Menin inhibitors for the treatment of myeloproliferative neoplasms

Abstract

The present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, optionally in combination with one or more therapeutically active agent, for treating, preventing, reducing the progression rate, and / or reducing the severity of myeloproliferative neoplasms (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera), and pharmaceutical compositions containing the same for treating, preventing, reducing the progression rate, and / or reducing the severity of myeloproliferative neoplasms (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

Description

[0001] Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0002] MENIN INHIBITORS FOR THE TREATMENT OF MYELOPROLIFERATIVE

[0003] NEOPLASMS

[0004] RELATED APPLICATIONS

[0005] This Application claims priority to, and the benefit of, U.S. Provisional Application Nos. 63 / 857,372, filed on August 4, 2025, and 63 / 706,402, filed on October 11, 2024, the entire contents of each of which are incorporated herein by reference.

[0006] BACKGROUND

[0007] Myeloproliferative neoplasms (MPNs) are hematologic neoplasms that arise from neoplastic hematopoietic myeloid progenitor cells in the bone marrow, such as the precursor cells of red cells, platelets and granulocytes.

[0008] Among these, myelofibrosis (MF) is a type of bone marrow cancer which disrupts the normal production of blood cells with low median survival ranges. Treatment options for myelofibrosis are limited and mortality remains high; therefore, there is currently an unmet medical need for developing therapeutics.

[0009] Menin inhibitors (including Revumenib) are new and promising agents currently in clinical development for targeting leukemogenesis in histone-lysine N-methyltransferase 2A- rearranged (KMT2Ar) and in NPMl-mutated (NPMlmut) acute leukemias. The mechanism of action of this new class of agents is based on the disruption of the menin-KMT2A complex (consisting of chromatin remodeling proteins), leading to the differentiation and apoptosis of AML cells expressing KMT2A or with mutated NPM1.

[0010] SUMMARY

[0011] Without wishing to be bound by any theory, in some aspects the present disclosure is directed to compounds which inhibit production of human megakaryocyte (MK) cells.

[0012] In some aspects, the present disclosure provides a method of treating a myeloproliferative neoplasm in a subject in need thereof comprising administering a menin inhibitor disclosed herein, or a pharmaceutically acceptable salt thereof, to the subject.

[0013] In some aspects, the myeloproliferative neoplasm is a BCR-ABL negative myeloproliferative neoplasm.

[0014] In some aspects, the myeloproliferative neoplasm is myelofibrosis, essential thrombocythemia, triple negative MPN, or polycythemia vera.

[0015] In some aspects, the myeloproliferative neoplasm is myelofibrosis. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0016] In some aspects, the myeloproliferative neoplasm is essential thrombocythemia.

[0017] In some aspects, the myeloproliferative neoplasm is triple negative MPN.

[0018] In some aspects, the myeloproliferative neoplasm is polycythemia vera.

[0019] In some aspects, the present disclosure provides a method of treating myelofibrosis in a subject in need thereof comprising administering a menin inhibitor disclosed herein, or a pharmaceutically acceptable salt thereof, to the subject.

[0020] In some aspects, the present disclosure provides a method of treating bone marrow fibrosis in a subject in need thereof comprising administering a menin inhibitor disclosed herein, or a pharmaceutically acceptable salt thereof, to the subject.

[0021] In some aspects, the menin inhibitor or the pharmaceutically acceptable salt thereof is a small molecule, or a pharmaceutically acceptable salt thereof.

[0022] In some aspects, the menin inhibitor is a compound of Table 1, or a pharmaceutically acceptable salt thereof.

[0023] In some aspects, the menin inhibitor is Compound No. 1, or a pharmaceutically acceptable salt thereof.

[0024] In some aspects, the myelofibrosis is characterized by a JAK gene mutation, a CALR gene mutation, or a MPL gene mutation.

[0025] In some aspects, the myelofibrosis is characterized by a JAK1, JAK2, JAK3, CALR type 1, CALR type 2, or MPL W515L gene mutation.

[0026] In some aspects, the myelofibrosis is characterized by a JAK2V617Fgene mutation.

[0027] In some aspects, the method further includes administering a second therapeutically active agent.

[0028] In some aspects, the second therapeutically active agent is a JAK inhibitor.

[0029] In some aspects, the second therapeutically active agent is ruxolitinib, fedratinib (SAR302503), momelotinib (CYT387), pacritinib, lestaurtinib, AZD-1480, BMS-911543, NS- 018, LY2784544, SEP-701, XL019, or AT-9283.

[0030] In some aspects, the second therapeutically active agent is ruxolitinib.

[0031] In some aspects, the present disclosure provides use of a menin inhibitor disclosed herein or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating a myeloproliferative neoplasm.

[0032] In some aspects, the present disclosure provides use of a menin inhibitor disclosed herein or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating myelofibrosis. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0033] In some aspects, the present disclosure provides use of a menin inhibitor disclosed herein or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating bone marrow fibrosis.

[0034] In some aspects, the present disclosure provides use of a menin inhibitor disclosed herein, or a pharmaceutically acceptable salt thereof, for treating a myeloproliferative neoplasm in a subject in need thereof.

[0035] In some aspects, the present disclosure provides use of a menin inhibitor disclosed herein, or a pharmaceutically acceptable salt thereof, for treating myelofibrosis in a subject in need thereof.

[0036] In some aspects, the present disclosure provides use of a menin inhibitor disclosed herein, or a pharmaceutically acceptable salt thereof, for treating bone marrow fibrosis in a subject in need thereof.

[0037] In some aspects, the present disclosure provides a pharmaceutical composition comprising a menin inhibitor of Table 1, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm.

[0038] In some aspects, the present disclosure provides a pharmaceutical composition comprising a menin inhibitor of Table 1, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

[0039] In some aspects, the present disclosure provides a pharmaceutical composition comprising a menin inhibitor of Table 1, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating bone marrow fibrosis.

[0040] In some aspects, the present disclosure provides a pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of Table 1, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm.

[0041] In some aspects, the present disclosure provides a pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of Table 1, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

[0042] In some aspects, the present disclosure provides a pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of Table 1, and at least one Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating bone marrow fibrosis.

[0043] In some aspects, the present disclosure provides a kit comprising a menin inhibitor disclosed herein or a pharmaceutically acceptable salt thereof, and instructions for its use, wherein the kit is used for treating a myeloproliferative neoplasm.

[0044] In some aspects, the present disclosure provides a kit comprising a menin inhibitor disclosed herein or a pharmaceutically acceptable salt thereof, and instructions for its use, wherein the kit is used for treating myelofibrosis.

[0045] In some aspects, the present disclosure provides a kit comprising a menin inhibitor disclosed herein or a pharmaceutically acceptable salt thereof, and instructions for its use, wherein the kit is used for treating bone marrow fibrosis.

[0046] In some aspects, the present disclosure provides a kit comprising a pharmaceutical composition disclosed herein and instructions for its use, wherein the kit is used for treating a myeloproliferative neoplasm.

[0047] In some aspects, the present disclosure provides a kit comprising a pharmaceutical composition disclosed herein and instructions for its use, wherein the kit is used for treating myelofibrosis.

[0048] In some aspects, the present disclosure provides a kit comprising a pharmaceutical composition disclosed herein and instructions for its use, wherein the kit is used for treating bone marrow fibrosis.

[0049] In some embodiments, administration of menin-KMT2A complex disruptors (z.e., menin inhibitors) inhibit production of human MK cells from CD34+ progenitor cells in colony forming assays. Menin inhibitors are shown herein to deplete a specific cell population, the megakaryocyte precursor (MKP) population in healthy CD34+ cell cultures. Megakaryocyte progenitor cells carrying genetic driver mutations (e.g., JAK2V617F, CALR, or MPL) in myelofibrosis. In some embodiments, administration of menin-KMT2A complex disruptors (z.e., menin inhibitors) inhibit production of human MK cells from CD34+ progenitor cells in colony forming assays. Menin inhibitors are shown herein to deplete a specific cell population, the megakaryocyte precursor (MKP) population in healthy CD34+ cell cultures. Megakaryocyte progenitor cells carrying genetic driver mutations (e.g., JAK2V6I7F, CALR, or MPL) in bone marrow fibrosis.

[0050] The details of the disclosure are set forth in the accompanying description below. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present application, illustrative methods and materials are now Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) described. In the case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and are not intended to be limiting. Other features, objects, and advantages of the disclosure will be apparent from the description and from the claims. In the specification and the appended claims, the singular forms also include the plural unless the context clearly dictates otherwise. 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 this disclosure belongs.

[0051] BRIEF DESCRIPTION OF THE FIGURES

[0052] FIG. 1 illustrates the dose response plots for the compounds on human megakaryocyte progenitor proliferation produced by GraphPad Prism 8.

[0053] FIGs. 2A-2D illustrate that menin acts as a potential target in MF: Compound No. 1 depleted about 90% of the megakaryocyte precursor (MKP) cell population. In FIG. 2D, the graph on the left corresponds to untreated human CD34+ cells and the graph on the right corresponds to human CD34+ cells treated with Compound No. 1.

[0054] FIGs. 3A-3C illustrate that menin inhibitors selectively inhibit megakaryocyte progenitors in comparison to total erythroid progenitors and myeloid progenitors.

[0055] FIGs. 4A-4B illustrate the dose response plots for compounds on human megakaryocyte progenitor proliferation.

[0056] FIGs. 5A-5G illustrate the effect of Compound No. 1 on formation of megakaryocyte proliferation; a) granulocyte / macrophage and burst forming unit-erythroid b) colonies from human CD34+cells, c) schematic for assaying the effect of Compound No. 1 on megakaryocyte development in vitro. d,e) Effect of Compound No. 1 on generation of immature CD41+CD42‘ and mature CD41+CD42+megakaryocytes from CD34+cells, (e) Representative flow cytometry plots. f,g) Effect of Compound No. 1 on generation of CD41+MEP cells. Percentage and absolute numbers are shown in FIG 5F. (g) Representative flow cytometry plots. Data were analyzed for statistical significance by paired Student’s T-test. * p<0.05; *** p<0.001; **** pO.OOOl.

[0057] FIGs. 6A-6E illustrate menin inhibitors inhibit megakaryocytic cell cycle and induces apoptosis, a) Ploidy states of CD41+CD42+megakaryocytes derived in liquid culture from human CD34+cells in the absence or presence of Compound No. 1. (b,c) Percentages of Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) apoptotic (b) CD41+CD42‘ and (c) CD41+CD42+megakaryocytes in the absence or presence of Compound No. 1. (d,e) Percentages of Gl, S and G2 / M phase cells in (d) CD41+CD42‘ and (e) CD41+CD42+megakaryocytes in the absence or presence of Compound No. 1. Data were analyzed for statistical significance by paired Student’s T Test. *p<0.05; **p<0.01.

[0058] FIGs. 7A-D illustrate scRNA-seq data for menin inhibitor treatment human CD34+cells, a) Gating strategy to enrich for MEP cells from liquid cultures, b) Quality control analysis of the scRNA-data for the 11 primary samples, c) UMAP projection of the 11 clusters as defined in FIGs 8A-8E. d) Feature plots highlighting expression of lineage defining genes, including MPO and ELAINE (myeloid cells) and ITGA2B (megakaryocytes).

[0059] FIGs 8A-8E illustrate menin inhibitors negatively impact megakaryocyte progenitors, a) Uniform manifold approximation and projection (UMAP) of fourteen cell clusters that can be grouped into five cell populations, including early and late megakaryocyte progenitors (MKP), common myeloid progenitors (CMP), megakaryocyte erythroid progenitor (MEP), and early erythroid progenitor (ERP). b) Annotation of cell populations by expression of representative genes, c) Heat map depicting expression levels of genes that define each of the five clusters, d) Effect of Compound No. 1 on the 5 cell populations, e) Violin plots of the expression levels of the KMT2A / menin target gene MEIS1 in the five cell clusters in the absence or presence of Compound No. 1. The effect of Compound No. 1 on MEIS1 expression in MEPs is highlighted on the right. **** p<0.0001.

[0060] FIGs. 9A-9B illustrate expression levels of KMT2A / menin target genes MEF2C (a) and PBX3 (b) in the five cell populations, as defined in FIGs 8A-8E. ****p<0.0001.

[0061] FIGs. 10A-10I illustrate loss of MEN1 phenocopies the effect of Compound No. 1 in cultured CD34+cells, a) Indel frequency in CD34+cells 72 hours after nucleofection of two independent sgRNAs targeting MEN1. b,c) Effect of MEN1 knockout on generation of immature CD41+CD42‘ and mature CD41+CD42+megakaryocytes. Representative flow cytometry plots are shown in c. d,e) Effect of MEN1 knockout on megakaryocyte ploidy. Representative flow cytometry plots are shown in e. f,g) Effect oiMENl knockout on apoptosis of immature and mature megakaryocytes. Representative flow cytometry plots are shown in g. h,i) Effect of MEN1 knockout on percentage and absolute number of CD41+MEP cells. Representative flow cytometry plots are shown in i. j) UMAP projections of CMP, MEP, ERP, and megakaryocytes populations from the control versus MEN1 knockout cultures. Changes in cell counts and percentages are shown on the right. Data were analyzed for statistical Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) significance by paired one way ANOVA. * p<0.05; ** p<0.01; *** p<0.001; **** p<0.0001. NS, not significant.

[0062] FIGs. 11 A-l IE illustrate additional scRNA-seq analysis for Menin knockout in human CD34+ cells, a) Quality control analysis of the scRNA-seq data for the 18 samples, b) UMAP projection of the clusters for the entire collection of cells, c) Feature plots highlighting expression of lineage defining genes, including MPO and ELAINE (myeloid cells) and ITGA2B (megakaryocytes), d) Re-clustering and UMAP by filtering out myeloid clusters from (b) only focusing on early and late megakaryocyte progenitors (MKP), common myeloid progenitors (CMP), megakaryocyte erythroid progenitors (MEP), megakaryocytes (MK1 and MK2), and erythroid progenitors (ERP). e) Annotation of cell populations by expression of representative genes.

[0063] FIG 12 illustrates MEN1 knockout leads to suppression of megakaryocyte populations with concomitant increase in CMPs and MEPs.

[0064] FIGs. 13A-13J illustrate menin inhibitors are potent anti-tumor agents in the JAK2V671F mouse model of MPNs. a) Study scheme, b-g) Peripheral blood counts (b-e), GFP+burden (f), and body weight (g) of animals fed control chow or chow containing 0.25% Compound No. 1. h) Spleen weight at sacrifice, i) Reticulin grade for marrows from control or Compound No. 1 fed mice, j) H&E (upper) and reticulin (lower) staining of bone marrows from mice fed with control or Compound No. 1 chow. Original magnification, 10X. Data were analyzed for statistical significance by non-paired Student’s T test. * p<0.05; ** p<0.01.

[0065] FIGs. 14A-14J illustrates the combination of a menin inhibitors and JAK inhibitors have potent anti-tumor effects in the JAK2V617F MPN animal model, a) Study schema, b-g) Peripheral blood counts (b-e), and body weight (f) of animals fed control chow or chow containing 0.25% Compound No. 1. g,h) Spleen (g) and liver (h) weights at sacrifice, i) Level of engraftment of the transplanted CD45.2 cells, j) Percentages of CD41+cells in the marrow of the mice at sacrifice. Ruxolitinib was administered at 90 mg / kg. Data were analyzed for statistical significance by non-paired one-way ANOVA. * p<0.05; ** p<0.01; **** p<0.0001. NS, not significant.

[0066] FIGs. 15A-15K illustrate dose response in MPLW515L model of myelofibrosis, a) Study scheme, b-e) Peripheral blood counts over the course of the study, f) Percentage of GFP+ cells in the peripheral blood over time, g-i) Body (g), liver (h), and spleen (i) weights, j) Degree of bone marrow fibrosis, k) Kaplan-Meier survival curve of the mice. The treatment interval is Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) shaded. Data were analyzed for statistical significance by non-paired one-way ANOVA. * p<0.05; ** p<0.01; **** p<0.0001. NS, not significant.

[0067] FIGs. 16A-16M illustrate menin inhibitors are active in the MPLW515L mouse model of myelofibrosis as a single agent and in combination with JAK inhibitors, a) Study schema, b-g) Peripheral blood counts (b-e), GFP+ burden (f), and body weight (g) of animals fed control chow or chow containing 0.1% Compound No. 1, i.p. injected captisol or ruxolitinib, or treated with combination of chow containing 0.1% Compound No. 1 with ruxolitinib. h,i) Spleen (h) and liver (i) weights at sacrifice, j) Levels of TGF-b in plasma from mice at the time of sacrifice, k) Percentage of megakaryocytes in the bone marrow in the different groups of mice at sacrifice. 1) Degree of fibrosis in the bone marrow, m). Kaplan-Meier survival curve of MPLW515L mice. Ruxolitinib was administered at 90 mg / kg. Data were analyzed for statistical significance by non-paired one-way ANOVA. * p<0.05; ** p<0.01; *** p<0.001; **** p<o 0001. NS, not significant.

[0068] FIGs. 17A-17I illustrate menin inhibition is effective in the MPLS504N model of myelofibrosis, a) Study schema, b-e) Peripheral blood counts of animals fed control chow or chow containing 0.1% Compound No. 1. f,g) Spleen (f) and liver (g) weights at sacrifice, h) Percentage of megakaryocytes in the bone marrow, i) Degree of bone marrow fibrosis. Data were analyzed for statistical significance by the non-paired Student’s T test. ** p<0.01; *** p<0.001. NS, not significant.

[0069] FIGs. 18A-18G illustrate menin inhibition reduces the growth of human MF stem and progenitor cells in vitro, a) Effect of Compound No. 1 on CFU-MK activity in primary MF patient samples. b,c) Effect of Compound No. 1 on derivation of CD41+CD42‘ and CD41+CD42+megakaryocytes from human MF specimens. Individual patient samples (b) and representative flow cytometry data (c) are shown. d,e) Ploidy state of CD41+CD42+megakaryocytes derived from MF patient samples. Individual patient samples (d) and representative flow cytometry data (e) are shown. f,g) Percentages and absolute numbers of CD41+MEPs derived from human MF specimens in the absence or presence of Compound No. 1. Individual patient samples (f) and representative flow cytometry data (g) are shown. Data were analyzed for statistical significance by paired Student’s T test. *p<0.05, ***p<0.001.

[0070] FIGs. 19A-19J illustrate knockout of MEIS1 phenocopies megakaryocyte defects induced by Compound No. 1, but its overexpression is not sufficient to rescue megakaryopoiesis following Compound No. 1 treatment, a) Frequency of indels following Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0071] CRISPR targeting of MEIS1 in human CD34+cells, b) Percentages of CD41+CD42‘ and CD41+CD42+cells in cultures with control guides orthose targeting MEIS1. c) Effect oiMEISl loss on ploidy state of CD41+CD42+megakaryocytes. d,e) Percentages (d) and absolute numbers (e) of CD41+MEPs generated in human CD34+cultures with control guides or those targeting MEIS1. f) Percentages of CD41+CD42‘ and CD41+CD42+cells generated following overexpression of MEIS1 in liquid culture of human CD34+cells treated with vehicle or Compound No. 1. g,h) Percentages (g) and absolute numbers (h) of CD41+MEPs generated following overexpression oiMEISl in liquid culture of human CD34+cells treated with vehicle or Compound No. 1. i,j) Western blot and qRT-PCR for MEIS 1 in cultures of vector or MEI SI transduced cells. Data were analyzed for statistical significance by paired one-Way ANOVA.

[0072] * p<0.05, *** p<0.001. NS, not significant.

[0073] FIGs 20A-20J illustrate loss oiMENl an MEISl inhibit megakaryopoiesis in human MF specimens, a) Frequency of indels following CRISPR targeting of MEN1 in human MF specimens, b) Percentages of CD41+CD42‘ and CD41+CD42+cells in MF cultures with control guides or those targeting MEN1. c) Effect of MEN1 loss on ploidy state of CD41+CD42+ megakaryocytes. d,e) Percentages (d) and absolute numbers (e) of CD41+MEPs generated in human MF cultures with control guides or those targeting MEN1. f) Frequency of indels following CRISPR targeting oiMEISl in human MF cells, g) Percentages of CD41+CD42‘ and CD41+CD42+cells in MF cultures with control guides or those targeting MEIS1. h) Effect of MEIS1 loss on ploidy state of CD41+CD42+megakaryocytes. i,j) Percentages (i) and absolute numbers (j) of CD41+MEPs generated in human MF cultures with control guides or those targeting MEIS1. Data were analyzed for statistical significance by paired one-Way ANOVA.

[0074] * p<0.05, ** p<0.01, *** p<0.001, **** pO.OOOl. NS, not significant.

[0075] FIGs 21A-21J illustrate menin inhibition affects megakaryocytes but is well tolerated in healthy mice over five weeks.

[0076] FIGs. 22A-22H illustrate class activity of menin inhibitors affecting development of human megakaryocyte lineage, a) IC50 curve for ziftomenib (Zif, compound 4) in CFU-Mk assay. b,c) Percentages of CD41+CD42‘ (b) and CD41+CD42+(c) megakaryocytes in the absence or presence of ziftomenib. d) Ploidy states of CD41+CD42+megakaryocytes derived in liquid culture from human CD34+cells in the absence or presence of ziftomenib. e,f) Percentages of apoptotic CD41+CD42‘ (e) and CD41+CD42+(f) megakaryocytes in the absence or presence of ziftomenib. g,h) Percentages and absolute numbers of CD41+MEPs derived Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) from human CD34+cells in the absence or presence of ziftomenib. Zif = ziftomenib. Data were analyzed for statistical significance by paired Student’s T Test. *P<0.05.

[0077] FIGs 23 A-23B illustrate consistent and dose-dependent plasma exposure of Compound No. 1 across both FIG 22 A: KMT2Ar mutated AML and FIG 22B: MPLW515L induced MF models.

[0078] FIG. 24A illustrates Compound No. 1 is more effective at reducing bone marrow fibrosis than ruxolitinib, as measured by reticulin grade.

[0079] FIG. 24B illustrates a synergistic combination of Compound No. 1 / ruxolitinib in reducing bone marrow fibrosis, as measured by reticulin grade.

