;89(6):2079-2088). Low-risk and intermediate-1 risk MDS patients can be referred to as having "low-risk" disease, and intermediate-2 and high-risk MDS patients can be referred to as having "high-risk" disease.

[0005] For patients aged 70 years or older in Western countries, the incidence of MDS is conservatively estimated at approximately 30-40 cases per 100,000 population per year. Due to the aging of the population, the number of MDS cases is expected to increase. Despite a decrease in the rate of leukemia transformation in low-risk patients, most patients are affected by anemia and anemia-related symptoms, which have a significant impact on patient-reported outcomes (Almeida et al., Leukemia Res. 2017;52:50-57). Many anemic patients with MDS eventually develop red blood cell ("RBC") transfusion dependence. Evidence suggests that iron overload due to chronic RBC transfusions may be a contributing factor to the overall morbidity of the disease (Malcovati et al., J Clin Oncol 2005;23:7594-7603; Malcovati et al., Haematologica 2006;91:1588-1590; Steensma DP., Mayo Clinic Proc. 2015;90(7):969-983). A retrospective analysis of 426 patients diagnosed with MDS according to WHO criteria in Italy between 1992 and 2004 showed that the need for 2 units of blood transfusion per month reduces the life expectancy of MDS patients by approximately 50% (Malcovati et al., Haematologica 2006).

[0006] The treatment strategy for MDS is mainly based on the IPSS score. In patients classified as IPSS intermediate-2 risk or high risk (high-risk MDS), the median survival time is only about 12 months if untreated, and the goal of treatment is to modify the disease course, avoid progression to AML, and prolong survival. In patients classified as IPSS low or intermediate-1 risk (low-risk MDS), survival is longer, but many patients die of causes other than MDS. Treatment for these patients is mainly aimed at improving cytopenias and transfusion outcomes, as well as improving quality of life (Ades et al., Lancet 2014;383(9936):2239-2252).

[0007] First-line treatment of anemia in patients with low-risk non-del(5q) MDS often involves the use of erythropoietin stimulating agents (ESAs) or other hematopoietic growth factors. High-dose ESAs (e.g., epoetin alfa), with or without granulocyte colony-stimulating factor, have produced erythroid response rates in the range of 30%-50% and with a median duration of 2 years (ibid.). Important favorable prognostic predictors of response to ESAs are low or absent need for RBC transfusions (<2 packed red blood cell units / month) and low serum erythropoietin levels (≦500 units / L) (Hellstrom-Lindberg et al., Br J Haematol. 2003;120(6):1037-1046). Several studies have shown that ESAs do not affect the risk of progression to higher-risk MDS and AML, strongly suggesting that ESAs may even improve survival in low-risk MDS compared with RBC transfusion alone (Garcia-Manero et al., J Clin Oncol. 2011;29(5):516-523). In the absence of concurrent progression to higher-risk MDS or AML, patients with primary refractory to ESAs or who relapsed within 6 months after achieving response were observed to have a relatively high risk of AML transformation (23.1%) and short survival (median 3 years), whereas patients who responded to treatment and relapsed >6 months had a better outcome after failure, with a 9% risk of AML at 7 years and a median overall survival of 4.5 years (Kelaidi et al., Leukemia 2013;27(6):1283-1290).

[0008] In the United States, there are no approved therapies for patients with low-risk non-del(5q) MDS who do not respond to ESAs, and treatment options after ESA failure are limited. Most patients with low-risk MDS ultimately require long-term RBC transfusions, often with iron overload (Ades et al., Lancet 2014; Fenaux et al., Blood 2013;121:4280-4286; Steensma et al., Mayo Clinic Proc. 2015). Life expectancy in MDS patients has been shown to be inversely related to RBC transfusion burden (Malcovati et al., Haematologica 2006). Patients with chronic anemia despite frequent RBC transfusions may be at risk for associated morbidity (e.g., heart failure, falls, fatigue) and reduced quality of life (Crawford et al., Cancer 2002;95:888-895).

[0009] Hypomethylating agents (HMAs) (e.g., azacitidine and decitabine) are approved for the treatment of all French-American-British (FAB) subtypes of MDS, including some patients with lower-risk MDS. Although these agents reduce the need for blood transfusions in patients with higher-risk MDS, there is no evidence that they improve the long-term outcomes of lower-risk patients who receive HMAs after ESA failure. A retrospective study of 1698 patients with non-del(5q) lower-risk MDS treated with ESAs showed no significant improvement in 5-year overall survival in patients (n=194) treated with HMAs after ESA failure (Park et al.,J Clin Oncol.2017;35(14):1591-1597). Other reports indicate that within cohorts of low-risk MDS patients who are transfusion-dependent after ESA failure, azacitidine induces RBC-TI in approximately 14-33% of patients (Fill et al., Clin Cancer Res. 2013;19:3297-3308; Thepot et al., Haematologica 2016;101:918-925; Tobiasson et al., Blood Cancer J. 2014:4,el89). Given the limited benefit and observed toxicities (neutropenia, infections), azacitidine cannot be recommended as treatment for these patients (Tobiasson et al., Blood Cancer J. 2014).

[0010] The del(5q) chromosomal abnormality is observed in 10-15% of patients with MDS and is associated with a favorable prognosis (Oliva et al., Ahh Hematol. 2013;92(1):25-32). Treatment with lenalidomide results in transfusion independence in approximately two-thirds of these patients (Ades et al., Lancet 2014; Fenaux et al., Blood 2013;121(21):4280-4286). In phase 3 trials, the median duration of TI was not reached (median follow-up, 1.55 years) (Fenaux et al., Blood 2011;118(14):3765-3776). Myelosuppression was the most frequently reported grade 3 or 4 toxicity, and close monitoring of blood counts is required during the first week of lenalidomide therapy (ibid.).

[0011] Lenalidomide is also being studied as a treatment for transfusion-dependent non-del(5q) MDS, which represents 85%-90% of the MDS population. The majority of these subjects do not respond to lenalidomide. Hematological toxicity (i.e., neutropenia and thrombocytopenia) was less severe than in del(5q) MDS patients (Loiseau et al., Exp Hematol. 2015;43(8):661-72). Similar to HMAs, treatment with lenalidomide after ESA failure has not been shown to significantly improve overall survival when used to treat low-risk non-del(5q) MDS patients (Park et al., J Clin Oncol. 2017). Immunosuppressive therapy is a treatment option for certain low-risk non-del(5q) patients, but no significant impact on transformation-free survival has been observed, and adverse events, including hematological toxicity, and associated serious adverse events (e.g., bleeding and infection) have been reported (Almeida Allogeneic stem cell transplantation is typically reserved for medically fit patients with high-risk MDS, but may be considered an option for lower-risk patients (e.g., patients younger than 60-70 years with IPSS intermediate-1 risk MDS, unfavorable cytogenetics, or persistent blast expansion) when other treatment options are ineffective (ibid.). [Prior art documents] [Non-patent literature]

[0012] [Non-Patent Document 1] Cheson et al.,Blood 2006;108:419-425 [Non-Patent Document 2] Vardiman,et al.,Blood 2009;114(5):937-951 [Non-Patent Document 3] Greenberg et al.,Blood 1997;89(6):2079-2088 Summary of the Invention [Means for solving the problem]

[0013] Methods for monitoring therapeutic efficacy in subjects with MDS are provided. Also provided are methods for identifying subjects with myelodysplastic syndromes (MDS) for treatment with a telomerase inhibitor and methods for treating MDS. The subject methods can include administering an effective amount of a telomerase inhibitor to a subject and evaluating hTERT expression levels in a biological sample obtained from the subject. In some cases, a 50% or greater decrease in hTERT expression levels identifies subjects likely to benefit from treatment with a telomerase inhibitor. The subject can be naïve to treatment with HMA, lenalidomide, or both. In some cases, the subject is classified as having low or intermediate-1 IPSS risk MDS and / or relapsed / refractory MDS to erythropoietin stimulating agents (ESAs). In certain cases, the subject is non-del5q. In some cases, the telomerase inhibitor is imetelstat or imetelstat sodium.

[0014] Methods are provided for treating MDS in a subject with a telomerase inhibitor. The telomerase inhibitor is imetelstat or imetelstat sodium. The subject can be naive to treatment with HMA, lenalidomide, or both. In some cases, the subject is classified as having low or intermediate-1 IPSS risk MDS and / or relapsed / refractory MDS to erythropoietin stimulating agents (ESAs). In certain cases, the subject is non-del5q. In some cases, the subject is classified as IPSS-R intermediate risk and poor cytogenetic risk.

[0015] The foregoing summary, as well as the following detailed description of the invention, will be better understood when read in conjunction with the accompanying drawings. For the purpose of illustrating the invention, the drawings show embodiments of the invention, it being understood, however, that the invention is not limited to the precise arrangements, examples, and instrumentalities shown. [Brief description of the drawings]

[0016] [Figure 1A]1A and 1B (first data cut) show waterfall plots of the longest transfusion-free interval (FIG. 1A) and absolute change in transfusion volume over the best 8-week interval (FIG. 1B) in a study of imetelstat sodium in red blood cell (RBC) transfusion-dependent (TD) patients, as described in the experimental section herein. HI-E=red blood cell hematological improvement (based on an increase in Hb above pretreatment levels of at least 1.5 g / dL for at least 8 weeks or a reduction in RBC transfusions of at least 4 units per 8 weeks compared to previous RBC transfusion burden (criteria adapted from IWG 2006)); HI-E Hb=HI-E with a sustained increase in hemoglobin of at least 1.5 g / dL for 8 weeks; TI=transfusion independence; TR=transfusion reduction of at least 4 units for 8 weeks. [Figure 1B] Same as above. [Diagram 2] FIG. 2 (first data cut) shows the hematology and imetelstat sodium dosing timeline for an exemplary 24-week transfusion-independent (TI) responder. [Figure 3A] Figures 3A and 3B (second data cut) show waterfall plots of the longest transfusion-free interval (Figure 3A) and absolute change in transfusion volume over the best 8-week interval (Figure 3B) in a study of imetelstat sodium in red blood cell (RBC) transfusion-dependent (TD) patients, as described in the experimental section herein. HI-E = red blood cell hematological improvement (based on an Hb increase above pretreatment levels of at least 1.5 g / dL for at least 8 weeks or a reduction in RBC transfusions of at least 4 units per 8 weeks compared to previous RBC transfusion burden (criteria adapted from IWG 2006)); TI = transfusion independence; TR = reduction in transfusions of at least 4 units over 8 weeks. [Figure 3B] Same as above. [Figure 4] FIG. 4 (second data cut) shows efficacy results in the EPO and RS subgroups. [Diagram 5]FIG. 5 (second data cut) shows the hematology and imetelstat sodium dosing timeline for an exemplary 24-week transfusion-independent (TI) responder over up to 115 weeks.

