Combination therapy for cancer

Abstract

The present disclosure relates to methods of treating cancer in a subject, of reducing cancer cell proliferation and / or tumor growth in a subject as well as preventing cancer cells from recovering from chemotherapeutic injury in a subject, by administering a fatty acid metabolism inhibitor, and an adenosine monophosphate-activated protein kinase (AMPK) activating compound, with or without a chemotherapeutic agent.

Description

[0001] COMBINATION THERAPY FOR CANCER CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of priority under 35 U.S.C. § 119(e) to U.S. Provisional Application No. 63 / 613,618, filed December 21, 2023, and U.S. Provisional Application No. 63 / 720,988, filed November 15, 2024, each of which is incorporated herein by reference in its entirety. BACKGROUND

[0002] Many cancers have long been thought to primarily metabolize glucose for energy production—a phenomenon known as the Warburg Effect, after the classic studies of Otto Warburg in the early twentieth century. Yet cancer cells also utilize other substrates, such as fatty acids, to produce raw materials for cellular maintenance and energetic currency to accomplish cellular tasks. The contribution of these substrates is increasingly appreciated in the context of glioma, the most common form of primary malignant brain tumor in the adult population (Lin, H., et al. “Fatty acid oxidation is required for the respiration and proliferation of malignant glioma cells”; Neuro Oncology. 2017; 19(1):43-54; Strickland and Stoll. “Metabolic Reprogramming in Glioma”; Front Cell Dev Biol, 2017; 5(43):1-32). Recent research has also shown fatty acid metabolism to play critical roles in breast cancer (Camarda, R., et al. “Inhibition of fatty acid oxidation as a therapy for MYC-overexpressing triple- negative breast cancer”; Nat Med 2016; 22(4):427-432) and prostate cancer (Schlaepfer, I., et al. “Lipid Catabolism via CPT1 as a Therapeutic Target for Prostate Cancer”; Mol Cancer Therapeutics, 2014; 13(10):2361-2371), bladder cancer (Cheng, S., et al. “Fatty acid oxidation inhibitor etomoxir suppresses tumor progression and induces cell cycle arrest via PPARγ- mediated pathway in bladder cancer”; Clinical Science, 2019; 133 1745–1758), pancreatic cancer (Mascaraque, M., et al. “Fatty acid oxidation is critical for the tumorigenic potential and chemoresistance of pancreatic cancer stem cells” Journal of Translational Medicine, 2024; 22:797), lung cancer (Yu, L., et al. “Integrated omics and gene expression analysis identifies the loss of metabolite-metabolite correlations in small cell lung cancer” Onco Targets Ther, 2018; 11:3919-3929), and skin cancer (Aloia, A., et al. “A fatty acid oxidation-dependent metabolic shift regulates the adaptation of BRAF-mutated melanoma to MAPK inhibitors” Clin Cancer Res, 2019; 25:6852–67).

[0003] The rate-limiting step in fatty acid oxidation is completed by the enzyme carnitine palmitoyl transferase I (CPT1), which brings fatty acids (converted into acyl-carnitine molecules) into the mitochondria to be metabolized for energy production. A natural genetic variant of CPT1 is common in Inuit people, with a frequency of 0.81 (Greenberg, C.R. et al. “The paradox of the carnitine palmitoyl transferase type Ia P479L variant in Canadian Aboriginal populations” Mol Gen Metab, 2009; 96:201-207). This allele corresponds to a notable decrease in CPT1 activity, similar to CPT1 deficiency. Notably, this population has a dramatically reduced incidence of certain cancers, including the aforementioned brain cancer, bladder cancer, breast cancer, prostate cancer, and melanoma (Friborg, J.T. and Melbye, M. “Cancer patterns in Inuit populations” Lancet Oncol, 2008; 9:892-900).

[0004] Glioma is the most common form of primary malignant brain tumor in adults; this broad term encompasses both astrocytomas and oligodendrogliomas (Ostrom, Q., et al. “CBTRUS Statical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2012-2016”; Neuro Oncology. 2019; 21(5):v1-v100). Higher-grade gliomas typically have wild-type Isocitrate Dehydrogenase 1 and 2 (IDH1 and IDH2) genes, while lower-grade gliomas tend to carry gain-of-function mutations in these critical genes, so gliomas can be diagnosed and graded not only with histopathological assays but also with genetic analysis.

[0005] In approximately 50% of cases, glioma manifests as a high-grade tumor called glioblastoma (GBM). GBMs are highly malignant and invasive cancers of the central nervous system, with a median patient survival of only twelve months from diagnosis, while lower- grade gliomas tend to increase in malignancy over time, with associated increases in mortality (Ohgaki, H. and Kleihues. P. “Population-based studies on incidence, survival rates, and genetic alterations in astrocytic and oligodendroglial gliomas”; (2005) J. Neuropathol. Exp. Neurol.64(6):479-489). With an incidence of approximately 3.2 per 100,000 people per year, around 10,560 individuals are diagnosed with GBM each year in the United States; thousands more travel to the United States annually for expert medical care. Current treatments – including surgical resection, radiotherapy, and chemotherapy – only provide modest benefit to patients, with an increased overall survival time of 14.6 months rather than 12.3 months with surgery and radiotherapy alone (Stupp, R., et al. “Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma”; 2005; N. Engl. J. Med.352(10):987-996).

[0006] New therapies are desperately needed to treat these primary malignant brain tumors. Hundreds of drugs have been designed to target oncogenic pathways in these cancers, or repurposed after successes with other cancers, but nearly all of these options have failed at clinical trial (Stupp, R. et al. “Drug development for glioma: are we repeating the same mistake?”; 2019; Lancet Oncol.20(1):10-12.). After seventy long years of research in this field, only radiotherapy (e.g. gamma knife) and a single chemotherapeutic agent (temozolomide) have been shown to significantly prolong survival in glioma patients (Stupp, R., et al. “Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma”; 2005; N. Engl. J. Med. 352(10):987-996). With a dire prognosis and few treatment options, there is a great need to develop new therapeutic approaches for this patient population. Similar challenges exist for the treatment of ER-PR-HER2- (so-called “triple-negative”) breast cancer, androgen- insensitive prostate cancer, bladder cancer, pancreatic cancer, small-cell lung cancer, and melanoma. All of these treatment-resistant cancers have shown limited benefits with chemotherapies and tend to recur with high rates of malignant growth under current standards of care. SUMMARY

[0007] The present disclosure provides methods of treating the above cancers, among others, by administering a multi-modal therapy comprising a fatty acid metabolism inhibitor (or any pharmaceutically acceptable salt or ester thereof), an AMPK activating compound, and optionally a chemotherapeutic agent. Other methods include the use of the disclosed multi- modal therapy to reduce the proliferation of cancerous cells and / or to inhibit tumor growth in a subject, and methods of preventing cancer cells from adjusting to, or “recovering from,” chemotherapy. All such methods involve the administration of the disclosed multi-modal therapy. Generally speaking, the multi-modal therapy is a novel drug combination, administered as one or more pharmaceutical compositions, and kits that include the multi- modal therapy, as well as instructions for administration and / or use.

[0008] One embodiment provided herein, is a method of treating cancer in a subject, in need thereof, comprising administering to the subject, a therapeutically effective amount of a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and a therapeutically effective amount of an adenosine monophosphate-activated protein kinase (AMPK) activating compound or pharmaceutically acceptable salt thereof.

[0009] Another embodiment provided herein, is a method of reducing cancer cell proliferation and / or tumor growth in a subject in need thereof, comprising administering to the subject, a therapeutically effective amount of a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and a therapeutically effective amount of an AMPK activating compound or pharmaceutically acceptable salt thereof.

[0010] Still another embodiment provided herein, is a method of preventing cancer cells from recovering from chemotherapeutic injury, in a subject in need thereof, comprising administering to the subject, a therapeutically effective amount of a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and a therapeutically effective amount of an AMPK activating compound or pharmaceutically acceptable salt thereof.

[0011] In one aspect of any of the embodiments related to a method or use described herein, the cancer is a solid tumor.

[0012] In one aspect of any of the embodiments related to a method or use described herein, the solid tumor is a primary malignant brain tumor.

[0013] In one aspect of any of the embodiments related to a method or use described herein, the primary malignant brain tumor is a glioma.

[0014] In another aspect of any of the embodiments related to a method or use described herein, the cancer is selected from the group consisting of brain cancer, bladder cancer, lung cancer, pancreatic cancer, melanoma, breast cancer and prostate cancer.

[0015] In still another aspect of any of the embodiments related to a method or use described herein, the cancer is resistant to chemotherapy treatment.

[0016] In another aspect of any of the embodiments related to a method or use described herein, the fatty acid metabolism inhibitor is selected from the group consisting of etomoxir, perhexiline, oxfenicine, ranolazine, trimetazidine and pharmaceutically acceptable salts or esters thereof.

[0017] In still another aspect of any of the embodiments related to a method or use described herein, the fatty acid metabolism inhibitor is etomoxir, trimetazidine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 8 mg to about 400 mg per day. In one aspect, the fatty acid metabolism inhibitor is etomoxir and is in the R-enantiomeric form.

[0018] In another aspect of any of the embodiments related to a method or use described herein, the fatty acid metabolism inhibitor is perhexiline, oxfenicine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 10 mg to about 2000 mg per day.

[0019] In still another aspect of any of the embodiments related to a method or use described herein, the fatty acid metabolism inhibitor is ranolazine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 150 mg to about 3000 mg per day.

[0020] In one aspect of any of the embodiments related to a method or use described herein, the fatty acid metabolism inhibitor or a pharmaceutically acceptable salt or ester thereof is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intranasal delivery, intravenous delivery, intrathecal injection, intracranial placement and combinations thereof.

[0021] In one aspect of any of the embodiments related to a method or use described herein, the AMPK activating compound is selected from the group consisting of a biguanide, a polyphenol, and a thiazolidinedione.

[0022] In one aspect of any of the embodiments related to a method or use described herein, the biguanide is metformin or a pharmaceutically acceptable salt thereof.

[0023] In another aspect of any of the embodiments related to a method or use described herein, the polyphenol is selected from the group consisting of resveratrol, quercetin, genestein, epigallocatechin-3-gallate, berberine, and curcumin.

[0024] In another aspect of any of the embodiments related to a method or use described herein, the thiazolidinedione is selected from the group consisting of troglitazone, pioglitazone, and rosiglitazone.

[0025] In one aspect of any of the embodiments related to a method or use described herein, the AMPK activating compound is metformin or a pharmaceutically acceptable salt thereof and is administered to the subject in a dose amount of about 250 mg to 2500 mg per day.

[0026] In one aspect of any of the embodiments related to a method or use described herein, the AMPK activating compound or a pharmaceutically acceptable salt thereof is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intranasal delivery, intravenous delivery, intrathecal injection, intracranial placement and combinations thereof.

[0027] In one aspect of any of the embodiments related to a method or use described herein, the method further comprises administering a chemotherapeutic agent to the subject.

[0028] In another aspect of any of the embodiments related to a method or use described herein, the chemotherapeutic agent is an imidazotetrazinone.

[0029] In another aspect of any of the embodiments related to a method or use described herein, the imidazotetrazinone is temozolomide (TMZ) or an analog thereof.

[0030] In another aspect of any of the embodiments related to a method or use described herein, the chemotherapeutic agent is selected from the group consisting of procarbazine, lomustine, and vincristine.

[0031] In another aspect of any of the embodiments related to a method or use described herein, the chemotherapeutic agent is an alkylating-like agent selected from the group consisting of cisplatin, carboplatin, loboplatin, oxaliplatin, and nedaplatin.

[0032] In one aspect of any of the embodiments related to a method or use described herein, the chemotherapeutic agent is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intracranial delivery and intravenous delivery.

[0033] In one aspect of any of the embodiments related to a method or use described herein, the chemotherapeutic agent is administered orally.

[0034] In another aspect of any of the embodiments related to a method or use described herein, the chemotherapeutic agent is administered to the subject in an initial (bolus) dose followed by a maintenance dose.

[0035] In one aspect of any of the embodiments related to a method or use described herein, the fatty acid metabolism inhibitor, and the AMPK activating compound are co-administered as separate dosage forms simultaneously, sequentially in any order, or separately.