[0080] FIGs. 25A-25E further illustrate Compound No. 1 and menin knockout negatively impact megakaryocyte progenitors, a) Uniform manifold approximation and projection (UMAP) of 21 cell clusters that can be grouped into seven cell populations, including megakaryocytes (MK), megakaryocyte progenitors (MKP), megakaryocyte erythroid progenitor (MEP), and erythroid progenitor (ERP), cycling progenitors, eosinophil / basophil / mast cell precursors (EoBasoMast), and common myeloid progenitors (CMP), b) Annotation of cell populations by expression of representative genes, c) Effect of Compound No. 1 on the 7 cell populations. Changes in the proportion of cells are shown on the right, d) Effect of MEN1 knockout on the 7 cell populations. Changes in the proportion of cells are shown on the right, e) Violin plots of the expression levels of the KMT2A-menin target genes MEIS1, MEF2C, and PBX3 in MKP and MK in the absence (red) or presence of Compound No. 1 (green). Data were analyzed for statistical significance by the Wilcoxon Rank-sum test. **** p<0.0001.

[0081] FIGs. 26A-26C illustrate Compound No. 1 reduces the levels of inflammatory cytokines in the plasma, a-c) Comparison of the levels of MIG / CXCL9 (a), MIPla / CCL3 (b), and TNF-a (c) in the plasma of animals treated with control chow / vehicle, Compound No. 1 alone, ruxolitinib alone and the combination of Compound No. 1 and ruxolitinib. Data were analyzed for statistical significance by two sample Student’s t-test.

[0082] FIGs. 27A-27B illustrate Compound No. 1 alone and in combination with ruxolitinib reduces the megakaryocyte burden in the MPLW515L model, a) Tissue classifier mark-up images of sternum bone marrow from the different treatment groups labeled for megakaryocytes (cyan), myeloid / erythroid cells (purple), and trabecular bone (yellow). Scale Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) bars 1mm. b) Hematoxylin / eosin stained bone marrow sections from mice of the different treatment groups highlighting megakaryocyte morphology. Scale bars top) 50pm, bottom) 100pm.

[0083] FIGs. 28A-28B illustrate Compound No. 1 alone and in combination with ruxolitinib reduces degree of bone marrow fibrosis in the MPLW515L model. a,b) Hematoxylin / eosin (a) and reticulin (b) stained bone marrow sections from mice of the different treatment groups. Scale bars 100pm.

[0084] FIGs. 29A-29D illustrate Compound No. 1 reduces the megakaryocyte burden and degree of fibrosis in the MPLS504N model of myelofibrosis, a) Tissue classifier mark-up images of sternum bone marrow from the different treatment groups labeled for megakaryocytes (mid gray), myeloid / erythroid cells (dark gray), and trabecular bone (light gray). Scale bars 1mm. b) Hematoxylin / eosin stained bone marrow sections from mice fed control or 0.1% Compound No. 1 chow highlighting megakaryocyte morphology. Scale bars 50pm. c,d) Hematoxylin / eosin (c) and reticulin (d) stained bone marrow sections from mice fed control or 0.1% Compound No. 1 chow. Scale bars 100pm.

[0085] FIGs. 30A-30J illustrate Compound No. 1 affects megakaryocytes in healthy C57B1 / 6 mice but is well tolerated over twelve weeks, a) Study schema, b-e) Peripheral blood counts of animals fed control chow or chow containing 0.1% Compound No. 1 for 12 weeks, f-h) Body (f), spleen (g) and liver weights (h). i,j) Percentage (i) and absolute numbers (j) of MKPs in the bone marrow at sacrifice 12 weeks after treatment. Data were analyzed for statistical significance by linear mixed effect model (b-f) and the non-paired Student’s T test (g-j). n=5 mice per group. *p<0.05; ** p<0.01; *** p<0.001; ****p<0.0001.

[0086] DETAILED DESCRIPTION

[0087] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (MPN) (e.g., Myelofibros s, Essential thrombocythemia (ET), triple negative MPN, and Polycythemia Vera (PV)) in a subject in need thereof, wherein the method comprises administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0088] In some embodiments, the present disclosure is directed to a method of treating a myeloproliferative neoplasm (e g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the method comprises Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0089] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and pol y cy th emi a vera) .

[0090] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating a myeloproliferative neoplasm (e g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0091] In some embodiments, the present disclosure is directed to a pharmaceutical combination comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a JAK inhibitor for the manufacture of a medicament for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0092] In some embodiments, the present disclosure is directed to a pharmaceutical combination comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a JAK inhibitor for the manufacture of a medicament for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and pol y cy th emi a vera) .

[0093] In some embodiments, the present disclosure is directed to a method of treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0094] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a subject in need thereof wherein the method comprises administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0095] In some embodiments, the present disclosure is directed to a method of treating bone marrow fibrosis in a subject in need thereof, wherein the method comprises administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0096] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis.

[0097] In some embodiments, the subject is diagnosed with polycythemia vera and is resistant to hydroxyurea.

[0098] In some embodiments, the subject is diagnosed with polycythemia vera and is refractory to hydroxyurea.

[0099] In some embodiments, the subject is diagnosed with polycythemia vera and is resistant or refractory to hydroxyurea.

[0100] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis in a subject in need thereof, wherein the method comprises administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0101] In some embodiments, the present disclosure is directed to a method of treating myelofibrosis in a subject in need thereof, wherein the method comprises administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0102] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis.

[0103] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating myelofibrosis.

[0104] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis.

[0105] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating myelofibrosis.

[0106] In some embodiments, the present disclosure is directed to a menin inhibitor, or a pharmaceutically acceptable salt thereof, for use in treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis.

[0107] In some embodiments, the present disclosure is directed to a menin inhibitor, or a pharmaceutically acceptable salt thereof, for use in treating myelofibrosis. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0108] In some embodiments, the present disclosure is directed to a method of treating myelofibrosis in a subject in need thereof comprising administering a rnenin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0109] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a subject in need thereof, wherein the method comprises administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0110] In some embodiments, the present disclosure is directed to a method of treating bone marrow fibrosis in a subject in need thereof, wherein the method comprises administering to said subject a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0111] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis.

[0112] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating bone marrow fibrosis.

[0113] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating, preventing, reducing the progression rate, and / or reducing die severity of bone marrow fibrosis.

[0114] In some embodiments, the present disclosure is directed to the use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating bone marrow fibrosis.

[0115] In some embodiments, the present disclosure is directed to a menin inhibitor, or a pharmaceutically acceptable salt thereof, for use in treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis.

[0116] In some embodiments, the present disclosure is directed to a menin inhibitor, or a pharmaceutically acceptable salt thereof, for use in treating bone marrow fibrosis.

[0117] In some embodiments, the present disclosure is directed to a method of treating bone marrow fibrosis in a subject in need thereof, comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0118] In some embodiments, die myelofibrosis is characterized by a gene mutation. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0119] In some embodiments, the myelofibrosis is characterized by a gene mutation, wherein the gene mutation is nullizygosity for JAK246 / 1 haplotype, JAK2V617F, CALR, MPL, IDH1, IDH2, EZH2, SRSF2, ASXL1, JAK2, or combinations of such mutations.

[0120] In some embodiments, the method comprises administering a menin inhibitor to a subject, wherein the menin inhibitor, or the pharmaceutically acceptable salt thereof, inhibits megakaryocyte progenitors.

[0121] In some embodiments, the method comprises administering a menin inhibitor to a subject, wherein the menin inhibitor, or a pharmaceutically acceptable salt thereof, inhibits megakaryocyte progenitors.

[0122] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythernia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0123] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0124] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0125] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythernia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0126] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0127] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0128] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0129] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0130] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier. In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0131] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0132] In some embodiments, the present disclosure is directed to a pharmaceutical composition for use in treating bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0133] In some embodiments, the present disclosure is directed to use of a pharmaceutical composition for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0134] In some embodiments, the present disclosure is directed to the use of pharmaceutical composition for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0135] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0136] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0137] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0138] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0139] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0140] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0141] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0142] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0143] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating myelofibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0144] In some embodiments, the present disclosure is directed to the use of a pharmaceutical composition for treating bone marrow fibrosis in a subject in need thereof, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0145] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera), comprising administering to a subject in need thereof a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0146] In some embodiments, the present disclosure is directed to a method of treating the use of pharmaceutical composition for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis, comprising administering to a subject in need thereof a Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0147] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosi s, comprising administering to a subject in need thereof a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0148] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera), comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0149] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis in a subject in need thereof, comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0150] In some embodiments, the present disclosure is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis, comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0151] In some embodiments, the present disclosure is directed to a method of treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera), comprising administering to a subject in need thereof a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0152] In some embodiments, the present disclosure is directed to a method of treating myelofibrosis, comprising administering to a subject in need thereof a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0153] In some embodiments, the present disclosure is directed to a method of treating bone marrow fibrosis, comprising administering to a subject in need thereof a pharmaceutical Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0154] In some embodiments, the present disclosure is directed to a method of treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera), comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0155] In some embodiments, the present disclosure is directed to a method of treating myelofibrosis, comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0156] In some embodiments, the present disclosure is directed to a method of treating bone marrow fibrosis, comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0157] In some embodiments, the present disclosure is directed to a use of a menin inhibitor or a pharmaceutically acceptable salt thereof.

[0158] In some embodiments, the subject is a mammal.

[0159] In some embodiments, the subject is a human.

[0160] In some embodiments, the menin inhibitor comprises a compound in Table 1 or a pharmaceutically acceptable salt thereof.

[0161] Table 1. Representative Compounds of the Present Disclosure Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0162] In some embodiments, the menin inhibitor is 5“fluoro-N,N-diisopropyl-2“((4"(7~ ((lS,3Ss4R)-5-methylene-2~azabicyclo[2.2.2]octane-3~carbonyi)~2,7-diazaspiro[3.5]nonan-2~ yl)pyrimidin-5-yl)oxy)benzamide mono-L(-i )-tartrate. In some embodiments, the menin inhibitor is trans N-ethyl-2-((4-(7-((4-

[0163] (ethylsulfonamido) cyclohexyl)methyl)-2,7-diazaspiro[3.5]nonan-2-yl)pyrimidin-5-yl)oxy)-5- fluoro-N-isopropylbenzamide (Compound No. 1) monocitrate monohydrate.

[0164] The compounds of the application are defined herein by their chemical structures and / or chemical names. Where a compound is referred to by both a chemical structure and a chemical name, and the chemical structure and chemical name conflict, the chemical structure is determinative of the compound's identity.

[0165] It is appreciated that certain features of the disclosure, which are, for clarity, described in the context of separate embodiments, can also be provided in combination in a single embodiment. Conversely, various features of the disclosure which are, for brevity, described in the context of a single embodiment, can also be provided separately or in any suitable subcombination.

[0166] Definitions Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0167] In some embodiments, the compounds of the disclosure, or salts thereof, or crystalline forms of any of the aforementioned, are purified or substantially isolated. By "substantially isolated" is meant that the compound is at least partially or substantially separated from the environment in which it was formed or detected. Partial separation can include, for example, a composition enriched in a compound of the disclosure. Substantial separation can include compositions containing at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, at least about 95%, at least about 97%, or at least about 99% by weight of the compounds of the disclosure, or salt thereof. In some embodiments, the compounds of the disclosure, or salts thereof, or crystalline forms of any of the aforementioned, can be prepared with a purity of about 75% or more, 80% or more, 85% or more, 90% or more, 95% or more, 98% or more, or 99% or more.

[0168] The term “small molecule” refers to an organic compound with a molecular weight equal to or below 1,000 kDa, preferably below 900 daltons, or more preferably below 500 daltons. The molecular weight (expressed in daltons) is the mass of a molecule and is calculated as the sum of the atomic weights of each constituent element multiplied by the number of atoms of that element in the molecular formula.

[0169] The phrase "pharmaceutically acceptable" is employed herein to refer to those compounds, materials, compositions, and / or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit / risk ratio.

[0170] The present disclosure also includes pharmaceutically acceptable salts of the compounds described herein. As used herein, "pharmaceutically acceptable salts" or "pharmaceutically acceptable salt" refers to derivatives of the disclosed compounds wherein the parent compound is modified by converting an existing acid or base moiety to its salt form. Examples of pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic residues such as amines; alkali or organic salts of acidic residues such as carboxylic acids; and the like. The pharmaceutically acceptable salts of the present disclosure include the conventional non-toxic salts of the parent compound formed, for example, from non-toxic inorganic or organic acids. The pharmaceutically acceptable salts of the present disclosure can be synthesized from the parent compound which contains a basic or acidic moiety by conventional chemical methods. Generally, such salts can be prepared by reacting the free acid or base forms of these compounds with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent, or in a mixture of the two; generally, Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) non-aqueous media like ether, ethyl acetate, alcohols e.g., methanol, ethanol, iso-propanol, or butanol) or acetonitrile (MeCN) are preferred.

[0171] The compounds disclosed herein include the compounds themselves, as well as their salts, their solvates, and their prodrugs, if applicable. A salt, for example, can be formed between an anion and a positively charged group (e.g., protonated amino) on a compound of this disclosure. Suitable anions include chloride, bromide, iodide, sulfate, bisulfate, sulfamate, nitrate, phosphate, citrate, methanesulfonate, trifluoroacetate, glutamate, glucuronate, glutarate, malate, maleate, succinate, fumarate, tartrate, tosylate, salicylate, lactate, naphthalenesulfonate, and acetate (e.g., trifluroacetate). The term “pharmaceutically acceptable anion” refers to an anion suitable for forming a pharmaceutically acceptable salt. Likewise, a salt can also be formed between a cation and a negatively charged group (e.g., carboxylate) on a compound of this disclosure. Suitable cations include sodium ion, potassium ion, magnesium ion, calcium ion, and an ammonium cation such as tetramethylammonium ion. The compounds of this disclosure also include those salts containing quaternary nitrogen atoms. Examples of prodrugs include esters and other pharmaceutically acceptable derivatives, which, upon administration to a subject, are capable of providing active compounds of this disclosure.

[0172] Additionally, physiologically acceptable, i.e., pharmaceutically compatible, salts can be salts of the compounds disclosed herein with inorganic or organic acids. Preference is given to salts with inorganic acids, such as, for example, hydrochloric acid, hydrobromic acid, phosphoric acid or sulphuric acid, or to salts with organic carboxylic or sulphonic acids, such as, for example, acetic acid, trifluoroacetic acid, propionic acid, maleic acid, fumaric acid, malic acid, citric acid, tartaric acid, lactic acid, benzoic acid, or methanesulphonic acid, ethanesulphonic acid, benzenesulphonic acid, toluenesulphonic acid or naphthalenedisulphonic acid.

[0173] Other pharmaceutically compatible salts which may be mentioned are salts with customary bases, such as, for example, alkali metal salts (for example sodium or potassium salts), alkaline earth metal salts (for example calcium or magnesium salts) or ammonium salts, derived from ammonia or organic amines, such as, for example, diethylamine, triethylamine, ethyldiisopropylamine, procaine, dibenzylamine, N-methylmorpholine, dihydroabietylamine or methylpiperidine.

[0174] As used herein, “pharmaceutically acceptable salts” can refer to derivatives of the compounds of the present disclosure wherein the parent compound is modified by making acid or base salts thereof. Examples of pharmaceutically acceptable salts include, but are not limited Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) to, mineral or organic acid salts of basic residues such as amines, alkali or organic salts of acidic residues such as carboxylic acids, and the like. The pharmaceutically acceptable salts include the conventional non-toxic salts or the quaternary ammonium salts of the parent compound formed, for example, from non-toxic inorganic or organic acids. For example, such conventional non-toxic salts include, but are not limited to, those derived from inorganic and organic acids selected from 2-acetoxybenzoic, 2-hydroxyethane sulfonic, acetic, ascorbic, benzene sulfonic, benzoic, bicarbonic, carbonic, citric, edetic, ethane disulfonic, 1,2-ethane sulfonic, fumaric, glucoheptonic, gluconic, glutamic, glycolic, glycollyarsanilic, hexylresorcinic, hydrabamic, hydrobromic, hydrochloric, hydroiodic, hydroxymaleic, hydroxynaphthoic, isethionic, lactic, lactobionic, lauryl sulfonic, maleic, malic, mandelic, methane sulfonic, napsylic, nitric, oxalic, pamoic, pantothenic, phenylacetic, phosphoric, polygalacturonic, propionic, salicylic, stearic, subacetic, succinic, sulfamic, sulfanilic, sulfuric, tannic, tartaric, toluene sulfonic, and the commonly occurring amine acids, e.g., glycine, alanine, phenylalanine, arginine, etc.

[0175] Other examples of pharmaceutically acceptable salts can include hexanoic acid, cyclopentane propionic acid, pyruvic acid, malonic acid, 3-(4-hydroxybenzoyl)benzoic acid, cinnamic acid, 4-chlorobenzenesulfonic acid, 2-naphthalenesulfonic acid, 4-toluenesulfonic acid, camphorsulfonic acid, 4-methylbicyclo-[2.2.2]-oct-2-ene-l -carboxylic acid, 3- phenylpropionic acid, trimethylacetic acid, tertiary butylacetic acid, muconic acid, and the like. The present disclosure also encompasses salts formed when an acidic proton present in the parent compound either is replaced by a metal ion, e.g., an alkali metal ion, or an alkaline earth metal ion, e.g., an aluminum ion; or coordinates with an organic base such as ethanolamine, diethanolamine, triethanolamine, tromethamine, N-m ethylglucamine, diethylamine, diethylaminoethanol, ethylenediamine, imidazole, lysine, arginine, morpholine, 2- hydroxyethylmorpholine, dibenzylethylenediamine, trimethylamine, piperidine, pyrrolidine, benzylamine, tetramethylammonium hydroxide and the like.

[0176] It should be understood that all references to pharmaceutically acceptable salts include solvent addition forms (solvates) or crystal forms (polymorphs) as defined herein, of the same salt.

[0177] It is to be understood that, unless otherwise stated, any description of a method of treatment or prevention includes use of the compounds to provide such treatment or prevention as is described herein. It is to be further understood, unless otherwise stated, any description of a method of treatment or prevention includes use of the compounds to prepare a medicament Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) to treat or prevent such condition. The treatment or prevention includes treatment or prevention of human or non-human animals including rodents and other disease models.

[0178] It is to be understood that, unless otherwise stated, any description of a method of treatment includes use of the compounds to provide such treatment as is described herein. It is to be further understood, unless otherwise stated, any description of a method of treatment includes use of the compounds to prepare a medicament to treat such condition. The treatment includes treatment of human or non-human animals including rodents and other disease models.

[0179] As used herein, the term “subject” includes human and non-human animals, as well as cell lines, cell cultures, tissues, and organs. In some embodiments, the subject is a mammal. The mammal can be e.g., a human or appropriate non-human mammal, such as primate, mouse, rat, dog, cat, cow, horse, goat, camel, sheep or a pig. The subject can also be a bird or fowl. In some embodiments, the subject is a human.

[0180] As used herein, the term “subject in need thereof’ refers to a subject having a disease or having an increased risk of developing the disease. A subject in need thereof can be one who has been previously diagnosed or identified as having a disease or disorder disclosed herein. A subject in need thereof can also be one who is suffering from a disease or disorder disclosed herein. Alternatively, a subject in need thereof can be one who has an increased risk of developing such disease or disorder relative to the population at large (i.e., a subject who is predisposed to developing such disorder relative to the population at large). A subject in need thereof can have a refractory or resistant a disease or disorder disclosed herein (i.e., a disease or disorder disclosed herein that does not respond or has not yet responded to treatment). The subject may be resistant at start of treatment or may become resistant during treatment. In some embodiments, the subject in need thereof received and failed all known effective therapies for a disease or disorder disclosed herein. In some embodiments, the subject in need thereof received at least one prior therapy.

[0181] As used herein, the term “treating” or “treat” describes the management and care of a patient for the purpose of combating a disease, condition, or disorder and includes the administration of a compound of the present disclosure, or a pharmaceutically acceptable salt thereof, polymorph or solvate thereof, to alleviate the symptoms or complications of a disease, condition or disorder, or to eliminate the disease, condition or disorder. The term “treat” can also include treatment of a cell in vitro or an animal model. It is to be appreciated that references to “treating” or “treatment” include the alleviation of established symptoms of a condition. “Treating” or “treatment” of a state, disorder or condition therefore includes: (1) preventing or Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) delaying the appearance of clinical symptoms of the state, disorder or condition developing in a human that may be afflicted with or predisposed to the state, disorder or condition but does not yet experience or display clinical or subclinical symptoms of the state, disorder or condition, (2) inhibiting the state, disorder or condition, i.e., arresting, reducing or delaying the development of the disease or a relapse thereof (in case of maintenance treatment) or at least one clinical or subclinical symptom thereof, or (3) relieving or attenuating the disease, i.e., causing regression of the state, disorder or condition or at least one of its clinical or subclinical symptoms.

[0182] It is to be understood that a compound of the present disclosure, or a pharmaceutically acceptable salt thereof, polymorph or solvate thereof, can or may also be used to prevent a relevant disease, condition or disorder, or used to identify suitable candidates for such purposes.

[0183] As used herein, the term “preventing,” “prevent,” or “protecting against” describes reducing or eliminating the onset of the symptoms or complications of such disease, condition or disorder.

[0184] It is to be understood that one skilled in the art may refer to general reference texts for detailed descriptions of known techniques discussed herein or equivalent techniques. These texts include Ausubel et al., Current Protocols in Molecular Biology, John Wiley and Sons, Inc. (2005); Sambrook et al., Molecular Cloning, A Laboratory Manual (3rdedition), Cold Spring Harbor Press, Cold Spring Harbor, New York (2000); Coligan et al., Current Protocols in Immunology, John Wiley & Sons, N.Y.; Enna et al., Current Protocols in Pharmacology, John Wiley & Sons, N.Y.; Fingl et al., The Pharmacological Basis of Therapeutics (1975), Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, PA, 18thedition (1990). These texts can, of course, also be referred to in making or using an aspect of the disclosure.

[0185] It is to be understood that the present disclosure also provides pharmaceutical compositions comprising any compound described herein in combination with at least one pharmaceutically acceptable excipient or carrier.

[0186] The compounds of the present disclosure may be administered in the form of a prodrug which is broken down in the human or animal body to release a compound of the disclosure. A prodrug may be used to alter the physical properties and / or the pharmacokinetic properties of a compound of the disclosure. A prodrug can be formed when the compound of the disclosure contains a suitable group or substituent to which a property-modifying group can be attached.

[0187] Accordingly, the present disclosure includes those compounds of the present disclosure as defined hereinbefore when made available by organic synthesis and when made available Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) within the human or animal body by way of cleavage of a prodrug thereof. Accordingly, the present disclosure includes those compounds of the present disclosure that are produced by organic synthetic means and also such compounds that are produced in the human or animal body by way of metabolism of a precursor compound, that is a compound of the present disclosure may be a synthetically-produced compound or a metabolically-produced compound.