[0017] [Figure 6] FIG. 6 (second data cut) shows hemoglobin and imetelstat sodium dosing in patients with persistent TI. [Figure 7] FIG. 7 (fourth data cut) shows that mean hTERT RNA expression levels decline from pre-treatment baseline in patients during the first and second cycles of the study. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0018] The present application provides a method for monitoring the efficacy of treatment in a subject with MDS. Also provided are methods for identifying a subject with myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, and methods for treating MDS. The subject method may include administering an effective amount of a telomerase inhibitor to a subject and evaluating an hTERT expression level in a biological sample obtained from the subject. In some cases, a 50% or greater decrease in the hTERT expression level identifies a subject likely to benefit from treatment with a telomerase inhibitor. The subject may be naive to treatment with HMA, lenalidomide, or both. In some cases, the subject to be treated is classified as having low IPSS risk MDS, intermediate-1 IPSS risk MDS, MDS relapsing to erythropoietin stimulating agents (ESAs), MDS refractory to MS, or a combination thereof. The subject may also be non-del5q. For clarity of disclosure, and not by way of limitation, the detailed description of the invention is divided into subsections that describe or illustrate certain features, embodiments, or applications of the invention. In some embodiments, the subject is diagnosed with trisomy 8.

[0019] A.Definition As used herein, the term "about" when referring to a measurable value, such as an amount, temporal duration, and the like, is intended to encompass variations of ±20% to ±0.1% from the specified value, preferably ±20% or ±10%, more preferably ±5%, even more preferably ±1%, and still more preferably ±0.1%, where such variations are deemed appropriate for carrying out the methods of the present disclosure.

[0020] The term "pharmaceutical acceptable salt" refers to a salt that is acceptable for administration to a patient (e.g., a mammal) (a salt with a counterion that is acceptable for mammalian safety for a given dosage regimen). Such salts can be derived from pharmaceutical acceptable inorganic or organic bases and pharmaceutical acceptable inorganic or organic acids. "Pharmaceutical acceptable salt" refers to a pharmaceutical acceptable salt of a compound, which is derived from a variety of organic and inorganic counterions well known in the art, such as sodium, by way of example only, and, when the molecule contains a basic functional group, an organic or inorganic acid salt, such as hydrochloride. Pharmaceutically acceptable salts of interest include, but are not limited to, aluminum, ammonium, arginine, barium, benzathine, calcium, cholinate, ethylenediamine, lysine, lithium, magnesium, meglumine, procaine, potassium, sodium, tromethamine, N-methylglucamine, N,N'-dibenzylethylene-diamine, chloroprocaine, diethanolamine, ethanolamine, piperazine, zinc, diisopropylamine, diisopropylethylamine, triethylamine, and triethanolamine salts.

[0021] The term "salt thereof" refers to a compound formed when a proton of an acid is replaced by a cation (such as a metal cation or an organic cation). Preferably, the salt is a pharma- ceutically acceptable salt. By way of example, salts of the compounds of the present invention include those in which the compound is protonated by an inorganic or organic acid to form a cation, with the conjugate base of the inorganic or organic acid as the anion component of the salt. Salts of interest include, but are not limited to, salts of aluminum, ammonium, arginine, barium, benzathine, calcium, cesium, cholinate, ethylenediamine, lithium, magnesium, meglumine, procaine, N-methylglucamine, piperazine, potassium, sodium, tromethamine, zinc, N,N'-dibenzylethylene-diamine, chloroprocaine, diethanolamine, ethanolamine, piperazine, diisopropylamine, diisopropylethylamine, triethylamine, and triethanolamine. With respect to any oligonucleotide structure described herein that includes a backbone of internucleoside linkages, it is understood that such oligonucleotides may include any convenient salt form. In some embodiments, the internucleoside bond in its acidic form is shown for simplicity. In some cases, the salt of the subject compound is a monovalent cation salt. In certain cases, the salt of the subject compound is a divalent cation salt. In some cases, the salt of the subject compound is a trivalent cation salt. "Solvate" refers to a complex formed by the combination of a solvent molecule with a molecule or ion of the solute. The solvent can be an organic compound, an inorganic compound, or a mixture of both. Some examples of solvents include, but are not limited to, methanol, N,N-dimethylformamide, tetrahydrofuran, dimethylsulfoxide, and water. When the solvent is water, the solvate formed is a hydrate.

[0022] "Stereoisomer" and "stereoisomer" refer to compounds that have the same atomic connectivity but different arrangements of atoms in space. Stereoisomers include, for example, cis-trans isomers, E and Z isomers, enantiomers, and diastereomers. For any group that contains one or more substituents disclosed herein, it is of course understood that such group does not include any substitutions or substitution patterns that are sterically impractical and / or synthetically impractical. All stereoisomers are intended to be included within the scope of the present disclosure.

[0023] One of ordinary skill in the art will recognize that other tautomeric configurations are possible for the groups described herein. It is understood that all tautomeric forms of the subject compounds are encompassed by the depicted structures, even if not specifically shown, in which case one possible tautomeric configuration of the groups of the compounds is encompassed.

[0024] Pharmaceutically acceptable salt solvates of the stereoisomeric tautomers of the subject compounds are intended to be included within the scope of this disclosure.

[0025] Before describing certain embodiments in more detail, it is to be understood that the invention is not limited to certain embodiments described, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing certain embodiments only, and is not intended to be limiting, since the scope of the invention will be limited only by the appended claims.

[0026] When a range of values ​​is given, it is understood that each intervening value (to the nearest tenth of the lower limit, unless the context clearly dictates otherwise, between the upper and lower limits of the range) and each stated or intervening value is included in the invention. The upper and lower limits of these smaller ranges may be independently included in the smaller ranges, which are also encompassed in the invention, subject to any specifically excluded limit in the stated range. When the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the invention.

[0027] 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 belongs. In carrying out or testing the present invention, any methods and materials similar or equivalent to those described herein can be used, but representative exemplary methods and materials are described herein.

[0028] All publications and patents cited herein are incorporated by reference to the same extent as if each individual publication or patent was specifically and individually indicated to be incorporated by reference, and are incorporated by reference to disclose and describe the methods and / or materials for which the publications are cited. The citation of any publication is for its disclosure prior to the filing date and should not be construed as an admission that the invention is not entitled to antedate such publication by prior disclosure. Further, the publication dates provided may be different from the actual publication dates, which may need to be independently confirmed.

[0029] It should be noted that, as used in this specification and the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. It should also be noted that the claims may be drafted to exclude any optional element. As such, this statement is intended to serve as a prelude to the use of exclusive terminology such as "solely," "only," or the use of a "negative" limitation in connection with the recitation of claim elements.

[0030] The individual embodiments described and illustrated herein have discrete elements and features which may be readily separated from or combined with any of the features of the other several embodiments without departing from the scope and spirit of the invention. Any shown method can be carried out in the order of events shown or in any other order which is logically possible.

[0031] As used throughout, "MDS" refers to myelodysplastic syndrome(s).

[0032] B. Pharmacodynamics (PD) The present disclosure is based in part on pharmacodynamic effects showing a relationship between the response of subjects with MDS to telomerase inhibitor therapy and the reduction in the subjects' telomerase hTERT expression levels from baseline levels. For example, in the clinical studies described herein, a higher percentage of subjects in 8-week transfusion-independent (TI) responders achieved a 50% or greater reduction in hTERT RNA expression levels than did non-responders.

[0033] The present disclosure provides for the stratification and identification or selection of patients likely to benefit from telomerase inhibition therapy for MDS, as well as methods for monitoring response, recurrence, and prognosis of treated subjects.

[0034] Aspects of the present disclosure include a method for identifying or selecting a subject with myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, and a method for treating MDS. A method for monitoring the efficacy of treatment in a subject with MDS is also provided. In some cases, the pharmacodynamic effect that the subject method embodiment is based on is a 50% or more decrease in hTERT RNA expression, for example, a 60% or more decrease, a 70% or more decrease, a 80% or more decrease, or a 90% or more decrease.

[0035] Telomerase ribonucleoprotein consists of components or subunits, two of which are the telomerase RNA template (hTR) and the telomerase reverse transcriptase protein (hTERT). hTERT expression levels can be assessed, quantified, and / or measured using any convenient method. A variety of methods can be applied to amplify, detect, and measure the mRNA of telomerase components or associated proteins in body fluids. Methods and assays of interest that can be adapted for use in the subject methods include, but are not limited to, real-time quantitative RT-PCR assays (e.g., based on TaqMan fluorescent methodology), immunohistochemistry methods for protein expression, and methods described in U.S. Pat. No. 6,607,898; Bieche et al., Clin. Cancer Res February 1 2000(6)(2)452-459; Terrin et al. ("Telomerase expression in B-cell chronic lymphocytic leukemia predicts survival and delineates subgroups of patients with the same igVH mutation status and different outcome.”Leukemia 2007;21:965-972); and Palma et al. (“Telomere length and expression of An example is the method described in “Human telomerase reverse transcriptase splice variants in chronic lymphocytic leukemia.” Experimental Hematology 2013;41:615-626).

[0036] hTERT expression level can be evaluated or measured in any convenient target cell. Target cell can be any convenient cell of a patient, including but not limited to bone marrow or peripheral blood cells of a patient. In some cases, target cell is isolated from a bone marrow sample of a patient. In some cases, target cell is isolated from a peripheral blood sample of a patient. Target cell can be granulocyte.

[0037] hTERT RNA expression level can be evaluated or measured in an RNA sample using any convenient method. The RNA sample can be obtained by first obtaining a bone marrow sample, a peripheral blood sample, or both, and then isolating RNA from the bone marrow sample, the peripheral blood sample, or both. In one embodiment, obtaining a sample from a patient includes obtaining a bone marrow sample from a patient, isolating cells from the bone marrow sample, and extracting RNA and / or DNA from the isolated cells. In another embodiment, obtaining an RNA sample from a patient includes obtaining a peripheral blood sample from a patient, isolating cells (e.g., granulocytes) from the peripheral blood sample, and extracting RNA and / or DNA from the isolated cells.