[0036] In one aspect of any of the embodiments related to a method or use described herein, the fatty acid metabolism inhibitor and the AMPK activating compound are administered as a single composition. In one aspect, the single composition is in the form of a tablet or oral suspension or solution. In one aspect, the tablet is in the form of a bilayer tablet, wherein one layer of the bilayer comprises the fatty acid metabolism inhibitor and the other layer comprise the AMPK activating compound. In one aspect, the fatty acid metabolism inhibitor, the AMPK activating compound and the chemotherapeutic agent are co-administered as separate dosage forms simultaneously, sequentially in any order, or separately. In still another aspect, the fatty acid metabolism inhibitor and the AMPK activating compound are administered as a single composition and wherein the chemotherapeutic agent is administered in a different composition. In one aspect, the single composition comprising the fatty acid metabolism inhibitor and the AMPK activating compound is in the form of a tablet or oral suspension or solution. In one aspect, the tablet is in the form of a bilayer tablet, wherein one layer of the bilayer tablet comprises the fatty acid metabolism inhibitor and the other layer comprises the AMPK activating compound.

[0037] In one aspect of any of the embodiments related to a method or use described herein, the method further comprises administration of a therapy selected from the group consisting of radiation therapy, immunotherapy, adjuvant therapy, viral vector-mediated gene therapy, antibody-based therapy and combinations thereof.

[0038] In one aspect of any of the embodiments related to a method or use described herein, the method further comprises administration of a protein kinase (PK) inhibitor, an ataxia telangiectasia-mutated (ATM) inhibitor, a mitogen-activated protein kinase inhibitor, a growth factor receptor inhibitor, and / or dendritic cell vaccine.

[0039] Another embodiment provided herein is related to a pharmaceutical composition comprising a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, an AMPK activating compound and a pharmaceutically acceptable carrier.

[0040] In one aspect of any of the embodiments related to a composition described herein, the composition is formulated into a solid, semi-solid, or liquid form.

[0041] In one aspect of any of the embodiments related to a composition described herein, the composition is formulated into a tablet, capsule, wafer, elixir, powder, granules, ointment, solution, inhalant or injectable.

[0042] In one aspect of any of the embodiments related to a composition, the composition is formulated into a tablet, wherein the tablet is formulated into a bilayer tablet, wherein on layer of the bilayer tablet comprises the fatty acid metabolism inhibitor and the other layer comprises the AMPK activating compound.

[0043] In one aspect of any of the embodiments related to a composition, the composition is formulated into an oral solution or suspension.

[0044] In one aspect of any of the embodiments related to a composition described herein, the composition further comprises a chemotherapeutic agent.

[0045] Another embodiment provided is the use of the compositions described herein for treating cancer in a subject, reducing cancer cell proliferation and / or tumor growth in a subject, and / or for preventing cancer cells from recovering from chemotherapeutic injury.

[0046] Another embodiment provided herein is related to a kit comprising a fatty acid metabolism inhibitor; an AMP-activated protein kinase (AMPK) activating compound; and instructions for use of the kit (e.g., mixing, diluting and / or administering or treating cancer).

[0047] In one aspect, the kit further comprises a chemotherapeutic agent.

[0048] In one aspect of any of the embodiments related to a kit described herein, the fatty acid metabolism inhibitor is in one container and the AMPK activating compound is in a second container.

[0049] In one aspect of any of the embodiments related to a kit described herein, the fatty acid metabolism inhibitor is in one container, the AMPK activating compound is in a second container and the chemotherapeutic agent is in a third container.

[0050] In one aspect of any of the embodiments related to a kit, the kit comprises a bilayer tablet wherein one layer of the bilayer tablet comprises the fatty acid metabolism inhibitor and the other layer comprises the AMPK activating compound.

[0051] In yet another aspect of any of the embodiments related to a kit described herein, the fatty acid metabolism inhibitor and the AMPK activating compound are in one container and wherein the chemotherapeutic agent is in a separate container.

[0052] Another embodiment provided herein is related to a method to identify and treat a subject having a solid tumor responsive to treatment with a fatty acid metabolism inhibitor, the method comprising: determining the subject’s expression level of one or more fatty acid oxidation enzymes and / or fatty acid metabolism enzymes in a tumor tissue sample from the subject; identifying the subject as responsive to treatment with the fatty acid metabolism inhibitor; and treating the subject identified as responsive to treatment with a composition comprising a fatty acid metabolism inhibitor. In one aspect, the fatty acid metabolism inhibitor is etomoxir. In one aspect, the solid tumor is a malignant brain tumor.

[0053] Another embodiment provided herein is related to a method to identify and treat a subject having a solid tumor responsive to treatment with a composition comprising a fatty acid metabolism inhibitor, the method comprising: determining alteration in the expression or sequence of one or more genes involved in fatty acid metabolism in a tumor tissue sample from the subject; determining alteration in the expression or sequence of one or more genes whose products play a role in cell cycle control and which are normally activated by etomoxir in a tumor tissue sample from the subject; identifying the subject as responsive to treatment with the fatty acid metabolism inhibitor; and treating the subject identified with a fatty acid metabolism inhibitor. In one aspect, the fatty acid metabolism inhibitor is etomoxir. In one aspect, the solid tumor is a malignant brain tumor. BRIEF DESCRIPTION OF THE DRAWING

[0054] Fig. 1 is a schematic of a proposed mechanism of action of the drug combination disclosed herein. A chemotherapeutic alkylating agent damages the DNA of a cancer cell, thus the cancer cell needs both energy and raw materials to repair its DNA. Energy production, or catabolism, is blocked by treatment with a fatty acid oxidation inhibitor such as etomoxir. Production of raw materials, or anabolism, is blocked by treatment with an AMPK-activating agent such as metformin. According to the disclosed embodiment, the drug combination is expected to only affect cells that are both dividing and relying on fatty acid oxidation as a major catabolic pathway. It is expected the alkylating agent will stress the cancer cell, the AMPK- activating agent will then drive the cancer cell into a catabolic state, and finally, the fatty acid oxidation inhibitor will then prevent catabolism from occurring. As a result, the cancer cell should not have sufficient energy to divide or repair its DNA. Individual cancer cells may not die off, but they should be unable to proliferate; therefore in this condition, the tumor is not expected to grow and the patient is expected to maintain health.

[0055] Fig. 2. A Kaplan-Meier Survival Plot is shown for human glioma samples with differential gene expression of short-chain acyl CoA dehydrogenase (ACADS) a fatty acid oxidation enzyme. Downregulation of ACADS is rare; upregulation of ACADS is associated with significantly worse patient survival, compared with intermediate expression. Statistical Report: number of samples in groups were: 48 up-regulated, 7 down-regulated, 288 intermediate; log-rank p-value (for significance of difference of survival between group of samples) was 0.0200054002 for up-regulated vs. intermediate, 0.0448670649 for up-regulated vs. down regulated, 0.2566387715 for down-regulated vs. intermediate, 0.0152636569 for up- regulated vs. all other samples, 0.2125687917 for down-regulated vs. all other samples, and 0.1203742204 for intermediate vs. all other samples. In graph: diamonds = All Glioma; triangles = ACADS Up-Reg. >=2.0X; circles = ACADS Down-Reg. >=2.0X; squares = ACADS intermediate.

[0056] Fig. 3. A Kaplan-Meier Survival Plot is shown for human glioma samples with differential gene expression of long-chain acyl CoA dehydrogenase (ACADL) a fatty acid oxidation enzyme. Upregulation of ACADL is associated with significantly worse patient survival, compared with intermediate expression. Statistical Report: number of samples in groups were: 55 up-regulated, 49 down-regulated, 239 intermediate; log-rank p-value (for significance of difference of survival between group of samples) was 0.0024504707 for up- regulated vs. intermediate, 0.0160910256 for up-regulated vs. down regulated, 0.7077248179 for down-regulated vs. intermediate, 0.017159784 for up-regulated vs. all other samples, 0.3996366617 for down-regulated vs. all other samples, and 0.1150203363 for intermediate vs. all other samples. In graph: diamonds = All Glioma; triangles = ACADL Up-Reg. >=2.0X; circles = ACADL Down-Reg. >=2.0X; squares = ACADL intermediate.

[0057] Fig. 4. A Kaplan-Meier Survival Plot is shown for human glioma samples with differential gene expression of very-long-chain acyl CoA dehydrogenase (ACADVL). Downregulation of ACADVL is rare; upregulation of ACADVL is associated with significantly worse patient survival, compared with intermediate expression. Statistical Report: number of samples in groups were: 43 up-regulated, 1 down-regulated, 299 intermediate; log- rank p-value (for significance of difference of survival between group of samples) was 9.223354E-4 for up-regulated vs. intermediate, 1.0E-10 for up-regulated vs. down regulated, 2.0E-10 for down-regulated vs. intermediate, 0.0010423006 for up-regulated vs. all other samples, 0.0 for down-regulated vs. all other samples, and 4.951274E-4 for intermediate vs. all other samples. In graph: diamonds = All Glioma; triangles = ACADVL Up-Reg. >=2.0X; circles = ACADVL Down-Reg. >=2.0X; squares = ACADVL intermediate.

[0058] Fig. 5. A Kaplan-Meier Survival Plot is shown for human glioma samples with amplification or deletion of medium-chain acyl CoA dehydrogenase (ACADM), a key enzyme in fatty acid oxidation. Deletion of ACADM is associated with significantly better patient survival, compared with amplification of this gene. Statistical Report: number of samples in groups were: 127 amplified and 55 deleted; log-rank p-value (for significance of difference of survival between group of samples) was0.01932309 for amplified vs. deleted, 0.01932309 for amplified vs. all other samples, and 0.0193230731 for deleted vs. all other samples. In graph: diamonds = All Glioma; triangles = ACADM Amplified >=2.0 copies; circles = ACADM Deleted <=2.0 copies; squares = ACADM intermediate.

[0059] Fig. 6. A Kaplan-Meier Survival Plot is shown for human glioma samples with amplification or deletion of hexokinase (HK1), a key enzyme in glycolysis. Amplification of HK1 is associated with significantly better patient survival, compared with deletion of this gene. Statistical Report: number of samples in groups were: 34 amplified and 107 deleted; log- rank p-value (for significance of difference of survival between group of samples) was 0.009785877 for amplified vs. deleted, 0.009785877 for amplified vs. all other samples, and 0.0097858879 for deleted vs. all other samples. In graph: diamonds = All Glioma; triangles = HK1 Amplified >=2.0 copies; circles = HK1 Deleted < =2.0 copies; squares = HK1 intermediate.

[0060] Figs. 7A and 7B. Glioma cells, like many cancer cells, are highly oxidative when maintained in optimal culture conditions. Treatment of cells with the drug metformin increases oxygen consumption rates, by activating AMPK and triggering catabolic activity. Treatment of cells with the drug etomoxir then decreases oxygen consumption rates below baseline, by blocking catabolic activity via fatty acid oxidation (Fig. 7A). FCCP (carbonyl cyanide 4- trifluoromethoxy phenylhydrazone) uncouples the mitochondrial electron transport chain and AA (antimycin) shuts down all mitochondrial respiration; these poisons reveal the total mitochondrial respiratory capacity of the cells and the amount of non-mitochondrial respiration in the cells, respectively (Fig.7A). Approximately one-third of induced cellular respiration is blocked with etomoxir treatment in these cancer cells (Fig.7B)

[0061] Figs.8A-8C. Glioma cells do not die when treated with 100μM etomoxir in cell culture; they tend to go into a quiescent state and store fats in the form of lipid droplets for later use, should conditions permit. Cell numbers are not significantly affected after one day of treatment with 100μM etomoxir, but cell numbers significantly decrease after one day of treatment with 250μM metformin or 500μM metformin (Fig.8A). Synergistic effects are observed when cells are treated with a combination of 100μM etomoxir and 250μM metformin, or 100μM etomoxir and 500μM metformin (Fig. 8A). No effects on cell viability are observed in any of these treatment groups (Fig.8B), indicating the non-toxic nature of the drug combination.

[0062] Fig. 9. Cell cycle arrest was induced by nocodozole treatment, to achieve synchronization of the cell cycle over time. The cells were then treated with 100μM etomoxir or vehicle control and collected at various timepoints - in unsynchronized cells, at 0 hours post- nocodozole treatment, 3 hours post-nocodozole treatment and 6 hours post-nocodozole treatment. Cell lysates were then probed for expression of the tumor suppressor proteins p53 and p27, and the housekeeping protein beta-actin, by western blot. DETAILED DESCRIPTION

[0063] After reading this description it will become apparent to one skilled in the art how to implement the present disclosure in various alternative embodiments and alternative applications. However, all the various embodiments of the present technology may not be described herein. It will be understood that the embodiments presented here are presented by way of an example only, and not limitation. As such, this detailed description of various alternative embodiments should not be construed to limit the scope or breadth of the present disclosure as set forth herein.

