Methods for treating myeloproliferative neoplasms

Abstract

Therapeutic methods and pharmaceutical compositions for treating myeloproliferative neoplasms (MPNs) with a combination of an MDM2 inhibitor and a JAK inhibitor.

Description

[Technical Field]

[0001] A method for treating myeloproliferative neoplasms (MPNs) using a mouse double minute 2 homolog (MDM2) inhibitor and a JAK inhibitor. [Background technology]

[0002] p53 is a tumor suppressor and transcription factor that responds to cellular stress by activating the transcription of numerous genes involved in cell cycle arrest, apoptosis, senescence, and DNA repair. Unlike normal cells, which rarely undergo p53 activation, tumor cells are under constant cellular stress from a variety of insults, including hypoxia and activation of proapoptotic oncogenes. Therefore, it has been proposed that there is a strong selective advantage to inactivating the p53 pathway in tumors, making abolishing p53 function a prerequisite for tumor survival. To support this view, three groups of researchers used mouse models to demonstrate that the absence of p53 function is a continuous requirement for the maintenance of established tumors. When researchers restored p53 function in p53-inactivated tumors, the tumors regressed.

[0003] p53 is inactivated by mutation and / or loss in 50% of solid tumors and 10% of liquid tumors. Other key members of the p53 pathway are also genetically or epigenetically altered in cancer. The oncoprotein MDM2 inhibits p53 function and is activated by gene amplification, with incidences reported to be as high as 10%. MDM2 is in turn inhibited by another tumor suppressor, p14ARF. It has been suggested that downstream modifications of p53 may be responsible for at least partial inactivation of the p53 pathway in p53WT tumors (p53 wild-type). Supporting this concept, some p53WT tumors appear to exhibit reduced apoptotic potential, even though their ability to withstand cell cycle arrest remains intact. One cancer treatment strategy involves the use of small molecules that bind to MDM2 and neutralize its interaction with p53. MDM2 inhibits p53 activity through three mechanisms: 1) acting as an E3 ubiquitin ligase to promote p53 degradation; 2) binding to and blocking the p53 transcriptional activation domain; and 3) exporting p53 from the nucleus to the cytoplasm. All three of these mechanisms would be blocked by neutralizing the MDM2-p53 interaction. Notably, this therapeutic strategy can be applied to tumors that are p53 WT, and studies using small-molecule MDM2 inhibitors have produced promising reductions in tumor growth both in vitro and in vivo. Furthermore, in patients with tumors in which p53 is inactivated, stabilization of wild-type p53 in normal tissues by MDM2 inhibition may enable selective protection of normal tissues from mitotic toxins. As used herein, MDM2 refers to the human MDM2 protein, and p53 refers to the human p53 protein. Note that human MDM2 is sometimes referred to as HDM2 or hMDM2. Several MDM2 inhibitors are in human clinical trials for the treatment of various cancers.

[0004] Myeloproliferative neoplasms (MPN), including but not limited to polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), are clonal hematopoietic stem cell (HSC) disorders characterized by the clonal proliferation of terminally differentiated myeloid cells. Approximately 1%, 4%, and 20% of patients with ET, PV, and PMF, respectively, progress to a blast crisis phase (BP), termed MPN-BP, over a 10-year period from the time of diagnosis. Cervantes F et al., Acta Haematol. 1991;85(3):124-127. MPN-BP and de novo acute myeloid leukemia (AML) have distinct mutation patterns and clinical courses. Rampal R et al., Proc Natl Acad Sci USA. 2014;111(50):E5401-10. Patients with MPN-BP have a particularly dismal prognosis, with a median survival of less than 6 months with currently available therapies. Summary of the Invention

[0005] The present invention relates to a method for suppressing the expression level of p21 in a human suffering from a myeloproliferative neoplasm (MPN), comprising administering to the human a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein the administering suppresses the expression level of p21 in the human compared to the expression level of p21 in MDM2 inhibitor monotherapy.

[0006] In one aspect, the disclosure provides a method of suppressing the expression level of p21 in a human suffering from a myeloproliferative neoplasm (MPN), comprising administering to the human a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein the MDM2 inhibitor is a compound of formula (I):

[0007] [ka] or a pharmaceutically acceptable salt thereof, wherein the administering step suppresses the expression level of p21 in a human compared to the expression level of p21 in an MDM2 inhibitor monotherapy. In certain embodiments, the administering step suppresses p21 levels by at least 50%, or may suppress p21 levels by at least 60%, at least 70%, at least 80%, at least 90%, at least 95%, at least 96%, at least 97%, at least 98%, or at least 99% compared to an MDM2 inhibitor monotherapy.

[0008] In some embodiments, the administering step stimulates apoptosis of malignant myeloid cells in a human suffering from a myeloproliferative neoplasm (MPN). In some embodiments, the malignant cells are CD34+ myeloid cells or CD45+ myeloblasts.

[0009] In some embodiments, the MPN is polycythemia vera (PV). In some embodiments, the MPN is thrombocythemia. In some embodiments, the thrombocythemia is essential thrombocythemia (ET).

[0010] In some embodiments, the MPN is myelofibrosis, hi some embodiments, the myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF).

[0011] In some embodiments, the MPN is chronic myeloid leukemia. In some embodiments, the MPN is systemic mastocystosis (SM). In some embodiments, the MPN is chronic neutrophilic leukemia (CNL). In some embodiments, the MPN is myelodysplastic syndrome (MDS). In some embodiments, the MPN is mast cell disease (SMCD). In some embodiments, the MPN is chronic eosinophilic leukemia. In some embodiments, the MPN is chronic myelomonocytic leukemia (CMML). In some embodiments, the MPN is atypical chronic myeloid leukemia (aCML). In some embodiments, the MPN is juvenile myelomonocytic leukemia (JMML). In some embodiments, the MPN is hypereosinophilic syndrome (HES).

[0012] In certain embodiments, the MDM2 inhibitor is a pharmaceutically acceptable salt of a compound of Formula (I).

[0013] In one embodiment, the compound of Formula (I) is administered once daily at a dose selected from the group consisting of 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg. In one embodiment, the compound of Formula (I) is administered twice daily at a dose selected from the group consisting of 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg. In certain embodiments, the human is treated with the MDM2 inhibitor for a period selected from the group consisting of about 14 days, about 21 days, about 28 days, about 35 days, about 42 days, about 49 days, and about 56 days. In certain embodiments, the compound of Formula (I) is administered orally.

[0014] In certain embodiments, the JAK inhibitor is selected from the group consisting of AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cerdulatinib, CHZ868, CYT387, decernotinib, ENMD-2076, fedratinib, filgotinib, ganetespib, INCB039110, INCB-047986, itacitinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, NSC42834, and NVP-BSK805. , oclacitinib, pacritinib, peficitinib, pyridone 6, R348, RGB-286638, ruxolitinib, ruxolitinib-S, SAR-20347, SB1317, solcitinib, TG101209, TG101348, tofacitinib (3R,4S), tofacitinib (3S,4R), tofacitinib (3S,4S), tofacitinib, TYK2-IN-2, upadacitinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and pharmaceutically acceptable salts thereof. In one embodiment, the JAK inhibitor is selected from the group consisting of baricitinib phosphate, CYT387 mesylate, CYT387 sulfate, NS-018 hydrochloride, NS-018 maleate, NVP-BSK805 dihydrochloride, oclacitinib maleate, ruxolitinib phosphate, ruxolitinib sulfate, tofacitinib citrate, and ZM39923 hydrochloride. In one embodiment, the JAK inhibitor is administered orally.

[0015] In some embodiments, the MDM2 inhibitor is administered before the administration of the JAK inhibitor. In some embodiments, the MDM2 inhibitor is administered after the administration of the JAK inhibitor. In some embodiments, the MDM2 inhibitor is administered concurrently with the administration of the JAK inhibitor.

[0016] In one embodiment, the therapeutically effective amount of an MDM2 inhibitor is 100 mg.

[0017] In one embodiment, the MPN in the human subject has a JAK2V617F mutation.

[0018] The foregoing summary, as well as the following detailed description of the present invention, will be better understood when read in conjunction with the appended drawings. [Brief explanation of the drawings]

[0019] [Figure 1] FIG. 1 illustrates the effect of navtemadilin (compound of formula (I)) and ruxolitinib on p21 expression in ex vivo CD34+ bone marrow cells from patients with myelofibrosis. Abbreviations: DMSO, dimethyl sulfoxide; μM, micromolar; MF, myelofibrosis; QD, once daily; RUX, ruxolitinib. [Figure 2A] 1 is a graph depicting the cytotoxicity of nabtemadrine in combination with ruxolitinib in UKE-1 cells. [Figure 2B] 1 is a graph depicting the synergism of nabtemadrine and ruxolitinib to drive apoptosis in UKE-1 cells, a JAK2 V617F cell line. Abbreviations: Nvtm, nabtemadrine; Rux, ruxolitinib. [Figure 3] Figure 1 illustrates the effect of nabtemadrine and ruxolitinib on apoptosis and p21 protein expression in progenitor cells from myelofibrosis patients. Abbreviations: MFI, median fluorescence intensity; NVTM, nabtemadrine; Rux, ruxolitinib. [Figure 4]

[0023] Figure 1 illustrates the effect of nabtemadrine and ruxolitinib on MCL-1 protein expression in progenitor cells from myelofibrosis patients. Abbreviations: MFI, median fluorescence intensity; NVTM, nabtemadrine; Rux, ruxolitinib. DETAILED DESCRIPTION OF THE INVENTION

[0020] While preferred embodiments of the present invention have been shown and described herein, such embodiments are provided by way of example only and are not intended to otherwise limit the scope of the invention. Various alternatives to the described embodiments of the invention may be employed in practicing the invention.

[0021] 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.

[0022] The terms "administered in combination with" and "co-administration," as used herein, encompass the administration of two or more active pharmaceutical ingredients to a subject such that both agents and / or their metabolites are present in the subject at the same time. Co-administration includes simultaneous administration in separate compositions, administration at different times in separate compositions, or administration in a composition in which two or more agents are present.

[0023] The term "combination" or "pharmaceutical combination" is defined herein to refer to either a fixed combination in the form of a single dosage unit, a non-fixed combination, or a kit of parts for combined administration, where the MDM2 and JAK inhibitors may be administered together, independently at the same time, or separately within a time interval, thereby preferably allowing the combination partners to exhibit cooperativity, e.g., synergistic effects. Thus, the single compounds of the pharmaceutical combinations of the present disclosure may be administered simultaneously or sequentially.

[0024] Furthermore, the pharmaceutical combinations of the present disclosure may be in the form of a fixed combination or a non-fixed combination.

[0025] The term "effective amount" or "therapeutically effective amount" refers to an amount of an active pharmaceutical ingredient or a combination of active pharmaceutical ingredients as described herein sufficient to achieve the intended use, including but not limited to disease treatment. The therapeutically effective amount may vary depending on the intended use (in vitro or in vivo), or the subject and condition being treated (e.g., the subject's weight, age, and sex), the severity of the condition, the mode of administration, and other factors that can be easily determined by those skilled in the art. The term also applies to a dose that will induce a specific response in target cells (e.g., reduced platelet adhesion and / or cell migration). The specific dose will vary depending on the specific compound selected, the dosing regimen followed, whether the compound is administered in combination with other compounds, the timing of administration, the tissue to which it is administered, and the bodily delivery system by which the compound is delivered.

[0026] The term "fixed combination" means that the MDM2 and JAK inhibitor, e.g., a single compound of the combination, are in the form of a single entity or dosage form.

[0027] "MPN-BP" refers to the blast crisis phase (BP) of a myeloproliferative neoplasm (MPN) as described in this disclosure.

[0028] The term "non-fixed combination" means that the MDM2 and JAK inhibitors, e.g., single compounds of the combination, are administered to a patient as separate entities or dosage forms, either simultaneously or sequentially with no specific time limit, wherein preferably, such administration provides therapeutically effective levels of the two JAK inhibitors in the body of a subject, e.g., a mammal or human, in need thereof.

[0029] "Pharmaceutically acceptable carrier" or "pharmaceutically acceptable excipient" is intended to include any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents. The use of such media and agents for active pharmaceutical ingredients is well known in the art. Except insofar as any conventional media or agent is incompatible with the active pharmaceutical ingredient, its use in the therapeutic compositions of the present invention is contemplated. Supplementary active ingredients can also be incorporated into the compositions described. Unless otherwise specified or clearly indicated by the text, references to MDM2 and JAK inhibitors useful in the pharmaceutical combinations of the present disclosure include both the free acid or free base of the compound, and all pharmaceutically acceptable salts of the compound.

[0030] The term "pharmaceutically acceptable salt" refers to salts derived from various organic and inorganic counterions known in the art. Pharmaceutically acceptable acid addition salts can be formed with inorganic and organic acids. Inorganic acids from which salts can be derived include, for example, hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, and phosphoric acid. Organic acids from which salts can be derived include, for example, acetic acid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, maleic acid, malonic acid, succinic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, and salicylic acid. Pharmaceutically acceptable base addition salts can be formed with inorganic and organic bases. Inorganic bases from which salts can be derived include, for example, sodium, potassium, lithium, ammonium, calcium, magnesium, iron, zinc, copper, manganese, and aluminum. Organic bases from which salts can be derived include, for example, primary, secondary, and tertiary amines, substituted amines, including naturally occurring substituted amines, cyclic amines, and basic ion exchange resins. Specific examples include isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, and ethanolamine. In selected embodiments, the pharmaceutically acceptable base addition salt is selected from ammonium, potassium, sodium, calcium, and magnesium salts. The term "cocrystal" refers to a molecular complex derived from any of several cocrystal formers known in the art. Unlike salts, cocrystals typically do not involve proton transfer between the cocrystal and the drug, but instead involve intermolecular interactions such as hydrogen bonding, aromatic ring stacking, or dispersion forces between the cocrystal former and the drug in the crystal structure.

