US007727968B2

(12) United States Patent (10) Patent No.: US 7,727,968 B2 Feingold et al. (45) Date of Patent: Jun. 1, 2010

(54) COMBINATION THERAPY FOR THE 5,773,001 A * 6/1998 Hamann et al...... 424,181.1 TREATMENT OF ACUTE LEUKEMIA AND 2002/0103141 A1 8/2002 McKearnet al. MYELODYSPLASTC SYNDROME (75) Inventors: Jay Marshall Feingold, Wynnewood, PA (US); Matthew L. Sherman, OTHER PUBLICATIONS S. M.SVEE"Ron Lowenberg etal (New Journal of Medicine, vol. 341, pp. 1051-1062, s s s 1999.* Station, PA (US) Kellet al (Blood (2201) 98-123a-124), 2001.* R. Berkow et al. The Merck Manual. Sixteenth Edition, pp. 1243 (73) Assignee: Wyeth LLC, Madison, NJ (US) 1244. Merck Research Laboratories, Rahway, NJ.(1992). (*) Notice: Subject to any disclaimer, the term of this Mark H. Beers and Robert Berkow. The Merck Manual. Seventeenth patent is extended or adjusted under 35 .tions, Carcia-Manero, 11, e R, Myelodyplastic C. Syndromes Acute MveloidMyeloi. U.S.C. 154(b) by 214 days. Leukemia, Haematologica, vol. 87(8): 804-807 Aug. 2002. (21) Appl. No.: 11/811,626 Elihu H. Estey, et al, Gemtuzumab OZogamicin With or Without Interleukin 11 in Patients 65 Years of Age or Older With Untreated 1-1. Acute Myeloid Leukemia and High-Risk Myelodysplastic Syn (22) Filed: Jun. 11, 2007 drome: Comparison With Idarubicin Plus Continuous-Infusion, O O High-Dose Cytosine Arabinoside, Blood, vol. 99(12), pp. 4343 (65) Prior Publication Data 4349, Jun. 2002. US 2007/O26943O A1 Nov. 22, 2007 * cited by examiner Related U.S. Application Data Primary Examiner Elli Peselev (63) Continuation of application No. 10/700,650, filed on Nov. 4, 2003, now abandoned. (57) ABSTRACT (60) Provisional application No. 60/424,156, filed on Nov. 6, 2002. Methods of treatment and pharmaceutical combinations are (51) Int. Cl provided for the treatment of acute leukemia, such as acute A. iK I/70 (2006.01) myelogenous leukemia, and myelodysplastic syndrome. The 52) U.S. C 51 4/34: 4247181.1 : 514/45: methods of treatment and pharmaceutical combinations (52) U.S. Cl...... s • us 51474 9 employ an anti-CD33 cytotoxic conjugate in combination with at least one compound selected from the group consist (58) Field t list Seash ------hhi ------None ing of an anthracycline and a pyrimidine or purine nucleoside ee application file for complete search history. analog. Preferred methods of treatment and pharmaceutical (56) References Cited combinations employ gemtuzumab ozogamicin, daunorubi cin, and cytarabine. U.S. PATENT DOCUMENTS 5,744,460 A 4, 1998 Miller et al. 20 Claims, No Drawings US 7,727,968 B2 1. 2 COMBINATION THERAPY FOR THE part of the normal stem-cell pool. Induction of remission is TREATMENT OF ACUTE LEUKEMIA AND usually possible with intensive chemotherapy. Complete MYELODYSPLASTC SYNDROME remission has been stated to be achievable in up to 80% of younger patients and about 50% of older patients (who form CROSS REFERENCE TO RELATED the majority of those with AML), but patients suffer severe APPLICATIONS neutropenia during induction and remission rate is to some extent dependent upon the standard of Supportive care. This application is a continuation of U.S. application Ser. Remission rates are lower in those with adverse prognostic No. 10/700,650 filed on Nov. 4, 2003, now abandoned which factors such as poor performance status, AML Secondary to claims the benefit under 35 U.S.C. S 119(e) of U.S. provi 10 myelodysplasia or antineoplastics, high white cell count, fea sional application No. 60/424,156 filed on Nov. 6, 2002, the tures of multidrug resistance, and unfavorable cytogenetics. entire disclosures of which are hereby incorporated by refer Löwenberg, B., et al., N. Engl. J. Med. (1999) 341:1051-62: CCC. Correction. ibid.: 1484. The greatest unmet medical need is in AML patients over 70 years of age. For these elderly AML FIELD OF THE INVENTION 15 patients, complete remission may be difficult to obtain, but an Methods of treatment and pharmaceutical combinations increased benefit in their quality of life is a treatment goal to are provided for the treatment of acute leukemia, in particular, be achieved. acute myelogenous leukemia and myelodysplastic syndrome. Established regimens are based on cytarabine, a pyrimi The methods of treatment and pharmaceutical combinations dine nucleoside analog, with the anthracycline daunorubicin. employ an anti-CD33 cytotoxic conjugate in combination Löwenberg, B., et al., N. Engl. J. Med. (1999) 341:1051-62: with at least one compound selected from the group consist Correction. ibid.: 1484, Burnett, A. K. & Eden O. B., Lancet ing of an anthracycline and a pyrimidine or purine nucleoside (1997) 349:270-275: Hiddemann, W., et al., J. Clin. Oncol. analog, in particular, gemtuzumab ozogamicin, daunorubi (1999) 17:3569-76. The first successful regimens also cin, and cytarabine. 25 included thioguanine, which is still used by some medical centers, although the majority opinion is that it gives no BACKGROUND OF THE INVENTION additional advantage and thioguanine has been dropped from most induction protocols. Alternatives to daunorubicin Acute leukemia is typically a rapidly progressing leukemia include idarubicin and mitoxantrone. Löwenberg, B., et al., characterized by replacement of normal bone marrow by blast 30 N. Engl.J.Med. (1999)341:1051-62; Correction, ibid.: 1484. cells of a clone arising from malignant transformation of a Etoposide has been added to induction protocols of cytara hematopoietic stem cell. There are two types of acute leuke bine and daunorubicin with improved results in younger mias, acute lymphoblastic leukemia (ALL) and acute myel patients. ogenous leukemia (AML). ALL is the most common malig The basic induction regimen for treatment of AML nancy in children, but also occurs in adolescents and has a 35 includes administration of cytarabine by continuous intrave second, lower peak in adults. AML, also know as acute nous (IV) infusion for 7 days, with an anthracycline Such as myeloid leukemia and acute myelocytic leukemia, is the more daunorubicin or idarubicin given IV for 3 days during this common acute leukemia in adults and its incidence increases time, usually in the first three days. The Merck Manual, Sec. with age, but AML also occurs in children. For both types of 11, Ch. 138 (17' ed. 1999). This widely used regimen for the acute leukemias, the primary goal of treatment is to achieve 40 treatment of AML is known as a 3+7 regimen and produces complete remission, with resolution of abnormal clinical fea complete remission rates of 60-80%. De Nully Brown, P., et tures, return to normal blood counts and normal hematopoie al., Leukemia (1997) 11:37-41. Treatment usually results in sis in the bone marrow with <5% blast cells, a neutrophil significant myelosuppression, often for long periods before count of >1,000-1,500, a platelet count of >100,000, and marrow recovery. Other adverse events from these two drugs disappearance of the leukemic clone; however, the drug regi 45 include chemical arachnoiditis, myocardial toxicity, and neu mens for treating ALL and AML have differed. The Merck rotoxicity. The induction regimen may be repeated, usually Manual, Sec. 11, Ch. 138 (17' ed. 1999); Estey, E., Cancer up to a total of three times, to achieve remission. Before (2001) 92(5): 1059-1073. Initial therapy aims at inducing repeating the induction regimen, a bone marrow analysis is remission. Treatment of AML differs most from ALL in that done on after fourteen days from the completion of the last patients with