[0064] Before the present technology is disclosed and described, it is to be understood that the aspects described below are not limited to specific compositions, methods of preparing such compositions, or uses thereof as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular aspects only and is not intended to be limiting.

[0065] The instant application describes methods and uses for treating cancer, reducing cancer cell proliferation and / or tumor growth, as well as preventing cancer cells from recovering from chemotherapeutic injury using a novel multi-modal therapy comprising a novel drug combination comprising a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, an AMPK activating compound. Further, the combination can include a chemotherapeutic agent. Further the instant application describes compositions and kits comprising the novel drug combination.

[0066] Focusing on cancer cell metabolism provides ample scope for the identification of new therapeutic targets. Many cancers have long been thought to primarily metabolize glucose for energy production. Yet cancer cells also utilize other substrates, such as fatty acids, to produce raw materials for cellular maintenance and energetic currency to accomplish cellular tasks. The contribution of these substrates is increasingly appreciated in the context of glioma, the most common form of primary malignant brain tumor in the adult population (Strickland and Stoll 2017, supra).

[0067] Multiple catabolic pathways are used for energy production within glioma cells, and are linked in many ways to anabolic pathways supporting cellular function. For example: glycolysis both supports energy production and provides carbon skeletons for the synthesis of nucleic acids; amino acids are used both as energetic substrates and as raw materials for protein synthesis; fatty acids are used both as energetic substrates and as raw materials for lipid membranes.

[0068] Bio-energetic pathways are also deeply connected to pro-oncogenic signaling within glioma cells. For example: AMPK signaling links catabolism with cell cycle progression; mTOR signaling contributes to metabolic flexibility and cancer cell survival; the electron transport chain produces both ATP and reactive oxygen species (ROS) which act as signaling molecules; Hypoxia Inducible Factors (HIFs) mediate interactions with cells and vasculature within the tumor environment. Meanwhile, mutations in the critical tumor suppressor protein p53, and the tricarboxylic acid cycle enzymes Isocitrate Dehydrogenase 1 and 2, have been implicated in oncogenic signaling as well as establishing metabolic phenotypes in genetically- defined subsets of malignant glioma. These pathways critically contribute to tumor biology, and provide valuable opportunities for new therapeutic interventions. Human brain tumor cells primarily metabolize ketones and fatty acids, not glucose, and the fatty acid oxidation pathway is required to maintain the growth of these tumors (Lin et al. Neuro Oncology 2016, Kant et al. Cell Death Dis 2020, Juraszek et al. J Neurochem 2021, Shim et al. Cancer Cell Int 2022, Jiang et al. Nat Commun 2022).

[0069] Cancer cells recover from chemotherapeutic injury by making energy and raw materials to repair DNA. Provided for herein is a multi-modal therapy comprising a novel drug combination as a new therapeutic for treating cancer, reducing cancer cell proliferation, and slowing the progression of cancers such as malignant brain tumors. The novel multi-modal therapy used in the methods disclosed herein may damage DNA with an alkylating agent; prevent the cancer cells from making the necessary energy to support malignant growth by the highly-efficient method of mitochondrial beta-oxidation; and prevent the cancer cells from making the raw materials needed to support malignant growth. This method may first introduce mutations, forcing the cancer cells into an anabolic state of repair; forcing cancer cells to abandon anabolic metabolism and instead engage in catabolic metabolism, via AMPK activation; then prevent the cancer cells from engaging in one form of catabolic metabolism, via inhibition of fatty acid oxidation. This multi-modal therapy is expected to force the cells into a quiescent state or prompt cell death. Critically, not many healthy cells rely on fatty acid metabolism – these cells include cardiac muscle cells and slow-twitch muscle cells. Because these healthy cell types are post-mitotic, their genetic material is wrapped in histones and is not damaged by alkylating chemotherapy agents. Therefore, only the cancer cells which engage in cell division and rely on fatty acid oxidation will be targeted by the disclosed multi-modal therapy, leaving healthy cells largely intact or capable of recovery.

[0070] Also provided herein are methods to identify subjects / patients with solid tumors that will benefit from pharmacologically targeting the fatty acid oxidation pathway. These methods include determining gene expression and / or protein expression and / or metabolomic signatures of the genes and proteins involved in this metabolic pathway. The purpose is to identify subjects whose tumor samples contain the necessary enzymatic machinery to support fatty acid oxidation and thus are believed to be treatable by the compositions disclosed herein. Definitions

[0071] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the technology herein pertains. Although any methods and materials similar or equivalent to those described herein can be used in the practice for testing, the preferred materials and methods are described herein. In describing and claiming the present technology, the following terminology will be used. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting.

[0072] The articles “a” and “an” are used herein to refer to one or to more than one (i.e., to at least one) of the grammatical object of the article. For example, “an element” means one element or more than one element. Thus, “a cell,” for example, includes a plurality of cells of the same type. Furthermore, to the extent that “including,” “includes,” “having,” “has,” “with,” or variants thereof are used, such terms are intended to be inclusive in a manner similar to “comprising.”

[0073] The term “about” when used before a numerical designation, e.g., temperature, time, amount, concentration, and such other, including a range, indicates approximations which may vary by ( + ) or ( - ) 10%, 5%, 1%, or any subrange or sub-value therebetween. The term “about” when used with regard to an amount means that the amount may vary by, e.g., + / - 10%.

[0074] “Cancer” conveys a disease, condition, trait, genotype or phenotype characterized by unregulated cell growth or replication. “Cancer” includes solid tumors including but not limited to primary malignant brain tumors, including gliomas. “Cancer” also includes other brain tumors, lung cancers, pancreatic cancers, breast cancers and prostate cancers. “Cancer” includes multidrug resistant cancers as well as cancers resistant to chemotherapy treatment.

[0075] “Cancer cell” conveys a cell exhibiting neoplastic phenotype, which may be characterized by one or more of, for example, abnormal cell growth, abnormal cellular proliferation, loss of density dependent growth inhibition, anchorage-independent growth potential, ability to promote tumor growth and / or development in an immunocompromised non-human animal model, and / or any appropriate indicator of cellular transformation. “Cancer cell” may be used interchangeably herein with “tumor cell”, “malignant cell,” or “cancerous cell”, and encompasses cancer cells of a solid tumor, a semi-solid tumor, a primary tumor, a metastatic tumor, and the like.

[0076] “Cancer therapy” or “anti-cancer therapy” are used interchangeably to convey a therapy useful in treating cancer. Examples of anti-cancer therapeutic agents include, but are not limited to surgery, chemotherapeutic agents, immunotherapy, growth inhibitory agents, cytotoxic agents, agents used in radiation therapy, anti-angiogenesis agents, apoptotic agents, anti- tubulin agents, and other agents to treat cancer, such as anti-HER-2 antibodies (e.g., HERCEPTINTM), anti-CD20 antibodies, an epidermal growth factor receptor (EGFR) antagonist (e.g., a tyrosine kinase inhibitor), HER1 / EGFR inhibitor (e.g., erlotinib (TARCEVATM)), platelet derived growth factor inhibitors (e.g., GLEEVECTM(Imatinib Mesylate)), a COX-2 inhibitor (e.g., celecoxib), interferons, cytokines, antagonists (e.g., neutralizing antibodies) that bind to one or more of the following targets ErbB2, ErbB3, ErbB4, PDGFR-beta, BlyS, APRIL, BCMA or VEGF receptor(s), TRAIL / Apo2, and other bioactive and organic chemical agents, etc. Combinations thereof are also contemplated for use with the methods described herein.

[0077] A “chemotherapeutic agent” is a chemical compound useful in the treatment of cancer. Examples of chemotherapeutic agents include imidazotetrazinone such as temozolomide (TMZ) ; and pharmaceutically acceptable salts, acids or derivatives / analogs of thereof.

[0078] Also included in this definition of “chemotherapeutic agent” are: procarbazine, lomustine, vincristine and pharmaceutically acceptable salts, acids or derivatives / analogs of any of the above.

[0079] Also included in this definition of “chemotherapeutic agent” are alkylating-like agents including cisplatin, carboplatin, loboplatin, oxaliplatin, and nedaplatin and pharmaceutically acceptable salts, acids or derivatives / analogs of any of the above

[0080] “Effective amount” and “therapeutically effective amount” of a compound, formulation or formulation / composition component means a sufficient amount of the compound, formulation or component, alone or in a combination, to provide the desired effect. For example, “an effective amount” means an amount of a compound, alone or in a combination, required to ameliorate the symptoms of a disease relative to an untreated patient. The effective amount of active compound(s) used for therapeutic treatment of a disease varies depending upon the manner of administration, the age, body weight, and general health of the subject.

[0081] “In combination” in the context of the administration of a therapy to a subject refers to the use of more than one therapy for therapeutic benefit. “In combination” in the context of administration can also refer to the prophylactic use of a therapy to a subject when used with at least one additional therapy. The use of “in combination” does not restrict the order in which the therapies (e.g., afirst and second therapy) are administered. A therapy can be administered prior to (e.g., 1 minute, 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks before), concomitantly with, or subsequent to (e.g., 1 minute, 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks after) the administration of a second therapy to a subject which had, has, or is susceptible to cancer. The therapies are administered to a subject in a sequence and within a time interval such that the therapies can act together. In a particular embodiment, the therapies are administered to a subject in a sequence and within a time interval such that they provide an increased benefit relative to administration otherwise. Any additional therapy can be administered in any order with the other additional therapy.

[0082] As used herein, “obtaining” as in “obtaining an agent” includes synthesizing, purchasing, or otherwise acquiring the agent.

[0083] “Optional” or “optionally” mean that the subsequently described event or circumstance can or cannot occur, and that the description includes instances where the event or circumstance occurs and instances where it does not.

[0084] As used herein, “or” is employed in its sense including “and / or” unless the content clearly dictates otherwise.

[0085] As used herein, “oral” administration of a compound means taken by mouth, including buccal, sublabial, and sublingual administration. Compounds may be formulated as tablets to chew, swallow, dissolve in water or under the tongue, as a capsule with a time or sustained release in the mouth, stomach, and / or bowel, as a powder, as granules, as a tea, as a drop, or liquid formulation.

[0086] “Parenteral” administration of a composition includes, e.g., subcutaneous (s.c.), intravenous (i.v.), intramuscular (i.m.), or intrasternal injection, or infusion techniques.

[0087] “Patient” or “individual” or “subject” are used interchangeably herein, and refer to a mammalian subject to be treated, with human patients being preferred. In some cases, the methods disclosed herein are used in experimental animals, in veterinary application, and in the development of animal models for disease, including, but not limited to, rodents including mice, rats, and hamsters, and primates.

[0088] As used herein, a “pharmaceutically acceptable” component / carrier etc. is suitable for use with humans and / or animals without undue adverse side effects (such as toxicity, irritation, and allergic response) commensurate with a reasonable benefit / risk ratio.

[0089] “Preventing” and “prevention” refer to administration of an agent or composition to a clinically asymptomatic individual who is susceptible or predisposed to a particular adverse condition, disorder, or disease, to prevent occurrence of symptoms and / or their underlying cause.

[0090] “Reduces” means a negative alteration of at least 5%, 10%, 25%, 50%, 75%, or 100%.

[0091] “Treating” and “treatment” refer to administering agent(s), composition(s) or formulation(s) to a clinically symptomatic individual afflicted with a cancer, to reduce severity and / or frequency of symptoms, eliminate the symptoms and / or their underlying cause, and / or facilitate improvement or remediation of damage. Although not precluded, treating does not require that the cancer or symptoms associated therewith be completely eliminated.

[0092] Treatment of cancer patients may also include any of the following: adjuvant therapy (also called adjunct therapy or adjunctive therapy) to destroy residual tumor cells that may be present after the known tumor is removed by surgical therapy, thereby preventing possible cancer reoccurrence; radiation therapy, immunotherapy, viral vector-mediated gene therapy, antibody-based therapy and combinations thereof.

[0093] As used herein, “tumor” means a mass of transformed cells engaged in neoplastic uncontrolled cell multiplication and, at least in part, containing angiogenic vasculature. Abnormal neoplastic cell growth is rapid and continues even after the stimuli that initiated the new growth have ceased. “Tumor” is used broadly to include the tumor parenchymal cells as well as the supporting stroma, including the angiogenic blood vessels that infiltrate the tumor parenchymal cell mass. Although a tumor generally is a malignant tumor, i.e., a cancer having the ability to metastasize (i.e. a metastatic tumor), a tumor also can be nonmalignant (i.e. non- metastatic tumor).