[0031] A "therapeutic effect," as that term is used herein, encompasses therapeutic and / or prophylactic benefits, as defined above. A prophylactic effect includes delaying or eliminating the appearance of a disease or condition, delaying or eliminating the onset of symptoms of a disease or condition, slowing, halting, or reversing the progression of a disease or condition, or any combination thereof.

[0032] When ranges are used herein to describe physical or chemical properties, such as, for example, molecular weight or chemical formula, all combinations and subcombinations of ranges and specific embodiments therein are intended to be included. The use of the term "about" when referring to a number or numerical range means that the stated number or numerical range is approximate within experimental variability (or within statistical experimental error); thus, the number or numerical range may vary, for example, by 1% to 15% of the stated number or numerical range. The term "comprising" (and related terms such as "comprise" or "comprises" or "having" or "including") includes embodiments, such as any composition of matter, method, or process embodiment, for example, "consisting of" or "consisting essentially of" the described feature.

[0033] The present invention encompasses a method for regulating p21 expression in CD34+ myeloid cells using a combination of an MDM2 inhibitor and a JAK inhibitor. p21, also known as cyclin-dependent kinase inhibitor 1 or CDK-interacting protein 1, is a cyclin-dependent kinase inhibitor (CKI) that is primarily involved in inhibiting CDK2 but can inhibit all cyclin / CDK complexes. p21 represents a major target of p53 activity and is therefore involved in linking DNA damage to cell cycle arrest. This protein is encoded by the CDKN1A gene, located on human chromosome 6 (6p21.2). The MDM2 / p53 inhibitory axis upregulates p21 expression, which functions to induce cell cycle arrest in damaged cells. MDM2 inhibitors must overcome this checkpoint to drive apoptosis. JAK inhibitors (i.e., ruxolitinib) do not upregulate p21, which is not surprising, since ruxolitinib would not be expected to biologically modulate p21. However, combined treatment of CD34+ bone marrow cells from patients with myelofibrosis with an MDM2 inhibitor and a JAK inhibitor results in suppression of p21 levels (i.e., they remain unincreased). Thus, the present invention is based on the surprising finding that p21 expression, which does not occur when combined with a JAK inhibitor, is still upregulated in the presence of an MDM2 inhibitor. Because it is no longer necessary to overcome this p21 checkpoint, the apoptosis threshold is much lower, and further apoptosis occurs in the presence of an MDM2 inhibitor. This effect enhances the activity of MDM2 inhibitors, making them more effective in treating MPNs.

[0034] Co-administration of compounds The present invention relates to a pharmaceutical combination or pharmaceutical composition that is particularly useful as a medicine. Specifically, the combination or composition of the present disclosure can be applied in the treatment of cancer. In one embodiment, the cancer is MPN. The present invention also relates to the use of the pharmaceutical combination or pharmaceutical composition of the present disclosure for preparing a medicament for treating cancer, particularly MPN, and to a method for treating cancer in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of a pharmaceutical combination according to the present disclosure or a pharmaceutical composition according to the present disclosure.

[0035] In certain embodiments, the MPN is selected from the group consisting of polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mast cell disease (SMCD).

[0036] In certain embodiments, the myelofibrosis is selected from the group consisting of primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF).

[0037] In certain embodiments, primary myelofibrosis (PMF) is selected from the group consisting of prefibrotic / early PMF and overt fibrotic PMF.

[0038] In certain embodiments, the MPN is selected from the group consisting of chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myelogenous leukemia (aCML), juvenile myelomonocytic leukemia (JMML), hypereosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (MDS / MPN-RS-T).

[0039] One embodiment of the invention is a composition, such as a pharmaceutical composition comprising a combination comprising an MDM2 inhibitor in combination with a JAK inhibitor. Another embodiment is a kit containing both components formulated in separate pharmaceutical compositions, which are formulated for co-administration.

[0040] Another embodiment of the present invention is a method for treating a myeloproliferative neoplasm (MPN), wherein the MPN is selected from the group consisting of polycythemia vera (PV), myelofibrosis, thrombocythemia, idiopathic myelofibrosis, chronic myelogenous leukemia, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mast cell disease (SMCD) in a subject, comprising co-administering to a subject in need thereof a therapeutically effective amount of a combination comprising an MDM2 inhibitor in combination with a JAK inhibitor. Pharmaceutical compositions comprising the combination, and kits are both for use in treating such diseases or conditions.

[0041] In certain embodiments, the MDM2 inhibitor is a compound of Formula (I) or Formula (II).

[0042] In certain embodiments, the MDM2 inhibitor is selected from the group consisting of a compound of Formula (I), Formula (II), RG7388, triptolide, HDM201, RG7112, CGM097A, CGM0970B, SJ-172550, SAR405838, MI-773, MX69, YH239-EE, RO8994, Nutlin-3, Nutlin-3a, Nutlin-3b, Serdemetan, NSC59984, CHEMBL2386350, MK-8242, DS-3032, DS-3032B, RO6839921, APG-115, MI-1601, and a pharmaceutically acceptable salt thereof.

[0043] In certain embodiments, the MDM2 inhibitor is selected from the group consisting of a compound of Formula (I), Formula (II), RG7388, HDM201, RG7112, CGM097A, CGM0970B, SAR405838, MK-8242, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0044] In certain embodiments, the JAK inhibitor is a JAK1 inhibitor.

[0045] In certain embodiments, the JAK inhibitor is a JAK2 inhibitor.

[0046] In certain embodiments, the JAK inhibitor is a JAK3 inhibitor.

[0047] In certain embodiments, the JAK inhibitor is a selective JAK inhibitor.

[0048] In certain embodiments, the JAK inhibitor is a pan JAK inhibitor.

[0049] In certain embodiments, the JAK inhibitor is selected from the group consisting of AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cerdulatinib, CHZ868, CYT387, decernotinib, ENMD-2076, fedratinib, filgotinib, ganetespib, INCB039110, INCB-047986, itacitinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, NSC42834, NVP-BSK805, and ocracycin. nib, pacritinib, peficitinib, pyridone 6, R348, RGB-286638, ruxolitinib, ruxolitinib-S, SAR-20347, SB1317, solcitinib, TG101209, TG101348, tofacitinib (3R,4S), tofacitinib (3S,4R), tofacitinib (3S,4S), tofacitinib, TYK2-IN-2, upadacitinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and pharmaceutically acceptable salts thereof.

[0050] In certain embodiments, the JAK inhibitor is selected from the group consisting of baricitinib phosphate, CYT387 mesylate, CYT387 sulfate, NS-018 hydrochloride, NS-018 maleate, NVP-BSK805 dihydrochloride, oclacitinib maleate, ruxolitinib phosphate, ruxolitinib sulfate, tofacitinib citrate, and ZM39923 hydrochloride.

[0051] The combination may be administered by any route known in the art. In exemplary embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered orally, intravenously, intramuscularly, intraperitoneally, subcutaneously, or transdermally. In one embodiment, the MDM2 inhibitor is administered orally.

[0052] In an exemplary embodiment, the MDM2 inhibitor is in the form of a pharmaceutically acceptable salt.

[0053] In an exemplary embodiment, the MDM2 inhibitor is administered to the subject prior to administration of the JAK inhibitor.

[0054] In an exemplary embodiment, the MDM2 inhibitor is administered to the subject after administration of the JAK inhibitor.

[0055] In an exemplary embodiment, the MDM2 inhibitor is administered to the subject concurrently with the administration of the JAK inhibitor.

[0056] In certain embodiments, the present disclosure provides a method for treating blast phase myeloproliferative neoplasm (MPN-BP) in a subject, comprising co-administering to a subject in need thereof a therapeutically effective amount of a combination comprising an MDM2 inhibitor in combination with a JAK inhibitor. Pharmaceutical compositions and kits containing the combinations are both for use in treating such diseases or conditions. In certain embodiments, the MPN-BP is selected from the group consisting of polycythemia vera in blast phase (BP-PV), blast phase myelofibrosis, blast phase primary myelofibrosis, blast phase thrombocythemia, blast phase essential thrombocythemia (BP-ET), blast phase idiopathic myelofibrosis, blast phase systemic mastocytosis (BP-SM), blast phase chronic neutrophilic leukemia (BP-CNL), blast phase myelodysplastic syndrome (BP-MDS), and blast phase systemic mast cell disease (BP-SMCD). In certain embodiments, the blast crisis phase myelofibrosis is selected from the group consisting of primary blast crisis phase myelofibrosis (BP-PMF), post-polycythemia vera blast crisis phase myelofibrosis (post-BP-PV MF), and post-essential thrombocythemia blast crisis phase myelofibrosis (post-BP-ET MF). In certain embodiments, the blast crisis phase primary myelofibrosis (BP-PMF) is selected from the group consisting of pre-blast crisis phase / early PMF and overt blast crisis phase PMF. In certain embodiments, the MPN-BP is selected from the group consisting of blastic phase chronic neutrophilic leukemia (BP-CNL), blastic phase chronic eosinophilic leukemia, blastic phase chronic myelomonocytic leukemia (BP-CMML), blastic phase atypical chronic myelogenous leukemia (BP-aCML), blastic phase juvenile myelomonocytic leukemia (BP-JMML), blastic phase hypereosinophilic syndrome (BP-HES), and blastic phase myelodysplastic / myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (BP-MDS / MPN-RS-T). In certain embodiments, the MDM2 inhibitor is a compound of Formula (I) or Formula (II).In certain embodiments, the MDM2 inhibitor is selected from the group consisting of a compound of Formula (I), Formula (II), RG7388, triptolide, HDM201, RG7112, CGM097A, CGM0970B, SJ-172550, SAR405838, MI-773, MX69, YH239-EE, RO8994, nutlin-3, nutlin-3a, nutlin-3b, celdemethane, NSC59984, CHEMBL2386350, MK-8242, DS-3032, DS-3032B, RO6839921, APG-115, MI-1601, and a pharmaceutically acceptable salt thereof. In certain embodiments, the MDM2 inhibitor is selected from the group consisting of a compound of Formula (I), Formula (II), RG7388, HDM201, RG7112, CGM097A, CGM0970B, SAR405838, MK-8242, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0057] In one embodiment, the MPN in the human subject is characterized by a CALR mutation (calreticulin, located on chromosome 19p13.2) as described in Massie, N. Engl. J. Med. (2013) 25:2379-2390.

[0058] In one embodiment, the MPN in a human subject is characterized by an MPL mutation (myeloproliferative leukemia viral oncogene; located on chromosome 1p34) as described in Pikman, Plos Med. (2006) 3(7):e270.

[0059] In one embodiment, the MPN in the human subject is characterized by the JAK2V617F mutation, a functional mutation that promotes cytokine-independent growth of myeloid cells and accounts for the majority of myeloproliferative neoplasms (MPNs), as described in Nakatake, Oncogene (2012) 31, 1323-1333.

[0060] In certain embodiments, the MPN in the human subject is characterized by having one or more mutations selected from the group consisting of JAK2V617F, MPL, CALR, and combinations thereof.

[0061] In an exemplary embodiment, the subject is a mammal, such as a human.

[0062] MDM2 inhibitors The compound of formula (I) is known as 2-((3R,5R,6S)-5-(3-chlorophenyl)-6-(4-chlorophenyl)-1-((S)-1-(isopropylsulfonyl)-3-methylbutan-2-yl)-3-methyl-2-oxopiperidin-3-yl)acetic acid.

[0063] In certain embodiments, the MDM2 inhibitor is the compound of formula (II) known as 4-(2-((3R,5R,6S)-1-((S)-2-(tert-butylsulfonyl)-1-cyclopropylethyl)-6-(4-chloro-3-fluorophenyl)-5-(3-chlorophenyl)-3-methyl-2-oxopiperidin-3-yl)acetamido)-2-methoxybenzoic acid.

[0064] In one embodiment, the MDM2 inhibitor is RG 7388. RG 7388 is known as 4-[[(2R,3S,4R,5S)-3-(3-chloro-2-fluorophenyl)-4-(4-chloro-2-fluorophenyl)-4-cyano-5-(2,2-dimethylpropyl)pyrrolidine-2-carbonyl]amino]-3-methoxybenzoic acid.

[0065] In one embodiment, the MDM2 inhibitor is triptolide, also known as (5bS,6aS,7aS,8R,8aR,9aS,9bS,10aS,10bS)-8-hydroxy-8a-isopropyl-10b-methyl-2,5,5b,6,6a,8,8a,9a,9b,10b-decahydrotris(oxireno)[2',3':4b,5;2'',3'':6,7;2''',3''':8a,9]phenanthro[1,2-c]furan-3(1H)-one.

[0066] In one embodiment, the MDM2 inhibitor is Nutlin-3a, known as 4-[(4S,5R)-4,5-bis(4-chlorophenyl)-2-(4-methoxy-2-propan-2-yloxyphenyl)-4,5-dihydroimidazole-1-carbonyl]piperazin-2-one.

[0067] In one embodiment, the MDM2 inhibitor is HDM201. HDM201 is known as (4S)-5-(5-chloro-1-methyl-2-oxopyridin-3-yl)-4-(4-chlorophenyl)-2-(2,4-dimethoxypyrimidin-5-yl)-3-propan-2-yl-4H-pyrrolo[3,4-d]imidazol-6-one.

[0068] In one embodiment, the MDM2 inhibitor is RG7112, known as [(4S,5R)-2-(4-tert-butyl-2-ethoxyphenyl)-4,5-bis(4-chlorophenyl)-4,5-dimethylimidazol-1-yl]-[4-(3-methylsulfonylpropyl)piperazin-1-yl]methanone.

[0069] In one embodiment, the MDM2 inhibitor is CGM097A, known as (1S)-1-(4-chlorophenyl)-6-methoxy-2-[4-[methyl-[[4-(4-methyl-3-oxopiperazin-1-yl)cyclohexyl]methyl]amino]phenyl]-7-propan-2-yloxy-1,4-dihydroisoquinolin-3-one.

