Adjunct therapy for the treatment of glioblastoma multiforme

Abstract

Provided is a method of treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, comprising administering to the subject an adjunct therapy comprising a Gardos channel inhibitor (GCI) or a pharmaceutically acceptable salt or ester thereof, in association with a course of radiation treatment.

Description

Atorney Docket No.: 063697-507001 WOADJUNCT THERAPY FOR THE TREATMENT OF GLIOBLASTOMA MULTIFORMECROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of priority to U.S. Provisional Patent Application No. 63 / 738,376, filed December 23, 2024, which is incorporated by reference herein in its entirety.TECHNICAL FIELD

[0002] The following relates generally to methods of treatment for glioblastoma multiforme (GBM) or glioblastoma, comprising the administration of an adjunct therapy comprising a Gardos channel inhibitor (GCI), in one embodiment 2,2-bis(4-fluorophenyl)-2-phenylacetamide, to a subject, in association with a course of radiation treatment. In one embodiment, the subject has a GBM tumor characterized by having a population of tumor cells exhibiting a higher hypoxia score, in comparison to a clinically accepted average hypoxia score for glioblastoma. In one embodiment, the subject has a GBM tumor characterized by having an elevated expression level of a KCNN4 encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor. In one embodiment, the subject has a GBM tumor characterized by (i) an NF1 gene abnormality comprising a homozygous deletion or ahemizygous deletion ofNFl, and (ii) overexpression of one or more mesenchymal markers selected from S100A1, ST3GAL1, BIRC3, SORT1 (sortilin), MET, CD68, and TNF.BACKGROUND

[0003] Glioma, also known as glioblastoma multiforme (GBM) or glioblastoma, is an aggressive type of cancer that occurs in the brain or spinal cord. GBM is the most common and aggressive form of malignant primary brain tumor in adults, though its occurrence in younger persons and even in adolescents is not uncommon. Glioblastomas arise from astrocytes, these being the star-shaped cells comprising the supportive tissue of the brain, and they are characterized by regions of necrosis surrounded by an aggressive, often extensive, mix of tumor cells and they exhibit significant vascular proliferation.Atorney Docket No.: 063697-507001 WO

[0004] Subjects afflicted with GBM often initially (and thereafter) exhibit symptoms that include one or more of headaches, seizures, nausea and vomiting, neurological deficits (such as weakness or difficulty with movement), memory problems, cognitive, mood or personality changes, and speech or vision problems. The occurrence of such symptoms, however, can vary and often depend on the tumor’s location and size within the brain. Diagnosis typically involves neurological examinations, imaging tests such as MRI or CT scans, and a biopsy to analyze the type and grade of the tumor, its location (GBM is most commonly found in the cerebral hemispheres), and any specific characteristic(s) associated with the given subject’s GBM condition.

[0005] Given their rapid growth and high degree of invasiveness, glioblastomas can quickly infiltrate the surrounding brain tissue, which makes complete surgical removal difficult and treatment with chemotherapy very challenging. Treatment may involve one or more of surgery, radiation therapy, and chemotherapy, however, notwithstanding any aggressive treatment employed, glioblastoma tends to recur, in many cases quite rapidly, and long-term survival is challenging. The median survival time from diagnosis is currently in the range of 12-14 months.

[0006] Treatment options for GBM are currently very limited; apart from surgery (though complete removal of the tumor is difficult through surgical resection due to the infiltrative nature of this type oof cancer) and radiation (conventional external beam radiation therapy is administered post-surgery to kill the remaining cancer cells and shrink tumors that cannot be removed surgically), the most common chemotherapy employed is temozolomide (Temodar®). Notwithstanding whichever current standard-of-care treatment option may be administered to the glioblastoma patient, the problem of the aggressive regrowth of the of GBM due to the surrounding tumor cells not being eliminated, or even worse being primed for consequential regrowth stemming from the administered treatment, typically results in a GBM patient facing a scenario of the GBM growing back at an accelerated rate. Hence, the prospect for long-term survival remains remote, and a treatment option that at the least could provide an enhanced quality of life to the patient if the patient’s medical history and prognosis indicates that they may be positively affected from having administered to them an adjunct therapy would certainly qualify as an improvement in the treatment options available to glioblastoma-afflicted patients.Atorney Docket No.: 063697-507001 WO

[0007] Hence, with respect to treating subjects afflicted with glioma, there is a need for a treatment regimen for a subject having GBM disease wherein the regimen allows for an administration of an adjunct therapy to be utilized in association with the administration of a course of radiation treatment to the subject, wherein the adjunct therapy alleviates or lessens the regrowth of the GBM in the subject after the completion of the radiation therapy.

[0008] The Gardos channel, encoded by the KCNN4 gene, is a calcium-activated potassium channel (KCa3.1) that is highly expressed in a variety of cell types. For example, in human erythrocytes, Gardos channels play a vital role in regulating the volume and ion homeostasis in red blood cells; their activation is crucial for maintaining proper cell function and preventing hemolysis. In patients afflicted with sickle cell disease (SCD), for example, when intracellular calcium levels rise, the Gardos channel opens allowing efflux of potassium and water loss, leading to cellular dehydration. In other cell types, for example, T lymphocytes and mast cells of the human immune system, Gardos channels are involved in the activation and proliferation of T cells, as well as mediating the release of inflammatory mediators in mast cells. Gardos channels are also found in endothelial cells lining blood vessels, where they contribute to vasodilation and regulate vascular tone, and they are also present in smooth muscle cells were they are involved in regulating muscle cell contraction and relaxation. Regarding cancer cells, Gardos channels have been observed particularly in some solid tumor cell types exhibit an elevated expression of Gardos channels, which may contribute to their proliferation and metastatic potential.SUMMARY

[0009] In one aspect, provided is a method of treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, comprising administering to the subject an adjunct therapy comprising a Gardos channel inhibitor (GCI) or a pharmaceutically acceptable salt or ester thereof, in association with a course of radiation treatment. Also provided are uses of a GCI for the methods disclosed herein. Also provided are uses of a GCI for the manufacture of a medicament for the methods disclosed herein. Also provided are GCIs for use in the methods disclosed herein. Also provided are pharmaceutical compositions comprising a GCI for use in the methods disclosed herein.Atorney Docket No.: 063697-507001 WOBRIEF DESCRIPTION OF THE DRAWINGS

[0010] FIG. 1 is a graph showing a time course of senicapoc plasma concentrations and pharmacodynamic response following administration of an initial loading dose of 150 mg followed by daily maintenance dosing of 10 mg. The figure is adapted from Ataga et al. (2008) “Efficacy and safety of the Gardos channel inhibitor, senicapoc (ICA- 17043), in patients with sickle cell anemia” Blood, volume 11 (8), pages 3991-3997.DETAILED DESCRIPTIONDefinitions

[0011] Unless otherwise defined, all terms of art, notations, and other scientific terms or terminology used herein are intended to have meanings commonly understood by those of skill in the art to which this application pertains. In some cases, terms with commonly understood meanings are defined herein for clarity and / or for ready reference, and the inclusion of such definitions herein should not necessarily be construed to represent a substantial difference over what is generally understood in the art. Many of the techniques and procedures described or referenced herein are well understood and commonly employed using conventional methodology by those skilled in the art.