[0038] C. Treatment Aspects of the present disclosure include methods of treating myelodysplastic syndromes (MDS) with a telomerase inhibitor in subjects who are naive to treatment with a particular agent (e.g., an agent selected from a hypomethylating agent (HMA) and lenalidomide). A subject is considered "naive" to a treatment if they have never received a particular treatment for a disease. Treating MDS patients relapsed / refractory to ESA therapy with imetelstat can improve outcomes, including reducing the incidence of anemia.

[0039] The subject is a mammalian animal that requires cancer treatment. Generally, the subject is a human patient. In some embodiments of the present invention, the subject may be a non-human mammalian animal (e.g., a non-human primate), an animal model (e.g., an animal such as a mouse or a rat that is used in screening, characterizing, and evaluating pharmaceutical drugs), and other mammalian animals. As used herein, the terms patient, subject, and individual are used interchangeably.

[0040] As used herein and as well understood in the art, "treatment" is an approach to obtain results, including beneficial or desired clinical results. For the purposes of the present invention, beneficial or desired clinical results include, but are not limited to, alleviation or amelioration of one or more symptoms, whether detectable or undetectable, reduction in the extent of disease, stabilization of disease state (i.e., not worsening), prevention of disease spread, delay or slowing of disease progression, improvement or mitigation of disease state, and remission (whether partial or complete). "Treatment" can also mean prolonging survival compared to the expected survival if not receiving treatment.

[0041] In certain cases, the subject methods provide an enhanced therapeutic response in subjects not previously treated with a hypomethylating agent (HMA) or lenalidomide, relative to subjects previously treated with such therapy. By "enhanced therapeutic response" is meant a statistically significant improvement in a primary and / or secondary endpoint of MDS treatment, and / or an improvement in one or more symptoms of MDS (e.g., symptoms as described herein), e.g., an improvement in the rate and / or duration of red blood cell (RBC) transfusion independence (TI), or the rate of hematological improvement (HI), compared to a suitable control. In some cases, the subject methods result in a sustained therapeutic effect of red blood cell (RBC) transfusion independence (TI), e.g., for 4 weeks or more, e.g., 5 weeks or more, 6 weeks or more, 7 weeks or more, 8 weeks or more, 9 weeks or more, 10 weeks or more, 12 weeks or more, 16 weeks or more, 20 weeks or more, 24 weeks or more, or more. In some cases, the time to TI and / or duration of TI is significantly improved. In certain cases, the subject methods provide a TI duration of 24 weeks or more, e.g., a duration of 30 weeks or more, 36 weeks or more, 42 weeks or more, 48 weeks or more, 60 weeks or more, or even longer.

[0042] Hypomethylating agents (HMAs) are agents that inhibit DNA methylation, for example by blocking the activity of DNA methyltransferase (DNA methyltransferase inhibitors / DNMT inhibitors). HMAs of interest include, but are not limited to, decitabine (CAS Registry Number: 2353-33-5; 5-aza-2'-deoxycytidine), azacitidine (CAS Registry Number: 320-67-2,5-azacitidine), and guadecitabine (SGI-110). In some cases, the subject is treatment naive to decitabine. In some cases, the subject is treatment naive to azacitidine. In other cases, the subject is treatment naive to both decitabine and azacitidine.

[0043] Lenalidomide is a drug used to treat various inflammatory diseases and cancers, including multiple myeloma and MDS. Lenalidomide (CAS Registry Number: 191732-72-6; 2,6-piperidinedione, 3-(4-amino-1,3-dihydro-1-oxo-2H-isoindol-2-yl)-); 3-(4-amino-1-oxoisoindolin-2-yl)piperidine-2,6-dione) is a derivative of thalidomide. Lenalidomide has a variety of mechanisms of action that result in a broad range of biological activity and can therefore be utilized in the treatment of various hematological and solid cancers.

[0044] Deletion 5q (del5q) refers to a chromosomal abnormality found in certain forms in MDS subjects (Adema et al., Haematologica. 2013 Dec;98(12):1819-1821; Sole et al., Haematologica 2005;90(9):1168-78). In some cases of the subject methods, the subject is a human patient with del5q. In some cases, the subject is a non-del5q human patient. A non-del5q subject is a subject that does not have a del5q chromosomal abnormality. In certain cases, the non-del5q subject is a human.

[0045] In certain cases, the subject has not been pretreated with either a hypomethylating agent (HMA) or lenalidomide, and does not have a del(5q) chromosomal abnormality (e.g., is non-del5q). In certain cases, the non-del5q subject is a human.

[0046] In certain embodiments, the subject is a human patient with medium or low cytogenetic risk. In some cases, the subject is a human patient diagnosed with trisomy 8. In certain cases, the subject is a human patient with mosaic trisomy 8. In other cases, the subject is a human patient with trisomy 8 without mosaicism. The term "mosaicism" is used herein in its conventional sense to mean a state in which cells in a subject have different genetic makeup. In the case of a human patient diagnosed with mosaic trisomy 8, some cells of the subject have three copies of chromosome 8, and other cells have two copies of chromosome 8.

[0047] In certain embodiments, a method includes identifying a subject having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, the method includes identifying a subject having trisomy 8 (with or without mosaicism), measuring hTERT expression levels in a biological sample obtained from the patient after administration of a telomerase inhibitor, and comparing the hTERT expression level in the biological sample to a baseline hTERT expression level before administration of the telomerase inhibitor, wherein a decrease in hTERT expression levels in the biological sample identifies a patient likely to benefit from treatment with the telomerase inhibitor.

[0048] In other embodiments, a method includes treating myelodysplastic syndrome (MDS) in a subject diagnosed with trisomy 8, the method includes identifying a subject diagnosed with trisomy 8, administering to the subject an effective amount of a telomerase inhibitor, and assessing hTERT expression levels in a biological sample obtained from the patient after administration of the telomerase inhibitor.

[0049] In yet another embodiment, a method comprises monitoring therapeutic efficacy in a subject having myelodysplastic syndrome (MDS), the method comprising measuring hTERT expression levels in a biological sample obtained from a patient diagnosed with trisomy 8 after administering a telomerase inhibitor and comparing the hTERT expression level in the biological sample to a baseline hTERT expression level before administering the telomerase inhibitor, wherein a 50% or greater decrease in hTERT expression levels in the biological sample identifies a subject likely to benefit from treatment with the telomerase inhibitor.

[0050] In the method according to certain embodiments, the subject is a patient diagnosed with trisomy 8. In other embodiments, the subject is a patient diagnosed with trisomy 8 and is naive to treatment with an agent selected from hypomethylating agents (HMA), lenalidomide, and combinations thereof. In other embodiments, the subject is a patient diagnosed with trisomy 8 and is a non-del5q human patient. In yet other embodiments, the subject is a patient diagnosed with trisomy 8 and the MDS is relapsed or refractory MDS, for example, relapsed / refractory MDS to erythropoietin stimulating agents (ESA).

[0051] D. Myelodysplastic syndrome (MDS) Myelodysplastic syndromes ("MDS") are a group of diseases that include cancers of the blood and bone marrow and, in some cases, can be characterized by cytopenias resulting from ineffective hematopoiesis. The subject methods can be used to treat a variety of MDS, including, but not limited to, refractory anemia, refractory anemia with excess blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, chronic myelomonocytic leukemia, MDS with isolated del(5q), and unclassifiable MDS.

[0052] MDS is characterized by clonal myeloproliferation arising from malignant progenitor cell clones with short telomeres and multiple clonal genetic abnormalities. Telomerase activity (TA) and human telomerase reverse transcriptase (hTERT) expression are significantly increased in MDS and play a role in dysregulating cell growth, which may lead to persistent and uncontrolled proliferation of malignant progenitor cell clones. Higher TA and hTERT, as well as shorter telomere length, are poor prognostic features of low-risk MDS patients, leading to shorter overall survival. There are limited therapeutic options for anemia in low-risk MDS patients who have relapsed after or are refractory to ESA therapy. Targeting MDS clones with imetelstat can improve outcomes, including anemia, in MDS patients who are relapsed / refractory to ESA therapy.

[0053] In some embodiments, the subject methods are used to alleviate at least one symptom associated with myelodysplastic syndrome (e.g., refractory anemia, refractory anemia with excess blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia). In some embodiments, the symptoms include shortness of breath, fatigue, weakness, fainting, nosebleeds, bruising, bleeding from the mouth or gums, bloody stools, petechiae, or stroke.

[0054] In some cases, the subject has relapsed or refractory MDS. "Refractory MDS" refers to a patient with residual MDS cells in the bone marrow after treatment with any favorable MDS-related therapy. "Relapsed MDS" refers to a patient with relapse of MDS cells in the bone marrow and loss of normal blood cells after remission. In certain cases, the subject has MDS that is relapsed / refractory to erythropoietin stimulating agents (ESAs). In some MDS cases, ESAs can increase hemoglobin levels and eliminate transfusion dependency over a period of time. ESAs of interest include, but are not limited to, erythropoietin-alpha, erythropoietin-beta, and darbepoetin.

[0055] In some embodiments, the subject is identified as a human patient with trisomy 8. In certain cases, the subject is a human patient with mosaic trisomy 8. In other cases, the subject is a human patient with trisomy 8 without mosaicism.

[0056] In certain embodiments of the subject method, the subject is classified as a low or intermediate-1 IPSS risk MDS subject. Myelodysplastic syndrome (MDS) patients can be classified into a low-risk group (low and intermediate-1 [INT-1] IPSS) with high apoptotic events in the bone marrow and defective response to cytokines (including erythropoietin) and a high-risk group (intermediate-2 [INT-2] and high IPSS) with a major change being a maturation block of bone marrow progenitors. In some cases, transfusion dependency is a poor prognostic variable. Thus, in certain embodiments of the method, the subject is red blood cell (RBC) transfusion dependent. In some cases, transfusion-dependent subjects require RBC transfusions of about 4 units or more for 8 weeks, or 4-14 units for 8 weeks, or about 6 units or more per 8 weeks, prior to administration according to the subject method. The unit of packed red blood cells (PRBCs) can be about 300 mL / unit. The unit of whole blood can be about 450-500 mL / unit.