[0070] In one embodiment, the MDM2 inhibitor is Nutlin-3, known as 4-[4,5-bis(4-chlorophenyl)-2-(4-methoxy-2-propan-2-yloxyphenyl)-4,5-dihydroimidazole-1-carbonyl]piperazin-2-one.

[0071] In one embodiment, the MDM2 inhibitor is SJ-172550, known as methyl 2-[2-chloro-6-ethoxy-4-[(3-methyl-5-oxo-1-phenylpyrazol-4-ylidene)methyl]phenoxy]acetate.

[0072] In one embodiment, the MDM2 inhibitor is SAR405838, known as (2'R,3R,3'S,5'S)-6-chloro-3'-(3-chloro-2-fluorophenyl)-5'-(2,2-dimethylpropyl)-N-(4-hydroxycyclohexyl)-2-oxospiro[1H-indole-3,4'-pyrrolidine]-2'-carboxamide.

[0073] In one embodiment, the MDM2 inhibitor is MI-773, known as (2'R,3S,3'S,5'R)-6-chloro-3'-(3-chloro-2-fluorophenyl)-5'-(2,2-dimethylpropyl)-N-(4-hydroxycyclohexyl)-2-oxospiro[1H-indole-3,4'-pyrrolidine]-2'-carboxamide.

[0074] In one embodiment, the MDM2 inhibitor is MX69, known as 4-[8-[(3,4-dimethylphenyl)sulfamoyl]-3a,4,5,9b-tetrahydro-3H-cyclopenta[c]quinolin-4-yl]benzoic acid.

[0075] In one embodiment, the MDM2 inhibitor is YH239-EE, known as ethyl 3-[2-(tert-butylamino)-1-[(4-chlorophenyl)methyl-formylamino]-2-oxoethyl]-6-chloro-1H-indole-2-carboxylate.

[0076] In one embodiment, the MDM2 inhibitor is RO8994, known as (2'R,3R,3'S,5'S)-N-(4-carbamoyl-2-methoxyphenyl)-6-chloro-3'-(3-chloro-2-fluorophenyl)-5'-(2,2-dimethylpropyl)-2-oxospiro[1H-indole-3,4'-pyrrolidine]-2'-carboxamide.

[0077] In one embodiment, the MDM2 inhibitor is Nutlin-3b, known as 4-[(4R,5S)-4,5-bis(4-chlorophenyl)-2-(4-methoxy-2-propan-2-yloxyphenyl)-4,5-dihydroimidazole-1-carbonyl]piperazin-2-one.

[0078] In one embodiment, the MDM2 inhibitor is celdemethane, also known as 1-N-[2-(1H-indol-3-yl)ethyl]-4-N-pyridin-4-ylbenzene-1,4-diamine.

[0079] In one embodiment, the MDM2 inhibitor is NSC 59984, known as (E)-1-(4-methylpiperazin-1-yl)-3-(5-nitrofuran-2-yl)prop-2-en-1-one.

[0080] In certain embodiments, the MDM2 inhibitor is CHEMBL 2386350. CHEMBL 2386350 is known as 2-[4-[(4S,5R)-2-(4-tert-butyl-2-ethoxyphenyl)-4,5-bis(4-chlorophenyl)-4,5-dimethylimidazole-1-carbonyl]piperazin-1-yl]-1-morpholin-4-ylethanone.

[0081] In one embodiment, the MDM2 inhibitor is CGM0970B, known as (1R)-1-(4-chlorophenyl)-6-methoxy-2-[4-[methyl-[[4-(4-methyl-3-oxopiperazin-1-yl)cyclohexyl]methyl]amino]phenyl]-7-propan-2-yloxy-1,4-dihydroisoquinolin-3-one.

[0082] In one embodiment, the MDM2 inhibitor is MK-8242, known as 4-amino-1-[(2R,3S,4S,5R)-3,4-dihydroxy-5-(hydroxymethyl)oxolan-2-yl]pyrimidin-2-one.

[0083] In one embodiment, the MDM2 inhibitor is DS-3032, known as (3'R,4'S,5'R)-N-((3R,6S)-6-carbamoyltetrahydro-2H-pyran-3-yl)-6"-chloro-4'-(2-chloro-3-fluoropyridin-4-yl)-4,4-dimethyl-2"-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3"-indoline]-5'-carboxamide.

[0084] In one embodiment, the MDM2 inhibitor is DS-3032B, known as (3'R,4'S,5'R)-N-((3R,6S)-6-carbamoyltetrahydro-2H-pyran-3-yl)-6"-chloro-4'-(2-chloro-3-fluoropyridin-4-yl)-4,4-dimethyl-2"-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3"-indoline]-5'-carboxamide 4-methylbenzenesulfonate.

[0085] In one embodiment, the MDM2 inhibitor is HDM201. HDM201 is known as (4S)-5-(5-chloro-1-methyl-2-oxopyridin-3-yl)-4-(4-chlorophenyl)-2-(2,4-dimethoxypyrimidin-5-yl)-3-propan-2-yl-4H-pyrrolo[3,4-d]imidazol-6-one.

[0086] In one embodiment, the MDM2 inhibitor is APG-115, known as 4-((3'R,4'S,5'R)-6''-chloro-4'-(3-chloro-2-fluorophenyl)-1'-ethyl-2''-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3''-indoline]-5'-carboxamide)bicyclo[2.2.2]octane-1-carboxylic acid.

[0087] In one embodiment, the MDM2 inhibitor is APG-115, known as 4-((3'R,4'S,5'R)-6''-chloro-4'-(3-chloro-2-fluorophenyl)-2''-oxodispiro[cyclohexane-1,2'-pyrrolidine-3',3''-indoline]-5'-carboxamido)benzoic acid.

[0088] JAK inhibitors In one embodiment, the JAK inhibitor is ruxolitinib (available from Incyte Corp. and Novartis AG). Ruxolitinib is known as (R)-3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-3-cyclopentylpropanenitrile.

[0089] In some embodiments, the JAK inhibitor is ruxolitinib phosphate (available from Incyte Corp. and Novartis AG). In some embodiments, the JAK inhibitor is (R)-3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-3-cyclopentylpropanenitrile phosphate.

[0090] In one embodiment, the JAK inhibitor is baricitinib (available from Incyte Corp. and Eli Lilly & Co.). Baricitinib is known as 2-(3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-1-(ethylsulfonyl)azetidin-3-yl)acetonitrile.

[0091] In one embodiment, the JAK inhibitor is momelotinib (Gilead Sciences). Momelotinib is also known as CYT-387. Momelotinib is known as N-(cyanomethyl)-4-(2-((4-morpholinophenyl)amino)pyrimidin-4-yl)benzamide.

[0092] In one embodiment, the JAK inhibitor is ganetespib, also known as 5-(2,4-dihydroxy-5-isopropylphenyl)-4-(1-methyl-1H-indol-5-yl)-2,4-dihydro-3H-1,2,4-triazol-3-one.

[0093] In one embodiment, the JAK inhibitor is NS-018. NS-018 is (S)-N 2 -(1-(4-fluorophenyl)ethyl)-6-(1-methyl-1H-pyrazol-4-yl)-N 4 -(pyrazin-2-yl)pyrimidine-2,4-diamine.

[0094] In one embodiment, the JAK inhibitor is BMS-911543, known as N,N-dicyclopropyl-4-((1,5-dimethyl-1H-pyrazol-3-yl)amino)-6-ethyl-1-methyl-1,6-dihydroimidazo[4,5-d]pyrrolo[2,3-b]pyridine-7-carboxamide.

[0095] In one embodiment, the JAK inhibitor is gandotinib, known as 3-(4-chloro-2-fluorobenzyl)-2-methyl-N-(5-methyl-1H-pyrazol-3-yl)-8-(morpholinomethyl)imidazo[1,2-b]pyridazin-6-amine.

[0096] In one embodiment, the JAK inhibitor is ENMD-2076, known as (E)—N-(5-methyl-1H-pyrazol-3-yl)-6-(4-methylpiperazin-1-yl)-2-styrylpyrimidin-4-amine.

[0097] In one embodiment, the JAK inhibitor is AT-9283. AT-9283 is known as 1-cyclopropyl-3-(3-(5-

[0098] In one embodiment, the JAK inhibitor is pacritinib, also known as 11-(2-pyrrolidin-1-yl-ethoxy)-14,19-dioxa-5,7,26-triaza-tetracyclo[19.3.1.1(2,6).1(8,12)]heptacosa-1(25),2(26),3,5,8,10,12(27),16,21,23-decaene.

[0099] In one embodiment, the JAK inhibitor is AC-410 (available from Ambit Biosciences). AC-410 is known as (S)-(4-fluorophenyl)(4-((5-methyl-1H-pyrazol-3-yl)amino)quinazolin-2-yl)methanol.

[0100] In one embodiment, the JAK inhibitor is AZD-1480. AZD-1480 is (S)-5-chloro-N 2 -(1-(5-fluoropyrimidin-2-yl)ethyl)-N 4 It is known as -(5-methyl-1H-pyrazol-3-yl)pyrimidine-2,4-diamine.

[0101] In one embodiment, the JAK inhibitor is CYT387, known as N-(cyanomethyl)-4-(2-(4-morpholinophenylamino)pyrimidin-4-yl)benzamide.

[0102] In one embodiment, the JAK inhibitor is TYK2-IN-2, known as 6-((3,5-dimethylphenyl)amino)-8-(methylamino)imidazo[1,2-b]pyridazine-3-carboxamide.

[0103] In one embodiment, the JAK inhibitor is SAR-20347, known as 2-(2-chloro-6-fluorophenyl)-5-[4-(morpholine-4-carbonyl)anilino]-1,3-oxazole-4-carboxamide.

[0104] In one embodiment, the JAK inhibitor is upadacitinib (ABT-494), known as (3S,4R)-3-ethyl-4-(3H-imidazo[1,2-a]pyrrolo[2,3-e]pyrazin-8-yl)-N-(2,2,2-trifluoroethyl)pyrrolidine-1-carboxamide.

[0105] In one embodiment, the JAK inhibitor is WP1066, known as (E)-3-(6-bromopyridin-2-yl)-2-cyano-N-[(1S)-1-phenylethyl]prop-2-enamide.

[0106] In one embodiment, the JAK inhibitor is GLPG0634 (filgotinib), known as N-[5-[4-[(1,1-dioxo-1,4-thiazinan-4-yl)methyl]phenyl]-[1,2,4]triazolo[1,5-a]pyridin-2-yl]cyclopropanecarboxamide.

[0107] In one embodiment, the JAK inhibitor is TG101348 (fedratinib; SAR302503). TG101348 is known as N-tert-butyl-3-[[5-methyl-2-[4-(2-pyrrolidin-1-ylethoxy)anilino]pyrimidin-4-yl]amino]benzenesulfonamide.

[0108] In one embodiment, the JAK inhibitor is celdulatinib (PRT062070; PRT2070). Cerdulatinib is known as 4-(cyclopropylamino)-2-[4-(4-ethylsulfonylpiperazin-1-yl)anilino]pyrimidine-5-carboxamide.

[0109] In one embodiment, the JAK inhibitor is tofacitinib, also known as 3-[(3R,4R)-4-methyl-3-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]piperidin-1-yl]-3-oxopropanenitrile.

[0110] In one embodiment, the JAK inhibitor is itacitinib, known as 2-[1-[1-[3-fluoro-2-(trifluoromethyl)pyridine-4-carbonyl]piperidin-4-yl]-3-[4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)pyrazol-1-yl]azetidin-3-yl]acetonitrile.

[0111] In one embodiment, the JAK inhibitor is decernotinib, known as (2R)-2-methyl-2-[[2-(1H-pyrrolo[2,3-b]pyridin-3-yl)pyrimidin-4-yl]amino]-N-(2,2,2-trifluoroethyl)butanamide.

[0112] In one embodiment, the JAK inhibitor is CHZ868, known as N-[4-[2-(2,4-difluoroanilino)-1,4-dimethylbenzimidazol-5-yl]oxypyridin-2-yl]acetamide.

[0113] In one embodiment, the JAK inhibitor is SB1317, known as (E)-6-methyl-12-oxa-3,6-diaza-2(4,2)-pyrimidina-1,4(1,3)-dibenzenacyclododecaphan-8-ene.

[0114] In one embodiment, the JAK inhibitor is solcitinib, also known as N-[5-[4-(3,3-dimethylazetidine-1-carbonyl)phenyl]-[1,2,4]triazolo[1,5-a]pyridin-2-yl]cyclopropanecarboxamide.

[0115] In one embodiment, the JAK inhibitor is peficitinib, known as 4-[[(1R,3S)-5-hydroxy-2-adamantyl]amino]-1H-pyrrolo[2,3-b]pyridine-5-carboxamide.

[0116] In one embodiment, the JAK inhibitor is CEP-33779, known as N-[3-(4-methylpiperazin-1-yl)phenyl]-8-(4-methylsulfonylphenyl)-[1,2,4]triazolo[1,5-a]pyridin-2-amine.

[0117] In one embodiment, the JAK inhibitor is pyridone 6. Pyridone 6 is known as 2-(tert-butyl)-9-fluoro-3H-benzo[h]imidazo[4,5-f]isoquinolin-7-ol.

[0118] In one embodiment, the JAK inhibitor is LFM-A13, known as (Z)-2-cyano-N-(2,5-dibromophenyl)-3-hydroxybut-2-enamide.

[0119] In one embodiment, the JAK inhibitor is BMS-911543, known as (Z)—N,N-dicyclopropyl-4-((1,5-dimethyl-1,2-dihydro-3H-pyrazol-3-ylidene)amino)-6-ethyl-1-methyl-1,6-dihydroimidazo[4,5-d]pyrrolo[2,3-b]pyridine-7-carboxamide.