[0012] The singular form “a”, “an”, and “the” include plural references unless the context clearly dictates otherwise. “A and / or B” is used herein to include all of the following alternatives: “A”, “B”, “A or B”, and “A and B”.

[0013] Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit, unless the context clearly dictates otherwise, between the upper and lower limit of that range and any other stated or intervening value in that stated range, is encompassed within the disclosure. The upper and lower limits of these smaller ranges may independently be included in the smaller ranges, and are also encompassed within the disclosure, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the disclosure.

[0014] Certain ranges are presented herein with numerical values being preceded by the term “about.” The term “about” is used herein to provide literal support for the exact number thatAttorney Docket No.: 063697-507001 WOit precedes, as well as a number that is near to or approximately the number that the term precedes. In determining whether a number is near to or approximately a specifically recited number, the near or approximating unrecited number may be a number that, in the context in which it is presented, provides the substantial equivalent of the specifically recited number. If the degree of approximation is not otherwise clear from the context, “about” means either within plus or minus 10% of the provided value, or rounded to the nearest significant figure, in all cases inclusive of the provided value. In some embodiments, the term “about” indicates the designated value ± up to 10%, up to ± 5%, or up to ± 1%.

[0015] As used herein, a “subject” or an “individual” includes animals, such as human (e.g., human individuals) and non-human animals. In some embodiments, a “subject” or “individual” is a patient under the care of a physician. Thus, the subject can be a human patient or an individual who has, is at risk of having, or is suspected of having a health condition of interest and / or one or more symptoms of the health condition. The subject can also be an individual who is diagnosed with a risk of the health condition of interest at the time of diagnosis or later. The term “non-human animals” includes all vertebrates, e.g., mammals, e.g., rodents, e.g., mice, non-human primates, and other mammals, such as e.g., sheep, dogs, cows, chickens, and non-mammals, such as amphibians, reptiles, etc.

[0016] As used herein, the terms “administration” and “administering” refer to the delivery of a compound or composition by an administration route including, but not limited to, oral, intravenous, intra-arterial, intramuscular, intraperitoneal, subcutaneous, intramuscular, and topical administration, or combinations thereof. The term includes, but is not limited to, administering by a medical professional and self-administering.

[0017] As used herein, and unless otherwise specified, a “therapeutically effective” or “pharmaceutically effective” amount of a compound or composition of the disclosure generally refer to an amount or number sufficient for a compound or composition to accomplish a stated purpose relative to the absence of the composition, e.g., to provide a therapeutic benefit in the treatment or management of the GBM tumor or disease or any form of GBM, or to delay or minimize one or more symptoms associated with the subject’s GBM condition. A therapeutically effective amount of a compound means an amount of therapeutic agent, alone or in combination with other therapeutic agents, which provides a therapeutic benefit in the treatment or management of the subject’s GBM tumor or disease. The term “therapeutically effective amount” can encompass an amount that improves overall therapy,Atorney Docket No.: 063697-507001 WOreduces or avoids symptoms or causes of the GBM, or enhances the therapeutic efficacy of another therapeutic agent. An example of an “effective amount” is an amount sufficient to contribute to the treatment, prevention, or reduction of a symptom or symptoms of a disease, which could also be referred to as a “therapeutically effective amount.” A “reduction” of a symptom means decreasing of the severity or frequency of the symptom(s), or elimination of the symptom(s). The exact amount of a composition including a “therapeutically effective amount” will depend on the purpose of the treatment, and will be ascertainable by one skilled in the art using known techniques (see, e.g., Lieberman, Pharmaceutical Dosage Forms (vols.1-3, 1992); Lloyd, The Art, Science and Technology of Pharmaceutical Compounding (1999); Pickar, Dosage Calculations (1999); and Remington: The Science and Practice of Pharmacy, 20th Edition, 2003, Gennaro, Ed., Lippincott, Williams & Wilkins).

[0018] As used herein, "pharmaceutically acceptable salt" includes both acid and base addition salts. A pharmaceutically acceptable salt of a compound described herein is intended to encompass any and all pharmaceutically suitable salt forms. Preferred pharmaceutically acceptable salts of a compound described herein are pharmaceutically acceptable acid addition salts and pharmaceutically acceptable base addition salts.

[0019] As used herein, “suspected glioblastoma” or “suspected GBM” refers to a state in which a qualified healthcare provider has formed a reasonable suspicion that the subject has glioblastoma (or another high-grade glioma likely to be managed initially as glioblastoma), based on one or more of: neurological symptoms (e.g., seizure, focal deficit, progressive headache, cognitive change), imaging findings (e.g., CT and / or MRI features consistent with a high-grade glioma), referral for neurosurgical evaluation, planned biopsy or resection, or other clinical indicators.

[0020] As used herein, “formal diagnosis” and “confirmatively diagnosed” refers to confirmation by histopathology and / or integrated molecular classification (e.g., from a biopsy or resection specimen).

[0021] All publications, patents, and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication, patent, or patent application was specifically and individually indicated to be incorporated by reference.Atorney Docket No.: 063697-507001 WOGlioblastoma - Disease Development Stages

[0022] Glioblastoma is an aggressive primary malignant brain tumor with poor prognosis despite multimodal therapy that commonly includes maximal surgical resection followed by radiotherapy with concomitant and maintenance temozolomide. Tumor growth and infdtration can proceed rapidly, and delays between first presentation, diagnostic work-up, biopsy / resection, and subsequent initiation of definitive therapy can be clinically consequential. In terms of its developmental progression, glioblastoma typically exhibits several distinct phases of development.

[0023] In its earliest stage, prior to the manifestation of any symptoms by the subject, glioblastoma initiates from its cellular origin. This stage is a “clinically silent stage” that may last for months or even years while the tumor remains small and asymptomatic, however, the tumor is infiltrative. The GBM tumor cell(s) of origin are from a neural lineage of cells within in the brain, most likely from neural stem cells, oligodendrocyte precursor cells (OPCs) and / or dedifferentiated astrocytes. The oncogenic mutations that these cells acquire allow for them to exhibit altered biological processes such as cell-cycle control, DNA repair, apoptosis, and cellular differentiation programs that thus enable them to maintain a tumor phenotype. Key common early molecular events and genetic alterations include TERT promoter mutations (leading to cellular immortality), EGFR amplification or EGFRvIII mutation (which lead to excessive growth signaling), PTEN loss (which leads to unchecked PI3K / AKT signaling), TP53 mutations (which leads to a failure of DNA damage checkpoints), and CDKN2A / B deletions (which leads to a loss of cell-cycle braking).

