Pharmaceuticals and methods for reducing cancer immunotherapy-associated cytokine release syndrome

Abstract

Disclosed is a p38 MAP kinase inhibitor for use in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient, wherein the p38 MAPK inhibitor is administered before the onset of CRS. Related methods, products, and uses thereof are also disclosed.

Description

[Technical Field]

[0001] This application claims the benefit of GB Patent Application No. 2300510.1 filed January 13, 2023, GB Patent Application No. 2300512.7 filed January 13, 2023, GB Patent Application No. 2316713.3 filed November 1, 2023, GB Patent Application No. 2316714.1 filed November 1, 2023, and GB Patent Application No. 2316715.8 filed November 1, 2023, each of which is incorporated by reference in its entirety.

[0002] Cytokine release syndrome ("CRS") is a common side effect of cancer immunotherapy. The present disclosure relates to products and methods for preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS. More particularly, but not exclusively, the present disclosure relates to a p38 MAP kinase inhibitor for use in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient, wherein the p38 MAPK inhibitor is administered before the onset of CRS. Related products, including pharmaceutical compositions and kits, and related methods are also disclosed. [Background technology]

[0003] In certain cancer immunotherapy, efficacy may depend on the survival, function, and phenotype of one or more populations of T cells in a patient. This may be particularly true for therapies that use genetically modified (or otherwise modified or cultured) T cells. Such dependency is thought to be involved in, for example, tumor-infiltrating lymphocyte ("TIL") therapy, T cell checkpoint modulator therapy, and chimeric antigen receptor ("CAR") T cell therapy.

[0004] To illustrate this, CAR T-cell therapy relies on genetic modification of T cells to recognize, target, and destroy cancer cells. T cells are harvested (often from the same patient, although T cells may alternatively be harvested from a healthy donor), genetically modified to express a CAR with specificity for a cancer cell antigen (e.g., an anti-CD19 or anti-BCMA CAR), and administered to the cancer patient via infusion ("adoptive transfer"). The CAR T cells are then transported through the circulation and recognize antigen-expressing (e.g., CD19-expressing or BCMA-expressing) cancer cells. Therefore, the survival, function, and phenotype of the infused CAR T cells may be determinants of therapeutic efficacy.

[0005] On the other hand, in other types of cancer immunotherapy, the survival and memory function of specific T cells is not considered essential for providing the desired therapeutic effect, and turnover of T cell populations is not expected to result in a complete loss of therapeutic efficacy. Nevertheless, for a therapy to function, a population of T cells must generally be present with proper function, preferably with a phenotype beneficial to the therapy. This may be particularly true for T cell-engaging therapies, such as bispecific T cell engager (BiTE) therapy, bifunctional checkpoint inhibitory T cell engager (CiTE) therapy, simultaneous multi-interacting T cell engager (SMITe) therapy, other bispecific antibody-based therapies, trispecific killer engager (TriKE) therapy, or other immunostimulatory molecules capable of inducing cytokine release.

[0006] There are other cancer immunotherapies that are not necessarily dependent on T cell survival, function, and phenotype, but that may nevertheless benefit from enhanced T cell activity, such as adoptive immunotherapy with unmodified or genetically modified natural killer (NK) cells and cancer vaccines.

[0007] T cell survival, function, and phenotype can be regulated by four distinct signals. The first of these (commonly known as "signal 1") is involved in antigen recognition. Signal 1 is antigen-specific and occurs via stimulation of the T cell receptor ("TCR") upon binding to an antigenic peptide complexed with the major histocompatibility complex ("MHC"), resulting in changes in the TCR's intracellular machinery. The second signal ("signal 2") is involved in costimulation and / or coinhibition. That is, signal 2 occurs via costimulatory signaling by costimulatory receptors on the T cell with their corresponding ligands on antigen-presenting cells ("APCs," i.e., monocytes and dendritic cells) and / or coinhibitory signaling by costimulatory receptors on the T cell with their corresponding ligands on APCs.

[0008] Signal 2 can affect T cell polarization. As used herein, the term "T cell polarization" refers to the specialization of T cells into subsets (phenotypes) of T cells that are restricted to producing a specific pattern(s) of cytokines, such as a T1 pattern or a T2 pattern. When naive or resting memory T cells differentiate into effector T cells, they can produce a wide range of cytokines in the T0 pattern. For example, when T cells are polarized to be restricted to a T1 pattern or a T2 pattern, the T1 pattern of cytokines may include interleukin (IL)-12 and interferon (IFN)γ, while the T2 pattern of cytokines may include IL-4. If signal 2 is not provided following signal 1, the result may be T cell unresponsiveness ("anergy").

[0009] Numerous additional signals can further regulate the activity of T cells during or after activation. Thus, "signal 3" encompasses cytokines such as interferon-α, IFNγ, IL-4, IL-10, and IL-12, as well as other extracellular factors in vivo. Signal 3 can ensure that T cells can behave in coordination with their environment. Like signal 2, signal 3 can affect T cell polarization. Thus, signal 3 may be involved in cytokine-mediated differentiation and proliferation of T cells.

[0010] "Signal 4," on the other hand, may be involved in post-activation events in vivo and may control the duration of T cell responses, affecting T cell phenotype, persistence, and function after activation. "Signal 4" is a less conventional term (especially since it is less well established in the art than Signals 1 or 2), but was coined in recognition of the important phenomena involved. Signal 4 may include, for example, cytokines such as IFN-I, which induce monocyte-derived cells to provide a survival checkpoint for T cell activation.

[0011] T cell function may depend on environmental stimuli provided to the T cell, such as signal 3 and signal 4, as described above, among others. Signal 3 and signal 4 may contribute to T cell survival, proliferation, and antigen-specific cell-mediated cell death.

[0012] When cytotoxic T cells recognize their cognate antigens, they release perforin, granzymes, and inflammatory cytokines. For example, the release of such cytokines by CAR T cells in CAR T-cell therapy is thought to induce high levels of pyroptotic cancer cell death (Liu et al., 2020, Sci. Immunol. 5:43). At the time of writing, CAR T-cell therapy has been approved by the U.S. Food and Drug Administration as the standard of care for several forms of aggressive, relapsed, or refractory non-Hodgkin's lymphoma, including diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, and mantle cell lymphoma. CAR T-cell therapy has also been approved for the treatment of B-cell acute lymphoblastic leukemia and multiple myeloma. Additionally, CAR-T therapy is under review for the treatment of additional cancers, including hematologic malignancies and solid tumors.

[0013] Efforts to enhance CAR T cell functionality have also been undertaken. In one study (Gurusamy et al., 2020, Cancer Cell 37, 818-833), in vitro monocultures of CAR T cells were subjected to knockout of Mapk14, which encodes the p38α kinase. Mapk14-KO cells showed increased cell proliferation and CD62L expression, as well as reduced accumulation of reactive oxygen species and γH2AX. Next, the authors attempted to mimic the phenotypic effects of genetically KO Mapk14 in a reversible manner, using the p38 MAP kinase inhibitor dorampimod / BIRB796, such that inhibition of p38 restricted in vitro proliferation. This was found to promote the desired CAR T cell phenotype in vitro. Dorampimod was washed out before adoptive transfer.

[0014] Cancer immunotherapy, such as infusion of CAR T-cell therapy or T-cell-engaging agents, can cause significant toxicities, including CRS. CRS can manifest clinically from one day to several weeks after administration of cancer immunotherapy. CRS can present with a range of symptoms, from mild flu-like symptoms to severe, life-threatening manifestations of an exacerbated systemic inflammatory response. In severe cases, CRS can be fatal despite therapeutic intervention (Shimabukuro-Vornhagen et al., 2018, J. Immunother. Cancer, 15 6(1):56).

[0015] CRS is thought to result from the on-target effect of CAR T cell therapy (Morris et al., 2022, Nat. Rev. Immunol. 22, 85-96). Monocytes can be activated by cytokines (such as IL-6 and / or TNFα) produced by T cells involved in cancer cell destruction. Additionally or alternatively, monocytes can be activated by contact-dependent engagement of T cell-expressed CD40 ligand with monocyte-expressed CD40. Additionally or alternatively, monocytes can be activated by damage-associated molecular patterns ("DAMPs") released by dying cancer cells and recognizable by pattern recognition receptors ("PRRs") on monocytes.

[0016] Activated monocytes are a major source of secreted cytokines in vivo, such as interleukin 6 (IL-6). Cytokines secreted by monocytes can signal various non-immune cells, particularly endothelial cells. Activation of endothelial cells causes vascular leakage, hypotension, and the secretion of additional cytokines, such as interleukin 6 (IL-6) and interleukin 8 (IL-8), thus amplifying the inflammatory response in patients.

[0017] Cytokines can attract circulating monocytes, leading to the accumulation of activated monocytes near the interaction of T cells with cancer cells, thus amplifying the inflammatory loop. Furthermore, T cells themselves may overflow or redistribute, exacerbating an uncontrolled immune response.

[0018] In one study, the supernatant of anti-CD19 CAR T cell / Nalm6-luc co-culture was used to stimulate endothelial (HUVEC) cells, and the p38MAPK inhibitor SB203580 was applied to examine inhibition of endothelial activation (Chen et al., 2021, Front. Immunol., 12:623610).

[0019] Meanwhile, WO 2021 / 022186 and WO 2021 / 195475 (both to Aclaris Therapeutics Inc.) disclose methods for modulating p38 MAP kinase-mediated function in patients, and in some embodiments, it is contemplated that the methods may be used to treat CRS.

[0020] Current treatments for CRS are passive, requiring evidence of the onset of the syndrome before treatment can begin. In patients who develop CRS, physicians may use a number of treatments. For example, tocilizumab (an IL-6 receptor agonist), optionally in combination with corticosteroids, is indicated for the treatment of symptoms after the onset of CRS. In patients refractory to tocilizumab and corticosteroids, anakinra (an IL-1 receptor agonist) may be used.

[0021] At the time of writing, CRS prophylaxis is not routinely practiced, and there remains an urgent need for interventions to prevent cancer immunotherapy-associated CRS.

[0022] It is advantageous for a therapy for CRS to be clinically acceptable (i.e., have no or low risk of side effects). Preferably, a therapy for CRS does not cause the elimination of core immune functions in cancer immunotherapy patients who are already at risk for viral and bacterial infections. The therapy for CRS is preferably provided in a form suitable for outpatient administration.

[0023] The present disclosure seeks to alleviate one or more of these and other problems. Summary of the Invention

[0024] In a first aspect of the present disclosure, there is provided a p38 MAP kinase inhibitor for use in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient, wherein the p38 MAPK inhibitor is administered before the onset of CRS.

[0025] As demonstrated in Examples 5 and 6 (particularly Example 6) below, administration of a p38 MAPK inhibitor to a human patient prior to the onset of CRS can prevent or reduce the severity of signs or symptoms of cancer immunotherapy-associated CRS. Relatedly, p38 MAPK inhibitors can inhibit cytokine release by all three of T cells, monocytes, and endothelial cells in the environment of cancer cells (particularly IL-6 release by T cells, monocytes, and endothelial cells, as demonstrated in Examples 3, 4, and 6 below). Thus, p38 MAPK inhibitors appropriately inhibit IL-6 release by T cells, monocytes, and endothelial cells.

[0026] Surprisingly, when a p38 MAPK inhibitor is administered to a patient before the onset of CRS, the p38 MAPK inhibitor can enhance T cells in the patient, even in the presence of cancer cells. The p38 MAPK inhibitor can enhance or at least maintain the anti-cancer efficacy of T cells. In particular, the p38 MAPK inhibitor can increase the number of circulating T cells (see, in particular, Example 5 below), promote or enable the maintenance of T cell-induced cancer cell death (see, in particular, Example 6 below), and / or reduce markers of exhaustion (in particular, TIM3 and / or LAG3) in T cells (see, in particular, Example 3 below). Reduction of markers of exhaustion may be interpreted as prolonging the anti-cancer efficacy of T cells; additionally or alternatively, reduction of markers of exhaustion may be related to T cell polarization, and thus to "signal 2" as described above. Meanwhile, maintenance (or improvement) of T cell proliferation and anti-cancer efficacy may each be related to modulation of "signal 4" as described above. Thus, in addition to preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS, p38 MAPK inhibitors may enable or enhance the anti-cancer effects of immunotherapy. Surprisingly, p38 MAP kinase inhibitors can have these effects when administered directly to a subject (in vivo) before the onset of CRS in the subject, as claimed by the present disclosure and as modeled, for example, in Example 6 described herein.

[0027] Therefore, p38 MAPK inhibitors may prolong the anti-cancer efficacy (duration) of T cells. p38 MAPK inhibitors may help maintain or increase the strength of the anti-cancer efficacy of T cells. p38 MAPK inhibitors may prolong the anti-cancer efficacy (duration) of T cells and help maintain or increase the strength of the anti-cancer efficacy of T cells.

[0028] Most suitably, p38MAPK inhibitors may maintain or increase the anti-cancer efficacy of T cells.

[0029] As used herein, the term "cancer immunotherapy" refers to the therapeutic stimulation of the immune system to treat cancer.Cancer immunotherapy is believed to enhance the immune system's natural ability to recognize and destroy cancer cells, and enhance the memory function of immune cells, thereby preventing or reducing the risk of cancer recurrence.

[0030] Cancer immunotherapy, as that term is used herein, may particularly include one or more of therapies using genetically modified (or otherwise modified or cultured) T cells, immune cell engagement therapies (particularly BiTEs and other bispecific antibodies), and other therapies such as natural killer ("NK") cell therapy, cancer vaccines, and T cell checkpoint modulators (particularly T cell checkpoint inhibitors). These therapies may benefit from modulation by a p38 MAPK inhibitor of one or more of T cell survival, phenotype, and function. Additionally or alternatively, these therapies may benefit from modulation by a p38 MAPK inhibitor of the activation of monocytes and / or endothelial cells, particularly those in the vicinity of cancer cells targeted by the immune system, particularly cancer cells targeted by T cells.

[0031] According to the present disclosure, cancer immunotherapy may preferably comprise or consist of adoptive T cells, or may alternatively involve T cells. It will be understood that cancer immunotherapy that is "alternatively involving T cells" is not necessarily limited to T cell engaging therapy (such as BiTE, CiTE, SMITe, or TriKE), but may instead encompass any cancer immunotherapy involving T cells. Thus, cancer immunotherapy has the following effects, as will be apparent from the following examples: (i) reducing pro-inflammatory cytokine release by T cells (particularly reducing IL-6 release by T cells); (ii) reducing pro-inflammatory cytokine release by monocytes (particularly reducing IL-6 release by monocytes); (iii) reducing pro-inflammatory cytokine release by endothelial cells (in particular, reducing IL-6 release by endothelial cells, and optionally, reducing IL-8 release by endothelial cells); (iv) modulation of T cell signal 3 and / or signal 4 (particularly signal 4); (v) modulation of T cell polarization and / or reduction of T cell exhaustion (particularly reduction of TIM3 and / or reduction of LAG3 on the surface of T cells); (vi) maintaining or increasing T cell anti-cancer efficacy; and (vii) maintaining or increasing T cell proliferation; In particular, this may be enhanced (or at least not significantly diminished) by one or more of maintaining or increasing T cell anti-cancer cell efficacy. In particular, Example 2 provides evidence of a reduction in TIM3 and LAG3 (markers of exhaustion) on the surface of CAR T cells upon administration of a p38 MAPK inhibitor to CAR T cells in the presence of (in co-culture with) cancer cells. The reduction in markers of exhaustion may be interpreted as prolonging the anti-cancer efficacy of T cells; additionally, or alternatively, the reduction in markers of exhaustion may be related to T cell polarization and thus to "signal 2" as described above. Three structurally distinct p38 MAPK inhibitors have been shown to have this effect (all of which are selective for p38 and suggest no or minimal off-target effects). Example 2 also demonstrates reduced TNFα secretion by CAR T cells upon p38 MAPK inhibition, and Example 6 demonstrates a reduction in various cytokines, including IL-6, which is understood to encompass those released by T cells in addition to those released by monocytes and endothelial cells. Example 5 demonstrates maintenance of CAR T cell efficacy upon p38 MAPK inhibition; by day 10 of the described mouse study, the p38 MAPK inhibitor UR-13870 administered at 25 mg / kg twice daily significantly increased the number of circulating CAR T cells (see Figure 18A). Furthermore, Example 6 demonstrates a downward trend in the mean number of CD19+ cancer cells per ml on days 9 and 10 (especially on day 10) of the described study after treatment with UR-13870 (compared to CD28 stimulation alone), indicating enhanced T cell / increased T cell anticancer activity (see Figure 30A). On the other hand, Examples 3 and 4 demonstrate reduced IL-6 release by monocytes and endothelial cells, and reduced IL-8 release by endothelial cells when treated with a p38 MAPK inhibitor in the face of insult with supernatant from co-cultures of cancer cells and CAR T cells, suggesting a beneficial effect on key mediators of CRS.

[0032] For some uses of p38 MAP kinase inhibitors according to the present disclosure, cancer immunotherapy may include therapies mediated by T cell effector function and memory, particularly those using engineered T cells (such as, for example, CAR T cell therapy and TCR therapy), or those using otherwise engineered or cultured T cells (such as, for example, TIL therapy), or those using T cell checkpoint modulators.

[0033] With regard to some uses of p38 MAP kinase inhibitors according to the present disclosure, the cancer immunotherapy of the present disclosure can be a therapy mediated by T cell effector function (but not specifically dependent on T cell memory), for example, a T cell engaging therapy, particularly a BiTE therapy, such as bispecific T cell engager (BiTE) therapy, therapy using other bispecific antibodies, bifunctional checkpoint inhibitory T cell engager (CiTE) therapy, simultaneous multi-interacting T cell engager (SMITe) therapy or trispecific killer engager (TriKE) therapy, or therapy using other immunostimulatory molecules capable of inducing cytokine release.

[0034] Thus, the cancer immunotherapy of the present disclosure may suitably be a T cell-engaging cancer immunotherapy (particularly a BiTE therapy or other bispecific antibody-based therapy). This may be advantageous because p38 MAP kinase inhibitors may benefit T cells as described herein, for example, by increasing their level of anti-cancer efficacy and / or extending the period over which they exhibit anti-cancer efficacy. Surprisingly, p38 MAP kinase inhibitors may have these effects when administered directly to a subject (in vivo) before the onset of CRS in the subject, as claimed by the present disclosure and as modeled, for example, in Example 6 described herein.

[0035] Regarding some uses of p38 MAP kinase inhibitors according to the present disclosure, the cancer immunotherapy of the present disclosure may be a therapy that does not obviously depend on T cell effector function or T cell memory. Nevertheless, improving T cell function may be beneficial. For example, the cancer immunotherapy may include CAR NK therapy or a cancer vaccine.

[0036] For some uses of p38 MAP kinase inhibitors according to the present disclosure, cancer immunotherapy can be a therapy that can benefit from modulation of signal 3 by a p38 MAP kinase inhibitor, as described above and elsewhere, such as, for example, T cell engaging therapy, particularly bispecific T cell engager (BiTE) therapy (or therapy using another bispecific antibody), CAR NK therapy, cancer vaccine, or T cell checkpoint modulator, or therapy using engineered T cells (such as, for example, CAR T cell therapy and TCR therapy), or otherwise engineered or cultured T cells (such as, for example, TIL therapy).

[0037] With regard to some uses of p38 MAP kinase inhibitors according to the present disclosure, the cancer immunotherapy of the present disclosure can be a therapy that can benefit from modulation of signal 4 by a p38 MAP kinase inhibitor, as described above and elsewhere, such as, for example, a T cell engaging therapy, particularly a bispecific T cell engager (BiTE) therapy (or a therapy using another bispecific antibody), a CAR NK therapy, a cancer vaccine, or a T cell checkpoint modulator, or a therapy using engineered T cells (such as, for example, CAR T cell therapy and TCR therapy), or an therapy using otherwise engineered or cultured T cells (such as, for example, TIL therapy).