[0094] Ranges: throughout this disclosure, various ranges are mentioned. Description in range format is merely for convenience and brevity and should not be construed as an inflexible limitation. Accordingly, the description of a range should be considered to have specifically disclosed all the possible subranges as well as individual numerical values within that range. For example, description of a range such as from 1 to 6 should be considered to have specifically disclosed subranges such as from 1 to 3, from 1 to 4, from 1 to 5, from 2 to 4, from 2 to 6, from 3 to 6 etc., as well as individual numbers within that range, for example, 1, 2, 2.7, 3, 4, 5, 5.3, and 6. This applies regardless of the breadth of the range.

[0095] Any compositions or methods or uses provided herein can be combined with one or more of any of the other compositions and methods provided herein, unless the context clearly requires otherwise.

[0096] Provided herein, are methods of treating cancer in a subject; reducing cancer cell proliferation and / or tumor growth in a subject; and preventing cancer cells from recovering from chemotherapeutic injury. The methods comprise administering to the subject a therapeutically effective amount of a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, together or in parallel with a therapeutically effective amount of an adenosine monophosphate-activated protein kinase (AMPK) activating compound or pharmaceutically acceptable salt thereof. Further, a chemotherapeutic agent can also be administered.

[0097] In various aspects disclosed herein, a "fatty acid metabolism inhibitor," as used herein, is a compound able to inhibit (e.g., prevent, or at least decrease or inhibit the activity by an order of magnitude or more) a reaction within the fatty acid metabolism pathway, such as an enzyme-catalyzed reaction within the pathway or the transport of an intermediate molecule. The inhibitor may inhibit the enzyme or transporter, e.g., by binding to the enzyme or transporter or otherwise interfering with operation of the enzyme or transporter (for example, by blocking an active site or a docking site, altering the configuration of the enzyme, competing with an enzyme substrate for the active site of an enzyme, etc.), and / or by reacting with a coenzyme, cofactor, etc. necessary for the protein to react with a substrate. The fatty acid metabolism pathway is the pathway by which fatty acids are metabolized within a cell for energy (e.g., through the synthesis of ATP and the breakdown of fatty acids into simpler structures, such as CO2, acyl groups, etc.).

[0098] The fatty acid metabolism pathway includes several enzymatic reactions, which uses various enzymes such as reductases or isomerases. Specific examples of enzymes within the fatty acid metabolism pathway include 2,4-dienoyl-CoA reductase, 2,4-dienoyl-CoA isomerase, butyryl dehydrogenase, etc., as further discussed below. The fatty acid metabolism inhibitor may be an inhibitor able to inhibit a beta-oxidation reaction in the fatty acid metabolism pathway. The inhibitor may be an inhibitor for a fatty acid transporter (e.g., a transporter that transports fatty acids into the cell, or from the cytoplasm into the mitochondria for metabolism). The inhibitor may react or otherwise inhibit key steps within the fatty acid metabolism pathway. The inhibitor may be an inhibitor of fatty acids as a source of energy in the mitochondria. For example, the inhibitor may inhibit the breakdown of intermediates such as butyryl CoA, glutaryl CoA, or isovaleryl CoA.

[0099] In one aspect, the fatty acid inhibitor may be an oxirane carboxylic acid compound, such as etomoxir. Etomoxir is an irreversible and specific inhibitor of beta-oxidation reaction in the fatty acid metabolism pathway. This small-molecule inhibitor blocks the rate-limiting step in fatty acid metabolism, Carnitine Palmitoyl Transferase I (CPT1), a transporter that brings fatty acyl-CoA molecules into the mitochondria to undergo beta-oxidation. Etomoxir inhibits fatty acid oxidation and fatty acid and cholesterol synthesis in an enantiomer-selective manner: only the R-enantiomer of etomoxir inhibits fatty acid oxidation, while the S- enantiomer inhibits fatty acid and cholesterol synthesis but not fatty acid oxidation (NIH Inxight Drugs: drugs.ncats.io / drug / MSB3DD2XP6). Thus, as provided for herein, the preferred enantiomeric form of etomoxir is the R-enantiomer, however the S-enantiomer as well as a racemic mixture of both the R and S enantiomeric forms of etomoxir are contemplated. The generic salt formulation of etomoxir slows glioma growth after systemic doses in vivo, prolonging median survival time by 17% in a clinically-relevant mouse model of the disease (Lin, H., et al.2017). The ester formulation of this drug is more likely to penetrate the blood- brain barrier, leading to improved drug delivery and improved efficacy.

[0100] It is most particularly preferred to use etomoxir, i.e., 2-(6-(4-chlorophenoxy)-hexyl)- oxirane-2-carboxylic acid ethyl ester. Examples of other oxirane carboxylic acid compounds useful in the invention are 2-(4-(3-chlorophenoxy)-butyl)-oxirane-2-carboxylic acid ethyl ester, 2-(4-(3-trifluoromethylphenoxy)-butyl)-oxirane-2-carboxylic acid ethyl ester, 2-(5-(4- chlorophenoxy)-pentyl)-oxirane-2-carboxylic acid ethyl ester, 2-(6-(3,4-dichlorophenoxy)- hexyl)-oxirane-2-carboxylic acid ethyl ester, 2-(6-(4-fluorophenoxy)-hexyl)-oxirane-2- carboxylic acid ethyl ester, and 2-(6-phenoxyhexyl)-oxirane-2-carboxylic acid ethyl ester, the corresponding oxirane carboxylic acids, and their pharmacologically acceptable salts.

[0101] Other, non-limiting examples of fatty acid metabolism inhibitors include fatty acid transporter inhibitors, beta-oxidation process inhibitors, reductase inhibitors, and / or isomerase inhibitors within the fatty acid metabolism pathway. Specific examples of other fatty acid metabolism inhibitors include, but at not limited to perhexiline, oxfenicine, ranolazine, trimetazidine and pharmaceutically acceptable salts or esters thereof.

[0102] Inhibition of either fatty acid synthesis or beta-oxidation reduces proliferation of both glioma cells (Grube, S., et al. “Overexpression of fatty acid synthase in human gliomas correlates with the WHO tumor grade and inhibition with Orlistat reduces cell viability and triggers apoptosis”; 2014; J. Neuro Oncol. 118(2):277-287; Lin, H., et al. 2017) and normal neural stem cells (Knobloch, M., et al. “Metabolic control of adult neural stem cell activity by Fasn-dependent lipogenesis”; 2013; Nature 493(7431):226-230; Stoll, E., et al. “Neural stem cells in the adult subventricular zone oxidize fatty acids to produce energy and support neurogenic activity”; 2015; Stem Cells 33(7):2306-2319). These twinned metabolic pathways provide energy and raw materials for cancer cell growth, and are critically important in glioma cell malignancy.

[0103] In some aspects, the fatty acid metabolism inhibitor or a pharmaceutically acceptable salt or ester thereof is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intranasal delivery, intravenous delivery, intrathecal injection, intracranial placement and combinations thereof. In a preferred aspect, the delivery route is via oral delivery.

[0104] AMP kinase (AMPK) both regulates metabolic processes and activates tumor suppressive mechanisms in proliferative cancer cells. Cell cycle inhibition resulting from AMPK activation can occur at both the G1 / S and G2 / M phases of the cell cycle, by differing mechanisms. By inhibiting fatty acid synthesis, AMPK is able to inhibit G2 / M phase progression by regulating the biosynthesis of membrane components required for cytokinesis (Guo, D., et al. “AMPK: A metabolic checkpoint that regulates the growth of EGFR activated glioblastomas”; 2010 Cell Cycle 9(2): 211-212). AMPK also has the ability to bind and phosphorylate p53 and activate TSC2, in order to halt cell cycle progression until homeostasis is restored (Jones, R., et al. "AMP-activated protein kinase induces a p53-dependent metabolic checkpoint." 2005 Mol. Cell 18(3):283-293; Vucicevic, M., et al. (2009). "AMP-activated protein kinase-dependent and -independent mechanisms underlying in vitro antiglioma action of compound C." Biochem Pharmacol 77(11): 1684-1693.). In addition, AMPK activates p21CIP1 and p27KIP1, both directly and indirectly through p53. Both these proteins act as cyclin-dependent kinase inhibitors and prevent Rb from releasing E2F thus preventing entry into the cell cycle (Isakovic, A., et al. (2007). "Dual antiglioma action of metformin: cell cycle arrest and mitochondria-dependent apoptosis." Cell Mol Life Sci 64(10): 1290-1302). In support of these tumor suppressive mechanisms, AMPK activation has been shown to enhance glioma response to temozolomide in some studies (Zhang, W. et al. (2010). "Activation of AMP-activated protein kinase by temozolomide contributes to apoptosis in glioblastoma cells via p53 activation and mTORC1 inhibition." J Biol Chem 285(52): 40461-40471), correlating with improved therapeutic response (Aldea, M. D., et al. (2014). "Metformin plus sorafenib highly impacts temozolomide resistant glioblastoma stem-like cells." J BUON 19(2): 502-511; Sesen, J., et al. (2015). "Metformin inhibits growth of human glioblastoma cells and enhances therapeutic response." PLoS One 10(4): e0123721D).

[0105] Yet paradoxically, AMPK activation is also correlated with pro-oncogenic activities, with this event driving tumor growth (Rios, M., et al. (2014). "Lipoprotein internalisation induced by oncogenic AMPK activation is essential to maintain glioblastoma cell growth." Eur J Cancer 50(18): 3187-3197). Specifically, AMPK has been shown to play a role in increased glioma cell migration and survival in response to glucose withdrawal within the U-251-MG human cell line (Godlewski, J., (2010). "MicroRNA-451 regulates LKB1 / AMPK signaling and allows adaptation to metabolic stress in glioma cells." Mol Cell 37(5): 620-632N). Radio- and temozolomide- resistant human GSC clones show upregulation of genes associated with autophagy and lipid catabolism alongside increased AMPK phosphorylation (Ye, F., et al. (2013). "Protective properties of radio-chemoresistant glioblastoma stem cell clones are associated with metabolic adaptation to reduced glucose dependence." PLoS One 8(11): e80397Z). By inducing autophagy and inhibiting apoptosis, AMPK activation can increase glioma cell viability; these findings have established a role for AMPK in tumor growth and decreased patient survival (Zhang, W. et al.2010; Rios, M., et al. (2013). "AMPK activation by oncogenesis is required to maintain cancer cell proliferation in astrocytic tumors." Cancer Res 73(8): 2628-26382013).

[0106] The contradictory roles of AMPK may be resolved by considering how a cycling cell achieves metabolic homeostasis. DNA replication and cytokinesis undertaken during the process of cell division require much energy, and glioma cells couple catabolic activity to cell cycle progression (Strickland & Stoll, 2017). AMPK and its family members, as nutrient- sensing effector proteins, are hypothesized to act as regulators of a futile cycle to accomplish this task. An increased AMP / ATP ratio activates AMPK, which inhibits biosynthetic processes and activates beta-oxidation by inhibiting ACC (Hardie D. G. and D. A. Pan (2002). "Regulation of fatty acid synthesis and oxidation by the AMP-activated protein kinase." Biochem Soc Trans 30(Pt 6): 1064-1070; Griss, T., et al. (2015). "Metformin Antagonizes Cancer Cell Proliferation by Suppressing Mitochondrial-Dependent Biosynthesis." PLoS Biol 13(12): e10023092015). AMPK simultaneously acts to inhibit cell cycle progression by activating tumor suppressor proteins (Jones, R. G., et al. (2005). "AMP-activated protein kinase induces a p53-dependent metabolic checkpoint." Mol Cell 18(3): 283-293; Huang, S. W., et al. (2013). "p53 modulates the AMPK inhibitor compound C induced apoptosis in human skin cancer cells." Toxicol Appl Pharmacol 267(1): 113-124). Once the cell has enough energy, AMPK is no longer activated and the activated protein is degraded, allowing release from the cell cycle checkpoint. The process of mitosis then depletes energy stores, allowing AMPK to be activated again. In support of this model, the knockdown and overexpression of AMPK causes the same effect in cells: halting of the cell cycle resulting in aneuploidy (Banko, M. R., et al. (2011). "Chemical genetic screen for AMPKalpha2 substrates uncovers a network of proteins involved in mitosis." Mol Cell 44(6): 878-892). A carefully-regulated, cyclical pattern of AMPK activity—and functional downstream effector molecules—are expected to be required for cycling cancer cells to function properly. In short, driving AMPK activation is expected to drive catabolic activity, while inhibiting catabolic activity with an inhibitor of fatty acid oxidation, is expected to force the cancer cells into a metabolic paralysis, so they are unable to support malignant growth.