AML respond to fewer drugs and have a high 50 induction regimen. If the bone marrow has been cleaned out, rate of relapse. i.e., there is a complete response, then the physician will wait Patients with AML who achieve a complete remission live until the patient’s peripheral blood counts recover before longer than patients who do not, and only patients who administering another induction regimen. If the bone marrow achieve complete remission are potentially cured if their com analysis shows that disease is still present, i.e., there is a plete remission remains for at least three years. Estey, E., 55 partial or minimal response, then the induction regimen will Cancer (2001) 92(5): 1059, 1060. Remission induction rates be repeated without waiting for the patient’s peripheral blood in patients with AML range from 50 to 85%, with patients counts to recover. The waiting period between induction regi older than 50 years, and especially those older than 65 years, mens is therefore twenty-eight to thirty-five days for a com less likely to achieve remission. Long-term disease-free Sur plete responder, and fourteen to twenty-one days for partial vival occurs in a low percentage of patients, 20-40%, and 60 and minimal responders. For patients with relapsed AML, the increases to 40-50% in younger patients treated with bone standard induction therapy of cytarabine and daunorubicin marrow transplants. Patients with secondary AML have a does not produce a good response rate, typically <40%, and poor prognosis. The Merck Manual, Sec. 11, Ch. 138 (17" ed. the prognosis is poor for these patients. 1999). After remission is achieved, a second treatment regimen Treatment of AML is problematic because normal stem 65 using the same drugs or other drugs to knockout the disease, cell precursors are sensitive to the agents used, and therapy known as consolidation therapy, may be employed. However, aimed at myeloid leukemic clones results in destruction of a high percentage of patients suffer from relapse, even in US 7,727,968 B2 3 4 series with intensive post-remission consolidation chemo ozogamicin (between day 28 and 35 following the last infu therapy. De Nully Brown, P., et al., Leukemia (1997) 11:37 sion). Significant non-hematologic adverse events included, 41. among others, VOD (6%), arrhythmia (6%), and infection The current trend is towards the use of more intensive (24%). At the end of the whole induction program, thirteen induction regimens. Use of high-dose cytarabine in doses of 5 patients were in complete remission (38.2%) and 3 achieved up to 3 g/m every twelve hours for up to six days per day a complete remission with incomplete platelet recovery (with daunorubicin and etoposide) has been reported to (8.8%) for an overall response rate of 47%, not an improve improve the duration of first remission and disease-free Sur ment over existing therapies for AML. Amadori, S., et al., vival compared with standard doses of cytarabine. Bishop, J. “Sequential Administration of Gemtuzumab OZogamicin F., et al., Blood (1996) 87.1710-1717. Equally the timing of 10 (GO) and Intensive Chemotherapy for Remission Induction induction cycles may be important: intensive timing (where in Previously Untreated Patients with AML over the Age of the second cycle was given 10 days after the first) has 60: Interim Results of the EORTC Leukemia Group AML improved disease-free survival, despite more toxicity-related 15A Phase II Trial.” Blood (2001) 98:587a. deaths, compared with the standard interval of 14 days or In another study, patients with poor prognosis AML (>70 more. Woods, W. G., et al., Blood (1996) 87:4979-4989. 15 years age, myelodysplasia, leukemia developing after toxic Once remission is induced, further treatment (post remis exposure) were either treated under a protocol designated sion therapy) is essential in preventing relapse. Löwenberg, “AML 9503” in which the patient received two “pulses” of B., et al., N. Engl. J. Med. (1999) 341:1051-62; Correction. chemotherapy each consisting of 2 gm/m of cytarabine (a ibid.: 1484; Burnett, A. K. & Eden O. B., Lancet (1997) high dose of cytarabine) administered at time-0 and time=12 349:270-275: Hiddemann, W., et al., J. Clin. Oncol. (1999) hours and mitoxantrone in an amount of 35 mg/m immedi 17:3569-76. Options include further chemotherapy, or allo ately after the second cytarabine dose, with the second geneic or autologous bone marrow transplantation. Long “pulse' being given 96 hours later, or were treated under a term survival of about 50% may be possible with these protocol designated “AML 9798 in which the patient options when used in patients in first remission. However, received two “pulses” of chemotherapy each consisting of 2 which option to use is controversial. The most Successful 25 gm/m of cytarabine administered at time–0 and time=12 chemotherapy regimens use high-dose cytarabine for up to 4 hours and mitoxantrone in an amount of 35 mg/m immedi courses, and appear to be comparable to bone marrow trans ately after the second cytarabine dose, with the second plantation in terms of survival. Mayer, R. J. et al., N. Engl. J. “pulse' being given 96 hours later, followed by administra Med. (1994) 331:896-903; Cassileth, P. A., et al., N. Engl. J. tion of amifostine. The complete remission rate for AML Med. (1998).339:1649-1656. Consequently, some advocate a 30 9503 was 30% and for AML 9798 was 40%. When the che policy of intensive post remission chemotherapy, reserving motherapy was changed to add a single dose of gemtuzumab transplantation for subsequent relapse, particularly for ozogamicin in an amount of 9 mg/m three days prior to the patients with favorable cytogenetics. Edenfield, W.J. & Gore, first pulse of chemotherapy, two of four such treated patients S. D., Semin. Oncol. (1999) 26:21-34. with refractory AML entered complete remission. Preisler, H. Another drug used in the treatment of AML is gemtuzumab 35 D., et al., “Synergistic Antileukemia Effects of Mylotarg and oZogamicin (MylotargR). Gemtuzumab ozogamicin was Chemotherapy in AML.” Blood (2001) 98:193b. approved in May 2000 in the United States of America for the In a feasibility study, patients <60 years of age received treatment of AML in patients in first relapse who are 60 years H-DAT3+10 regimen (daunorubicin 45 mg/m days 1, 3, 5: old or older and not considered candidates for other cytotoxic cytarabine 400 mg/mbd days 1-10; thioguanine 100 mg/m chemotherapy. Gemtuzumab ozogamicin is administered as a 40 bd days 1-10) with gemtuzumab ozogamicin (3 or 6 mg/m two-hour IV infusion in a dose of 9 mg/m. A second dose given as a 2-hour infusion on day 1). The second course given may be administered fourteen days later. While many patients was H-DAT3+8 with the same gemtuzumab ozogamicin dose receiving gemtuzumab ozogamicin have achieved complete as in course 1. While both the 3 mg/m and 6 mg/m doses of remission, a significant number of patients have had a delay in gemtuzumab ozogamicin were tolerated in these two regi platelet recovery or incomplete platelet recovery. Physician's 45 mens, increased liver toxicity was seen when gemtuzumab Desk Reference (56" ed. 2002). Hepatic venoocclusive dis ozogamicin was given at 6 mg/m in the first course and it was ease (VOD), which is potentially fatal, has occurred in decided to thereafter use 3 mg/m of gemtuzumab ozogami patients who have undergone stem cell transplantation after cin in courses 1 and 2. Kell, J. W., et al., “Effects of Mylo gemtuzumab ozogamicin