[0120] In one embodiment, the JAK inhibitor is NS-018, known as 6-N-[(1S)-1-(4-fluorophenyl)ethyl]-4-(1-methylpyrazol-4-yl)-2-N-pyrazin-2-ylpyridine-2,6-diamine.

[0121] In one embodiment, the JAK inhibitor is JANEX-1. JANEX-1 is known as 4-[(6,7-dimethoxyquinazolin-4-yl)amino]phenol.

[0122] In one embodiment, the JAK inhibitor is TG101209. TG101209 is known as N-tert-butyl-3-[[5-methyl-2-[4-(4-methylpiperazin-1-yl)anilino]pyrimidin-4-yl]amino]benzenesulfonamide.

[0123] In one embodiment, the JAK inhibitor is WHI-P154, known as 2-bromo-4-[(6,7-dimethoxyquinazolin-4-yl)amino]phenol.

[0124] In one embodiment, the JAK inhibitor is NVP-BSK805, known as 4-[[2,6-difluoro-4-[3-(1-piperidin-4-ylpyrazol-4-yl)quinoxalin-5-yl]phenyl]methyl]morpholine.

[0125] In one embodiment, the JAK inhibitor is ZM39923, known as 3-[benzyl(propan-2-yl)amino]-1-naphthalen-2-ylpropan-1-one.

[0126] In one embodiment, the JAK inhibitor is ruxolitinib-S, known as (3S)-3-cyclopentyl-3-[4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)pyrazol-1-yl]propanenitrile.

[0127] In one embodiment, the JAK inhibitor is XL019, known as (2S)—N-[4-[2-(4-morpholin-4-ylanilino)pyrimidin-4-yl]phenyl]pyrrolidine-2-carboxamide.

[0128] In one embodiment, the JAK inhibitor is AZ960, known as 5-fluoro-2-[[(1S)-1-(4-fluorophenyl)ethyl]amino]-6-[(5-methyl-1H-pyrazol-3-yl)amino]pyridine-3-carbonitrile.

[0129] In one embodiment, the JAK inhibitor is JAK3IN-1, known as N-[3-[[[5-chloro-2-[2-methoxy-4-(4-methylpiperazin-1-yl)anilino]pyrimidin-4-yl]amino]methyl]phenyl]prop-2-enamide.

[0130] In one embodiment, the JAK inhibitor is WHI-P97, known as 2,6-dibromo-4-[(6,7-dimethoxyquinazolin-4-yl)amino]phenol.

[0131] In one embodiment, the JAK inhibitor is RGB-286638, known as 1-[3-[4-[[4-(2-methoxyethyl)piperazin-1-yl]methyl]phenyl]-4-oxo-1H-indeno[1,2-c]pyrazol-5-yl]-3-morpholin-4-ylurea; dihydrochloride.

[0132] In one embodiment, the JAK inhibitor is tofacitinib (3R,4S), also known as 3-[(3R,4S)-4-methyl-3-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]piperidin-1-yl]-3-oxopropanenitrile.

[0133] In one embodiment, the JAK inhibitor is NSC 42834. NSC 42834 is known as 2-methyl-1-phenyl-4-pyridin-2-yl-2-(2-pyridin-2-ylethyl)butan-1-one.

[0134] In one embodiment, the JAK inhibitor is PF-06651600. PF-06651600 is known as benzyl 2-(hydroxymethyl)-5-[(2-methylpropan-2-yl)oxycarbonylamino]piperidine-1-carboxylate.

[0135] In one embodiment, the JAK inhibitor is tofacitinib (3S,4S), known as 3-[(3S,4S)-4-methyl-3-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]piperidin-1-yl]-3-oxopropanenitrile.

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

[0137] In one embodiment, the JAK inhibitor is AEG3482, known as 6-phenylimidazo[2,1-b][1,3,4]thiadiazole-2-sulfonamide.

[0138] In one embodiment, the JAK inhibitor is lestaurtinib (CEP-701), also known as (5R,7S,8S)-7-hydroxy-7-(hydroxymethyl)-8-methyl-5,6,7,8,13,14-hexahydro-15H-16-oxa-4b,8a,14-triaza-5,8-methanodibenzo[b,h]cycloocta[jkl]cyclopenta[e]-as-indacen-15-one.

[0139] In one embodiment, the JAK inhibitor is oclacitinib, known as N-methyl-1-[4-[methyl(7H-pyrrolo[2,3-d]pyrimidin-4-yl)amino]cyclohexyl]methanesulfonamide.

[0140] In certain embodiments, the JAK inhibitor is (E)-4-(2-(pyrrolidin-1-yl)ethoxy)-6,11-dioxa-3-aza-2(4,2)-pyrimidina-1(2,5)-furan-4(1,3)-benzeneacyclododecaphan-8-ene.

[0141] In one embodiment, the JAK inhibitor is (9E)-15-(2-(pyrrolidin-1-yl)ethoxy)-7,12,25-trioxa-19,21,24-triaza-tetracyclo[18.3.1.1(2,5).1(14,18)]hexacosa-1(24),2,4,9,14(26),15,17,20,22-nonaene.

[0142] In one embodiment, the JAK inhibitor is (R)-(4-fluorophenyl)(4-((5-methyl-1H-pyrazol-3-yl)amino)quinazolin-2-yl)methanol, which is also known in the art to be active as a JAK inhibitor. In one embodiment, the JAK inhibitor is racemic (4-fluorophenyl)(4-((5-methyl-1H-pyrazol-3-yl)amino)quinazolin-2-yl)methanol, which is also known in the art to be active as a JAK inhibitor.

[0143] In certain embodiments, the JAK inhibitor is (S)-5-fluoro-2-((1-(4-fluorophenyl)ethyl)amino)-6-((5-methyl-1H-pyrazol-3-yl)amino)nicotinonitrile.

[0144] In certain embodiments, the JAK inhibitor is ((R)-7-(2-aminopyrimidin-5-yl)-1-((1-cyclopropyl-2,2,2-trifluoroethyl)amino)-5H-pyrido[4,3-b]indole-4-carboxamide, which is also referred to as 7-(2-aminopyrimidin-5-yl)-1-{[(1R)-1-cyclopropyl-2,2,2-trifluoroethyl]amino}-5H-pyrido[4,3-b]indole-4-carboxamide.

[0145] Pharmaceutical Composition In some embodiments, the present invention provides a pharmaceutical composition comprising a combination comprising an MDM2 inhibitor and a JAK inhibitor. In certain embodiments, the MPN is selected from the group consisting of polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mast cell disease (SMCD). In certain embodiments, the myelofibrosis is selected from the group consisting of primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF). In certain embodiments, the primary myelofibrosis (PMF) is selected from the group consisting of prefibrotic / early PMF and overt fibrotic PMF. In certain embodiments, the MPN is selected from the group consisting of chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myelogenous leukemia (aCML), juvenile myelomonocytic leukemia (JMML), hypereosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (MDS / MPN-RS-T).

[0146] In certain embodiments, the MDM2 inhibitor is a compound of Formula (I) or Formula (II) or a pharmaceutically acceptable salt thereof.

[0147] In certain embodiments, the MDM2 inhibitor is selected from the group consisting of a compound of Formula (I), Formula (II), RG7388, triptolide, HDM201, RG7112, CGM097A, CGM0970B, SJ-172550, SAR405838, MI-773, MX69, YH239-EE, RO8994, nutlin-3, nutlin-3a, nutlin-3b, celdemethane, NSC59984, CHEMBL2386350, MK-8242, DS-3032, DS-3032B, RO6839921, APG-115, MI-1601, and a pharmaceutically acceptable salt thereof.

[0148] In certain embodiments, the MDM2 inhibitor is selected from the group consisting of a compound of Formula (I), Formula (II), RG7388, HDM201, RG7112, CGM097A, CGM0970B, SAR405838, MK-8242, DS-3032B, RO6839921, APG-115, MI-1601, and pharmaceutically acceptable salts thereof.

[0149] In certain embodiments, the JAK inhibitor is selected from the group consisting of AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cerdulatinib, CHZ868, CYT387, decernotinib, ENMD-2076, fedratinib, filgotinib, ganetespib, INCB039110, INCB-047986, itacitinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, NSC42834, NVP-BSK805, and ocracycin. nib, pacritinib, peficitinib, pyridone 6, R348, RGB-286638, ruxolitinib, ruxolitinib-S, SAR-20347, SB1317, solcitinib, TG101209, TG101348, tofacitinib (3R,4S), tofacitinib (3S,4R), tofacitinib (3S,4S), tofacitinib, TYK2-IN-2, upadacitinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and pharmaceutically acceptable salts thereof.

[0150] In certain embodiments, the JAK inhibitor is selected from the group consisting of baricitinib phosphate, CYT387 mesylate, CYT387 sulfate, NS-018 hydrochloride, NS-018 maleate, NVP-BSK805 dihydrochloride, oclacitinib maleate, ruxolitinib phosphate, ruxolitinib sulfate, tofacitinib citrate, and ZM39923 hydrochloride.

[0151] In certain embodiments, the thrombocythemia is essential thrombocythemia (ET).

[0152] In certain embodiments, the myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF).

[0153] polycythemia vera In some embodiments, the present invention provides a pharmaceutical composition comprising a combination of a compound of Formula (I) or Formula (II) or a pharmaceutically acceptable salt thereof and a JAK inhibitor, wherein the JAK inhibitor is selected from the group consisting of AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cerdulatinib, CHZ868, CYT387, decernotinib, ENMD-2076, fedratinib, filgotinib, ganetespib, INCB039110, INCB-047986, itacitinib, JAK3-IN-1, JANEX-1, LFM-A13, LY278454 4, NS-018, NSC42834, NVP-BSK805, oclacitinib, pacritinib, peficitinib, pyridone 6, R348, RGB-286638, ruxolitinib, ruxolitinib-S, SAR-20347, SB1317, solcitinib, TG101209, TG101348, tofacitinib (3R,4S), tofacitinib (3S,4R), tofacitinib (3S,4S), tofacitinib, TYK2-IN-2, upadacitinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and pharmaceutically acceptable salts thereof.

[0154] Essential thrombocythemia (ET) In some embodiments, the present invention provides a pharmaceutical composition comprising a combination of a compound of Formula (I) or Formula (II) or a pharmaceutically acceptable salt thereof and a JAK inhibitor, wherein the JAK inhibitor is selected from the group consisting of AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cerdulatinib, CHZ868, CYT387, decernotinib, ENMD-2076, filgotinib, ganetespib, INCB039110, INCB-047986, itacitinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS -018, NSC42834, NVP-BSK805, oclacitinib, pacritinib, peficitinib, pyridone 6, R348, RGB-286638, ruxolitinib, ruxolitinib-S, SAR-20347, SB1317, solcitinib, TG101209, TG101348, tofacitinib (3R,4S), tofacitinib (3S,4R), tofacitinib (3S,4S), tofacitinib, TYK2-IN-2, upadacitinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and pharmaceutically acceptable salts thereof.

[0155] Myelofibrosis In some embodiments, the present invention provides a pharmaceutical composition comprising a combination of a compound of Formula (I) or Formula (II) or a pharmaceutically acceptable salt thereof and a JAK inhibitor, wherein the JAK inhibitor is selected from the group consisting of AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cerdulatinib, CHZ868, CYT387, decernotinib, ENMD-2076, filgotinib, ganetespib, INCB039110, INCB-047986, itacitinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS -018, NSC42834, NVP-BSK805, oclacitinib, pacritinib, peficitinib, pyridone 6, R348, RGB-286638, ruxolitinib, ruxolitinib-S, SAR-20347, SB1317, solcitinib, TG101209, TG101348, tofacitinib (3R,4S), tofacitinib (3S,4R), tofacitinib (3S,4S), tofacitinib, TYK2-IN-2, upadacitinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and pharmaceutically acceptable salts thereof.

[0156] In certain embodiments, the myelofibrosis is selected from primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF).

[0157] Pharmaceutical compositions are typically formulated to provide a therapeutically effective amount of MDM2 inhibitor and JAK inhibitor.If desired, pharmaceutical compositions contain pharmaceutically acceptable salt and / or its coordination complex, and one or more pharmaceutically acceptable excipients, carriers including inert solid diluents and fillers, diluents including sterile aqueous solutions and various organic solvents, penetration enhancers, solubilizers and adjuvants.

[0158] In selected embodiments, the concentrations of the MDM2 inhibitor and the JAK inhibitor provided in the pharmaceutical compositions of the invention may be independently greater than or equal to, for example, 100%, 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19%, 18%, 17%, 16%, 15%, 14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 1.0 ... %, 0.07%, 0.06%, 0.05%, 0.04%, 0.03%, 0.02%, 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002% or less w / w, w / v, or v / v.

[0159] In selected embodiments, the concentrations of the MDM2 inhibitor and the JAK inhibitor provided in the pharmaceutical compositions of the invention are independently 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19.75%, 19.50%, 19.25% 19%, 18.75%, 18.50%, 18.25% 18%, 17.75%, 17.50%, 17.25% 17%, 16.75%, 16.50%, 16.25% 16%, 15.75%, 15.50%, 15.25% 15%, 14.75%, 14.50%, 14.25% 14%, 13.75%, 13.50%, 13.25% 13%, 12.75%, 12.50%, 12.25% 12%, 11.75%, 11.50%, 11.25% 11%, 10.75%, 10.50%, 10.25% 10%, 9.75%, 9.50%, 9.25% 9%, 8.75%, 8.50%, 8.25% 8%, 7.75%, 7.50%, 7.25% 7%, 6.75%, 6.50%, 6.25% 6%, 5.75%, 5.50%, 5.25% 5%,4.75%,4.50%,4.25%,4%,3.75%,3.50%,3.25%,3%,2.75%,2.50%,2.25%,2%,1.75%,1.50%,125%,1%,0.5%,0.4%,0.3%,0.2%,0.1%,0.09%,0.08%,0.07%,0.06%,0.05%,0.04%,0.03%,0.02%,0 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002% or greater than 0.0001% w / w, w / v, or v / v.