[0038] With respect to some uses of p38 MAP kinase inhibitors according to the present disclosure, cancer immunotherapy can be, in particular, a therapy involving the administration of genetically modified (or otherwise modified or cultured) T cells. As used herein, depending on the context, the term "therapy involving the administration of genetically modified T cells" can refer to either or both of CAR T cell therapy and TCR therapy, or to a broader group of therapies including CAR T cell therapy and TCR therapy. Meanwhile, "therapy involving the administration of otherwise modified or cultured T cells" can refer to tumor infiltrating lymphocyte (TIL) therapy, or to a broader group of therapies including TIL therapy.

[0039] The T cells described herein may be PD-1, CTLA4, TIM-3, TIGIT, CD3, or CD28-expressing T cells. CD28 can provide costimulatory signals for T cell activation and survival. CD28 can play a role in signals 1, 2, 3, and / or 4 described herein. CD28 can play a role in CRS described herein.

[0040] Optionally, the cancer immunotherapy may be a combination cancer immunotherapy, e.g., using CAR T cell therapy in combination with one or more checkpoint inhibitors, e.g., one or more anti-PD-1 antibodies (such as nivolumab, pembrolizumab, or cemiplimab), or one or more anti-PD-L1 antibodies (such as atezolizumab, avelimab, or durvalumab), or one or more CTLA-4 antibodies (such as ipilimumab or tremelimumab).

[0041] As used herein, "CAR T cell therapy" refers to a therapy for the treatment of cancer patients in which T cells harvested (optionally, but not necessarily, from the same cancer patient, as T cells may be harvested from a healthy donor) and genetically modified in vitro to express a CAR with specificity for a relevant cancer cell antigen (optionally, but not necessarily, expanded in vitro) are administered to the cancer patient by adoptive transfer. Suitably, CAR T cell therapy can be performed in the treatment of CD19-expressing malignancies or BCMA-expressing malignancies. See, for example, Morris et al., Cytokine release syndrome and associated neurotoxicity in cancer immunotherapy, Nat. Rev. Immunol., 2022, (22) 85-96, incorporated herein by reference. Thus, CAR T cell therapy can be autologous (in that the T cells are harvested from the same cancer patient). Alternatively, CAR T cell therapy can be allogeneic ("commercially available"), using T cells harvested from healthy donors and modified to express a CAR. In allogeneic CAR T cell therapy, the T cells may optionally be further modified to prevent graft-versus-host disease and host-allorejection, for example, via genome editing techniques such as CRISPR / Cas9 or base editing.

[0042] Similarly, TCR therapy involves genetic modification of T cells followed by their adoptive transfer to patients in need thereof. CAR T cells are capable of recognizing and binding to antigens naturally present on the surface of cancer cells, while in TCR therapy, T cells are genetically modified to express receptors that bind to major histocompatibility complex (MHC) proteins. However, the manufacturing process for T cells for use in TCR therapy may otherwise be similar to that described above for CAR T cells.

[0043] Thus, TCR therapy may be used herein to refer to a therapy for the treatment of a cancer patient in which T cells that have been harvested (optionally, but not necessarily, harvested from the same cancer patient, as T cells may be harvested from a healthy donor) and genetically modified in vitro (optionally, but not necessarily, expanded in vitro) to express an engineered T cell receptor that is configured to recognize an MHC-presented polypeptide fragment molecule are administered to the cancer patient by adoptive transfer.

[0044] In certain preferred embodiments, the cancer immunotherapy is CAR T cell therapy or TCR therapy.

[0045] "Tumor-infiltrating lymphocytes" ("TILs") herein refer to white blood cells that leave the bloodstream and migrate toward solid tumors. TILs can be found within tumors and within the tumor stroma. The abundance and phenotype of TILs can vary depending on the type and stage of the tumor. In particular, TILs can include T cells.

[0046] "TIL therapy" herein refers to adoptive T cell transfer therapy in patients in need thereof, in which TILs, particularly T cells, which can be derived from the patient or another individual, are administered to the patient. Thus, TILs derived from resected tumors are typically expanded in vitro. Several TIL cultures can be established separately and then assayed for sufficient tumor recognition function. Once selected, sufficient TILs can be expanded for several weeks, usually using IL-2 as a general growth factor. After a further TIL cell selection step, TIL lines with the best tumor recognition can be further expanded for several weeks in a "rapid expansion protocol" (REP) using anti-CD3 activation. Finally, the TILs after REP are infused into the patient.

[0047] For some uses of p38 MAP kinase inhibitors according to the present disclosure, the cancer immunotherapy can be a T cell engaging therapy, such as, for example, bispecific T cell engager (BiTE) therapy or therapy with another bispecific antibody, bifunctional checkpoint inhibitory T cell engager (CiTE) therapy, simultaneous multi-interacting T cell engager (SMITe) therapy, or trispecific killer engager (TriKE) therapy.

[0048] The term "BiTE" as used herein refers to a bispecific monoclonal antibody for use as an anti-cancer drug. In particular, a BiTE can be a fusion protein containing two single-chain variable fragments ("scFv") of different antibodies, or amino acid sequences from four different genes, on a single peptide chain. One of the scFvs can be designed to bind to T cells (particularly via the CD3 receptor), while the other can be designed to bind to tumor cells.

[0049] The term bispecific antibody, as used herein, refers to an antibody that can simultaneously bind to two different types of antigens. A variety of bispecific antibodies, including BiTEs, are known in the art.

[0050] For some uses of p38 MAP kinase inhibitors according to the present disclosure, the cancer immunotherapy can be natural killer ("NK") cell therapy, a cancer vaccine, or a T-cell checkpoint modulation therapy.

[0051] The term "NK cell therapy" may be used interchangeably herein with "CAR NK cell therapy." Similar to CAR T cells, CAR NK cells are genetically modified to encode a CAR that recognizes a tumor antigen. The manufacturing process for CAR NK cells is broadly similar to that described above for CAR T cells.

[0052] By "CAR NK cell therapy" herein is meant a therapy for the treatment of cancer patients in which natural killer cells that are harvested (optionally, but not necessarily, harvested from the same cancer patient, as NK cells may be harvested from a healthy donor) and genetically modified in vitro to express a CAR (optionally, but not necessarily, expanded in vitro) are administered to the cancer patient by adoptive transfer.

[0053] The term "cancer vaccine," as used herein, refers to one or more tumor antigen vaccines, whether autologous or allogeneic. Cancer vaccines can include, for example, one or more cancer cell proteins and / or one or more fragments (peptides) thereof, one or more whole cells (such as tumor cells or dendritic cells), one or more nucleic acids, and / or one or more virus-based vaccines (including oncolytic viruses).

[0054] As used herein, the term "T cell checkpoint modulator" has its ordinary meaning in the medical arts and refers to a T cell checkpoint inhibitor that is designed to prevent or otherwise antagonize the binding of an inhibitory immune checkpoint protein on a tumor cell to a partner protein, or a T cell checkpoint stimulator that is designed to enhance or otherwise agonize signaling involving a costimulatory checkpoint protein on a tumor cell.

[0055] The term "cancer immunotherapy-induced cytokine release syndrome" (CRS), as used herein, refers to an uncontrolled systemic inflammatory response induced by cancer immunotherapy.

[0056] It is believed that p38 MAP kinase inhibitors may attenuate, rather than eliminate, the uncontrolled systemic inflammatory response that can result from cancer immunotherapy in some patients, with the aim of alleviating the harmful effects of uncontrolled inflammation while maintaining its protective and pro-disease resolution effects, such as anti-cancer efficacy. While complete suppression of inflammation is likely to be harmful, attenuation of the explosive process of uncontrolled systemic inflammation should provide protection against the harmful effects caused by excessive inflammatory responses while maintaining essential innate defense activity. Thus, p38 MAP kinase inhibitors for use in the methods of the present disclosure aim to attenuate, rather than eliminate, components in their entirety.

[0057] Patient populations receiving cancer immunotherapy may be or include highly sensitive patient populations for whom complete suppression of essential innate defense activity is particularly harmful. Patient populations receiving cancer immunotherapy may be at risk for being particularly vulnerable to viral and / or bacterial infections due to the elimination of core immune functions. For these patients, reducing or preventing vulnerability to viral and / or bacterial infections is of significant interest. Attenuating the immune response without eliminating cancer immunotherapy can reduce the risk of serious viral and / or bacterial complications resulting from immune system suppression. Such infections may prompt physicians to delay or discontinue cancer immunotherapy. Therefore, reducing the risk of serious viral and / or bacterial complications reduces the risk of delaying or discontinuing cancer immunotherapy and enhances its potential anti-cancer efficacy.

[0058] Cancer immunotherapy-induced CRS can present with a variety of symptoms and signs. The symptoms and signs of CRS can range from mild flu-like symptoms to severe, life-threatening manifestations of exacerbated inflammatory responses. Examples 5 and 6 herein describe mouse experiments in which symptoms of CRS modeled in mice were recorded. In particular, Example 6 demonstrated that administration of a p38 MAPK inhibitor before the onset of CRS counteracted CRS symptoms, as evidenced by a reduction in CRS scores (see Figures 20A-20C).

[0059] The onset of CRS can vary. CRS can occur within 5, 4, 3, 2, or 1 day after administration of the cancer immunotherapy. Symptoms or signs of CRS can be observed within 1 day after administration of the cancer immunotherapy.

[0060] "Onset" of CRS, as that term is used herein, can refer to the onset of one or more detectable symptoms or signs of CRS. A detectable symptom or sign can refer to a symptom or sign that is detectable by a physician.

[0061] However, CRS may develop later, for example, several weeks after administration of the cancer immunotherapy. Thus, CRS may develop at least 10, 20, 30, 40, or 50 days after administration of the cancer immunotherapy.

[0062] For example, replicative TCR-modified cells, T cells, NK cells, or genetically modified immune cells can remain in the body for a long period of time, for example, up to 6 months or up to 12 months, or even longer. Thus, the cells can induce CRS even several weeks after injection. Thus, the onset of CRS can occur about one week after administration of the cancer immunotherapy, for example, within about one to six weeks after administration of the cancer immunotherapy.

[0063] Mild symptoms or signs of CRS may first be observed, for example, within a few days after the onset of CRS (eg, within 1 or 2 days after the onset of CRS).

[0064] Mild symptoms of CRS may include fever, fatigue, headache, rash, joint pain, and muscle pain, especially fever. As used herein, the term fever refers to a core body temperature above 38°C. Respiratory symptoms may be common in patients with CRS. Mild respiratory symptoms and signs may include cough and tachypnea (respiratory rate >30 for children aged 12 years and older, respiratory rate >40 for children aged 6-12 years, respiratory rate >45 for children aged 3-6 years, and respiratory rate >50 for children aged 1-3 years).

[0065] The signs or symptoms of CRS to be prevented or reduced may be those of Grade 1 CRS, graded according to the American Society for Transplantation and Cellular Therapy Consensus Guidelines (2019), as set forth below in Table 5. Thus, the patient may have symptoms that include or consist of fever.

[0066] Thus, preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS can be or include preventing (or reducing the severity of) signs or symptoms of grade 1 CRS. Preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient can be or include preventing (or reducing the risk of) signs or symptoms of grade 1 CRS progressing to signs or symptoms of grade 2 CRS. These effects can be particularly beneficial when the cancer immunotherapy is or includes T-cell-engaging cancer immunotherapy, most particularly BiTE therapy or therapy using one or more other bispecific antibodies. These effects can be particularly beneficial for enabling cancer immunotherapy patients to be discharged from the hospital earlier and / or limiting the patient's length of stay to approximately 1 to 3 days. Thus, prevention of grade 1 CRS, or prevention of (or reduction in the risk of) progression of grade 1 CRS to grade 2 CRS in patients receiving BiTE therapy or therapy with one or more other bispecific antibodies, is specifically contemplated herein (e.g., so that patients can be discharged from the hospital, or even so that all patient treatment can be performed outside of a hospital setting).

[0067] Thus, preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient may be or may include primary prevention (by administering a p38 MAP kinase inhibitor before the onset of any form of CRS, e.g., before administration of cancer immunotherapy) and / or secondary prevention (by administering a p38 MAP kinase inhibitor when the patient has already received cancer immunotherapy, e.g., when the patient is showing symptoms or signs of grade 1 CRS).

[0068] More severe symptoms or signs of CRS can be observed after the onset of milder symptoms or signs of CRS, although more severe symptoms or signs can be observed shortly after the onset of CRS, e.g., within days or weeks after the onset of CRS (e.g., within 2, 3, 4, 5, 6, 15, or 25 days after the onset of CRS).

[0069] Preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient can be or can include preventing (or reducing the severity of) signs or symptoms of grade 2 CRS, or preventing (or reducing the risk of) signs or symptoms of grade 2 CRS from progressing to signs or symptoms of grade 3 (or grade 4) CRS. These effects can be particularly beneficial when the cancer immunotherapy is or includes CAR T-cell therapy.

[0070] Symptoms and signs of CRS, especially if left untreated, can last for a week or longer after the onset of CRS, for example, up to 10 days, up to 20 days, or up to 50 days after the onset of CRS.

[0071] Severe symptoms of CRS may include hypotension. As used herein, hypotension may refer to blood pressure less than about 90 / 60 mmHg. Severe signs of CRS may include hyperthermia. As used herein, the term hyperthermia may refer to core body temperature greater than 40°C. In particular, severe symptoms and signs of CRS may include both hypotension and hyperthermia.

[0072] Severe respiratory symptoms and signs of CRS may include one or more of the following: dyspnea, hypoxemia (patients may have an arterial oxygen saturation of 92% or less on room air by transcutaneous means), and acute respiratory distress syndrome (ARDS) with bilateral opacities on chest X-ray. ARDS due to CRS may require mechanical ventilation.

[0073] Severe symptoms and signs of CRS can include circulatory shock, particularly circulatory shock requiring vasopressors. Additionally or alternatively, severe symptoms and signs of CRS can include vascular leakage, which may be accompanied by peripheral and pulmonary edema, and in some cases, disseminated intravascular coagulation.

[0074] The severe symptoms and signs of CRS may include the dysfunction of one or more organs.Therefore, the severe symptoms and signs of CRS may include the symptoms and signs of renal failure.The severe symptoms and signs of CRS may include the symptoms and signs of cardiac dysfunction, as observed by, for example, a reduced ejection fraction in echocardiography or multi-gated acquisition (MUGA) scan.The symptoms and signs of CRS may progress to the symptoms and signs of multiple organ failure.

[0075] CRS may be characterized by one or more of the following: cytopenias (lower than normal counts of one or more types of blood cells), elevated creatinine and liver enzymes, abnormal coagulation parameters, and higher than normal levels of C-reactive protein.

[0076] In particularly severe cases, CRS can be fatal.

[0077] The symptoms and signs of CRS may vary from patient to patient. A "first-dose effect" may occur, in which patients who receive therapy involving multiple doses of cancer immunotherapy over a period of time only experience severe symptoms and signs after the first dose. A higher cancer burden may be a strong predictor of CRS, especially severe CRS. A higher dose of cancer immunotherapy may be a strong predictor of CRS, especially severe CRS. Children (as used herein, this may refer to children aged 12 or younger) may experience more severe CRS than adults.

[0078] It will be understood that symptoms and signs of CRS in this context may be taken to mean symptoms and signs that are primarily induced by CRS and not by any other cause.

[0079] In particularly severe cases, CRS can be accompanied by clinical signs and laboratory abnormalities similar to those of hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS). However, CRS induced by cancer immunotherapy is distinct from HLH and MAS.

[0080] CRS is also distinct from other conditions. Thus, CRS is distinct from sepsis (at least in terms of its initiating factors). CRS is likewise distinct from tumor lysis syndrome.

[0081] As used herein, "reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient" means attenuating one or more of the aforementioned symptoms or signs of CRS. As used herein, "reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include, for example, preventing fever or reducing the severity of fever. As used herein, "reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include delaying the onset of fever. As used herein, "reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include preventing one or more of the severe symptoms and signs of CRS described herein, particularly the dysfunction of one or more organs. As used herein, "reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include preventing death.

[0082] "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may refer herein to avoiding one or more of the above-mentioned symptoms and signs of CRS. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include preventing fever. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include preventing one or more of the severe symptoms and signs of CRS described herein, particularly the dysfunction of one or more organs. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include preventing death.

[0083] "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient," as used herein, may refer to reducing the patient's risk of suffering from signs or symptoms of cancer immunotherapy-associated CRS, such as one or more of the signs or symptoms described above. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include reducing the risk of fever. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include reducing the risk of one or more of the severe symptoms and signs of CRS described herein, particularly the dysfunction of one or more organs. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include reducing the risk of death.

[0084] "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient," as used herein, may refer to prophylactically reducing the patient's risk of suffering from signs or symptoms of cancer immunotherapy-associated CRS, such as one or more of the signs or symptoms described above. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include reducing the risk of fever. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include reducing the risk of one or more of the severe symptoms and signs of CRS described herein, particularly the dysfunction of one or more organs. "Preventing signs or symptoms of cancer immunotherapy-associated CRS in a human patient" may include reducing the risk of death.

[0085] In one embodiment, preventing or reducing the severity of signs or symptoms of cancer immunotherapy-related CRS can be defined by the mechanism of CRS induction by cancer immunotherapy. It is believed that cytokines produced by T cells (e.g., TNFα and / or IL-6, particularly IL-6) in the presence of cancer cells and damage-associated molecular patterns (DAMPs) from dead cancer cells attract circulating monocytes. Monocytes then release proinflammatory mediators (e.g., IL-6). This, in turn, is believed to induce the release of proinflammatory mediators (e.g., IL-6 and IL-8, particularly IL-6) from nearby endothelial cells. Furthermore, T cells may overflow or redistribute systemically, causing the activation of monocytes and endothelial cells in various regions. Thus, one or more of the aforementioned symptoms and signs of CRS, including fever, subsequent hypotension, hypoxia, and / or organ dysfunction, may be considered sequelae (or sequelae) of the excessive induction of cytokines near the interaction between T cells and cancer cells, which may include excessive release of proinflammatory mediators from nearby monocytes. One or more of the aforementioned symptoms and signs of CRS may further include excessive release of proinflammatory mediators from nearby endothelial cells. This activity on the part of endothelial cells, also known as "endothelial cell activation," may lead to vascular leakage and therefore hypotension (and further cytokine release).

[0086] Therefore, preventing or attenuating excessive induction of cytokines near the interaction between T cells and cancer cells, i.e., preventing or attenuating one or both of (i) proinflammatory mediator release by monocytes and (ii) proinflammatory mediator release by endothelial cells in close proximity to monocytes, may be effective in preventing or at least reducing the symptoms and signs of cancer immunotherapy-associated CRS and the risk of death.

[0087] Thus, according to the present disclosure, p38 MAP kinase inhibitors can suitably inhibit the release of pro-inflammatory mediators from monocytes in vivo, in some implementations, the pro-inflammatory mediators including one or more of IFNγ, IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12, IL-18, CCL2, CCL5, CXCL10, MCP-1, MIP-1β, GM-CSF, VEGF, and TNFα, particularly IL-6.

[0088] Monocytes may be involved in releasing a substantial proportion of cytokines (especially IL-6) produced near the interaction between cancer cells and T cells. Thus, by targeting cytokine (especially IL-6) release by monocytes, p38 MAPK inhibitors may eliminate or attenuate a critical step in the cascade of intracellular signaling, or cytokine feedback loop, that otherwise leads to CRS.