therapy. Tack, D. K. et al., Bone targTM (Gemtuzumab Ozogamicin, GO) in Combination with Marrow Transplantation (2001) 28(9):895-897. It was also 50 Standard Induction Chemotherapy in the Treatment of Acute reported in July 2001 that patients receiving gemtuzumab Myeloid Leukaemia (AML): A Feasibility Study. Blood oZogamicin who did not undergo stem cell transplantation (2001) 98:123a-124a. developed as much as a 10% increased risk of developing In a further study, patients <60 years of age were given significant hepatotoxicity and possible morbidity and mortal H-DAT3+10 (daunorubicin 50 mg/m daily by slow IV push ity, although most of these patients received gemtuzumab 55 on days 1, 3, 5; cytarabine 200 mg/m IV push bd days 1-10; oZogamicin in previously untested combinations or outside thioguanine 100 mg/mbd oral days 1-10) or S-DAT 3+10 the approved labeled use. Giles, F. J., et al., Cancer (2001) (daunorubicin 50 mg/m daily by slow IV push on days 1,3, 92(2):406-413. Like the standard cytarabine-daunorubicin 5: cytarabine 100 mg/m IV push bd days 1-10; thioguanine induction therapy, the response rate of patients with relapsed 100 mg/mbd oral days 1-10) with 3 or 6 mg/m gemtuzumab AML to gemtuzumab ozogamicin therapy can be <40%. 60 oZogamicinas induction therapy. A second course of H-DAT Combination therapies with gemtuzumab ozogamicin 3+8 (daunorubicin 50 mg/m daily by slow IV push on days 1, have been tried with limited Success. In one study, gemtu 3,5; cytarabine 200 mg/m IV pushbd days 1-8; thioguanine Zumab ozogamicin was administered to elderly patients pre 100 mg/mbd oral days 1-10) or S-DAT 3+8 (daunorubicin viously untreated for AML by 2-hour IV infusion at a dose of 50 mg/m daily by slow IV push on days 1, 3, 5; cytarabine 9 mg/mon day 1 and 15, with MICE (mitoxantrone, cytara 65 100 mg/m IV push bd days 1-8; thioguanine 100 mg/mbd bine and etoposide) being given for one or two courses within oral days 1-10) was given with or without gemtuzumab ozo seven days from the response assessment to gemtuzumab gamicin in an amount of 3 mg/m. Consolidation therapy US 7,727,968 B2 5 6 consisted of MACE (MACE: Amsacarine 100 mg/m daily by enrolled in this group with one patient with refractory AML one hour infusion (in 5% dextrose on days 1-5); cytarabine developing hepatic VOD Soon after completing induction 200 mg/m by daily continuous IV infusion days 1-5, Etopo therapy and dying on day 28. Another patient with de novo side 100 mg/m daily by one hour IV infusion days 1-5) AML died of cardiac arrest on day 24 and also had reversible chemotherapy with or without gemtuzumab ozogamicin in an 5 grade 3 elevation of ALT. In light of the foregoing results, it amount of 3 mg/m. Patients who received gemtuzumab ozo was concluded that six additional patients would be enrolled gamicin in courses 1 and 2 had delayed hematological recov in dosage group 1 to expand the safety data, and if the com ery and VOD, one of whom died. The 6 mg/m dose of bination of cytarabine 100 mg/m/day, daunorubicin 45 gemtuzumab ozogamicin was also associated with increased mg/m, and gemtuzumab ozogamicin 6 mg/m would be liver toxicity. It was concluded that 3 mg/m gemtuzumab 10 found to be well tolerated in this expanded group, then the ozogamicin can be given with H-DAT3+10 in course 1 and in phase II portion of the study would begin and approximately course 3 with MACE, but that two courses of gemtuzumab 45 patients with de novo AML would be enrolled. DeAngelo, oZogamicin in induction or an increase of the dose of gemtu D., et al., Supra. The efficacy of the combination of cytarabine Zumab ozogamicin to 6 mg/m is associated with increased 100 mg/m/day, daunorubicin 45 mg/m, and gemtuzumab toxicity and not recommended. Burnett, A. K. and Kell, J., 15 ozogamicin 6 mg/m could not be determined based on the “The Feasibility of Combining Immunoconjugate and Che limited number of patients enrolled in the phase I portion of motherapy in AML. Hematology J. (June 2002) Vol. 3, Supp. the study or the efficacy of this combination compared to the 1, p. 156. efficacy of standard chemotherapy for AML. In another preliminary study to assess safety and efficacy, Myelodysplastic syndrome (MDS) is a group of syn gemtuzumab ozogamicin was given to de novo and relapsed/ dromes (preleukemia, refractory anemias, Ph-negative refractory AML patients >60 years old in a combination chronic myelocytic leukemia, chronic myelomonocytic leu therapy with cytarabine. Six patients were treated with cyt kemia, agnogenic myeloid metaplasia) commonly seen in arabine by continuous infusion in an amount of 100 mg/m/ patients >50 years old. Its incidence is unknown, but it is day on days 1 to 7 and gemtuzumab ozogamicin in an amount increasing, probably in part due to the increasing proportion of 6 mg/mon days 1 and 15. While the combination was well 25 of elderly in the population and an increase in treatment tolerated, four patients died. To reduce the duration of myelo associated leukemias. Exposure to benzene and radiation Suppression following induction therapy, gemtuzumab ozo may be related to its development. In the preleukemic phase gamicin was administered on days 1 and 8 in an amount of 6 of some of the secondary leukemias (e.g., after drug or toxic mg/m on day 1 and 4 mg/mon day 8. Of seven patients who exposure), altered and defective cellular production may be were treated, three achieved complete remission. Durrant, S., 30 seen with diagnostic features of myelodysplasia. The Merck et al., Proc. Amer. Soc. Clin. Oncol. (2002) 21:271a. Manual, Sec. 11, Ch. 138 (17" ed. 1999). To assess the safety and efficacy of gemtuzumab ozogami MDS is characterized by clonal proliferation of hemato cin as part of combination therapy for AML, a phase I/II study poietic cells, including erythroid, myeloid, and megakaryo was developed in the United States of America combining cytic forms. The bone marrow is normal or hypercellular, and gemtuzumab ozogamicin with cytarabine and daunorubicin. 35 ineffective hematopoiesis causes variable cytopenias, the The phase I portion of the study began in October 2000 and a most frequent being anemia. The disordered cell production preliminary report was published at the 43" American Soci is also associated with morphologic cellular abnormalities in ety of Hematology Annual Meeting electronically on Nov. 6, marrow and blood. Extramedullary hematopoiesis may 2001 and in print on Nov. 7, 2001. DeAngelo, D., et al., occur, leading to hepatomegaly and splenomegaly. Myelofi “Preliminary Report of the Safety and Efficacy of Gemtu 40 brosis is occasionally present at diagnosis or may develop Zumab OZogamicin (Mylotargr) Given in Combination with during the course of MDS. The MDS clone is unstable and Cytarabine and Daunorubicin in Patients with Acute Myeloid tends to progress to AML. The prognosis of a patient with Leukemia, Blood (2001) 98:199(b). That report described MDS is highly dependent on FAB classification and on any the treatment of three patients, one with de novo AML and associated disease. Patients with refractory anemia or refrac two with relapsed/refractory AML, with cytarabine in an 45 tory anemia with sideroblasts are less likely to progress to the amount of 100 mg/m/day by continuous infusion on days 1 more aggressive forms and may die of unrelated causes. The to 7, daunorubicin in an amount of 45 mg/m on days 1 to 3. Merck Manual, Sec. 11, Ch. 138 (17' ed. 1999). and gemtuzumab ozogamicin in an amount of 6 mg/monday There is no established