[0160] In selected embodiments, the concentrations of the MDM2 inhibitor and the JAK inhibitor are independently between about 0.0001% and about 50%, between about 0.001% and about 40%, between about 0.01% and about 30%, between about 0.02% and about 29%, between about 0.03% and about 28%, between about 0.04% and about 27%, between about 0.05% and about 26%, between about 0.06% and about 25%, between about 0.07% and about 24%, between about 0.08% and about 100%, between about 0.09% and about 22%, between about 0.10% and about 120%, between about 0.11% and about 130%, between about 0.12% and about 140%, between about 0.13% and about 150%, between about 0.14% and about 160%, between about 0.15% and about 170%, between about 0.16% and about 180%, between about 0.17% and about 190%, between about 0.18% and about 220%, between about 0.19% and about 230%, between about 0.19% and about 240%, between about 0.20% and about 250%, between about 0.21% and about 250%, between about 0.22% and about 260%, between about 0.23% and about 260%, between about 0.24% and about 270%, between about 0.25% and about 270%, between about 0.26% and about 270%, between about 0.27% and about 280%, between about 0.28% and about 280%, between about 0.29% and about 290%, between about 0.30% and about 280%, between about 0 about 0.09% to about 22%, about 0.1% to about 21%, about 0.2% to about 20%, about 0.3% to about 19%, about 0.4% to about 18%, about 0.5% to about 17%, about 0.6% to about 16%, about 0.7% to about 15%, about 0.8% to about 14%, about 0.9% to about 12%, or about 1% to about 10% w / w, w / v, or v / v.

[0161] In selected embodiments, the concentrations of the MDM2 inhibitor and the JAK inhibitor are independently within the range of about 0.001% to about 10%, about 0.01% to about 5%, about 0.02% to about 4.5%, about 0.03% to about 4%, about 0.04% to about 3.5%, about 0.05% to about 3%, about 0.06% to about 2.5%, about 0.07% to about 2%, about 0.08% to about 1.5%, about 0.09% to about 1%, about 0.1% to about 0.9% w / w, w / v or v / v.

[0162] In selected embodiments, the amounts of MDM2 inhibitor and JAK inhibitor are independently 10 g, 9.5 g, 9.0 g, 8.5 g, 8.0 g, 7.5 g, 7.0 g, 6.5 g, 6.0 g, 5.5 g, 5.0 g, 4.5 g, 4.0 g, 3.5 g, 3.0 g, 2.5 g, 2.0 g, 1.5 g, 1.0 g, 0.95 g, 0.9 g, 0.85 g, 0.8 g, 0.75 g, 0.7 g, 0.65 g, 0.6 g, 0.55 g, 0.5 g, 0.45 g, 0.4 g, 0.35 g, 0.3 g, 0.25 g , 0.2g, 0.15g, 0.1g, 0.09g, 0.08g, 0.07g, 0.06g, 0.05g, 0.04g, 0.03g, 0.02g, 0.01g, 0.009g, 0.008g, 0.007g, 0.006g, 0.005g, 0.004g, 0.003g, 0.002g, 0.001g, 0.0009g, 0.0008g, 0.0007g, 0.0006g, 0.0005g, 0.0004g, 0.0003g, 0.0002g or 0.0001g.

[0163] In selected embodiments, the amounts of MDM2 inhibitor and JAK inhibitor are independently 0.0001 g, 0.0002 g, 0.0003 g, 0.0004 g, 0.0005 g, 0.0006 g, 0.0007 g, 0.0008 g, 0.0009 g, 0.001 g, 0.0015 g, 0.002 g, 0.00 25g, 0.003g, 0.0035g, 0.004g, 0.0045g, 0.005g, 0.0055g, 0.006g, 0.0065g, 0.0 07g, 0.0075g, 0.008g, 0.0085g, 0.009g, 0.0095g, 0.01g, 0.015g, 0.02g, 0.025g, 0.03g, 0.035g, 0.04g, 0.045g, 0.05g, 0.055g, 0.06g, 0.065g, 0.07g, 0.075g, 0. 08g, 0.085g, 0.09g, 0.095g, 0.1g, 0.15g, 0.2g, 0.25g, 0.3g, 0.35g, 0.4g, 0.45g, More than 0.5g, 0.55g, 0.6g, 0.65g, 0.7g, 0.75g, 0.8g, 0.85g, 0.9g, 0.95g, 1g, 1.5g, 2g, 2.5, 3g, 3.5, 4g, 4.5g, 5g, 5.5g, 6g, 6.5g, 7g, 7.5g, 8g, 8.5g, 9g, 9.5g or 10g.

[0164] MDM2 inhibitors are effective over a wide dosage range. For example, in treating adults, dosages ranging from 0.01 to 1000 mg per day, 0.5 to 100 mg per day, 1 to 50 mg per day, and 5 to 40 mg per day are examples of dosages that may be used. The exact dosage will depend on the route of administration, the form in which the compound is administered, the sex and age of the subject being treated, the weight of the subject being treated, and the preferences and experience of the attending physician.

[0165] Pharmaceutical Composition for Oral Administration In selected embodiments, the present invention provides pharmaceutical compositions for oral administration containing a combination comprising an MDM2 inhibitor and a JAK inhibitor, and a pharmaceutical excipient suitable for oral administration.

[0166] In selected embodiments, the present invention provides a solid pharmaceutical composition for oral administration containing (i) an effective amount of a combination comprising an MDM2 inhibitor and a JAK inhibitor, in combination with (ii) a pharmaceutical excipient suitable for oral administration. In selected embodiments, the composition further contains (iii) an effective amount of at least one additional active ingredient.

[0167] In selected embodiments, the pharmaceutical composition may be a liquid pharmaceutical composition suitable for oral ingestion. Pharmaceutical compositions of the present invention suitable for oral administration may be presented as discrete dosage forms, such as capsules, cachets, or tablets, or liquids or aerosol sprays, each containing a predetermined amount of the active ingredient as a powder or granules, a solution or suspension in an aqueous or non-aqueous liquid, an oil-in-water emulsion, or a water-in-oil emulsion. Such dosage forms may be prepared by any method, but all methods include the step of bringing the active ingredient into association with a carrier that constitutes one or more necessary ingredients. Generally, the compositions are prepared by uniformly and intimately admixing the active ingredient with a liquid carrier or finely divided solid carrier, or both, and then, if necessary, shaping the product into the desired presentation. For example, tablets may be prepared by compression or molding, optionally with one or more accessory ingredients. Compressed tablets can be prepared by compressing in a suitable machine the active ingredient in a free-flowing form such as a powder or granules, optionally mixed with excipients such as, but not limited to, binders, lubricants, inert diluents, and / or surfactants or dispersing agents. Molded tablets can be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent.

[0168] The present invention further encompasses anhydrous pharmaceutical compositions and dosage forms, as water can facilitate the degradation of some compounds. For example, water (e.g., 5%) may be added in pharmaceutical applications as a means of simulating long-term storage to determine characteristics such as shelf life or the stability of a formulation over time. Anhydrous pharmaceutical compositions and dosage forms of the present invention may be prepared using anhydrous or low-moisture-containing ingredients and low-moisture or low-humidity conditions. Pharmaceutical compositions and dosage forms of the present invention containing lactose can be made anhydrous if substantial contact with moisture and / or humidity is expected during manufacturing, packaging, and / or storage. Anhydrous pharmaceutical compositions may be prepared and stored such that their anhydrous nature is maintained. Thus, anhydrous compositions may be packaged using materials known to prevent exposure to water and, therefore, may be included in suitable formulary kits. Examples of suitable packaging include, but are not limited to, hermetically sealed foils, plastics, unit-dose containers, blister packs, and strip packs.

[0169] The combination of MDM2 inhibitor and JAK inhibitor can be further combined in intimate admixture with pharmaceutical carriers according to conventional pharmaceutical compounding techniques.Carriers can take a variety of forms depending on the form of preparation desired for administration.When preparing compositions for oral dosage forms, for example, for oral liquid preparations (such as suspensions, solutions, and elixirs) or aerosols, any of the usual pharmaceutical media such as water, glycols, oils, alcohols, flavoring agents, preservatives, coloring agents, etc. can be used as carriers, or for oral solid preparations, carriers such as starch, sugars, microcrystalline cellulose, diluents, granulating agents, lubricants, binders, and disintegrants can be used, and for oral solid preparations, in some embodiments, lactose can be omitted.For example, suitable carriers include powders, capsules, and tablets, along with solid oral preparations.If desired, tablets can be coated by standard aqueous or non-aqueous techniques.

[0170] Binders suitable for use in pharmaceutical compositions and dosage forms include, but are not limited to, corn starch, potato starch, or other starches, gelatin, natural and synthetic gums such as acacia, sodium alginate, alginic acid, other alginates, powdered tragacanth, guar gum, cellulose and its derivatives (e.g., ethyl cellulose, cellulose acetate, calcium carboxymethylcellulose, sodium carboxymethylcellulose), polyvinylpyrrolidone, methylcellulose, pregelatinized starch, hydroxypropyl methylcellulose, microcrystalline cellulose, and combinations thereof.

[0171] Examples of fillers suitable for use in the pharmaceutical compositions and dosage forms disclosed herein include, but are not limited to, talc, calcium carbonate (e.g., granules or powder), microcrystalline cellulose, powdered cellulose, dextrates, kaolin, mannitol, silicic acid, sorbitol, starch, pregelatinized starch, and combinations thereof.

[0172] Disintegrants may be used in the compositions of the present invention to provide tablets that disintegrate when exposed to an aqueous environment. Too much disintegrant may result in tablets that disintegrate in the bottle. Too little may be insufficient for disintegration to occur, thereby altering the rate and extent of release of the active ingredient from the dosage form. Therefore, a sufficient amount of disintegrant may be used to form a dosage form of the compounds disclosed herein, but not too little to alter the release of the active ingredient, nor too much to adversely alter it. The amount of disintegrant used may vary based on the type of formulation and mode of administration and can be readily discerned by those skilled in the art. About 0.5 to about 15 weight percent of disintegrant, or about 1 to about 5 weight percent of disintegrant, may be used in the pharmaceutical composition. Disintegrants that can be used to form pharmaceutical compositions and dosage forms of the invention include, but are not limited to, agar, alginic acid, calcium carbonate, microcrystalline cellulose, croscarmellose sodium, crospovidone, polacrilin potassium, sodium starch glycolate, potato or tapioca starch, other starches, pregelatinized starch, other starches, clays, other algins, other celluloses, gums, or combinations thereof.

[0173] Lubricants that can be used to form the pharmaceutical compositions and dosage forms of the present invention include, but are not limited to, calcium stearate, magnesium stearate, mineral oil, light mineral oil, glycerin, sorbitol, mannitol, polyethylene glycol, other glycols, stearic acid, sodium lauryl sulfate, talc, hydrogenated vegetable oils (e.g., peanut oil, cottonseed oil, sunflower oil, sesame oil, olive oil, corn oil, and soybean oil), zinc stearate, ethyl oleate, ethyl aureate, agar, or combinations thereof. Additional lubricants include, for example, syloid silica gel, a coagulated aerosol of synthetic silica, or combinations thereof. Lubricants may be added in an amount of less than about 1 weight percent of the pharmaceutical composition.

[0174] When aqueous suspensions and / or elixirs are desired for oral administration, the essential active ingredient therein may be combined with various sweetening or flavoring agents, coloring substances or dyes, and, if so desired, emulsifying and / or suspending agents, along with diluents such as water, ethanol, propylene glycol, glycerin, and various combinations thereof.

[0175] Tablets may be uncoated or may be coated by known techniques to delay disintegration and absorption in the gastrointestinal tract, thereby providing a sustained effect over a long period of time.For example, time-delay materials such as glyceryl monostearate or glyceryl distearate can be used.The preparations for oral use may be presented as hard gelatin capsules in which the active ingredient is mixed with an inert solid diluent, such as calcium carbonate, calcium phosphate or kaolin, or as soft gelatin capsules in which the active ingredient is mixed with water or an oil medium, such as peanut oil, liquid paraffin or olive oil.

[0176] Surfactants that can be used to form the pharmaceutical compositions and dosage forms of the present invention include, but are not limited to, hydrophilic surfactants, lipophilic surfactants, and combinations thereof, i.e., a mixture of hydrophilic surfactants can be used, a mixture of lipophilic surfactants can be used, or a mixture of at least one hydrophilic surfactant and at least one lipophilic surfactant can be used.

[0177] Suitable hydrophilic surfactants generally have an HLB value of at least 10, while suitable lipophilic surfactants generally have an HLB value of about 10 or less. The empirical parameter used to characterize the relative hydrophilicity and hydrophobicity of nonionic amphiphilic compounds is the hydrophilic-lipophilic balance ("HLB" value). Surfactants with lower HLB values ​​are more lipophilic or hydrophobic and have greater solubility in oils, while surfactants with higher HLB values ​​are more hydrophilic and have greater solubility in aqueous solutions. Hydrophilic surfactants are generally considered to be compounds with an HLB value greater than about 10, as well as anionic, cationic, or zwitterionic compounds for which the HLB index is generally not applicable. Similarly, lipophilic (i.e., hydrophobic) surfactants are compounds with an HLB value of about 10 or less. However, the HLB value of a surfactant is only a rough guideline generally used to enable the formulation of industrial, pharmaceutical, and cosmetic emulsions.

[0178] Hydrophilic surfactants can be either ionic or nonionic.Suitable ionic surfactants include but are not limited to alkylammonium salts; fusidate salts; fatty acid derivatives of amino acids, oligopeptides, and polypeptides; glyceride derivatives of amino acids, oligopeptides, and polypeptides; lecithin and hydrogenated lecithin; lysolecithin and hydrogenated lysolecithin; phospholipids and their derivatives; lysophospholipids and their derivatives; carnitine fatty acid ester salts; alkyl sulfate salts; fatty acid salts; sodium docusate; acyl lactate salts; mono- and diacetylated tartaric acid esters of mono- and diglycerides; succinylated mono- and diglycerides; citrate esters of mono- and diglycerides; and combinations thereof.