[0107] In various aspects disclosed herein, the AMPK activating compound is selected from the group consisting of a biguanide, a polyphenol, and a thiazolidinedione. In one aspect, the AMPK activating compound is a biguanide and is preferably metformin or a pharmaceutically acceptable salt thereof. Biguanides such as metformin inhibit Complex 1 of the electron transport chain, leading to increased AMP:ATP ratios.

[0108] In yet another aspect, the AMPK activating compound is a polyphenol selected from the group consisting of resveratrol, quercetin, genestein, epigallocatechin-3-gallate, berberine, and curcumin. These compounds generally raise AMP:ATP levels by inhibiting the mitochondrial F0F1 ATPase.

[0109] Still in another aspect, the AMPK activating compound is a thiazolidinedione selected from the group consisting of troglitazone, pioglitazone, and rosiglitazone. These compounds are thought to activate the nuclear peroxisome proliferator-activated receptors, such as PPAR gamma.

[0110] In some aspects, the AMPK activating compound is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intranasal delivery, intravenous delivery, intrathecal injection, intracranial placement and combinations thereof. In a preferred aspect, the delivery route is via oral delivery.

[0111] In various aspects disclosed herein the chemotherapeutic agent is an imidazotetrazinone, such as temozolomide (TMZ; 3,4-dihydro-3-methyl-4-oxoimidazo- [5,1- d] 1,2,3,4-tetrazine-8-carboximide) and pharmaceutically acceptable salts, acids or derivatives / analogs of thereof. The concomitant use of whole-brain radiotherapy and protracted low-dose orally-administered TMZ is a well-tolerated regimen, with anti-tumor activity against gliomas, malignant melanomas, and brain metastases (Stupp, R. et al.2005; Addeo, R., et al. (2008). "Phase 2 trial of temozolomide using protracted low-dose and whole-brain radiotherapy for nonsmall cell lung cancer and breast cancer patients with brain metastases." Cancer 113(9): 2524-2531). TMZ is an alkylating agent, which damages the DNA of highly mitotic cancer cells (Wedge, S. R., et al. (1996). "Potentiation of temozolomide and BCNU cytotoxicity by O(6)-benzylguanine: a comparative study in vitro." Br J Cancer 73(4): 482-490; Wedge, S. R., et al. (1997). "Effect of single and multiple administration of an O6- benzylguanine / temozolomide combination: an evaluation in a human melanoma xenograft model." Cancer Chemother Pharmacol 40(3): 266-272). This drug is presently administered with a five-day oral dosing schedule every four weeks. It is well tolerated (Nassiri, F., S., et al. (2020). "Determining the Optimal Adjuvant Therapy for Improving Survival in Elderly Patients with Glioblastoma: A Systematic Review and Network Meta-analysis." Clin Cancer Res 26(11): 2664-2672) and cost-effective (Wasserfallen, J. B., et al. (2005). "Cost of temozolomide therapy and global care for recurrent malignant gliomas followed until death." Neuro Oncol 7(2): 189-195), although some cells demonstrate resistance, leading to tumor recurrence (Robinson, C. G., et al. (2010). "Effect of alternative temozolomide schedules on glioblastoma O(6)-methylguanine-DNA methyltransferase activity and survival." Br J Cancer 103(4): 498-50).

[0112] Further, TMZ is a small, nitrogen-rich, hydrophilic heterocycle of the imidazotetrazine class, and has low molecular weight (194 Da) and clogP (-1.97). It is acid stable, orally bioavailable and able to cross the blood-brain barrier (BBB) (Summers, HS., et al. Discovery of new imidazotetraxinones with potential to overcome tumor resistance. Eur. J. Med Chem., 257:May 2023)).

[0113] Additional imidazotetrazinones, with a similar chemical structure to TMZ, have recently been synthesized (Summers, H. S., et al. (2023). "Discovery of new imidazotetrazinones with potential to overcome tumor resistance." Eur J Med Chem 257: 115507). These TMZ analogs incorporate a propargyl alkylating moiety and a thiazole ring as isosteric replacement for a carboxamide and include: 8-carbamoyl-3-propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 3-Propargyl-8-thiocarbamoylimidazo[5,1-d]-1,2,3,5-tetrazin-4 (3H)-one; 3-propargyl-8-(thiazol- 2-yl)imidazo[5,1-d]-1,2,3,5-tetrazin-4(3H)-ones; 8-[4-(4-Fluorophenyl)-thiazol-2-yl]-3-propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-[4-(4-Methylsulfonylphenyl)-thiazol-2-yl]-3-propargylimidazo [5,1-d]-1,2,3,5-tetrazin- 4(3H)-one; 3-Propargyl-8-[4-(pyridin-4-yl)-thiazol-2-yl]imidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 3-Propargyl-8-(thiazol-2-yl)imidazo[5,1-d]-1,2,3,5-tetrazin-4(3H)- one; 8-(4-Methylthiazol-2-yl)-3-propargylimidazo[5,1-d]-1,2,3,5- tetrazin-4(3H)-one; 8-(4-Ethylthiazol-2-yl)-3-propargylimidazo[5,1-d]-1,2,3,5-tetrazin- 4(3H)-one; 3-Propargyl-8-(4-isopropylthiazol-2-yl)-imidazo[5,1-d]-1,2,3,5- tetrazin-4(3H)-one; 3-Propargyl-8-[4-(1-propen-2-yl)thiazol-2-yl]-imidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-(4-Cyclopropylthiazol-2-yl)-3-propargylimidazo[5,1-d]-1,2,3,5- tetrazin-4(3H)-one; 8-(4-Cyclobutylthiazol-2-yl)-3-propargylimidazo[5,1-d]-1,2,3,5- tetrazin-4(3H)-one; 8-(4-Cyclopentylthiazol-2-yl)-3-propargylimidazo[5,1-d]-1,2,3,5- tetrazin-4(3H)-one; 8-(5-Methylthiazol-2-yl)-3-propargylimidazo[5,1-d]-1,2,3,5- tetrazin-4(3H)-one; 8-(4-Bromomethylthiazol-2-yl)-3-propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-(4-Morpholinomethylthiazol-2-yl)-3-propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-(4-Hydroxymethylthiazol-2-yl)-3-propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-(4-Azidomethylthiazol-2-yl)-3-propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-[4-(N,N-tert-Butoxycarbonylamino)methylthiazol-2-yl]-3- propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-[4-Hydroxy-4-(trifluoromethyl)-5,5-dihydrothiazol-2-yl]-3- propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-[4-Hydroxy-4-(pentafluoroethyl)-5,5-dihydrothiazol-2-yl]-3- propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 3-Propargyl-8-(4-trifluoromethylthiazol-2-yl)imidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; 8-(4-(Pentafluoroethylthiazol-2-yl)-3-propargylimidazo[5,1-d]- 1,2,3,5-tetrazin-4(3H)-one; and 5-(3-propargyltriazen-1-yl)-4-(thiazol-2-yl)imidazole.

[0114] In various aspects disclosed herein, the chemotherapeutic agent is selected from the group consisting of procarbazine, lomustine, and vincristine.

[0115] In still other aspects, the chemotherapeutic agent is an alkylating-like agent selected from the group consisting of cisplatin, carboplatin, loboplatin, oxaliplatin, and nedaplatin.

[0116] In various aspects disclosed herein, the chemotherapeutic agent is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intracranial delivery, intramuscular delivery and intravenous delivery.

[0117] Another route of delivery for the chemotherapeutic agent is by direct implantation of a chemotherapy drug-soaked wafer, such as the carmustine-containing GLIADEL® wafer (McGirt, M. J., et al. (2009). "Gliadel (BCNU) wafer plus concomitant temozolomide therapy after primary resection of glioblastoma multiforme." J Neurosurg 110(3): 583-588 T., et al. 2009).

[0118] In various aspects disclosed herein the chemotherapeutic agent is insoluble. In some aspects, the chemotherapeutic agent is formulated for timed release. In still other aspects, the chemotherapeutic agent is formulated into a capsule. In some aspects, the capsule is timed- release. In yet other aspects, the chemotherapeutic agent is formulated into a solution, a slurry, a syrup, a powder, a suspension, an orodispensible film, a tablet, a chewable tablet, a flexible tablet, a dispersible tablet, an orally disintegrating tablet, and / or as granules. All acceptable oral formulations derived from the United States Pharmacopeia (USP) and the National Formulary (NF) are incorporated by reference herein (United States Pharmacopeia and National Formulary, United States Pharmacopeial Convention; 2020).

[0119] In various aspects disclosed herein, the fatty acid metabolism inhibitor is formulated for timed release. In some aspects, the fatty acid metabolism inhibitor is formulated into a capsule. In some aspects, the capsule is timed-release. In still other aspects, the fatty acid metabolism inhibitor is formulated into a solution, a slurry, a syrup, a powder, a suspension, an orodispensible film, a tablet, a chewable tablet, a flexible tablet, a dispersible tablet, an orally disintegrating tablet, and / or as granules. All acceptable oral formulations derived from the United States Pharmacopeia (USP) and the National Formulary (NF) are incorporated by reference herein (United States Pharmacopeia and National Formulary, United States Pharmacopeial Convention; 2020).

[0120] In various aspects disclosed herein, the AMPK activating compound is formulated for timed release. In some aspects, the AMPK activating compound is formulated into a capsule. In still some other aspects, the capsule is timed-release. In yet other aspects, the AMPK activating compound is formulated into a solution, a slurry, a syrup, a powder, a suspension, an orodispensible film, a tablet, a chewable tablet, a flexible tablet, a dispersible tablet, an orally disintegrating tablet, and / or as granules. All acceptable oral formulations derived from the United States Pharmacopeia (USP) and the National Formulary (NF) are incorporated by reference herein (United States Pharmacopeia and National Formulary, United States Pharmacopeial Convention; 2020).

[0121] In still other aspects, the chemotherapeutic agent is administered with the fatty acid metabolism inhibitor and the AMPK activating compound. The chemotherapeutic agent and fatty acid metabolism inhibitor and the AMPK activating compound can be co-administered. In some aspects, the chemotherapeutic agent is administered prior to the fatty acid metabolism inhibitor and the AMPK activating compound. In other aspects, the fatty acid metabolism inhibitor and the AMPK activating compound are administered prior to the chemotherapeutic agent. In yet other aspects, the chemotherapeutic agent and the fatty acid metabolism inhibitor and the AMPK activating compound are formulated together in the same composition. In still other aspects, the chemotherapeutic agent and the fatty acid metabolism inhibitor and the AMPK activating compound are formulated in different compositions. In still another aspect, the fatty acid metabolism inhibitor and the AMPK activating compound are formulated together in the same composition and the chemotherapeutic agent is formulated in a different composition. In still yet another aspect, the fatty acid metabolism inhibitor, the AMPK activating compound and the chemotherapeutic agent are co-administered as separate dosage forms simultaneously, sequentially in any order, or separately.

[0122] In various aspects, the chemotherapeutic agent is administered as an initial bolus dose followed by one or more subsequent maintenance doses.

[0123] In some variations, there is provided a method of administering a composition comprising the chemotherapeutic agent, wherein the chemotherapeutic agent composition is administered over a period of at least one month, wherein the interval between each administration is no more than about a week. In some variations, there is provided a method of administering a composition comprising the chemotherapeutic agent, wherein the chemotherapeutic agent composition is administered over a period of at least one month, wherein the interval between each administration is no more than about a week. Traditional dosing schedule refers to the dosing schedule that is generally established in a clinical setting. For example, the tradition dosing schedule for TMZ®is 75 mg / m2 / day for 7 days as an initial bolus dose followed by 150 mg / m2 / day every 28 days.

[0124] Dosing frequency for the chemotherapeutic agent (such as TMZ) composition includes, but is not limited to, at least about any of once a week, twice a week, three times a week, four times a week, five times a week, six times a week, or daily. Typically, the interval between each administration is less than about a week, such as less than about any of 6, 5, 4, 3, 2, or 1 day. In some variations, the interval between each administration is constant. For example, the administration can be carried out daily, every two days, every three days, every four days, every five days, or weekly. In some variations, the administration can be carried out twice daily, three times daily, or more frequent.