treatment for MDS. Therapy is 4 (dosage group 1). The combination was well tolerated, no supportive with RBC transfusions, platelet transfusions for dose-limiting toxicity (DLT) was observed, and two patients 50 bleeding, and antibiotic therapy for infection. In some achieved a remission. Three patients with relapsed/refractory patients, cytokine therapy (erythropoietin to Support red AML then were enrolled in the next dosage group in which blood center needs, granulocyte colony-stimulating factor to the dose of gemtuzumab ozogamicin was escalated to 9 manage severe symptomatic granulocytopenia, and, when mg/m (dosage group 2), with the combination well tolerated, available, thrombopoietin for severe thrombocytopenia) can but all three patients were nonresponders. Six additional 55 serve as important hematopoietic Support. Allogeneic bone patients, three with de novo AML and three with relapsed/ marrow transplantation is not recommended for patients >50 refractory AML, were enrolled at the dosage level of 9 years old. Colony-stimulating factors (e.g., granulocyte mg/m. Therapy was again well tolerated, and no DLT was colony-stimulating factor, granulocyte-macrophage colony observed. There were, however, 2 episodes of grade 3 non stimulating factor) increase neutrophil counts, and erythro drug-related elevations of ALT/AST and 2 episodes of grade 60 poietin increases RBC production in 20 to 25% of cases, but 4 non-drug-related dyspnea. All 3 patients with denovo AML survival advantage has not been shown. Response of MDS to achieved remission and recovered both an ANC >1500/XL AML chemotherapy is similar to that of AML, after age and and platelets >100,000/EL on days 26, 28, and 36, respec karyotype are considered. The Merck Manual, Sec. 11, Ch. tively. Patients then were enrolled in the next dosage group in 138 (17" ed. 1999). which the cytarabine dose was increased to 200 mg/m/day 65 Thus, there is a need for an improved treatment for patients (dosage group 3). Infusion of the combination therapy was with acute leukemia or myelodysplastic syndrome which will well tolerated, but DLT was observed in four of six patients produce a higher rate of complete remission, thereby increas US 7,727,968 B2 7 8 ing the Survival prospects of Such patients. It has been Sur In another preferred embodiment, the cytarabine is admin prisingly been found that a combination therapy employing istered by continuous infusion, the daunorubicin, preferably an anti-CD33 cytotoxic conjugate in combination with an daunorubicin hydrochloride, is administered by intravenous anthracycline and a pyrimidine or purine nucleoside analog, bolus, and the gemtuzumab ozogamicin is administered by in particular, gemtuzumab ozogamicin, daunorubicin, and 2-hour infusion. cytarabine, respectively, a significant improvement in effi The present invention further provides a pharmaceutical cacy compared to the combination therapy of daunorubicin combination for enhanced induction of remission in a patient and cytarabine or to gemtuzumab ozogamicin alone. having acute leukemia or MDS comprising: (a) an anti-CD33 cytotoxic conjugate, wherein the cytotoxin in the anti-CD33 SUMMARY OF THE INVENTION 10 cytotoxic conjugate is selected from the group consisting of a calicheamicin and an esperamicin; (b) an anthracycline The present invention provides a method of treating acute selected from the group consisting of doxorubicin, daunoru leukemia or MDS comprising administering to a patient in bicin, idarubicin, aclarubicin, Zorubicin, mitoxantrone, epi need of said treatment an anti-CD33 cytotoxic conjugate in rubicin, carubicin, nogalamycin, menogaril, pitarubicin, and combination with at least one compound selected from the 15 valrubicin; and (c) a pyrimidine or purine nucleoside analog group consisting of an anthracycline and a pyrimidine or selected from the group consisting of cytarabine, gemcitab purine nucleoside analog in an amount effective to ameliorate ine, trifluridine, ancitabine, enocitabine, azacitidine, doxiflu the symptoms of said acute myelogenous leukemia or said ridine, pentostatin, broXuridine, capecitabine, cladribine, myelodysplastic syndrome. The acute leukemia being treated decitabine, floXuridine, fludarabine, gougerotin, puromycin, is preferably AML. tegafur, tiazofurin, and tubercidin. In a preferred embodiment, the cytotoxin in the anti-CD33 The present invention further provides a pharmaceutical cytotoxic conjugate is selected from the group consisting of a combination for enhanced induction of remission in a patient calicheamicin and an esperamicin. having acute leukemia or MDS comprising gemtuzumab ozo In another preferred embodiment, the anthracycline is gamicin in an amount of about 3 mg/m to about 9 mg/m per selected from the group consisting of doxorubicin, daunoru 25 day, preferably 6 mg/m per day, daunorubicin, preferably bicin, idarubicin, aclarubicin, Zorubicin, mitoxantrone, epi daunorubicin hydrochloride, in an amount of about 45 mg/m rubicin, carubicin, nogalamycin, menogaril, pitarubicin, and to about 60 mg/m per day, preferably 45 mg/m per day, and valrubicin. cytarabine in an amount of about 100 mg/m to about 200 In another preferred embodiment, the pyrimidine or purine mg/m per day, preferably 100 mg/m per day. nucleoside analog is selected from the group consisting of 30 The present invention further provides a method of treating cytarabine, gemcitabine, trifluridine, ancitabine, enocitabine, acute leukemia or MDS comprising: azacitidine, doxifluridine, pentostatin, broXuridine, capecit (a) administering a first course of therapy to a patient in abine, cladribine, decitabine, floXuridine, fludarabine, goug need of treatment comprising (i) administering an anti-CD33 erotin, puromycin, tegafur, tiazofurin, and tubercidin. cytotoxic conjugate for one day, wherein the cytotoxin in the The present invention further provides a method of treat 35 anti-CD33 cytotoxic conjugate is selected from the group ment of a patient having acute leukemia or MDS, comprising consisting of a calicheamicin and an esperamicin; (ii) admin administering to the patient: (a) gemtuzumab ozogamicin in istering an anthracycline selected from the group consisting an amount of about 3 mg/m to about 9 mg/m per day; (b) of doxorubicin, daunorubicin, idarubicin, aclarubicin, Zoru daunorubicin, preferably daunorubicin hydrochloride, in an bicin, mitoxantrone, epirubicin, carubicin, nogalamycin, amount of about 45 mg/m to about 60 mg/m per day; and (c) 40 menogaril, pitarubicin, and valrubicin for up to three days; cytarabine in an amount of about 100 mg/m to about 200 and (iii) administering a pyrimidine or purine nucleoside mg/m per day. analog selected from the group consisting of cytarabine, gem In a preferred embodiment, the gemtuzumab ozogamicinis citabine, trifluridine, ancitabine, enocitabine, azacitidine, in an amount of about 6 mg/m per day. doxifluridine, pentostatin, broXuridine, capecitabine, cladrib In another preferred embodiment, the daunorubicin, pref 45 ine, decitabine, floXuridine, fludarabine, gougerotin, puromy erably daunorubicin hydrochloride, is in an amount of 45 cin, tegafur, tiazofurin, and tubercidin for up to ten days; mg/m per day. (b) administering a second course of therapy to a patient in In another preferred embodiment, the cytarabine is in an need of treatment comprising: (i) administering an anti-CD33 amount of 100 mg/m per day. cytotoxic conjugate for one day, wherein the cytotoxin in the The present invention further