[0188] A suitable pharmaceutically acceptable prodrug of a compound of the present disclosure is one that is based on reasonable medical judgment as being suitable for administration to the human or animal body without undesirable pharmacological activities and without undue toxicity. Various forms of prodrug have been described, for example in the following documents: a) Methods in Enzymology, Vol. 42, p. 309-396, edited by K. Widder, et al. (Academic Press, 1985); b) Design of Pro-drugs, edited by H. Bundgaard, (Elsevier, 1985); c) A Textbook of Drug Design and Development, edited by Krogsgaard-Larsen and H. Bundgaard, Chapter 5 “Design and Application of Pro-drugs”, by H. Bundgaard p. 113-191 (1991); d) H. Bundgaard, Advanced Drug Delivery Reviews, 8, 1-38 (1992); e) H. Bundgaard, et al., Journal of Pharmaceutical Sciences, 77, 285 (1988); f) N. Kakeya, et al., Chem. Pharm. Bull., 32, 692 (1984); g) T. Higuchi and V. Stella, “Pro-Drugs as Novel Delivery Systems”, A.C.S. Symposium Series, Volume 14; and h) E. Roche (editor), “Bioreversible Carriers in Drug Design”, Pergamon Press, 1987.

[0189] A suitable pharmaceutically acceptable prodrug of a compound of the present disclosure that possesses a hydroxy group is, for example, an in vivo cleavable ester or ether thereof. An in vivo cleavable ester or ether of a compound of the present disclosure containing a hydroxy group is, for example, a pharmaceutically acceptable ester or ether which is cleaved in the human or animal body to produce the parent hydroxy compound. Suitable pharmaceutically acceptable ester forming groups for a hydroxy group include inorganic esters such as phosphate esters (including phosphoramidic cyclic esters). Further suitable pharmaceutically acceptable ester forming groups for a hydroxy group include Ci-Cio alkanoyl groups such as acetyl, benzoyl, phenylacetyl and substituted benzoyl and phenylacetyl groups, Ci-Cio alkoxycarbonyl groups such as ethoxycarbonyl, N,N-(Ci-Ce alkyl)2carbamoyl, 2- dialkylaminoacetyl and 2-carboxyacetyl groups. Examples of ring substituents on the phenylacetyl and benzoyl groups include aminomethyl, N-alkylaminomethyl, N,N- dialkylaminomethyl, morpholinomethyl, piperazin- 1-ylmethyl and 4-(CI-C4 alkyl)piperazin-l- ylmethyl. Suitable pharmaceutically acceptable ether forming groups for a hydroxy group include a-acyloxyalkyl groups such as acetoxymethyl and pivaloyloxymethyl groups. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0190] A suitable pharmaceutically acceptable prodrug of a compound of the present disclosure that possesses a carboxy group is, for example, an in vivo cleavable amide thereof, for example an amide formed with an amine such as ammonia, a C1-C4 alkylamine such as methylamine, a (C1-C4 alkyl)2amine such as dimethylamine, N-ethyl N-methylamine or diethylamine, a C1-C4 alkoxy C2-C4 alkylamine such as 2 methoxyethylamine, a phenyl C1-C4 alkylamine such as benzylamine and amino acids such as glycine or an ester thereof.

[0191] A suitable pharmaceutically acceptable prodrug of a compound of the present disclosure that possesses an amino group is, for example, an in vivo cleavable amide derivative thereof. Suitable pharmaceutically acceptable amides from an amino group include, for example an amide formed with C1-C10 alkanoyl groups such as an acetyl, benzoyl, phenylacetyl and substituted benzoyl and phenylacetyl groups. Examples of ring substituents on the phenylacetyl and benzoyl groups include aminomethyl, N-alkylaminomethyl, N,N- dialkylaminomethyl, morpholinomethyl, piperazin- 1-ylmethyl, and 4-(CI-C4 alkyl)piperazin- 1-ylmethyl.

[0192] The in vivo effects of a compound of the present disclosure may be exerted in part by one or more metabolites that are formed within the human or animal body after administration of a compound of the present disclosure. As stated hereinbefore, the in vivo effects of a compound of the present disclosure may also be exerted by way of metabolism of a precursor compound (a prodrug).

[0193] All percentages and ratios used herein, unless otherwise indicated, are by weight. Other features and advantages of the present disclosure are apparent from the different examples. The provided examples illustrate different components and methodology useful in practicing the present disclosure. The examples do not limit the claimed disclosure. Based on the present disclosure the skilled artisan can identify and employ other components and methodology useful for practicing the present disclosure.

[0194] As use herein, the phrase “compound of the disclosure” refers to those compounds which are disclosed herein, both generically and specifically.

[0195] All publications and patent documents cited herein are incorporated herein by reference as if each such publication or document was specifically and individually indicated to be incorporated herein by reference. Citation of publications and patent documents is not intended as an admission that any is pertinent prior art, nor does it constitute any admission as to the contents or date of the same. The invention having now been described by way of written description, those of skill in the art will recognize that the invention can be practiced in a variety Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) of embodiments and that the foregoing description and examples below are for purposes of illustration and not limitation of the claims that follow.

[0196] Menin Inhibitors

[0197] The terms “menin inhibitor” and “menin inhibitors” are used herein interchangeably and may be understood in their broadest sense. A menin inhibitor includes one or a combination of any agents such as a small molecule, nucleic acid (e.g., siRNAs), or antibody, peptide, peptidomimetic or aptamer that acts to disrupt that acts to disrupt, directly or indirectly, and reduce or even eliminate the function or expression of the menin protein, the multiple endocrine neoplasia 1 (MENL) gene, or the menin-MLL complex. Protein disruption may include direct activity blockage, protein-protein interaction blocking, or the like. Menin, the protein product of the MEN1 (multiple endocrine neoplasia syndrome type 1) gene, interacts with mixed lineage leukemia (MLL) family proteins in a histone methyltransferase complex including MLL1 (also known as lysine (K)-specific methyltransferase 2A (KMT2A)), Ash2, Rbbp5, and WDR5. As a consequence of chromosomal rearrangements of the MLL gene, MLL is fused with one of over 60 different protein partners, resulting in upregulated expression of H0XA9 and MEIS1 genes that are critical to leukemogenesis.

[0198] Representative small molecule menin inhibitors include VTP-50469 (5-fluoro-N,N- diisopropyl-2-((4-(7-(((lr,4r)-4-(methylsulfonamido)cyclohexyl)methyl)-2,7- diazaspiro[3.5]nonan-2-yl)pyrimidin-5-yl)oxy)benzamide), KO-539 ((R)-4-methyl-5-((4-((2- (methylamino)-6-(2,2,2-trifluoroethyl)thieno[2,3-d]pyrimidin-4-yl)amino)piperidin-l- yl)methyl)-l-(2-(4-(methylsulfonyl)piperazin-l-yl)propyl)-lH-indole-2-carbonitrile, also used in NCT04067336), JNJ-75276617 ((R)-N-ethyl-5-fluoro-N-isopropyl-2-((5-(2-(6-((2- methoxyethyl)(methyl)amino)-2-methylhexan-3-yl)-2,6-diazaspiro[3.4]octan-6-yl)-l,2,4- triazin-6-yl)oxy)benzamide, also used in NCT04811560), SNDX-5613 (N-ethyl-2-((4-(7- (((lr,4r)-4-(ethylsulfonamido)cyclohexyl)methyl)-2,7-diazaspiro[3.5]nonan-2-yl)pyrimidin- 5-yl)oxy)-5-fhroro-N-isopropylbenzamide, also used in NCT04065399), DS-1594 ((lR,2S,4R)-4-((4-(5,6-dimethoxypyridazin-3-yl)benzyl)amino)-2-(methyl(6-(2,2,2- trifluoroethyl)thieno[2,3-d]pyrimidin-4-yl)amino)cyclopentan-l-ol, also used in NCT04752163), BMF-219 ((R)-N-(l-(2-(2-((4-(4-morpholino-7H-pyrrolo[2,3 -d]pyrimidin-6- yl)phenyl)amino)-2-oxoethyl)pyridin-4-yl)piperidin-3-yl)but-2-ynamide), DSP-5336 (N- ethyl-5-fluoro-N-isopropyl-2-((5-(7-((lS,3S,4R)-5-methylene-2-azabicyclo[2.2.2]octane-3- carbonyl)-2,7-diazaspiro[3.5]nonan-2-yl)-l,2,4-triazin-6-yl)oxy)benzamide, also used in NCT04988555), the antibody A300-105A (commercially available from Bethyl Laboratories), Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0199] MI-3453 (N-(3-((2-cyano-4-methyl-5-((4-((2-(methylamino)-6-(2,2,2- trifluoroethyl)thieno[2, 3-d]pyrimidin-4-yl)amino)piperi din-1 -yl)methyl)-lH-indol-l- yl)methyl)bicyclo[l.l.l]pentan- l-yl)formamide, M-808 (methyl ((lS,2R)-2-((S)-2-(azetidin- 1 -yl)- 1 -(3-fluoropheny 1)- 1 -(1 -(( 1 -(4-(( 1 -((E)-4-(piperidin- 1 -yl)but-2-enoy l)azeti din-3 - yl)sulfonyl)phenyl)azeti din-3 - yl)methyl)piperidin-4-yl)ethyl)cyclopentyl)carbamate), MI-0202 (4-(4-(5,5-dimethyl-4,5- dihydrothiazol-2-yl)piperazin-l-yl)-6-(2,2,2- trifluoroethyl)thieno[2,3-d]pyrimidine), MI-503 (1 -((lH-pyrazol-4-yl)methyl)-4-methyl-5- ((4-((6-(2,2,2-trifluoroethyl)thieno[2,3- d]pyrimidin-4-yl)amino)piperidin-l-yl)methyl)-lH- indole-2-carbonitrile), MI-463 (4-methyl- 5-((4-((6-(2,2,2-trifluoroethyl)thieno[2,3- d]pyrimidin-4-yl)amino)piperidin-l-yl)methyl)-lH- indole-2-carbonitrile), MI-136 (5-((4-((6- (2,2,2-trifluoroethyl)thieno[2,3-d]pyrimidin-4- yl)amino)piperidin-l-yl)methyl)-lH-indole-2- carbonitrile), and ML-227 (4-(3-(4-

[0200] (cyclopentyl(hydroxy)(phenyl)methyl)piperidin-l- yl)propoxy)benzonitrile).

[0201] Representative small molecule menin inhibitors may also include 2-(3-(l-(5,5- dimethylpyrrolidine-2-carbonyl)piperidine-4-carbonyl)-2-methyl-lH-pyrrolo[2,3-c]pyridin-l- yl)-5-fluoro-N,N-diisopropylbenzamide, (S)-2-(3-(l-(5,5-dimethylpyrrolidine-2- carbonyl)piperidine-4-carbonyl)-2-methyl-lH-pyrrolo[2,3-c]pyridin-l-yl)-5-fluoro-N,N- diisopropylbenzamide , (M)-2-(3-(l-((S)-5,5-dimethylpyrrolidine-2-carbonyl)piperidine-4- carbonyl)-2-methyl-lH-pyrrolo[2,3-c]pyridin-l-yl)-5-fluoro-N,N-diisopropylbenzamide, and (P)-2-(3-(l-((S)-5,5-dimethylpyrrolidine-2-carbonyl)piperidine-4-carbonyl)-2-methyl-lH- pyrrolo[2,3-c]pyridin-l-yl)-5-fluoro-N,N-diisopropylbenzamide.

[0202] In some embodiments, the menin inhibitor or the pharmaceutically acceptable salt thereof is known in the art, including, e.g., any one of the compounds disclosed in WO20 11 / 029054, WO2014 / 164543, WO2014 / 200479, WO2016 / 040330, WO2016 / 195776, WO20 16 / 197027, WO2017 / 112768, W02017 / 161002, W02017 / 161028, WO2017 / 192543, WO20 17 / 207387, WO2017 / 214367, WO2018 / 024602, WO2018 / 050684, WO2018 / 050686, WO20 18 / 053267, W02018 / 109088, WO2018 / 183857, WO2018 / 226976, W02019 / 060365, W02019 / 120209, WO2019 / 189732, WO2019 / 191526, W02020 / 032105, W02020 / 045334, W02020 / 116662, W02020 / 142557, WO2020 / 142559, W02021 / 060453, WO2021 / 121327, WO2021 / 207335, WO2022 / 133064, WO2022 / 237626, WO2022 / 237627, WO2022 / 241265, WO2023 / 098876, US2021 / 269454, US2024 / 0335431, or US2021 / 338668, each of which is incorporated herein by reference in its entirety (including, in particular, the compounds described in the examples section of each one of these documents). Accordingly, the menin inhibitor or the pharmaceutically acceptable salt thereof may be, e.g., a compound disclosed in Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) any one of the aforementioned documents, wherein said compound may be used in non-salt form or in the form of a pharmaceutically acceptable salt thereof.

[0203] In some embodiments, the menin inhibitor or the pharmaceutically acceptable salt thereof is known in the art, including, e.g., any one of the compounds disclosed in WO20 11 / 029054, WO2014 / 164543, WO2014 / 200479, WO2016 / 040330, WO2016 / 195776, WO20 16 / 197027, WO2017 / 112768, W02017 / 161002, W02017 / 161028, WO2017 / 192543, WO20 17 / 207387, WO2017 / 214367, WO2018 / 024602, WO2018 / 050684, WO2018 / 050686, WO20 18 / 053267, W02018 / 109088, WO2018 / 183857, WO2018 / 226976, W02019 / 060365, W02019 / 120209, WO2019 / 189732, WO2019 / 191526, W02020 / 032105, W02020 / 045334, W02020 / 116662, W02020 / 142557, WO2020 / 142559, W02021 / 060453, WO2021 / 121327, WO2021 / 207335, WO2022 / 133064, WO2022 / 237626, WO2022 / 237627, WO2022 / 241265, WO2023 / 098876, US2021 / 269454, or US2021 / 338668, each of which is incorporated herein by reference in its entirety (including, in particular, the compounds described in the examples section of each one of these documents). Accordingly, the menin inhibitor or the pharmaceutically acceptable salt thereof may be, e.g., a compound disclosed in any one of the aforementioned documents, wherein said compound may be used in non-salt form or in the form of a pharmaceutically acceptable salt thereof.

[0204] In some embodiments, the menin inhibitor or the pharmaceutically acceptable salt thereof is a compound selected from the group consisting of revumenib, VTP50469, ziftonienib, JNJ-75276617, DS-1594, DSP-5336, MI-136, Menin-MLL inhibitor 20, BMF- 219, MI-3454, BAY-155. MI- 503, zefa enib (BN 104), AZD3632, and pharmaceutically acceptable salts thereof.

[0205] In some embodiments, the menin inhibitor or the pharmaceutically acceptable salt thereof is a compound selected from the group consisting of revumenib, VTP50469, ziftonienib, JNJ-75276617, DS-1594, DSP-5336, MI-136, Menin-MLL inhibitor 20, BMF- 219, MI-3454, BAY-155, MI- 503, BN104, and pharmaceutically acceptable salts thereof.

[0206] In some embodiments, the menin inhibitor is revumenib.

[0207] In some embodiments, the menin inhibitor is VTP50469.

[0208] In some embodiments, the menin inhibitor is ziftomenib.

[0209] In some embodiments, the menin inhibitor is JNJ-75276617.

[0210] In some embodiments, the menin inhibitor is DS-1594.

[0211] In some embodiments, the menin inhibitor is DSP-5336.

[0212] In some embodiments, the menin inhibitor is MI-136.

[0213] In some embodiments, the menin inhibitor is Menin-MLL inhibitor 20. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0214] In some embodiments, the menin inhibitor is BMF-219.

[0215] In some embodiments, the menin inhibitor is MI-3454.

[0216] In some embodiments, the menin inhibitor is BAY-155.

[0217] In some embodiments, the menin inhibitor is MI-503.

[0218] In some embodiments, the menin inhibitor is zefamenib.

[0219] In some embodiments, the menin inhibitor is BN104.

[0220] In some embodiments, the menin inhibitor is Compound No. 15.

[0221] In some embodiments, the menin inhibitor is Compound No. 16.

[0222] In some embodiments, the menin inhibitor is Compound No. 17.

[0223] In some embodiments, the menin inhibitor is AZD3632.

[0224] In some embodiments, the menin inhibitor or a pharmaceutically acceptable salt thereof is any one of the compounds disclosed in WO2017 / 214367A1; US Provisional Patent Application No. 62 / 348,496; WO2022 / 241265A1; US Provisional Patent Application No. 63 / 188,704; WO2018 / 053267A1; US Provisional Patent Application No. 62 / 395,618; US10781218; W02017 / 161028; US Provisional Application No. 62 / 309,372; US Provisional Application No. 62 / 334,369; US Provisional Application No. 62 / 431,389; US Provisional Application No. 62 / 446,640; US11369605; W02020 / 045334; JP2018-158315;

[0225] WO2021121327; PCT / CN2019 / 126760; US Provisional Patent Application No. 62 / 961,775; PCT / CN2020 / 126595; US2023 / 0030720; W02020 / 116662; JP 2018-229397;

[0226] WO2023056589A1; WO2023 / 098876; US2023 / 0405008A1; WO2024 / 046457A1; US2024 / 0100049 Al; CN118161612A; WO2024 / 110649A1; WO2024 / 112819A1; W02024 / 100250A1; CN118021815A; WO2024 / 140798A1; WO2022 / 237719A1; and WO2022 / 237720A1; each of which is incorporated herein by reference in its entirety (including, in particular, the compounds described in the examples section of each one of these documents).

[0227] In some embodiments, the menin inhibitor or the pharmaceutically acceptable salt thereof is amorphous or crystalline.

[0228] Combination with a Second Therapeutically Active Agent

[0229] In some embodiments, the present disclosure is directed to methods of treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in need thereof, comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a second therapeutically active agent. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0230] In some embodiments, the present disclosure is directed to methods of treating myelofibrosis in a subject in need thereof, comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a second therapeutically active agent.

[0231] In some embodiments, the second therapeutically active agent is a therapeutic known for the treatment of a myeloproliferative neoplasm (e g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0232] In some embodiments, the second therapeutically active agent is a therapeutic known for the treatment of myelofibrosis.

[0233] In some embodiments, the menin inhibitor, or the pharmaceutically acceptable salt thereof, and the second therapeutically active agent are in a combined dosage form.

[0234] In some embodiments, the menin inhibitor, or the pharmaceutically acceptable salt thereof, and the second therapeutically active agent are in separate dosage forms.

[0235] In some embodiments, the menin inhibitor, or the pharmaceutically acceptable salt thereof, and the second therapeutically active agent are administered concurrently.

[0236] In some embodiments, the menin inhibitor, or the pharmaceutically acceptable salt thereof, and the second therapeutically active agent are administered simultaneously, essentially simultaneously or within the same treatment protocol.

[0237] In some embodiments, the menin inhibitor, or the pharmaceutically acceptable salt thereof, and the second therapeutically active agent are administered sequentially.

[0238] In some embodiments, die second therapeutically active agent is selected from a CDK4 inhibitor, a CDK6 inhibitor, a BET inhibitor, an LSD 1 inhibitor, an XPO-1 inhibitor, a MDM2 inhibitor, an Aurora Kinase Inhibitor, a CD79A inhibitor, a CD79B inhibitor, a CD 19 inhibitor, a Lyn inhibitor, a Syk inhibitor, a PI3K inhibitor, a Bink inhibitor, a PLCy inhibitor, a PKCP inhibitor, or a combination thereof. In some embodiments, the additional therapeutic agent is an antibody, B cell receptor signaling inhibitor, a PI3K inhibitor, an IAP inhibitor, an mTOR inhibitor, a radioimmunotherapeutic, a DNA damaging agent, a proteosome inhibitor, a histone deacetylase inhibitor, a protein kinase inhibitor, a hedgehog inhibitor, an Hsp90 inhibitor, a telomerase inhibitor, a JAK inhibitor, a protease inhibitor, a PKC inhibitor, a PARP inhibitor, or a combination thereof.

[0239] In some embodiments, the second therapeutically active agent is selected from a CD79 A inhibitor, a CD79B inhibitor, a CD 19 inhibitor, a Lyn inhibitor, a Syk inhibitor, a PI3K inhibitor, a Bink inhibitor, a PLCy inhibitor, a PKCP inhibitor, or a combination thereof. In some embodiments, the additional therapeutic agent is an antibody, B cell receptor Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) signaling inhibitor, a PI3K inhibitor, an IAP inhibitor, an mTOR inhibitor, a radioimmunotherapeutic, a DNA damaging agent, a proteosome inhibitor, a histone deacetylase inhibitor, a protein kinase inhibitor, a hedgehog inhibitor, an Hsp90 inhibitor, a telomerase inhibitor, a JAK inhibitor, a protease inhibitor, a PKC inhibitor, a PARP inhibitor, or a combination thereof.

[0240] In some embodiments, the second therapeutically active agent is a Janus Kinase (JAK) inhibitor.

[0241] In some embodiments, the second therapeutically active agent is ruxolitinib, fedratinib (SAR302503), momelotinib (CYT387), pacritinib, lestaurtinib, AZD- 1480, BMS-911543, NS-018, LY2784544, SEP-701, XL019, or AT-9283.

[0242] In some embodiments, the JAK inhibitor is ruxolitinib.

[0243] In some embodiments, the JAK inhibitor is fedratinib (SAR302503).

[0244] In some embodiments, the JAK inhibitor is momelotinib (CYT387).

[0245] In some embodiments, the JAK inhibitor is pacritinib.

[0246] In some embodiments, the JAK inhibitor is lestaurtinib.

[0247] In some embodiments, the JAK inhibitor is AZD-1480.

[0248] In some embodiments, the JAK inhibitor is BMS-911543.

[0249] In some embodiments, the JAK inhibitor is NS-018.

[0250] In some embodiments, the JAK inhibitor is LY2784544.

[0251] In some embodiments, the JAK inhibitor is SEP-701.

[0252] In some embodiments, the JAK inhibitor is XL019.

[0253] In some embodiments, the JAK inhibitor is AT-9283.

[0254] In some embodiments, die present di closure s directed to a combination therapy for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia v era). In some embodiments, the present disclosure is directed to a combination therapy for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis.

[0255] In some embodiments, the present disclosure i directed to the use of a pharmaceutical combination for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera). In some embodiments, die present disclosure is directed to a combination therapy for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0256] In some embodiments, the present disclosure is directed to a pharmaceutical combination for use in treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera). In some embodiments, the present disclosure is directed to a combination therapy for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis.

[0257] In some embodiments, the pharmaceutical combination comprises the menin inhibitor and the second active agent are in a single dosage form.