[0089] The terms monocyte and macrophage may be used interchangeably herein. Those skilled in the art will understand that monocytes typically evolve into macrophages upon recruitment from blood vessels to other tissues via extravasation. When monocytes are attracted to T cell and cancer cell interactions within the lumen of blood vessels, they may exhibit characteristics and / or behaviors typically associated with macrophages, including, but not limited to, the release of proinflammatory mediators, including one or more of IFNγ, IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12, IL-18, CCL2, CCL5, CXCL10, MCP-1, MIP-1β, GM-CSF, VEGF, and TNFα, most particularly IL-6. It will also be understood that the terms "cytokine" and "proinflammatory mediator" may be used interchangeably herein.

[0090] On the other hand, the term cancer may generally be used herein to refer to blood cancer, such as leukemia, lymphoma, or myeloma.For example, blood cancer may be acute myeloid leukemia (AML), chronic myeloid leukemia (CML), acute lymphoblastic cell leukemia (ALL), chronic lymphocytic leukemia (CLL), non-Hodgkin's lymphoma (NHL), Hodgkin's lymphoma (HL), or myeloma.Therefore, in some implementations, cancer may be B-cell or T-cell acute lymphoblastic leukemia, or large cell lymphoma.In particular, cancer may be aggressive, relapsed, or refractory non-Hodgkin's lymphoma, including diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, high-grade B-cell lymphoma, transformed follicular lymphoma, mantle cell lymphoma, and peripheral T-cell lymphoma.

[0091] The cancer may be a CD19-expressing malignancy (e.g., a CD19-expressing refractory or relapsed B-cell malignancy). The cancer may be a BMCA-expressing malignancy (e.g., a BCMA-expressing myeloma). The cancer may be uveal melanoma.

[0092] It should be understood that the term cancer can also be used herein to refer to solid tumors.In this case, the term cancer cell can be used interchangeably with the term tumor cell.Cancer with one or more solid tumors can include, for example, sarcoma, carcinoma, carcinosarcoma, or lymphoma.Solid tumors can be found in, for example, prostate, breast, lung, esophagus, stomach, small intestine, pancreas, colon and / or rectum, central nervous system, bladder, thyroid, kidney, uterine body, oral cavity, larynx, pharynx, or ovary.

[0093] In some embodiments, the cancer may be skin cancer.

[0094] In some embodiments, p38 MAP kinase inhibitors may inhibit the release of pro-inflammatory mediators from endothelial cells (another major source of cytokines) in vivo. Optionally, the pro-inflammatory mediators may include one or more of IL-1β, IL-2, IL-6, IL-8, IL-10, CCL2, CCL5, CXCL10, IL-18, TNFα, MCP-1, MIP-1β, IP10, and GM-CSF, particularly IL-6 and IL-8, most particularly IL-6.

[0095] In some embodiments, p38 MAP kinase inhibitors may inhibit the upregulation of one or more proteins (such as, for example, E-selectin, VCAM1 and / or ICAM1) on the surface of endothelial cells, particularly ICAM1.

[0096] Appropriately, p38 MAP kinase inhibitors may inhibit the release of pro-inflammatory mediators from monocytes in vivo and inhibit the release of pro-inflammatory mediators from endothelial cells in vivo.

[0097] A p38 MAP kinase inhibitor may suitably inhibit the release of IL-6 from monocytes in vivo and may also inhibit the release of IL-6 from endothelial cells in vivo. A p38 MAP kinase inhibitor may most suitably inhibit the release of IL-6 from T cells, inhibit the release of IL-6 from monocytes, and inhibit the release of IL-6 from endothelial cells (in vivo; thus, it will be appreciated that this effect may occur when T cells, monocytes, and endothelial cells are all present, and that it would be advantageous for this effect to occur in the presence of cancer cells).

[0098] In particular, p38 MAP kinase inhibitors can prevent signaling from monocytes to endothelial cells by inhibiting the release of pro-inflammatory mediators from monocytes in vivo, meaning that endothelial cell activation is reduced and endothelial cells release fewer pro-inflammatory mediators (or even that endothelial cells are not activated at all and do not themselves release pro-inflammatory mediators).

[0099] Any treatment for preventing CRS should preferably avoid significantly attenuating the anti-cancer effects of cancer immunotherapy. Using a representative, but non-limiting, example, T cells in genetically modified T cell therapy should preferably retain their anti-cancer phenotype for a practically useful duration. Furthermore, pharmaceuticals for preventing CRS that enhance cancer immunotherapy are more desirable.

[0100] p38MAPK inhibitors may suitably inhibit the release of cytokines (e.g., TNFα, see Example 3 below, and particularly IL-6, see Example 6 below) from T cells in vivo, such as in the presence of cancer cells. p38MAPK inhibitors may suitably inhibit the release of cytokines from T cells after they undergo antigen recognition, thereby altering signal 3 or signal 4 described herein. In this way, p38MAPK inhibitors may prevent or reduce the risk of cytokine feedback loops initiated by T cells, and may therefore prevent or reduce monocyte recruitment and activation by T cells and cancer cells.

[0101] p38 MAPK inhibitors may be effective in preventing or attenuating CRS without eliminating the anti-cancer cell efficacy of cancer immunotherapy. Advantageously, in some implementations, p38 MAPK inhibitors may increase the anti-cancer cell efficacy of cancer immunotherapy (e.g., in the presence of cancer cells) and simultaneously be effective in preventing or attenuating CRS. Example 2 provides evidence of a reduction in TIM3 and LAG3 (markers of exhaustion) on the surface of CAR T cells upon administration of a p38 MAPK inhibitor to CAR T cells in the presence of (in co-culture with) cancer cells. The reduction in exhaustion markers may be interpreted as extending the anti-cancer efficacy of T cells, which may additionally or alternatively be related to T cell polarization and thus to the aforementioned "signal 2." Similarly, Example 5 showed no reduction in CAR T cell efficacy upon p38 MAPK inhibition, and by day 10 of the described mouse study, the p38 MAPK inhibitor UR-13870, administered at 25 mg / kg twice daily, significantly enhanced the number of circulating CAR T cells (see Figure 18A). Furthermore, Example 6 shows a downward trend in the mean number of CD19+ cancer cells per ml (compared to CD28 stimulation alone) after treatment with UR-13870 on days 9 and 10 (especially day 10) of the described study, indicating enhanced T cell / increased T cell anti-cancer activity (see Figure 30A). The retention (or improvement) of T cell proliferation and anti-cancer efficacy may each be related to modulation of "signal 4" as described above.

[0102] p38MAPK inhibitors are effective in preventing or reducing the severity of signs or symptoms of CRS in human patients. p38MAP kinase inhibitors may prevent or reduce the severity of signs or symptoms of CRS, while maintaining the anti-cancer cell efficacy of cancer immunotherapy (suitably in the presence of cancer cells). p38MAPK inhibitors may prevent or reduce the severity of signs or symptoms of CRS in human patients without excessively attenuating the anti-cancer cell efficacy of cancer immunotherapy in the presence of cancer cells.

[0103] Advantageously, p38MAPK inhibitors can increase the anti-cancer cell efficacy of cancer immunotherapy (in vivo). Advantageously, p38MAPK inhibitors can increase the anti-cancer cell efficacy of cancer immunotherapy in the presence of cancer cells. These effects can be suitably obtained by administering p38MAPK inhibitors at dosages as described herein.

[0104] As used herein, the term "anti-cancer cell efficacy" refers to the ability of cancer immunotherapy to contribute to a reduction in a patient's cancer burden. T cells can help achieve such a reduction in a patient's cancer burden. Thus, suitably, a p38MAP kinase inhibitor may increase one or more of the following in T cells: cancer cell-directed cytotoxicity, in vivo proliferation, IFNγ production, persistence of an antigen-specific response, viability, and a memory phenotype (e.g., cell surface markers), and / or may reduce one or more of the following in T cells: oxidative stress markers (e.g., iNOS) and genomic stress markers (e.g., γH2AX). A p38MAPK inhibitor may increase one or more of the following in CAR T cells: cancer cell-directed cytotoxicity, in vivo proliferation, IFNγ production, persistence of an antigen-specific response, viability, and a memory phenotype (e.g., cell surface markers), and / or may reduce one or more of the following in CAR T cells: oxidative stress markers (e.g., iNOS) and genomic stress markers (e.g., γH2AX).

[0105] Suitably, not excessively attenuating the anti-cancer cell efficacy of cancer immunotherapy in the presence of cancer cells may be or include not excessively attenuating the anti-cancer cell efficacy of T cells in the presence of cancer cells. Suitably, increasing the anti-cancer cell efficacy of cancer immunotherapy may be or include increasing the anti-cancer cell efficacy of T cells. Increasing the anti-cancer cell efficacy of cancer immunotherapy in the presence of cancer cells may be or include increasing the anti-cancer cell efficacy of T cells in the presence of cancer cells.

[0106] p38MAPK inhibitors can prevent or reduce T cell exhaustion (e.g., as evidenced by a reduction in TIM3 and LAG3 on the surface of T cells). Therefore, suitably, p38MAPK inhibitors can prevent or reduce T cell exhaustion. As used herein, "T cell exhaustion" can refer to T cells that are unable to cause cancer cell death; such T cells are nonfunctional and have a transcriptional state distinct from that of functional T cells. Thus, p38MAPK inhibitors can prolong the anti-cancer cell efficacy of T cells. It will be understood that p38MAPK inhibitors can be administered to human patients in dosages effective to do so. Reduction of markers of exhaustion can be interpreted as prolonging the anti-cancer efficacy of T cells, which may additionally or alternatively be related to T cell polarization and thus to the aforementioned "signal 2." Therefore, suitably, p38MAPK inhibitors can regulate T cell polarization. Thus, p38 MAPK inhibitors can be administered in dosages effective to modulate T cell polarization and / or prevent or reduce T cell exhaustion.

[0107] It is believed that signal 3 and signal 4 of T cell activation as described herein can be regulated by external factors. It is believed that p38 MAPK inhibitors may regulate signal 3 and signal 4 in a manner that is not significantly detrimental to T cells, and that in some embodiments, this may have a beneficial effect on the anti-cancer cell efficacy of T cells.

[0108] In some embodiments, signal 3 may be modulated by reducing secretion of cytokines (particularly IL-6) by monocytes and / or endothelial cells. Signal 4 may be modulated. Both signal 3 and signal 4 may be modulated.

[0109] Thus, in some embodiments, p38 MAPK inhibitors can modulate T cell polarization: p38 MAPK inhibitors can modulate T cell specialization into subsets of T cells restricted to producing a particular pattern(s) of cytokines.

[0110] p38MAPK inhibitors can modulate the development of T cell effector functions, such as T cell-mediated tumor cell death. T cells can develop more potent effector functions. Additionally, or alternatively, larger protective T cell memory populations can be formed as a result of p38MAPK inhibition.

[0111] On the other hand, in some embodiments, p38 MAPK inhibitors may modulate events following administration of cancer immunotherapy in vivo, may modulate the duration of T cell responses to therapy, and may affect subsequent T cell phenotype and function.

[0112] In some embodiments, the p38 MAPK inhibitor does not reduce the in vivo proliferation of non-anergic T cells. In some embodiments, the p38 MAPK inhibitor does not reduce the in vivo lifespan of non-anergic T cells. In some embodiments, the p38 MAPK inhibitor does not reduce the in vivo proliferation of non-anergic T cells and does not reduce the in vivo lifespan of non-anergic T cells.

[0113] In some embodiments, the p38 MAPK inhibitor increases the in vivo proliferation of non-anergic T cells. In some embodiments, the p38 MAPK inhibitor increases the in vivo lifespan of non-anergic T cells. In some embodiments, the p38 MAPK inhibitor increases the in vivo proliferation of non-anergic T cells and also increases the in vivo lifespan of non-anergic T cells.

[0114] There may be a smaller proportion of T cells that survive for a long period of time (eg, 3, 6, 9 or 12 months or longer) but are anergic.

[0115] On the other hand, despite maintaining or increasing T cell proliferation, persistence, and / or lifespan, reducing monocyte and / or endothelial cell secretion of cytokines using p38 MAPK inhibitors may prevent or reduce the severity of signs or symptoms of cancer immunotherapy-associated CRS. Thus, even if the anti-cancer cell efficacy of cancer immunotherapy remains the same or increases (which may be a predictor of CRS in other situations, similar to how higher doses of cancer immunotherapy have been associated with a higher risk and / or increased severity of CRS), signs and symptoms of CRS may be prevented or their severity reduced.

[0116] Therefore, it may be advantageous to establish p38 MAPK inhibition in vivo by or during the early stages of cancer immunotherapy, e.g., by the time of administration of the cancer immunotherapy or shortly thereafter, e.g., within 5, 4, 3, 2, or 1 days after administration of the cancer immunotherapy. In this way, p38 MAPK inhibitors may shape early factors during T cell activation and / or proliferation associated with the early stages of cancer immunotherapy, which may affect the efficacy of anti-cancer therapy, particularly signal 3 and signal 4.

[0117] In summary, in broad terms, the correlated beneficial effects of the use of p38 MAPK inhibitors according to the present disclosure may include, but are not necessarily limited to, one or more of the following: (i) reducing pro-inflammatory cytokine release by T cells (particularly reducing TNFα release by T cells); (ii) reducing pro-inflammatory cytokine release by monocytes (particularly reducing IL-6 release by monocytes); (iii) reducing pro-inflammatory cytokine release by endothelial cells (in particular, reducing IL-6 release by endothelial cells, and optionally, reducing IL-8 release by endothelial cells); (iv) modulation of T cell signal 3 and / or signal 4 (particularly signal 4); (v) modulation of T cell polarization and / or reduction of T cell exhaustion (particularly reduction of TIM3 and / or reduction of LAG3 on the surface of T cells); (vi) maintaining or increasing T cell anti-cancer efficacy; and (vii) Maintenance or increase of T cell proliferation.

[0118] Most particularly, the beneficial effect may relate to maintaining or increasing T cell anti-cancer cell efficacy.

[0119] It will be appreciated that p38 MAP kinase exists in various isoforms, including α, β, γ, and δ isoforms. In some embodiments, the p38 MAP kinase inhibitor can be an inhibitor of one or more of p38α MAP kinase, p38β MAP kinase, p38γ MAP kinase, and p38δ MAP kinase, e.g., an inhibitor of p38α MAP kinase and / or an inhibitor of p38β MAP kinase.

[0120] Without prejudice to the generality of this disclosure, references above and elsewhere herein to the use of p38 MAP kinase inhibitors specifically include the use of at least one active agent of the type described below.

[0121] Thus, suitably the p38 MAP kinase inhibitor has the following formula I:

[0122] [ka]

[0123] wherein R is one or more halo, NR 1 R 2 or C optionally substituted by hydroxyl 1~3 alkyl, and R 1 and R 2 are independently H, halo, or C optionally substituted by one or more F. 1~3 alkyl) or a pharmaceutically acceptable salt or solvate thereof.

[0124] For example, R is halo, NR 1 R 2 or hydroxyl, or halo, NR 1 R 2 or hydroxyl, or halo, NR 1 R 2 or hydroxyl. When R is more than one (e.g., two or three) halo, NR 1 R 2 and / or hydroxyl, the substituents may be independently selected from the list.

[0125] R 1 and / or R 2 C optionally replaced by one or more F 1~3 If alkyl, C 1~3 Each alkyl may be, for example, optionally substituted with one, two, or three F, optionally substituted with one or two F, optionally substituted with one or three F, optionally substituted with one F, or optionally substituted with three F.

[0126] In some embodiments, R is methyl or ethyl. In other embodiments, R can be propyl.

[0127] R may be substituted by one or more fluoride atoms.

[0128] In some embodiments, R may be substituted with hydroxy. For example, R may be an ω-substituted alkyl, i.e., an ω-hydroxyalkyl. Thus, in one embodiment, R may be 3-propanol.

[0129] Appropriately, R 1 and R 2 may be independently selected from H and CH3.

[0130] R is C substituted by one, two or three of halo, NRR or hydroxy 1~3 It can be alkyl.

[0131] In some embodiments, the p38 MAPK inhibitor has Formula II:

[0132] [ka]

[0133] or a pharmaceutically acceptable salt or solvate thereof.

[0134] Compounds of formula II, and the synthesis of such compounds, are disclosed in WO 2004 / 076450 (see Example 18), the contents of which are incorporated herein by reference.

[0135] The contents of WO 2018 / 007788 and WO 2019 / 122909 are also incorporated herein by reference.

[0136] Compounds of formula II may be particularly suitable for oral administration, which is advantageous due to their ease of delivery (e.g., ease of delivery outside of a hospital setting, as opposed to other routes of administration such as intravenous administration, which may typically require a hospital setting). The compound of formula II may particularly be administered orally at about 5 to about 1000 mg BID, particularly at about 5 to about 200 mg BID, such as about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg BID, particularly about 70 or about 150 mg BID.

[0137] The compound of Formula II may be particularly suitable for oral administration at about 5 to about 1000 mg BID (particularly at about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, or 200 mg BID, most particularly at about 70 or about 150 mg BID), starting about 4 days to about 2 hours before administration of the cancer immunotherapy (which may suitably be administered as a single dose, e.g., by infusion), and up to about 10 days after administration of the cancer immunotherapy.

[0138] Compounds of Formula II may be tolerable (i.e., have low or no side effects or toxicity), particularly when administered acutely (e.g., in dosing regimens described herein, such as regimens lasting a few days, as opposed to regimes lasting months or years).

[0139] In summary, (i) the attenuation of uncontrolled systemic inflammatory responses in at-risk patient populations without ablating core immune functions, (ii) the convenient oral dosing regimen, and (iii) the tolerability of compounds of Formula II may be particularly beneficial for patients undergoing cancer immunotherapy, for which it would be desirable to provide a method for reducing the severity of or preventing signs or symptoms of cancer immunotherapy-associated CRS without ablating core immune functions and therefore without exposing them to the risk of viral and / or bacterial complications, without requiring continuous in-hospital monitoring and / or administration of compounds (e.g., achieved by oral administration rather than IV dosing), and without causing adverse side effects.