provides a method of treating 50 anti-CD33 cytotoxic conjugate is selected from the group acute leukemia or MDS syndrome comprising administering consisting of a calicheamicin and an esperamicin; (ii) admin to a patient in need of treatment thereof: (a) gemtuzumab istering an anthracycline selected from the group consisting ozogamicinin an amount of about 3 mg/m to 9 mg/m for one of doxorubicin, daunorubicin, idarubicin, aclarubicin, Zoru day; (b) daunorubicin in an amount of about 45 mg/m to 60 bicin, mitoxantrone, epirubicin, carubicin, nogalamycin, mg/m per day for three days; and (c) cytarabine in an amount 55 menogaril, pitarubicin, and valrubicin for up to three days; of about 100 mg/m to 200 mg/m per day for at least seven and (iii) administering a pyrimidine or purine nucleoside days. analog selected from the group consisting of cytarabine, gem In a preferred embodiment, the daunorubicin is adminis citabine, trifluridine, ancitabine, enocitabine, azacitidine, tered on the first three days that cytarabine is administered, doxifluridine, pentostatin, broXuridine, capecitabine, cladrib preferably in an amount of 45 mg/m per day. 60 ine, decitabine, floXuridine, fludarabine, gougerotin, puromy In another preferred embodiment, the cytarabine is admin cin, tegafur, tiazofurin, and tubercidin for up to ten days; and istered for ten days, more preferably for seven days, and (c) administering a third course of therapy to a patient in preferably in an amount of 100 mg/m per day. need of treatment comprising: (i) administering an anthracy In another preferred embodiment, the gemtuzumab ozo cline selected from the group consisting of doxorubicin, gamicin is administered to the patient on the fourth day that 65 daunorubicin, idarubicin, aclarubicin, Zorubicin, mitox cytarabine is administered to the patient, preferably in an antrone, epirubicin, carubicin, nogalamycin, menogaril, pita amount of 6 mg/m. rubicin, and valrubicin for up to three days; and (ii) adminis US 7,727,968 B2 10 tering a pyrimidine or purine nucleoside analog selected from antibody is linked to the calicheamicin or esperamicin. When the group consisting of cytarabine, gemcitabine, trifluridine, N-acetyl-gamma calicheamicin is used, it is preferred to link ancitabine, enocitabine, azacitidine, doxifluridine, pentosta the antibody by a bifunctional linker. Such conjugates and tin, broXuridine, capecitabine, cladribine, decitabine, floXu methods for making them are described in U.S. Pat. Nos. ridine, fludarabine, gougerotin, puromycin, tegafur, tiaZoflu 5,733,001; 5,739,116; 5,767.285; 5,877,296; 5,606,040: rin, and tubercidin for up to ten days. 5,712.374; and 5,714,586, which are incorporated by refer The present invention further provides a method of treating ence herein in their entirety. acute leukemia or MDS comprising: A preferred form of the anti-CD33 cytotoxic conjugate for (a) administering a first course of therapy to a patient in use in the present invention is gemtuzumab ozogamicin, a need of treatment comprising (i) gemtuzumab ozogamicin in 10 chemotherapy agent composed of a recombinant humanized an amount of about 3 mg/m to about 9 mg/m, preferably 6 IgG4, kappa antibody conjugated with calicheamicin. Gem mg/m, per day for one day; (ii) daunorubicin in an amount of tuZumab ozogamicin is available commercially as Mylo about 45 mg/m to about 60 mg/m, preferably 45 mg/m, per targr) (Wyeth Pharmaceuticals, Philadelphia, Pa.). The anti day for up to three days; and (iii) cytarabine in an amount of body portion of gemtuzumab ozogamicin binds specifically about 100 mg/m to about 200 mg/m, preferably 100 mg/m. 15 to the CD33 antigen. Gemtuzumab ozogamicin contains per day for up to ten days; amino acid sequences of which approximately 98.3% are of (b) administering a second course of therapy to a patient in human origin. The constant region and framework regions need of treatment comprising: (i) gemtuzumab ozogamicin in contain human sequences while the complementarity-deter an amount of about 3 mg/m to about 9 mg/m, preferably 6 mining regions are derived from a murine antibody (p67.6) mg/m, per day for one day; (ii) daunorubicin in an amount of that binds CD33. This antibody is linked to N-acetyl-gamma about 45 mg/m to about 60 mg/m, preferably 45 mg/m, per calicheamicin via a bifunctional linker. Gemtuzumab ozo day for up to three days; and (iii) cytarabine in an amount of gamicin has approximately 50% of the antibody loaded with about 100 mg/m to about 200 mg/m, preferably 100 mg/m. 4-6 moles calicheamicin per mole of antibody. The remaining per day for up to ten days; and 50% of the antibody is not linked to the calicheamicin deriva (c) administering a third course of therapy to a patient in 25 tive. Gemtuzumab ozogamicin has a molecular weight of 151 need of treatment comprising: (i) daunorubicin in an amount to 153 kDa. Gemtuzumab ozogamicin and methods for mak of about 45 mg/m to about 60 mg/m, preferably 45 mg/m. ing it are described in U.S. Pat. Nos. 5,733,001; 5,739,116; per day for up to three days; and (ii) cytarabine in an amount 5,767,285; 5,877,296; 5,606,040; 5,712,374; and 5,714,586, of about 100 mg/m to about 200 mg/m, preferably 100 which are incorporated by reference herein in their entirety. mg/m, per day for up to ten days. 30 When given as a single agent therapy for the treatment of AML, the recommended dose of gemtuzumab ozogamicin is DETAILED DESCRIPTION OF THE INVENTION 9 mg/m, administered as a two-hour intravenous infusion. The recommended treatment course with gemtuzumab ozo This invention provides advantageous pharmaceutical gamicinalone has been a total of two doses with fourteen days combinations and methods of treatment for acute leukemia, 35 between the doses. In the combination therapy of the present such as AML, and for myelodysplastic syndrome (MDS) invention, gemtuzumab ozogamicin is given in an amount which employ an anti-CD33 cytotoxic conjugate, an anthra ranging from about 3 mg/m to 9 mg/m per day. cycline, and a pyrimidine or purine nucleoside analog. The U.S. Pat. No. 5,773,001, in col. 62, lines 37-46, and method of treatments and pharmaceutical combinations Example 112, describes dosage amounts of calicheamicin described herein provide a better rate of complete remission 40 conjugates, including gemtuzumab ozogamicin, based on and improved quality of life in Such patients than the standard calicheamicin equivalents, i.e., 10 ug calicheamicin/m pro 3+7 regimen of daunorubicin and cytarabine. Surprisingly, a tein, as compared to the clinical dose description based on preferred embodiment employing gemtuzumab ozogamicin, mg/m body-surface. When calicheamicin is loaded onto the daunorubicin, and cytarabine provides a higher rate of com antibody, there is approximately 27 Jug calicheamicin/mg pro plete remission than the standard 3+7 regimen of daunorubi 45 tein. A9 mg/m dose of gemtuzumab ozogamicin is equiva cin and cytarabine. lent to 243 Lig calicheamicin/m protein. A 6 mg/m dose of The patients to be treated with the methods of treatment gemtuzumab ozogamicin is equivalent to 162 ug calicheami and pharmaceutical combinations provided herein are those cin/m protein. A 3 mg/m dose of gemtuzumab ozogamicin who have been untreated for acute leukemia such as AML and is equivalent to 81 ug calicheamicin/m protein. are being treated de novo, those who are being treated with 50 Another composition used in the present invention is an induction therapy, those who are being treated with consoli anthracycline, an