[0258] In some embodiments, the pharmaceutical combination comprises the menin inhibitor and the second active agent are in separate dosage forms.

[0259] In some embodiments, the menin inhibitor and the second active agent are administered sequentially.

[0260] In some embodiments, the menin inhibitor and the second active agent are administered simultaneously.

[0261] In some embodiments, the menin inhibitor and the second active agent are administered essentially simultaneously.

[0262] In some embodiments, the menin inhibitor and the second active agent are administered in temporal proximity.

[0263] In some embodiments, the menin inhibitor is administered before the second active agent.

[0264] In some embodiments, the menin inhibitor is administered after the second active agent.

[0265] In some embodiments, the present disclosure is directed to a combination therapy for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0266] In some embodiments, the present disclosure is directed to a combination therapy for treating myelofibrosis.

[0267] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a second pharmaceutically active agent for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0268] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a second Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) pharmaceutically active agent for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis.

[0269] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a second pharmaceutically active agent for treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis.

[0270] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a second pharmaceutically active agent for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0271] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a second pharmaceutically active agent for treating myelofibrosis.

[0272] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a second pharmaceutically active agent for treating bone marrow fibrosis.

[0273] In some embodiments, the second pharmaceutically active agent is combined with the menin inhibitor or a pharmaceutically acceptable salt thereof in a single dosage form.

[0274] In some embodiments, the second pharmaceutically active agent and the menin inhibitor or a pharmaceutically acceptable salt thereof are administered as separate dosage forms.

[0275] In some embodiments, the second pharmaceutically active agent and the menin inhibitor or a pharmaceutically acceptable salt thereof are administered simultaneously as separate dosage forms. In some embodiments, the second pharmaceutically active agent and the menin inhibitor or a pharmaceutically acceptable salt thereof are administered sequentially as separate dosage forms.

[0276] In some embodiments, the present disclosure provides a combination therapy comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and a JAK inhibitor.

[0277] In some embodiments, the present disclosure relates to a combination therapy for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) described herein. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0278] In some embodiments, the present disclosure relates to a combination therapy for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis described herein.

[0279] In some embodiments, the present disclosure relates to a combination therapy for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) described herein.

[0280] In some embodiments, the present disclosure relates to a combination therapy for treating myelofibrosis described herein.

[0281] In some embodiments, the present disclosure relates to the use of a pharmaceutical combination for treating bone marrow fibrosis described herein.

[0282] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more pharmaceutically active agents for treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0283] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more pharmaceutically active agents for treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis.

[0284] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more pharmaceutically active agents for treating a myeloproliferative neoplasm (e.g., myelofibrosi , essential thrombocythemia, triple negative MPN, and polycythemia vera).

[0285] In some embodiments, the combination therapy comprises administering at least one menin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more pharmaceutically active agents for treating myelofibrosis.

[0286] The pharmaceutically active agents can be combined with a menin inhibitor or a pharmaceutically acceptable salt thereof in a single dosage form, or the therapeutics can be administered simultaneously or sequentially as separate dosage forms.

[0287] In some embodiments, the invention is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a patient comprising (a) administering a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) administering a JAK inhibitor. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0288] In some embodiments, the invention is directed to a method of treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera.) in a patient comprising (a) administering a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) administering a JAK inhibitor.

[0289] In some embodiments, the invention is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of myelofibrosis in a patient comprising (a) administering a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) administering a JAK inhibitor.

[0290] In some embodiments, the invention is directed to a method of treating myelofibrosis in a patient comprising (a) administering a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) administering a JAK inhibitor.

[0291] In some embodiments, the invention is directed to a method of treating, preventing, reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a patient comprising (a) administering a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) administering a JAK inhibitor.

[0292] In some embodiments, the invention is directed to a method of treating bone marrow fibrosis in a patient comprising (a) administering a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) administering a JAK inhibitor.

[0293] In some embodiments, the invention is directed to a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor for use in reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a patient.

[0294] In some embodiments, the invention is directed to a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor for use in reducing the progression rate, and / or reducing the severity of myelofi brosis in a patient.

[0295] In some embodiments, the invention is directed to a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor for use in reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a patient.

[0296] In some embodiments, the invention is directed to a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) inhibitor for use in treating a myeloproliferative neoplasm (e.g., myelofibrosi , essential thrombocythemia, triple negative MPN, and polycythemia vera) in a patient.

[0297] In some embodiments, the invention is directed to a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor for use in treating myelofibrosis in a patient.

[0298] In some embodiments, the invention is directed to a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor for use in treating bone marrow fibrosis in a patient.

[0299] In some embodiments, the invention is directed to use of a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor in reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosi , essential thrombocythemia, triple negative MPN, and polycythemia vera) in a patient.

[0300] In some embodiments, the invention is directed to use of a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor in reducing the progression rate, and / or reducing the severity of myelofibrosis in a patient.

[0301] In some embodiments, the invention is directed to use of a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor in reducing the progression rate, and / or reducing the severity of bone marrow fibrosis in a patient.

[0302] In some embodiments, the invention is directed to use of a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a patient.

[0303] In some embodiments, the invention is directed to use of a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor in treating myelofibrosis in a patient.

[0304] In some embodiments, the invention is directed to a pharmaceutical combination comprising (a) a menin inhibitor or a pharmaceutically acceptable salt thereof, and (b) a JAK inhibitor in treating bone marrow fibrosis in a patient.

[0305] Some embodiments of this invention are directed to combination therapies designed to treat a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, wherein the combination therapies Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) comprise administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor. In particular, some embodiments of this invention are directed to methods of treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, comprising administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0306] Some embodiments of this invention are directed to combination therapies designed to treat myelofibrosis in a subject, wherein the combination therapies comprise administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor. In particular, some embodiments of this invention are directed to methods of treating myelofibrosis in a subject, comprising administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0307] Some embodiments of this invention are directed to combination therapies designed to treat bone marrow fibrosis in a subject, wherein the combination therapies comprise administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor. In particular, some embodiments of this invention are directed to methods of treating bone marrow fibrosis in a subject, comprising administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0308] Some embodiments of this invention are directed to a pharmaceutical combination for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, wherein the combination comprises a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor. In particular, some embodiments of this invention are directed to a pharmaceutical combination for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, comprising a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0309] Some embodiments of this invention are directed to a pharmaceutical combination for use in treating myelofibrosis in a subject, wherein the combination therapies comprise administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) with a JAK inhibitor. In particular, some embodiments of this invention are directed to methods of treating myelofibrosis in a subject, comprising administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0310] Some embodiments of this invention are directed to a pharmaceutical combination for use in treating bone marrow fibrosis in a subject, wherein the pharmaceutical combination comprises a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor. In particular, some embodiments of this invention are directed a pharmaceutical combination for use in treating bone marrow fibrosis in a subject, comprising administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0311] Some embodiments of this invention are directed to the use of a pharmaceutical combination for treating a myeloproliferative neoplasm (e g , myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, wherein the combination comprises a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor. In particular, some embodiments of this invention are directed to use of a pharmaceutical combination for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thromboc themia, triple negative MPN, and polycythemia vera) in a subject, comprising a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0312] Some embodiments of this invention are directed to the use a pharmaceutical combination for use in treating myelofibrosis in a subject, wherein the combination therapies comprise administering a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a JAK inhibitor. In particular, some embodiments of this invention are directed to use of a pharmaceutical combination for treating myelofibrosis in a subject, comprising a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0313] Some embodiments of this invention are directed to use of a pharmaceutical combination for treating bone marrow fibrosis in a subject, wherein the pharmaceutical combination comprises a menin inhibitor or a pharmaceutically acceptable salt thereof in Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) combination with a JAK inhibitor. In particular, some embodiments of this invention are directed use of a pharmaceutical combination for treating bone marrow fibrosis in a subject, comprising a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0314] Some embodiments of this invention are directed to methods of treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, comprising administering a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0315] Some embodiments of this invention are directed to methods of treating myelofibrosis in a subject, comprising administering therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0316] Some embodiments of this invention are directed to methods of treating bone marrow fibrosis in a subject, comprising administering a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0317] Some embodiments of this invention are directed to a pharmaceutical combination for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, comprising a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0318] Some embodiments of this invention are directed to a pharmaceutical combination for use in treating myelofibrosis in a subject, comprising a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0319] Some embodiments of this invention are directed to a pharmaceutical combination for use in treating bone marrow fibrosis in a subject, comprising administering a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) combination with a therapeutically effective amount of a JAK inhibitor administered simultaneously, separately or sequentially.

[0320] Some embodiments of this invention are directed to use of a pharmaceutical combination for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject, comprising a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0321] Some embodiments of this invention are directed to use of a pharmaceutical combination for treating myelofibrosis in a subject, comprising a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0322] Some embodiments of this invention are directed use of a pharmaceutical combination for treating bone marrow fibrosis in a subject, comprising a therapeutically effective amount of a menin inhibitor or a pharmaceutically acceptable salt thereof in combination with a therapeutically effective amount of a JAK inhibitor, wherein the pharmaceutical combination is formulated for administration simultaneously, separately or sequentially.

[0323] Some embodiments provide a kit comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and instructions for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythem vera) in a subject.

[0324] Some embodiments provide a kit comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and instructions for use in treating myelofibrosis in a subject.

[0325] Some embodiments provide a kit comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and instructions for use in treating bone marrow fibrosis in a subject.

[0326] Some embodiments provide a kit comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof and instructions for use in combination with a JAK inhibitor for treating a myeloproliferative neoplasm (e.g , myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in combination with a JAK inhibitor in a subject. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0327] Some embodiments provide a kit comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and instructions for use in combination with a JAK inhibitor for treating myelofibrosis in a subject.

[0328] Some embodiments provide a kit comprising a menin inhibitor, or a pharmaceutically acceptable salt thereof, and instructions for use in combination with a JAK inhibitor for use in treating bone marrow fibrosis in a subject.

[0329] Some embodiments provide a kit comprising a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and instructions for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject.

[0330] Some embodiments provide a kit comprising a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and instructions for use in treating myelofibrosis in a subject.

[0331] Some embodiments provide a kit comprising a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and instructions for use in treating bone marrow fibrosis in a subject.

[0332] Some embodiments provide a kit comprising a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a therapeutically effective amount of a JAK inhibitor and instructions for use in treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject.

[0333] Some embodiments provide a kit comprising a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a therapeutically effective amount of a JAK inhibitor and instructions for use in treating myelofibrosis in a subject.

[0334] Some embodiments provide a kit comprising a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a therapeutically effective amount of JAK inhibitor and instructions for use in treating bone marrow fibrosis in a subject.

[0335] Some embodiments provide a kit comprising a pharmaceutical composition, wherein the pharmaceutical composition comprises a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and at least one pharmaceutically acceptable carrier, wherein the kit further comprises instructions for use in treating a myeloproliferative Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject.

[0336] Some embodiments provide a kit comprising pharmaceutical composition, wherein the pharmaceutical composition comprises a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and at least one pharmaceutically acceptable carrier, wherein the kit further comprises instructions for use in treating myelofibrosis in a subject.

[0337] Some embodiments provide a kit comprising pharmaceutical composition, wherein the pharmaceutical composition comprises a menin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with a JAK inhibitor and at least one pharmaceutically acceptable carrier, wherein the kit further comprises instructions for use in treating bone marrow fibrosis in a subject.

[0338] Some embodiments provide a kit comprising a pharmaceutical composition, wherein the pharmaceutical composition comprises a menin inhibitor, or a pharmaceutically acceptable salt thereof, instructions for treating a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in combination with a JAK inhibitor, and at least one pharmaceutically acceptable carrier.

[0339] Some embodiments provide a kit comprising a pharmaceutical composition, wherein the pharmaceutical composition comprises a menin inhibitor, or a pharmaceutically acceptable salt thereof, instructions for treating myelofibrosis in a subject in combination with a JAK inhibitor, and at least one pharmaceutically acceptable carrier.

[0340] Some embodiments provide a kit comprising a pharmaceutical composition, wherein the pharmaceutical composition comprises a menin inhibitor, or a pharmaceutically acceptable salt thereof, instructions for treating bone marrow fibrosis in a subject in combination with a JAK inhibitor, and at least one pharmaceutically acceptable carrier.

[0341] Some embodiments provide a kit comprising a pharmaceutical composition, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, instructions for treating a myeloproliferative neoplasm (e.g., myelofibros s, essential thrombocythemia, triple negative MPN, and polycythemia vera) in a subject in combination with a therapeutically effective amount of a JAK inhibitor, and at least one pharmaceutically acceptable carrier.

[0342] Some embodiments provide a kit comprising a pharmaceutical composition, wherein the pharmaceutical composition comprises a therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, instructions for treating myelofibrosis Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) in a subject in combination with a therapeutically effective amount of a JAK inhibitor, and at least one pharmaceutically acceptable carrier.

[0343] Some embodiments provide a kit comprising a pharmaceutical composition, wherein the pharmaceutical composition comprises therapeutically effective amount of a menin inhibitor, or a pharmaceutically acceptable salt thereof, instructions for treating bone marrow fibrosis in a subject in combination with a therapeutically effective amount of a JAK inhibitor, and at least one pharmaceutically acceptable carrier.

[0344] Pharmaceutical Compositions

[0345] The menin inhibitor or a pharmaceutically acceptable salt thereof may be administered in combination, e.g. simultaneously, sequentially or separately, with one or more other therapeutically active compounds. Pharmaceutical compositions maybe conveniently presented in unit dose forms containing a predetermined amount of an active agent of the invention per dose. Such a unit may contain for example but without limitation, lOOOmg / kg to O.Olmg / kg for example.

[0346] Pharmaceutically acceptable carriers for use in the invention may take a wide variety of forms depending, e.g. on the route of administration.

[0347] Compositions for oral administration may be liquid or solid. Oral liquid preparations may be in the form of, for example, aqueous or oily suspensions, solutions, emulsions, syrups or elixirs, or may be presented as a dry product for reconstitution with water or other suitable vehicle before use. Oral liquid preparations may contain suspending agents as known in the art. In the case of oral solid preparations such as pow'ders, capsules and tablets, carriers such as starches, sugars, micro crystalline cellulose, granulating agents, lubricants, binders, disintegrating agents, and the like may be included. Because of their ease of administration, tablets and capsules represent the most advantageous oral dosage unit form in which case solid pharmaceutical carriers are generally employed.

[0348] In addition to the common dosage forms set out above, active agents of the invention may also be administered by controlled release means and / or delivery devices. Tablets and capsules may comprise conventional carriers or excipients such as binding agents for example, syrup, acacia, gelatin, sorbitol, tragacanth, or polyvinylpyrrolidone, tillers, for example lactose, sugar, maize-starch, calcium phosphate, sorbitol or glycine; tableting lubricants, for example magnesium stearate, talc, polyethylene glycol or silica; disintegrants, for example potato starch; or acceptable wetting agents such as sodium lauryl sulphate. The tablets may be coated Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) by standard aqueous or non-aqueous techniques according to methods well known in normal pharmaceutical practice.

[0349] Pharmaceutical compositions of the present invention suitable for oral administration may be presented as discrete units such as capsules, cachets or tablets, each containing a predetermined amount of the active agent, as a powder or granules, or as a solution or a suspension in an aqueous liquid, a non-aqueous liquid, an oil-in-water emulsion or a water- inoil liquid emulsion . Such compositions may be prepared by any of the methods of pharmacy but all methods include the step of bringing into association the active agent with the carrier, which constitutes one or more necessary ingredients. In general, the compositions are prepared by uniformly and intimately admixing the active agent with liquid carriers or finely divided solid carriers or both, and then, if necessary', shaping the product into the desired presentation. For example, a tablet may be prepared by compression or molding, optionally with one or more accessory’ ingredients.

[0350] Pharmaceutical compositions suitable for parenteral administration may be prepared as solutions or suspensions of the active agents of the invention in water suitably mixed with a surfactant such as hydroxypropylcellulose. Dispersions can also be prepared in glycerol, liquid polyethylene glycols, and mixtures thereof in oils. Under ordinary conditions of storage and use, these preparations contain a preservative to prevent the growth of microorganisms. The pharmaceutical forms suitable for injectable use include aqueous or non-aqueous sterile injection solutions which may contain anti-oxidants, buffers, bacteriostats and solutes which render lite composition isotonic with the blood of the intended recipient, and aqueous and nonaqueous sterile suspensions which may include suspending agents and thickening agents. Extemporaneous injection solutions, dispersions and suspensions may be prepared from sterile powders, granules and tablets. Pharmaceutical compositions can be administered with medical devices known in the an. For example, in a preferred embodiment, a pharmaceutical composition of the invention can be administered with a needleless hypodermic injection device, such as the devices disclosed in US 5,399,163; 5,383,851; 5,312,335; 5,064,413; 4,941,880; 4,790,824; or 4,596,556. Examples of well-known implants and modules useful in the present invention include: US 4,487,603, wdiich discloses an implantable micro-infusion pump for dispensing medication at a controlled rate; US 4,486, 194, which discloses a therapeutic device for administering medicaments through the skin; US 4,447,233, which discloses a medication infusion pump for delivering medication at a precise infusion rate, US 4,447,224, which discloses a variable flow implantable infusion apparatus for continuous drug delivery'; US 4,439,196, which discloses an osmotic drag deliveiy system having multi- Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) chamber compartments; and US 4,475,196, which discloses an osmotic drag delivery system. Many other such implants, delivery systems, and modules are known to those skilled in the art.

[0351] The dosage to be administered of the menin inhibitor or the pharmaceutically acceptable salt thereof will vary according to the particular inhibitor, the subject and the nature and severity of the disease and the physical condition of the subject, and the selected route of administration; the appropriate dosage can be readily determined by a person skilled in the art. For treating, preventing, reducing the progression rate, and / or reducing the severity of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) in humans and animals pharmaceutical compositions comprising a menin inhibitor or a pharmaceutically acceptable salt thereof can be administered to patients (e.g., human subjects) at therapeutically or prophylactically effective dosages (e.g., dosages which result in inhibition of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) and / or relief of a myeloproliferative neoplasm (e.g., myelofibrosis, essential thrombocythemia, triple negative MPN, and polycythemia vera) symptoms) using any suitable route of administration, such as injection and other routes of administration known in the art for clinical products. The compositions may contain at least 0.05 percent by weight, for example 0.5 to 50 percent byweight such as 1 to 10 percent by weight, or more, by weight, of the inhibitor of the invention, depending on the method of administration. It wil I be recognized by one of skil I in the art that the optimal quantity and spacing of individual dosages of an inhibitor of the invention will be determined by the nature and extent of the condition being treated, die form, route and site of administration, and the age and condition of the particular subject being treated, and that a physician will ultimately determine appropriate dosages to be used. This dosage may be repeated as often as appropriate. If side effects develop the amount and / or frequency of the dosage can be altered or reduced, in accordance with normal clinical practice.

[0352] When employed as pharmaceuticals, the compounds of the disclosure can be administered in the form of a pharmaceutical composition which refers to a combination of a compound of the disclosure, or its pharmaceutically acceptable salt, and at least one pharmaceutically acceptable carrier. These compositions can be prepared in a manner well known in the pharmaceutical art, and can be administered by a variety of routes, depending upon whether local or systemic treatment is desired and upon the area to be treated. Administration may be topical (including ophthalmic and to mucous membranes including intranasal, vaginal and rectal delivery), pulmonary (e.g., by inhalation or insufflation of powders or aerosols, including by nebulizer; intratracheal, intranasal, epidermal and Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) transdermal), ocular, oral or parenteral. Methods for ocular delivery can include topical administration (eye drops), subconjunctival, periocular or intravitreal injection or introduction by balloon catheter or ophthalmic inserts surgically placed in the conjunctival sac. Parenteral administration includes intravenous, intraarterial, subcutaneous, intraperitoneal, or intramuscular injection or infusion; or intracranial, e.g., intrathecal or intraventricular, administration. Parenteral administration can be in the form of a single bolus dose, or may be, for example, by a continuous perfusion pump. Pharmaceutical compositions and formulations for topical administration may include transdermal patches, ointments, lotions, creams, gels, drops, suppositories, sprays, liquids and powders. Conventional pharmaceutical carriers, aqueous, powder or oily bases, thickeners and the like may be necessary or desirable.

[0353] This disclosure also includes pharmaceutical compositions which contain, as the active ingredient, one or more menin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more pharmaceutically acceptable carriers. In making the compositions of the disclosure, the active ingredient is typically mixed with an excipient, diluted by an excipient or enclosed within such a carrier in the form of, for example, a capsule, sachet, paper, or other container. When the excipient serves as a diluent, it can be a solid, semisolid, or liquid material, which acts as a vehicle, carrier or medium for the active ingredient. Thus, the compositions can be in the form of tablets, pills, powders, lozenges, sachets, cachets, elixirs, suspensions, emulsions, solutions, syrups, aerosols (as a solid or in a liquid medium), ointments containing, for example, up to 10% by weight of the menin inhibitor or the pharmaceutically acceptable salt thereof, soft and hard gelatin capsules, suppositories, sterile injectable solutions, and sterile packaged powders.

[0354] Compounds or compositions described herein may be administered to a patient using any amount and any route of administration effective for treating or lessening the severity of one or more of the diseases and conditions described herein. The exact amount required will vary from subject to subject, depending on the species, age, and general condition of the subject, the severity of the infection, disease or disorder, the particular agent, its mode of administration, and the like. The menin inhibitor or the pharmaceutically acceptable salt thereof is preferably formulated in a particular unit dosage form for ease of administration and uniformity of dosage. The expression "unit dosage form" as used herein refers to a physically discrete unit of agent appropriate for the patient to be treated.

[0355] The therapeutic dosage of the menin inhibitor or the pharmaceutically acceptable salt thereof can vary according to, for example, the particular use for which the treatment is made, the manner of administration of the menin inhibitor or the pharmaceutically acceptable salt Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) thereof, the health and condition of the patient, and the judgment of the prescribing physician. The proportion or concentration of a menin inhibitor or a pharmaceutically acceptable salt thereof in a pharmaceutical composition can vary depending upon a number of factors including dosage, chemical characteristics (e.g., hydrophobicity), and the route of administration. For example, the menin inhibitor or the pharmaceutically acceptable salt thereof can be provided in an aqueous physiological buffer solution containing about 0.1 to about 10% w / v of the menin inhibitor or the pharmaceutically acceptable salt thereof for parenteral administration. The dosage is likely to depend on such variables as the type and extent of progression of the disease or disorder, the overall health status of the particular patient, the relative biological efficacy of the menin inhibitor or the pharmaceutically acceptable salt thereof selected, formulation of the excipient, and its route of administration.