[0140] In some embodiments, the p38 MAP kinase inhibitor is 2-(4-chlorophenyl)-4-(fluorophenyl)-5-pyridin-4-yl-1,2-dihydropyrazol-3-one; 4-[4-(4-fluorophenyl)-1-(3-phenylpropyl)-5-(4-pyridinyl)-1H-imidazol-2-yl]-3-butyn-1-ol; (2R)-2-[[(2R)-2-amino-5-(diaminoethylideneamino)pentanoyl]amino]-N—[(2R)-1-[[(2R)-1-[[(2R)-1-[[(2R)- 1-[[(2R)-1-[[2-[[(2R)-1-amino-3-(4-hydroxyphenyl)-1-oxopropan-2-yl]amino]-2-oxoethyl]amino]-1-oxohexan-2-yl]amino]-1-oxohexan-2-yl]amino]-1-oxohexan-2-yl]amino]-5-(diaminomethylideneamino)-1-oxopentan-2-yl]amino]-1-oxohexan-2-yl]amino]-1-oxohexan-2-yl]hexanamide;2-[6-chloro-5-[(2R,5S)-4-[(4-fluoro 6-[(6R)-2-(4-fluorophenyl)-6-(hydroxymethyl)-4,5,6,7-tetrahydropyrazolo[1,5-a]pyrimidin-3-yl]-2-(2-methylphenyl)pyridazin-3-one; 4-[3-[4-(4-fluorophenyl)-5-pyridin-4-ylimidazol-1-yl]propyl]morpholine, 4-[5-(4-fluorophenyl)-3-piperidine -4-ylimidazol-4-yl]pyrimidin-2-amine; 4-[5-(4-fluorophenyl)-3-piperidin-4-imidazol-4-yl]pyridine; 4-[4-(4-fluorophenyl)-2-(4-methylsulfinylphenyl)-1H-imidazol-5-yl]pyridine; 4-[4-(4-fluorophenyl)-5-(2-methoxypyrimidin-4-yl)imidazol-1-yl]cyclohexan-1-ol; 4-[5-(4-fluorophenyl)-3-piperidin-4-imidazol-4-yl]-2-methoxypyrimidine;6-(N-Carbamoyl-2,6-difluoroanilino)-2-(2,4-difluorophenyl)pyridine-3-carboxamide;5-(2,6-Dichlorophenyl)-2-(2,4-difluorophenyl)sulfanylpyrimido[1,6-b]pyridazin-6-one;2-[[(2S)-2-Amino-3-phenylpropyl]amino]-3-methyl-5-naphthalen-2-yl-6-pyridin-4-ylpyrimidin-4-one;1-[5-tert-butyl-2-(4-methylphenyl) Pyrazol-3-yl]-3-[4-(2-morpholin-4-ylethoxy)naphthalen-1-yl]urea;6-(2,4-Difluorophenoxy)-2-(1,5-dihydroxypentan-3-ylamino)-8-methylpyrido[2,3-d]pyrimidin-7-one;1-[7-(4-Fluorophenyl)-8-pyridin-4-yl-3,4-dihydro-1H-pyrazolo[5,1-c][1,2,4]triazin-2-yl]-2-phenylethane-1,2-dione;8-(2,6-Difluorophenyl)- 2-[4-(4-fluorophenyl)-5-(2-phenoxypyrimidin-4-yl)imidazol-1-yl]propane-1,3-diol;N,N'-Bis[3,5-bis[(E)-N-(diaminomethylideneamino)-C-methylcarbonimidoyl]phenyl]decanediamide;[2-[4-(4-fluorophenyl)-2-(1,3-dihydroxypropan-2-ylamino)-4-(4-fluoro-2-methylphenyl)pyrido[2,3-d]pyrimidin-7-one; ... [5-amino-1-(4-fluorophenyl)pyrazol-4-yl]-[3-[(2S)-2,3-dihydroxypropoxy]phenyl]methanone;2-(2-chloro-6-fluorophenyl)-N-[3-(4-fluorophenyl)-4-pyrimidin-4-yl-1,2-oxazol-5-yl]acetamide;[(2R,3S,4R,5R,6R)-5-[[2-(aminomethylideneamino)acetyl]-methylamino]-3-hydroxy-2-(hydroxymethyl)-6-[(7-hydroxy-5-methyl-4-oxo-3a,6,7,7a-tetrahydro-1H-imidazo[4,5-c]pyridin-2-yl)amino]oxan-4-yl]carbamate; 1-[5-tert-butyl-2-(4-methylphenyl)pyrazol-3-yl]-3-[[5-fluoro-2-[1-(2-hydroxyethyl)indazol-5-yl]oxyphenyl] Methyl]urea;5-(2,4-Difluorophenoxy)-N-[2-(dimethylamino)ethyl]-1-(2-methylpropyl)indazole-6-carboxamide;N-Cyclopropyl-3-fluoro-4-methyl-5-[3-[[1-[2-[2-(methylamino)ethoxy]phenyl]cyclopropyl]amino]-2-oxopyrazin-1-yl]benzamide;3-[5-Amino-4-(3-cyanobenzoyl)pyrazol-1-yl]-N-cyclopropyl-4-methylbenzamide;4-[5-(Cyclopropylcarbamoyl)-2- Methylanilino]-5-methyl-N-propylpyrrolo[2,1-f][1,2,4]triazine-6-carboxamide;4-[4-(4-fluorophenyl)-2-(4-methylsulfonylphenyl)-1H-imidazol-5-yl]pyridine;N-[4-[5-(4-fluorophenyl)-3-methyl-2-methylsulfinylimidazol-4-yl]pyridin-2-yl]acetamide;1-(5-tert-butyl-2-phenylpyrazol-3-yl)-3-[2-fluoro-4-[(3-oxo-4H-pyrido[2,3-b]pyrazol-3-yl]pyridin-2-yl]acetamide 4-(3,4-Dichlorophenyl)-5-(4-pyridinyl)-2-thiazolamine dihydrochloride; 5-(2-Chloroethyl)-4-methyl-1,3-thiazole; Ethane-1,2-disulfonic acid; 2'-Fluoro-N-(4-hydroxyphenyl)-[1,1'-biphenyl]-4-butanamide;[4-(2-Amino-4-bromoanilino)-2-chlorophenyl]-(2-methylphenyl)methanone;(E)-3-[4-(imidazol-1-ylmethyl)phenyl]prop-2-enoic acid;17alpha-ethynyl-5-androstene-3beta,7beta,17beta-triol;(Z)-6-Amino-2-(3',5'-dibromo-4'-hydroxybenzylidene)-2H-benzo[b][1,4]oxazin-3(4H)-one;(4-Benzylpiperidin-1-yl)-(2-methoxy-4-methylsulfanylphenyl)methanone ;6-[5-(cyclopropylcarbamoyl)-3-fluoro-2-methylphenyl]-N-(2,2-dimethylpropyl)pyridine-3-carboxamide;5-[2-tert-butyl-4-(4-fluorophenyl)-1H-imidazol-5-yl]-3-(2,2-dimethylpropyl)imidazole[4,5-b]pyridin-2-amine;Methanesulfonic acid;4-[5-(4-fluorophenyl)-2-methylsulfanyl-1H-imidazol-4-yl]-N-(1-phenylethyl)pyridin-2-amine;2-(3,4-dihydroxyphenyl)- Nyl)-3-hydroxychromen-4-one;1-[5-tert-butyl-2-(3-chloro-4-hydroxyphenyl)pyrazol-3-yl]-3-[[2-[[3-[2-(2-hydroxyethylsulfanyl)phenyl]-[1,2,4]triazolo[4,3-a]pyridin-6-yl]sulfanyl]phenyl]methyl]urea;3-[3-bromo-4-[(2,4-difluorophenyl)methoxy]-6-methyl-2-oxopyridin-1-yl]-N,4-dimethylbenzamide;5-[2-tert-butyl-4-(4-fluorophenyl) )-1H-imidazol-5-yl]-3-(2,2-dimethylpropyl)imidazo[4,5-b]pyridin-2-amine; 4-[4-[[4-chloro-3-(trifluoromethyl)phenyl]carbamoylamino]-3-fluorophenoxy]-N-methylpyridine-2-carboxamide; [5-amino-1-(4-fluorophenyl)pyrazol-4-yl]-[3-[(2S)-2,3-dihydroxypropoxy]phenyl]methanone, 4-[4-(4-fluorophenyl)-5-pyridin-4-yl-1H-imidazol-2-yl]phenol;4-[4-(4-Fluorophenyl)-2-(4-methylsulfinylphenyl)-1H-imidazol-5-yl]pyridine hydrochloride;4-[4-(4-Fluorophenyl)-5-pyridin-4-yl-1H-imidazol-2-yl]phenol hydrochloride;1-[4-[3-(4-Chlorophenyl)-4-pyrimidin-4-yl-1H-pyrazol-5-yl]piperidin-1-yl]-2-hydroxyethanone;N,N'-Bis[3,5-bis[(E)-N-(diaminomethylideneamino)-C-methylcarbonimidoyl]phenyl]decanediamide,6-(4-Fluorophenyl)-5-pyridin-4-yl-2,3-dihydroimidazo[2,1-b][1,3]thiazole;2-[6-Chloro-5-[4-[(4-fluorophenyl)methyl]piperidine-1 -carbonyl]-1-methylindol-3-yl]-N,N-dimethyl-2-oxoacetamide; [5-amino-1-(4-fluorophenyl)pyrazol-4-yl]-[3-(2,3-dihydroxypropoxy)phenyl]methanone; N-[4-[2-ethyl-4-(3-methylphenyl)-1,3-thiazol-5-yl]pyridin-2-yl]benzamide; 4-[4-(6-methoxynaphthalen-2-yl)-2-(4-methylsulfinylphenyl)-1H-imidazol-5-yl]pyridine; 4,6-bis(p-fluorophenyl)-2-methyl-5-(4-pyridyl)-1,2,7-triaza-2H-indene; and 2-(3-phenyl-4,5-dihydro-1,2-oxazol-5-yl)acetic acid.

[0141] In some embodiments, the p38 MAP kinase inhibitor is 8-(2,6-difluorophenyl)-2-(1,3-dihydroxypropan-2-ylamino)-4-(4-fluoro-2-methylphenyl)pyrido[2,3-d]pyrimidin-7-one, (E)-3-[4-(imidazol-1-ylmethyl)phenyl]prop-2-enoic acid; 6-[5-(cyclopropylcarbamoyl)-3-fluoro-2-methylphenyl] 1-[5-tert-butyl-2-(3-chloro-4-hydroxyphenyl)pyrazol-3-yl]-3-[[2-[[3-[2-(2-hydroxyethylsulfanyl)phenyl]-[1,2, 4]triazolo[4,3-a]pyridin-6-yl]sulfanyl]phenyl]methyl]urea, 3-[3-bromo-4-[(2,4-difluorophenyl)methoxy]-6-methyl-2-oxopyridin-1-yl]-N,4-dimethylbenzamide, 2-methoxy-1-{4-[(4-{3-[5-(tert-butyl)-2-(p-tolyl)-2H-pyrazol-3-yl]ureido}-1-naphthyloxy)methyl

[0033] The compound may be or include 2-methoxy-1-[4-(4-{3-[5-(tert-butyl)-2-(p-tolyl)-2H-pyrazol-3-yl]ureido}-1-naphthyloxy)-2-pyridylamino]-1-ethanone, ... and 4,6-bis(p-fluorophenyl)-2-methyl-5-(4-pyridyl)-1,2,7-triaza-2H-indene.

[0142] According to the present disclosure, the p38 MAPK inhibitor, which may optionally be at least one of the active agents described above, is administered before the onset of CRS. It will be understood that this does not preclude administration of the p38 MAPK inhibitor after the onset of CRS, e.g., continuous administration. Rather, continuous administration after the onset of CRS is preferred. Administration of the p38 MAPK inhibitor may begin about 4 days to about 2 hours before administration of the cancer immunotherapy (suitably, the cancer immunotherapy is administered in a single dose, e.g., by infusion), and the patient may then continue the oral dosing regimen described above with the p38 MAPK inhibitor, with the endpoint of the oral dosing regimen being up to about 10 days after administration of the cancer immunotherapy.

[0143] The p38 MAPK inhibitor is administered to a human patient before the onset of CRS. The p38 MAPK inhibitor is administered directly to a human patient (e.g., intravenously, orally, or both) before the onset of CRS. The p38 MAPK is not administered in vitro, for example, to a T cell culture, and the cells are subsequently administered to a human patient. Preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient is achieved by in vivo administration of the p38 MAPK inhibitor. Thus, the p38 MAPK inhibitor is administered in vivo to a human patient before the onset of CRS.

[0144] The timing of administration of p38 MAPK inhibitors before the onset of CRS can be as modeled in the mouse experiments described in Examples 5 and 6 herein.

[0145] The p38 MAPK inhibitor may be administered orally, intravenously, intraperitoneally, topically, transdermally, intramuscularly, subcutaneously, intranasally, sublingually, intrathecally, intracerebroventricularly, intratumorally, or by any other suitable route. In a preferred embodiment, the p38 MAPK inhibitor may be administered intravenously, orally, or both (e.g., via an initial intravenous dose, followed by multiple oral doses, as disclosed herein).

[0146] Oral administration of the p38 MAPK inhibitor (such as a compound of Formula II) is particularly preferred. Suitably, oral administration may be convenient in an outpatient setting. This may reduce the cost of patient treatment by reducing the need for hospitalization or other inpatient monitoring. Suitably, the patient is administered an oral dosing regimen of the p38 MAPK inhibitor (e.g., from about 5 mg BID to about 1000 mg BID, particularly from about 50 mg BID to about 200 mg BID, e.g., about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 170, 180, 190, 210, 220, 230, 240, 250, 260, 270, 280, 290, 310, 320, 330, 340, 350, 360, 370, 380, 390, 410, 420, 430, 440, 450, 460, 470, 480, 490, 510, 520, 530, 540, 550, 560, 570, 580, 590, 610, 620, 630, 640, 650, 660, 670, 680, 690, In one embodiment, the patient is started (e.g., begins in a hospital) (e.g., still in a hospital, suitably where the cancer immunotherapy is administered in a single dose, e.g., by infusion) on a single oral dose of the p38 MAPK inhibitor, e.g., 65, 170, 175, 180, 185, 190, 195 or 200 mg, particularly about 70 mg BID or about 150 mg BID, orally), and thereafter (e.g., is discharged from the hospital) and continues on the oral dosing regimen with the p38 MAPK inhibitor, with the endpoint of the oral dosing regimen being up to about 10 days after administration of the cancer immunotherapy.

[0147] The p38 MAPK inhibitor can be administered prior to administration of the cancer immunotherapy to the patient. The p38 MAPK inhibitor can be administered simultaneously with administration of the cancer immunotherapy to the patient. The p38 MAPK inhibitor can be administered after administration of the cancer immunotherapy to the patient but before the onset of CRS.

[0148] The p38 MAPK inhibitor may be administered prior to the administration of the cancer immunotherapy. Optionally, a dose of the p38 MAPK inhibitor may be administered (e.g., intravenously or orally) at a time ranging from about 1 minute to about 6 hours, or from about 10 minutes to about 2 hours, or from about 30 minutes to about 6 hours prior to the administration of the cancer immunotherapy. For example, a dose of the p38 MAPK inhibitor may be administered intravenously about 30 minutes prior to the administration of the cancer immunotherapy.

[0149] More preferably, administration of the p38 MAPK inhibitor may begin at a time ranging from about 6 days to about 30 minutes, e.g., about 5 days to about 1 hour, particularly about 4 days to about 2 hours, prior to administration of the cancer immunotherapy. Such administration of the p38 MAPK inhibitor is most suitably oral and BID, e.g., 10 to 1000 mg orally BID. Such administration of the p38 MAPK inhibitor suitably continues (orally BID) until an endpoint of up to 15 days, e.g., up to 10 days, particularly up to 7 days, after administration of the cancer immunotherapy (i.e., thereafter discontinued).

[0150] In such embodiments, p38 MAPK inhibitors may be effective in preventing or at least reducing the severity of type 1 infusion-related hypersensitivity reactions. The term "type 1 infusion-related hypersensitivity reaction" may be used herein to refer to an acute immune-mediated response to any intravenous administration of cancer immunotherapy. In contrast to cancer immunotherapy-induced CRS, the classical mechanism of type 1 immune-mediated hypersensitivity reactions may involve the formation of immunoglobulin E (IgE) antibodies in response to infusion. IgE then binds to mast cells, which can cause the release of multiple cytokines. Signs and symptoms may include itching, hives, fever, chills / chills, sweating, bronchospasm, and cardiovascular collapse.

[0151] Optionally, one or more doses of the p38 MAPK inhibitor can be administered repeatedly (e.g., intravenously or orally), particularly orally BID, or the p38 MAPK inhibitor can be administered continuously, particularly by intravenous infusion, preferably starting at a time ranging from about 4 days to about 2 hours, for example about 3 days to about 1 day, before administration of the cancer immunotherapy in such a manner as to establish a steady-state plasma concentration of the p38 MAPK inhibitor by the time of administration of the cancer immunotherapy.

[0152] Establishing a steady-state plasma concentration of a p38 MAPK inhibitor by the time of administration of cancer immunotherapy may enhance its prophylactic effect as described herein.

[0153] To establish a steady-state plasma concentration of the p38 MAPK inhibitor by the time of administration of the cancer immunotherapy, the p38 MAPK inhibitor may be orally administered (e.g., twice daily) in one or more repeated doses, beginning at a time ranging from about 4 days to about 2 hours, e.g., about 3 days to about 1 day, before administration of the cancer immunotherapy. Such a dosing regimen may continue until an endpoint of up to about 15, 10, or particularly 7 days after administration of the cancer immunotherapy. Advantageously, patients may be relatively healthy, conscious, and able to receive the p38 MAPK inhibitor by oral administration at this stage in their treatment cycle. To date, treatment of cancer immunotherapy-induced CRS, for example, using tocilizumab and steroids as described above, has been reactive rather than preventative; however, reactive treatment of severely ill patients can be difficult to achieve using oral medications, and clinicians must therefore turn to alternative administration modes, which are usually more laborious and / or invasive.

[0154] For some patients, the p38 MAPK inhibitor may be administered by intravenous infusion, preferably starting about 3 days to about 1 day before administration of the cancer immunotherapy, to establish a steady-state plasma concentration of the p38 MAPK inhibitor by the time of administration of the cancer immunotherapy. The intravenous infusion may be continuous or may be administered at regular intervals to establish a steady-state plasma concentration of the p38 MAPK inhibitor. Intravenous infusion may be particularly appropriate when oral administration of the p38 MAPK inhibitor is inappropriate for the patient in question, such as a patient undergoing intensive care.

[0155] Those skilled in the art are familiar with suitable methods for calculating when a steady-state plasma concentration of an active agent, such as a p38 MAP kinase inhibitor, used in accordance with the present disclosure has been achieved. ss ) is defined as the time for which the concentration remains stable or consistent when the active agent is given repeatedly or continuously (IV infusion). The time to reach steady state is T 1 / 2 is a function of and is achieved when the rate of active agent entering the systemic circulation equals the rate of elimination. For most active agents, Css is reached in approximately five half-lives. The time to reach steady state is independent of dose size, dosing interval, and number of doses. In the case of multiple dosing, when an active agent is administered at fixed doses and fixed intervals, the plasma concentration is approximately equal to the T of the agent. 1 / 2 The increase is exponential, reaching a plateau or steady state with a half-life equal to

[0156] The steady-state plasma concentration of the p38 MAPK inhibitor can range from about 1 to about 750 μg / L, about 5 to about 600 μg / L, about 10 to about 500 μg / L, about 25 to about 500 μg / L, about 50 to about 500 μg / L, or about 100 to about 400 μg / L.

[0157] Thus, in accordance with the present disclosure, a p38 MAPK inhibitor may be administered beginning about 4 days to about 2 hours, e.g., about 1 day to about 3 days, prior to administration of the cancer immunotherapy in a manner that establishes a steady-state plasma concentration of the p38 MAPK inhibitor in the range of about 1 to about 750 μg / L by the time of administration of the cancer immunotherapy. In particular, such administration of the p38 MAPK inhibitor may be oral in repeated doses (e.g., BID) or by intravenous infusion. Most particularly, the p38 MAPK inhibitor may be administered orally at 5 to 1000 mg BID beginning about 4 days to about 2 hours prior to administration of the cancer immunotherapy, and continuing until an endpoint of up to about 15, 10, or particularly 7 days after administration of the cancer immunotherapy, thus establishing a steady-state plasma concentration of the p38 MAPK inhibitor for an appropriate period before, during, and after administration of the cancer immunotherapy.

[0158] Additionally or alternatively, the p38 MAPK inhibitor can be administered (e.g., intravenously) at the same time as the administration of the cancer immunotherapy. Optionally, the p38 MAPK inhibitor and the cancer immunotherapy can be administered at the same time, but in separate formulations and optionally via separate administration routes. In some embodiments, the cancer immunotherapy and the p38 MAPK inhibitor can be administered at the same time by two separate intravenous injections in different formulations. In some embodiments, the cancer immunotherapy is infused intravenously, while the p38 MAPK inhibitor is administered orally at the same time. In some embodiments, the p38 MAPK inhibitor and the cancer immunotherapy can be administered in the same formulation, for example, both can be administered by the same intravenous injection.

[0159] Additionally or alternatively, the p38 MAPK inhibitor can be administered after administration of the cancer immunotherapy to the patient but before the onset of CRS. The p38 MAPK inhibitor can be administered within one, two, or three days after administration of the cancer immunotherapy (still before the onset of CRS). Because the risk of CRS is thought to be particularly high approximately two weeks after administration of the cancer immunotherapy, the p38 MAPK inhibitor can be administered within one or two weeks after administration of the cancer immunotherapy, before the onset of CRS.