[0024] The next stage of GBM development, during which time the tumorous state may be morphologically visible (based on an MRI / CT scan), and the patient may begin to exhibit some symptoms of being afflicted with GBM. At this stage, the GBM tumor is at a malignant transformation wherein the tumor transitions to a high-grade malignancy as mutations accumulate and the malignant nature of the tumor accelerates. Histopathologic hallmarks of this stage include rapidly dividing tumor cells, areas of hypoxia, microvascular proliferation, and necrosis with pseudopalisading cells (a defining GBM feature) and tumor microtubes form invasive networks. To note, however, such histopathological markers are only observable after a biopsy has been performed on the subject, typically obtained in an initial surgical resection of the tumor, with that surgical procedure typically being performed after a period of time has elapsed from the subject’s initial clinical visit (i.e. a first interaction with aAttorney Docket No.: 063697-507001 WOhealthcare provider); the biopsy sample may be obtained and thereafter examined weeks from the subject’s initial visit. Biological consequences during this stage of GBM development include factors such as the tumor outgrowing its blood supply, which in turn can result in a low oxygen (hypoxia) environment at the tumor. This hypoxia can lead to an induction of VEGF for blood vessel growth to supply the tumor, however, such angiogenesis is abnormal as new vessels supplying the tumor are leaky and inefficient, which may be manifested as edema and increased intracranial pressure.

[0025] In the next stage of GBM development, a clinical inflection point is reached as, typically, the GBM tumor has grown to a critical size or has impacted upon key neural networks depending on the location of the tumor within the brain. The subject may experience symptoms such as persistent or worsening headaches, new-onset seizures (which are a very common presenting sign), cognitive or personality changes, progressive focal neurological deficits, and language disturbance or visual field loss. A subject may or may not experience all of the aforementioned symptoms, and the frequency or occurrence of any one symptom relative to the frequency or occurrence of any one or more the other symptoms is not necessarily uniform or universal. Noteworthy, however, a presence of such symptoms should cause a suspicion that the subject may be afflicted with GBM albeit no diagnosis has been made at such point; at this stage of clinical development, an evaluation of the subject’s symptoms may at least allow for a conclusion, at that point in time, that the subject is afflicted with a suspected glioblastoma. Nonetheless, the GBM tumor is advanced and is likely to be aggressively growing, underscoring an urgent need for an intervention that may abate or otherwise reduce any growth signaling stimulation and benefit the outcome of a definitive therapy such a post-surgical radiation treatment.

[0026] The next stage of GBM development is that of a rapid clinical progression after symptom onset has begun. Typically, at such a stage, the GBM tumor has a very high mitotic rate and there may be diffuse infiltration along white matter tracts. As well, the GBM tumor may have a capacity to co-opt normal brain vasculature, evade the subject’s immune system, and exhibit a strong resistance to apoptosis. From a growth dynamic perspective, at this stage of GBM development, the tumor may exhibit a doubling time of about 10 to about 30 days, and radiographic progression can occur within weeks, while with neurological deterioration may evolve over days to months.Attorney Docket No.: 063697-507001 WO

[0027] In a next stage of development, the subject is in a GBM diagnosis phase with a surgical resection and biopsy being performed for subsequent histopathological confirmation of GBM and a evaluation of the precise nature of the GBM (whether the GBM tumor is of a particular sub-type of GBM). Typically at this stage, however, the GBM tumor has reached several centimeters in diameter and has already infiltrated surrounding unafflicted brain tissue. At such stage, edema often exceeds the visible tumor mass, and microscopic disease may be present far beyond surgical margins. MRI imaging may show a ring-enhancing lesion with central necrosis.

[0028] In a next stage of GBM development, the subject has been formally diagnosed with GBM and is in a post-diagnosis disease course that involves definitive treatment, with regimens including maximal safe surgical resection, radiation therapy, and chemotherapy such as the administration of temozolomide. To note, however, at such point, tumor cells may have migrated centimeters from the main lesion and there may be no clear tumor-unafflicted brain tissue boundary, and the presence of cancer stem-like cells that are able to resist chemotherapy may be present. Median survival, from this stage, is typically 12 to 15 months, with progression-free survival being in a range of about 6 months to about 8 months. To note, tumor recurrence is near universal, and radiation therapy, once completed, is often associated with a more aggressive tumor recurrence.

[0029] In a final stage, that being terminal progression, edema worsens and there is an acceleration of neurological decline and loss of cognitive and motor functions, with the subject ultimately succumbing due to increased intracranial pressure, brain herniation and loss of vital neural functions.GBM patient theratype identification

[0030] In one embodiment, the present disclosure pertains to identification of a defined patient population (or theratype) of GBM that would benefit from treatment as well as treatment and aiding in the treatment of defined subgroups of patients who may be effectively treated for glioma by administering a therapeutically effective amount of one or more Gardos channel inhibitors, such as 2, 2-bis(4-fluorophenyl)-2 -phenylacetamide, as an adjunct therapeutic to a course of radiation treatment to be received and / or being received by the GBM-afilicted patient.Atorney Docket No.: 063697-507001 WO

[0031] In the context of the present disclosure, subjects will be explored in order to classify their gene expression profdes so as to allow them to be characterized as belonging to a cadre of potential responders to an adjunct therapy. By way of example, subjects who may exhibit the mesenchymal subtype will be considered to be most sensitive to the adjunct therapy regimen. Within this subtype there is further KCNN4 variation in expression, and it is understood that the GBM subjects with tumors with highly elevated KCNN4 expression will be most sensitive. Also, GBM cells with higher hypoxia scores may be more sensitive, and thus, with such characteristic profdes in hand, a threshold level of expression may be defined that would allow for the given subject being a prospective candidate who would efficaciously respond to a GBM adjunct therapy comprising administration of a Gardos channel inhibitor with radiation therapy administration.

[0032] In a further embodiment, with respect to transcriptome based patient clustering and a utilization of mesenchymal markers, GBM tumors will often have NF1 abnormalities (homozygous and hemizygous deletions), and express high levels of other markers such as S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNF. As such, as GBM tumors tend to be more angiogenic, subjects exhibiting elevated levels of such markers may also be amenable to being administered a Gardos channel inhibitor adjunct therapy in conjunction with radiation treatment in order to treat the GBM condition.GCI administration prior to formal diagnosis of GBM

[0033] In the context of glioma and glioblastoma, KCNN4 / KCa3.1 expression and function have been implicated in tumor cell migration, invasion, and interaction with the tumor microenvironment, including microglia. Published studies using KCa3.1 pharmacologic inhibitors such as TRAM-34 have reported reductions in glioma / GBM migration or invasion, and have also explored KCa3.1 inhibition in combination with standard-of-care modalities such as temozolomide and irradiation in experimental systems (see Stransky et al. (2023) “Efficacy of combined tumor irradiation and K(Ca)3.1 -targeting with TRAM-34 in a syngeneic glioma mouse model” Scientific Reports, 13: 20604, and D’ Alessandro et al. (2019) “Radiation increases functional KCa3.1 expression and invasiveness in glioblastoma” Cancers, 11(3): 279).

[0034] Notwithstanding the foregoing, these published approaches generally contemplate administration of a KCa3.1 inhibitor in the setting of an established glioblastoma diagnosisAtorney Docket No.: 063697-507001 WOand / or in established tumor models (see Catacuzzeno and Franciolini (2018) “Role of KCa3.1 in modulating Ca2+ oscillations during glioblastoma cell migration and invasion” Int. J. Mol. Sci., 19, 2970). In contrast, the present disclosure provides strategies for initiating administration of a Gardos channel inhibitor at an earlier stage (e.g., at first clinical suspicion and prior to confirmatory diagnosis), and for administering the inhibitor as an adjunct in association with a course of radiation treatment.