[0356] Biological Assays

[0357] In some aspects, menin inhibitors are evaluated for efficacy in the treatment of myelofibrosis.

[0358] Megakaryocytes are hematopoietic precursors and megakaryocyte proliferation is a key contributor to myelofibrosis symptoms (Melo-Cardenas et al, “The Role of Megakaryocytes in Myelofibrosis”, HematoL Oncol. Clin. North. Am. 2021, 35, 191-203). Compounds that inhibit the proliferation of megakaryocytes are reliable tools in the treatment of MF. Menin inhibitors are shown herein to inhibit megakaryocyte proliferation as measured by colony forming unit assays and several MPN mouse models. Genetic testing has revealed a requirement for menin and an on-target effect of menin inhibitors on the disruption of megakaryocyte proliferation. Thus, menin inhibition is an effective strategy in the treatment of myelofibrosis.

[0359] The MPLW515L mutation produces a phenotype that closely resembles myelofibrosis in humans, characterized by excessive proliferation of megakaryocytes and high levels of platelet-derived growth factors, inducing fibrosis in the bone marrow, and excessive blood cell production (z.e., thrombocytosis, and leukocytosis) (see, e.g., Jacquelin et al. “Murine Models of Myelofibrosis,” Cancers, 202, 12, 2381 . Thus, the MPLW515L mouse model serves as an in vivo tool to evaluate the efficacy of menin inhibitors in the treatment of myelofibrosis. Similarly, the JAK2V617F retroviral transduction / transplantation model is a reliable in vivo MF model, which produces a phenotype characterized by polycythemia, splenomegaly, modest lymphoproliferation, and bone marrow fibrosis. Further, the MPL S504N constitutive knock- in mouse model, which spontaneously develops thrombocytosis and bone marrow fibrosis over Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) several months, was employed to further assess menin inhibitors in MF treatment. In all models, menin inhibitors as single agents or in combination with JAK inhibitors were highly efficacious. The mechanism is confirmed by genetic studies indicating menin inhibition disrupts megakaryocyte formation from progenitors at the early or late megakaryocyte progenitor stage. The findings of the present disclosure thus indicate that menin inhibitors as single agents or in combination with JAK inhibitors are reliable in the treatment of MPNs and MF.

[0360] Formation of reticulin fibrosis is key characterization of myelofibrosis. Menin inhibitors were shown to reduce myelofibrotic tissue buildup, as measured by reticulin grade, in comparison to controls. Menin inhibitors are effective in the treatment of myelofibrosis.

[0361] In some embodiments, the menin inhibitor inhibits megakaryocyte cell development.

[0362] In some embodiments, the menin inhibitor inhibits megakaryocyte cell development in a colony forming unit assay.

[0363] In some embodiments, the menin inhibitors of the present disclosure are used for reducing or preventing myelofibrotic tissue buildup in a subject in need thereof.

[0364] In some embodiments, the present disclosure is directed to a method of the reduction or prevention of myelofibrotic tissue buildup in a subject in need thereof comprising administering a menin inhibitor of the present disclosure or a pharmaceutically acceptable salt thereof.

[0365] In some embodiments, the myeloproliferative neoplasms contemplated herein feature a MPL mutation.

[0366] In some embodiments, the myeloproliferative neoplasms contemplated herein feature a MPLS504N mutation.

[0367] In some embodiments, the essential thrombocytosis and myelofibrosis contemplated herein feature a MPL mutation.

[0368] In some embodiments, the essential thrombocytosis and myelofibrosis contemplated herein feature a MPLS504N mutation.

[0369] In some embodiments, the essential thrombocytosis contemplated herein feature a MPL mutation.

[0370] In some embodiments, the essential thrombocytosis contemplated herein feature a MPLS504N mutation.

[0371] In some embodiments, the myelofibrosis contemplated herein feature a MPL mutation. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0372] In some embodiments, the myelofibrosis contemplated herein feature a MPL S504N mutation. In some embodiments, the menin inhibitor when administered to a subject inhibits megakaryocyte cell proliferation in the subject.

[0373] In some embodiments, the menin inhibitor when administered to a subject reduces the concentration of leukocytes in the subject.

[0374] In some embodiments, the menin inhibitor when administered to a subject reduces the concentration of platelets in the subject.

[0375] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor inhibits megakaryocyte cell proliferation in the subject.

[0376] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor reduces the concentration of leukocytes in the subject.

[0377] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor reduces the concentration of platelets in the subject.

[0378] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor inhibits megakaryocyte cell proliferation in the subject to a greater extent when compared to administration of the menin inhibitor alone.

[0379] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor reduces the concentration of leukocytes in the subject to a greater extent when compared to administration of the menin inhibitor alone.

[0380] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor reduces the concentration of platelets in the subject to a greater extent when compared to administration of the menin inhibitor alone.

[0381] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor inhibits megakaryocyte cell proliferation in the subject to a greater extent when compared to administration of the JAK inhibitor alone.

[0382] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor reduces the concentration of leukocytes in the subject to a greater extent when compared to administration of the JAK inhibitor alone.

[0383] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor reduces the concentration of platelets in the subject to a greater extent when compared to administration of the JAK inhibitor alone.

[0384] In some embodiments, the menin inhibitor when administered to a subject decreases leukocyte concentration in the subject in a dose-dependent manner. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0385] In some embodiments, the menin inhibitor when administered to a subject decreases platelet concentration in the subject in a dose-dependent manner.

[0386] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor decreases leukocyte concentration in the subject in a dosedependent manner.

[0387] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor decreases platelet concentration in the subject in a dosedependent manner.

[0388] In some embodiments, the menin inhibitor is administered to a subject after a bone marrow transplant.

[0389] In some embodiments, the menin inhibitor is administered to a subject in combination with a JAK inhibitor after a bone marrow transplant.

[0390] In some embodiments, the menin inhibitor is administered to a subject after a bone marrow transplant and decreases leukocyte concentration in the subject.

[0391] In some embodiments, the menin inhibitor is administered to a subject after a bone marrow transplant and decreases platelet concentration in the subject.

[0392] In some embodiments, the menin inhibitor is administered to a subject in combination with a JAK inhibitor after a bone marrow transplant and decreases leukocyte concentration in the subject.

[0393] In some embodiments, the menin inhibitor is administered to a subject in combination with a JAK inhibitor after a bone marrow transplant and decreases platelet concentration in the subject.

[0394] In some embodiments, the menin inhibitor is administered to a subject in combination with a JAK inhibitor after a bone marrow transplant and decreases leukocyte concentration in the subject to a greater extent when compared to the menin inhibitor alone.

[0395] In some embodiments, the menin inhibitor is administered to a subject in combination with a JAK inhibitor after a bone marrow transplant and decreases platelet concentration in the subject to a greater extent when compared to the menin inhibitor alone.

[0396] In some embodiments, the menin inhibitor is administered to a subject in combination with a JAK inhibitor after a bone marrow transplant and decreases leukocyte concentration in the subject to a greater extent when compared to the JAK inhibitor alone.

[0397] In some embodiments, the menin inhibitor is administered to a subject in combination with a JAK inhibitor after a bone marrow transplant and decreases platelet concentration in the subject to a greater extent when compared to the JAK inhibitor alone. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0398] In some embodiments, the menin inhibitor when administered to a subject decreases levels of fibrotic tissue in the subject.

[0399] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor decreases levels of fibrotic tissue in the subject.

[0400] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor decreases levels of fibrotic tissue in the subject to a greater extent when compared to administration of the menin inhibitor alone.

[0401] In some embodiments, the menin inhibitor when administered to a subject in combination with a JAK inhibitor decreases levels of fibrotic tissue in the subject to a greater extent when compared to administration of the JAK inhibitor alone.

[0402] In some embodiments, the menin inhibitor exhibits dose-dependent plasma exposure when administered to a subject.

[0403] In some embodiments, the menin inhibitor disrupts proliferation of a megakaryocyte progenitor.

[0404] In some embodiments, the megakaryocyte progenitor is a common myeloid progenitor (CMP), megakaryocyte-erythroid progenitor (MEP), or an early or late megakaryocyte progentior (MKP).

[0405] In some embodiments, the megakaryocyte progenitor is a MK-biased hematopoietic stem cell, a megakaryocyte-erythroid progenitor (MEP), or an early or late megakaryocyte progenitor (MKP).

[0406] In some embodiments, the megakaryocyte progenitor is an early megakaryocyte progenitor or a late megakaryocyte progenitor.

[0407] In some embodiments, the megakaryocyte progenitor is an early megakaryocyte progenitor.

[0408] In some embodiments, the megakaryocyte progenitor is a late megakaryocyte progenitor.

[0409] In some embodiments, the menin inhibitor reduces the severity of a symptom of myelofibrosis.

[0410] In some embodiments, the menin inhibitor reduces the severity of lymphocytosis, polycythemia, lymphoproliferation, bone marrow fibrosis, thrombocytosis, splenomegaly, accumulation of atypical megakaryocytes, fibrosis or impaired survival. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0411] Numbered Claims Clauses A:

[0412] Clause Al . A method of treating a myeloproliferative neoplasm in a subject in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0413] Clause A2. The method of clause Al, wherein the myeloproliferative neoplasm is myelofibrosis, essential thrombocythemia, triple negative MPN, or polycythemia vera.

[0414] Clause A3. The method of clause Al, wherein the myeloproliferative neoplasm is myelofibrosis.

[0415] Clause A4. The method of clause Al, wherein the myeloproliferative neoplasm is es sent! al thronib ocy themi a .

[0416] Clause A5. The method of clause Al, wherein the myeloproliferative neoplasm is triple negative MPN.

[0417] Clause A6. The method of clause Al, wherein the myeloproliferative neoplasm is polycythemia vera.

[0418] Clause A7. A method of treating myelofibrosis in a subject in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0419] Clause A8. The method of any one of the previous clauses, wherein the menin inhibitor or the pharmaceutically acceptable salt thereof is a small molecule, or a pharmaceutically acceptable salt thereof.

[0420] Clause A9a. The method of any one of the previous clauses, wherein the menin Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) a stereoisomer thereof, or a pharmaceutically acceptable salt thereof.

[0421] Clause A9b. The method of any one of the previous clauses, wherein the menin inhibitor is Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) or a pharmaceutically acceptable salt thereof.

[0422] Clause AlOa. The method of any one of the previous clauses, wherein the menin inhibitor is Compound No. 1, or a pharmaceutically acceptable salt thereof.

[0423] Clause AlOb. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 2, or a pharmaceutically acceptable salt thereof.

[0424] Clause AlOc. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 3, or a pharmaceutically acceptable salt thereof.

[0425] Clause AlOd. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 4, or a pharmaceutically acceptable salt thereof.

[0426] Clause AlOe. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 5, or a pharmaceutically acceptable salt thereof.

[0427] Clause Al Of. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 6, or a pharmaceutically acceptable salt thereof.

[0428] Clause AlOg. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 7, or a pharmaceutically acceptable salt thereof.

[0429] Clause Al Oh. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 8, or a pharmaceutically acceptable salt thereof.

[0430] Clause AlOi. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 9, or a pharmaceutically acceptable salt thereof.

[0431] Clause AlOj. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 10, or a pharmaceutically acceptable salt thereof.

[0432] Clause Al Ok. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 11, or a pharmaceutically acceptable salt thereof. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0433] Clause Al 01. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 12, or a pharmaceutically acceptable salt thereof.

[0434] Clause AlOm. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 13, or a pharmaceutically acceptable salt thereof.

[0435] Clause Al On. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 14, or a pharmaceutically acceptable salt thereof.

[0436] Clause AlOo. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 15, or a pharmaceutically acceptable salt thereof.

[0437] Clause Al Op. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 16, or a pharmaceutically acceptable salt thereof.

[0438] Clause AlOq. The method of any one of the previous clauses Al-A9b, wherein the menin inhibitor is Compound No. 17, or a pharmaceutically acceptable salt thereof.

[0439] Clause Al la. The method of any one of clauses A2-A10n, wherein the myelofibrosis is characterized by a JAK gene mutation, a CALR gene mutation, or a MPL gene mutation.

[0440] Clause Al lb. The method of any one of clauses A2-A10n, wherein the myelofibrosis is characterized by a JAK gene mutation.

[0441] Clause Al ic. The method of any one of clauses A2-A10n, wherein the myelofibrosis is characterized by a CALR gene mutation.

[0442] Clause Al Id. The method of any one of clauses A2-A10n, wherein the myelofibrosis is characterized by a MPL gene mutation.

[0443] Clause Al le. The method of any one of clauses A2-A10n, wherein the myelofibrosis is characterized by a MPL gene mutation.

[0444] Clause A12a. The method of any one of clauses A2-A1 le, wherein the myelofibrosis is characterized by a JAK1, J K2, J AK3, CALR type 1, CALR type 2, or MPL W515L gene mutation.

[0445] Clause A12b. The method of any one of clauses A2-A1 le, wherein the myelofibrosis is characterized by a JAK1 gene mutation.

[0446] Clause A12c. The method of any one of clauses A2-A1 le, wherein the myelofibrosis is characterized by a JAK2 gene mutation.

[0447] Clause A12d. The method of any one of clauses A2-A1 le, wherein the myelofibrosis is characterized by a JAK3 gene mutation.

[0448] Clause A12e. The method of any one of clauses A2-A1 le, wherein the myelofibrosis is characterized by a CALR type 1 gene mutation. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0449] Clause A12f. The method of any one of clauses A2-A1 le, wherein the myelofibrosis is characterized by a CALR type 2 gene mutation.

[0450] Clause A12g. The method of any one of clauses A2-A1 le, wherein the myelofibrosis is characterized by a MPL W515L gene mutation.

[0451] Clause A13. The method of any one of clauses A2-A12g, wherein the myelofibrosis is characterized by a JAK2V617Fgene mutation.

[0452] Clause A14. The method of any one of the previous clauses, wherein the method further comprises administering a second therapeutically active agent.

[0453] Clause Al 5. The method of any one of the previous clauses, wherein the second therapeutically active agent is a JAK inhibitor.

[0454] Clause Al 6a. The method of any one of the previous clauses, wherein the second therapeutically active agent is ruxolitinib, fedratinib (SAR302503), momelotinib (CYT387), pacritinib, iestaurtinib, AZD-1480, B.MS-911543, NS-018, LY2784544, SEP-701, XL019, or AT-9283.

[0455] Clause A16b. The method of any one of the previous clauses, wherein the second therapeutically active agent is ruxolitinib.

[0456] Clause Al 6c. The method of any one of the previous clauses, wherein the second therapeutically active agent is fedratinib (SAR302503).

[0457] Clause A16d. The method of any one of the previous clauses, wherein the second therapeutically active agent is momelotinib (CYT387).

[0458] Clause A16e. The method of any one of the previous clauses, wherein the second therapeutically active agent is pacritinib.

[0459] Clause A16f. The method of any one of the previous clauses, wherein the second therapeutically active agent is Iestaurtinib.

[0460] Clause Al 6g. The method of any one of the previous clauses, wherein the second therapeutically active agent is AZD-1480.

[0461] Clause A16h. The method of any one of the previous clauses, wherein the second therapeutically active agent is BMS-911543.

[0462] Clause A16i. The method of any one of the previous clauses, wherein the second therapeutically active agent is NS-018.

[0463] Clause A16j. The method of any one of the previous clauses, wherein the second therapeutically active agent is LY2784544.

[0464] Clause Al 6k. The method of any one of the previous clauses, wherein the second therapeutically active agent is SEP-701. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0465] Clause Al 61. The method of any one of the previous clauses, wherein the second therapeutically active agent XL019.

[0466] Clause Al 6m. The method of any one of the previous clauses, wherein the second therapeutically active agent is AT-9283.

[0467] Clause Al 7. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating a myeloproliferative neoplasm.

[0468] Clause Al 8. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating myelofibrosis.

[0469] Clause Al 9. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating a m eloprol ferative neoplasm in a subject in need thereof.

[0470] Clause A20. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating myelofibrosis in a subject in need thereof.

[0471] Clause A21. A pharmaceutical composition comprising a menin inhibitor of clause A9, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm .

[0472] Clause A22. A pharmaceutical composition comprising a menin inhibitor of clause A9-A10n, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

[0473] Clause A23a. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of clause A9-A10n, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm.

[0474] Clause A23b. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of clause A9-A10n, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm.

[0475] Clause A24. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of clause A9-A10n, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

[0476] Clause A25. A kit comprising a menin inhibitor of clause A9 or a pharmaceutically acceptable salt thereof, and instructions for its use, wherein the kit is used for treating a myeloproliferative neopl as .

[0477] Clause A26. A kit comprising a menin inhibitor of clause A9 or a pharmaceutically acceptable salt thereof, and instructions for its use, wherein the kit is used for treating myelofibrosis. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0478] Clause A27. A kit comprising the pharmaceutical composition of clause A21 and instructions for its use, wherein the kit is used for treating a myeloproliferative neoplasm.

[0479] Clause A28. A kit comprising the pharmaceutical composition of clause A22 and instructions for its use, wherein the kit is used for treating myelofibrosis.

[0480] Clause A29. A kit comprising the pharmaceutical composition of clause A23a-b and instructions for its use, wherein the kit is used for treating a myeloproliferative neoplasm.

[0481] Clause A30. A kit comprising the pharmaceutical composition of clause A24 and instructions for its use, wherein the kit is used for treating myelofibrosis.

[0482] Numbered Claims Clauses B:

[0483] Clause Bl. A method of treating a myeloproliferative neoplasm in a subj ect in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0484] Clause B2. The method of clause Bl, wherein the myeloproliferative neoplasm is myelofibrosis, essential thrombocythemia, triple negative MPN, or polycythemia vera.

[0485] Clause B3. The method of clause Bl, wherein the myeloproliferative neoplasm is myelofibrosis.

[0486] Clause B4. The method of clause Bl, wherein the myeloproliferative neoplasm is essential thrombocy them! a.

[0487] Clause B5. The method of clause Bl, wherein the myeloproliferative neoplasm is triple negative MPN.

[0488] Clause B6. The method of clause Bl, wherein the myeloproliferative neoplasm is polycythemia vera.

[0489] Clause B7. A method of treating myelofibrosis in a subject in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0490] Clause B8. A method of treating bone marrow fibrosis in a subject in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

[0491] Clause B9. The method of any one of the previous clauses, wherein the menin inhibitor or the pharmaceutically acceptable salt thereof is a small molecule, or a pharmaceutically acceptable salt thereof.

[0492] Clause BIO. The method of any one of the previous clauses, wherein the menin inhibitor is Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) or a pharmaceutically acceptable salt thereof.

[0493] Clause B 11. The method of any one of the previous clauses, wherein the menin inhibitor is Compound No. 1, or a pharmaceutically acceptable salt thereof.

[0494] Clause B12. The method of any one of clauses B1-B7 or B9-B11, wherein the myelofibrosis is characterized by a JAK gene mutation, a CALR gene mutation, or a MPL gene mutation.

[0495] Clause B13. The method of any one of clauses B1-B7 or B9-B12, wherein the myelofibrosis is characterized by a LAKI, JAK2, JAK3, CALR type 1, CALR type 2, or MPL W515L gene mutation.

[0496] Clause B14. The method of any one of clauses B1-B7 or B9-B13, wherein the myelofibrosis is characterized by K JAK2V617Fgene mutation

[0497] Clause Bl 5. The method of any one of the previous clauses, wherein the method further comprises administering a second therapeutically active agent.

[0498] Clause Bl 6. The method of any one of the previous clauses, wherein the second therapeutically active agent is a JAK inhibitor.

[0499] Clause Bl 7. The method of any one of the previous clauses, wherein the second therapeutically active agent is ruxoiitinib, fedratinib (SAR302503), momelotinib (CYT387), pacriiinib, lestaurtinib, AZD-1480, BMS-91 1543, NS-018, LY2784544, SEP-701, XL 019, or AT-9283.

[0500] Clause Bl 8. The method of any one of the previous clauses, wherein the second therapeutically active agent is ruxoiitinib.

[0501] Clause Bl 9. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating a myeloproliferative neoplasm. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0502] Clause B20. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating myelofibrosis.

[0503] Clause B21. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating bone marrow fibrosis.

[0504] Clause B22. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating a myeloproliferative neoplasm in a subject in need thereof.

[0505] Clause B23. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating myelofibrosis in a subject in need thereof.

[0506] Clause B24. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating bone marrow fibrosis in a subject in need thereof.

[0507] Clause B25. A pharmaceutical composition comprising a menin inhibitor of clause BIO, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a my el oprolit erative neoplasm .

[0508] Clause B26. A pharmaceutical composition comprising a menin inhibitor of clause BIO, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

[0509] Clause B27. A pharmaceutical composition comprising a menin inhibitor of clause BIO, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating bone marrow fibrosis.

[0510] Clause B28. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of clause BIO, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm.

[0511] Clause B29. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of clause BIO, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

[0512] Clause B30. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of clause BIO, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating bone marrow fibrosis.

[0513] Clause B31. A kit comprising a menin inhibitor of clause B 10 or a pharmaceutically acceptable salt thereof, and instructions for use for treating a myeloproliferative neoplasm.

[0514] Clause B32. A kit comprising a menin inhibitor of clause BIO or a pharmaceutically acceptable salt thereof, and instructions for use for treating myelofibrosis. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0515] Clause B33. A kit comprising a menin inhibitor of clause BIO or a pharmaceutically acceptable salt thereof, and instructions for use for treating bone marrow fibrosis.

[0516] Clause B34. A kit comprising the pharmaceutical composition of clause B25 and instructions for use for treating a myeloproliferative neoplasm.

[0517] Clause B35. A kit comprising the pharmaceutical composition of clause B26 and instructions for use for treating myelofibrosis.

[0518] Clause B36. A kit comprising the pharmaceutical composition of clause B27 and instructions for use for treating myelofibrosis.

[0519] Clause B37. A kit comprising the pharmaceutical composition of clause B28 and instructions for use for treating a myeloproliferative neoplasm.

[0520] Clause B38. A kit comprising the pharmaceutical composition of clause B29 and instructions for use for treating myelofibrosis.

[0521] Clause B38. A kit comprising the pharmaceutical composition of clause B30 and instructions for use for treating myelofibrosis.

[0522] EXAMPLES

[0523] The formation of megakaryocyte (MK) cells occurs in a stepwise fashion from the hematopoietic stem cell, including either those with the ability to give rise to the complete repertoire of blood cells or those that are biased to produce megakaryocytes (MK-biased HSCs). The capacity of menin inhibitors to block MK cell formation from HSC cells in CFU assays, suggests that menin inhibition selectively inhibits differentiation of an intermediate MK precursor cell prior to MK cell formation.