[0160] The p38 MAPK inhibitor may be administered on an OD (once a day), BID (twice a day), TID (three times a day), QID (four times a day) or more frequent dosing schedule. For example, the p38 MAPK inhibitor may be administered from about once a day to about six times a day. In particular, the p38 MAPK inhibitor may be administered BID. In some embodiments, the p38 MAPK inhibitor may be administered on an every other day, three times a week, twice a week, weekly, or biweekly dosing schedule. Examples 5 and 6 described herein model BID dosing. In particular, the p38 MAPK inhibitor may be administered orally BID, for example at about 5 to about 1000 mg BID, particularly at about 5 to about 200 mg BID, for example at about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg BID, particularly at about 70 or about 150 mg BID.

[0161] The dosing schedule of the p38 MAPK inhibitor may generally include one or more on-days followed by one or more off-days. For example, the p38 MAPK inhibitor may be administered on one on-day and one off-day; or on two on-days and one off-day; or on three on-days and one off-day, or the p38 MAPK inhibitor may be administered continuously without a drug-free day. Optionally, the p38 MAPK inhibitor may be administered at an initial dose (which may be a unique dose or a one-time dose that does not form part of the above-mentioned dosing schedule) before or at the same time as the administration of the cancer immunotherapy, followed by the above-mentioned dosing schedule. For example, an initial intravenous dose may be followed by multiple oral doses according to the above-mentioned dosing schedule (e.g., BID, for example, for about 1 to about 50 days).

[0162] Administration of the p38 MAPK inhibitor may continue for as long as necessary. In some embodiments, the p38 MAPK inhibitor may be administered for less than about 28 days, about 14 days, about 7 days, about 6 days, about 5 days, about 4 days, about 3 days, or about 2 days. In some embodiments, the p38 MAPK inhibitor may be administered for about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7 days, about 14 days, or more than about 28 days. In some cases, continuous administration may be achieved and maintained for as long as necessary. In some embodiments, the p38 MAPK inhibitor may be administered for about 1 to 50 days, preferably about 7 to 40 days, and more preferably about 14 to 28 days, following administration of the cancer immunotherapy. However, it is contemplated that administration of the p38 MAPK inhibitor according to the present disclosure should be an acute treatment lasting several days or weeks. The treatment of the present disclosure is not intended to be chronic, lasting for several months or longer.

[0163] Therefore, preferably, administration of the p38 MAPK inhibitor may begin about 4 days to about 2 hours before administration of the cancer immunotherapy, and such administration may continue until an endpoint of about 15 days after administration of the cancer immunotherapy.

[0164] Example 5 herein describes a mouse model of BID dosing for up to 11 days, while Example 6 herein describes a mouse model of BID dosing for up to 7 days.

[0165] The p38MAPK inhibitor may be administered starting from about 1 to about 5 days, particularly about 1 to about 4 days, for example, about 1 to about 3 days before the onset of CRS. The p38MAPK inhibitor may be administered until about 7 to about 28 days after the onset of CRS (i.e., the administration is stopped thereafter).

[0166] The selected dosage form and regimen will depend on a variety of factors, including, for example, the activity of the p38 MAPK inhibitory compound(s) used, the route of administration, the time of administration, the excretion rate of the p38 MAPK inhibitory compound(s) used, the rate and extent of absorption, the duration of treatment, the formulation of the pharmaceutical containing the p38 MAPK inhibitor, the presence of other drugs, compounds and / or materials used in combination with the p38 MAPK inhibitor used, the age, sex, weight, condition, general health and medical history of the patient being treated, and other such factors well known in the medical arts.

[0167] Generally, a suitable dosage (e.g., a twice-daily dose) of a p38 MAPK inhibitor described herein is, in some embodiments, the amount of compound that is the lowest dosage effective to produce a therapeutic and / or prophylactic effect.

[0168] The dosage may, in some embodiments, be the minimum dosage effective to achieve one or more of the following effects: (i) reducing pro-inflammatory cytokine release by T cells (particularly reducing TNFα release by T cells); (ii) reducing pro-inflammatory cytokine release by monocytes (particularly reducing IL-6 release by monocytes); (iii) reducing pro-inflammatory cytokine release by endothelial cells (in particular, reducing IL-6 release by endothelial cells, and optionally, reducing IL-8 release by endothelial cells); (iv) modulation of T cell signal 3 and / or signal 4 (particularly signal 4); (v) modulation of T cell polarization and / or reduction of T cell exhaustion (particularly reduction of TIM3 and / or reduction of LAG3 on the surface of T cells); (vi) maintaining or increasing T cell anti-cancer efficacy; and (vii) Maintenance or increase in proliferation of non-anergic T cells.

[0169] Most particularly, the dosage may be the lowest dosage effective to maintain or increase T cell anti-cancer efficacy.

[0170] The effective dosage generally depends on the factors described herein. Generally, the dosage of the p38 MAPK inhibitor, when used for the indicated effects, ranges from about 10 mg to about 1400 mg per day, or from about 10 mg to about 1300 mg per day, or from about 10 mg to about 1200 mg per day, or from about 20 mg to about 1120 mg per day.

[0171] Therefore, the dosage of the p38 MAPK inhibitor can be in the range of about 10 mg per day to about 600 mg per day. For example, the dosage can be about 150 mg per day. The dosage can be, for example, about 300 mg per day.

[0172] The p38 MAPK inhibitor may optionally be delivered BID. The dosage of the p38 MAPK inhibitor, when used for the indicated effects, may range from about 5 mg BID to about 1000 mg BID, or from about 5 mg to about 700 mg BID (i.e., a total of about 10 mg to about 1400 mg per day), or from about 5 mg to about 650 mg BID, or from about 5 mg to about 600 mg BID, such as about 10 mg to about 560 mg BID. In some embodiments, the dosage may be about 20 mg, about 80 mg, about 400 mg, about 600 mg, about 800 mg, or about 1120 mg per day. In some embodiments, the dosage may be about 10 mg, about 40 mg, about 200 mg, about 300 mg, about 400 mg, or about 560 mg BID. The dosage may particularly be about 5 to about 1000 mg BID, particularly about 5 to about 200 mg BID, such as about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg BID, particularly about 70 or about 150 mg BID.

[0173] In some embodiments, for a human patient, a suitable dose is from about 0.001 to about 20 mg / kg / day, or from about 0.001 to about 10 mg / kg / day, or from about 0.001 to about 5 mg / kg / day.

[0174] As described above, when the p38 MAPK inhibitor is a compound of Formula II, 70 mg BID or 150 mg BID are particularly preferred.

[0175] The actual dosage of the p38 MAPK inhibitor can be varied to obtain an amount of the p38 MAPK inhibitor that is effective to achieve the desired therapeutic response for a given patient, composition, and mode of administration without being toxic to the patient. In some cases, dosages below the lower end of the disclosed ranges may be appropriate, while in other cases, higher dosages may be used without causing any adverse side effects.

[0176] In some embodiments, an initial intravenous dose (e.g., about 10 mg to about 1000 mg) of a p38 MAPK inhibitor may be administered, for example, but not exclusively, contemporaneously with or prior to (e.g., about 1 minute to 6 hours, e.g., about 20 to 60 minutes before) the cancer immunotherapy, and then subsequent doses of the p38 MAPK inhibitor may be administered orally (e.g., about 10 mg to about 560 mg of a p38 MAPK inhibitor may be administered orally, e.g., BID, 1 to 3 times per day for about 1 to 50 days).

[0177] In another aspect, provided herein is a p38 MAP kinase inhibitor of Formula II, or a pharmaceutically acceptable salt or solvate thereof, for use in preventing or treating cancer immunotherapy-associated CRS in a human patient. The p38 MAP kinase inhibitor of Formula II, salt or solvate may suitably be administered orally, for example at 5 to 1000 mg BID, particularly about 5 to about 200 mg BID, for example about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195 or 200 mg BID, particularly about 70 or about 150 mg BID.

[0178] In a second aspect of the present disclosure, there is provided a pharmaceutical composition comprising a p38 MAP kinase inhibitor for use in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient, wherein the pharmaceutical composition is administered in vivo before the onset of CRS.

[0179] Suitably, the pharmaceutical composition may comprise a p38 MAP kinase inhibitor as defined in accordance with the first aspect of the present disclosure, including the specific active agents described above.

[0180] In some embodiments, the pharmaceutical composition may be suitable for oral administration. Pharmaceutical compositions suitable for oral administration may be presented as individual dosage forms, such as capsules, cachets, or tablets, or liquids or aerosol sprays, each containing a predetermined amount of p38MAPK inhibitor as a powder, or as granules, a solution, or a suspension in an aqueous or non-aqueous liquid, an oil-in-water emulsion, or a water-in-oil liquid emulsion. Such dosage forms may be prepared by any method of pharmacy, but all methods include the step of bringing the p38MAP kinase inhibitor into association with a carrier, which constitutes one or more ingredients. Generally, pharmaceutical compositions are prepared by uniformly and intimately mixing the p38MAP kinase inhibitor with a liquid carrier or a 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 may be prepared by compressing in a suitable machine the p38 MAPK inhibitor 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 may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent.

[0181] The present disclosure further encompasses anhydrous pharmaceutical compositions and dosage forms containing p38 MAPK inhibitors. Anhydrous pharmaceutical compositions and dosage forms can be prepared using anhydrous or low-moisture-containing ingredients and low-moisture or low-humidity conditions. For example, pharmaceutical compositions and dosage forms 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 can be prepared and stored to maintain their anhydrous nature. Thus, anhydrous pharmaceutical compositions can be packaged using materials known to prevent exposure to water so that they can be included in suitable prescription kits. Examples of suitable packaging include, but are not limited to, hermetically sealed foils, plastics, unit-dose containers, blister packs, and strip packs.

[0182] The p38 MAPK inhibitor can be intimately mixed and combined 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 pharmaceutical compositions for oral dosage forms, any common pharmaceutical medium such as water, glycols, oils, alcohols, flavorings, preservatives, coloring agents, etc. can be used as carriers for oral liquid preparations (such as suspensions, solutions, and elixirs) or aerosols; or carriers such as starch, sugar, microcrystalline cellulose, diluents, granulating agents, lubricants, binders, and disintegrants can be used without lactose in some embodiments for oral solid preparations.For example, suitable carriers include powders, capsules, and tablets for solid oral preparations.In some embodiments, tablets can be coated by standard aqueous or non-aqueous techniques.

[0183] 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 gum arabic, 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 mixtures thereof.

[0184] 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 mixtures thereof.

[0185] Disintegrants can be used in the pharmaceutical compositions disclosed herein to provide tablets that disintegrate when exposed to an aqueous environment. The amount of disintegrant used can vary based on the type of formulation and mode of administration and is readily discernible to those skilled in the art. For example, about 0.5 to about 15 weight percent of disintegrant, or about 1 to about 5 weight percent of disintegrant, can be used in the pharmaceutical composition. Disintegrants that can be used to form pharmaceutical compositions and dosage forms 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 mixtures thereof.

[0186] Lubricants that can be used to form pharmaceutical compositions and dosage forms 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 laurate, agar, or mixtures thereof. Additional lubricants include, for example, syloid silica gel, coagulated aerosol of synthetic silica, or mixtures thereof. Lubricants can optionally be added in an amount of less than about 1 weight percent of the pharmaceutical composition.

[0187] When aqueous suspensions and / or elixirs are desired for oral administration, the p38 MAPK inhibitors therein may be combined with diluents such as water, ethanol, propylene glycol, glycerin, and various combinations thereof, as well as various sweeteners or flavorings, coloring substances or dyes, and, for example, emulsifying and / or suspending agents.

[0188] The tablet dosage form disclosed herein can be uncoated, or can be coated by known techniques to delay disintegration and absorption in the gastrointestinal tract, thereby providing sustained action over a long period of time.For example, time-delay materials such as glyceryl monostearate or glyceryl distearate can be used.The preparation for oral use can also be presented as a hard gelatin capsule, in which p38MAPK inhibitor is mixed with an inert solid diluent such as calcium carbonate, calcium phosphate or kaolin, or as a soft gelatin capsule, in which p38MAPK inhibitor is mixed with water or oil medium, such as peanut oil, liquid paraffin or olive oil.

[0189] In some embodiments, pharmaceutical compositions can comprise one or more surfactants.The surfactant that can be used to form pharmaceutical compositions includes but is not limited to hydrophilic surfactant, lipophilic surfactant, and their mixture.Can use a mixture of hydrophilic surfactant, can use a mixture of lipophilic surfactant, or can use a mixture of at least one hydrophilic surfactant and at least one lipophilic surfactant.

[0190] In some embodiments, the pharmaceutical composition may include a solubilizing agent to ensure good solubilization and / or dissolution of the p38 MAPK inhibitor and minimize precipitation of the p38 MAPK inhibitor. A solubilizing agent may also be added to increase the solubility of the p38 MAPK inhibitor and / or other components, such as surfactants, or to maintain the pharmaceutical composition as a stable or homogeneous solution or dispersion.

[0191] 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-caprolidone, hydroxypropyl methylcellulose ... 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, ε-caprolactone and its isomers, δ-valerolactone and its isomers, β-butyrolactone and its isomers; and other solubilizing agents known in the art, such as, but not limited to, dimethylacetamide, dimethyl isosorbide, N-methylpyrrolidone, monooctanoin, diethylene glycol monoethyl ether, and water.

[0192] Mixtures of solubilizers can also be used. Examples include, but are not limited to, triacetin, triethyl citrate, ethyl oleate, ethyl caprylate, dimethylacetamide, N-methylpyrrolidone, N-hydroxyethylpyrrolidone, polyvinylpyrrolidone, hydroxypropylmethylcellulose, hydroxypropylcyclodextrin, ethanol, polyethylene glycol 200-100, glycofurol, transquitol, propylene glycol, and dimethyl isosorbide. In some embodiments, the solubilizer includes sorbitol, glycerol, triacetin, ethyl alcohol, PEG-400, glycofurol, and propylene glycol.

[0193] The amount of solubilizer that can be included is not particularly limited. The amount of a given solubilizer may be limited to a bioacceptable amount, which can be easily determined by one skilled in the art. In some situations, for example, to maximize the drug concentration, it may be advantageous to include a solubilizer in an amount far in excess of the bioacceptable amount, with the excess solubilizer being removed using conventional techniques such as distillation or evaporation before providing the pharmaceutical composition to a subject. Thus, when present, the solubilizer may be present in a weight ratio of about 10%, 25%, 50%, 100%, or up to about 200% by weight, based on the combined weight of the drug and other excipients. Optionally, very small amounts of solubilizer, such as about 5%, 2%, 1%, or even 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.

[0194] The pharmaceutical composition may further comprise one or more pharmaceutically acceptable additives and excipients, including, but not limited to, detackifiers, antifoaming agents, buffers, polymers, antioxidants, preservatives, chelating agents, viscomodulators, tonicifiers, flavors, colorants, oils, fragrances, opacifiers, suspending agents, binders, fillers, plasticizers, lubricants, and mixtures thereof.

[0195] Exemplary preservatives may include antioxidants, chelating agents, antibacterial preservatives, antifungal preservatives, alcohol preservatives, acidic preservatives, and other preservatives. Exemplary antioxidants include, but are not limited to, alpha-tocopherol, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, monothioglycerol, potassium metabisulfite, propionic acid, propyl gallate, sodium ascorbate, sodium bisulfite, sodium metabisulfite, and sodium sulfite. Exemplary chelating agents include ethylenediaminetetraacetic acid (EDTA), citric acid monohydrate, disodium edetate, dipotassium edetate, edetic acid, fumaric acid, malic acid, phosphoric acid, sodium edetate, tartaric acid, and trisodium edetate. Exemplary antibacterial preservatives include, but are not limited to, benzalkonium chloride, benzethonium chloride, benzyl alcohol, bronopol, cetrimide, cetylpyridinium chloride, chlorhexidine, chlorobutanol, chlorocresol, chloroxylenol, cresol, ethyl alcohol, glycerin, hexetidine, imidurea, phenol, phenoxyethanol, phenylethyl alcohol, phenylmercuric nitrate, propylene glycol, and thimerosal. Exemplary antifungal preservatives include, but are not limited to, butylparaben, methylparaben, ethylparaben, propylparaben, benzoic acid, hydroxybenzoic acid, potassium benzoate, potassium sorbate, sodium benzoate, sodium propionate, and sorbic acid. Exemplary alcohol preservatives include, but are not limited to, ethanol, polyethylene glycol, phenol, phenolic compounds, bisphenol, chlorobutanol, hydroxybenzoate, and phenylethyl alcohol. Exemplary acidic preservatives include, but are not limited to, vitamin A, vitamin C, vitamin E, beta-carotene, citric acid, acetic acid, dehydroacetic acid, ascorbic acid, sorbic acid, and phytic acid.Other preservatives include, but are not limited to, tocopherol, tocopherol acetate, deteroxime mesylate, cetrimide, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), ethylenediamine, sodium lauryl sulfate (SLS), sodium lauryl ether sulfate (SLES), sodium bisulfite, sodium metabisulfite, potassium sulfite, potassium metabisulfite, Glydant Plus, Phenonip, methylparaben, Germall 115, Germaben II, Neolone, Kathon, and Euxyl.In certain embodiments, the preservative is an antioxidant.In other embodiments, the preservative is a chelating agent.

[0196] Representative oils include almond, apricot kernel, avocado, babassu, bergamot, blackcurrant seed, borage, cade, chamomile, canola, caraway, carnauba, castor, cinnamon, cocoa butter, coconut, cod liver oil, coffee, corn, cottonseed, emu, eucalyptus, evening primrose, fish, flaxseed, geraniol, gourd, grapeseed, hazelnut, hyssop, isopropyl myristate, jojoba, kukui nut, lavandin, lavender, lemon, and litsea cubeba. Exemplary oils include, but are not limited to, sorbitan, sorbitan stearate ...

[0197] Additionally, acids or bases may be incorporated into pharmaceutical compositions 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 hydrocalcite, 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 acid, 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, parabromophenylsulfonic 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 may also be used. When the base is a salt, the cation may be any convenient pharmaceutically acceptable cation, such as ammonium, an alkali metal, or an alkaline earth metal. Examples include, but are not limited to, sodium, potassium, lithium, magnesium, calcium, and ammonium.

[0198] 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 acid, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid, citric acid, fatty acid, formic acid, fumaric acid, gluconic acid, hydroquinosulfonic acid, isoascorbic acid, lactic acid, maleic acid, methanesulfonic acid, oxalic acid, parabromophenylsulfonic acid, propionic acid, p-toluenesulfonic acid, salicylic acid, stearic acid, succinic acid, tannic acid, tartaric acid, thioglycolic acid, toluenesulfonic acid, uric acid, etc.

[0199] In some embodiments, provided herein is a pharmaceutical composition for parenteral administration, such as intravenous administration, comprising a p38 MAPK inhibitor as disclosed herein and a pharmaceutical excipient suitable for parenteral administration.

[0200] Forms in which the disclosed pharmaceutical compositions can be incorporated for administration by injection include aqueous or oil suspensions or emulsions using sesame oil, corn oil, cottonseed oil, or peanut oil, as well as elixirs, mannitol, dextrose, or sterile aqueous solutions and similar pharmaceutical vehicles.

[0201] Aqueous solutions in physiological saline are also conventionally used for injection. Ethanol, glycerol, propylene glycol, liquid polyethylene glycol, etc. (and suitable mixtures thereof), cyclodextrin derivatives, and vegetable oils can also be used. Proper fluidity can be maintained, for example, by the use of a coating such as lecithin to maintain the required particle size in the case of dispersions, and by the use of surfactants. Prevention or attenuation of the action of microorganisms can be brought about by various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, sorbic acid, thimerosal, etc.