[0179] Among the aforementioned groups, ionic surfactants include, by way of example, lecithin, lysolecithin, phospholipids, lysophospholipids and their derivatives; carnitine fatty acid ester salts; salts of alkyl sulfates; fatty acid salts; sodium docusate; acyl lactate salts; mono- and diacetylated tartaric acid esters of mono- and diglycerides; succinylated mono- and diglycerides; citrate esters of mono- and diglycerides; and combinations thereof.

[0180] Ionic surfactants include lecithin, lysolecithin, phosphatidylcholine, phosphatidylethanolamine, phosphatidylglycerol, phosphatidic acid, phosphatidylserine, lysophosphatidylcholine, lysophosphatidylethanolamine, lysophosphatidylglycerol, lysophosphatidic acid, lysophosphatidylserine, PEG-phosphatidylethanolamine, PVP-phosphatidylethanolamine, and lactylic acid esters of fatty acids (lactylic ester), stearoyl-2-lactylate, stearoyl lactylate, succinylated monoglycerides, mono / diacetylated tartaric acid esters of mono / diglycerides, citrate esters of mono / diglycerides, cholyl sarcosine, caproate, caprylate, caprate, laurate, myristate, palmitate, oleate, ricinoleate, linoleate, linolenate, stearate, lauryl sulfate, teracecyl sulfate, docusate, lauroylcarnitine, palmitoylcarnitine, myristoylcarnitine, and salts and combinations thereof.

[0181] Hydrophilic nonionic surfactants may include, but are not limited to, alkyl glucosides; alkyl maltosides; alkyl thioglucosides; lauryl macrogol glycerides; polyoxyalkylene alkyl ethers such as polyethylene glycol alkyl ethers; polyoxyalkylene alkylphenols such as polyethylene glycol alkylphenols; polyoxyalkylene alkylphenol fatty acid esters such as polyethylene glycol fatty acid monoesters and polyethylene glycol fatty acid diesters; polyethylene glycol glycerol fatty acid esters; polyglycerol fatty acid esters; polyoxyalkylene sorbitan fatty acid esters such as polyethylene glycol sorbitan fatty acid esters; hydrophilic transesterification products of polyols with at least one member of the group consisting of glycerides, vegetable oils, hydrogenated vegetable oils, fatty acids, and sterols; polyoxyethylene sterols, derivatives and analogs thereof; polyoxyethylated vitamins and derivatives thereof; polyoxyethylene-polyoxypropylene block copolymers; and combinations thereof; hydrophilic transesterification products of polyols with polyethylene glycol sorbitan fatty acid esters and at least one member of the group consisting of triglycerides, vegetable oils, and hydrogenated vegetable oils. The polyol can be glycerol, ethylene glycol, polyethylene glycol, sorbitol, propylene glycol, pentaerythritol, or a sugar.

[0182] Other hydrophilic nonionic surfactants include, but are not limited to, PEG-10 laurate, PEG-12 laurate, PEG-20 laurate, PEG-32 laurate, PEG-32 dilaurate, PEG-12 oleate, PEG-15 oleate, PEG-20 oleate, PEG-20 dioleate, PEG-32 oleate, PEG-200 oleate, PEG-400 oleate, PEG-15 stearate, PEG-32 distearate, PEG-40 stearate, PEG stearate -100, PEG-20 Dilaurate, PEG-25 Glyceryl Trioleate, PEG-32 Dioleate, PEG-20 Glyceryl Laurate, PEG-30 Glyceryl Laurate, PEG-20 Glyceryl Stearate, PEG-20 Glyceryl Oleate, PEG-30 Glyceryl Oleate, PEG-30 Glyceryl Laurate, PEG-40 Glyceryl Laurate, PEG-40 Palm Kernel Oil, PEG-50 Hydrogenated Castor Oil, PEG-40 Castor Oil, PEG-35 Castor Oil, PEG-6 Castor Oil, PEG-40 Hydrogenated Castor Oil, PEG-60 Hydrogenated Castor Oil, PEG-60 Corn Oil, PEG-6 Caprylic / Capric Glycerides, PEG-8 Caprylic / Capric Glycerides, Polyglyceryl-10 Laurate, PEG-30 Cholesterol, PEG-25 Phytosterols, PEG-30 Soy Sterols, PEG-20 Trioleate, PEG-40 Sorbitan Oleate, PEG-80 Sorbitan Laurate, Polysorbate 20, Polysorbate 80, POE-9 Lauryl Sulfate PEG-20 oleyl ether, POE-23 lauryl ether, POE-10 oleyl ether, POE-20 oleyl ether, POE-20 stearyl ether, tocopheryl PEG-100 succinate, PEG-24 cholesterol, polyglyceryl-10 oleate, Tween 40, Tween 60, sucrose monostearate, sucrose monolaurate, sucrose monopalmitate, PEG 10-100 nonylphenols, PEG 15-100 octylphenols, and poloxamer.

[0183] Suitable lipophilic surfactants include, by way of example only, fatty alcohols; glycerol fatty acid esters; acetylated glycerol fatty acid esters; lower alcohol fatty acid esters; propylene glycol fatty acid esters; sorbitan fatty acid esters; polyethylene glycol sorbitan fatty acid esters; sterols and sterol derivatives; polyoxyethylated sterols and sterol derivatives; polyethylene glycol alkyl ethers; sugar esters; sugar ethers; lactic acid derivatives of mono- and diglycerides; the hydrophobic transesterification product of polyols with at least one member of the group consisting of glycerides, vegetable oils, hydrogenated vegetable oils, fatty acids and sterols; oil-soluble vitamins / vitamin derivatives; and combinations thereof.In this group, preferred lipophilic surfactants include glycerol fatty acid esters, propylene glycol fatty acid esters, and combinations thereof, or the hydrophobic transesterification product of polyols with at least one member of the group consisting of vegetable oils, hydrogenated vegetable oils and triglycerides.

[0184] In some embodiments, the composition may contain a solubilizer to ensure good solubilization and / or dissolution of the compound of the present invention and minimize precipitation of the compound of the present invention. This may be particularly important for compositions for parenteral use, such as for injectable compositions. A solubilizer may be added to increase the solubility of other components, such as hydrophilic drugs and / or surfactants, or to maintain the composition as a stable or homogeneous solution or dispersion.

[0185] Examples of suitable solubilizers include: alcohols and polyols, such as ethanol, isopropanol, butanol, benzyl alcohol, ethylene glycol, propylene glycol, butanediol and its isomers, glycerol, pentaerythritol, sorbitol, mannitol, transcutol, dimethyl isosorbide, polyethylene glycol, polypropylene glycol, polyvinyl alcohol, hydroxypropyl methylcellulose and other cellulose derivatives, cyclodextrins and cyclodextrin derivatives; ethers of polyethylene glycol having an average molecular weight of about 200 to about 6000, such as tetrahydrofurfuryl alcohol PEG ether (glycofurol) or methoxy PEG; amides and other nitrogen-containing compounds, such as 2-pyrrolidone, 2-piperidone, ε-caprolactam, N- Alkyl pyrrolidone, N-hydroxyalkyl pyrrolidone, N-alkyl piperidone, N-alkyl caprolactam, dimethyl acetamide, and polyvinyl pyrrolidone; esters, such as ethyl propionate, tributyl citrate, acetyl triethyl citrate, acetyl tributyl citrate, triethyl citrate, ethyl oleate, ethyl caprylate, ethyl butyrate, triacetin, propylene glycol monoacetate, propylene glycol diacetate, epsilon-caprolactone and its isomers, δ-valerolactone and its isomers, β-butyrolactone and its isomers; and other solubilizing agents known in the art, including, but not limited to, dimethyl acetamide, dimethyl isosorbide, N-methyl pyrrolidone, monooctanoin, diethylene glycol monoethyl ether, and water.

[0186] Mixtures of solubilizers may also be used. Examples include, but are not limited to, triacetin, triethyl citrate, ethyl oleate, ethyl caprylate, dimethylacetamide, N-methylpyrrolidone, N-hydroxyethylpyrrolidone, polyvinylpyrrolidone, hydroxypropyl methylcellulose, hydroxypropyl cyclodextrin, ethanol, polyethylene glycol 200-100, glycofurol, transcutol, propylene glycol, and dimethyl isosorbide. Particularly preferred solubilizers include sorbitol, glycerol, triacetin, ethyl alcohol, PEG-400, glycofurol, and propylene glycol.

[0187] The amount of solubilizer that can be included is not particularly limited. The amount of a given solubilizer may be limited to a biotolerable amount, which can be easily determined by one of ordinary skill in the art. In some situations, it may be advantageous to include an amount of solubilizer that far exceeds the biotolerable amount, for example, to maximize the drug concentration by removing the excess solubilizer using conventional techniques such as distillation or evaporation before providing the composition to a patient. Thus, when present, the solubilizer can be present in a weight ratio of 10%, 25%, 50%, 100%, or up to about 200% by weight, based on the combined weight of the drug and other excipients. If desired, very small amounts of solubilizer, such as 5%, 2%, 1%, or less, may be used. Typically, the solubilizer may be present in an amount of about 1% to about 100% by weight, more typically about 5% to about 25% by weight.

[0188] The composition may further comprise one or more pharmaceutically acceptable additives and excipients, including, but not limited to, detackifiers, anti-foaming agents, buffers, polymers, antioxidants, preservatives, chelating agents, viscomodulators, tonicifiers, flavors, colorants, odorants, opacifiers, suspending agents, binders, fillers, plasticizers, lubricants, and combinations thereof.

[0189] In addition, acids or bases may be incorporated into the composition to facilitate processing, enhance stability, or for other reasons. Examples of pharmaceutically acceptable bases include amino acids, amino acid esters, ammonium hydroxide, potassium hydroxide, sodium hydroxide, sodium bicarbonate, aluminum hydroxide, calcium carbonate, magnesium hydroxide, magnesium aluminum silicate, synthetic aluminum silicate, synthetic hydrotalcite, magnesium aluminum hydroxide, diisopropylethylamine, ethanolamine, ethylenediamine, triethanolamine, triethylamine, triisopropanolamine, trimethylamine, tris(hydroxymethyl)aminomethane (TRIS), and the like. Also suitable are bases that are salts of pharmaceutically acceptable acids, such as acetic acid, acrylic acid, adipic acid, alginic acid, alkanesulfonic acids, amino acids, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid, citric acid, fatty acids, formic acid, fumaric acid, gluconic acid, hydroquinosulfonic acid, isoascorbic acid, lactic acid, maleic acid, oxalic acid, para-bromophenylsulfonic acid, propionic acid, p-toluenesulfonic acid, salicylic acid, stearic acid, succinic acid, tannic acid, tartaric acid, thioglycolic acid, toluenesulfonic acid, and uric acid. Salts of polybasic acids, such as sodium phosphate, disodium hydrogen phosphate, and sodium dihydrogen phosphate, can also be used. When the base is a salt, the cation can be any convenient and pharmaceutically acceptable cation, such as ammonium, alkali metals, and alkaline earth metals. Examples may include, but are not limited to, sodium, potassium, lithium, magnesium, calcium, and ammonium.

[0190] Suitable acids are pharmaceutically acceptable organic or inorganic acids. Examples of suitable inorganic acids include hydrochloric acid, hydrobromic acid, hydroiodic acid, sulfuric acid, nitric acid, boric acid, phosphoric acid, etc. Examples of suitable organic acids include acetic acid, acrylic acid, adipic acid, alginic acid, alkanesulfonic acid, amino acids, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid, citric acid, fatty acids, formic acid, fumaric acid, gluconic acid, hydroquinonesulfonic acid, isoascorbic acid, lactic acid, maleic acid, methanesulfonic acid, oxalic acid, para-bromophenylsulfonic acid, propionic acid, p-toluenesulfonic acid, salicylic acid, stearic acid, succinic acid, tannic acid, tartaric acid, thioglycolic acid, toluenesulfonic acid, and uric acid.

[0191] Injectable pharmaceutical composition In selected embodiments, the present invention provides an injectable pharmaceutical composition comprising a combination comprising an MDM2 inhibitor and a JAK inhibitor, and a pharmaceutical excipient suitable for injection.

[0192] Forms into which the compositions of the present invention may be incorporated for administration by injection include aqueous or oil suspensions or emulsions in sesame oil, corn oil, cottonseed oil, or peanut oil, as well as elixirs, mannitol, dextrose, or sterile aqueous solutions, and similar pharmaceutical vehicles.

[0193] Aqueous solutions in physiological saline are also commonly used for injection. Ethanol, glycerol, propylene glycol, and liquid polyethylene glycol (and suitable combinations thereof), cyclodextrin derivatives, and vegetable oils may also be used. Proper fluidity can be maintained, for example, by using a coating such as lecithin to maintain the required particle size in the case of dispersions, and by using surfactants. Prevention of microbial activity can be achieved by various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, sorbic acid, and thimerosal.

[0194] Sterile injectable solution is prepared by incorporating the required amount of MDM2 inhibitor and JAK inhibitor into suitable solvent, and if necessary, with various other ingredients as listed above, and then sterilized by filtration.Generally, dispersion is prepared by incorporating various sterilized active ingredients into the sterile vehicle that contains basic dispersion medium and other ingredients that are required from the above-listed ones.For the sterile powder that is used to prepare sterile injectable solution, some preferred preparation methods are vacuum drying and freeze-drying technology, which can produce the powder of active ingredients and any additional desired ingredients from its previously sterilized filtered solution.

[0195] Administration of a combination comprising an MDM2 inhibitor and a JAK inhibitor can be achieved by any method that allows delivery of the compounds to the site of action, including oral routes, intraduodenal routes, parenteral injection (including intravenous, intraarterial, subcutaneous, intramuscular, intravascular, or infusion), topical (e.g., transdermal application), and via localized delivery by catheter or stent.