[0057] The International Prognostic Scoring System (IPSS) is a system developed for staging MDS. The IPSS evaluates three factors: the percentage of leukemic blasts in bone marrow cells (scored on a scale of 0 to 2); chromosomal abnormalities in bone marrow cells (if present) (scored 0 to 1); and the presence of one or more blood cytopenias (scored 0 or 0.5). Each factor is given a score, with the lowest score having the best outlook. The factor scores are then summed to create the IPSS score. The IPSS classifies MDS patients into four groups: low risk, intermediate-1 risk, intermediate-2 risk, and high risk.

[0058] E. Telomerase inhibitors Any convenient telomerase inhibitor can be used in the subject method. In some embodiments, the telomerase inhibitor is an oligonucleotide having telomerase inhibitory activity, in particular an oligonucleotide as defined in WO2005 / 023994 and / or WO2014 / 088785, the disclosures of which are incorporated herein by reference in their entirety. In some cases, one or more telomerase inhibitors (e.g., two or three telomerase inhibitors) can be administered to a mammal to treat a hematological malignancy.

[0059] Imetelstat In certain embodiments, the telomerase inhibitor is imetelstat (including its tautomers and salts (e.g., pharma- ceutically acceptable salts)). Imetelstat is a first-in-class telomerase inhibitor with clinical activity in hematological malignancies (Baerlocher et al., NEJM 2015;373:920-928; Tefferi et al., NEJM 2015;373:908-919) (shown below). [ka] In the formula, "nps" represents a thiophosphoramidate bond, --NH--P(=O)(SH)--O--, connecting the 3'-carbon of one nucleoside to the 5'-carbon of an adjacent nucleoside.

[0060] In some cases, the telomerase inhibitor is imetelstat sodium (including its tautomers). Imetelstat sodium is the sodium salt of imetelstat, a 13-mer oligonucleotide N3'→P5'-thiophosphoramidate conjugated to a synthetic lipid. Imetelstat sodium is a covalently lipidated 13-mer oligonucleotide telomerase inhibitor (shown below) that is complementary to the human telomerase RNA (hTR) template region. The chemical name of imetelstat sodium is DNA, d(3'-amino-3'-deoxy-P-thio)(TAGGGTTAGACAA), 5'-[O-[2-hydroxy-3-(hexadecanoylamino)propyl]phosphorothioate], sodium salt (1:13) (SEQ ID NO: 1). Imetelstat sodium does not function via an antisense mechanism and is therefore free of the side effects commonly observed with such therapies. [ka]

[0061] Imetelstat Sodium Unless otherwise indicated or clear from the context, a reference herein to imetelstat also includes its tautomers and salts (e.g., pharma- ceutically acceptable salts). As mentioned above, imetelstat sodium is specifically the sodium salt of imetelstat. Unless otherwise indicated or clear from the context, a reference herein to imetelstat sodium also includes all its tautomers.

[0062] Imetelstat and imetelstat sodium can be produced, formulated, or obtained as described elsewhere (see, for example, Asai et al., Cancer Res., 63:3931-3939 (2003); Herbert et al., Oncogene, 24:5262-5268 (2005); and Gryaznov, Chem. Biodivers., 7:477-493 (2010)). Unless otherwise indicated or clear from the context, references to imetelstat herein also include salts thereof. As stated above, imetelstat sodium is specifically the sodium salt of imetelstat.

[0063] Imetelstat targets the RNA template of telomerase and inhibits telomerase activity and cell proliferation in various cancer cell lines and tumor xenografts in mice. Phase I studies in patients with breast cancer, non-small cell lung cancer, and other solid tumors, multiple myeloma, or chronic lymphocytic leukemia have provided pharmacokinetic and pharmacodynamic information. Subsequent Phase II studies in patients with essential thrombocythemia have demonstrated platelet lowering activity with a significant reduction in JAK2 V617F and CALR mutant allele burden. Imetelstat sodium is typically administered intravenously, and it is contemplated that other routes of administration, such as intrathecal administration, intratumoral injection, oral administration, etc., may be used in the practice of the subject method. Imetelstat sodium can be administered at doses comparable to those typically utilized in clinical settings. In certain embodiments, imetelstat sodium is administered as described elsewhere herein.

[0064] Certain embodiments are according to any one of the other embodiments, where imetelstat is limited to imetelstat sodium.

[0065] F. Pharmaceutical Compositions To facilitate administration, the telomerase inhibitors (e.g., as described herein) may be formulated into various pharmaceutical forms for administration purposes. In some cases, the telomerase inhibitors are administered as pharmaceutical compositions. The carriers or diluents of the pharmaceutical compositions must be "acceptable" in the sense of being compatible with the other ingredients of the composition and not deleterious to the recipient thereof. The pharmaceutical compositions may be in a unit dosage form suitable for administration, particularly orally, rectally, transdermally, parenterally by injection, or by inhalation. In some cases, administration may be via intravenous injection. For example, in preparing compositions in oral dosage form, any of the usual pharmaceutical media may be used, such as water, glycols, oils, alcohols, and the like, for oral liquid preparations (e.g., suspensions, syrups, elixirs, emulsions, and solutions), or solid carriers, such as starches, sugars, kaolins, diluents, lubricants, binders, disintegrants, and the like, for powders, pills, capsules, and tablets. Because of their ease of administration, tablets and capsules represent the most advantageous oral dosage forms, where a solid pharmaceutical carrier is obviously employed. For parenteral compositions, the carrier will usually comprise sterile water, at least in large part, although other ingredients, for example, to aid solubility, may be included. For example, injectable solutions can be prepared in which the carrier comprises saline solution, glucose solution, or a mixture of saline and glucose solutions. For example, injectable solutions can be prepared in which the carrier comprises saline solution, glucose solution, or a mixture of saline and glucose solutions. Injectable solutions containing the telomerase inhibitors described herein can be formulated with oils for sustained action. Suitable oils for this purpose are, for example, peanut oil, sesame oil, cottonseed oil, corn oil, soybean oil, synthetic glycerol esters of long chain fatty acids, and mixtures of these and other oils. Injectable suspensions can also be prepared, in which case suitable liquid carriers, suspending agents, and the like may be used. Also included are solid form preparations that are intended to be converted to liquid form preparations immediately prior to use. In compositions suitable for transdermal administration, the carrier optionally comprises a penetration enhancer and / or a suitable wetting agent, optionally combined with suitable additives of any nature in minor proportions that do not introduce significant deleterious effects on the skin.Such additives may facilitate application to the skin and / or may be useful in preparing the desired composition. The composition may be administered in a variety of ways, for example, as a transdermal patch, a spot-on, an ointment.

[0066] It is particularly advantageous to formulate the above-mentioned pharmaceutical composition in unit dosage form, in order to facilitate administration and ensure uniformity of dosage.As used herein, unit dosage form means a physically separate unit suitable as unit dosage, each unit containing a predetermined amount of active ingredient calculated to produce desired therapeutic effect together with required pharmaceutical carrier.The example of such unit dosage form is tablet (including divided tablet or coated tablet), capsule, pill, powder packet, wafer, suppository, injection solution or suspension, etc., and multiple separates thereof.

[0067] To enhance the solubility and / or stability of the drugs described herein in pharmaceutical compositions, it may be advantageous to use α-, β-, or γ-cyclodextrin or derivatives thereof, particularly hydroxyalkyl-substituted cyclodextrins, such as 2-hydroxypropyl-β-cyclodextrin or sulfobutyl-β-cyclodextrin. Co-solvents such as alcohols may also improve the solubility and / or stability of the telomerase inhibitors in pharmaceutical compositions.

[0068] Depending on the mode of administration, the pharmaceutical composition preferably comprises 0.05-99% by weight, more preferably 0.1-70% by weight, and even more preferably 0.1-50% by weight of a telomerase inhibitor described herein, and 1-99.95% by weight, more preferably 30-99.9% by weight, and even more preferably 50-99.9% by weight of a pharma- ceutical acceptable carrier (all percentages based on the total weight of the composition).

[0069] G. Administration and Dosing Regimens The frequency of administration can be any frequency that reduces the severity of MDS symptoms (e.g., as described herein) without causing significant toxicity to the subject. For example, the frequency of administration can be about once every two months to about once per week, alternatively about once per month to about twice per month, alternatively about once per six weeks, about once per five weeks, alternatively about once per four weeks, alternatively about once per three weeks, alternatively about once per two weeks, or alternatively about once per week. The frequency of administration can remain constant or can vary over the duration of the treatment. A course of treatment with a composition comprising one or more telomerase inhibitors can include a rest period. For example, a composition comprising a telomerase inhibitor can be administered weekly for a period of three weeks followed by a two-week rest period, and such a regimen can be repeated multiple times. As with the effective amount, various factors can affect the actual frequency of administration used for a particular application. For example, the effective amount, the duration of treatment, the use of multiple therapeutic agents, the route of administration, and the severity of the MDS and related conditions may require increased or decreased frequency of administration.

[0070] The effective duration for administering a composition comprising a telomerase inhibitor (e.g., imetelstat or imetelstat sodium) can be any duration that reduces the severity of MDS symptoms (e.g., as described herein) without causing significant toxicity to the subject. Thus, the effective duration can vary from one month to several months or years (e.g., one month to one year, three months to two years, three months to ten months, or three months to eighteen months). In general, the effective duration for treating MDS can range from two months to twenty months. In some cases, the effective duration can be as long as the individual subject is alive. Multiple factors can affect the actual effective duration used for a particular treatment. For example, the effective duration can vary depending on the frequency of administration, the effective amount, the use of multiple therapeutic agents, the route of administration, and the severity of MDS and related symptoms.

[0071] In certain cases, the course of treatment and the severity of one or more symptoms associated with MDS can be monitored.Any method can be used to determine whether the severity of MDS symptoms is reduced.For example, the severity of MDS symptoms (e.g., as described herein) can be evaluated using biopsy techniques.

[0072] The telomerase inhibitors used in the subject methods can be administered at any therapeutically effective dose, e.g., at doses comparable to those commonly used in clinical practice. Specific dosing regimens (e.g., recommended effective doses) for known and approved anticancer drugs are known to physicians and are set forth, for example, in the product descriptions in PHYSICIANS' DESK REFERENCE, 2003, 57th Ed., Medical Economics Company, Inc., Oradell, NJ; Goodman & Gilman's "THE PHARMACOLOGICAL BASIS OF THERAPEUTICS" 2001, 10th Edition, McGraw-Hill, New York, and / or are available from the Federal Drug Administration, and / or are discussed in the medical literature.