[0125] As described, a therapeutically effective amount of a composition (i.e., an effective dosage) means an amount sufficient to produce a clinically desirable result. The compositions can be administered from one or more times per day to one or more times per week; including once every other day. Certain factors influence the dosage and timing required to effectively treat a subject, including but not limited to the severity of the disease or disorder, previous treatments, the general health and / or age of the subject, and other diseases present. Moreover, treatment of a subject with a therapeutically effective amount of the compositions of the technology can include a single treatment or a series of treatments.

[0126] Effective dose can vary, depending upon factors such as the condition of the patient, and the manner in which the pharmaceutical composition is administered. Effective dose differs from patient to patient, but in general includes amounts starting where desired therapeutic effects occur but below the amount where significant side effects are observed.

[0127] In various aspects, the fatty acid metabolism inhibitor or a pharmaceutically acceptable salt or ester thereof, is administered to the subject in a dose amount of about 2 mg, about 4 mg. about 8 mg, about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 50 mg, about 60 mg, about 70 mg, about 80 mg, about 90 mg, about 100 mg, about 110 mg, about 120 mg, about 130 mg, about 140 mg, about 150 mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about 200 mg, about 300 mg, about 400 mg, about 500 mg, about 600 mg, about 700 mg, about 800 mg, about 900, to about 1000 mg per day. In one aspect, the dose amount is between 4 mg to 400 mg per day. In one aspect, the dose amount is between 8 mg to 400 mg. In one aspect, the dose amount is between 8 mg to 200 mg. In another aspect, the dose amount is between 4 mg to 80 mg. In still another aspect, the dose amount is between 8 mg to 80 mg per day.

[0128] In various aspect, the fatty acid metabolism inhibitor is etomoxir, trimetazidine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 8 mg to about 400 mg per day.

[0129] In one preferred aspect, the fatty acid metabolism inhibitor is etomoxir. In one aspect, the etomoxir is in the R-enantiomeric form. In one aspect, the etomoxir is in the S-enantiomeric form. In yet another aspect, the etomoxir is a racemic mixture of the R and S forms of etomoxir. In one aspect, the etomoxir (R, S or racemic enantiomer form) is administered to the subject in a dose amount between 8 mg to 400 mg per day.

[0130] In various aspects, the fatty acid metabolism inhibitor is perhexiline, oxfenicine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 10 mg to about 2000 mg per day.

[0131] In various aspects, the fatty acid metabolism inhibitor is ranolazine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 150 mg to about 3000 mg per day.

[0132] In various aspects, the AMPK activating compound is metformin or a pharmaceutically acceptable salt thereof and is administered to the subject in a dose amount of about 100 mg, about 110 mg, about 120 mg, about 140 mg, about 150 mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about 200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg about 280 mg, about 290 mg, about 300 mg, about 350 mg, about 400 mg, about 450 mg, about 500 mg, about 550 mg, about 600 mg, about 650 mg, about 700 mg, about 750 mg, about 800 mg, about 850 mg, about 900 mg, about 950 mg, about 1000 mg, about 1100 mg, about 1200 mg, about 1300 mg, about 1400 mg, about 1500 mg, about 1600 mg, about 1700 mg, about 1800 mg, about 1900 mg, about 2000 mg, about 2100 mg, about 2200 mg, about 2300 mg, about 2400 mg, about 2500 mg, about 2600 mg, about 2700 mg, about 2800 mg, about 2900 mg, to about 3000 mg per day. In one aspect, the dose amount is between 20 mg to 3000 mg. In one aspect, the dose amount is between 50 mg to 2500 mg per day. In one aspect, the dose amount is between 250 mg to 2500 mg per day. In one aspect, the dose amount is between 250 mg to 500 mg per day.

[0133] In various aspects of any of the methods disclosed herein, the method further comprises administration of a therapy selected from the group consisting of radiation therapy, immunotherapy, adjuvant therapy, viral vector-mediated gene therapy, antibody-based therapy and combinations thereof.

[0134] In various aspects of any of the methods disclosed herein, the method further comprises administration of a protein kinase (PK) inhibitor, an ataxia telangiectasia-mutated (ATM) inhibitor, a mitogen-activated protein kinase inhibitor, a growth factor receptor inhibitor, or dendritic cell vaccine.

[0135] The methods disclosed herein can be expressed in terms of the preparation of a medicament. Accordingly, the instant technology encompasses the use of the agents and compositions described herein in the preparation of a medicament. The compounds described herein are useful in therapeutic compositions and regimens or for the manufacture of a medicament for use in treatment of diseases or conditions as described herein.

[0136] Any composition described herein can be administered to any part of the host’s body for subsequent delivery to a target cell. A composition can be delivered to, without limitation, the brain, the cerebrospinalfluid, joints, nasal mucosa, blood, lungs, intestines, muscle tissues, skin, or the peritoneal cavity of a mammal. In terms of routes of delivery, a composition can be administered by intravenous, intracranial, intraperitoneal, intramuscular, subcutaneous, intramuscular, intrarectal, intravaginal, intrathecal, intratracheal, intradermal, or transdermal injection, by oral or nasal administration, or by gradual perfusion over time. In a further example, an aerosol preparation of a composition can be given to a host by inhalation. In still a further example the composition and / or compounds within the composition can be administered by direct implantation of a wafer soaked with the compositions and / or compound (such as the chemotherapeutic agent).

[0137] Treatment duration can be any length of time, from as short as one day to as long as the life span of the host (e.g., many years). For example, a compound can be administered once a week (for, for example, 4 weeks to many months or years); once a month (for, for example, three to twelve months or for many years); or once a year for a period of 5 years, ten years, or longer. Treatment frequency can be variable. For example, the present compounds can be administered once (or twice, three times, etc.) daily, weekly, monthly, or yearly.

[0138] Formulation of Pharmaceutical Compositions: The compositions disclosed herein may be administered by any suitable means to achieve a concentration that, combined with other components, ameliorates, reduces, or stabilizes a cancer. The composition may be provided in dosage forms suitable for oral as well as parenteral (e.g., subcutaneous, intravenous, intramuscular, intravesicular, intratumoral or intraperitoneal) administration routes. For example, the pharmaceutical compositions are formulated according to conventional pharmaceutical practice (see, e.g., Remington: The Science and Practice of Pharmacy (20th ed.)).

[0139] Pharmaceutical compositions are formulated with appropriate excipients into a pharmaceutical composition that, upon administration, releases the therapeutic in a controlled manner. Examples include single or multiple unit tablet or capsule compositions, oil solutions, suspensions, emulsions, microcapsules, microspheres, molecular complexes, nanoparticles, patches, and liposomes. The pharmaceutical compositions embodied herein may be administered orally and / or parenterally by injection, infusion, or implantation (subcutaneous, intravenous, intramuscular, intratumoral, intravesicular, intraperitoneal) in dosage forms, formulations, or via suitable delivery devices or implants containing conventional, non-toxic pharmaceutically acceptable carriers and adjuvants. Suitable formulations can be found in Remington, supra.

[0140] Compositions comprising a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and an AMPK activating compound for parenteral use may be provided in unit dosage forms (e.g., in single-dose ampoules). Alternatively, a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and an AMPK activating compound may be provided in vials containing several doses, and in which a suitable preservative may be added (see below). The composition may be in solution, suspension, emulsion, infusion device, or a delivery device for implantation. Compositions comprising a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and an AMPK activating compound may be provided as dry powder to be reconstituted with water or another suitable vehicle before use. Apart from the active agent that reduces or ameliorates a cancer, the composition includes suitable parenterally acceptable carriers and / or excipients. The active therapeutic agent(s) may be incorporated into microspheres, microcapsules, nanoparticles, or liposomes for controlled release. Furthermore, the composition may include suspending, solubilizing, stabilizing, pH-adjusting agents, tonicity adjusting agents, and / or dispersing, agents. In a further aspect, the composition comprises a chemotherapeutic agent.

[0141] In various aspects, a composition comprising a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, an AMPK activating compound and a pharmaceutically acceptable carrier is formulated into a solid, semi-solid, or liquid form. In a further aspect, the composition comprises a chemotherapeutic agent.

[0142] In various aspects, a composition comprising a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, an AMPK activating compound, and a pharmaceutically acceptable carrier is formulated into a tablet, capsule, wafer, elixir, powder, granules, ointment, solution, inhalant or injectable. In a further aspect, the composition comprises a chemotherapeutic agent.

[0143] Compositions comprising both a fatty acid metabolism inhibitor or a pharmaceutically acceptable salt or ester thereof, and an AMPK activating compound as the active agents of the composition can be formulated for oral administration such as in the form of one or more tablets and / or as an oral solution or suspension. In one aspect, the form is a single tablet that comprises a homogenous mixture of both the fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and the AMPK activating compound. The tablet may take the form of a bilayer tablet, with one layer comprising the fatty acid metabolism inhibitor and the other layer comprising the AMPK activating compound. In a preferred aspect, one layer of the bilayer tablet comprises etomoxir (preferably the R form or racemic mixture thereof) and the other layer comprises metformin (preferably metformin hydrochloride). In one aspect, one layer of the bilayer comprises between about 20 mg and about 80 mg of etomoxir (preferably the R form or racemic mixture thereof) and the other layer of the bilayer comprises between about 40 mg and about 400 mg of metformin (preferably metformin hydrochloride). Further, the bilayer tablet may be encapsulated. In one aspect, the bilayer tablet is encapsulated under a single coating.

[0144] In still another aspect, the composition is formulated as an oral solution or suspension comprising both a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and an AMPK activating compound as the active agents. In a preferred aspect, the oral solution or suspension comprises etomoxir (preferably the R form or racemic mixture thereof) and metformin (preferably metformin hydrochloride). In one aspect, the dose of oral solution or suspension comprises between about 20 mg and about 80 mg of etomoxir (preferably the R form or racemic mixture thereof) and between about 40 mg and about 400 mg of metformin (preferably metformin hydrochloride). In one aspect, the oral solution or suspension is formulated so that it remains in a stable suspension or is able to return to a stable suspension upon agitation.

[0145] The components of the tablet and / or oral solution or suspension disclosed herein may undergo granulation or milling to achieve similar or smaller particle size. Roller compaction or other methods may then be used to achieve, for example, a solid tablet with high structural integrity. The tablet and / or oral solution or suspension may further comprise excipients, emulsifiers, solvents, preservatives, lubricants, surfactants, coloring agents, binding agents and combinations thereof.

[0146] Non-limiting examples of excipients include but are not limited to silicon dioxide, candelilla wax, maize starch, purified talc, abietinic acid, levopimaric acid, capric acid (C- 10:0), lauric acid (C-12:0), myristic acid (C-14:0), palmitic acid (C-16:0), oleic acid (C-18:1), linoleic acid (C-18:2) and combinations thereof.

[0147] Non-limiting examples of emulsifiers include but are not limited to xanthan gum, guar gum, carrageenan, cellulose gum and combinations thereof.

[0148] Non-limiting examples of dilutes / solvents include but are not limited to benzyl alcohol, fluorouracil, glycerol, acetone, phenol and combinations thereof.

[0149] Non-limiting example of surfactants include but are not limited to sodium dodecyl sulfate, sodium lauryl sulfate, polypropylene glycol, polyethylene glycol, polyvinyl alcohol, polysorbate 20, polysorbate 80, poloxamer 188, poloxamer 237, poloxamer 338, poloxamer 407 and combinations thereof.

[0150] Non-limiting examples of lubricants include but are not limited to stearic acid, magnesium stearate, calcium stearate and combinations thereof.

[0151] Non-limiting examples of preservatives include but are not limited to chlorobutanol, potassium sorbate, sodium benzoate and combinations thereof.

[0152] Non-limiting examples of coloring agents include but are not limited to red ferric oxide, yellow ferric oxide, zinc oxide, titanium dioxide, caramel, canthaxanthin, aluminum lakes, spirulina extract and combinations thereof.

[0153] Non-limiting examples of binding agents include but are not limited to lecithin, sucrose, acacia, tragacanth, gelatine, cellulose, methylcellulose, cellulose gum, xanthan gum, guar gum and combinations thereof.

[0154] Pharmaceutical compositions may be suitable for sterile injection. To prepare such a composition, the suitable active therapeutic(s) are dissolved or suspended in a parenterally acceptable liquid vehicle. Among acceptable vehicles and solvents that may be employed are water, water adjusted to a suitable pH by addition of an appropriate amount of hydrochloric acid, sodium hydroxide or a suitable buffer, 1,3-butanediol, Ringer’s solution, and isotonic sodium chloride solution and dextrose solution. The aqueous formulation may also contain one or more preservatives (e.g., methyl, ethyl or n-propyl p-hydroxybenzoate). In cases where one of the compounds is only sparingly or slightly soluble in water, a dissolution enhancing or solubilizing agent can be added, or the solvent may include 10-60% w / w of propylene glycol.