[0196] Exemplary parenteral dosage forms include solutions or suspensions of the active compounds in sterile aqueous solutions, for example, aqueous propylene glycol or dextrose solutions. Such dosage forms can be suitably buffered, if desired.

[0197] The present invention also provides kits. The kits include an MDM2 inhibitor and a JAK inhibitor, either alone or combined in suitable packaging, as well as written materials that may include instructions for use, a discussion of clinical studies, and a list of side effects. Such kits may also include information such as references to scientific literature, package inserts, clinical trial results, and / or summaries that indicate or establish the activity and / or benefits of the composition and / or describe dosing, administration, side effects, drug interactions, or other information useful to healthcare providers. Such information may be based on the results of various studies, for example, studies using laboratory animals involving in vivo models and studies based on human clinical trials. The kits may further contain another active pharmaceutical ingredient. Suitable packaging and additional items of use (e.g., measuring cups for liquid preparations, foil wrappers to minimize exposure to air, etc.) are known in the art and may be included in the kits. The kits described herein may be provided, sold, and / or promoted to healthcare providers, including physicians, nurses, pharmacists, prescribers, etc. The kits, in selected embodiments, may also be sold directly to consumers. In one embodiment, the present invention provides a kit comprising a combination comprising an MDM2 inhibitor and a JAK inhibitor for use in treating MPN. In one embodiment, the MPN is selected from the group consisting of polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mast cell disease (SMCD). In one embodiment, the myelofibrosis is selected from the group consisting of primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF). In one embodiment, the primary myelofibrosis (PMF) is selected from the group consisting of prefibrotic / early PMF and overt fibrotic PMF.In certain embodiments, the MPN is selected from the group consisting of chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myelogenous leukemia (aCML), juvenile myelomonocytic leukemia (JMML), hypereosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (MDS / MPN-RS-T).

[0198] Dosage and Dosage Regimen The amounts of MDM2 inhibitor and JAK inhibitor administered will depend independently on the individual being treated, the severity of the disorder or condition, the rate of administration, the pharmacokinetics of the compounds, and the discretion of the prescribing physician. However, effective dosages range from about 0.001 to about 100 mg per kg of body weight per day, e.g., from about 1 to about 35 mg / kg / day, in single or divided doses. For a 70 kg individual, this would amount to about 0.05 to 7 g / day, e.g., from about 0.05 to about 2.5 g / day. In some cases, dosage levels below the lower end of the range may be more than sufficient, while in other cases, larger doses may be used without causing any adverse side effects by dividing such larger doses into several smaller doses for administration throughout the day.

[0199] In some embodiments, MDM2 inhibitor and JAK inhibitor are administered independently in a single dose.Usually, this administration is by injection, for example, intravenous injection, in order to rapidly introduce active substance.However, other routes can also be used appropriately.A single dose of MDM2 inhibitor and JAK inhibitor can be used to treat acute conditions.

[0200] In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered in multiple doses to treat MPNs. In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently orally administered in multiple doses. In some embodiments, the administration can be once, twice, three times, four times, five times, six times, or more than six times per day. In some embodiments, the administration can be selected from the group consisting of once a day, twice a day, three times a day, four times a day, five times a day, six times a day, once every other day, once a week, twice a week, three times a week, four times a week, every other week, and monthly. In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered three times a week, including every Monday, Wednesday, and Friday.

[0201] The administration of the MDM2 inhibitor and the JAK inhibitor can continue independently for as long as necessary. In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered for more than 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 days or more. In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered for less than 28, 14, 7, 6, 5, 4, 3, 2, or 1 day. In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered for about 14 days, about 21 days, about 28 days, about 35 days, about 42 days, about 49 days, or about 56 days. In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered continuously and chronically to treat chronic effects. In another embodiment, the administration of the MDM2 inhibitor and the JAK inhibitor independently continues for less than about 7 days. In yet another embodiment, the administration continues for more than about 6, 10, 14, 28 days, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, or 1 year. In some embodiments, the administration continues for more than about 1 year, 2 years, 3 years, 4 years, or 5 years. In some embodiments, continuous dosing is achieved and maintained as long as necessary.

[0202] In some embodiments, the effective dosages of the MDM2 inhibitor and the JAK inhibitor are, independently, from about 1 mg to about 500 mg, from about 10 mg to about 300 mg, from about 20 mg to about 250 mg, from about 25 mg to about 200 mg, from about 10 mg to about 200 mg, from about 20 mg to about 150 mg, from about 30 mg to about 120 mg, from about 10 mg to about 90 mg, from about 20 mg to about 80 mg, from about 30 mg to about 70 mg, from about 40 mg to about 60 mg, from about 45 mg to about 55 mg, or from about 48 mg to about 59 mg. mg to about 52 mg, about 50 mg to about 150 mg, about 60 mg to about 140 mg, about 70 mg to about 130 mg, about 80 mg to about 120 mg, about 90 mg to about 110 mg, about 95 mg to about 105 mg, about 150 mg to about 250 mg, about 160 mg to about 240 mg, about 170 mg to about 230 mg, about 180 mg to about 220 mg, about 190 mg to about 210 mg, about 195 mg to about 205 mg, or about 198 mg to about 202 mg. In some embodiments, the effective dosage of the MDM2 inhibitor and the JAK inhibitor is about 25 mg, about 50 mg, about 75 mg, about 100 mg, about 125 mg, about 150 mg, about 175 mg, about 200 mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about 325 mg, about 350 mg, about 375 mg, about 400 mg, about 425 mg, about 450 mg, about 475 mg, or about 500 mg. In some embodiments, the effective dosage of the MDM2 inhibitor or JAK inhibitor is 25 mg, 50 mg, 75 mg, 100 mg, 125 mg, 150 mg, 175 mg, 200 mg, 225 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 375 mg, 400 mg, 425 mg, 450 mg, 475 mg, or 500 mg.

[0203] In some embodiments, the effective dosage of the MDM2 inhibitor or JAK inhibitor is, independently, about 0.01 mg / kg to about 4.3 mg / kg, about 0.15 mg / kg to about 3.6 mg / kg, about 0.3 mg / kg to about 3.2 mg / kg, about 0.35 mg / kg to about 2.85 mg / kg, about 0.15 mg / kg to about 2.85 mg / kg, about 0.3 mg to about 2.15 mg / kg, about 0.45 mg / kg to about 1.7 mg / kg, about 0.15 mg / kg to about 1.3 mg / kg, about 0.3 mg / kg to about 1.15 mg / kg, about 0.45 mg / kg to about 1 mg / kg, about 0.55 mg / kg to about 0.85 mg / kg, about 0.65 mg / kg to about 0.8 mg / kg, or about 0. The dose is within the range of 7 mg / kg to about 0.75 mg / kg, about 0.7 mg / kg to about 2.15 mg / kg, about 0.85 mg / kg to about 2 mg / kg, about 1 mg / kg to about 1.85 mg / kg, about 1.15 mg / kg to about 1.7 mg / kg, about 1.3 mg / kg to about 1.6 mg / kg, about 1.35 mg / kg to about 1.5 mg / kg, about 2.15 mg / kg to about 3.6 mg / kg, about 2.3 mg / kg to about 3.4 mg / kg, about 2.4 mg / kg to about 3.3 mg / kg, about 2.6 mg / kg to about 3.15 mg / kg, about 2.7 mg / kg to about 3 mg / kg, about 2.8 mg / kg to about 3 mg / kg, or about 2.85 mg / kg to about 2.95 mg / kg. In some embodiments, the effective dosage of the MDM2 inhibitor or JAK inhibitor is about 0.35 mg / kg, about 0.7 mg / kg, about 1 mg / kg, about 1.4 mg / kg, about 1.8 mg / kg, about 2.1 mg / kg, about 2.5 mg / kg, about 2.85 mg / kg, about 3.2 mg / kg, or about 3.6 mg / kg.

[0204] In some embodiments, the MDM2 inhibitor or a pharmaceutically acceptable salt thereof is administered in a dosage of 10-500 mg BID, including dosages of 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg BID.

[0205] In some embodiments, the MDM2 inhibitor or a pharmaceutically acceptable salt thereof is administered in a dosage of 10-500 mg QD, including dosages of 15 mg, 25 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 120 mg, 150 mg, 175 mg, 200 mg, 225 mg, 240 mg, 250 mg, 275 mg, 300 mg, 325 mg, 350 mg, 360 mg, 375 mg, and 480 mg QD.

[0206] An effective amount of an MDM2 inhibitor or JAK inhibitor may be administered by any of the accepted modes of administration for agents with similar utilities, including buccal, sublingual, and transdermal routes, by intra-arterial injection, intravenously, parenterally, intramuscularly, subcutaneously, or orally, in either single or multiple doses.

[0207] In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered to a subject intermittently, known as intermittent administration. "Intermittent administration" refers to a period of administration of a therapeutically effective dose of the MDM2 inhibitor and / or the JAK inhibitor, followed by a period of withdrawal, followed by another administration period, etc. During each administration period, the dosing frequency can be independently selected from three times daily, twice daily, daily, once weekly, twice weekly, three times weekly, four times weekly, five times weekly, six times weekly, or monthly. In one embodiment, the MDM2 inhibitor is a compound of Formula (I) or Formula (II). In one embodiment, the JAK inhibitor is selected from the group consisting of ruxolitinib, ruxolitinib-S, and fedratinib.

[0208] "Discontinuation period" or "discontinuation period" or "quiescent period" refers to the length of time when administration of an MDM2 inhibitor and / or a JAK inhibitor is discontinued. The discontinuation period may be longer or shorter than the administration period, or may be the same as the administration period. For example, if the administration period includes three times a day, twice a day, daily, once a week, twice a week, three times a week, four times a week, five times a week, six times a week, or monthly administration, the discontinuation period may be at least about 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 days, one month, two months, three months, four months, or more. During the discontinuation period, a JAK inhibitor other than an MDM2 inhibitor and a JAK inhibitor may be administered.

[0209] In some embodiments, the MDM2 inhibitor and the JAK inhibitor are independently administered to a human subject in need thereof for a first dosing period to treat a myeloproliferative neoplasm (MPN), followed by a withdrawal period, followed by a second dosing period, etc. In some embodiments, the MPN is selected from the group consisting of polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mast cell disease (SMCD). In some embodiments, the myelofibrosis is selected from the group consisting of primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF). In some embodiments, the primary myelofibrosis (PMF) is selected from the group consisting of prefibrotic / early PMF and overt fibrotic PMF. In certain embodiments, the MPN is selected from the group consisting of chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myelogenous leukemia (aCML), juvenile myelomonocytic leukemia (JMML), hypereosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (MDS / MPN-RS-T). The first administration period, the second administration period, and the discontinuation period are independently selected from the group consisting of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, more than 29 days, 1 month, 2 months, 3 months, 4 months, and more, wherein the MDM2 inhibitor and the JAK inhibitor are independently administered to the subject three times a day, twice a day, daily, once a week, twice a week, three times a week, four times a week, five times a week, six times a week, or monthly. In some embodiments, the first administration period is the same length as the second administration period. In some embodiments, the first administration period is shorter than the second administration period. In some embodiments, the first administration period is longer than the second administration period. In one embodiment, the first dosing period and the second dosing period are about 3 weeks, wherein the MDM2 inhibitor and the JAK inhibitor are independently administered daily to the subject, with a withdrawal of about 2 weeks.In some embodiments, the first and second administration periods are about 3 weeks, wherein the MDM2 inhibitor and the JAK inhibitor are independently administered to the subject weekly, with a discontinuation period of about 2 weeks. In some embodiments, the first and second administration periods are about 4 weeks, wherein the MDM2 inhibitor and the JAK inhibitor are independently administered to the subject daily, with a discontinuation period of about 2 weeks. In some embodiments, the first and second administration periods are about 4 weeks, wherein the MDM2 inhibitor and the JAK inhibitor are independently administered to the subject weekly, with a discontinuation period of about 2 weeks. In some embodiments, the MDM2 inhibitor is a compound of Formula (I) or Formula (II). In some embodiments, the JAK inhibitor is selected from the group consisting of ruxolitinib, ruxolitinib-S, and fedratinib.

[0210] In some embodiments, the MDM2 inhibitor is administered to the human being intermittently, while the JAK inhibitor is administered to the human being non-intermittently. In some embodiments, the JAK inhibitor is administered to the human being intermittently, while the MDM2 inhibitor is administered to the human being non-intermittently. In some embodiments, both the MDM2 inhibitor and the JAK inhibitor are administered to the human being intermittently. In some embodiments, both the MDM2 inhibitor and the JAK inhibitor are administered to the human being non-intermittently.

[0211] Methods for treating myeloproliferative neoplasms (MPNs) In one embodiment, the present invention encompasses a method for suppressing the expression level of p21 in a human suffering from a myeloproliferative neoplasm (MPN), comprising administering to the human a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein the MDM2 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof, and the administering step suppresses the expression level of p21 in the human compared to the expression level of p21 in MDM2 inhibitor monotherapy. In one embodiment, the present invention provides a method of treating MPN in a human, comprising administering to the human a therapeutically effective amount of an MDM2 inhibitor and a JAK inhibitor at a dose of 15 mg QD, 25 mg QD, 30 mg QD, 50 mg QD, 60 mg QD, 75 mg QD, 100 mg QD, 120 mg QD, 150 mg QD, 175 mg QD, 200 mg QD, 225 mg QD, 240 mg QD, 250 mg QD, 275 mg QD, 300 mg QD, 325 mg QD, 350 mg QD, 360 mg QD, 375 mg QD, 480 mg QD, 15 mg BID, 25 mg BID, 30 mg BID, 50 mg BID, 60 mg BID, 75 mg BID, 100 mg BID, 120 mg BID, 150 mg BID, 175 mg BID, 200 mg 225 mg BID, 240 mg BID, 250 mg BID, 275 mg BID, 300 mg BID, 325 mg BID, 350 mg BID, 360 mg BID, 375 mg BID, and 480 mg BID. In one embodiment, the MPN is selected from the group consisting of polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mast cell disease (SMCD). In one embodiment, the myelofibrosis is selected from the group consisting of primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF). In certain embodiments, primary myelofibrosis (PMF) is selected from the group consisting of prefibrotic / early PMF and overt fibrotic PMF.In some embodiments, the MPN is selected from the group consisting of chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myelogenous leukemia (aCML), juvenile myelomonocytic leukemia (JMML), hypereosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (MDS / MPN-RS-T). In some embodiments, the MDM2 inhibitor is a compound of Formula (I) or Formula (II). In some embodiments, the JAK inhibitor is selected from the group consisting of ruxolitinib, ruxolitinib-S, and fedratinib.