[0073] In some embodiments, the dose of the telomerase inhibitor, imetelstat sodium, administered to the subject is about 1.0 mg / kg to about 13.0 mg / kg. In other embodiments, the dose of the telomerase inhibitor is about 4.5 mg / kg to about 11.7 mg / kg, or about 6.0 mg / kg to about 11.7 mg / kg, or about 6.5 mg / kg to about 11.7 mg / kg. In some embodiments, the dose of the telomerase inhibitor is at least about 4.7 mg / kg, 4.8 mg / kg, 4.9 mg / kg, 5.0 mg / kg, 5.5 mg / kg, 6.0 mg / kg, 6.1 mg / kg, 6.2 mg / kg, 6.3 mg / kg, 6.4 mg / kg, 6.5 mg / kg, 6.6 mg / kg, 6.7 mg / kg, 6.8 mg / kg, 6.9 mg / kg, 7 mg / kg, 7.1 mg / kg, 7.2 mg / kg, 7.3 mg / kg, 7.4 mg / kg, 7.5 mg / kg, 7.6 mg / kg, 7.7 mg / kg, 7.8 mg / kg, 7.9 ... .2mg / kg, 7.3mg / kg, 7.4mg / kg, 7.5mg / kg, 7.6mg / kg, 7.7mg / kg, 7.8mg / kg, 7.9mg / kg, 8mg / kg, 8.1mg / kg, 8.2mg / kg kg, 8.3mg / kg, 8.4mg / kg, 8.5mg / kg, 8.6mg / kg, 8.7mg / kg, 8.8mg / kg, 8.9mg / kg, 9mg / kg, 9.1mg / kg, 9.2mg / kg, 9.3 mg / kg, 9.4mg / kg, 9.5mg / kg, 9.6mg / kg, 9.7mg / kg, 9.8mg / kg, 9.9mg / kg, 10mg / kg, 10.1mg / kg, 10.2mg / kg, 10.3m g / kg, 10.4mg / kg, 10.5mg / kg, 10.6mg / kg, 10.7mg / kg, 10.8mg / kg, 10.9mg / kg, 11mg / kg, 11.1mg / kg, 11.2mg / kg, Contains either 11.3mg / kg, 11.4mg / kg, 11.5mg / kg, 11.6mg / kg, 11.7mg / kg, 11.8mg / kg, 11.9mg / kg, 12mg / kg, 12.1mg / kg, 12.2mg / kg, 12.3mg / kg, 12.4mg / kg, 12.5mg / kg, 12.6mg / kg, 12.7mg / kg, 12.8mg / kg, 12.9mg / kg, or 13mg / kg.

[0074] In some embodiments, the effective amount of the telomerase inhibitor administered to an individual comprises at least about any of 1 mg / kg, 2.5 mg / kg, 3.5 mg / kg, 4.7 mg / kg, 5 mg / kg, 6.0 mg / kg, 6.5 mg / kg, 7.5 mg / kg, 9.4 mg / kg, 10 mg / kg, 15 mg / kg, or 20 mg / kg. In some embodiments, the effective amount of the telomerase inhibitor administered to an individual is at least about any of 1 mg / kg, 2.5 mg / kg, 3.5 mg / kg, 5 mg / kg, 6.5 mg / kg, 7.5 mg / kg, 9.4 mg / kg, 10 mg / kg, 15 mg / kg, or 20 mg / kg. In various embodiments, the effective amount of telomerase inhibitor administered to an individual comprises less than about any of 350 mg / kg, 300 mg / kg, 250 mg / kg, 200 mg / kg, 150 mg / kg, 100 mg / kg, 50 mg / kg, 30 mg / kg, 25 mg / kg, 20 mg / kg, 10 mg / kg, 7.5 mg / kg, 6.5 mg / kg, 5 mg / kg, 3.5 mg / kg, 2.5 mg / kg, 1 mg / kg, or 0.5 mg / kg of telomerase inhibitor.

[0075] Exemplary dosing frequencies of pharmaceutical compositions comprising telomerase inhibitors include, but are not limited to, daily; every other day; twice a week; three times a week; weekly without interruption; weekly, three times every four weeks; once every three weeks; once every two weeks; weekly, twice every three weeks. In some embodiments, the pharmaceutical composition is administered about once a week, once every two weeks, once every three weeks, once every four weeks, once every five weeks, once every six weeks, once every seven weeks, or once every eight weeks. In some embodiments, the composition is administered at least about once, twice, three times, four times, five times, six times, or seven times a week (i.e., daily), or three times a day, twice a day. In some embodiments, the interval between each administration is less than about 6 months, 3 months, 1 month, 20 days, 15 days, 12 days, 10 days, 9 days, 8 days, 7 days, 6 days, 5 days, 4 days, 3 days, 2 days, or 1 day. In some embodiments, the interval between each administration is more than about 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 8 months, or 12 months.In some embodiments, there is no break in the administration schedule.In some embodiments, the interval between each administration is about 1 week or less.

[0076] The telomerase inhibitor, e.g., imetelstat (e.g., imetelstat sodium), can be administered using any suitable method. For example, the telomerase inhibitor, e.g., imetelstat (e.g., imetelstat sodium), can be administered intravenously over a period of time (e.g., 1, 2, 3, 4, or 5 hours) once every four weeks. In some embodiments, imetelstat is administered intravenously at 7-10 mg / kg over a period of about two hours once every week. In certain embodiments, imetelstat is administered intravenously at 2.5-7 mg / kg over a period of about two hours once every three weeks. In one embodiment, imetelstat is administered intravenously at 0.5-5 mg / kg over a period of about two hours once every four weeks. In one embodiment, imetelstat is administered intravenously at about 2.5-10 mg / kg over a period of about two hours once every three weeks. Alternatively, imetelstat is administered intravenously over a period of about 2 hours at about 0.5-9.4 mg / kg once every four weeks.

[0077] In certain embodiments of the method, imetelstat is administered over 1, 2, 3, 4, 5, 6, 7, 8, or more than 8 dosage cycles, each cycle comprising intravenous administration of about 7-10 mg / kg of imetelstat once every 4 weeks, intravenous administration of about 7-10 mg / kg of imetelstat once per week for 4 weeks, intravenous administration of about 2.5-10 mg / kg of imetelstat once per 3 weeks, or intravenous administration of about 0.5-9.4 mg / kg of imetelstat once per 4 weeks. In certain cases, each dosage cycle comprises intravenous administration of about 7-10 mg / kg of imetelstat once per 4 weeks. In some cases, each dosage cycle comprises intravenous administration of about 7.5 mg / kg of imetelstat once per 4 weeks.

[0078] In one embodiment of the invention, imetelstat is administered intravenously at a dose of about 7 to 10 mg / kg of imetelstat once every four weeks, following premedication with an antihistamine, a corticosteroid, or both. In another embodiment, imetelstat is administered intravenously at a dose of about 7.5 mg / kg of imetelstat, alternatively about 7.0 mg / kg to about 7.7 mg / kg, once every four weeks, following premedication with an antihistamine, a corticosteroid, or both.

[0079] In certain embodiments, imetelstat is administered at a dose of about 7.5 mg / kg, alternatively at a dose of about 7.0 mg / kg to about 7.7 mg / kg, once every 4 weeks for at least three cycles, followed by dose escalation. In certain embodiments, the ANC and platelet nadir are each about 1.5×10 9 / L~Approx. 75×10 9 If the serum lipids have not decreased to about 10 mg / kg / L and no grade 3 or higher non-hematological toxicity is observed, the dose of imetelstat can be increased to about 9.4 mg / kg, alternatively to about 8.8 mg / kg to about 9.6 mg / kg / L.

[0080] It will be appreciated that cancer treatment sometimes involves multiple "rounds" or "cycles" of drug administration, with each cycle including administration of one or more drugs according to a designated schedule (e.g., three consecutive days every three weeks, once a week, etc.). For example, an anticancer drug may be administered for one to eight cycles or for a longer period. When multiple drugs (e.g., two drugs) are administered to a subject, each may be administered according to its own schedule (e.g., weekly, once every three weeks, etc.). It will be apparent that administration of multiple drugs, even drugs administered at different cycles, may be coordinated such that both drugs are administered on the same day at least sometimes, or alternatively, the drugs are administered on consecutive days at least sometimes.

[0081] As is understood in the art, treatment with cancer therapeutic agents can be temporarily interrupted and then resumed if toxicity is observed or for patient convenience without departing from the scope of the invention.

[0082] In certain embodiments, the present invention relates to a telomerase inhibitor for use in a method of treating myelodysplastic syndromes (MDS), the method comprising administering to a subject in need thereof an effective amount of the telomerase inhibitor, wherein the subject is naïve to treatment with an agent selected from a hypomethylating agent (HMA) and lenalidomide. In other embodiments, the present invention relates to a telomerase inhibitor for use in a method of treating myelodysplastic syndromes (MDS), the method comprising administering to a subject in need thereof an effective amount of the telomerase inhibitor, wherein the subject is naïve to treatment with an agent selected from a HMA, lenalidomide, and combinations thereof.

[0083] In certain embodiments, the present invention relates to a telomerase inhibitor for use in the method defined in any other embodiment.

[0084] H. Exemplary Embodiments Exemplary embodiments of the methods of treating MDS of the present invention, involving administering to a subject in need thereof an effective amount of a telomerase inhibitor, wherein the subject is naïve to treatment with an agent selected from a hypomethylating agent (HMA) and lenalidomide, are shown in Table A below.

[0085] Exemplary embodiments include using any telomerase inhibitor in Table A to treat any one of the types of MDS shown in Table A in any one of the subjects shown in Table A, where the subjects are naive to any one of the treatments shown in Table A. In certain embodiments, one of the dosing regimens set forth in Table A is used. In other embodiments, the method can be used to treat any one of the types of MDS shown in Table A with imetelstat (imetelstat sodium) in any one of the subjects shown in Table A, where the subjects are naive to any one of the treatments shown in Table A. When imetelstat (imetelstat sodium) is used, any dosing regimen shown in Table A can be used. [Table A-1] [Table A-2] The following examples are offered by way of illustration and not by way of limitation. EXAMPLES

[0086] Example 1: Efficacy and Safety of Imetelstat in Transfusion-Dependent (TD) Patients with International Prognostic Scoring System (IPSS) Low / Intermediate-1 Risk Myelodysplastic Syndrome and Relapsed / Refractory to Erythropoietin Stimulating Agent (ESA) Therapy (IMerge™)

[0087] Introduction IMerge™: An ongoing two-part global study of imetelstat sodium in red blood cell (RBC) transfusion-dependent (TD) patients (ESA-relapsed / refractory and lower-risk MDS). Part 1 consists of an open-label, single-arm design with imetelstat sodium monotherapy. This example provides safety and efficacy findings from 32 patients enrolled in part 1. Subgroup analysis of patients who were lenalidomide and hypomethylating agent (HMA) treatment naïve and without del(5q) is also presented. Results suggested improved efficacy in these patients.