[0155] As used herein, the term "expression", when used in connection with detecting the expression of a gene, can refer to detecting transcription of the gene (i.e., detecting mRNA levels) and / or to detecting translation of the gene (detecting the protein produced). To detect expression of a gene refers to the act of actively determining whether a gene is expressed or not. This can include determining whether the gene expression is upregulated (or increased) as compared to a reference or a control, downregulated as compared to a reference or a control, or unchanged as compared to a reference or a control or increased or decreased as compared to a reference or control level. Therefore, the step of detecting or determining expression does not require that expression of the gene actually is upregulated or downregulated or increased or decreased, but rather, can also include detecting or determining that the expression of the gene has not changed (i.e., detecting no expression of the gene or no change in expression of the gene).

[0156] Expression of transcripts and / or proteins is measured by any of a variety of known methods in the art. For RNA expression, methods include but are not limited to: extraction of cellular mRNA and Northern blotting using labeled probes that hybridize to transcripts encoding all or part of the gene; amplification of mRNA using gene-specific primers, polymerase chain reaction (PCR), and reverse transcriptase-polymerase chain reaction (RT- PCR), quantitative PCR, and / or RNA Ampliseq, followed by quantitative detection of the product by any of a variety of means; multiplexed quantitative PCR enrichment of cDNA amplicons, followed by conversion of amplicons to sequence libraries and Next-generation based sequencing of libraries to generate digital count expression data; extraction of total RNA from the cells, which is then labeled and used to probe cDNAs or oligonucleotides encoding the gene on any of a variety of surfaces; in situ hybridization; microarray and detection of a reporter gene. For DNA expression, methods include Southern blotting.

[0157] Methods for assessing the sequence of nucleic acids within cells or tissues include Sanger sequencing, capillary electrophoresis and fragment analysis, as well as next-generation sequencing.

[0158] Methods to measure protein expression levels generally include, but are not limited to: mass spectrometry, Western blot, immunohistochemistry, immunocytochemistry, immunoblot, enzyme-linked immunosorbant assay (ELISA), radioimmunoassay (RIA), immunoprecipitation, surface plasmon resonance, chemiluminescence, fluorescent polarization, phosphorescence, immunohistochemical analysis, matrix-assisted laser desorption / ionization time-of-flight (MALDI-TOF) mass spectrometry, microcytometry, microarray, microscopy, fluorescence activated cell sorting (FACS), and flow cytometry, as well as assays based on a property of the protein including but not limited to enzymatic activity or interaction with other protein partners.

[0159] Methods to genotype cells or tissues from glioma subjects include karyotyping, Southern blot analysis as well as comparative genomic hybridization techniques.

[0160] Determination of genetic alterations, amplification and / or deletions, of one or more genes involved in fatty acid metabolism including but not limited to fatty acid synthase (FASN), acyl-CoA dehydrogenase short chain (ACADS), acyl-CoA dehydrogenase medium chain (ACADM), acyl-CoA dehydrogenase long chain (ACADL), acyl-CoA dehydrogenase very long chain (ACADVL), hydroxylacyl-CoA dehydrogenase trifunctional multienzyme complex subunit alpha (HADHA), carnitine palmitoyltransferase 1 A (CPT1a), carnitine palmitoyltransferase 1 B (CPT1b), carnitine palmitoyltransferase 1 C (CPT1c), and / or carnitine palmitoyltransferase 2 (CPT2) is contemplated herein for diagnostic as well as prognostic indicators for brain cancers, breast cancers and prostate cancers.

[0161] Measurement of the gene expression of key enzymes involved in fatty acid metabolism, including but not limited to fatty acid synthase (FASN), short-chain acyl CoA dehydrogenase (ACADS), medium-chain acyl CoA dehydrogenase (ACADM), long-chain acyl CoA dehydrogenase (ACADL), very long-chain acyl CoA dehydrogenase (ACADVL), hydroxyacyl-CoA dehydrogenase trifunctional multienzyme complex subunit alpha (HADHA), carnitine palmitoyltransferase IA (CPT1a), carnitine palmitoyltransferase IB (CPT1b), carnitine palmitoyltransferase IC (CPT1c), and / or carnitine palmitoyltransferase II (CPT2), as well as downstream effectors which modulate cell cycle progression, such as tumor protein P53 (TP53) or other tumor suppressor proteins such as p27, p21 and p16, within patient samples is contemplated herein. Methods contemplated include but are not limited to multiplexed qPCR and can include validation of the primers used. Alternative methods include determining gene expression levels by in situ hybridization or any other methods of quantifying mRNA.

[0162] Further, a quantitative analysis of variability in the expression of gene products involved in fatty acid metabolism and oncogenic effectors of these pathways in a statistically- relevant sample of glioblastoma patients is contemplated herein.

[0163] Still further, a quantitative analysis of survival time, in the context of upregulated or downregulated expression of key factors, in a statistically-relevant sample of glioblastoma patients is contemplated herein.

[0164] In addition, evaluation of protein expression of key enzymes involved in fatty acid metabolism (including but not limited to FASN, ACADS, ACADM, ACADL, ACADVL, HADHA, CPT1a, CPT1b, CPT1c, and / or CPT2), as well as key downstream effectors which modulate cell cycle progression, such as TP53 or other tumor suppressor proteins such as p27, p21 and p16, within patient samples is contemplated herein. Methods contemplated include but are not limited to multiplexed immunohistochemistry and can include validation of the antibodies used. Alternative methods for determining protein expression levels in cells or tissue samples include western blot, immunohistochemistry, immunocytochemistry, fluorescence- activated cell sorting, or any other method of quantifying protein.

[0165] Further, a quantitative analysis of variability in the expression of enzymatic machinery and oncogenic effectors in a statistically-relevant sample of patients with brain cancer, breast cancer or prostate cancer is contemplated herein.

[0166] Additionally, a quantitative analysis of survival time, in the context of upregulated or downregulated expression of key factors, in a statistically-relevant sample of patients with brain cancer, breast cancer or prostate cancer is contemplated herein.

[0167] In one aspect, the present invention provides any of the above-mentioned compositions may be provided in kits, optionally including instructions for use of the composition e.g., for the treatment of cancers. The "kit" typically defines a package including one or more compositions of the invention and the instructions, or homologs, analogs, derivatives, enantiomers and functionally equivalent compositions thereof. That is, the kit can include a description of use of the composition for participation in any biological or chemical mechanism disclosed herein associated with cancers. The kits can further include a description of activity of the cancers in treating the pathology, as opposed to the symptoms. The kit can include a description of use of the compositions as discussed herein. The kit also can include instructions for use of a combination of two or more compositions of the invention, or instruction for use of a combination of a composition of the invention and one or more other compounds indicated for treatment of a cancer. Instructions also may be provided for administering the composition by any suitable technique as previously described, for example, orally, intravenously, pump or implantable delivery device, or via another known route of drug delivery. The instructions may be of any form provided in connection with the composition in a manner such that a clinical professional will clearly recognize that the instructions are to be associated with the specific composition.

[0168] The kits described herein may also contain one or more containers, which may contain the inventive composition and other ingredients as previously described. The kits also may contain instructions for mixing, diluting, and / or administrating the compositions in some cases. The kits also can include other containers with one or more solvents, surfactants, preservative and / or diluents (e.g., normal saline (0.9% NaCl), or 5% dextrose) as well as containers for mixing, diluting or administering the components to a subject in need of such treatment.

[0169] The compositions of the kit may be provided as any suitable form, for example, as liquid solutions or as dried powders. When the composition provided is a dry powder, the composition may be reconstituted by the addition of a suitable solvent, which may also be provided. In embodiments where liquid forms of the composition are used, the liquid form may be concentrated or ready to use. The solvent will depend on the active compound(s) within the composition and the mode of use or administration. Suitable solvents are well known, for example as previously described, and are available in the literature. The solvent will depend on the compound and the mode of use or administration.

[0170] The following experimental results are provided for purposes of illustration and are not intended to limit the scope of the invention. EXAMPLES

[0171] Experiments referred to in Examples 1 and 2 are conducted in vitro using serum-free human glioma cell cultures which have been shown to maintain their original genetic and epigenetic characteristics and are understood to be more suitable for drug testing for that reason (Pollard, S. M., et al. (2009). "Glioma stem cell lines expanded in adherent culture have tumor- specific phenotypes and are suitable for chemical and genetic screens." Cell stem cell 4(6): 568-580). Additional experiments are conducted in vitro using serum-free mouse-derived cell cultures which have been oncogenically transformed to mimic human glioma cells (Lin, H., et al. Neuro Oncology. 2017; 19(1):43-54; Mikheev AM et al. “Increased age of transformed mouse neural progenitor / stem cells recapitulates age-dependent clinical features of human glioma malignancy”; Aging Cell. 2012; 11(6):1027-35; Mikheev AM et al. “A syngeneic glioma model to assess the impact of neural progenitor target cell age on tumor malignancy”; Aging Cell. 2009; 8(4):499-501). Experiments are conducted in vivo using a state-of-the-art orthotopic, syngeneic, mouse model of malignant glioma with clinically-validated features of the human disease (Lin, H., et al. Neuro Oncology. 2017; 19(1):43-54; Mikheev AM et al. Aging Cell.2012; 11(6):1027-35; Mikheev AM et al. Aging Cell.2009; 8(4):499-501).

[0172] Example 1 In Vitro Studies—Etomoxir (ETX), metformin (MTF) and temozolomide (TMZ) combination treatment:

[0173] 1) Cell respiration: Primary-cultured human glioma cells and mouse glioma-initiating cells are assessed for respiratory activity upon treatment with ETX, MTF, and TMZ (alone and in combination,) – such as by plate reader-based colorimetric enzyme assays (in isolated mitochondria), and / or metabolic flux analysis (with live cells) (see Figs.7A-7B).

[0174] 2) Cell growth: Primary-cultured human glioma cells and mouse glioma-initiating cells are assessed for proliferative activity upon treatment with ETX, MTF, and TMZ (alone and in combination) – such as by KI67 index, FACS-based mitotic profiling, viability assays, cell counts, and / or live-cell imaging (see Figs.8A-8C).

[0175] 3) Mechanism of Action: Primary-cultured human glioma cells and mouse glioma- initiating cells are assessed for expression and activation of tumor suppressor proteins (such as by western blot analysis) in cell samples (see Fig.9).

[0176] Example 2 Determination of genetic alterations, amplification and / or deletions, of one or more genes involved in fatty acid metabolism including but not limited to FASN, ACADS, ACADM, ACADL, ACADVL, HADHA, CPT1a, CPT1b, CPT1c, and / or CPT2 is determined.

[0177] As shown in Figs 2-6, Kaplan-Meier Survival Plots for human glioma samples with varying expression levels, or amplification or deletion of key metabolic genes, were produced using the REMBRANDT database. Lower expression of short-chain acyl-coA dehydrogenase, long-chain acyl-coA dehydrogenase and very-long-chain acyl-coA dehydrogenase are associated with longer survival time in patients with glioma. Deletion of the medium-chain acyl-coA dehydrogenase gene (ACADM), important in fatty acid oxidation, is associated with significantly better patient survival, while amplification of the hexokinase gene (HK), important in glucose metabolism, is associated with better patient survival.

[0178] Example 3 Treatment with the combination of etomoxir and metformin is anticipated to decrease KI67+ proliferation index in cancer cells.

[0179] Human-derived cancer cells are treated with vehicle control (CONTROL), etomoxir (ETX), metformin (MTF), or a combination of the two drugs (COMBO). The total live cell count is assessed with Hoechst nuclear dye and the fraction of dividing cells is assessed using a KI67 primary antibody and a rabbit Cy2-conjugated secondary antibody. Results are assessed in bladder cancer cells (e.g. T24, a muscle-invading bladder carcinoma cell line); pancreatic cancer cells (e.g. SNU-324, an aggressive pancreatic ductal adenocarcinoma cell line); lung cancer cells (e.g. NCI-H446, an aggressive small-cell lung carcinoma cell line); breast cancer cells, e.g. CRL-3180, a triple-negative epithelial-like breast adenocarcinoma cell line); prostate cancer cells (e.g. CRL-2876, a hormone-responsive epithelial-like prostate adenocarcinoma cell line); and skin cancer cells (e.g. A375, a malignant melanoma cell line). It is anticipated that the KI67+ index decreases significantly with single agent treatment, compared with vehicle control, and the KI67+ index decreases significantly with combination treatment, compared with single agent treatment (statistical comparison by two-tailed t-test).