[0212] In one embodiment, the present invention provides a therapeutically effective amount of a combination of an MDM2 inhibitor and a JAK inhibitor for use in treating MPN in a human, wherein the MDM2 inhibitor and the JAK inhibitor are administered in the following doses: 15 mg QD, 25 mg QD, 30 mg QD, 50 mg QD, 60 mg QD, 75 mg QD, 100 mg QD, 120 mg QD, 150 mg QD, 175 mg QD, 200 mg QD, 225 mg QD, 240 mg QD, 250 mg QD, 275 mg QD, 300 mg QD, 325 mg QD, 350 mg QD, 360 mg QD, 375 mg QD, 480 mg QD, 15 mg BID, 25 mg BID, 30 mg BID, 50 mg BID, 60 mg BID, 75 mg BID, 100 mg BID, 120 mg BID, 150 mg BID, 175 mg 200 mg BID, 225 mg BID, 240 mg BID, 250 mg BID, 275 mg BID, 300 mg BID, 325 mg BID, 350 mg BID, 360 mg BID, 375 mg BID, and 480 mg BID. In one embodiment, the MPN is selected from the group consisting of polycythemia vera (PV), myelofibrosis, primary myelofibrosis, thrombocythemia, essential thrombocythemia (ET), idiopathic myelofibrosis, systemic mastocytosis (SM), chronic neutrophilic leukemia (CNL), myelodysplastic syndrome (MDS), and systemic mast cell disease (SMCD). In one embodiment, the myelofibrosis is selected from the group consisting of primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), and post-essential thrombocythemia myelofibrosis (post-ET MF). In some embodiments, the primary myelofibrosis (PMF) is selected from the group consisting of prefibrotic / early PMF and overt fibrotic PMF. In some embodiments, the MPN is selected from the group consisting of chronic neutrophilic leukemia (CNL), chronic eosinophilic leukemia, chronic myelomonocytic leukemia (CMML), atypical chronic myelogenous leukemia (aCML), juvenile myelomonocytic leukemia (JMML), hypereosinophilic syndrome (HES), and myelodysplastic / myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (MDS / MPN-RS-T).In certain embodiments, the MDM2 inhibitor is a compound of Formula (I) or Formula (II). In certain embodiments, ruxolitinib, ruxolitinib-S, and fedratinib.

[0213] The methods as described above may be used as first line cancer therapy or following treatment with conventional chemotherapeutic active pharmaceutical ingredients including cyclophosphamide, fludarabine (FC chemotherapy), and chlorambucil.

[0214] The combination of an MDM2 inhibitor and a JAK inhibitor may also be used in conjunction with radiation therapy, hormone therapy, surgery, and immunotherapy, which are well known to those skilled in the art. [Example]

[0215] The embodiments encompassed herein will now be described with reference to the following examples, which are provided for illustrative purposes only, and the disclosure encompassed herein should in no way be construed as being limited to these examples, but rather as encompassing any and all variations that become evident as a result of the teachings provided herein.

[0216] Example 1: Effect of the combination of the compound of formula (I) and a JAK inhibitor on CD34+ bone marrow cells from patients with myelofibrosis The procedure for testing the effect of the compound of formula (I) in combination with a JAK inhibitor on CD34+ bone marrow cells is based on that described in Lu, Blood (2012) 120(15); 3098-3105. The procedure is briefly described below.

[0217] Peripheral blood samples were obtained from myelofibrosis (MF) patients. Peripheral blood samples were layered onto Ficoll-Hypaque (1.077 g / mL; GE Healthcare) and low-density mononuclear cells were isolated via centrifugation. CD34+ cells were isolated using a human CD34+ cell selection kit (StemCell Technologies) according to the manufacturer's instructions. The purity of the CD34+ cell population was analyzed using a FaxCalibur flow cytometer (BD Biosciences) and required to be at least 85% for all experiments. Fresh normal human bone marrow CD34+ cells from ALLCELLS were used as a control.

[0218] The efficacy of the compound of formula (I) in combination with ruxolitinib in MF patients can be assessed by the HPC assay described in Lu, Blood (2012) 3098-3105. Briefly, CD34+ cells are cultured in serum-free medium (StemCell Technologies) containing 50 ng / mL stem cell factor (SCF), 50 ng / mL thrombopoietin (TPO), 50 ng / mL Fms-like tyrosine kinase 3 (Flt-3) ligand, and 50 ng / mL IL-3, and treated with various doses of the compound of formula (I) and / or ruxolitinib for 4 days. After 4 days of treatment, CD34+ cells are assayed in semi-solid medium as described in Bruno, Blood (2006) 3128-3134, the entire contents of which are incorporated by reference. Briefly, 5×10 2 CD34+ cells were plated per dish in dual medium containing 1 mL of IMDM supplemented with 1.1% methylcellulose and 20% FBS, supplemented with 50 ng / mL each of SCF, TPO, Flt-3 ligand, IL-3, and GM-CSF, and 2 U / mL of erythropoietin (EPO). After 14 days of incubation, colonies were enumerated, and individual colonies were isolated and genotyped for JAK2V617F.

[0219] Genomic DNA was isolated from randomly picked colonies using the Extract-N-Amp Blood PCR Kit (Sigma-Aldrich). JAK2V617F was detected by nested allele-specific PCR as described in Bruno, Blood (2006) 3128-3134. The final PCR products were analyzed on a 2.0% agarose gel. A 279-bp product indicated allele-specific JAK2V617F positivity, whereas a 229-bp product indicated JAK2V617F negativity. Colonies were classified as homozygous for JAK2V617F if they contained only the 279-bp band, whereas heterozygous colonies were identified based on the presence of both the 279-bp and 229-bp bands.

[0220] Treated cells were harvested and washed with PBS for staining with Annexin-V (BD Biosciences). The staining procedure was performed according to the manufacturer's protocol. Data were acquired on a Faxcaliber flow cytometer (BD Biosciences), with at least 10,000 viable cells acquired for each analysis (BD FACS Diva software; BD Biosciences).

[0221] CD34+ cells are purified from the peripheral blood of patients with MF and cultured in serum-free medium containing SCF, FL-3 ligand, IL-3, and TPO.Cells are treated with various doses of the compound of formula (I) for 4 hours.Cells are harvested and whole cell protein extracts are prepared using RIPA lysis buffer (Boston BioProducts) for Western blotting.

[0222] To prepare cytoplasmic and nuclear protein fractions of cells from patients with MF, CD34+ cells are expanded for 10 days in serum-free medium containing SCF, FL-3 ligand, and IL-3.The CD34+ cells are then repurified and treated with various doses of the compound of formula (I) and / or ruxolitinib in the presence of SCF, FL-3 ligand, IL-3, and TPO for 48 hours.Protein extracts are prepared using NE-PER nuclear and cytoplasmic extraction reagent (Thermo Scientific) according to the manufacturer's instructions.

[0223] Prior to Western blotting, all samples were denatured by heating at 95°C for 5 min with Laemmli SDS sample buffer (Boston BioProducts). Each sample was separated on an SDS-PAGE gel and transferred to a polyvinyl difluoride membrane (Bio-Rad). Antibodies (Cell Signaling Technologies) and ECL Western blotting reagents (Denville Scientific) were used to visualize phospho-p53, p53, MDM2, p21, p-STAT1, PUMA, and Bak.

[0224] The MDM2 / p53 inhibitory axis upregulates p21 expression, which functions to arrest damaged cells in the cell cycle. MDM2 inhibitors must overcome this checkpoint to trigger apoptosis. JAK inhibitors (i.e., ruxolitinib) do not upregulate p21 expression, which is not surprising, as ruxolitinib would not be expected to biologically modulate p21 expression. However, combined treatment of CD34+ cells from patients with myelofibrosis with ruxolitinib and the compound of formula (I) results in unincreased p21 expression levels despite the inclusion of treatment with an MDM2 inhibitor (the compound of formula (I)). While it would be expected that p21 expression would still be upregulated in the presence of an MDM2 inhibitor, this is not the case. Because overcoming this p21 checkpoint is no longer necessary, the apoptotic threshold is much lower, and further ex vivo apoptosis is observed (see Figure 1). As shown in Figure 1 , monotherapy nabtemadrine treatment increased the levels of p21, an apoptosis checkpoint in progenitors, while the addition of ruxolitinib to nabtemadrine inhibited p21-mediated cell cycle arrest.

[0225] Example 2: Cytotoxicity of the combination of the compound of formula (I) and a JAK inhibitor in UKE-1 cell line. Cell viability was assessed according to the procedure described in Canon et al., Mol Cancer Ther (2015) 14(3):649-658. The procedure is briefly described below.

[0226] UKE-1 cells were plated at an optimal initial seeding density in 96- or 384-well plates to ensure that the cells did not reach confluence by the end of the assay. Cells were treated with DMSO control or various concentrations of nabtemadrine and ruxolitinib combinations for 24 hours of incubation. The number of viable cells was determined using a commercially available cell viability assay kit. Growth inhibition (GI) was calculated on a 200-point scale according to the following equation, where V 24is the luminescence of the DMSO control at 24 h, and T 24 was the emission of the sample treated with the compound: T 24 If >V0, GI=100×(1-((T 24 -V0) / (V 24 -V0)));T 24 <V0ならば、GI=100×(1-((T 24 -V) / V). GI values ​​of 0, 100, and 200 represent uninhibited cell growth (i.e., DMSO control), cell stasis, and complete cell death, respectively. The results are shown in Figure 2A.

[0227] These data were analyzed for synergy using the HSA model (Combenefit software), and the results are shown in Figure 2B. The y-axis represents the percentage of baseline cell proliferation under control conditions (i.e., without nabutemadoline and without ruxolitinib). A decrease in y-axis value corresponds to increased apoptosis. Dark blue / blue indicates drug combinations that elicit synergistic apoptosis that exceeds the sum of cell death produced by the drugs when presented alone.

[0228] Example 3: Apoptosis and protein expression after 24 and 72 hours of exposure to nabtemadrine and ruxolitinib. The effects of nabutemadoline in combination with ruxolitinib on apoptosis and protein expression in progenitor cells derived from myelofibrosis subjects were evaluated. As shown in Figure 3, nabutemadoline in combination with ruxolitinib enhanced apoptosis in progenitor cells derived from myelofibrosis subjects, and complete suppression of p21 expression was observed with the addition of ruxolitinib. Viable cells were defined as CD45+mid, SSClow, CD14-, and cPARP-. As shown in Figure 4, nabutemadoline in combination with ruxolitinib reduced prosurvival MCL-1 levels.

[0229] The above description is for the purpose of teaching those skilled in the art how to practice the invention and is not intended to detail all of those obvious modifications and variations that will become apparent to those skilled in the art upon reading the description. However, all such obvious modifications and variations are intended to be included within the scope of the invention as defined by the following claims. The claims are intended to cover the components and steps in any order that is effective to fulfill the purposes intended therein, unless the context specifically dictates to the contrary.

Claims

1. 1. A method of suppressing the expression level of p21 in a human suffering from a myeloproliferative neoplasm (MPN), comprising administering to said human a therapeutically effective amount of an MDM2 inhibitor in combination with a JAK inhibitor, wherein said MDM2 inhibitor is a compound of formula (I): 【Chemistry 1】 or a pharmaceutically acceptable salt thereof, wherein said administering step suppresses the expression level of p21 in said human compared to the expression level of p21 in MDM2 inhibitor monotherapy.

2. 2. The method of claim 1, wherein the administering step suppresses p21 levels by at least 50%, and may suppress p21 levels by at least 60%, at least 70%, at least 80%, at least 90%, at least 95%, at least 96%, at least 97%, at least 98%, or at least 99% compared to MDM2 inhibitor monotherapy.

3. 10. The method of claim 1, wherein said administering stimulates apoptosis of malignant myeloid cells in a human afflicted with said myeloproliferative neoplasm (MPN).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

23. 23. The method of any one of claims 1 to 22, wherein the human is treated with the MDM2 inhibitor for a period selected from the group consisting of about 14 days, about 21 days, about 28 days, about 35 days, about 42 days, about 49 days, and about 56 days.

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

25. The JAK inhibitor is selected from the group consisting of AC-410, AT9283, AZ960, AZD-1480, baricitinib, BMS-911543, CEP-33779, cerdulatinib, CHZ868, CYT387, decernotinib, ENMD-2076, fedratinib, filgotinib, ganetespib, INCB039110, INCB-047986, itacitinib, JAK3-IN-1, JANEX-1, LFM-A13, LY2784544, NS-018, NSC42834, NVP-BSK805, oclacitinib, pacritinib, and peficitinib. nib, pyridone 6, R348, RGB-286638, ruxolitinib, ruxolitinib-S, SAR-20347, SB1317, solcitinib, TG101209, TG101348, tofacitinib (3R,4S), tofacitinib (3S,4R), tofacitinib (3S,4S), tofacitinib, TYK2-IN-2, upadacitinib, WHI-P154, WHI-P97, WP1066, XL019, ZM39923, and pharmaceutically acceptable salts thereof.

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

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

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

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

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

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

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

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