[0035] 2,2-bis(4-fluorophenyl)-2-phenylacetamide, also known formally as 4-fluoro-a-(4-fhrorophenylj-a-phenyl-benzeneacetamide, as 1S / C2OHI5F2NO / C21-17-10-6-15(7-11-17)20(19(23)24, 14-4-2-l-3-5-14)16-8-12-18(22)13-9-16 / hl-13H,(H2, 23, 24), by its molecular formula C20H15F2NO, and is also known as Senicapoc, is a potent Gardos channel inhibitor that has previously been studied for treatment of SCD. Senicapoc has the structure of:

[0036] The compound was studied in Phase 2 and Phase 3 clinical trials for the treatment of SCD but was ultimately not approved for use in humans by the FDA or any other regulatory body due to its failure to meet clinical endpoints in a Phase 3 trial. The compound, however, is very lipophilic, and despite having a modest bioavailability profile subsequent to its administration, the compound has been observed to be present in brain tissue of subjects who have had the compound administered to them. As such, the ability of the compound to cross the blood-brain barrier (BBB) offers a prospect of its use in a GBM treatment regimen, especially as an adjunct therapy to radiation or chemoradiation treatment.

[0037] In certain embodiments, early initiation of senicapoc administration is performed in order to provide an improved therapeutic profile relative to initiation after formal diagnosis. Early initiation is considered as beneficial as (i) glioblastoma is clinically fast moving and definitive intervention typically begins promptly after diagnosis, and (ii) senicapoc exhibits pharmacokinetic (PK) and pharmacodynamic (PD) behavior indicating that maximal or near-maximal systemic and / or functional effects may not be immediate upon first administration, even in the presence of a loading dose (i.e. a first dose).Atorney Docket No.: 063697-507001 WO

[0038] In certain embodiments, the long half-life and associated accumulation kinetics can create a clinically important delay between first dosing and achievement of a desired exposure profile (e.g., near steady-state systemic exposure) unless dosing is initiated early and / or a loading-dose strategy is employed.

[0039] Regarding PK accumulation and delayed attainment of target exposure, senicapoc exhibits a long terminal elimination half-life in humans. A long terminal elimination T1 / 2 of approximately 17 days has been observed, and an estimated time to reach steady-state plasma concentration of approximately 86 days (e.g., about 5 half-lives) has been reported. In other clinical descriptions, senicapoc has been reported to have a long T1 / 2 of approximately 13 days (range 11-17). Consistent with such long half-life behavior, steady state pharmacokinetics were not achieved after four weekly doses in at least one multiple-dose regimen.

[0040] Regarding clinical PK / PD time course demonstrates non-immediacy of effect.Published Phase 2 data in humans (in the context of treating sickle cell disease) describe that, following administration of loading doses, plasma concentrations of senicapoc approached steady-state levels that were then maintained during the study, and mean plasma concentration over a 12-week treatment period appeared dose proportional. In that Phase 2 setting, senicapoc was administered using LD / MD regimens (e.g., 100 mg LD followed by 6 mg / day, or 150 mg LD followed by 10 mg / day). As can be seen in Figure 1 (adapted from the publication of the Phase 2 study - Agata et al. (2008)), despite administration of a high loading dose substantially exceeding chronically administered clinical (i.e. maintenance) doses, senicapoc plasma concentrations increase gradually over time and do not reach maximal levels until approximately 15-20 days after initiation of dosing, with continued increases observed thereafter. A corresponding delay in pharmacodynamic effect is also observed, with peak pharmacodynamic response occurring substantially later than initial dosing. Also of importance, the time course of measured plasma concentrations and a PD marker of Gardos channel inhibition was reported over multiple sampling days, including sampling on day 8 and day 15 after initiation of dosing. As such, this temporal behavior evidences that clinically relevant systemic exposure and associated functional effects are not instantaneous upon first dosing, and may develop over a period of days to weeks, even when a loading dose is used. Furthermore, delayed PD readout supports initiation before definitive therapy. Gardos channel inhibition, as measured by calcium-induced86Rb+flux across the redAtorney Docket No.: 063697-507001 WOblood cell (RBC) membrane, has been observed for both 6 mg and 10 mg dosing groups and appeared dose dependent, with a maximal reduction of approximately 70% at a 10 mg once-daily dose. Measurements of such flux were obtained at baseline (including day 1 before dose) and then at later time points during the course of the study. As the PD marker in the aforementioned study was observed to evolve over time after treatment initiation (rather than being fully realized immediately upon first administration Without being bound by theory, the present disclosure recognizes that in the context of treating GBM, that initiating senicapoc only after formal diagnosis (which may occur after biopsy / resection and associated scheduling delays) may postpone attainment of desired functional inhibition during a critical early window of glioblastoma management. Accordingly, initiating senicapoc at suspicion (pre-diagnostic initiation) can provide sufficient lead time such that, by the time definitive therapy begins (e.g., surgery and / or chemoradiation), the subject has already developed meaningful pharmacologic activity.

[0041] It is known that senicapoc is highly protein bound in human serum (e.g., about 97% at tested conditions). At present, no studies have reported on senicapoc’s ability to enter into the human brain, however, it is known from non-clinical distribution studies that senicapoc crosses the blood-brain barrier in an animal model system. In one rat study, free (unbound) brain and free plasma concentrations increased from approximately 37.2 nM and 16.7 nM at 1 hour post-dose to approximately 136 nM and 63.7 nM at 4 hours post-dose, with a free braimfree plasma ratio of about 2.1-2.2, and cerebrospinal fluid concentrations similar to free brain concentrations — findings consistent with CNS distribution.

[0042] In certain embodiments, in the context of the present disclosure regarding a method of treating GBM by administration of senicapoc (or a pharmaceutically-acceptable salt or ester thereof) or use of senicapoc for such or in the manufacture of a medicament for such use, senicapoc administration is initiated (a) on the same calendar day as upon a healthcare provider, on concluding an examination of the subject and taking into consideration the signs and symptoms of the subject, such symptoms comprising neurological symptoms (e.g., seizure, focal deficit, progressive headache, cognitive change), imaging findings (e.g., CT and / or MRI features consistent with a high-grade glioma), and any other relevant symptoms and medical history of the subject, provides a recommendation of the subject having a suspected glioblastoma based on the healthcare provider’s reasonable suspicion of the subject being afflicted with glioblastoma, (b) within 24 hours of such suspicion, (c) within 72 hoursAtorney Docket No.: 063697-507001 WOof such suspicion, or (d) within 7 days of such suspicion, and in each case prior to receipt of histopathology results confirming glioblastoma. In certain embodiments, senicapoc is initiated after imaging suggests a high-grade glioma and before the subject undergoes biopsy or tumor resection.

[0043] With respect to a loading-dose (first dose) regimen, in certain embodiments, senicapoc is administered according to a loading dose (LD) followed by a maintenance dose (MD). By way of a non-limiting example with respect to sickle cell disease treatment, clinical regimens have included: (i) a 150 mg single-day LD followed by a 10 mg / day MD; and (ii) a 100 mg single-day LD followed by a 6 mg / day MD. Additional regimens described in clinical development contexts include multi-day loading strategies (e.g., 40 mg / day for 4 days followed by 10 mg / day). As such, with respect to treatment of GBM and a need to achieve an as-rapid -as possible accumulation of senicapoc within the brain of a patient suspected of being afflicted with GBM, in certain embodiments of the present disclosure, the LD may be, for example, about 25 mg to about 300 mg total, including about 50 mg to about 200 mg total, including about 100 mg to about 180 mg total, including about 150 mg total, and the MD may be, for example, about 1 mg / day to about 40 mg / day, including about 4 mg / day to about 20 mg / day, including about 6 mg / day to about 10 mg / day. The dosing may be once daily or divided dosing, provided that senicapoc exposure is adequate to inhibit KCa3.1 activity in relevant compartments or cells of the patient’s brain.