[0202] A preferred mode of administration according to the present disclosure may be or include intravenous infusion of a solution or dispersion of a p38 MAPK inhibitor, particularly beginning about 1 to about 3 days before administration of the cancer immunotherapy or the onset of CRS, thereby achieving a steady-state plasma concentration of the p38 MAPK inhibitor by the time of administration of the cancer immunotherapy or the onset of CRS. Accordingly, the present disclosure particularly encompasses pharmaceutical compositions in which the p38 MAPK inhibitor is incorporated into a powder for preparation of such a solution or dispersion. The powder may be a vacuum-dried or freeze-dried (lyophilized) powder containing the p38 MAPK inhibitor and, optionally, suitable excipients and / or additives. Suitably, the powder may contain at least one p38 MAPK inhibitor in a sufficient amount so that, when configured to form a solution for infusion, the concentration of active agent in the solution is suitable to achieve the required dosage per hour at an infusion rate of about 500 to 3000 mL / 24 hours.

[0203] Sterile injectable solution can be prepared by incorporating the required amount of p38MAPK inhibitor as disclosed herein in a suitable solvent with various other ingredients as listed above, if necessary, followed by filtration sterilization.Generally, dispersion is prepared by incorporating sterilized p38MAPK inhibitor into a sterile vehicle containing a basic dispersion medium and other appropriate ingredients from those listed above.For the preparation of sterile powder for sterile injectable solution, certain preparation methods are vacuum drying and freeze-drying techniques, whereby powder of p38MAPK inhibitor and any additional ingredients is obtained from its previously sterile-filtered solution.

[0204] Injectable formulations can be sterilized, for example, by filtration through a bacterial-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions that can be dissolved or dispersed in sterile water or other sterile injectable medium before use. The injectable compositions can contain about 0.1 to about 5% w / w of a p38 MAPK inhibitor as disclosed herein.

[0205] In some embodiments, provided herein are pharmaceutical compositions for controlled release administration comprising a p38 MAPK inhibitor as disclosed herein and a pharmaceutical excipient suitable for controlled release administration.

[0206] The p38 MAPK inhibitor can be administered by controlled release means or by a delivery device known to those skilled in the art. Such dosage forms can be used to provide sustained or controlled release of the p38 MAPK inhibitor using, for example, hydropropylmethylcellulose, other polymer matrices, gels, permeable membranes, osmotic systems, multilayer coatings, microparticles, liposomes, microspheres, or combinations thereof to provide the desired release profile at various ratios. Suitable controlled-release formulations known to those skilled in the art, including those described herein, can be easily selected for use with the p38 MAPK inhibitors disclosed herein. Thus, the provided pharmaceutical compositions include single-unit dosage forms suitable for oral administration, such as, but not limited to, tablets, capsules, gel caps, and caplets adapted for controlled release.

[0207] All controlled-release pharmaceuticals share a common goal of improving drug therapy over that achieved by their non-controlled counterparts. In some embodiments, the use of controlled-release preparations in medical treatment is characterized by the use of minimal drug substance to cure or control a disease, disorder, or condition in a minimal amount of time. Advantages of controlled-release formulations include prolonging the activity of the drug, reducing the frequency of dosing, and increasing subject compliance. In addition, controlled-release formulations may be used to affect other characteristics, such as the onset time or blood level of the drug, and thus may affect the occurrence of side (e.g., adverse) effects.

[0208] In some embodiments, a controlled-release formulation is designed to initially release a p38 MAPK inhibitor as disclosed herein in an amount that quickly produces the desired therapeutic effect, and then gradually and continuously release another amount of the p38 MAPK inhibitor so as to maintain this level of therapeutic or prophylactic effect over an extended period of time. To maintain this constant level of the compound in the body, the p38 MAPK inhibitor should be released from the dosage form at a rate that replaces the amount of drug being metabolized and excreted from the body. The controlled-release of the p38 MAPK inhibitor can be stimulated by various conditions, including, but not limited to, pH, temperature, enzymes, water, or other physiological conditions or compounds.

[0209] In certain embodiments, the pharmaceutical composition can be administered using intravenous infusion, an implantable osmotic pump, a transdermal patch, or other modes of administration. In one embodiment, a pump can be used. In another embodiment, a polymeric material can be used. In yet another embodiment, a controlled release system can be placed in the subject at an appropriate site, for example, as determined by a person skilled in the art, and thus only a fraction of the total systemic dose is required.

[0210] In a third aspect of the present disclosure, there is provided a method for reducing or reducing the severity of cancer immunotherapy-associated CRS in a human patient, the method comprising administering to the patient a prophylactically effective amount of a p38 MAPK inhibitor prior to the onset of CRS.

[0211] Suitably, the method may comprise administering to the patient a prophylactically effective amount of a p38 MAPK inhibitor defined according to the first aspect of the present disclosure, including the specific active agents described above.

[0212] In a fourth aspect of the present disclosure, there is provided a kit comprising: (i) a pharmaceutical composition as defined according to the second aspect of the present disclosure; and (ii) a leaflet containing instructions for use of the pharmaceutical composition in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient, wherein the p38 MAPK inhibitor is administered before the onset of CRS.

[0213] A preferred mode of administration according to the present disclosure may be, inter alia, intravenous infusion of a solution or dispersion of a p38 MAPK inhibitor, beginning about 1 to about 3 days before administration of the cancer immunotherapy or the onset of CRS, thereby achieving a steady-state plasma concentration of the p38 MAPK inhibitor by the time of administration of the cancer immunotherapy or the onset of CRS. Accordingly, the present disclosure particularly encompasses kits comprising a pharmaceutical composition in which a p38 MAPK inhibitor is incorporated into a powder for the preparation of such a solution or dispersion, and a leaflet containing printed instructions for using the powder according to the methods disclosed herein. The powder may be vacuum-dried or freeze-dried (lyophilized) powder containing the p38 MAPK inhibitor and, optionally, suitable excipients and / or additives.

[0214] Another preferred mode of administration according to the present disclosure may be repeated oral administration, particularly BID, of a p38 MAPK inhibitor, particularly beginning about 1 to about 3 days before administration of the cancer immunotherapy or the onset of CRS, thereby achieving a steady-state plasma concentration of the p38 MAPK inhibitor by the time of administration of the cancer immunotherapy or the onset of CRS. Accordingly, the present disclosure particularly encompasses kits comprising multiple oral dosage forms of a p38 MAPK inhibitor for such administration and a leaflet containing printed instructions for using the dosage forms according to the methods disclosed herein.

[0215] In addition to the leaflet, the kit may contain further printed material, e.g., a discussion of clinical studies, a listing of side effects, etc. Such kits may also include information such as scientific literature references, package inserts, clinical trial results, and / or summaries thereof, that demonstrate or establish the activity and / or benefits of the pharmaceutical composition and / or describe dosage, administration, side effects, drug interactions, or other information useful to medical professionals.

[0216] In some embodiments, a memory aid may be provided with the kit, for example, in the form of numbers next to individual dosage forms (e.g., tablets or capsules as disclosed herein), whereby the numbers correspond to the days of the dosing schedule on which the forms so designated should be taken. Another example of such a memory aid is a calendar printed on a card, for example, as follows: "Week 1, Monday, Tuesday, ... etc. ... Week 2, Monday, Tuesday, ..." etc. Other variations of memory aids are readily apparent. The "daily dose" can be a single dosage form or several dosage forms to be taken on a given day (e.g., doses designated as BID).

[0217] Suitable packaging and additional items for use (e.g., measuring cups for liquid preparation, foil packaging to minimize exposure to air, etc.) are known in the art and may be included in the kit. In other embodiments, the kit may further include a device used to administer the pharmaceutical composition. Examples of such devices include, but are not limited to, syringes, drip bags, patches, and inhalers. The kits described herein may be provided, sold, and / or promoted to medical professionals, including doctors, nurses, pharmacists, prescribers, etc. The kits may also, in some embodiments, be sold directly to consumers.

[0218] An example of such a kit is a so-called blister pack. Blister packs are well known in the packaging industry and are widely used for packaging pharmaceutical unit dosage forms (tablets, capsules, etc.). Blister packs generally consist of a sheet of relatively stiff material covered with a foil, preferably a transparent plastic material. During the packaging process, recesses are formed in the plastic foil. The recesses have the size and shape of the tablets or capsules to be packed. The tablets or capsules are then placed in the recesses, and the sheet of relatively stiff material is sealed to the plastic foil on the side of the foil opposite to the direction in which the recesses were formed. As a result, the tablets or capsules are sealed in the recesses between the plastic foil and the sheet. The strength of the sheet is such that the tablets or capsules can be removed from the blister pack by applying manual pressure to the recesses, thereby forming openings in the sheet at the locations of the recesses. The tablets or capsules can be removed through the openings.

[0219] The kit may further comprise a pharmaceutically acceptable vehicle that can be used to administer the pharmaceutical composition. For example, if the pharmaceutical composition is provided in a solid form that must be reconstituted for parenteral administration, the kit may comprise a sealed container of a suitable vehicle in which the p38 MAPK inhibitor can be dissolved to form a particulate-free, sterile solution suitable for parenteral administration.

[0220] In a fifth aspect of the present disclosure, there is provided use of a p38 MAP kinase inhibitor in the manufacture of a medicament for preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient, wherein the pharmaceutical composition is administered in vivo before the onset of CRS. Suitably, the p38 MAP kinase inhibitor may be defined according to the first aspect of the present disclosure, including the specific active agents described above.

[0221] In a sixth aspect of the present disclosure, there is provided use of a pharmaceutical composition comprising a p38 MAP kinase inhibitor in the manufacture of a medicament for preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient, wherein the pharmaceutical composition is administered in vivo before the onset of CRS. Suitably, the pharmaceutical composition may be defined according to the third aspect of the present disclosure.

[0222] In a seventh aspect of the present disclosure, there is provided a method for reducing cytokine (particularly IL-6) release by monocytes resulting from the administration of cancer immunotherapy to a human patient while maintaining or increasing the anti-cancer cell efficacy of the cancer immunotherapy by administering a therapeutically or prophylactically effective amount of a p38 MAPK inhibitor to the patient. It will be understood that the reduction of cytokine release by monocytes in the method according to the seventh aspect of the present disclosure is carried out in the presence of cancer cells. Suitably, the p38 MAPK inhibitor may be defined according to the first aspect of the present disclosure, including the specific active agents described above.

[0223] Optionally, the method further comprises reducing cytokine (particularly TNFα) release by T cells. Additionally or alternatively, the method comprises reducing cytokine (particularly IL-6) release by endothelial cells. Additionally or alternatively, the method comprises modulating T cell signal 3 and / or signal 4. Additionally or alternatively, the method comprises maintaining or increasing T cell proliferation.

[0224] The method may suitably include prolonging the anti-cancer cell efficacy of T cells. The p38 MAP kinase inhibitor may regulate T cell polarization. The p38 MAP kinase inhibitor may prevent or reduce T cell exhaustion. The p38 MAP kinase inhibitor may reduce one or more of TIM3 and LAG3 in T cells.

[0225] It will be understood that features described in connection with one aspect of the present disclosure may be incorporated in other aspects of the present disclosure.

[0226] Embodiments of the present disclosure will now be described, by way of example only, with reference to the accompanying schematic drawings, in which: [Brief explanation of the drawings]

[0227] [Figure 1] FIG. 1 shows the structure of the CD19 CAR and pseudoCAR vectors used to transfect T293 cells (see Example 1). [Figure 2-1] [Figures 2A-2B] Flow cytometry confirmation of mock and CD19 CAR T cell transduction (see Example 1). [Figure 2-2] [Figures 2A-2B] Flow cytometry confirmation of mock and CD19 CAR T cell transduction (see Example 1). [Figure 3] FIG. 1 shows mCherry fluorescence in stably transfected Raji (cancer) cells (see Example 1). [Figure 4] Figure 1 shows tumor cell clearance of CD19 CAR T and mock CAR T cells at various CD19 CAR T (or mock CAR T) to tumor cell ratios as determined by the ratio of cancer cells after 28 and 48 hours of culture (see Example 1). [Figure 5] Figure 1 shows CD19 CAR T and mock CAR T cell proliferation after 24, 48 and 96 hours of incubation with tumor cells at a 1:1 ratio of CD19 CAR T (or mock CAR T) to tumor cells (see Example 1). [Figure 6] FIG. 1 shows the effect of p38 inhibitors on CAR T cell proliferation in CAR T:tumor cell co-cultures (see Example 2). [Figure 7] Figure 1 shows the effect of p38 inhibition (only at "high" dose) on tumor cell killing by CAR T cells in a 24 hour co-culture at a 1:1 CAR T to cancer cell ratio (see Example 2). [Figure 8][Figures 8A-8B] CAR T cell activation and exhaustion as examined in the experiments described in Example 2. [Figure 9] Figure 1 shows the effect of p38 inhibition on supernatant levels of TNFα from CAR T:tumor cell co-cultures (see Example 2). [Figure 10] FIG. 1 shows the effect of p38 inhibition on supernatant levels of IL-6 from THP-1 (monocytic) cells treated with "sCAR T" for 24 hours (see Example 3). [Figure 11] [Figures 11A-11B] Shows the effect of p38 inhibition on supernatant levels of IL-6 and IL-8 from HUVEC (endothelial) cells treated with "sCAR T" for 24 hours (see Example 3). [Figure 12] [Figures 12A-12C] Figures showing the effect of p38 inhibition on IL-6, ICAM1 and VCAM1 RNA levels in HUVEC cells treated with "sCAR T" for 24 hours (see Example 3). [Figure 13] FIG. 1 is a schematic diagram of the apparatus for co-culture of the experiment described in Example 4. [Figure 14] [Figure 14A-Figure 14B] Shows the effect of p38 inhibition on IL-6 and IL-8 levels in supernatants from HUVEC cells treated with "sCAR T mono" supernatants for 24 hours (see Example 4). [Figure 15] FIG. 1 shows the effect of p38 inhibition on ICAM1 RNA levels in HUVEC cells treated with "sCAR T mono" supernatant for 24 hours (see Example 4). [Figure 16] 1 is a schematic timeline of the experiments described in Example 5. [Figure 17] 17A-17B show the results of IVIS imaging of tumor cell fluorescence in the mouse experiment described in Example 5. [Figure 18] [Figure 18A-Figure 18B] Mouse CRS scores and CAR T cells / ml (see Example 5). [Figure 19]1 is a schematic timeline of the mouse experiment described in Example 6. [Figure 20-1] 20A to 20C show mouse CRS scores in the mouse experiment described in Example 6. [Figure 20-2] 20A to 20C show mouse CRS scores in the mouse experiment described in Example 6. [Figure 21] FIG. 1 shows tumor cell growth during the mouse experiment described in Example 6. [Figure 22] FIG. 1 shows IFNγ levels in the mouse experiments described in Example 6. [Figure 23] FIG. 1 shows TNFα levels in the mouse experiment described in Example 6. [Figure 24] FIG. 1 shows IL-10 levels in the mouse experiments described in Example 6. [Figure 25] FIG. 1 shows IL-6 levels in the mouse experiments described in Example 6. [Figure 26] FIG. 1 shows IL-2 levels during the mouse experiment described in Example 6. [Figure 27] FIG. 1 shows IL-4 levels during the mouse experiment described in Example 6. [Figure 28] FIG. 1 shows IL-8 levels during the mouse experiment described in Example 6. [Figure 29] FIG. 1 shows MIP-1α levels in the mouse experiments described in Example 6. [Figure 30-1] [FIG. 30A-FIG. 30B] Average CD19+ cancer cells per ml on days 9 and 10 during the mouse experiment described in Example 6. [Figure 30-2] [FIGS. 30C-30D] Average hCD45+ cells / μl, hCD3+ cells / μl, and hCD4+ cells / μl on days 9 and 10 (day 9 only for FIG. 30D) during the mouse experiment described in Example 6. DETAILED DESCRIPTION OF THE INVENTION

[0228] While the subject matter of the present disclosure is described and illustrated below with reference to particular embodiments, those skilled in the art will appreciate that the subject matter is susceptible to many different variations not specifically set forth herein. Certain possible variations are described herein by way of example only. [Example]

[0229] The following examples are provided to aid in the understanding of the subject matter of the present disclosure and to aid in the practice of the subject matter. In particular, the examples are intended to aid in understanding the effects that p38 MAP kinase inhibitors may have on cellular responses to cancer immunotherapy, which may be involved in CRS.

[0230] CRS is studied in this example based on CRS induction by CAR T therapy or anti-CD28 antibodies (the latter being a T cell superagonist and therefore providing an excellent model for CRS induced by T cell activity), for which relatively readily available research materials exist. The shared mechanism means that it is reasonable to expect that the effects of p38 MAP kinase inhibitors observed in the context of CRS induced by CAR T cell therapy or CRS induced by T cell responses to anti-CD28 antibodies, as described herein, will extend to other cancer immunotherapies, particularly those that involve the use of adoptive T cells or otherwise engage T cells. Such cancer immunotherapies may activate signaling between T cells, monocytes, and endothelial cells that is observed in CRS induced by CAR T cells or CRS induced by anti-CD28 antibodies and that can be modulated by the p38 MAPK inhibitors of the present disclosure. Additionally or alternatively, the effects of p38 MAPK inhibitors on signal 3 and / or signal 4 on T cells, and therefore on T cell survival, phenotype, and memory, if beneficial in the context of CAR T or anti-CD28 antibodies, can reasonably be expected to benefit other cancer immunotherapies involving T cells.

[0231] As a general note, where applicable in the examples below, statistical analysis was performed using GraphPad Prism version 10.1.2. Two-way ANOVA was used for the data in Figures 4 and 5. For all other figures, one-way ANOVA was fitted to the data and comparisons of interest were made using the Bonferroni test, adjusting for multiple testing using a 5% significance interval. A p-value of less than 0.05 was considered significant and is represented in the relevant figures as follows: * =p<0.05, ** =p<0.01, *** =p<0.001, **** =p<0.0001. Unless otherwise specified on the graph, significance values ​​are compared to sCAR-T or CAR T only controls.

[0232] [Example 1] Optimizing the CAR T cell:cancer cell co-culture ratio The objective of Example 1 is to produce co-cultures of CAR T cells and cancer cells with optimized CAR T cell to cancer cell ratios and co-culture durations for use in subsequent examples. In summary, the optimal ratio and duration is selected as 1:1 for 24 hour co-cultures based on CAR T cell proliferation and cancer cell death relative to controls.

[0233] T cells are engineered to express a CAR with specificity for the B lymphocyte antigen CD19 ("CD19," also known in the art as the CD19 molecule, B lymphocyte surface antigen B4, T cell surface antigen Leu-12, or CVID3). Transduction is confirmed via flow cytometry to demonstrate cell surface CAR expression (throughout this example, flow cytometry is suitably performed using an Agilent NovoCyte 3 cytometer, available from Agilent, 5301 Stevens Creek Blvd, Santa Clara, CA 95051, US).

[0234] The CAR sequence encodes a fusion protein consisting of a leader sequence, a CD19-specific single-chain variable fragment, a CD8α hinge, a CD8α spacer or transmembrane domain, a 4-1BB endodomain, a CD3ζ endodomain, and a T2A tag. An enhanced green fluorescent protein (EGFP) sequence is added to enable detection of CAR expression by fluorescence. The resulting cDNA is subcloned into a replication-deficient lentiviral or retroviral vector. To generate viral particles, triple transfection of the vector, envelope, and gag-pol genes is performed in 293T cells (an immortalized cell line derived from human embryonic kidney cells harboring the SV40 replication origin, available from the American Type Culture Collection). The 293T cells are then grown and transfected. CAR-encoding viral particles are collected from the supernatant and concentrated. The viral titer is measured, and the virus is used to transduce activated T cells derived from human peripheral blood mononuclear cells (PBMCs) collected from the peripheral blood of healthy donors. T cells are expanded from PBMCs in a medium containing IL-7 and IL-15 using treatment with CD3 and CD28 coupled beads.T cells are then incubated in the presence of viral vectors, and CAR expression is confirmed using flow cytometry.