[0524] Example 1. In Vitro Evaluation of Four Test Compounds on Human Megakaryocyte Progenitor CFC Proliferation in Normal Bone Marrow

[0525] Four test compounds were evaluated for toxicity to the megakaryocyte lineage using the CFU-Mk colony forming cell assay. The compounds were tested at concentrations ranging from 15 - 0.005 pM. 5-FU was used as a positive control for toxicity and behaved as historically observed.

[0526] Definitions:

[0527] CFU-Mk (3-20): This megakaryocytic colony forming cells generates a small colony containing 3-20 megakaryocytes. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0528] CFU-Mk (21-49): This megakaryocytic colony forming cells generates a medium sized colony containing 21-49 megakaryocytes.

[0529] CFU-Mk (>50): This megakaryocytic colony forming cells generates a large colony containing >50 megakaryocytes. rhIL-3 : recombinant human Interleukin-3 rhIL-6: recombinant human Interleukin-6 rhTpo: recombinant human Thrombopoietin

[0530] IMDM + 10% FBS: Iscove’s Modified Dulbecco’s Medium containing 10% fetal bovine serum

[0531] DMSO: Dimethyl-sulfoxide

[0532] Purpose

[0533] The aim of this study was to evaluate the potential effects of four test compounds on human megakaryocyte progenitor proliferation using the CFU-Mk assay.

[0534] Tests performed

[0535] Clonogenic progenitors of the human megakaryocyte (CFU-Mk) lineage were assessed in a semi-solid, collagen-based matrix containing rhIL-3 (10 ng / mL), rhIL-6 (10 ng / mL) and rhTpo (50 ng / mL).

[0536] Cells

[0537] Normal human bone marrow light density cells, derived from normal bone marrow (iSpecimens, MA), were stored at -152°C until required for the assay. On the day of the experiment, the cells were thawed rapidly, the contents of each vial was diluted in 10 mL of Iscove’s modified Dulbecco’s medium containing 10% fetal bovine serum (IMDM + 10% FBS) and washed by centrifugation (approximately 1200 r.p.m. for 10 minutes, room temperature). The supernatant was discarded and the cell pellets resuspended in a known volume of IMDM + 10% FBS. A cell count (3% glacial acetic acid) and viability assessment (trypan blue exclusion test) was performed for the bone marrow sample. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0538] Compounds

[0539] The test compounds were supplied in powder format and were diluted in DMSO to generate stock concentrations of 30 mM. From there, serial dilutions were made in DMSO to generate working stock concentrations of 15, 5, 1.5, 0.5, 0.15, 0.05, 0.015 and 0.005 mM. 5- FU was used as a positive control for toxicity and concentrations of 1.0, 0.1 and 0.01 mg / mL were prepared in DMSO. When added to the collagen-based media at 1 : 1000 (v / v), the final desired test concentrations for the test compounds of 15, 5, 1.5, 0.5, 0.15, 0.05, 0.015 and 0.005 pM were achieved and for 5-FU, final concentrations of 1.0, 0.1 and 0.01 pg / mL were achieved.

[0540] Method Summary

[0541] Clonogenic progenitors of the human megakaryocytic (CFU-Mk) lineages were set up in the media formulation described above. All test compounds were added to the medium to give the final desired concentrations (15, 5, 1.5, 0.5, 0.15, 0.05, 0.015 and 0.005 pM). 5-FU was used as a positive control and was introduced to the human bone marrow cultures at 1.0, 0.1 and 0.01 pg / mL. Solvent control cultures (containing no compound but 0.1% DMSO), as well as a standard control (containing no compound and no DMSO), were also initiated.

[0542] Human megakaryocyte progenitor assays were initiated with 1 x 105cells per culture. Following 14 days in culture, the cultures were transferred from the 35 mm dishes to labeled glass slides, were fixed (methanol / acetone) and then stained using an anti-human CD41 antibody and an alkaline phosphate detection system according to manufacturers’ instructions. The colonies were assessed microscopically and scored by trained personnel and divided into the following categories based on size; CFU-Mk (3-20), CFU-Mk (21-49), CFU-Mk (> 50).

[0543] Statistical Analyses o f CFC numbers:

[0544] The mean ± 1 standard deviation of three replicate cultures was calculated for the progenitors. Two-tailed standard t-tests were performed to assess if there was a difference in the number of colonies generated between solvent control and treated cultures. Due to the potential subjectivity of colony enumeration, a p value of less than 0.01 is deemed significant. To calculate the concentration of 50% inhibition of colony growth (ICso) for each compound, a dose response curve was generated plotting the log of the compound concentration versus the percentage of control colony growth using Graphpad Prism 8. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0545] Results:

[0546] Megakaryocyte colony enumeration was performed by trained personnel. In addition, the distribution of colony types as well as general colony and cellular morphology was analyzed. The variance in colony number detected in replicate cultures was representative of the historical coefficient of variation for colony enumeration using these types of assays. The number and distribution of colonies detected in the solvent control (0.1% DMSO) was not significantly different from the standard control (containing no compound and no DMSO). For statistical analysis colony numbers in compound treated cultures were compared the solvent control cultures. 5-FU was used as a positive control for toxicity in these assays and behaved as historically observed.

[0547] The results of experiments to evaluate the potential effect of test compounds on human megakaryocyte progenitor proliferation in a collagen-based system are presented in Table A and Fig. 1. ICso values for all compounds are presented in Table B. The megakaryocyte progenitor assay allows for the evaluation of more primitive progenitors, detected by the presence of large colonies (CFU-Mk >50), the intermediate progenitors (CFU-Mk 21-49), detected by the presence of medium sized colonies, as well as the most mature progenitors (CFU-Mk 3-20), detected by the presence of small colonies. The total CFU-Mk value is the sum of the CFU-Mk (3-20), CFU-Mk (21-49) and CFU-Mk (>50). ICso values are determined based on the total CFU-Mk.

[0548] Compound No. 4 was the most potent compound in the series, with significant inhibition of megakaryocyte progenitors at concentrations ranging from 15 - 0.15 pM (Table A) and resulting in an ICso value of 0.27 pM (Table B). Compound No. 1 had a similar profile again with inhibition of megakaryocyte progenitors from 15 - 0.15 pM (Table A) and an ICso value of 0.33 pM (Table B). Compound No. 3 inhibited megakaryocyte progenitor proliferation from 15 - 0.5 pM (Table A), resulting in an ICso value of 0.95 pM (Table B). Finally Compound No. 2 was the least potent compound in the series but with a profile similar to Compound No. 3, and with inhibition of megakaryocyte progenitor proliferation at 15, 5 and 1.5 pM (Table A), resulting in an ICso value of 1.08 pM (Table B).

[0549] Compound No. 3 supported the most primitive megakaryocyte progenitor (CFU-Mk > 50) at 1.5 pM, whereas Compound No. 2 and Compound No. 1 supported the same progenitor at 0.5 pM. Compound No. 4, which was the most potent compound in the series did not support the CFU-Mk > 50 at concentrations greater than 0.15 pM.

[0550] Table A. Effect of test compounds on human megakaryocyte progenitor proliferation in a Collagen-based Medium Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0551] *p< 0.01, **p< 0.001, ***p< 0.0001, ND= none detected,

[0552] Table B. ICso Values for test compounds on human megakaryocyte progenitor determined by GraphPad Prism Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0553] Conclusion:

[0554] Four test compounds were evaluated for toxicity to the megakaryocyte lineage using the CFU-Mk colony forming cell assay. The compounds were tested at concentrations ranging from 15 - 0.005 pM. 5-FU was used as a positive control for toxicity and behaved as historically observed. Compound No. 4 was the most potent compound in the series, with significant inhibition of megakaryocyte progenitors at concentrations ranging from 15 - 0.15 pM and resulting in an ICso value of 0.27 pM. Compound No. 1 had a similar profile again with inhibition of megakaryocyte progenitors from 15 - 0.15 pM and an ICso value of 0.33 pM. Compound No. 3 inhibited megakaryocyte progenitor proliferation from 15 - 0.5 pM, resulting in an ICso value of 0.95 pM. Finally Compound No. 2 was the least potent compound in the series but with a profile similar to Compound No. 3, and with inhibition of megakaryocyte progenitor proliferation at 15, 5 and 1.5 pM, resulting in an ICso value of 1.08 pM.

[0555] Example IB: In Vitro Evaluation of Additional Test Compounds on Human

[0556] Megakaryocyte Progenitor CFC Proliferation in Normal Bone Marrow

[0557] Additional test compounds evaluated for inhibition of human MK progenitor CFC proliferation, as outlined in Example 1, can be found in Table Bl.

[0558] Table Bl: . Effect of test compounds on human megakaryocyte progenitor proliferation in a collagen based medium. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0559] Example 2. Effect of Compound No. 1 on the Formation of Human Megakaryocyte (MK)

[0560] Cells

[0561] Human megakaryocyte (MK) cells are the source of platelets in blood. It was demonstrated in preclinical assays that menin inhibitors inhibit MK cell production from CD34+ progenitor cells in colony forming assays. The aim of this study is to examine the effect of Compound No. 1 on the formation of human megakaryocyte (MK) cells from hematopoietic stem and progenitor cells (HSPCs).

[0562] Method Human CD34+ cells were purified using a kit from Miltenyi BioTech according to the manufacturer’s protocol. Human CD34+ cells were first expanded 8 days in Stem Span II media in the presence of recombinant human SCF, (final concentration 50ng / ml), human Flt3 ligand (final concentration lOOng / ml), human IL-6 (final concentration 50 ng / mL), and hLDL at 1 :250 dilution. Resulting cells were centrifuged and resuspended in Stem Span II media with human recombinant thrombopoietin (final concentration 50ng / ml) for 6 days. All the cytokines,

[0563] Stem Span II media and hLDL were purchased from Stem Cell Technologies. The cells were stained with V450 mouse lineage antibody cocktail (BD Biosciences), CD34 APCCy7 Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0564] (Biolegend), CD38 (Biolegend), CD45RA PercpCy5.5 (Biolegend) and CD 123 PeCy7 (Biolegend). MEPs (Lin7CD347CD38+ / CD1237CD45RA) were sorted by BD FACSAria™ The cells were lysed and subjected to single cell RNA-sequencing analysis (10X Genomics). Data were visualized by uniform manifold approximation and projection (UMAP) analysis. Cell lineages are labelled and colored for clarity.

[0565] Abbreviations

[0566] These studies show that Compound No. 1 appears to deplete a specific cell population, the megakaryocyte precursor (MKP) as shown in FIG. 2A-2D. In MF, the MKP cells carrying genetic driver mutations (e.g., JAK2V617F, CALR (e.g., type 1 and type 2 mutations), and MPL (e.g., W515L mutations)) in myelofibrosis. Depletion of MKP cells by Compound No. 1 suggests that menin inhibitors alone or when combined with SOC (Standard of Care) agents may be a potential treatment for MF. Example 3. Assessment of the Effect of Menin Inhibition on Colony Formation of the Myeloid, Erythroid, and Megakaryocyte Lineages Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0567] The objective of this study is to assay the effect of menin inhibition on colony formation of the myeloid, erythroid, and megakaryocyte lineages. Standard Colony -Forming Unit (CFU) assays are performed for these three lineages from both human CD34+ cells and mouse hematopoietic progenitor cells. The ICso values for Compound No. 1 are determined by treating cells with dose titrations of the compound ranging from InM to 20pM. Both numbers and morphology of colonies are evaluated.

[0568] Example 4. In Vitro Differentiation Assays for Assessing the Effect of Menin Inhibition on Megakaryocyte Maturation and Polyploidization

[0569] In vitro differentiation assays assess the effect of menin inhibition on megakaryocyte maturation and polyploidization. Since determining herein that menin inhibitors reduce CFU- MK, the effect on megakaryocyte progenitor cell growth is assessed. Liquid culture megakaryocyte differentiation assays (suspension cultures) are performed with human cells. Maturation of megakaryocytes are assessed by changes in cell surface marker expression and DNA content.

[0570] Example 5. Effect of Menin Inhibitors on the Megakaryocyte Lineage In Vivo

[0571] The objective of this study is to determine the effect of menin inhibitors on the megakaryocyte lineage in vivo. Although in vitro assays are an important way to assess the effect of the inhibitors on megakaryocytes, in vivo assays provide more comprehensive data. Wild-type C57B1 / 6 mice are provided with feed containing the menin inhibitors for up to five weeks. Peripheral blood counts are monitored on a weekly basis and a detailed assessment of hematopoiesis is performed at the endpoint. This study includes histological analysis of sternal bone marrow and spleen, myeloid, erythroid and megakaryocyte colony forming assays, and flow cytometry to assess the composition of hematopoietic stem and progenitor cells as well as mature myeloid lineages, erythroid cells and megakaryocytes.

[0572] Example 6. Effect of Menin Inhibitors on MPN progression In Vivo

[0573] The objective of this study is to assess the anti -tumor activity of menin inhibitors (e.g., those in Table 1, including Compound No. 1) in a mouse model of myelofibrosis. The MPLW515L mouse model of MF was established by transplanting mouse bone marrow cells that express this MPL mutant to recipient mice. In this model, animals develop leukocytosis and thrombocytosis with enlarged spleens and liver, and profound bone marrow fibrosis. Two weeks after transplant, mice are fed chow containing each menin inhibitor (e.g., those in Table Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0574] 1, including Compound No. 1) or control chow, and then the degree of myelofibrosis is monitored by assessing complete blood counts on a weekly basis as well as monitoring the animals’ appearance and weight. At the endpoint of the study, mice are euthanized and the extent of the disease is assessed by flow cytometry and histology.

[0575] Example 7. In vitro Evaluation of Three Test Compounds on Erythroid, Myeloid and Megakaryocyte Progenitor Proliferation using Colony Forming Cell Assays

[0576] Summary

[0577] In semi-solid methylcellulose-based or collagen-based culture systems, Compound No. 9, Compound No. 2 and Compound 1 were evaluated on human erythroid, myeloid and megakaryocyte progenitor proliferation. 5-FU was used as a positive control for toxicity and the inhibitory effects obtained for this compound were as historically observed. None of the three test compounds had a significant inhibitory effect on the myeloid lineage and ICso values could not be calculated and so are presented as > 15 pM (the highest concentration tested). Compound No. 9 and Compound No. 2 inhibited the total erythroid progenitor proliferation at 15 pM (Compound No. 9) or 15 and 5 pM (Compound No. 2) and this resulted in ICso values of 9.1 and 8.4 pM respectively. All compounds had a very significant effect on the megakaryocyte progenitors, with inhibition of the total CFU-Mk from 15 - 0.5 pM (Compound No. 9 and Compound No. 2) and additionally at 0.15 pM for Compound 1). This resulted in ICso values of 0.55, 0.66 and 0.12 pM respectively.

[0578] Definitions:

[0579] CFU-E: This erythroid colony-forming cell generates a small erythroid colony containing one to two clusters with a total number of 8-200 erythroblasts.

[0580] BFU-E: This is a more primitive colony-forming cell and it generates larger colonies containing more than 200 erythroblasts.

[0581] CFU-GM: This myeloid colony-forming cell is capable of producing colonies with 40 or more granulocyte-monocyte and / or macrophage cells.

[0582] CFU-GEMM: This primitive colony-forming cell is capable of producing colonies containing erythroid cells as well as 20 or more granulocytes, macrophages and megakaryocytes. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0583] CFU-Mk (3-20): This megakaryocytic colony forming cells generates a small colony containing 3-20 megakaryocytes.

[0584] CFU-Mk (21-49): This megakaryocytic colony forming cells generates a medium sized colony containing 21-49 megakaryocytes.

[0585] CFU-Mk (>50): This megakaryocytic colony forming cells generates a large colony containing >50 megakaryocytes

[0586] Abbreviations rhSCF: recombinant human Stem Cell Factor rhIL-3 : recombinant human Interleukin 3 rhIL-6: recombinant human Interleukin 6 rhGM-CSF : recombinant human Granulocyte / Monocyte-Colony Stimulating Factor rhEpo: recombinant human Erythropoietin rhTPO: recombinant human Thrombopoietin

[0587] IMDM + 10% FBS: Iscove’s Modified Dulbecco’s Medium containing 10% fetal bovine serum

[0588] DMSO: Dimethyl-sulfoxide

[0589] 5-FU: 5 -fluorouracil

[0590] Purpose

[0591] The aim of the study was to evaluate the potential effect of three test compounds on human erythroid, myeloid and megakaryocyte progenitors using colony forming cell assays.

[0592] Tests performed

[0593] Clonogenic progenitors of human erythroid (CFU-E, BFU-E), granulocyte-monocyte (CFU-GM) and multipotential (CFU-GEMM) lineages were assessed in a semi-solid methylcellulose-based media formulation containing 25% FBS, 2% BSA, rhIL-3 (10 ng / mL), rhGM-CSF (10 ng / mL), rhSCF (50 ng / mL) and Epo (3 U / mL).

[0594] Clonogenic progenitors of the human megakaryocyte lineage was assess in a semi-solid collagen-based media formulation containing 2% BSA, rhIL-3 (10 ng / mL), rhIL-6 (10 ng / mL) and rhTpo (50 ng / mL) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0595] Cells

[0596] Normal human bone marrow light density cells derived from a normal bone marrow (details below) and qualified at ReachBio, were stored in the gaseous phase of liquid nitrogen (-152°C) until required for the assay. On the day of the experiment, the cells were thawed rapidly diluted in 10 mL of Iscove’s modified Dulbecco’s medium containing 10% fetal bovine serum (IMDM + 10% FBS) and washed by centrifugation (approximately 1200 r.p.m. for 10 minutes, room temperature). The supernatant was discarded and the cell pellet resuspended in a known volume of IMDM + 10% FBS. A cell count (3% glacial acetic acid) and viability assessment (trypan blue exclusion test) was performed for the bone marrow sample.

[0597] Compounds

[0598] The test compounds were supplied in powder format and were diluted in DMSO to generate stock concentrations of 15 mM. From there, serial dilutions were made in DMSO to generate working stock concentrations of 6, 1.5, 0.5, 0.15 and 0.05 mM. 5-FU was used as a positive control for toxicity and concentrations of 1.0, 0.1 and 0.02 mg / mL were prepared in DMSO. When added to the media at 1 : 1000 (v / v), the final desired test concentrations for the test compounds of 15, 6, 1.5, 0.5, 0.15 and 0.05 pM were achieved. Additionally, 5FU was evaluated at final concentrations of 1, 0.1 and 0.01 pg / mL.

[0599] Method Summary

[0600] Clonogenic progenitors of the human erythroid (CFU-E and BFU-E) and myeloid (CFU-GM) lineages were set up in the methylcellulose-based media formulations described above. All compounds were added to the medium to give the final desired concentrations. 5FU was used as a positive control and was introduced to the human bone marrow cultures at 1, 0.1 and 0.01 pg / mL. Solvent control cultures (containing no compound but 0.1% DMSO), as well as standard controls (containing no compound and no DMSO), were also initiated.

[0601] Clonogenic progenitors of the human megakaryocytic (CFU-Mk) lineages were set up in the media formulation described above. All compounds were added to the medium to give the final desired concentrations, and 0.082 pM). 5FU was used as a positive control and was introduced to the human bone marrow cultures at 1, 0.1 and 0.01 pg / mL. Solvent control cultures (containing no compound but 0.1% DMSO), as well as standard controls (containing no compound and no DMSO), were also initiated. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0602] Human myeloid and erythroid progenitor assays were initiated at 2 x 104cells per culture and CFU-Mk were initiated at 1.2 x 105per culture. Following 14 days in culture, myeloid and erythroid colonies were assessed microscopically and scored by trained personnel. The colonies were divided into the following categories based on size and morphology: CFU- E, BFU-E, CFU-GM and CFU-GEMM. The megakaryocyte cultures were transferred from the 35 mm dishes to labeled glass slides, were fixed (methanol / acetone) and then stained using an anti-human CD41 antibody and an alkaline phosphate detection system according to manufacturers’ instructions. The colonies were assessed microscopically and scored by trained personnel and divided into the following categories based on size; CFU-Mk (3-20), CFU-Mk (21-49), CFU-Mk (> 50).

[0603] Statistical Analyses o f CFC numbers

[0604] The mean ± one standard deviation of three replicate cultures was calculated for progenitors of each category. Two-tailed t-tests were performed to assess if there was a difference in the number of colonies generated between solvent control and treated cultures. Due to the potential subjectivity of colony enumeration, a p value of less than 0.01 is deemed significant. To calculate the concentration of 50% inhibition of colony growth (ICso) for each compound, a dose response curve was generated plotting the log of the compound concentration versus the percentage of control colony growth using Graphpad 8. The concentration of 50% inhibition of colony growth (ICso) was calculated based on the sigmoid curve fit using Dose-Response, One-Site Model formula: y = A + [(B - A) / (l + ((C / x)AD))], where A = the initial value (baseline response), B = maximum response, C = center (drug concentration that provokes a response halfway between A and B) and D= slope of the curve at midpoint. Plots and additional dose response curves were generated using GraphPad Prism 8.0.

[0605] Results

[0606] Erythroid (CFU-E and BFU-E), myeloid (CFU-GM), multi-potential (CFU-GEMM) and megakaryocyte (CFU-Mk) colony enumeration was performed by trained personnel. The distribution of colony types as well as general colony and cellular morphology was analyzed. The variance in colony number detected in replicate cultures was representative of the historical coefficient of variation for colony enumeration using these types of assays. The number and distribution of colonies detected in the solvent control (0.1% DMSO) was no different from the standard control (containing no compound and no DMSO) (Tablesl and 2). Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0607] For statistical analysis, colony numbers in compound-treated cultures were compared to the solvent control culture condition. 5-FU was used as a positive control for toxicity in these assays and the inhibitory effects obtained for this compound were as historically observed with inhibition at 1 and 0.1 pg / mL.

[0608] The results of the experiment to evaluate the potential effect of test compounds on human erythroid and myeloid progenitor proliferation in a methylcellulose-based medium are presented in Table C. The results of the experiments to evaluate the potential effect of test compounds on human megakaryocyte progenitor proliferation are presented in Table D. The megakaryocyte progenitor assay allows for the evaluation of more primitive progenitors, detected by the presence of large colonies (CFU-Mk >50), the intermediate progenitors (CFU-Mk 21-49), detected by the presence of medium sized colonies, as well as the most mature progenitors (CFU-Mk 3-20), detected by the presence of small colonies. The total CFU-Mk value is the sum of the CFU-Mk (3-20), CFU-Mk (21-49) and CFU-Mk (>50). IC50 values are determined based on the total CFU-Mk. The ICso values calculated from Graphpad Prism 8.2.0 are presented in Table 3. Dose response curves for erythroid, myeloid and megakaryocyte toxicity generated by Graphpad Prism 8.2.0 are presented in FIGs 3A-3C.