[0044] Without being bound by theory, in certain embodiments the time required to achieve a therapeutically effective concentration at one or more intracranial target sites (e.g., within tumor tissue, infdtrative margins, perivascular niches, and / or microglia-rich regions) in a patient afflicted with GBM may be longer than would be inferred from a single plasma concentration measurement. Factors that may contribute include high protein binding (limiting free fraction), multi-compartment distribution and accumulation consistent with long half-life behavior, and heterogeneity in blood-brain barrier integrity and transport across different tumor and peritumoral regions. As such, certain embodiments, the pre-diagnostic initiation of senicapoc administration in a GBM patient described in the present disclosure is therefore particularly advantageous because it (a) compensates for non-immediate systemic accumulation, (b) provides time for CNS exposure to be established and sustained in advance of definitive therapy, and (c) reduces the likelihood that the subject begins surgery and / or chemoradiation without having reached a desired exposure and / or pharmacologic effect level.Attorney Docket No.: 063697-507001 WO

[0045] In a further aspect, the present disclosure provides for a safe treatment modality for addressing GBM in that Senicapoc is known to have a favorable safety and tolerability profde, and as such, this aspect supports early initiation of administration to a patient suspected of being afflicted with GBM. Outside of GBM, senicapoc has been administered to humans in multiple clinical settings. By way of non-limiting example, individual subjects have received single doses up to 200 mg and daily dosing of 10 mg / day for up to one year. Mean peak plasma concentrations after higher single doses in volunteers have been described as approximately 170 ng / mL (with individual peaks up to about 299 ng / mL) and were reported as well tolerated with no serious or dose-limiting side effects. Additionally, summaries of clinical safety experience describe no dose limiting toxicity and no deaths, with discontinuation due to adverse events being similar between senicapoc and placebo groups in at least one dataset. As such, the favorable safety and tolerability profile, together with the aggressiveness of GBM, supports a risk-benefit rationale for initiating senicapoc at suspicion (prior to formal diagnosis), particularly where the subject’s clinical presentation is consistent with a high likelihood of glioblastoma and the therapeutic plan anticipates near-term definitive intervention.Further embodiments

[0046] In a further aspect, the present disclosure provides use of a Gardos channel inhibitor, such as senicapoc, or a pharmaceutically acceptable salt or ester thereof, in the manufacture of a medicament for treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, wherein the medicament is administered to the subject in association with a course of radiation treatment, and wherein administration is initiated prior to commencement of the course of radiation treatment.

[0047] In certain embodiments, initiation of administration occurs at or shortly after first clinical suspicion of GBM and prior to confirmatory diagnosis (e.g., prior to biopsy and / or prior to receipt of histopathology results), optionally within 168 hours of the subject presenting one or more clinical symptoms consistent with GBM. In certain embodiments, the medicament is administered once daily (or in divided daily doses) throughout at least a portion of the course of radiation treatment and optionally for a period after conclusion of the course of radiation treatment.Atorney Docket No.: 063697-507001 WO

[0048] In a further aspect, the present disclosure provides for senicapoc or a pharmaceutically acceptable salt or ester thereof for use in the treatment of GBM, and pharmaceutical compositions comprising senicapoc for such use, optionally wherein the subject is selected as having a GBM tumor with a higher hypoxia score, elevated KCNN4 expression, and / or an NF1 abnormality together with elevated expression of one or more mesenchymal markers, and optionally wherein treatment correlates with reduction in the presence or growth of glioblastoma microtubes or a microtube network.

[0049] Additional non-limiting embodiments are enumerated in the list below.Enumerated Embodiments

[0050] Embodiment 1. A method of treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, comprising administering to the subject an adjunct therapy comprising a Gardos channel inhibitor (GCI) or a pharmaceutically acceptable salt or ester thereof, in association with a course of radiation treatment.

[0051] Embodiment 2. The method of embodiment 1, wherein the GCI is 2,2-bis(4-fluorophenyl)-2-phenylacetamide.

[0052] Embodiment 3. The method of any one of embodiments 1 or 2, wherein a first dose (loading dose (LD)) of the adjunct therapy is administered to the subject prior to the radiation treatment being administered to the subject.

[0053] Embodiment 4. The method of any one of embodiments 1 to 3, wherein the GCI is administered to the subject commencing with the first dose (loading dose (LD)) of the GCI being administered to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

[0054] Embodiment 5. The method of embodiment 4, wherein the first dose (loading dose (LD)) is administered within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

[0055] Embodiment 6. The method of any one of embodiments 1 to 5, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.Atorney Docket No.: 063697-507001 WO

[0056] Embodiment 7. The method of any one of embodiments 1 to 6, wherein the GCI is administered over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.

[0057] Embodiment 8. The method of any one of embodiments 1 to 7, wherein the adjunct therapy is administered to the subject throughout the course of the radiation treatment being administered to the subject.

[0058] Embodiment 9. The method of any one of embodiments 1 to 8, wherein the adjunct therapy is administered to the subject for a continued period of time after a conclusion of the radiation treatment administration.

[0059] Embodiment 10. The method of any one of embodiments 3 to 9, wherein subsequent to the administration of the first dose (loading dose (LD)) to the subject, the subject is administered a series of maintenance doses (MD) of the GCI in the adjunct therapy, wherein the maintenance dose has a dosage of the GCI lower than the first dose (loading dose (LD).

[0060] Embodiment 11. The method of embodiment 11, wherein the maintenance dose (MD) is administered once daily to the subject.

[0061] Embodiment 12. The method of any one of embodiments 3 to 11, wherein the GCI administered to the subject is maintained at a blood plasma level wherein the blood plasma level is correlative with a sustained level of the GCI being present in the brain tissue of the subject over the course of the administration of the adjunct therapy to the subject.

[0062] Embodiment 13. The method of any one of embodiments 1 to 12, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.

[0063] Embodiment 14. The method of any one of embodiments 1 to 13, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0064] Embodiment 15. The method of any one of embodiments 1 to 14, wherein the GBM tumor is characterized by having (1) a neurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of aAtorney Docket No.: 063697-507001 WOmesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNF.

[0065] Embodiment 16. The method of any one of embodiments 10 to 15, wherein the administration of the GCI correlates with a reduction in the presence or growth of a GBM microtube or GBM microtube network in the subject.

[0066] Embodiment 17. Use of a Gardos channel inhibitor (GCI) or a pharmaceutically acceptable salt or ester thereof, in the manufacture of a medicament for treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, wherein the medicament is administered to the subject in a dosing regimen comprising an administration of a first dose (loading dose (LD)) and a series of maintenance doses (MD) of the medicament prior to a optionally wherein the GCI is 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

[0067] Embodiment 18. The use of embodiment 17, wherein the medicament comprises a dose of about 10 mg to about 300 mg of 2, 2-bis(4-fluorophenyl)-2 -phenyl acetamide or a pharmaceutically acceptable salt or ester thereof.