[0088] method Eligibility: The following were the eligibility requirements for this study. Adults diagnosed with MDS; International Prognostic Scoring System (IPSS) low or intermediate grade -1 Transfusion dependent (TD): defined as the need for ≥4 units of red blood cell (RBC) transfusion over the 8 weeks prior to study enrollment. Epoetin alfa 40,000 U or darbepoetin alfa 150 mcg (or equivalent) once weekly for at least 8 weeks or serum erythropoietin (sEPO) >500 mU / mL in patients with ESA relapse or refractory disease. Any prior therapy (including lenalidomide or HMA) was permitted. Patients with del(5q) karyotype were allowed to enroll regardless of prior therapy. Eastern Cooperative Oncology Group (ECOG) score of 0-2. Absolute neutrophil count (ANC) ≥ 1.5 × 10 9 / L and platelet count ≥ 75 × 10 9 / L (regardless of growth factor or transfusion support). Liver function tests: AST, ALT, and ALP should be less than 2.5 times the upper limit of normal, total bilirubin should be less than 3 times the upper limit of normal, and direct bilirubin should be less than 2 times the upper limit of normal (excluding cases caused by Gilbert's syndrome).

[0089] Treatment: Imetelstat sodium was administered as a 2-h IV infusion at a starting dose of 7.5 mg / kg every 4 weeks, followed by premedication with an antihistamine and corticosteroid. Lack of adequate response after at least three cycles of the initial dose led to an ANC and platelet nadir of 1.5 × 10, respectively. 9 / L and 75×10 9 Dose escalation to 9.4 mg / kg was permitted provided that serum plasma glucose did not decrease to < 9.4 mg / L and there was no grade 3 or higher non-hematological toxicity. Transfusions and supportive care, including myeloid growth factors, were permitted as clinically indicated.

[0090] Endpoints and Analyses: Primary endpoint: RBC transfusion independence (TI) rate sustained for 8 weeks or more Key secondary endpoints: ○Safety ○TI rate of 24 weeks or more Time to TI and duration of TI ○Hematological improvement (HI) rate ○Complete response (CR) and partial response (PR) rates according to the International Working Group (IWG)

[0091] result patient Median RBC transfusion burden at baseline: 6 units / 8 weeks (range: 4-14)

[0092] Baseline characteristics are shown below in Table 1. The following abbreviations are used in Table 1: Eastern Cooperative Oncology Group performance status score 0-1 ("ECOG PS 0-1"), refractory anemia with ringed sideroblasts ("RARS"), or refractory cytopenia with multilineage dysplasia and ringed sideroblasts ("RCMD-RS"). [Table 1]

[0093] Key hematological criteria: ANC=1,500 and PLT=75,000. Based on baseline RBC transfusion burden, this was a massively transfused patient group. Results (first data snapshot)

[0094] exposure - Median follow-up period for this analysis: 66.1 weeks Median number of treatment cycles: 6.5 (range: 1-20 cycles) Adverse events led to dose reductions in 16 patients (50%) and cycle delays in 19 patients (59%). The dose of imetelstat sodium was increased to 9.4 mg / kg in seven patients.

[0095] Effectiveness The main efficacy outcomes are shown in Table 2 below. [Table 2]

[0096] The primary endpoint of RBC TI of 8 weeks or longer was achieved in 12 of 32 patients (38%).

[0097] Five of 32 patients (16%) achieved TI for 24 weeks (see Figures 1A, 1B, and 2). These patients also achieved a sustained hemoglobin increase of at least 1.5 g / dL for 8 weeks (HI-E Hb) (HI-E Hb = HI-E with a sustained hemoglobin increase of at least 1.5 g / dL for 8 weeks). The duration of TI in these patients (65.1 weeks) exceeded 1 year.

[0098] Twenty of 32 patients (63%) showed hematological improvement (HI) of red blood cells (see Figures 1A and 1B).

[0099] In the subset of patients who were lenalidomide- and HMA-naive and lacked del(5q), the 8- and 24-week TI rates were 54% and 31%, respectively (higher than the overall population), and the erythroid HI rate was 69% (similar to that reported in the overall population). Complete responses (CR) and myeloid CR (mCR) were reported in two patients each, no partial responses (PR) were observed, and the CR+PR+mCR rate was 13%.

[0100] One CR and both mCRs were observed in the subset of patients who were lenalidomide- and HMA-naive and lacked del(5q). 8-week TI was not different based on the presence or absence of ringed sideroblasts (RS), with 38% (6 of 16) RS+ and 38% (6 of 16) RS-. Responses did not appear to be dependent on sEPO levels. Of the 30 patients with reported baseline sEPO levels, 41% (7 of 17) of patients with sEPO levels ≤ 500 mU / L achieved a TI of ≥ 8 weeks, and 38% (5 of 13) of patients with sEPO levels > 500 mU / L achieved a TI of ≥ 8 weeks.

[0101] safety Cytopenias, particularly neutropenia and thrombocytopenia, were the most frequently reported adverse events overall and in the subset of lenalidomide- and HMA-naive patients lacking del(5q) (see Table 3 below). This subset of patients had a lower incidence of grade ≥3 neutropenia compared to the overall population, but a similar incidence of grade ≥3 thrombocytopenia (see Table 4 below). In most cases, grade ≥3 cytopenias were reversible within 4 weeks without clinical sequelae, and patients were able to continue imetelstat sodium treatment after dose adjustment.

[0102] One patient (of 22 neutropenic) experienced neutropenic fever, and two patients (of 18 thrombocytopenic) experienced concomitant grade 3 thrombocytopenia and grade 1 hemorrhagic events, both of which were considered related to imetelstat sodium. These events resolved without sequelae. Twenty-eight patients (88%) experienced at least one grade increase in liver function tests (LFTs). These events were generally grade 1 or 2 and were reversible. Four patients (including three in the subset of lenalidomide- and HMA-naive patients lacking del[5q]) experienced grade 3 deterioration in aspartate aminotransferase (AST) and / or alanine aminotransferase (ALT), and one of these patients experienced grade 3 deterioration in bilirubin, both of which were reversible.

[0103] Table 3 shows the most commonly treated adverse events, and Table 4 shows the maximum grade change from baseline in cytopenias. [Table 3-1] [Table 3-2] [Table 4] The results in Table 4 are based on the first data snapshot.

[0104] Results (second data snapshot) exposure - Median follow-up period for this analysis: 95 weeks Median number of treatment cycles: 6.5 (range: 1-28 cycles) Dose reductions and cycle delays occurred in 16 (50%) and 19 (59%) patients. The dose of imetelstat sodium was increased to 9.4 mg / kg in seven patients. efficiency

[0105] Table 5 below shows the main efficiency outcomes at the second data snapshot. [Table 5]

[0106] The longest follow-up duration for responding patients was 115 weeks (26 months).

[0107] Of the seven subjects who received dose escalation, one subject achieved an 8-week TI and three subjects achieved HI-E. The median number of treatment cycles in the subgroup was eight. The median duration of treatment overall and in the subgroup was 24 and 29 weeks, respectively.

[0108] Figure 3A shows the longest transfusion-free interval at the time of the second data snapshot. Three of the five patients with a 24-week TI are still on treatment. The data shown in Figure 3A are summarized in Table 6 below. [Table 6-1] [Table 6-2]

[0109] Figure 3B shows the absolute change in transfusion volume over the best 8-week interval. One patient's transfusion burden decreased from 10 to 0. Patients who did not achieve TI(HI-E(TR)) had a highly meaningful reduction in transfusion burden. The data shown in Figure 3B are summarized in Table 7 below. [Table 7]

[0110] Figure 4 shows efficacy results for EPO and RS subgroups at the second data snapshot. Similar efficacy was observed in these subgroups. Figure 5 shows hematology and imetelstat sodium dosing over time by patient at the second data snapshot. Figure 6 shows hemoglobin and imetelstat sodium dosing in patients with persistent TI. The top three patients in Figure 6 are still on treatment. The top two subjects in Figure 6 have the longest follow-up.

[0111] safety Safety findings in lenalidomide / HMA naive / non-del(5q) patients were similar to the overall study population.

[0112] Table 8 shows the most commonly treatment-emergent adverse events at the time of the second data snapshot. Table 9 shows the occurrence and recovery of grade 3 / 4 cytopenias. Table 10 shows the maximum post-baseline Common Terminology Criteria for Adverse Events (CTCAE) grade worsening from baseline for cytopenias by population and safety analysis set at the time of the second data snapshot. [Table 8-1] [Table 8-2] [Table 9]

[0113] Eleven patients received G-CSF during the study, either to treat adverse events or ongoing medical history (n=10) or as prophylaxis (n=1). [Table 10-1] [Table 10-2]

[0114] Observations (based on both data snapshots): Safety and efficacy data from the 32 patients enrolled in Part 1 of this study support continued investigation of imetelstat sodium at the current dosing regimen of 7.5 mg / kg every 4 weeks.

[0115] At the time of the first data snapshot, 38% of patients with IPSS low / intermediate-1 RBC transfusion-dependent MDS relapsed / refractory to ESAs demonstrated 8-week RBC TI and 63% had RBC HI. Sustained 24-week TI with persistently elevated Hb was observed in 16% of patients.

[0116] During the first data snapshot, 54% RBC TI was observed in 13 patients without del(5q) and no prior exposure to lenalidomide or HMAs (vs. 38% in the overall population), and responses were more durable (24-week TI rate of 31%).

[0117] Overall, 8-week TI was observed in 34% of all patients, and the 24-week TI rate was 16%. The median time to TI was 8.0 weeks. The median duration of TI was 23.1 weeks.

[0118] In lenalidomide / HMA-naive, non-del(5q) patients, the 8-week and 24-week TI rates were 54% and 31%, respectively. The median duration of TI in these patients was 42.9 weeks.

[0119] Overall, TR(HI-E) was observed in 59% of all patients. The mean relative reduction from baseline in RBC transfusion burden was 60%.