anticancer agent consisting of 3 moieties: a dation therapy, those who are being treated after one or more pigmented aglycone, an amino Sugar, and a lateral chain. relapses, and those who have MDS. Anthracyclines include doxorubicin, daunorubicin, idarubi One composition used in the present invention is an anti cin, aclarubicin, Zorubicin, mitoxantrone, epirubicin, carubi CD33 cytotoxic conjugate in which an anti-CD33 antibody is 55 cin, nogalamycin, menogaril, pitarubicin, and valrubicin. See conjugated with a cytotoxic antitumor or antibiotic, such as a Merck Index (13' ed. 2001). calicheamicin isolated from fermentation of a bacterium, A preferred anthracycline for use in the present invention is Micromonospora echinospora ssp. calichensis, or an espe daunorubicin. Daunorubicin, also known as daunomycin, is ramicin. Calicheamicins are described in U.S. Pat. Nos. an anthracycline cytotoxic antibiotic of the rhodomycin 4,970, 198; 5,037,651; and 5,079,233. Esperamicins are 60 group obtained from Streptomyces peucetius, which is used in described in U.S. Pat. Nos. 4,675, 187; 4,539.203; 4,554,162: the treatment of acute leukemia. Stedman's Medical Dictio and 4,837.206. The antibody portion of the conjugate binds nary (27" ed. 2002). Daunorubicin has a 4-ring anthracycline specifically to the CD33 antigen, a sialic acid-dependent moiety linked by a glycosidic bond to daunosamine, an amino adhesion protein found on the surface of leukemic blasts and Sugar. Daunorubicin may also be isolated from Streptomyces immature normal cells of myelomonocytic lineage, but not on 65 coeruleorubidus and has the following chemical name: (8S normal hematopoietic stem cells, and acts as a targeting unit cis)-8-acetyl-10-(3-amino-2,3,6-trideoxy-(alpha)-L-lyxo to deliver the cytotoxic agent to these targeted cells. This hexopyranosyl)oxy-7,8,9,10-tetrahydro-6,8,11-trihydroxy US 7,727,968 B2 11 12 1-methoxy-5,12-naphthacenedione hydrochloride. cytarabine is given in doses of up to 3 g/m by intravenous Daunorubicin is usually given as the hydrochloride, but doses infusion for every 12 hours for up to six days. are expressed in terms of the base. Cytarabine is also available commercially in a cytarabine A preferred form of daunorubicin used in the present liposome injection as DEPOCYTR (Chiron Corporation, invention is daunorubicin hydrochloride, the hydrochloride Emeryville, Calif.). DepoCytR) is a sterile, injectable suspen salt of daunorubicin. Daunorubicin hydrochloride is available sion of the antimetabolite cytarabine, encapsulated into mul commercially as Cerubidine(R) (Bedford Laboratories, Bed tivesicular lipid-based particles. Each vial contains 50 mg of ford Ohio). It may be described with the chemical name of (1 cytarabine. Cytarabine, the active ingredient, is present at a S.3 S)-3-Acetyl-1,2,3,4,6,11-hexahydro-3,5,12-trihydroxy concentration of 10 mg/ml and is encapsulated in the par 10-methoxy-6,11-dioxo-1-naphthacenyl 3-amino-2,3,6- 10 ticles. Inactive ingredients at their respective approximate trideoxy-(alpha)-L-lyxo-hexopyranoside hydrochloride. Its concentrations are cholesterol. 4.1 mg/ml, triolein, 1.2 molecular formula is C7H9NO.HCl with a molecular mg/ml; dioleoylphosphatidylcholine (DOPC), 5.7 mg/ml; weight of 563.99. In the treatment of adult acute nonlympho and dipalmitoylphosphatidylglycerol (DPPG), 1.0 mg/ml. cytic leukemia, Such as AML and ALL, daunorubicin hydro The pH of the product falls within the range from 5.5 to 8.5. chloride, used as a single agent, has produced complete 15 DepoCytR is administered intrathecally. remission rates of 40 to 50%, and in combination with cyt The present invention provides several methods for treat arabine, has produced complete remission rates of 53 to 65%. ing acute leukemia or MDS. In one method, a patient is given Physician's Desk Reference (56" ed. 2002). Typically, dauno an anti-CD33 cytotoxic conjugate in combination with at rubicin is given daily for three days in an amount of 30 to 45 least one compound selected from the group consisting of an mg/m by intravenous infusion for two to three days. In high anthracycline and a pyrimidine or purine nucleoside analog in dose regimens, daunorubicin is given daily in an amount of 50 an amount effective to ameliorate the symptoms of the acute mg/m for three days. leukemia, such as AML, or MDS. Preferably, the cytotoxin in Daunorubicin is also available commercially in a dauno the anti-CD33 cytotoxic conjugate is a calicheamicin or an rubicin citrate liposome injection as DaunoXomeR (Gilead esperamicin. The anthracycline is preferably selected from Sciences, Inc., Foster City, Calif.). DaunoXome(R) contains an 25 the group consisting of doxorubicin, daunorubicin, idarubi aqueous Solution of the citrate salt of daunorubicin encapsu cin, aclarubicin, Zorubicin, mitoxantrone, epirubicin, carubi lated within lipid vesicles (liposomes) composed of a lipid cin, nogalamycin, menogaril, pitarubicin, and valrubicin. The bilayer of distearoylphosphatidylcholine and cholesterol (2:1 pyrimidine or purine nucleoside analog is preferably selected molar ratio), with a mean diameter of about 45 nm. The lipid from the group consisting of cytarabine, gemcitabine, triflu to drug weight ratio is 18.7: 1 (total lipid:daunorubicin base), 30 ridine, ancitabine, enocitabine, azacitidine, doxifluridine, equivalent to a 10:5:1 molar ratio of distearoylphosphatidyl pentostatin, broXuridine, capecitabine, cladribine, decitab choline:cholesterol:daunorubicin. Each vial of DaunoX ine, floxuridine, fludarabine, gougerotin, puromycin, tegafur, omeR contains daunorubicin citrate equivalent to 50 mg of tiazofurin, and tubercid. Most preferred is that the cytotoxin daunorubicin base, encapsulated in liposomes consisting of in the anti-CD33 conjugate is a calicheamicin, the anthracy 704 mg distearoylphosphatidylcholine and 168 mg choles 35 cline is daunorubicin or daunorubicin hydrochloride, and the terol. The liposomes encapsulating daunorubicin are dis pyrimidine nucleoside analog is cytarabine. persed in an aqueous medium containing 2,125 mg Sucrose, In another method of treatment, a patient having acute 94 mg glycine, and 7 mg calcium chloride dihydrate in a total leukemia or MDS is given gemtuzumab ozogamicin in an volume of 25 ml/vial. The pH of the dispersion is between 4.9 amount of about 3 mg/m to about 9 mg/m per day; dauno and 6.0. DaunoXomeR) is administered intravenously over a 40 rubicin, preferably daunorubicin hydrochloride, in an amount 60 minute period at a dose of 40 mg/m, with doses repeated of about 45 mg/m to about 60 mg/m per day; and cytarabine every two weeks. in an amount of about 100 mg/m to about 200 mg/m per day. A third composition used in the present invention is a Preferably, the gemtuzumab ozogamicin is given in an pyrimidine nucleoside analog or a purine nucleoside analog. amount of about 6 mg/m per day. The daunorubicin, prefer Representative of Such nucleoside analogs are cytarabine, 45 ably daunorubicin hydrochloride, is preferably given in an gemcitabine, trifluridine, ancitabine, enocitabine, azaciti amount of 45 mg/m per day. The cytarabine is preferably dine, doxifluridine, pentostatin, broXuridine, capecitabine, given in an amount of 100 mg/m per day. cladribine, decitabine, floXuridine, fludarabine, gougerotin, In another method of treatment, a patient having acute puromycin, tegafur, tiazofurin, and tubercidin. See Merck leukemia or MDS is given gemtuzumab ozogamicin in an Index (13' ed. 2001). 