[0068] Embodiment 19. The use of embodiments 17 or 18, wherein the first dose (loading dose (LD) of the medicament is administered to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

[0069] Embodiment 20. The use of any one of embodiments 17 to 19, wherein the first dose (loading dose (LD)) is administered within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

[0070] Embodiment 21. The use of any one of embodiments 17 to 20, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.

[0071] Embodiment 22. The use of any one of embodiments 17 to 21, wherein the medicament is administered over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.Attorney Docket No.: 063697-507001 WO

[0072] Embodiment 23. The use of any one of embodiments 17 to 22, wherein the medicament is administered to the subject throughout the course of the radiation treatment or course of radiation treatments being administered to the subject.

[0073] Embodiment 24. The use of any one of embodiments 17 to 23, wherein the medicament is administered to the subject for a continued period of time after a conclusion of the radiation treatment or course of radiation treatments administration.

[0074] Embodiment 25. The use of any one of embodiments 17 to 24, wherein the maintenance dose (MD) is administered once daily to the subject.

[0075] Embodiment 26. The use of any one of embodiments 17 to 25, wherein the medicament administered to the subject maintains a blood plasma level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide wherein the blood plasma level is correlative with a sustained level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide being present in the brain tissue of the subject over the course of the dosing regimen administration.

[0076] Embodiment 27. The use of any one of embodiments 17 to 26, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.

[0077] Embodiment 28. The use of any one of embodiments 17 to 27, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0078] Embodiment 29. The use of any one of embodiments 17 to 28, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0079] Embodiment 30. The use of any one of embodiments 17 to 29, wherein the GBM tumor is characterized by having (1) a neurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of a mesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNE

[0080] Embodiment 31. A pharmaceutical composition comprising a Gardos channel inhibitor (GCI) or a pharmaceutically acceptable salt or ester thereof, and at least oneAttorney Docket No.: 063697-507001 WOpharmaceutically acceptable excipient, carrier, stabilizer or diluent, for use in the treatment of glioblastoma multiforme (GBM) disease or a GBM tumor in a subject in need thereof, wherein the 2,2-bis(4-fluorophenyl)-2-phenylacetamide is intended to be administered to the subject in a dosing regimen comprising an administration of a first dose (loading dose (LD)) and a series of maintenance doses (MD) of the pharmaceutical composition prior to a radiation treatment being administered to the subject, optionally wherein the GCI is 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

[0081] Embodiment 32. The pharmaceutical composition for the use of embodiment 31, wherein the pharmaceutical composition comprises a dose of about 10 mg to about 300 mg of 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

[0082] Embodiment 33. The pharmaceutical composition for the use of embodiment 31 or 32, wherein the first dose (loading dose (LD) of the medicament is administered to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

[0083] Embodiment 34. The pharmaceutical composition for the use of any one of embodiments 31 to 33, wherein the first dose (loading dose (LD)) is administered within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

[0084] Embodiment 35. The pharmaceutical composition for the use of any one of embodiments 31 to 34, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.

[0085] Embodiment 36. The pharmaceutical composition for the use of any one of embodiments 31 to 35, wherein the pharmaceutical composition is administered over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.

[0086] Embodiment 37. The pharmaceutical composition for the use of any one of embodiments 31 to 36, wherein the pharmaceutical composition is administered to the subjectAtorney Docket No.: 063697-507001 WOthroughout the course of the radiation treatment or course of radiation treatments being administered to the subject.

[0087] Embodiment 38. The pharmaceutical composition for the use of any one of embodiments 31 to 37, wherein the pharmaceutical composition is administered to the subject for a continued period of time after a conclusion of the radiation treatment or course of radiation treatments administration.

[0088] Embodiment 39. The pharmaceutical composition for the use of any one of embodiments 31 to 38, wherein the maintenance dose (MD) is administered once daily to the subject.

[0089] Embodiment 40. The pharmaceutical composition for the use of any one of embodiments 31 to 39, wherein the pharmaceutical composition administered to the subject maintains a blood plasma level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide wherein the blood plasma level is correlative with a sustained level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide being present in the brain tissue of the subject over the course of the dosing regimen administration.

[0090] Embodiment 41. The pharmaceutical composition for the use of any one of embodiments 31 to 40, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.

[0091] Embodiment 42. The pharmaceutical composition for the use of any one of embodiments 31 to 41, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0092] Embodiment 43. The pharmaceutical composition for the use of any one of embodiments 31 to 42, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0093] Embodiment 44. The pharmaceutical composition for the use of any one of embodiments 31 to 43, wherein the GBM tumor is characterized by having (1) aAtorney Docket No.: 063697-507001 WOneurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of a mesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, andTNF.

[0094] Embodiment 45. A Gardos Channel Inhibitor (GCI) for use in treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, wherein the GCI is for administration to the subject in a dosing regimen comprising a first dose (loading dose (LD)) and a series of maintenance doses (MD) prior to a radiation treatment being administered to the subject, optionally wherein the compound is 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

[0095] Embodiment 46. The GCI for use of embodiment 45, wherein the dosing regimen comprises a dose of about 10 mg to about 300 mg of 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

[0096] Embodiment 47. The GCI for use of embodiments 45 or 46, wherein the first dose (loading dose (LD)) is for administration to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

[0097] Embodiment 48. The GCI for use of any one of embodiments 45 to 47, wherein the first dose (loading dose (LD)) is for administration within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

[0098] Embodiment 49. The GCI for use of any one of embodiments 45 to 48, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.

[0099] Embodiment 50. The GCI for use of any one of embodiments 45 to 49, wherein the medicament is for administration over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.

[0100] Embodiment 51. The GCI for use of any one of embodiments 45 to 50, wherein the medicament is for administration to the subject throughout the course of the radiation treatment or course of radiation treatments being administered to the subject.Atorney Docket No.: 063697-507001 WO

[0101] Embodiment 52. The GCI for use of any one of embodiments 45 to 51, wherein the medicament is for administration to the subject for a continued period of time after a conclusion of the radiation treatment or course of radiation treatments administration.

[0102] Embodiment 53. The GCI for use of any one of embodiments 45 to 52, wherein the maintenance dose (MD) is for administration once daily to the subject.

[0103] Embodiment 54. The GCI for use of any one of embodiments 45 to 53, wherein the the subject maintains a blood plasma level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide wherein the blood plasma level is correlative with a sustained level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide being present in the brain tissue of the subject over the course of the regimen administration.

[0104] Embodiment 55. The GCI for use of any one of embodiments 45 to 54, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.