[0120] These results support further testing of imetelstat sodium (7.5mg / kg / 4 weeks) in IPSS low / intermediate-1, TD, ESA-relapsed / refractory MDS.For RBC TD patients with LR-MDS (median: 6U / 8 weeks), imetelstat sodium treatment led to red blood cell improvement in the majority of patients.

[0121] This study was repeated in a target population of 13 subjects with non-del(5q) MDS who had no prior exposure to HMAs or lenalidomide. In this target population, 53.8% achieved the primary endpoint of RBC TI at 8 weeks, compared with 21.1% of the remaining subjects not included in the target population. Responses were more durable in the target population than in the remaining subjects (median duration, 13.9 vs. 42.9 weeks), and more subjects in the target population achieved RBC TI at 24 weeks (5.3% vs. 30.8%). The target population had a comparable or better safety profile for cytopenias and other adverse events, and cytopenias appeared to resolve more quickly in the target population. Example 2: Results during the third data snapshot

[0122] A third data snapshot was conducted with a clinical cutoff of October 26, 2018. An additional 25 lenalidomide- and HMA-naive patients without del(5q) were enrolled and, together with the first 13 lenalidomide- and HMA-naive patients without del(5q) described above, updated results for this group have been compiled. Total patients N=38.

[0123] The median follow-up for the first 13 patients was 29.1 months. The median follow-up for the additional 25 patients was 8.7 months.

[0124] The median number of treatment cycles was 8.0 (range: 1-34). The mean dose intensity was 6.9 mg / kg / cycle.

[0125] [Table 11]

[0126] CR: complete remission; HI-E: hematological improvement of red blood cells; IWG: International Working Group; NE: Not probable; PR: Partial response; RBC: Red blood cells; TI: Transfusion independent.

[0127] Example 3: Results during the fourth data snapshot A fourth Data Snapshot was conducted with a clinical cutoff of January 23, 2019 to report updated efficacy data from 38 ESA-relapsed / refractory, lenalidomide / HMA-naive LR non-del(5q) MDS patients with a median follow-up of 12.1 months from the open-label, single-arm Part 1 of the IMerge™ trial.

[0128] method

[0129] Part 1 of the IMerge™ study included patients with low or intermediate-1 IPSS risk MDS (LR-MDS). The patients were massively transfused (≥4U / 8 weeks), relapsed / refractory to ESAs, or had sEPO >500mU / mL. Imetelstat 7.5mg / kg was administered intravenously every 4 weeks. The primary endpoint was 8-week transfusion independence (TI) rate, and secondary endpoints included 24-week TI rate, safety, TI duration, and hematological improvement (HI) rate. In the first enrolled patients, higher 8-week TI rates were observed in non-del5q, lenalidomide / HMA naive patients. Therefore, the study was amended to enroll only these patients from now on. Of the 57 patients enrolled in part 1, 38 were non-del(5q), lenalidomide / HMA naive patients (13 in the initial cohort, 25 in the expansion cohort). Long-term efficacy, safety, and biomarker data from these 38 patients will be reported.

[0130] result

[0131] The median prior RBC transfusion burden was 8 units / 8 weeks (range 4-14), 37% of patients had IPSS intermediate-1, 71% had WHO 2008 RARS (refractory anemia with ringed sideroblasts) or RCMD-RS (refractory cytopenia with multilineage dysplasia and ringed sideroblasts) subtype, and 32% with evaluable sEPO (serum erythropoietin) values ​​had baseline levels >500 mU / mL.

[0132] As of January 23, 2019, the median follow-up was 12.1 months, with 30.4 months for the 13 initial patients and 11.6 months for the 25 additional patients, respectively. The 8-week TI rate was 45% (17 of 38 patients), with a median TI duration of 8.5 months (range 1.8-32.4). Of the 17 responding patients, 10 (59%) were transfusion-free for 6 months or more. The 8-week TI rate did not differ based on the presence or absence of ring sideroblasts or baseline sEPO levels. The 24-week TI rate was 26% (10 of 38 patients), with a median duration of 10.5 months (range 8.3-32.4). 68% (26 of 38 patients) achieved hematologic improvement (HI) of red blood cells, defined as a ≥50% reduction in transfusion burden for at least 8 weeks. The most frequently reported adverse events were manageable and reversible grade ≥3 cytopenias.

[0133] Summary In patients with high RBC transfusion burden, non-del(5q)LR-MDS, relapsed / refractory to ESAs and lenalidomide / HMA-naive, the 8-week TI rate with imetelstat alone was 45%, with a median duration of 8.5 months (range 1.8-32.4). The 24-week TI rate was 26%, with a median duration of 10.5 months (range 8.3-32.4). All patients with IPSS-R intermediate and poor cytogenetic risk responded. Biomarker analysis of telomerase activity and mutant allele burden has demonstrated an effect on the malignant mutant clone, as described below.

[0134] Example 4: Biomarker Data A variety of biomarkers, including telomerase hTERT RNA levels, telomerase activity (TA), cytogenetic data, and mutational data, were monitored and evaluated over the course of the IMerge™ study. hTERT RNA expression levels were measured from whole blood samples taken from patients pre- and post-treatment. The results are summarized below.

[0135] Greenberg et al. (“Revised International "Prognostic Scoring System for Myelodysplastic Syndromes", Blood. 2012 Sep 20;120(12):2454-2465, the disclosure of which is incorporated herein by reference in its entirety, describes the International Prognostic Scoring System-Revised (IPSS-R) for assessing prognosis in primary untreated adult MDS patients. Table 2 of Greenberg et al. describes the MDS cytogenetic scoring system, which is reproduced below in Table 12 and was utilized to classify patients in the IMerge™ study.

[0136] [Table 12-1] [Table 12-2] OS indicates overall survival, and NR indicates not reached. * Patient data from the International Working Group on Prognostic Prediction of MDS (IWG-PM) database, multivariate analysis (n=7012). † Data (n=2754) from Schanz el al. (“New comprehensive cytogenetic scoring system for primary myelodysplastic syndromes and oligoblastic AML following MDS derived from an international database merge.” J. Clin. Oncol. 2012;30(8):820-829).

[0137] PD effect: Decreased telomerase hTERT RNA levels

[0138] [Table 13]

[0139] At the time of the fourth data snapshot, a decrease in telomerase hTERT RNA levels after treatment was observed in 25 of 34 (73.5%) patients with available samples. See also Figure 7.

[0140] Association of hTERT reduction with response

[0141] In 8-week transfusion independent (TI) responders, a higher percentage of subjects achieved a 50% or greater reduction in hTERT RNA expression levels than in non-responders.

[0142] [Table 14]

[0143] PD effect: telomerase activity (TA)

[0144] Some patients had a decrease in TA after treatment.

[0145] [Table 15]

[0146] Changes in variant frequency

[0147] At the third data snapshot, six subjects had SF3B1 mutations at baseline, and a decrease in mutation frequency was observed in the two subjects with the longest TI duration. One subject had a decrease in DNMT3A mutations and a significant decrease in bone marrow ring sideroblasts (from 75% to 3%).

[0148] At the time of the fourth data snapshot, of the seven patients who underwent pre- and post-treatment mutational analysis, six had SF3B1 mutations at baseline, and a decrease in mutant variant allele frequency was observed in the two patients with the longest TI duration at the time of study.

[0149] Cytogenetic Risk

[0150] Patients were classified based on the International Prognostic Scoring System-Revised (IPSS-R) as shown in Table 12.

[0151] At the time of the fourth data snapshot, 6 of 38 patients had IPSS-R intermediate / poor cytogenetic risk, 5 of 6 patients achieved an 8-week TI, and 2 of 6 patients achieved a partial cytogenetic response.

[0152] Summary

[0153] A reduction in telomerase activity / hTERT RNA levels after treatment was observed in a subset of subjects demonstrating PD activity of imetelstat.Subjects achieving a >50% reduction in hTERT were more likely to be 8-week TI responders compared to non-responders.

[0154] The majority of subjects had good or intermediate cytogenetic risk classification and were observed to have an 8-week transfusion independent (TI) response. At the time of the third data snapshot, two subjects with poor cytogenetic risk did not demonstrate a TI response. However, by the fourth data snapshot, in 6 of 38 patients with IPSS-R intermediate / poor cytogenetic risk, 5 of 6 patients achieved an 8-week TI and 2 of 6 patients achieved a partial cytogenetic response.

[0155] Of seven subjects with pre- and post-treatment mutation samples, six had SF3B1 mutations at baseline, with changes in mutation variant frequency observed in patients with the longest TI duration. Example 5: Treatment of heavily transfused non-del(5q) low-risk myelodysplastic syndrome patients relapsed / refractory to erythropoietin-stimulating agents (ESAs) with imetelstat

[0156] This example provides safety and efficacy findings from 38 patients enrolled in IMerge™, the study designation of which is described in more detail above. The results from this example demonstrate that treatment with imetelstat results in meaningful and sustained transfusion independence in this patient population.

[0157] method Eligibility: The following were the eligibility requirements for this study. Adults diagnosed with MDS; International Prognostic Scoring System (IPSS) low or intermediate grade -1 Transfusion dependent (TD): defined as the need for ≥4 units of red blood cell (RBC) transfusion over the 8 weeks prior to study enrollment. ESA relapse or ESA refractory or serum erythropoietin ("sEPO") >500mU / mL Patients were required to be non-del(5q) and lenalidomide- or HMA-naïve. Patient age range: 46-83 years, median age: 71.5 years Eastern Cooperative Oncology Group (ECOG) PS 0-1.

[0158] Treatment: Imetelstat sodium was administered as a 2-h IV infusion at a starting dose of 7.5 mg / kg every 4 weeks, followed by premedication with an antihistamine and corticosteroid. Lack of adequate response after at least three cycles of the initial dose led to an ANC and platelet nadir of 1.5 × 10, respectively. 9 / L and 75×10 9 Dose escalation to 9.4 mg / kg was permitted provided that serum plasma glucose did not decrease to < 9.4 mg / L and there was no grade 3 or higher non-hematological toxicity. Transfusions and supportive care, including myeloid growth factors, were permitted as clinically indicated.