50 amount of about 3 mg/m to 9 mg/m for one day; daunoru A preferred pyrimidine nucleoside analog used in the bicininanamount of about 45 mg/m to 60 mg/m per day for present invention is cytarabine, which is also known as ara three days; and cytarabine in an amount of about 100 mg/m binosylcytosine (aC, araC), arabinocytidine, or arabinofura to 200 mg/m per day for at least seven days. Preferably, the nosylcytosine. Chemically, cytarabine is 4-amino-1-(beta)- daunorubicin is administered on the first three days that cyt D-arabinofuranosyl-2(1H)-pyrimidinone, also known as 55 arabine is administered, and is preferably given in an amount cytosine arabinoside (CHNOs, molecular weight of 45 mg/m per day. The cytarabine is preferably adminis 243.22). Cytarabine is a cell cycle phase-specificantineoplas tered for ten days, more preferably for seven days, and is tic agent, affecting cells only during the S-phase of cell divi preferably given in an amount of 100 mg/m per day. The Sion. It is a compound of arabinose and cytosine that inhibits gemtuzumab ozogamicin is preferably administered to the the biosynthesis of DNA and is used as a chemotherapeutic 60 patient on the fourthday that cytarabine is administered to the agent because of its antiviral and tumor-growth-inhibiting patient, and is preferably given in an amount of 6 mg/m. In a properties. Typically, cytarabine is given in an amount of preferred embodiment, the cytarabine is administered by con 100-200 mg/m daily for five to ten days by constant intrave tinuous infusion, the daunorubicin, preferably daunorubicin nous infusion, usually for seven days. Cytarabine can be hydrochloride, is administered by intravenous bolus, and the given in an amount of 100 mg/m body-surface twice daily by 65 gemtuzumab ozogamicin is administered by 2-hour infusion. rapid intravenous injection. However, cytarabine can be given Pharmaceutical combinations for enhanced induction of in amounts of up to 3 g/m daily. In high-dose regimens, remission in a patient having acute leukemia or MDS are also US 7,727,968 B2 13 14 provided by the present invention. One Such pharmaceutical pyrimidine or purine nucleoside analog selected from the combination for enhanced induction of remission in a patient group consisting of cytarabine, gemcitabine, trifluridine, having acute leukemia or MDS comprises an anti-CD33 cyto ancitabine, enocitabine, azacitidine, doxifluridine, pentosta toxic conjugate, an anthracycline, and a pyrimidine or purine tin, broXuridine, capecitabine, cladribine, decitabine, floXu nucleoside analog. The cytotoxin in the anti-CD33 cytotoxic 5 ridine, fludarabine, gougerotin, puromycin, tegafur, tiaZoflu conjugate may be selected from the group consisting of a rin, and tubercidin for up to ten days. calicheamicin and an esperamicin. The anthracycline may be In another such method of treatment of acute leukemia or selected from the group consisting of doxorubicin, daunoru MDS, a patient is given a first course of therapy comprising bicin, idarubicin, aclarubicin, Zorubicin, mitoxantrone, epi gemtuzumab ozogamicin in an amount of about 3 mg/m to rubicin, carubicin, nogalamycin, menogaril, pitarubicin, and 10 about 9 mg/m, preferably 6 mg/m, per day for one day; valrubicin. The pyrimidine or purine nucleoside analog may daunorubicin in an amount of about 45 mg/m to about 60 be selected from the group consisting of cytarabine, gemcit mg/m, preferably 45 mg/m, per day for up to three days; and abine, trifluridine, ancitabine, enocitabine, azacitidine, doxi cytarabine in an amount of about 100 mg/m to about 200 fluridine, pentostatin, broXuridine, capecitabine, cladribine, mg/m, preferably 100 mg/m, per day for up to ten days. A decitabine, floXuridine, fludarabine, gougerotin, puromycin, 15 second course of therapy is given to the patient comprising tegafur, tiazofurin, and tubercidin. gemtuzumab ozogamicin in an amount of about 3 mg/m to Another pharmaceutical combination comprises gemtu about 9 mg/m, preferably 6 mg/m, per day for one day; Zumab ozogamicin in an amount of about 3 mg/m to about 9 daunorubicin in an amount of about 45 mg/m to about 60 mg/m per day, preferably 6 mg/m per day, daunorubicin, mg/m, preferably 45 mg/m, per day for up to three days; and preferably daunorubicin hydrochloride, in an amount of cytarabine in an amount of about 100 mg/m to about 200 about 45 mg/m to about 60 mg/m per day, preferably 45 mg/m, preferably 100 mg/m, per day for up to ten days. A mg/m per day, and cytarabine in an amount of about 100 third course of therapy may be administered to the patient mg/m to about 200 mg/m per day, preferably 100 mg/m per comprising daunorubicin in an amount of about 45 mg/m to day. about 60 mg/m, preferably 45 mg/m, per day for up to three The nature of acute leukemias and myelodysplastic syn 25 days, and cytarabine in an amount of about 100 mg/m to drome calls for the administration of intensive chemotherapy about 200 mg/m, preferably 100 mg/m, per day for up to ten to induce remission in patients having these diseases. In one days. embodiment of the present invention, a single course of com The Surprising and unexpected result disclosed herein is bination therapy comprises administering to the patient a the ability of the anti-CD33 cytotoxic conjugate, the anthra therapeutically effective amount of an anti-CD33 cytotoxic 30 cycline, and the pyrimidine or purine nucleoside analog to act conjugate, together with one or more chemotherapeutic synergistically in the treatment of various symptoms associ agents, such as anthracycline, and a pyrimidine or purine ated with acute leukemia or MDS. Synergistically” is used nucleoside analog. The present invention also provides treat herein to refer to a situation where the benefit conveyed by the ment regimens in which multiple courses of combination administration of these antineoplastic compositions in com therapy, which include an anti-CD33 cytotoxic conjugate and 35 bination is greater than the algebraic sum of the effects result other chemotherapeutic agents, are administered. Such treat ing from the separate administration of the components of the ment regimens may be administered from at least two to five combination. As shown in the Examples below, the combina courses of treatment, depending upon the drugs being admin tion treatment of an anti-CD33 cytotoxic conjugate, an istered, the severity of the disease, and the condition of the anthracycline, and an pyrimidine or purine nucleoside analog patient. 