[0105] Embodiment 56. The GCI for use of any one of embodiments 45 to 55, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0106] Embodiment 57. The GCI for use of any one of embodiments 45 to 56, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0107] Embodiment 58. The GCI for use of any one of embodiments 45 to 57, wherein the GBM tumor is characterized by having (1) a neurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of a mesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNE

[0108] Embodiment 59. Use of a Gardos channel inhibitor (GCI) or a pharmaceutically acceptable salt or ester thereof, for treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, wherein the GCI is intended for use in a dosing regimen comprising an administration of a first dose (loading dose (LD)) and a series of maintenanceAttomey Docket No.: 063697-507001 WOdoses (MD) of the medicament prior to a optionally wherein the GCI is 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

[0109] Embodiment 60. The use of embodiment 59, wherein the dosing regimen comprises a dose of about 10 mg to about 300 mg of 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

[0110] Embodiment 61. The use of embodiments 59 or 60, wherein the first dose (loading dose (LD) is for administration to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

[0111] Embodiment 62. The use of any one of embodiments 59 to 61, wherein the first dose (loading dose (LD)) is for administration within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

[0112] Embodiment 63. The use of any one of embodiments 59 to 62, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.

[0113] Embodiment 64. The use of any one of embodiments 59 to 63, wherein the GCI is for administration over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.

[0114] Embodiment 65. The use of any one of embodiments 59 to 64, wherein the GCI is for administration to the subject throughout the course of the radiation treatment or course of radiation treatments being administered to the subject.

[0115] Embodiment 66. The use of any one of embodiments 59 to 65, wherein the GCI is for administration to the subject for a continued period of time after a conclusion of the radiation treatment or course of radiation treatments administration.

[0116] Embodiment 67. The use of any one of embodiments 59 to 66, wherein the maintenance dose (MD) is for administration once daily to the subject.

[0117] Embodiment 68. The use of any one of embodiments 59 to 67, wherein the administration maintains a blood plasma level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide wherein the blood plasma level is correlative with a sustained level of 2,2-bis(4-Atorney Docket No.: 063697-507001 WOfluorophenyl)-2-phenylacetamide being present in the brain tissue of the subject over the course of the dosing regimen administration.

[0118] Embodiment 69. The use of any one of embodiments 59 to 68, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.

[0119] Embodiment 70. The use of any one of embodiments 59 to 69, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0120] Embodiment 71. The use of any one of embodiments 59 to 70, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

[0121] Embodiment 72. The use of any one of embodiments 59 to 71, wherein the GBM tumor is characterized by having (1) a neurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of a mesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNEEXAMPLESTo illustrate the concept of the invention, the following prophetic examples are provided. Example 1

[0122] Synopsis of the Proposed Treatment Regimen: This regimen integrates the investigational use of senicapoc alongside the current standard-of-care therapies for glioblastoma, initiating treatment even before a formal histopathological diagnosis is obtained.

[0123] Pre-Diagnostic Phase (Before Surgical Biopsy): Patients with a high clinical suspicion of glioblastoma based on imaging (MRI / CT) and neurological assessment begin oral senicapoc therapy pre-emptively. The rationale for beginning treatment before formal diagnosis is i) to achieve steady-state levels and brain accumulation prior to commencingAtorney Docket No.: 063697-507001 WOstandard of care, which, based on half-life of senicapoc would be impossible if waiting until after histopathological confirmation, ii) begin disrupting tumour network biology. Given surgical biopsy is scheduled as soon as possible following suspicion of GBM, and radiation / chemotherapy commences soon after histopathological results (as per Strupp protocol), treatment needs to begin immediately if it is to synergize with early radiation and chemo.

[0124] Surgical Intervention and Diagnostic Confirmation: Once a surgical biopsy or resection is planned, senicapoc administration is continued throughout the perioperative period. Standard neurosurgical techniques aim to achieve maximal safe resection, obtaining tissue for definitive diagnosis. Postoperatively, senicapoc is maintained as the initial systemic therapy is well tolerated, pending histopathological confirmation of glioblastoma.

[0125] Concurrent Chemoradiation (Standard-of-Care): Following a confirmed diagnosis of glioblastoma, patients proceed with the current standard-of-care regimen (Stupp protocol). Senicapoc is continued throughout this phase to potentially enhance treatment efficacy in subgroups with molecular responder profiles.

[0126] Adjuvant Temozolomide and Maintenance Therapy: After completing chemoradiation, patients enter the adjuvant phase, receiving up to six to twelve cycles of maintenance temozolomide. Senicapoc administration is continued, adjusted based on tolerance and clinical response, with regular imaging and neurological evaluations to monitor disease status, potential synergistic benefits, and safety.

[0127] Long-Term Management and Follow-Up: Patients remain on senicapoc during the maintenance and follow-up period as guided by response assessments, with dose modifications or discontinuation contingent upon toxicity, disease progression, or emergent data on long-term efficacy.Example 2

[0128] An off-target safety pharmacology profile characterizing the Gardos channel inhibitor senicapoc will be performed; a favorable profile will aid in supporting the suitability of senicapoc for early adjunct administration in a GBM treatment regimen, including initiation of administration on recommendation by an examining healthcare professional based on suspected glioblastoma affliction stemming from the subject’s initial examination(s) and prior to a formal diagnosis. To establish this profile, the compound is subjected to an in vitro SafetyAttorney Docket No.: 063697-507001 WO98 Panel screening with a panel comprising (by way of example) GPCRs, ion channels, transporters, nuclear receptors, and enzymes, wherein each target is evaluated in a single-point assay format in duplicate at a maximal final concentration of about 10 pM (or higher), which corresponds to at least a greater than a 10-fold multiple of anticipated clinically relevant exposure levels (e.g., total and / or unbound C max), thereby providing an exposure-margin screen for potential central nervous system (CNS) liabilities. The panel will include, without limitation, representative CNS / CV GPCRs (e.g., adenosine, adrenergic, cannabinoid, dopamine, histamine, serotonergic, muscarinic, opioid), key ion channels (including hERG, Cavl.2, sodium channel site 1, nAChR a7, GABA_A, NMDA / AMPA), and monoamine transporters (DAT, 5HTT, NET), together with selected enzymes and other targets (e g., AChE / BuChE, MAO-A / MAO-B, COX-l / COX-2, PDEs, ACE1 / ACE2, HDACs, ROCK1 / ROCK2, VEGFR, sigma receptors). Minimal clinically meaningful interactions across the foregoing target classes at the screening concentration(s) may be considered as being consistent with a clean CNS safety liability profile and thus supportive of administration in proximity to neurosurgical work-up and / or chemoradiation. Complementary cardiac safety assessment may be performed via a CiPA ion-channel panel (automated patch clamp; six channels / seven currents) and a human iPSC-derived ventricular cardiomyocyte MEA assay.

[0129] Although the above principles have been described with reference to certain specific examples, various modifications thereof will be apparent to those skilled in the art as outlined in the appended claims. In addition, each reference provided herein is incorporated by reference in its entirety to the same extent as if each reference was individually incorporated by reference. When a conflict exists between the instant application and a reference provided herein, the instant application shall dominate.

Claims

Atorney Docket No.: 063697-507001 WOWhat is claimed is:

1. A method of treating a glioblastoma multiforme (GBM) disease or tumor in a subj ect in need thereof, comprising administering to the subject an adjunct therapy comprising a Gardos channel inhibitor (GCI) or a pharmaceutically acceptable salt or ester thereof, in association with a course of radiation treatment.

2. The method of claim 1, wherein the GCI is 2,2-bis(4-fluorophenyl)-2-phenylacetamide.

3. The method of any one of claims 1 or 2, wherein a first dose (loading dose (LD)) of the adjunct therapy is administered to the subject prior to the radiation treatment being administered to the subject.