[0180] Example 4 Treatment with the combination of etomoxir and metformin is anticipated to increase Trypan Blue+ death index in cancer cells.

[0181] Human-derived cancer cells are treated with vehicle control (CONTROL), etomoxir (ETX), metformin (MTF), or a combination of the two drugs (COMBO). The fraction of dead and damaged cells is quantified with Trypan Blue stain, in each of the treatment groups. Results are assessed in bladder cancer cells (e.g. T24, a muscle-invading bladder carcinoma cell line); pancreatic cancer cells (e.g. SNU-324, an aggressive pancreatic ductal adenocarcinoma cell line); lung cancer cells (e.g. NCI-H446, an aggressive small-cell lung carcinoma cell line); breast cancer cells, e.g. CRL-3180, a triple-negative epithelial-like breast adenocarcinoma cell line); prostate cancer cells (e.g. CRL-2876, a hormone-responsive epithelial-like prostate adenocarcinoma cell line); and skin cancer cells (e.g. A375, a malignant melanoma cell line). It is anticipated that the Trypan Blue+ index increases significantly with single agent treatment, compared with vehicle control, and the KI67+ index decreases significantly with combination treatment, compared with single agent treatment (statistical comparison by two-tailed t-test).

[0182] Example 5 Kaplan-Meier survival curves after combination treatment in vivo.

[0183] The effects of etomoxir (ETX), metformin (MTF), standard-of-care chemotherapy (CHEMO), and combination treatment with ETX and MTF (COMBO) are evaluated in the context of a blinded, placebo-controlled preclinical efficacy study. Orthotopic tumor models are used to evaluate the effects of each drug treatment on malignant growth, in bladder cancer, pancreatic cancer, lung cancer, breast cancer, prostate cancer, and skin cancer. It is anticipated that mice treated with ETX survive significantly longer than mice treated with vehicle control, and mice treated with a two-drug combination of ETX and MTF live significantly longer than mice treated only with vehicle control.

[0184] While various embodiments of the composition and methods disclosed herein have been described above, it should be understood that they have been presented by way of example only, and not limitation. Numerous changes to the disclosed embodiments can be made in accordance with the disclosure herein. Thus, the breadth and scope of the claimed technology should not be limited by any of the above described embodiments.

[0185] All documents mentioned herein are incorporated herein by reference. All publications and patent documents cited in this application are incorporated by reference for all purposes to the same extent as if each individual publication or patent document were so individually denoted. By their citation of various references in this document, applicants do not admit any particular reference is “prior art” to their technology.

[0186] All publications and patent applications herein are incorporated by reference to the same extent as if each individual publication or patent application were specifically and individually indicated to be incorporated by reference. Where a definition or use of a term in an incorporated reference is inconsistent or contrary to the definition of that term provided herein, the definition of that term provided herein applies and the definition of that term in the reference does not apply.

Claims

What is Claimed is:

1. A method of treating cancer in a subject in need thereof, comprising administering to the subject, a therapeutically effective amount of a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and a therapeutically effective amount of an adenosine monophosphate-activated protein kinase (AMPK) activating compound or pharmaceutically acceptable salt thereof.

2. The method of claim 1, wherein the cancer is a solid tumor.

3. The method of claim 2, wherein the solid tumor is a primary malignant brain tumor.

4. The method of claim 3, wherein the primary malignant brain tumor is a glioma.

5. The method of claim 1 or claim 2, wherein the cancer is selected from the group consisting of brain cancer, bladder cancer, lung cancer, pancreatic cancer, melanoma, breast cancer and prostate cancer.

6. The method of any one of claims 1-5, wherein the cancer is resistant to chemotherapy treatment.

7. The method of any one of claims 1-5, further comprising administering a chemotherapeutic agent to the subject.

8. A method of reducing cancer cell proliferation and / or tumor growth in a subject in need thereof, comprising administering to the subject, a therapeutically effective amount of a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and a therapeutically effective amount of an AMPK activating compound or pharmaceutically acceptable salt thereof.

9. A method of preventing cancer cells from recovering from chemotherapeutic injury in a subject in need thereof, comprising administering to the subject, a therapeutically effective amount of a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, and a therapeutically effective amount of an AMPK activating compound or pharmaceutically acceptable salt thereof.

10. The method of any one of claims 1, 8 or 9, wherein the fatty acid metabolism inhibitor is selected from the group consisting of etomoxir, perhexiline, oxfenicine, ranolazine, trimetazidine and pharmaceutically acceptable salts or esters thereof.

11. The method of claim 10, wherein the fatty acid metabolism inhibitor is etomoxir, trimetazidine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 8 mg to about 400 mg per day.

12. The method of any one of claims 1-11, wherein the fatty acid metabolism inhibitor is etomoxir and is in the R-enantiomeric form.

13. The method of claim 10, wherein the fatty acid metabolism inhibitor is perhexiline, oxfenicine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 10 mg to about 2000 mg per day.

14. The method of claim 10, wherein the fatty acid metabolism inhibitor is ranolazine, or a pharmaceutically acceptable salt or ester thereof, and is administered to the subject in a dose amount of about 150 mg to about 3000 mg per day.

15. The method of any one of claims 1, 8 or 9, wherein the fatty acid metabolism inhibitor or a pharmaceutically acceptable salt or ester thereof is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intranasal delivery, intravenous delivery, intrathecal injection, intracranial placement and combinations thereof.

16. The method of any one of claims 1, 8 or 9, wherein the AMPK activating compound is selected from the group consisting of a biguanide, a polyphenol, and a thiazolidinedione.

17. The method of claim 16, wherein the biguanide is metformin or a pharmaceutically acceptable salt thereof.

18. The method of claim 16, wherein the polyphenol is selected from the group consisting of resveratrol, quercetin, genestein, epigallocatechin-3-gallate, berberine, and curcumin.

19. The method of claim 16, wherein the thiazolidinedione is selected from the group consisting of troglitazone, pioglitazone, and rosiglitazone.

20. The method of claim 17, wherein the AMPK activating compound is metformin or a pharmaceutically acceptable salt thereof and is administered to the subject in a dose amount of about 250 mg to 2500 mg per day.

21. The method of any one of claims 1, 8 or 9, wherein the AMPK activating compound or a pharmaceutically acceptable salt thereof is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intranasal delivery, intravenous delivery, intrathecal injection, intracranial placement and combinations thereof.

22. The method of any one of claims 8-21, further comprising administering a chemotherapeutic agent to the subject.

23. The method of claim 7 or 22, wherein the chemotherapeutic agent is an imidazotetrazinone.

24. The method of claim 23, wherein the imidazotetrazinone is temozolomide (TMZ) or an analog thereof.

25. The method of claim 7 or 22, wherein the chemotherapeutic agent is selected from the group consisting of procarbazine, lomustine, and vincristine.

26. The method of claim 7 or 22, wherein the chemotherapeutic agent is an alkylating-like agent selected from the group consisting of cisplatin, carboplatin, loboplatin, oxaliplatin, and nedaplatin.

27. The method of claim 7 or 22, wherein the chemotherapeutic agent is administered to the subject by an administration delivery route selected from the group consisting of oral delivery, intracranial delivery, intramuscular delivery and intravenous delivery.

28. The method of claim 7 or 22, wherein the chemotherapeutic agent is administered orally.

29. The method of claim 7 or 22, wherein the chemotherapeutic agent is administered to the subject in an initial bolus dose followed by a maintenance dose.

30. The method of any one of claims 1-29, wherein the fatty acid metabolism inhibitor and the AMPK activating compound are co-administered as separate dosage forms simultaneously, sequentially in any order, or separately.

31. The method of any one of claims 1-29, wherein the fatty acid metabolism inhibitor and the AMPK activating compound are administered as a single composition.

32. The method of claim 31, wherein the single composition is in the form of a tablet or oral suspension or solution.

33. The method of claim 32, wherein the tablet is in the form of a bilayer tablet, wherein one layer of the bilayer tablet comprises the fatty acid metabolism inhibitor and the other layer comprises the AMPK activating compound.

34. The method of claim 7 or 22, wherein the fatty acid metabolism inhibitor, the AMPK activating compound and the chemotherapeutic agent are co-administered as separate dosage forms simultaneously, sequentially in any order, or separately.

35. The method of claim 7 or 22, wherein the fatty acid metabolism inhibitor and the AMPK activating compound are administered as a single composition and wherein the chemotherapeutic agent is administered in a different composition.

36. The method of claim 35, wherein the single composition comprising the fatty acid metabolism inhibitor and the AMPK activating compound is in the form of a tablet or oral suspension or solution.

37. The method of claim 36, wherein the tablet is in the form of a bilayer tablet, wherein one layer of the bilayer tablet comprises the fatty acid metabolism inhibitor and the other layer comprises the AMPK activating compound.

38. The method of any one of claims 1 to 37, wherein the method further comprises administration of a therapy selected from the group consisting of radiation therapy, immunotherapy, adjuvant therapy, viral vector-mediated gene therapy, antibody-based therapy, and combinations thereof.

39. The method of any one of claims 1 to 38, wherein the method further comprises administration of a protein kinase (PK) inhibitor, an ataxia telangiectasia-mutated (ATM) inhibitor, a mitogen-activated protein kinase inhibitor, a growth factor receptor inhibitor, or dendritic cell vaccine.

40. A pharmaceutical composition comprising a fatty acid metabolism inhibitor or pharmaceutically acceptable salt or ester thereof, an AMPK activating compound and a pharmaceutically acceptable carrier.

41. The composition of claim 40, wherein the composition is formulated into a solid, semi- solid, or liquid form.

42. The composition of claim 40, wherein the composition is formulated into a tablet, capsule, wafer, elixir, powder, granules, ointment, solution, inhalant or injectable.

43. The composition of claim 42, wherein the tablet is formulated into bilayer tablet, wherein one layer of the bilayer tablet comprises the fatty acid metabolism inhibitor and the other layer comprises the AMPK activating compound.

44. The composition of claim 42, wherein the composition is formulated into an oral solution or suspension.

45. The composition of any one of claims 40-44, further comprising a chemotherapeutic agent.

46. A kit comprising: a) a fatty acid metabolism inhibitor; b) an AMPK activating compound; and c) instructions for use of the kit.

47. The kit of claim 46, wherein the kit further comprises a chemotherapeutic agent.

48. The kit of claim 46, wherein the fatty acid metabolism inhibitor is in one container and the AMPK activating compound is in a second container.

49. The kit of claim 46, wherein the fatty acid metabolism inhibitor is in one container, the AMPK activating compound is in a second container and the chemotherapeutic agent is in a third container.

50. The kit of claim 46, wherein the kit comprises a bilayer tablet wherein one layer of the bilayer tablet comprises the fatty acid metabolism inhibitor and the other layer comprises the AMPK activating compound.

51. The kit of claim 47, wherein the fatty acid metabolism inhibitor and the AMPK activating compound are in one container and wherein the chemotherapeutic agent is in a separate container.

52. A method to identify and treat a subject having a solid tumor responsive to treatment with a fatty acid metabolism inhibitor, the method comprising: a. determining the subject’s expression level of one or more fatty acid oxidation enzymes and / or tumor suppressor proteins in a tumor tissue sample from the subject; b. identifying the subject as responsive to treatment with the fatty acid metabolism inhibitor; and c. treating the subject identified in step b with a composition comprising a fatty acid metabolism inhibitor.

53. The method of claim 52, wherein the fatty acid metabolism inhibitor is etomoxir.

54. The method of claim 53, wherein the solid tumor is a malignant brain tumor.

55. A method to identify and treat a subject having a solid tumor responsive to treatment with a composition comprising a fatty acid metabolism inhibitor, the method comprising: a. determining alteration in the expression or sequence of one or more genes involved in fatty acid metabolism in a tumor tissue sample from the subject; b. determining alteration in the expression or sequence of one or more genes whose products play a role in cell cycle control and which are normally activated by etomoxir in a tumor tissue sample from the subject; c. identifying the subject as responsive to treatment with the fatty acid metabolism inhibitor; and d. treating the subject identified in step c with a fatty acid metabolism inhibitor.

56. The method of claim 55, wherein the fatty acid metabolism inhibitor is etomoxir.

57. The method of claim 55, wherein the solid tumor is a malignant brain tumor.

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