[0235] "Mock" CAR T cells with an irrelevant ectodomain (i.e., no antigen specificity for any of the cells in the culture) are used as a negative control.

[0236] A schematic diagram of the CD19 and pseudo-CAR vectors is shown in Figure 1.

[0237] The cells are washed with phosphate-buffered saline at pH 7.2. To confirm transduction, the co-expressed reporter gene enhanced green fluorescent protein (EGFP) is detected by fluorescence emission in flow cytometry, and CD19-specific CAR expression is confirmed by staining the cells with an anti-CD19 antibody.

[0238] Figures 2A and 2B show the results of flow cytometry and staining of the cells, respectively, confirming successful transduction.

[0239] (The process is repeated as necessary for subsequent experimental purposes. For each new transduction, gene transfer is confirmed using the methods described and recorded in a lab notebook in such a way that the associated batch analysis is associated with each subsequent experiment. A batch in this context refers to CAR T cells derived from the same donor and transduced as a single sample, then subdivided as necessary for further experiments).

[0240] Raji immortalized human B cell line CD19-expressing cancer cells (available from the American Type Culture Collection) were obtained, and stable transfection of the Raji cell line was performed with the mCherry reporter protein to facilitate identification of cancer cells within the co-culture by detection of mCherry protein fluorescence by flow cytometry.

[0241] Figure 3 shows the fluorescence of the mCherry tag in stably transfected Raji cells.

[0242] Next, co-cultures of CAR T cells (or mock CAR T cells for controls) are established with mCherry+CD19-expressing cancer cells in liquid medium with a pH of 7.2, supplemented with nutrients and growth factors including L-arginine, L-glutamine, and fetal bovine serum.

[0243] After incubating the CAR T cells and cancer cells in a humid atmosphere at 37°C and 5% CO for 24-96 hours, cancer cell clearance is measured by flow cytometry, as shown in Table 1. In this setting, cancer cells are detected as mCherry+ events, and CAR T cells are detected as EGFR+ events.

[0244] CO2 levels are managed using a controlled pump system, and the air is filtered in a high-efficiency particulate absorption (HEPA) filtration system. Ratios of CAR T cells (also called effector cells) to tumor cells of 1:2, 1:1, 2:1, and 5:1 are being considered.

[0245] [Table 1]

[0246] CAR T cell proliferation is confirmed by Cell Trace™ Violet staining of the CAR T cells (the stain was added before adding the T cells to the co-culture with the tumor cells). Staining can be observed by flow cytometry after co-culture.

[0247] Thus, Figure 4 shows tumor cell killing of CD19 CAR T (and mock CAR T) cells at various effector to tumor cell ratios, as determined by the ratio of cancer cells in the culture after 24 and 48 hours.

[0248] A 1:1 ratio of CAR T cells to tumor cells was investigated at various time points. Thus, Figure 5 shows CD19 CAR T cell and mock CAR T cell proliferation after 24, 48, and 96 hours of incubation with tumor cells at an effector to tumor ratio of 1:1. (As shown in Figure 5, the decrease in fluorescence is related to the number of rounds of replication each cell or progeny cell underwent during co-culture.)

[0249] A 1:1 ratio of CAR T cells to cancer cells co-cultured for 24 hours is selected for use in subsequent experiments by balancing the following two factors (per Figure 4 and Figure 5): 1. First, the ratio at which T cells proliferate optimally as determined by Cell Trace™ Violet staining. 2. Second, a significantly higher frequency of tumor cell death is evident in the co-cultures of CD19 CAR T cells and tumor compared to the sham CAR T cell and tumor cell co-culture controls.

[0250] A 1:1 ratio of CAR T cells to cancer cells co-cultured for 24 hours is expected to mimic the success of CAR T treatment (or other cancer immunotherapy) in a clinical setting and therefore provide an optimal context for evaluation of CRS induction.

[0251] Supernatants (sCAR) isolated from the co-culture of CAR T cells and tumor cells at a preferred ratio of 1:1, co-cultured for 24 hours, are used for subsequent analyses and experiments.

[0252] The supernatant (termed sCAR or sCAR T) is collected by isolating the medium into a new container and applying a centripetal force of 400 G to sediment the cells and debris. The cell- and debris-free supernatant is collected using a micropipette (for volumes of 0.01-2 ml) or a Pasteur pipette (for volumes greater than 2 ml).

[0253] All experiments using sCAR utilize a negative control of the same 1:1 ratio of mock CAR T cells to tumor cell-derived supernatant (referred to as smCAR, or smCAR T) cultured for 24 hours.

[0254] In Example 3 below, sCAR (or smCAR) is added using a micropipette to in vitro cultures of monocytic cells of the human monocytic cell line THP-1, available from the American Type Culture Collection. The cultures are incubated for approximately 24 hours in a sealed incubator at 37°C with 5% CO2 and a moderately humid atmosphere, after which cytokine release is observed. p38 MAPK activation and cytokine release are confirmed by assessment of the presence of IL-6 in THP-1 cells using an enzyme-linked immunosorbent assay (ELISA; for which kits are suitably available from Thermo Fisher Scientific, Kingfisher Dr, Swindon SN3 5BZ, UK).

[0255] Similarly, and in Example 3 below, sCAR (or smCAR) is added to endothelial (HUVEC) cells available from the American Type Culture Collection, and IL-6 and IL-8 release is then observed using a protocol equivalent to the treatment of THP-1 cells (but with individually optimized conditions, such as the concentration of sCAR used). The proinflammatory cytokines IL-6 and IL-8 are measured using enzyme-linked immunosorbent assay (ELISA), and IL-6, ICAM1, and VCAM1 are measured by quantitative PCR (QPCR, for which kits are suitably available from Thermo Fisher Scientific, Kingfisher Dr, Swindon SN3 5BZ, UK).

[0256] [Example 2] Addition of p38 MAP kinase inhibitor to CAR T cell / cancer cell co-cultures Example 2 examines the effects of several p38 MAPK inhibitors, namely UR-13870, ralimetinib, and acumapimod, on CAR T cells in the described co-cultures of cancer cells and CAR T cells, particularly on characteristics that contribute to the anti-cancer cell efficacy of CAR T cells and on characteristics that contribute to the pathogenesis of CRS, such as cytokine secretion. As shown in Table 2, several concentrations of p38 MAPK inhibitors were tested. UR-13870, ralimetinib, and acumapimod are each highly selective for p38, ensuring no (or minimal) off-target effects.

[0257] [Table 2]

[0258] Add UR-13870, ralimetinib, or acumapimod, respectively, to the culture of CD19+ cancer cells (using a micropipette to transfer the exact volume to achieve the desired final concentration in Table 2).

[0259] CAR T cells are then added to the same cultures 5-10 minutes later. Briefly, the CAR T cell concentration per ml is determined and used to dispense the desired number of CAR T cells into the cultures to achieve the described 1:1 CAR T to cancer cell ratio.

[0260] Gently rotate the co-culture containing CAR T cells and tumor cells to ensure even distribution of cells throughout the vessel. Incubate the resulting co-culture for 24-96 hours in a sealed incubator at 37 °C with 5% CO2 and a moderately humid atmosphere.

[0261] CAR T cell proliferation is confirmed by Cell Trace™ Violet staining observed via flow cytometry, as shown in Figure 6. Figure 6 shows CD19 CAR T (and mock CAR T) cell-induced tumor cell death at various CAR T to tumor cell ratios, as determined by the proportion of cancer cells remaining in the culture after 28 and 48 hours. Advantageously, UR-13870, ralimetinib, and acumapimod each maintain CAR T cell proliferation. These results indicate that p38 MAP kinase inhibitors can modulate post-activation events, particularly those involving signal 4, and affect the phenotype, persistence, and function of T cells after activation.

[0262] Tumor cell death is observed by examining the relative CAR T cell:tumor cell numbers by flow cytometry after 24 hours of co-culture, as shown in Figure 7. Thus, Figure 7 shows the effect of p38 inhibition (high dose only) on tumor cell killing by CAR T cells in 24 hours of co-culture at a 1:1 CAR T to cancer cell ratio. Advantageously, UR-13870, ralimetinib, and acumapimod maintain CAR T cell-induced cancer cell death as determined by the percentage of residual tumor cells in the co-culture.

[0263] T cell markers were observed via flow cytometry, as shown in Figures 8A and 8B. The T cell surface markers T cell immunoglobulin and mucin domain-containing protein 3 (TIM3 / CD366) and lymphocyte activation gene 3 (LAG3 / CD223) are both associated with T cell exhaustion and disease progression during immunotherapy treatment. Advantageously, UR-13870, ralimetinib, and acumapimod all reduced both the number of TIM3+ and LAG3+ CAR T cells. The reduction of TIM3 and LAG3 indicates that UR-13870, ralimetinib, and acumapimod, respectively, regulate T cell polarization (signal 2) by preventing the induction of an exhausted T cell phenotype. For LAG3+, the results for ralimetinib at 5 μM concentration appear to be influenced by experimental failure and may therefore be ignored.

[0264] Cytokine release by T cells was also quantified by TNFα enzyme-based immunosorbent assay of co-culture supernatants, as shown in Figure 9. Ralimetinib and acumapimod reduced TNF-α secretion after treatment. Data on UR-13870 were discarded due to failures in the UR-13870 experimental procedure.

[0265] [Example 3] Addition of p38 MAP kinase inhibitor and sCART to (i) THP-1 monocytes and (ii) HUVEC endothelial cells This experiment investigated the effects of UR-13870, acumapimod, and ralimetinib, respectively, on (i) monocytes and (ii) endothelial cells stimulated with supernatants obtained from the described co-cultures of cancer cells and CAR T cells (sCARs, or smCARs for controls), thus mimicking the in vivo environment of (i) monocytes and (ii) endothelial cells for patients exposed to CAR T therapy (see Example 1 for details).

[0266] (i) Monocytes sCARs (or smCARs) produced as described in Example 1 above are added to monocultures of THP-1 monocytes in the presence of UR-13870, ralimetinib, or acumapimod, respectively, at the concentrations shown in Table 2 above, for 24 hours at 37°C, 5% CO2, and a moderately humidified atmosphere.

[0267] Supernatant levels of IL-6 from THP-1 monocyte monocultures using sCAR (or smCAR) were determined by ELISA. The results are displayed in Figure 10, which show that UR-13870, ralimetinib, and acumapimod each significantly reduced IL-6 secretion by THP-1 monocytes.

[0268] (ii) Endothelial cells sCARs (or smCARs) produced as described in Example 1 above are added to monocultures of HUVEC endothelial cells in the presence of UR-13870, ralimetinib, or acumapimod, respectively, at the concentrations shown in Table 2 above, for 24 hours at 37°C, 5% CO2, and a moderately humid atmosphere.

[0269] The supernatant levels of IL-6 and IL-8 from HUVEC endothelial cell monocultures using sCAR (or smCAR) were determined by ELISA. As shown in Figure 11A, UR-13870, ralimetinib, and acumapimod each significantly reduced IL-6 secretion by HUVEC cells, and as shown in Figure 11B, IL-8 was also reduced.

[0270] Endothelial cell activation was also assessed by QPCR analysis of VCAM1, ICAM1, and IL-6, as shown in Figures 12A-12C. UR-13870, ralimetinib, and acumapimod significantly reduced IL-6 and ICAM1 mRNA levels, respectively, and VCAM1 mRNA levels, although not significantly.

[0271] [Example 4] Effect of supernatants obtained from co-cultures of monocytes with CAR T cells and cancer cells in the presence of p38 MAP kinase inhibitors on endothelial cells This experiment examined the effects of UR-13870, acumapimod, and ralimetinib, respectively, on endothelial cells stimulated with supernatants from in vitro cocultures of cancer cells, CAR T cells, and monocytes, thus providing a better approximation of the in vivo endothelial cell environment in patients exposed to CAR T therapy and the effect of p38 MAPK inhibitors thereon.

[0272] Referring to Figure 13 of the accompanying drawings, a co-culture (100) was established using a standard cell culture transwell dish with a first compartment (101) containing CAR T cells and cancer cells (in a 1:1 ratio), separated from a second compartment (102) containing monocytes by a semi-permeable membrane (103) composed of tissue culture-treated polyethylene terephthalate with a pore size of 0.4 μm. The membrane is permeable to solubilized factors but does not allow cells to migrate from one compartment to the other.

[0273] UR-13870, acumapimod and ralimetinib are each administered to the co-cultures (at concentrations as shown in Table 2 above) following a procedure similar to that described in Example 2 above.

[0274] The co-cultures are incubated for 24 hours at 37°C, 5% CO2, and a moderately humid environment. Upon completion, the transwell inserts are removed and the supernatants are isolated. Cells and debris are removed from the supernatants by subjecting the vessels to a centripetal force of 400 G and gently pipetting the supernatant into a new vessel without disturbing the cell pellet at the bottom of the previous vessel.

[0275] Subsequently, 30 minutes after addition of the p38 MAPK inhibitor, the supernatant obtained from the co-culture, designated sCART-mono, is added using a micropipette to the HUVEC endothelial cell monoculture in the presence of UR-13870, acumapimod, or ralimetinib at the respective concentrations as shown in Table 2. Before adding the p38 inhibitor and sCART-mono, the endothelial cells are incubated overnight at 37°C and 5% CO2 in a moderately humid environment to allow the cells to fully adhere to the tissue culture dish.

[0276] Supernatant levels of IL-6 and IL-8 were determined by ELISA after 24 hours of treatment with sCART-mono and p38 MAPK inhibitors. The results are shown in Figures 14A and 14B. UR-13870, acumapimod, and ralimetinib reduced supernatant IL-6 levels and showed a (non-significant) downward trend in supernatant IL-8 levels.

[0277] Endothelial cell activation is also assessed by QPCR analysis of ICAM1, as shown in Figure 15. Reduction in endothelial cell activation is evident from the reduction in ICAM1 expression in response to treatment with UR-13870, acumapimod, and ralimetinib.

[0278] [Example 5] In vivo (mouse) model of CRS induction using CAR T Example 5 examines the effect of p38MAPK inhibition on CRS induced by CAR T in cancer-bearing mice, as well as the effect of p38MAPK inhibition on the CAR T cells themselves.

[0279] An overview of the model timeline is provided in Figure 16, which begins 5 days before the study and ends on day 10 of the study.

[0280] The timing of the model is designed to evaluate the effect of administering the p38 MAPK inhibitor, UR-13870 (which is highly selective for p38 and therefore has no or minimal off-target effects) prior to CRS onset in the PBMC-humanized NSG-MHC I / II double knockout mice studied.

[0281] Therefore, 5 days before the study, 30 female 6-8 week-old NSG-(KbDb) null (IA) mice were irradiated with 100 cGy. 4 hours later on the same day (5 days before the study), each of them was injected with 0.25 × 10 mAb via the tail vein. 6 Raji-Luc CD19-expressing cancer cells (a Raji wild-type cell line with stable and high expression of luciferase, allowing detection of cancer burden by fluorescence) are injected.

[0282] Clinical observations (including weight monitoring) were initiated for all 30 mice two days prior to the study, and all 30 mice were imaged using in vivo fluorescence imaging (IVIS). For IVIS, mice were intraperitoneally injected with 150 mg / kg D-luciferin. Ten minutes after D-luciferin injection, mice were imaged dorsally and ventrally (autoexposure) using an IVIS Lumina system (available from PerkinElmer, Chalfont Road, Sheer Green, Beaconsfield, HP9 2FX, UK). Regions of interest (ROIs) were drawn on each mouse, their entire body was captured, and total flux (p / s) was reported. IVIS imaging of all 30 mice continued biweekly throughout the study to monitor cancer cell burden. Daily clinical observations, including observations for CRS, were continued throughout the study, and CRS was scored as follows: 0 = normal activity 1 = normal activity, hunched back + / - piloerection 2 = Hunched back and reduced activity, but still moving around cage without continued stimulation. 3 = No movement unless stimulated, moves when touched, but stops moving as soon as hand is removed. 4 = Critically Endangered (unresponsive to touch)

[0283] Twenty-five mice received 5 × 10 immunizations in phosphate-buffered saline on day 0 of the study. 6 Anti-CD19 CAR T cells are injected intraperitoneally.

[0284] As a control, a group of 5 mice ("Group 1") will not receive CAR T cells. Starting one day before the study and ending on day 9 of the study, Group 1 will receive treatment with 0.5% (w:v) HPMC, 0.1% (w:v) Tween 80 in sWFI (vehicle / control), administered at 5 mL / kg BID.

[0285] Twenty-five mice administered with CAR T cells will be divided into groups of 5 per group. Administration of control drug (Humira), vehicle or UR-13870 will be carried out according to the following protocol: Group 2 - 0.5% (w:v) HPMC, 0.1% (w:v) Tween 80 in sWFI (hereafter referred to as "vehicle"), 5 mL / kg BID, starting 1 day prior to the study and ending on day 9 of the study; Group 3 - UR-13870 (formulated in vehicle), 2 mg / kg, twice daily (BID), starting 1 day prior to study and ending on study day 9; Group 4 - UR-13870 (formulated in vehicle), 10 mg / kg, twice daily (BID), starting 1 day prior to study and ending on study day 9; Group 5 - UR-13870 (formulated in vehicle), 25 mg / kg, twice daily (BID), starting 1 day before the study and ending on day 9 of the study, and Group 6 - Humira (formulated in PBS pH 7.2) (plus positive control) 5 mg / kg once on study day 1.

[0286] UR-13870 or vehicle will be administered by subcutaneous injection. The subcutaneous injection site will rotate for each dose (rotating between right flank, left flank, right groin, and left groin). For UR-13870 and vehicle, AM and PM (BID) doses will be scheduled at least 6 hours apart. Humira will be administered by intraperitoneal injection once, approximately 24 hours after CAR T administration.

[0287] One day before the study, the first dose of UR-13870 was administered to groups 2-6, followed by 10 × 10 6 Human peripheral blood mononuclear cells (PBMCs) are humanized by IV dosing.

[0288] On days 2, 6, and 10 of the study, blood is collected from each of the 30 mice in groups 1-6 (50-300 μl blood samples from each mouse each time) for flow cytometry analysis, including analysis of CAR T cells per μl. It should be noted that when it comes to BID dosing groups, blood collection occurs between AM and PM dosing.

[0289] All mice in groups 1-6 are euthanized by CO2 asphyxiation on day 10 of the study.

[0290] CAR T cell therapy remains effective in the presence of UR-13870, as shown by tumor burden (as measured by IVIS) on days 7 and 9. See Figures 17A and 17B (also for Humira).

[0291] In the presence of UR-13870 (and in the presence of the positive control Humira), CAR T cells successfully expanded, and CAR T cell proliferation was successfully maintained (as measured by flow cytometry). See Figure 18A. Indeed, at day 10, high doses of UR-13870 significantly enhanced the number of circulating CAR T cells. See Figure 18A.

[0292] CRS scores were mild throughout the experiment (as indicated by a CRS score of 1 even in Group 2), and therefore, for this model, the anti-inflammatory effects of neither UR-13870 nor Humira could be parameterized by CRS scoring of their effects on cytokine levels in peripheral blood. See Figure 18B.

[0293] [Example 6] In vivo (mouse) model using anti-CD28 antibody for CRS induction Example 6 examines the effect of p38 MAPK inhibition on CRS induced by anti-CD28 antibody (a T cell superagonist) activation of naive T cells in cancer-bearing mice, and on the T cells themselves.

[0294] An overview of the model timeline is provided in Figure 19, which begins on study day 0 and ends on study day 10. It evaluates the effect of administering the p38 MAPK inhibitor, UR-13870 (which is highly selective for p38 and therefore has no or minimal off-target effects) on anti-CD28 toxicity in PBMC-humanized NSG-MHC I / II double knockout mice when the p38 MAPK inhibitor is administered prior to activation of natural T cells with an anti-CD28 antibody. Thus, it models the effect of administering a p38 MAPK inhibitor prior to the onset of CRS according to the present disclosure.