4. The method of any one of claims 1 to 3, wherein the GCI is administered to the subject commencing with the first dose (loading dose (LD)) of the GCI being administered to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

5. The method of claim 4, wherein the first dose (loading dose (LD)) is administered within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

6. The method of any one of claims 1 to 5, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.

7. The method of any one of claims 1 to 6, wherein the GCI is administered over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.

8. The method of any one of claims 1 to 7, wherein the adjunct therapy is administered to the subject throughout the course of the radiation treatment being administered to the subject.Attorney Docket No.: 063697-507001 WO9. The method of any one of claims 1 to 8, wherein the adjunct therapy is administered to the subject for a continued period of time after a conclusion of the radiation treatment administration.

10. The method of any one of claims 3 to 9, wherein subsequent to the administration of the first dose (loading dose (LD)) to the subject, the subject is administered a series of maintenance doses (MD) of the GCI in the adjunct therapy, wherein the maintenance dose has a dosage of the GCI lower than the first dose (loading dose (LD).

11. The method of claim 10, wherein the maintenance dose (MD) is administered once daily to the subject.

12. The method of any one of claims 3 to 11, wherein the GCI administered to the subject is maintained at a blood plasma level wherein the blood plasma level is correlative with a sustained level of the GCI being present in the brain tissue of the subject over the course of the administration of the adjunct therapy to the subject.

13. The method of any one of claims 1 to 12, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.

14. The method of any one of claims 1 to 13, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

15. The method of any one of claims 1 to 14, wherein the GBM tumor is characterized by having (1) a neurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of a mesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNF.

16. The method of any one of claims 10 to 15, wherein the administration of the GCI correlates with a reduction in the presence or growth of a GBM microtube or GBM microtube network in the subject.

17. Use of 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof in the manufacture of a medicament treating a glioblastoma multiforme (GBM) disease or tumor in a subject in need thereof, wherein the medicament is administeredAtorney Docket No.: 063697-507001 WOto the subject in a dosing regimen comprising an administration of a first dose (loading dose (LD)) and a series of maintenance doses (MD) of the medicament prior to a radiation treatment being administered to the subject.

18. The use of claim 17, wherein the medicament comprises a dose of about 10 mg to about 300 mg of 2, 2-bis(4-fluorophenyl)-2 -phenylacetamide or a pharmaceutically acceptable salt or ester thereof.

19. The use of claims 17 or 18, wherein the first dose (loading dose (LD) of the medicament is administered to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

20. The use of any one of claims 17 to 19, wherein the first dose (loading dose (LD)) is administered within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

21. The use of any one of claims 17 to 20, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.

22. The use of any one of claims 17 to 21, wherein the medicament is administered over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.

23. The use of any one of claims 17 to 22, wherein the medicament is administered to the subject throughout the course of the radiation treatment or course of radiation treatments being administered to the subject.

24. The use of any one of claims 17 to 23, wherein the medicament is administered to the subject for a continued period of time after a conclusion of the radiation treatment or course of radiation treatments administration.

25. The use of any one of claims 17 to 24, wherein the maintenance dose (MD) is administered once daily to the subject.

26. The use of any one of claims 17 to 25, wherein the medicament administered to the subject maintains a blood plasma level of 2,2-bis(4-fluorophenyl)-2-phenylacetamideAtorney Docket No.: 063697-507001 WOwherein the blood plasma level is correlative with a sustained level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide being present in the brain tissue of the subject over the course of the dosing regimen administration.

27. The use of any one of claims 17 to 26, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.

28. The use of any one of claims 17 to 27, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

29. The use of any one of claims 17 to 28, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

30. The use of any one of claims 17 to 29, wherein the GBM tumor is characterized by having (1) a neurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of a mesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNF.

31. A pharmaceutical composition comprising 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof and at least one pharmaceutically acceptable excipient, carrier, stabilizer or diluent, for use in the treatment of glioblastoma multiforme (GBM) disease or a GBM tumor in a subject in need thereof, wherein the 2,2-bis(4-fluorophenyl)-2 -phenylacetamide is intended to be administered to the subject in a dosing regimen comprising an administration of a first dose (loading dose (LD)) and a series of maintenance doses (MD) of the pharmaceutical composition prior to a radiation treatment being administered to the subject.

32. The pharmaceutical composition for the use of claim 31, wherein the pharmaceutical composition comprises a dose of about 10 mg to about 300 mg of 2,2-bis(4-fluorophenyl)-2-phenylacetamide or a pharmaceutically acceptable salt or ester thereof.Atorney Docket No.: 063697-507001 WO33. The pharmaceutical composition for the use of claim 31 or 32, wherein the first dose (loading dose (LD) of the medicament is administered to the subject upon a healthcare provider recommendation of the subject having a suspected glioblastoma.

34. The pharmaceutical composition for the use of any one of claims 31 to 33, wherein the first dose (loading dose (LD)) is administered within a period of time selected from: of at least the same day, of at least within 24 hours, or at least 168 hours, of the healthcare provider recommendation of the subject having a suspected glioblastoma.

35. The pharmaceutical composition for the use of any one of claims 31 to 34, wherein the GBM tumor or disease has not been confirmatively diagnosed in the subject.

36. The pharmaceutical composition for the use of any one of claims 31 to 35, wherein the pharmaceutical composition is administered over a course of administration commencing at least ten days prior to a commencement of the course of radiation treatment.

37. The pharmaceutical composition for the use of any one of claims 31 to 36, wherein the pharmaceutical composition is administered to the subject throughout the course of the radiation treatment or course of radiation treatments being administered to the subject.

38. The pharmaceutical composition for the use of any one of claims 31 to 37, wherein the pharmaceutical composition is administered to the subject for a continued period of time after a conclusion of the radiation treatment or course of radiation treatments administration.

39. The pharmaceutical composition for the use of any one of claims 31 to 38, wherein the maintenance dose (MD) is administered once daily to the subject.

40. The pharmaceutical composition for the use of any one of claims 31 to 39, wherein the pharmaceutical composition administered to the subject maintains a blood plasma level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide wherein the blood plasma level is correlative with a sustained level of 2,2-bis(4-fluorophenyl)-2-phenylacetamide being present in the brain tissue of the subject over the course of the dosing regimen administration.

41. The pharmaceutical composition for the use of any one of claims 31 to 40, wherein the GBM tumor comprises a population of tumor cells exhibiting a higher hypoxia score in comparison to a clinically accepted average hypoxia score for glioblastoma.Atorney Docket No.: 063697-507001 WO42. The pharmaceutical composition for the use of any one of claims 31 to 41, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

43. The pharmaceutical composition for the use of any one of claims 31 to 42, wherein the GBM tumor is characterized by having an elevated expression level of a KCNN4-encoding gene in a mesenchymal cell subtype population of cells of the GBM tumor.

44. The pharmaceutical composition for the use of any one of claims 31 to 43, wherein the GBM tumor is characterized by having (1) a neurofibromatosis factor 1 (NF1) abnormality comprising a homozygous deletion or a hemizygous deletion, and (2) an overexpression of a mesenchymal marker selected from S100A1, ST3GAL1, birc3, sortilin, MET, CD68, and TNF.

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