[0609] Compound No. 9, Compound No. 2 and Compound No. 1 did not demonstrate any significant inhibitory effect on the myeloid lineage (Table C) and ICso values could not be calculated and so are presented as > 15 pM (the highest concentration tested, Table E). Compound No. 9 inhibited the total erythroid progenitor proliferation at 15 pM and Compound No. 2 at 15 and 5 pM (Table C) and this resulted in ICso values of 9.1 and 8.4 pM respectively (Table E). All compounds had a very significant effect on the megakaryocyte progenitors, with inhibition of the total CFU-Mk from 15 - 0.5 pM (Compound No. 9 and Compound No. 2) and additionally at 0.15 pM for Compound No. 1 (Table C). This resulted in ICso values of 0.55, 0.66 and 0.12 pM respectively (TableD). These data suggest that the compounds may have a lineage specific toxicity, with inhibition to the megakaryocyte progenitors being more than a log greater than that to the erythroid or myeloid progenitors.

[0610] Table C: Effect of test compounds on human erythroid and myeloid progenitor proliferation in a methylcellulose-based medium Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0611] ND = none detected, *p< 0.01, **p< 0.001, ***p< 0.0001

[0612] Table D: Effect of test compounds on human megakaryocyte progenitor proliferation in a collagen-based medium Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0613] Table E. IC50 values (Graphpad Prism 8.2.0) for test compounds on human erythroid, myeloid progenitor proliferation Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0614] Conclusion:

[0615] In semi-solid methylcellulose-based or collagen-based culture systems, Compound No. 9, Compound No. 2 and Compound No. 1 were evaluated on human erythroid, myeloid and megakaryocyte progenitor proliferation. There were very different effects of the compounds on the various lineages. 5-FU was used as a positive control for toxicity and the inhibitory effects obtained for this compound were as historically observed. None of the three test compounds had a significant inhibitory effect on the myeloid lineage and ICso values could not be calculated and so are presented as > 15 pM (the highest concentration tested). Compound No. 9 and Compound No. 2 inhibited the total erythroid progenitor proliferation at 15 pM (Compound No. 9) or 15 and 5 pM (Compound No. 2) and this resulted in ICso values of 9.1 and 8.4 pM respectively. All compounds had a very significant effect on the megakaryocyte progenitors, with inhibition of the total CFU-Mk from 15 - 0.5 pM (Compound No. 9 and Compound No. 2) and additionally at 0.15 pM for Compound No. 1). This resulted in ICso values of 0.55, 0.66 and 0.12 pM respectively. These data suggest that the compounds may have a lineage specific toxicity, with inhibition to the megakaryocyte progenitors being more than a log greater than that to the erythroid or myeloid progenitors.

[0616] Example 8: Mechanism of Megakaryocyte Inhibition

[0617] We cultured human CD34+ progenitor cells in vitro under conditions to produce megakaryocytes. CD34+ cells were expanded for 7 days and then placed in differentiation media in the presence of Compound No. 1 or vehicle (FIG 5C). We examined the effect on megakaryocytes by flow cytometry for progenitors and different stages of mature cells and found that Compound No. 1 reduced the percentage and absolute number of CD41+MEP precursors and suppressed the formation of CD41+CD42- and CD41+CD42+ megakaryocytes (FIGs. 5D-5G). The drugs also decreased polyploidization and increased apoptotic markers with concomitant decreases in S-phase and G2 / M cells (FIGs. 6A-6E). Of note, ziftomenib had similar effects both in CFU assays and liquid cultures (FIGs. 22A-22H), indicating that this is a class effect of menin inhibitors. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0618] To gain further insights into the effects of menin inhibition on megakaryocytes, we performed single cell RNA-sequencing on cells derived from the CD34+cultures treated with Compound No. 1 or vehicle. As outlined above, we cultured CD34+ cells for 7 days in expansion media then added vehicle or Compound No. 1 at 0.3 pM, the IC50 in the CFU-MK assays in presence of thrombopoietin (TPO) to promote megakaryocyte development (FIG. 5 A). Cells were collected after 7 days of treatment with vehicle or Compound No. 1 and stained with antibodies against human lineage markers, CD34, CD38 CD123, and CD45RAto identify megakaryocyte erythroid progenitors (MEP) (Miyawaki et al, PMID: 28336526), which were then isolated by flow cytometry (FIG 7A). The sorted cells were then subjected to 10X genomics single cell RNA-sequencing (scRNA-seq). Eleven samples passed quality control criteria (FIG. 7B). The initial Seurat analysis revealed 11 clusters with a group of 3 ITGA2B (CD41) positive megakaryocytic clusters and a substantial population of myeloid lineage cells, composed of 5 clusters, as evidenced by staining for MPO and ELAINE (FIGs. 7C and 7D). We thus repeated the analysis after sub-clustering on the ITGA2B+group. This analysis identified 14 clusters that we annotated as CMP / MEP / ERP and early and late megakaryocyte progenitors (MKPs) (FIG. 8A). Genes that defined the clusters are highlighted in FIGs. 8B and 8C.

[0619] Next, we divided the samples into the vehicle and Compound No. 1 groups and performed Seurat analysis. We discovered that Compound No. 1 had a major detrimental effect on early and late MKP populations with significant reductions in both the numbers and percentages (FIG. 8D). This loss was accompanied by increases in the numbers and percentages of CMP, MEP and ERP cells. Together, these data indicate that Compound No. 1 has an effect on the specification or maintenance of megakaryocyte progenitor cells. We then examined expression of key KMT2A-menin targets across the different lineages and detected reductions inMEISl, MEF2C and PBX3 in the MEPs (FIG. 8E and FIGs. 9A-9B). Finally, we performed GO pathway analysis on the scRNA-seq data from the different populations. We found enrichment / depletion of cell cycle, DNA synthesis, and mitosis in the MKPs following Compound No. 1 treatment.

[0620] Example 9: Genetic Studies Show a Requirement for Menin and an on-target Effect of Menin Inhibition on Megakaryocytes

[0621] While Compound No. 1 is highly selective disruptor of the menin-KMT2A interaction, it was important to demonstrate an on-target effect and confirm the requirement for menin in megakaryocyte progenitors. To this end, we first assessed the effect of menin knockout by Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0622] CRISPR in human CD34+cell cultures. We found that editing menin with high efficiency by two separate sgRNAs led to significant decreases in the production of CD41+mature megakaryocytes, decreased megakaryocyte ploidy, increased apoptosis, and a significant reduction in CD41+MEPs (FIGs. 10A-10I). Next, to more comprehensively compare the effects of Compound No. 1, we performed 10X genomics scRNA-seq on the cultured cells. We analyzed a total of 18 samples, which included non-targeting control and two sgRNA targeting MEN1 from 3 independent experiments. All 18 samples passed our quality control criteria (FIG. 11 A). Similar to the Compound No. 1-treated scRNA-seq study (Example 8), sorted cells included a substantial myeloid population that expressed MPO and ELAINE (FIGs. 1 IB and 11C). We therefore sub-clustered on the ITGA2B+population and identified 34 clusters which were then grouped to 7 cell types that included early and late MKPs, MEP, CMP, and ERP (FIGs. 1 ID and 1 IE). When comparing the effect of menin KO to the non-targeting guide, we found that MEN1 knockout led to suppression of megakaryocyte populations with concomitant increases in CMPs and MEPs (FIG. 12).

[0623] The 7 sub-clustered cell types may also be classified as common myeloid progenitor (CMP), eosinophil / basophil / mast (Eo / Baso / Mast) cell progenitors, cycling progenitors, megakaryocyte erythroid progenitors (MEP), erythroid progenitors (ERP), megakaryocyte progenitors (MKP), and megakaryocytes (MK), as shown in FIGs. 25A-25D. Genes that defined the clusters are highlighted in FIG. 25B. We divided the samples into the pharmacologic and genetic groups and performed downstream analysis on annotated clusters. We discovered that Compound No. 1 had a major detrimental effect on MKP and MK populations with striking reductions in the percentages of these cells (FIG. 25C). This change was accompanied by substantial increases in the percentages of CMP and MEP. Similarly, knockout of MEN1 caused a decrease in the proportion of MKP and MK populations with an expansion of CMP and MEP (FIG. 25D). Together, these data indicate that revumenib and MEN1 loss have a major effect on the specification or maintenance of MKP cells and downstream megakaryocytes. We then examined the expression of key menin-KMT2A target genes across the different lineages and detected reductions in MEIS1, MEF2C, and PBX3 in MEPs and MKPs (FIG. 25E). We also performed Gene Ontology enrichment analysis on the scRNA-seq data from the different populations. We found depletion of pathways related to cell cycle, RNA splicing, and proliferation in megakaryocytes and MKPs following Compound No. 1 treatment with few pathways enriched in the non-megakaryocyte populations. Of note, we did not find significant enrichment of pathways related to JAK / STAT signaling. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0624] We investigated whether loss of MEIS1 could recapitulate the effect of genetic and pharmacologic menin loss. To this end, we knocked out MEIS1 in human CD34+cells by CRISPR gene editing. We achieved high rates of editing that were accompanied by significant reductions in the percentages of CD41+CD42‘ and CD41+CD42+megakaryocytes with a lower ploidy state (FIGs. 19A-19C). Depletion oiMEISl also reduced the percentage and absolute number of MKPs in cultured cells (FIGs. 19D and 19E). These observations indicate that loss of MEIS1 is sufficient to phenocopy the effect of menin inhibition on megakaryocytic differentiation. To determine whether restoration oiMEISl expression could overcome menin inhibition, we overexpressed MEIS1 in healthy human CD34+cells (FIGs. 191 and 19J), treated the cultures with revumenib or vehicle (DMSO), and assessed the effect on megakaryopoiesis. We observed no rescue with MEIS1 overexpression (FIGs. 19F-19H), indicating that additional menin target genes contribute to the megakaryocytic phenotype.

[0625] Additionally, interrogated the effect of MEN1 and A7 / US7 depletion on development of megakaryocytes from human MF hematopoietic progenitor cells in culture. Using CRISPR, we obtained efficient editing oiMENl (FIG. 20A). In contrast to CD34+cells from healthy donors, we failed to see an effect on the development of immature and mature megakaryocytes, which is likely explained by the inefficient production of mature MKs in MF cultures (FIG. 20B). There was also no effect on the degree of megakaryocyte polyploidy (FIG. 20C). However, MEN1 knockout gave rise to significant reductions in the percentage and absolute numbers of MKPs (FIGs. 20D and 20E). We observed the same effect of MEIS1 loss on megakaryocytes in MF cultures (FIGs. 20F-20J). These results indicate that the suppression of MKs by menin inhibition in MF manifests at the megakaryocyte progenitor stage.

[0626] Example 10: Effect of Menin Inhibitors in Combination with JAK Inhibitors on MPN progression In Vivo

[0627] We next performed pre-clinical studies with Compound No. 1 in mouse models of the MPNs. First, we leveraged the JAK2V617F retroviral transduction / transplantation model, which develops a phenotype characterized by polycythemia, splenomegaly, modest lymphoproliferation, and bone marrow fibrosis. Six weeks following transplantation of c-kit+hematopoietic stem and progenitor cells (HSPCs) from wild-type C57B1 / 6 mice transduced with JAK2V617F / GFP retrovirus, we fed mice control chow or chow containing 0.25% Compound No. 1 for 5 weeks (FIG. 13 A). We monitored peripheral blood counts and engraftment of the JAK2V617F / GFP cells by CBC and flow cytometry, respectively, on a weekly basis. Compound No. 1 blunted the increased white cell count and normalized both Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) hemoglobin and hematocrit (FIGs. 13B-13D). It also reduced the platelet count (FIG. 13E). Compound No. 1 treatment did not significantly alter the tumor burden but was associated with a reduction in body weight and a significant decrease in spleen weight (FIGs. 13F-13H). Finally, all the mice treated with Compound No. 1 showed a reticulin grade of zero compared to an average score of 1.5 for the control treated animals (FIGs. 131 and 13 J).

[0628] We then leveraged the inducible JAK2V617F mouse model (PMID: 20541703) to study the effect of the combination of Compound No. 1 and ruxolitinib in this disease, which manifests as polycythemia with modest increases in platelet and white blood cell counts (FIGs. 14B-14E). We collected bone marrow cells from JAK2V617F / Vav-Cre mice and transplanted 2 million mononuclear cells to irradiated C57B1 / 6 recipients. Five weeks post-transplant, we fed the animals chow containing 0.25% Compound No. 1 and / or ruxolitinib (90mg / kg, bid) and monitored the mice by weekly CBC during the three weeks of treatment. As a single agent, Compound No. 1 reduced the elevated white cell count while also reducing the platelet count (FIGs. 14B-14E). Treatment was also associated with reduced body weight, no change in liver weight, but a significant reduction in the spleen weight to the same as extent as ruxolitinib (FIGs. 14F-14H). Single agent treatment with ruxolitinib had stronger effects on the hemoglobin and hematocrit, but less of an effect on WBC and the platelet count. Of note, the combination of Compound No. 1 and ruxolitinib was even more effective, with normalization of WBC, hemoglobin and hematocrit and spleen weight (FIGs. 14B-14H).

[0629] Example 11: Doses and Effects of Menin Inhibitors on MPN progression In Vivo as Single Agents or in Combination with JAK Inhibitors

[0630] We next turned to the MPLW515L transduction / transplant model, which closely resembles an aggressive myelofibrosis with lymphocytosis, thrombocytosis, splenomegaly, accumulation of atypical megakaryocytes, fibrosis and impaired survival. We performed a dose response study in which mice were first engrafted with 600,000 c-kit+hematopoietic stem and progenitor cells expressing MPLW515L and GFP to irradiated Balb / C mice and then randomized the cohort to receive control chow or chow containing 0.04%, 0.1%, or 0.25% Compound No. 1 (FIG. 15 A). Mice were fed Compound No. 1 for up to 5 weeks beginning two weeks post-transplant, and in this time we assayed complete blood counts and GFP tumor burden in the peripheral blood on a weekly basis. We discovered that the 0.1% and 0.25% doses were better able to normalize peripheral blood counts than the 0.04% dose (FIGs 15B-15E). None of the doses led to a significant reduction in GFP tumor burden or a change in body weight (FIGs. 15F and 15G). Detailed analysis of mice at the time of sacrifice showed that Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) none of the doses reduced the spleen weight, while all three reduced the liver weight (FIGs. 15H and 151). Moreover, the 0.1% and 0.25% doses significantly reduced the degree of fibrosis in the bone marrow (FIG. 15 J). Of note, all doses of Compound No. 1 increased survival, such that all treated animals were alive until the end of study, which was three weeks after the last vehicle treated mouse succumbed to the disease (FIG 15K).

[0631] Next, given that the 0.1% dose was as effective as the 0.25% dose, we selected 0.1% chow for the next study in MPLW515L transplanted mice. This time we added ruxolitinib as a single agent and the combination of Compound No. 1 and ruxolitinib as additional treatment arms. We transplanted 300,000 c-kit+HSPCs expressing MPLW515L and GFP to irradiated Balb / C recipient mice, waited two weeks for engraftment, and then bled the mice to assess engraftment by flow cytometry for GFP (FIG 16A). We randomized the mice based on GFP percentages to treatment with control chow / captisol, Compound No. 1 chow (0.1%) / captisol, control chow / ruxolitinib (90mg / kg, bid), or Compound No. 1 chow (01%) with ruxolitinib (90mg / kg bid). Mice were treated for up to 6 weeks and bled weekly to assess peripheral blood counts and GFP tumor burden. Compound No. 1 and ruxolitinib had similar activity on peripheral blood counts, with suppression of leukocytosis and thrombocytosis but different effects on hemoglobin and hematocrit and a more pronounced effect of Compound No. 1 on platelet counts (FIGs. 16B-16E). There was also a modest decrease in the mutant allele burden at three weeks when the vehicle treated mice succumbed to disease as measured by the percentage of GFP+cells in peripheral blood; this was especially notable with the combination (FIG. 16F). Compound No. 1 treated animals showed a modest decrease in body weight (FIG. 16G). While there were no significant effects of Compound No. 1 or ruxolitinib on spleen weight, the combination notably normalized this parameter (FIG 16H), and livers weight were reduced in all treatment arms (FIG. 161). Cytokine profiling revealed decreases in several pro- fibrotic factors, including TGF-P, MIG / CXCL9, MIPla / CCL3, and TNF-a in the plasma (FIGs. 16J and 26A-26C). Finally, we evaluated the degree of megakaryocyte burden and fibrosis in the bone marrow. Quantitation of megakaryocytes within the total bone marrow region revealed that Compound No. 1 as a single agent significantly decreased the numbers of megakaryocytes, similar to the combination while ruxolitinib alone did not have this effect (FIGs. 16K, 27A-27B, and 28 A). Reticulin staining revealed a more significant reduction in fibrosis with Compound No. 1 treatment compared to ruxolitinib, while the combination recapitulated the Compound No. 1 single agent arm (FIGs. 16L and 28B). Compared to vehicle treated mice, which all succumbed to the disease by 3 weeks of treatment, both single agent Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) arms and the combination arm showed extended survival until the study was ended at 56 days (FIG. 16M).

[0632] Example 12: Effect of Menin Inhibitors on Thrombocytosis and Bone Marrow Fibrosis

[0633] We also evaluated Compound No. 1’s activity in the MPLS504N constitutive knock-in mouse model, which spontaneously develops thrombocytosis and bone marrow fibrosis over several months (PMID: 35999261). We fed 3 month old mice control chow or 0.1% Compound No. 1 chow for 8 weeks and monitored peripheral blood counts every other week (FIG. 17A). We found that Compound No. 1 reduced the WBC while having no effect on hemoglobin or hematocrit (FIGs. 17B-17D). Compound No. 1 reduced the platelet count and significantly reduced spleen weight while not affecting liver weight (FIGs. 17E-17G). It also decreased the percentage of megakaryocytes and abrogated fibrosis in the bone marrow (FIGs. 17H-17I and 29A-29D).

[0634] Example 13: Effect of Menin Inhibitors on Healthy Mice

[0635] Although Compound No. 1 is well tolerated and has been extensively used in mice at the 0.1% dose, we assessed the effect of the drug on healthy mice. We fed C57B1 / 6 mice with control chow or chow containing 0.1% Compound No. 1 for twelve weeks and assessed the effect over five weeks (FIGs. 21 A-21 J) and over twelve weeks (FIGs. 30A-30J).

[0636] In healthy mice, Compound No. 1 modestly decreased the WBC, hematocrit, hemoglobin and PLT counts, but these values remained in the normal range (FIGs. 21B-21E and 30B-30E). Revumenib-treated animals were slightly heavier with no change in spleen weight, but increased liver weight (FIGs. 30F-30H). Within the bone marrow, Compound No. 1 did not significantly reduce the percentage of MKPs, but was associated with a significant decrease in the absolute number of MKPs (FIGs. 211 and 30I-30J). Overall, although there were modest changes in hematopoiesis, the drug was well tolerated.

[0637] Example 14: Methods Used for the Preceding Examples

[0638] Drugs

[0639] For the in vitro studies, Compound No. 1 and ziftomenib (Catalog# E1290) were purchased from Selleck Chemicals. For the in vivo studies, mice were fed global rodent diet (2020, Teklad) or the same chow containing 0.04%, 0.01%, 0.25% or 0.3% Compound No. 1. Chow was irradiated and vacuum packaged after supplementation with Compound No. 1. Chow was fed to animals ad libitum. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0640] Patient samples

[0641] Frozen peripheral blood mononuclear cell (PBMC) samples were obtained from 11 patients diagnosed with primary myelofibrosis (PMF) at Mount Sinai Hospital, New York after informed consent. Frozen vials were rapidly thawed in a 37°C water bath. Cells were then treated with DNase I (Catalog # 07900, STEMCELL Technologies) following the manufacturer’s instructions to prevent clumping caused by released genomic DNA.

[0642] Cell culture

[0643] Granulocyte colony-stimulating factor (G-CSF) mobilized normal hematopoietic stem and progenitor cells (HSPCs) from healthy adult donors were purchased from CGT Global. CD34+HSPCs were initially isolated using the AutoMACS instrument (Miltenyi Biotec) and subsequently purified and sorted to ensure high purity for downstream applications. Human CD34+HSPCs were expanded for 7 days in CD34+expansion medium consisting of StemSpan™ SFEM II (Catalog #9655, STEMCELL Technologies), supplemented with a 1 : 10 dilution of StemSpan™ CD34+Expansion Supplement (Catalog #2691, STEMCELL Technologies), a 1 : 1000 dilution of human low-density lipoprotein (LDL; Catalog #2698, STEMCELL Technologies), and a 1 : 100 dilution of Penicillin-Streptomycin (Catalog #15140122, Thermo Fisher Scientific). Following expansion, cells were pelleted and resuspended in fresh StemSpan™ SFEM II medium supplemented with 1 :2000 human LDL, 1 : 100 Penicillin-Streptomycin, and 50 ng / mL thrombopoietin (TPO; Catalog #300-18-10UG, Thermo Fisher Scientific) to initiate megakaryocyte differentiation. For each experimental condition (DMSO vs. treatment; non-targeting vs. sgRNA; vector vs. MEIS1 overexpression), 4 * 106cells were allocated per group to ensure equal cell numbers. After 3 days of culture, the TPO concentration was increased to 100 ng / mL and maintained for an additional 4 days to further promote differentiation. On day 14, cells were harvested and analyzed for megakaryocytic differentiation. Peripheral blood mononuclear cells (PBMCs) isolated from patients with PMF were cultured under the same 7-day expansion conditions. A total of 1 x 106cells were distributed per experimental group (DMSO vs. treatment; nontargeting vs. sgRNA) prior to induction of megakaryocyte differentiation using 50 ng / mL TPO in StemSpan™ SFEM II medium supplemented with a 1 : 10 dilution of CD34+Expansion Supplement, 1 : 1000 human LDL, and 1 : 100 Penicillin-Streptomycin. On day 14, cells were harvested and assessed for megakaryocytic differentiation. Vehicle (DMSO) or Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) menin inhibitors (Compound No. 1 or ziftomenib) were added at the initiation of TPO treatment.