[0295] Anti-CD28 antibodies act as T cell superagonists (i.e., potently activate T cells), leading to T cell-mediated tumor cell death with the resulting rapid release of cytokines and knock-on effects on monocytes and endothelial cells, thus modeling CRS induced by many different types of T cell-mediated cancer immunotherapies.

[0296] Therefore, on study day 0, 30 female 6-8 week old NSG-(KbDb) null (IA) null mice are irradiated with 100 cGy. Approximately 4 hours later on the same day (study day 0), all mice are irradiated with 15 x 10 6 Human peripheral blood mononuclear cells (PBMCs) are humanized by IV dosing.

[0297] On study day 5, all mice received 0.25 × 10 6 Raji-Luc CD19-expressing cancer cells (a Raji wild-type cell line with stable and high expression of luciferase, allowing detection of tumor burden by fluorescence) are administered intravenously. Approximately 4 hours later, mice are imaged using in vivo fluorescence imaging (IVIS). For IVIS, mice are IP injected with 150 mg / kg D-luciferin. Ten minutes after D-luciferin injection, mice are imaged dorsally and ventrally (autoexposure) using an IVIS Lumina system (available from PerkinElmer, Chalfont Road, Sheer Green, Beaconsfield, HP9 2FX, UK). Regions of interest (ROIs) are drawn on each mouse, their entire body is captured, and total flux (p / s) is reported. Tumor burden continues to be monitored by IVIS twice weekly starting on study day 5 until the end of the study. Daily clinical observations, including observations for CRS, will continue throughout the study, and CRS will be scored as follows: 0 = normal activity 1 = normal activity, hunched back + / - piloerection 2 = Hunched back and reduced activity, but still moving around cage without continued stimulation. 3 = No movement unless stimulated, moves when touched, but stops moving as soon as hand is removed. 4 = Critically Endangered (unresponsive to touch)

[0298] On day 6 of the study, 25 of the 30 mice are treated with 1 mg / kg anti-CD28.

[0299] As a control, the remaining group of 5 mice ("Group 1") receives no anti-CD28. Beginning on study day 4 and ending on study day 10, Group 1 receives treatment with 0.5% (w:v) HPMC, 0.1% (w:v) Tween 80 in sWFI (vehicle / control), administered at 5 mL / kg BID.

[0300] The 25 mice treated with anti-CD28 are divided into groups of 5 mice per group. Administration of control drug (Humira), vehicle or UR-13870 is carried out according to the following protocol: Group 2 - Vehicle only, BID, starting on Study Day 4 and ending on Study Day 10; Group 3 - UR-13870 (formulated in vehicle), 2 mg / kg, twice daily (BID), starting on Study Day 4 and ending on Study Day 10; Group 4 - UR-13870 (formulated in vehicle), 10 mg / kg, twice daily (BID), starting on Study Day 4 and ending on Study Day 10; Group 5 - UR-13870 (formulated in vehicle), 25 mg / kg, twice daily (BID), starting on Study Day 4 and ending on Study Day 10, and Group 6 - Humira (formulated in PBS) (plus positive control) 5 mg / kg once daily starting on study day 4 and ending on study day 10.

[0301] Dosing of UR-13870 or vehicle will be by subcutaneous injection. The subcutaneous injection site will rotate for each dose (rotating between right flank, left flank, right groin, and left groin). For UR-13870 and vehicle, AM and PM (BID) doses will be scheduled at least 6 hours apart. Dosing of Humira will be by intraperitoneal injection.

[0302] On study days 6, 9, and 10, blood will be collected from each of the 30 mice in groups 1-6 (50-200 μl blood sample from each mouse at each time) for flow cytometry analysis, including analysis of CD19+ cancer cells per ml, and cytokine measurements. It should be noted that when it comes to BID dosing groups, blood collection will occur between AM and PM dosing.

[0303] All mice in groups 1-6 are euthanized by CO2 asphyxiation on day 10 of the study.

[0304] UR-13870 significantly reduces CRS scores (similar to the positive control, Humira). Scores for the entire study are shown in Figure 20A, and scores at days 9 and 10 are shown in Figures 20B and 20C, respectively.

[0305] All experimental groups demonstrated consistent tumor burden across measurements taken from day 5 to day 7 (intermediate dosing regimens with UR-13870 and Humira), indicating that UR-13870 does not increase tumor cell proliferation and maintains T cell-mediated cancer cell death (as does Humira). See Figure 21. This suggests that p38 MAP kinase inhibitors are effective in preventing CRS in the presence of cancer cells without unduly attenuating the anti-cancer cell efficacy of T cells.

[0306] Proinflammatory cytokines are measured from blood serum samples according to the manufacturer's guidelines using Luminex cytokine assay (Millipore Sigma Cat# HCYTA-60k, Human IFNγ, TNF, IL-10, IL-6, IL-4, IL-2, MIP-1α and IL-8) and analyzed on a BioRad BioPlex200 Luminex plate reader (kits available from Sigma Aldrich / Merck Life Science UK Limited, The Old Brickyard, New Rd, Gillingham, SP8 4XT, UK).

[0307] T cell phenotype was monitored from blood samples using flow cytometry to measure cytotoxicity and polarization (by monitoring hCD45, hCD3, and hCD4). Peak cytokines were observed on day 9 for all cytokines tested, except for IL-8, which continued to rise on day 10.

[0308] UR-13870 (and Humira) reduced key cytokines, including IFNγ (Figure 22), TNFα (Figure 23), IL-10 (Figure 24), IL-6 (Figure 25), IL-2 (Figure 26), IL-4 (Figure 27), IL-8 (Figure 28), and MIP-1α (Figure 29), which encompasses cytokines released by all T cells, monocytes, and endothelial cells.

[0309] Counts of CD19+ cancer cells per ml supported the observation that neither UR-13870 nor Humira increased tumor cell proliferation. Furthermore, there was a downward trend in mean CD19+ cancer cells per ml after treatment with UR-13870 compared to CD28 stimulation alone at days 9 and 10 (particularly day 10; a similar trend was observed for Humira only at day 10) (Figure 30A).

[0310] Neither UR-13870 nor Humira significantly affected hCD45+ cells / μl, hCD45+hCD3+ cells / μl, or hCD45+CD3+hCD4+ cells / μl (Figures 30B-30D; using serial gates on the data in that order), suggesting that p38 MAP kinase inhibition may increase the anticancer efficacy of T cells.

[0311] Due to the acute effects of the CD28 antibody and tumor burden, one animal in Group 2 was euthanized on Day 8, and one animal each from Groups 2, 3, and 6 was euthanized on Day 9.

[0312] The various effects on T cells in the presence of cancer cells, as shown in Examples 2-6 (including in vivo administration of a p38 MAP kinase inhibitor initiated prior to administration of an anti-CD28 antibody to mice, modeling administration prior to the onset of CRS in humans), can be summarized in the non-limiting Table 3 below:

[0313] [Table 3]

[0314] Meanwhile, the beneficial effects on monocytes and endothelial cells that may help reduce or prevent CRS can be summarized in the non-limiting Table 4 below:

[0315] [Table 4]

[0316] [Example 7] Administration to patients About 4 days to about 2 hours prior to administration of a cancer immunotherapy (such as, for example, adoptive transfer of CAR T cells) to a patient in need thereof, the patient begins an oral dosing regimen of about 5 mg BID to about 1000 mg BID of a p38 MAPK inhibitor, such as UR-13870 (a compound of Formula II), for example, about 70 mg BID or about 150 mg BID of UR-13870 (a compound of Formula II) (depending on the age, sex, weight, condition, general health, and medical history of the patient being treated).

[0317] For up to about 15 days after administration of the cancer immunotherapy (which is administered in a single dose, e.g., adoptive transfer of CAR T cells), the patient continues an oral BID dosing regimen of a p38 MAPK inhibitor, such as UR-13870. For example, an oral dose containing about 70 mg or about 150 mg of UR-13870 is administered BID.

[0318] Throughout, patients are monitored by medical personnel for fever, hypotension, and hypoxia. Patients may be provided with supportive care, including analgesics and / or antipyretics, as needed. CRS grading during monitoring follows the American Society for Transplantation and Cellular Therapy Consensus Guidelines (2019), as listed in Table 5.

[0319] [Table 5]

[0320] Prevention of signs or symptoms of CAR T-cell therapy-associated CRS in a patient, or reduction in their severity, may be confirmed by observing attenuation or prevention of one or more of the symptoms and signs listed in Table 5. Reduction or avoidance of fever may be observed. A delay in the onset of fever may be observed (e.g., by 1, 2, 3, 4, or 5 days). Maintenance of a rectal, ear, or temporal artery temperature below about 38°C may be observed, such as for a period of 1, 2, 3, or more weeks after administration of CAR T-cell therapy. Hypotension, hypoxia, and / or organ dysfunction may be avoided, or at least attenuated. Death may also be avoided. The period during which the above-described desired effects are observed may last for 1, 2, 3, or longer weeks. It will be understood that while CRS-induced patient fatigue may be attenuated or avoided, there is no guarantee that patient fatigue induced by other causes (e.g., the underlying cancer) will be attenuated or avoided.

[0321] Where the foregoing description refers to features or limitations that have equivalents that are known, obvious, or foreseeable to those skilled in the art in light of the present disclosure, such equivalents are incorporated herein as if specifically set forth. Reference should be made primarily to the claims to determine the scope of the presently disclosed subject matter. The scope of protection sought by this application further encompasses any such equivalents. Those skilled in the art will also understand that features or limitations of the disclosed subject matter described as being preferred, appropriate, advantageous, convenient, or the like may be optional and may not limit the scope of the independent claim(s) or the protection sought, unless expressly stated otherwise. Furthermore, it will be understood that such optional features or limitations, while potentially beneficial in some implementations of the disclosed subject matter, may be undesirable and therefore may not be present or omitted in other implementations. [Explanation of symbols]

[0322] 100 co-cultures 101 First Compartment 102 Second Compartment 103 Semi-permeable membrane

Claims

1. A p38 MAP kinase inhibitor for use in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient, wherein the p38 MAPK inhibitor is administered before the onset of CRS.

2. 2. The p38 MAP kinase inhibitor for use according to claim 1, wherein the p38 MAP kinase inhibitor prevents or reduces the severity of the signs or symptoms of CRS while maintaining the anti-cancer cell efficacy of the cancer immunotherapy.

3. The p38 MAP kinase inhibitor for use according to claim 2, wherein the maintenance of anti-cancer cell efficacy of the cancer immunotherapy is or comprises the maintenance of anti-cancer cell efficacy of T cells in the presence of cancer cells.

4. 4. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 3, wherein the p38 MAP kinase inhibitor increases the anti-cancer cell efficacy of the cancer immunotherapy.

5. The p38 MAP kinase inhibitor for use according to claim 4, wherein increasing the anti-cancer cell efficacy of the cancer immunotherapy is or comprises increasing the anti-cancer cell efficacy of T cells.

6. 6. The p38 MAP kinase inhibitor for use according to claim 4 or 5, wherein the p38 MAP kinase inhibitor increases the anti-cancer cell efficacy of the cancer immunotherapy in the presence of cancer cells.

7. The p38 MAP kinase inhibitor for use according to claim 6, wherein increasing the anti-cancer cell efficacy of the cancer immunotherapy in the presence of cancer cells is or comprises increasing the anti-cancer cell efficacy of T cells in the presence of cancer cells.

8. 8. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 7, wherein the p38 MAP kinase inhibitor prolongs the anti-cancer cell efficacy of T cells.

9. 9. A p38 MAP kinase inhibitor for use according to any one of claims 1 to 8, wherein said p38 MAP kinase inhibitor modulates T cell polarization and / or prevents or reduces T cell exhaustion.

10. 10. The p38 MAP kinase inhibitor for use according to claim 8 or 9, wherein the p38 MAP kinase inhibitor reduces one or more of TIM3 and LAG3 in T cells.

11. 11. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 10, wherein preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated CRS in a human patient is or includes preventing or reducing the severity of fever.

12. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 11, wherein the cancer immunotherapy is T-cell engaging therapy (such as BiTE therapy, therapy using another bispecific antibody, CiTE therapy, SMITe therapy or TriKE therapy), TIL therapy, CAR NK cell therapy, cancer vaccine, T-cell checkpoint modulator therapy, or CAR T-cell therapy.

13. The p38 MAP kinase inhibitor for use according to claim 12, wherein the cancer immunotherapy is CART therapy.

14. The p38 MAP kinase inhibitor for use according to claim 12, wherein the cancer immunotherapy is BiTE therapy or therapy using another bispecific antibody.

15. 15. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 14, wherein the p38 MAP kinase inhibitor inhibits the release of pro-inflammatory mediators from monocytes.

16. 16. The p38 MAP kinase inhibitor for use according to claim 15, wherein the pro-inflammatory mediator comprises one or more of IFNγ, IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12, IL-18, CCL2, CCL5, CXCL10, MCP-1, MIP-1β, GM-CSF, VEGF and TNFα.

17. 17. The p38 MAP kinase inhibitor for use according to claim 16, wherein the pro-inflammatory mediator comprises or is IL-6.

18. 18. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 17, wherein the p38 MAP kinase inhibitor inhibits the release of pro-inflammatory mediators from endothelial cells.

19. 19. The p38 MAP kinase inhibitor for use according to claim 18, wherein the pro-inflammatory mediators comprise one or more of IL-1β, IL-2, IL-6, IL-8, IL-10, CCL2, CCL5, CXCL10, IL-18, TNFα, MCP-1, MIP-1β, IP10 and GM-CSF.

20. 20. The p38 MAP kinase inhibitor for use according to claim 19, wherein the pro-inflammatory mediator comprises or is IL-6.

21. 21. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 20, wherein said p38 MAP kinase inhibitor inhibits the upregulation of E-selectin, VCAM1 and / or ICAM1 on the surface of endothelial cells.

22. 22. The p38 MAP kinase inhibitor for use according to claim 21, wherein the p38 MAP kinase inhibitor inhibits the upregulation of ICAM1 on the surface of endothelial cells.

23. 23. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 22, wherein the p38 MAP kinase inhibitor is an inhibitor of p38α MAP kinase and / or p38β MAP kinase.

24. The p38 MAP kinase inhibitor is represented by Formula I: 【Chemistry 1】 wherein R is one or more halo, NR １ R ２ or C optionally substituted by hydroxyl １～３ alkyl, and R １ and R ２ is independently H, halo, or C optionally substituted by one or more F. １～３ alkyl) 24. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 23, which is of the formula: or a pharmaceutically acceptable salt or solvate thereof.

25. The p38 MAP kinase inhibitor is represented by Formula II: 【Chemistry 2】 25. The p38 MAP kinase inhibitor for use according to claim 24, which is of the formula:

26. 26. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 25, wherein the p38 MAPK inhibitor is administered prior to the administration of the cancer immunotherapy.

27. 27. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 26, wherein the p38 MAPK inhibitor is administered starting from about 4 days to about 2 hours before administration of the cancer immunotherapy, or from about 1 day to about 3 days before the onset of CRS.

28. 28. The p38 MAP kinase inhibitor for use according to claim 27, wherein a steady state plasma concentration of the p38 MAPK inhibitor is reached by the time of administration of the cancer immunotherapy or by the time of onset of CRS.

29. 29. The p38 MAPK inhibitor for use according to any one of claims 1 to 28, wherein the p38 MAPK inhibitor is administered acutely over a period of days or weeks, for example, the p38 MAPK inhibitor is administered over a period of about 7 days to about 28 days.

30. 30. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 29, wherein said p38 MAPK inhibitor prevents an infusion-related hypersensitivity reaction or reduces the severity of an infusion-related hypersensitivity reaction.

31. 31. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 30, wherein said p38 MAPK inhibitor is administered orally BID.

32. 32. The p38 MAP kinase inhibitor for use according to claim 31, wherein the p38 MAP kinase inhibitor is administered at about 5 mg BID to about 1000 mg BID.

33. 33. The p38 MAP kinase inhibitor for use according to any one of claims 1 to 32, wherein the p38 MAP kinase inhibitor is administered starting from about 4 days to about 2 hours before administration of the cancer immunotherapy and until an endpoint of about 15 days after administration of the cancer immunotherapy.

34. 34. The p38 MAP kinase inhibitor for use according to claim 32 or 33, wherein the p38 MAP kinase inhibitor is of formula II:

35. A p38 MAP kinase inhibitor of Formula II, or a pharmaceutically acceptable salt or solvate thereof, for use in the prevention or treatment of cancer immunotherapy-associated CRS in a human patient.

36. 36. The p38 MAP kinase inhibitor of formula II, salt or solvate for use according to claim 35, wherein said p38 MAP kinase inhibitor of formula II, salt or solvate is administered orally BID.

37. 37. The p38 MAP kinase inhibitor, salt or solvate of formula II for use according to claim 36, wherein said p38 MAP kinase inhibitor, salt or solvate of formula II is administered at 5 to 1000 mg BID.

38. A pharmaceutical composition comprising a p38 MAP kinase inhibitor or a pharmaceutically acceptable salt or solvate thereof for use in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient, wherein the pharmaceutical composition is administered in vivo before the onset of CRS.

39. 39. The pharmaceutical composition for use according to claim 38, wherein the p38 MAP kinase inhibitor is one described in any one of claims 2 to 37.

40. A method for preventing cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient, comprising administering to the patient a therapeutically or prophylactically effective amount of a p38 MAPK inhibitor or a pharmaceutically acceptable salt or solvate thereof prior to the onset of CRS.

41. 41. The method of claim 40, wherein the p38 MAP kinase inhibitor is one described in any one of claims 2 to 37.

42. (i) a pharmaceutical composition according to claim 38 or 39, and (ii) a leaflet containing instructions for using the pharmaceutical composition in preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient. wherein the p38 MAPK inhibitor is administered before the onset of CRS.

43. Use of a p38 MAP kinase inhibitor in the manufacture of a medicament for preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient, wherein the pharmaceutical composition is administered in vivo before the onset of CRS.

44. 44. The use of claim 43, wherein the p38 MAPK inhibitor is one of claims 2 to 37.

45. Use of a pharmaceutical composition comprising a p38 MAP kinase inhibitor in the manufacture of a medicament for preventing or reducing the severity of signs or symptoms of cancer immunotherapy-associated cytokine release syndrome (CRS) in a human patient, wherein the pharmaceutical composition is administered in vivo before the onset of CRS.

46. 46. ​​The use according to claim 45, wherein the pharmaceutical composition is as defined in claim 38 or 39.

47. A method for maintaining or increasing the anti-cancer cell efficacy of a cancer immunotherapy while reducing cytokine release by monocytes resulting from the administration of the immunotherapy to a human patient by administering a therapeutically or prophylactically effective amount of a p38 MAPK inhibitor to the human patient.

48. 48. The method of claim 47, comprising reducing IL-6 release by monocytes.

49. 49. The method of claim 47 or 48, further comprising reducing cytokine release by T cells.

50. 50. The method of any one of claims 47 to 49, further comprising reducing cytokine release by endothelial cells.

51. 51. The method of claim 50, comprising reducing IL-6 release by endothelial cells.

52. 52. The method of any one of claims 47 to 51, further comprising maintaining or increasing T cell proliferation.

53. 53. The method of any one of claims 47 to 52, further comprising prolonging the anti-cancer cell efficacy of T cells.

54. 54. The method of any one of claims 47 to 53, further comprising modulating T cell polarization and / or preventing or reducing T cell exhaustion.

55. 55. The method of claim 53 or 54, wherein the p38 MAP kinase inhibitor reduces one or more of TIM3 and LAG3 in T cells.

56. 56. The method of any one of claims 47 to 55, wherein the p38 MAP kinase inhibitor is one described in any one of claims 2 to 37.

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