[0159] result patient Median RBC transfusion burden at baseline: 8 units / 8 weeks (range: 4-14) [Table 15A]

[0160] Baseline characteristics are shown below in Table 16. The following abbreviations are used in Table 16: Eastern Cooperative Oncology Group performance status score 0-1 ("ECOG PS 0-1"), refractory anemia with ringed sideroblasts ("RARS") or refractory cytopenia with multilineage dysplasia and ringed sideroblasts ("RCMD-RS"), RAEB-1: refractory anemia with excess blasts. [Table 16]

[0161] result exposure - Median follow-up period for this analysis: 15.7 months Median number of treatment cycles: 9 (range: 1-39 cycles)

[0162] Effectiveness

[0163] The primary efficacy outcomes are presented in Table 17 below. [Table 17]

[0164] The primary endpoint of RBC TI ≥ 8 weeks was achieved across different subgroups as shown in Table 18. [Table 18]

[0165] In 34 patients with baseline cytogenetic data: Six of 34 patients (18%) had intermediate or poor risk cytogenetics (see Table 19) Five of six patients (83%) achieved 8 weeks of transfusion independence (TI), and all had the ring sideroblast WHO subtype. Three of three patients with trisomy 8 achieved 8 weeks of transfusion independence (TI), and two of three patients achieved 24 weeks of TI. Two of three patients with available post-treatment cytogenetic data achieved a partial cytogenetic response [Table 19]

[0166] Effect of imetelstat on malignant clones

[0167] Two of six patients with a baseline SF3B1 mutation experienced a decrease in mutant allele frequency and maintained transfusion independence (TI) lasting for more than 1 year (Table 20). [Table 20]

[0168] Of the 16 patients who achieved 8 weeks of transfusion independence: Median transfusion independence (TI) was 86 weeks (range: 8-141 weeks) 11 of 16 patients (69%) achieved 24-week transfusion independence (TI) rate Twelve of 16 patients (75%) had an increase in Hgb >3g / dL from pretreatment levels The mean relative reduction from baseline in RBC transfusion burden was 68%

[0169] safety Adverse events included thrombocytopenia, neutropenia, and anemia (Table 21). [Table 21-1] [Table 21-2] [Table 22]

[0170] 91% of neutrophils were lost within 4 weeks, whereas 9% did not lose within 4 weeks. 92% of platelets were lost within 4 weeks, whereas 8% did not lose within 4 weeks. Febrile neutropenia occurred in 2 of 38 patients (5%). Hemorrhage occurred in 4 of 38 patients (10%), with 2 of 38 (5%) being grade 3 / 4.

[0171] On-target activity was demonstrated by reductions in telomerase activity and hTERT expression (Table 23). Results showed greater reductions in hTERT expression in transfusion-independent (TI) patients (Table 24). [Table 23] * A 50% reduction is a PD effect shown in correlation with in vivo antitumor activity from preclinical xenograft models. [Table 24] * A 50% reduction is a PD effect shown in correlation with in vivo antitumor activity from preclinical xenograft models.

[0172] Overall, 8-week TI was observed in 42% of all patients, and the 24-week TI rate was 29%. The median duration of transfusion independence (TI) was 20 months. Overall, TR(HI-E) was observed in 68% of all patients.

[0173] Transfusion independence was observed across various clinical subgroups, including patients with intermediate / poor cytogenetic risk. Biomarker data suggest potential effects on malignant clones and disease modification.

[0174] While certain embodiments have been described in some detail by way of illustration and example for clarity of understanding, it will be readily apparent that, in light of the teachings of the invention, certain changes and modifications may be made thereto without departing from the spirit and scope of the appended claims.

[0175] Thus, the foregoing merely illustrates the principles of the invention. Various arrangements can be devised that embody the principles of the invention and are within the spirit and scope of the invention, even if not explicitly described or shown herein. Furthermore, all examples and conditional language given herein are intended primarily to aid the reader in understanding the principles of the invention and the concepts that the inventors contribute to the advancement of the art, and should not be construed as being limited to such specifically given examples and conditions. Furthermore, all statements herein that recite the principles, aspects, and embodiments of the invention, as well as specific examples thereof, are intended to encompass both structural and functional equivalents thereof. In addition, such equivalents are intended to include both currently known equivalents and equivalents developed in the future (i.e., any elements developed that perform the same function, regardless of structure). Thus, the scope of the invention is not intended to be limited to the exemplary embodiments shown and described herein. Rather, the scope and spirit of the invention is embodied by the appended claims. The present invention provides, for example, the following items. (Item 1) A method for identifying a subject having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor. measuring the level of hTERT expression in a biological sample obtained from the subject after administering a telomerase inhibitor; and comparing the hTERT expression level in the biological sample to a baseline hTERT expression level prior to administering the telomerase inhibitor; A decrease in hTERT expression levels in the biological sample identifies subjects who are likely to benefit from treatment with the telomerase inhibitor. (Item 2) 2. The method of claim 1, wherein the decrease in hTERT expression level is 50% or more. (Item 3) 3. The method according to any one of items 1 to 2, wherein the subject is diagnosed with trisomy 8. (Item 4) 4. The method of claim 3, wherein the subject is diagnosed with mosaic trisomy 8. (Item 5) The method according to any one of items 3 to 4, further comprising diagnosing the subject with trisomy 8. (Item 6) 1. A method of treating myelodysplastic syndrome (MDS), comprising: administering to a subject in need thereof an effective amount of a telomerase inhibitor; assessing the level of hTERT expression in a biological sample obtained from the subject after administering the telomerase inhibitor; A method comprising: (Item 7) 7. The method of claim 6, wherein the hTERT expression level is reduced by 50% or more compared to a baseline hTERT expression level before administration of the telomerase inhibitor. (Item 8) 5. The method of claim 3 or 4, further comprising altering the dosage, frequency of administration, or course of treatment of the telomerase inhibitor administered to the subject. (Item 9) 9. The method according to any one of items 6 to 8, wherein the subject is diagnosed with trisomy 8. (Item 10) 10. The method of claim 9, wherein the subject is diagnosed with mosaic trisomy 8. (Item 11) 11. The method according to any one of items 9 to 10, further comprising diagnosing the subject with trisomy 8. (Item 12) 1. A method for monitoring therapeutic efficacy in a subject having myelodysplastic syndrome (MDS), comprising: measuring the level of hTERT expression in a biological sample obtained from the subject after administering a telomerase inhibitor; and comparing the hTERT expression level in the biological sample to a baseline hTERT expression level prior to administering the telomerase inhibitor; A method wherein a 50% or greater decrease in hTERT expression levels in the biological sample identifies subjects who are likely to benefit from treatment with the telomerase inhibitor. (Item 13) 13. The method according to any one of items 1 to 12, wherein the hTERT expression level measured or assessed is an hTERT RNA expression level. (Item 14) 13. The method according to any one of items 1 to 12, wherein the hTERT expression level measured or evaluated is an hTERT protein expression level. (Item 15) 15. The method of any one of items 1 to 14, wherein the subject is naive to treatment with an agent selected from a hypomethylating agent (HMA), lenalidomide, and combinations thereof. (Item 16) 16. The method according to any one of items 1 to 15, wherein the MDS is relapsed or refractory MDS. (Item 17) The method according to any one of items 1 to 16, wherein the MDS is relapsed / refractory MDS to erythropoietin stimulating agents (ESA). (Item 18) 18. The method according to any one of items 1 to 17, wherein the subject is classified as a low or moderate-1 IPSS risk MDS subject. (Item 19) 19. The method according to any one of items 1 to 18, wherein the subject is transfusion dependent. (Item 20) 20. The method of claim 19, wherein the transfusion-dependent subject requires about 4 or more units of blood transfusion in the 8 weeks prior to administration of the telomerase inhibitor. (Item 21) The method according to any one of items 1 to 20, wherein the subject is a non-del5q human patient. 22. The method according to any one of items 1 to 21, wherein the subject is naive to treatment with lenalidomide. (Item 23) 22. The method according to any one of items 1 to 21, wherein the subject is naive to treatment with a HMA selected from decitabine and azacitidine. (Item 24) 24. The method according to any one of items 1 to 23, wherein the telomerase inhibitor is imetelstat. (Item 25) 26. The method according to claim 24, wherein the imetelstat is imetelstat sodium. the telomerase inhibitor is imetelstat and is administered in 1, 2, 3, 4, 5, 6, 7, 8, or more than 8 dosage cycles, each cycle comprising: (a) Imetelstat administered intravenously at approximately 7-10 mg / kg once every 4 weeks; (b) Imetelstat administered intravenously at approximately 7-10 mg / kg once weekly for four weeks; (c) Imetelstat at approximately 2.5-10 mg / kg administered intravenously once every 3 weeks; or (d) Imetelstat, approximately 0.5-9.4 mg / kg, administered intravenously once every 4 weeks 25. The method according to item 24, comprising: (Item 27) 27. The method of item 26, wherein each dosage cycle comprises intravenous administration of about 7-10 mg / kg of imetelstat once every 4 weeks. (Item 28) 2. The method of claim 1, wherein the MDS is relapsed or refractory MDS and the subject is classified as a low or intermediate-1 IPSS risk MDS subject. (Item 29) 29. The method of claim 28, wherein the subject is transfusion dependent. (Item 30) 29. The method of claim 28, wherein the subject is a non-del5q human patient. (Item 31) 31. The method according to any one of items 1 to 30, wherein the subject is naive to treatment with an agent selected from a hypomethylating agent (HMA) and lenalidomide. (Item 32) 32. The method of any one of items 12 to 31, wherein the subject is diagnosed with trisomy 8. (Item 33) 33. The method of claim 32, wherein the subject is diagnosed with mosaic trisomy 8. (Item 34) 34. The method according to any one of items 32 to 33, further comprising diagnosing the subject with trisomy 8. (Item 35) 1. A method for identifying a subject having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, the method comprising diagnosing the subject with trisomy 8. (Item 36) 1. A method of treating myelodysplastic syndrome (MDS), comprising: 11. A method comprising administering to a subject in need thereof an effective amount of a telomerase inhibitor, wherein the subject is diagnosed with trisomy 8. (Item 37) 1. Use of a telomerase inhibitor in treating a subject having myelodysplastic syndrome (MDS), wherein a biological sample obtained from the subject is determined to have a decreased hTERT expression level after administration of the telomerase inhibitor compared to a baseline hTERT expression level in a biological sample obtained from the subject prior to administration of the telomerase inhibitor. (Item 38) 1. Use of a telomerase inhibitor in the treatment of a subject having myelodysplastic syndrome (MDS), wherein the subject is diagnosed with trisomy 8.

Claims

[Claim 1] The invention described in this specification.

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