[0644] CRISPR / Cas9 Editing and Quantification of On-Target Indels

[0645] Single guide RNAs (sgRNAs) used for genome editing were obtained from Synthego. Ribonucleoprotein (RNP) complexes were assembled by incubating Cas9-3*NLS protein at a final concentration of 4 pM with sgRNAs, modified with 2'-O-methyl 3' phosphorothioate at the first and last three nucleotides, at a final concentration of 12 pM. The Cas9 to sgRNA molar ratio was maintained at 1 :3. Complex formation was performed at room temperature for 15 minutes. CD34+HSPCs or PBMCs from PMF patients, previously cultured for 3 days in expansion medium, were washed and resuspended in P3 buffer (Lonza, catalog #V4LP- 3002). For electroporation, 0.2 to 1 million CD34+cells were processed in a 20 pL volume, and 1 to 5 million cells were processed in a 100 pL volume. Electroporation was conducted using the Lonza 4D-Nucleofector system (catalog # AAF-1003X) with program DS- 150, following the manufacturer’s protocol. Immediately after electroporation, cells were transferred into CD34+expansion medium without antibiotics and cultured overnight. The next morning, the medium was replaced with fresh CD34+expansion medium supplemented with antibiotics. Megakaryocyte differentiation was initiated on day 3 post-electroporation, corresponding to day 7 after cell thawing. Three days after RNP electroporation, on-target genome editing efficiency was assessed by sequencing gene-specific amplicons using the Illumina MiSeq platform. Genomic DNA was first amplified using primers containing partial Illumina adapter sequences (PCR 1, 35 cycles) with either MyTaq or Platinum SuperFi polymerase. Indexing was then performed in PCR 2 (5 cycles) using MyTaq polymerase. Amplicons were pooled, supplemented with 10% PhiX for sequence diversity, and sequenced using 2x250 bp paired-end reads. FastQ files were generated via demultiplexing, and indel frequencies were quantified using the CRIS.py tool.

[0646] Viral transduction

[0647] The human MEIS1 open reading frame (ORF) was synthesized using sequence-to- plasmid (S2P) gene synthesis. The synthesized ORF was subsequently cloned into the SJL12biG-MND-DEST vector. Lentiviral particles were produced using standard techniques. CD34+HSPCs were cultured in expansion medium for 3 days and then transduced by spinoculation with 0.5 mL of viral concentrate in 1 mL of expansion medium containing 8 pg / mL polybrene (Catalog # sc-134220, Santa Cruz Biotechnology) at 32 °C and 2,500 rpm Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) for 2 hours. Following transduction, cells were cultured in CD34+expansion medium for an additional 3 days before initiating megakaryocyte differentiation by exposure to TPO.

[0648] For transfection of murine hematopoietic progenitor cells with retroviruses, plat-E cells (3.5 x 106) (Cell BioLabs, Inc) were seeded in a 10-cm dish coated with poly-l-lysine (Sigma) the day before transfection and then transfected with Migrl plasmids (MSCV-IRES-GFP) containing human MPLW1515L using TransIT 293T (Mirus Bio), according to the manufacturer’s protocols. Forty-eight hours after transfection, the viral supernatant was collected, and 2 ml of viral supernatant was added to retronectin (Takara Bio) coated plates, and then centrifuged at 2,000G, for 90 min at 32 °C. Supernatant was removed and another 2 ml of fresh viral supernatant was added to each well, and then centrifuged at 2,000G, for 90 min at 32 °C. After the second spin, 2.0xl0e6 CD117 (c-KIT) enriched bone marrow cells (in 500ml of Basal Bone Marrow Media with Cytokines) were added to each well and centrifuged at 600G for 20 min and placed in 37°C incubator for 2 hours. After 2 hours, 1ml of basal bone marrow media with cytokines was added and incubated overnight.

[0649] Colony-forming assays

[0650] Colony-forming unit-megakaryocyte (CFU-MK) assays were performed using CD34+HSPCs or PBMCs from PMF patients that had been cultured for 3 days in expansion medium. A total of 10,000 cells were seeded in MegaCult-C medium supplemented with cytokines (Catalog #04901, STEMCELL Technologies) in the presence of either DMSO (vehicle control) or varying concentrations of menin inhibitors (Compound No. 1 or Ziftomenib). Following incubation for 10-12 days, slides containing MegaCult-C cultures were fixed with a 3: 1 mixture of acetone and methanol. Subsequently, cells were stained using the MegaCult-C Staining Kit (Catalog #04962, STEMCELL Technologies) according to the manufacturer’s protocol. CFU-MKs were quantified microscopically using a Leica microscope. Megakaryocyte colonies, defined as clusters comprising three or more red- stained cells, were identified and enumerated as CFU-MKs. Myeloid and erythroid colony assays were performed in the same way, but cells were plated in Stem Cell Technologies H4434 media rather than Mega-Cult-C. Colonies were scored with Stem Vision (Stem Cell Technologies). Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0651] Animal experiments

[0652] MPLW515Lmouse model was generated as described in Wen, Q.J., et al. Targeting megakaryocytic-induced fibrosis in myeloproliferative neoplasms by AURKA inhibition. Nat Med 21, 1473-1480 (2015). Briefly, BALB / c bone marrow progenitor cells were enriched by c-Kit-positive selection and cultured overnight in basal bone marrow media containing murine IL-3 (50ng / pL), murine IL-6 (50ng / pL), and murine SCF (50ng / pL). The next day, the cells were transduced with a retrovirus containing human MPLW515L. On the third day, 8- 10 week old female BALB / c recipient mice (The Jackson Laboratory #000651) that had been irradiated with 900 rads were transplanted with 3 * 105GFP+ transduced bone marrow cells. Recipient mice developed leukocytosis, polycythemia and thrombocytosis in 2-3 weeks.

[0653] For transplantation of Jak2V617F-expressing cells, bone marrow cells from Jak2V617Fknock-in mice (The Jackson Laboratory, #031658) with Vav-Cre-mediated expression of Cre recombinase (The Jackson Laboratory, #008610) were extracted and a total of 2 * 106cells were transplanted into lethally irradiated recipient animals. For the Jak2V617Fmodel, C57BL / 6 bone marrow progenitor cells were enriched by c-Kit-positive selection and cultured overnight. The next day, the cells were transduced with a retrovirus containing human Jak2V617F. On the third day, recipient C57BL / 6 mice (The Jackson Laboratory, #000664) that had been irradiated with 1100 rads were transplanted with 5 * 105GFP+transduced bone marrow cells.

[0654] The MPLS504Nknock-in mouse model was conducted as described in Leukemia. 2022 Oct;36(10):2535-2538.. MPLS504N / S504Nmice were aged to 3 months and then randomized into treatment groups. Control chow, vehicle (Captisol), Compound No. 1, ruxolitinib or a combination ruxolitinib and Compound No. 1 was administered to the transplant recipients by oral gavage twice a day 7 days a week for ruxolitinib and continuously fed Compound No. 1 impregnated chow or control chow. In the drug studies, mice were randomized to treatment groups based on the level of GFP+tumor cells in the peripheral blood, as well as platelet, WBC, hemoglobin, and hematocrit counts. Female mice between 8 and 12 weeks of age were used for all transplantation studies. All animal experiments complied with all relevant ethical regulations regarding animal research.

[0655] Hematology, Tissue Processing and Handling, and Histochemistry

[0656] Whole blood was collected into tubes containing EDTA anticoagulant (BD Microtainer, BD Diagnostics, Franklin Lakes, NJ). Complete blood counts (CBCs) were Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) performed on a ForCyte Hematology Analyzer (Oxford Science, Inc, Oxford, CT.) After euthanasia, the sternum, and spleen were collected and fixed in 10% neutral -buffered formalin, and the sternum was subsequently decalcified in 10% formic acid. Tissues were embedded in paraffin, sectioned at 4 pm, and stained with hematoxylin and eosin (HE). Reticular fibers in the bone marrow were stained using the Reticulum II Staining Kit (#860- 024, Roche Diagnostics, Indianapolis, IN) in conjunction with a BenchMark Special Stains automated instrument (Roche Diagnostics).

[0657] Flow Cytometry Analysis and Fluorescence-Activated Cell Sorting

[0658] Bone marrow cells were collected and washed with PBS, then resuspended in PBS containing 0.5% BSA and 2 mM EDTA (FACS buffer) to generate single-cell suspensions. Surface marker staining was performed by incubating the cells for 30 minutes in calcium- and magnesium-free PBS with fluorophore-conjugated antibodies. For human cells, staining included antibodies against CD41a (Catalog #559777, BD Biosciences) and CD42a (Catalog #558819, BD Biosciences) to identify megakaryocyte lineage cells. To further delineate megakaryocyte progenitor populations, cells were stained with an anti-human Lineage Cocktail (Catalog #348807, BioLegend) targeting CD3, CD14, CD16, CD19, CD20, and CD56, alongside markers for CD34 (Catalog #343614, BioLegend), CD38 (Catalog #12- 0389-42, Thermo Fisher Scientific), CD123 (Catalog #25-1239-42, Thermo Fisher Scientific), CD45RA (Catalog #45-0458-42, Thermo Fisher Scientific), and CD41a (Catalog #559777, BD Biosciences). This panel enabled the identification of human common myeloid progenitors (CMP), granulocyte-monocyte progenitors (GMP), megakaryocyte-erythroid progenitors (MEP), and megakaryocyte progenitors (MKP). MKPs are defined as Lin CD34 CD38 CD I 23 CD45R.A CD4 I a or as described elsewhere in the specification.

[0659] Mouse megakaryocytes were identified by staining with antibodies against CD41a (catalog #133927, BioLegend) and CD42b (catalog #M040-3, Emfret Analytics, Germany). To characterize hematopoietic progenitor populations, bone marrow cells were stained with a Mouse Lineage Antibody Cocktail (catalog #561301, BD Biosciences), containing antibodies against CD3e, CD1 lb, B220, TER-119, and Gr-1 to exclude lineage-positive cells. Concurrently, antibodies targeting c-Kit (catalog #553356, BD Biosciences), Sca-1 (catalog #25-5981-82, Thermo Fisher Scientific), CD41 (catalog #740903, BD Biosciences), CD150 (catalog #115904, BioLegend), and FcyR (catalog #101324, BioLegend) were used to define key progenitor subsets, including LSK, GMP, MEP, and MKPs. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0660] For DNA content analysis, live human or mouse cells were incubated with Hoechst 33342 (catalog #H3570, Thermo Fisher Scientific) at a final concentration of 10 pg / mL for 1 hour at 37°. Human cells were stained in StemSpan SFEM II medium supplemented with TPO, while mouse cells were stained in StemSpan medium (catalog #9650, STEMCELL Technologies) supplemented with 10 ng / mL mouse recombinant IL-3 (catalog #78042, STEMCELL Technologies), 10 ng / mL human recombinant IL-6 (catalog #78050, STEMCELL Technologies), and 50 ng / mL mouse recombinant stem cell factor (SCF; catalog #78064, STEMCELL Technologies). After staining, cells were washed with PBS and subsequently labeled with surface antibodies for megakaryocyte identification as described above.

[0661] To assess apoptosis, cells were stained with ApoTracker Green (catalog #427402, BioLegend) at a final concentration of 800 nM, according to the manufacturer’s protocol. The apoptotic dye was applied concurrently with surface marker staining, enabling the simultaneous evaluation of apoptosis and cell surface phenotype by flow cytometry.

[0662] For cell cycle analysis, cells were washed once with PBS and stained using the Click- iT Plus EdU Alexa Fluor™ 488 Flow Cytometry Assay Kit (catalog #C 10632, Thermo Fisher Scientific), following the manufacturer’s instructions. Briefly, cells were pulsed with EdU to label newly synthesized DNA, then fixed with paraformaldehyde and permeabilized using a saponin-based buffer. EdU incorporation was detected via a Click-iT reaction using Alexa Fluor 488-conjugated azide. After subsequent washes, cells were stained with DAPI to assess total DNA content and resuspended in FACS buffer for flow cytometric analysis. Data were acquired on a BD FACSymphony A3 and analyzed using FlowJo software (version 10.8.2). For DNA content analysis, gating was performed on CD41+ / CD42+populations to identify megakaryocyte-lineage cells.

[0663] To perform single-cell RNA sequencing of human megakaryocytes and megakaryocyte progenitor cells, MEPs were isolated using a BD Symphony S6 cell sorter. Briefly, following a 7-day culture in StemSpan SFEM II medium supplemented with thrombopoietin (TPO), CD34+HSPCs were stained with antibodies against Lineage markers, CD34, CD38, CD123, and CD45RA, as previously described. MEPs, defined as Lin CD34+CD38+CD123 CD45RA , were sorted using a 70 pm nozzle. Cells were maintained at 4°C throughout the procedure and collected into tubes containing PBS supplemented with 2% FBS to preserve viability for downstream single-cell analysis. Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)

[0664] Single cell RNA sequencing

[0665] MEPs (Lin CD34+CD38+CD123 CD45RA ) were sorted on a BD FACSAria Fusion (BD Biosciences), followed by construction of mRNA expression libraries using the Chromium 10X single cell 3’ reagent v3.1 protocol (10X Genomics). Libraries were sequenced using Illumina NovaSeq paired-end sequencing at a minimum of 50,000 reads per cell. We utilized Cell Ranger (version 7.0.0) to map raw sequencing reads against the GRch38 genome reference, and downstream analysis using Seurat package (version 5.1.0) was based on Cell Ranger outputs. We applied the following quality control criteria to remove unwanted cells: only cells with the number of genes detected per cell > 300 and < 7000, and a percentage of MT transcripts < 20% were included in further analysis. Gene counts were normalized using a log transform function with a scaling factor of 10,000. We selected 2,000 highly variable genes and utilized harmony integration to remove the batch effect and data integration. All Seurat analyses were performed following the Seurat v5 integration tutorial.

[0666] Gene Ontology (GO) Enrichment Analysis of Differentially Expressed Genes

[0667] To elucidate the biological processes altered in each cell population, we performed GO enrichment analysis using the DAVID Bioinformatics Resources database (version 6.8). Gene lists were generated for each population identified by scRNA-seq analysis, including MK, MKP, MEP, ERP, CMP, EoBasoMast precursors, and cycling progenitors. Only genes that met the following criteria were included: >1.5-fold change, adjusted p-value < 0.01, expression in at least 10% of cells in either the DMSO or Rev group, and expression in at least 3% of cells in both groups. GO terms with a false discovery rate (FDR) < 0.05 were considered statistically significant. This analysis highlights functional pathways significantly changed upon treatment, revealing potential disruptions in lineage-specific programs and cellular processes.

[0668] HALO analysis

[0669] Hematoxylin and eosin (HE)-stained sections of mouse sternum were analyzed for quantification of megakaryocytes in the bone marrow. Digital whole slide images (WSI) were acquired by virtual microscopy (Epredia 3DHistec Panoramic 250 FLASH III Digital Scanner, Kalamazoo, MI). The DenseNet algorithm within the HALO image analysis software (version 3.6; Indica Labs, Albuquerque, NM) was used to create a tissue classifier Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) for megakaryocytes, myeloid and erythroid hematopoietic cells, and trabecular bone. A WSI of each sternum was annotated by a veterinary pathologist blinded to the treatment group, analyzed by the trained model, and the results visually confirmed by the pathologist. Data are presented as the percentage of the marrow occupied by megakaryocytes.

[0670] Statistical analyses

[0671] For cell culture experiments, data comparing DMSO to menin inhibitors (Compound No. 1 or Ziftomenib), or non-targeting sgRNA to specific sgRNAs, were expressed as mean ± standard deviation (SD). A paired Student’s t-test was used for comparisons between two groups, while repeated-measures one-way ANOVA was applied for comparisons involving three groups. Paired statistical tests were used because all experiments were conducted in matched conditions. For each biological replicate, control (e.g., DMSO or non-targeting sgRNA) and treatment conditions (menin inhibitor or targeting sgRNA) were processed side by side, starting and ending simultaneously. Experimental values were collected in parallel at the same time point, ensuring that each control-treatment pair was directly comparable within the same experimental run. This design minimizes inter-experimental variability and justifies the use of paired t-tests or repeated-measures ANOVA for statistical analysis. To compare the control chow group with each of three rev chow groups, a linear mixed effect model was used. The model included either a random intercept alone or both random intercept and slope to account for difference in baseline levels and / or varying responses across mice. Normality of the data or residuals of the model was evaluated using Shapiro-Wilk test. A likelihood ratio test was used to compare the model with a random intercept only to that with both a random intercept and slope. False discovery rate adjusted p-values or Q-values were calculated according to standard methods (e.g., as described in Journal of the Royal Statistical Society, Series B. 57, 289-300 (1995)) to correct for multiple comparisons. A Q- value < 0.05 was considered statistically significant; otherwise, P < 0.05 was used for unadjusted analyses. All analyses were performed using GraphPad Prism version 10.

[0672] EQUIVALENTS

[0673] While we have described a number of embodiments of this disclosure, it is apparent that our basic examples may be altered to provide other embodiments that utilize the compounds and methods of this disclosure. The contents of all references (including literature references, issued patents, published patent applications, and co-pending patent applications) Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO) cited throughout this application are hereby expressly incorporated herein in their entireties by reference. Unless otherwise defined, all technical and scientific terms used herein are accorded the meaning commonly known to one with ordinary skill in the art. The foregoing description has been presented only for the purposes of illustration and is not intended to limit the disclosure to the precise form disclosed, but by the claims appended hereto. The references cited herein are not admitted to be prior art to the application.

[0674] The details of one or more embodiments of the disclosure are set forth in the accompanying description above. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present disclosure, the preferred methods and materials are now described. Other features, objects, and advantages of the disclosure will be apparent from the description and from the claims. In the specification and the appended claims, the singular forms include plural referents unless the context clearly dictates otherwise. 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 this disclosure belongs. All patents and publications cited in this specification are incorporated by reference.

Claims

Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)CLAIMSWhat is claimed is:

1. A method of treating a myeloproliferative neoplasm in a subject in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

2. The method of claim 1, wherein the myeloproliferative neoplasm is myelofibrosis, essential thrombocythemia, triple negative MPN, or polycythemia vera.

3. The method of claim 1, wherein the myeloproliferative neoplasm is myelofibrosis.

4. The method of claim 1, wherein the myeloproliferative neoplasm is essential thromb ocy them! a .

5. The method of claim 1, wherein the myeloproliferative neoplasm is triple negative MPN.

6. The method of claim 1, wherein the myeloproliferative neoplasm is polycy themia vera.

7. A method of treating myelofibrosis in a subject in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

8. A method of treating bone marrow fibrosis in a subject in need thereof comprising administering a menin inhibitor, or a pharmaceutically acceptable salt thereof, to the subject.

9. The method of any one of the previous claims, wherein the menin inhibitor or the pharmaceutically acceptable salt thereof is a small molecule, or a pharmaceutically acceptable salt thereof.

10. The method of any one of the previous claims, wherein the menin inhibitor isAttorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)or a pharmaceutically acceptable salt thereof.

11. The method of any one of the previous claims, wherein the menin inhibitor is Compound No. 1, or a pharmaceutically acceptable salt thereof.

12. The method of any one of claims 1-7 or 9-11, wherein the myelofibrosis is characterized by a J AK gene mutation, a CALR gene mutation, or a MPL gene mutation.

13. The method of any one of claims 1-7 or 9-12, wherein the myelofibrosis is characterized by a JAK 1, JAK2, J AK3, CALR type 1, CALR type 2, or MPL W515L gene mutation.

14. The method of any one of claims 1-7 or 9-13, wherein the myelofibrosis is characterized by a JAK2V617Fgene mutation.

15. The method of any one of the previous claims, wherein the method further comprises administering a second therapeutically active agent.

16. The method of any one of the previous claims, wherein the second therapeutically active agent is a JAK inhibitor.

17. The method of any one of the previous claims, wherein the second therapeutically active agent is ruxolitinib, fedratinib (SAR302503), momelotinib (CYT387), pacritinib, lestaurtinib, AZD-1480, BMS-911543, NS-018, LY2784544, SEP-701, XL019, or AT-9283.Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)18. The method of any one of the previous claims, wherein the second therapeutically active agent is ruxoiitinib.

19. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating a myeloproliferative neoplasm.

20. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating myelofibrosis.

21. Use of a menin inhibitor or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating bone marrow fibrosis.

22. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating a myeloproliferative neoplasm in a subject in need thereof.

23. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating myelofibrosis in a subject in need thereof.

24. Use of a menin inhibitor, or a pharmaceutically acceptable salt thereof, for treating bone marrow fibrosis in a subject in need thereof.

25. A pharmaceutical composition comprising a menin inhibitor of claim 10, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm.

26. A pharmaceutical composition comprising a menin inhibitor of claim 10, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

27. A pharmaceutical composition comprising a menin inhibitor of claim 10, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating bone marrow fibrosis.Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)28. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of claim 10, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating a myeloproliferative neoplasm.

29. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of claim 10, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating myelofibrosis.

30. A pharmaceutical composition comprising a salt or crystalline form of a menin inhibitor of claim 10, and at least one pharmaceutically acceptable carrier, wherein the pharmaceutical composition is used for treating bone marrow fibrosis.

31. A kit comprising a menin inhibitor of claim 10 or a pharmaceutically acceptable salt thereof, and instructions for use for treating a myeloproliferative neoplasm.

32. A kit comprising a menin inhibitor of claim 10 or a pharmaceutically acceptable salt thereof, and instructions for use for treating myelofibrosis.

33. A kit comprising a menin inhibitor of claim 10 or a pharmaceutically acceptable salt thereof, and instructions for use for treating bone marrow fibrosis.

34. A kit comprising a menin inhibitor of claim 10 or a pharmaceutically acceptable salt thereof, and instructions for use for treating a myeloproli erative neoplasm in combination with a JAK inhibitor.

35. A kit comprising a menin inhibitor of claim 10 or a pharmaceutically acceptable salt thereof, and instructions for use for treating myelofibrosis in combination with a JAK inhibitor.

36. A kit comprising a menin inhibitor of claim 10 or a pharmaceutically acceptable salt thereof, and instructions for use for treating bone marrow fibrosis in combination with a JAK inhibitor.Attorney Docket No. 43707-02970 / WO (SYND-066 / 001WO)37. A kit comprising the pharmaceutical composition of claim 25 and instructions for use for treating a myeloproliferative neoplasm.

38. A kit comprising the pharmaceutical composition of claim 26 and instructions for use for treating myelofibrosis.

39. A kit comprising the pharmaceutical composition of claim 27 and instructions for use for treating myelofibrosis.

40. A kit comprising the pharmaceutical composition of claim 28 and instructions for use for treating a myeloproliferative neoplasm.

41. A kit comprising the pharmaceutical composition of claim 29 and instructions for use for treating myelofibrosis.

42. A kit comprising the pharmaceutical composition of claim 30 and instructions for use for treating myelofibrosis.

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