40 is synergistic with respect to treating acute leukemia and In another method of treatment of the present invention, a increasing the efficacy as measured by complete remission. patient having acute leukemia or MDS is given three courses This combined treatment has the advantage of achieving the of therapy. In the first course of therapy, the patient is given an same result with a lower dose of the anti-CD33 cytotoxic anti-CD33 cytotoxic conjugate for one day; an anthracycline conjugate, thereby reducing any toxic effect from the conju for up to three days; and a pyrimidine or purine nucleoside 45 gate, providing an improved quality of life, and increasing the analog for up to ten days. The cytotoxin in the anti-CD33 chances for survival of the patient. cytotoxic conjugate may be selected from the group consist As with the use of other chemotherapeutic drugs, the indi ing of a calicheamicin and an esperamicin. The anthracycline vidual patient will be monitored in a manner deemed appro may be selected from the group consisting of doxorubicin, priate by the treating physician. The combination therapy daunorubicin, idarubicin, aclarubicin, Zorubicin, mitox 50 agents described herein may be administered with immuno antrone, epirubicin, carubicin, nogalamycin, menogaril, pita Suppressive agents, potentiators and side-effect relieving rubicin, and valrubicin. The pyrimidine or purine nucleoside agents as deemed necessary by the treating physician. analog may be selected from the group consisting of cytara In therapeutic applications, the dosages of the agents used bine, gemcitabine, trifluridine, ancitabine, enocitabine, aza in accordance with the invention may vary depending on the citidine, doxifluridine, pentostatin, broXuridine, capecitab 55 agent, the age, weight, and clinical condition of the recipient ine, cladribine, decitabine, floxuridine, fludarabine, patient, and the experience and judgment of the clinician or gougerotin, puromycin, tegafur, tiazofurin, and tubercidin. practitioner administering the therapy, among other factors The first course of therapy is repeated as a second course of affecting the selected dosage. Generally, the dose should be therapy in which the patient is given an anti-CD33 cytotoxic Sufficient to result in complete remission as previously conjugate for one day, an anthracycline for up to three days, 60 defined. An effective amount of a pharmaceutical agent is that and a pyrimidine or purine nucleoside analog for up to ten which provides an objectively identifiable improvement as days. A third course of therapy may be given to the patient noted by the clinician or other qualified observer. It is espe which comprises the administration to the patient of an cially advantageous to formulate compositions of these anti anthracycline selected from the group consisting of doxoru neoplastic compounds in dosage unit form for ease of admin bicin, daunorubicin, idarubicin, aclarubicin, Zorubicin, 65 istration and uniformity of dosage. "Dosage unit form as mitoxantrone, epirubicin, carubicin, nogalamycin, menog used herein refers to physically discrete units Suited as unitary aril, pitarubicin, and valrubicin for up to three days, and a dosages for the patients to be treated, each unit containing a US 7,727,968 B2 15 16 predetermined quantity of anti-neoplastic compounds calcu capsules, elixers, Suspensions, syrups, wafers and the like, or lated to produce the desired therapeutic effect in association it may be incorporated directly with the food in the diet. The with the required pharmaceutical carrier. As used herein, tablets, troches, pills, capsules and the like may also contain “pharmaceutically acceptable carrier includes any and all the following: a binder Such as gum tragacanth, acacia, corn Solvents, dispersion media, coating, antibacterial and antifun starch or gelatin; excipients such as dicalcium phosphate; a gal agents, isotonic and absorption delaying agents and the disintegrating agent Such as corn starch, alginic acid and the like which are compatible with the active ingredient and with like; a lubricant such as magnesium Stearate; a Sweetening the mode of administration and other ingredients of the for agent such as Sucrose, lactose or saccharin; or a flavoring mulation and not deleterious to the recipient. agent Such as peppermint, oil of wintergreen or cherry or The pharmaceutical compositions of this invention which 10 orange flavoring. When the dosage unit form is a capsule, it are found in the combination may also include, depending on may contain, in addition to material of the type described the formulation desired, pharmaceutically-acceptable, non herein, a liquid carrier. Various other materials may be present toxic carriers or diluents, which are defined as vehicles com as a coating or to otherwise modify the physical form of the monly used to formulate pharmaceutical compositions for dosage unit. For instance, tablets, pills or capsules may be animal or human administration. The diluent is selected so as 15 coated with shellac, Sugar or both. Of course, any material not to affect the biological activity of the combination. used in preparing any dosage unit form should be pharma Examples of Such diluents are distilled water, physiological ceutically pure and Substantially non-toxic in the amounts saline, Ringer's Solution, dextrose solution, and Hank’s Solu employed. In addition, the antineoplastic compound may be tion. In addition, the pharmaceutical composition or formu incorporated into a Sustained-release preparation and formu lation may also include other carriers, adjuvants, or nontoxic, lation. The amount of the antineoplastic compound in Such nontherapeutic, nonimmunogenic stabilizers and the like. therapeutically useful composition is such that a Suitable Effective amounts of such diluent or carrier will be those dosage will be obtained. amounts which are effective to obtain a pharmaceutically It is understood that the foregoing detailed description and acceptable formulation in terms of solubility of components, the following examples are illustrative only and are not to be or biological activity, and the like. 25 taken as limitations upon the scope of the invention. Various For parenteral therapeutic administration, each antine changes and modifications to the disclosed embodiments, oplastic compound may be incorporated with a sterile inject which will be apparent to those skilled in the art, may be made able solution. The sterile injectable solution may be prepared without departing from the spirit and scope of the present by incorporating the antineoplastic compound in the required invention. Further, all patents, patent applications, and pub amount in an appropriate pharmaceutically acceptable car 30 lications cited herein are incorporated herein by reference. rier, with various other ingredients, followed by filtered ster ilization. In the case of dispersions, each may be prepared by EXAMPLES incorporating the additional antineoplastic compound into a sterile vehicle which contains the basic dispersion medium Example 1 and the required other ingredients from those enumerated 35 herein. In the case of sterile injectable Solutions, each may be To assess the safety and efficacy of gemtuzumab ozogami prepared by incorporating a powder of the additional antine cin as part of a combination therapy for AML, a phase /2 oplastic compound and, optionally, any additional desired study was developed in the United States of America to com ingredient from a previously sterile-filtered solution thereof, bine gemtuzumab ozogamicin with cytarabine and daunoru wherein the powder is prepared by any suitable technique 40 bicin. Patients with relapsed, refractory, or de novo AML (e.g., vacuum drying and freeze drying). The use of Such were enrolled in phase 1 from October 2000 through Novem media and agents is well known in the art (see for example, ber 2001. The maximum tolerated dose was determined to be Remington's Pharmaceutical Sciences, 18th Ed. (1990), cytarabine 100 mg/m/day by continuous infusion on days 1 Mack Publishing Co., Easton, Pa. 18042, pages 1435-1712, through 7, daunorubicin 45 mg/m by intravenous bolus on the disclosure of which is hereby incorporated by reference). 45 days 1 through 3, and gemtuzumab ozogamicin 6 mg/m by Supplementary active ingredients can also be incorporated 2-hour infusion on day 4. The phase 2 portion of the study was into the compositions. The specific dose of the antineoplastic open to enrollment on November 2001 and 42 of the planned compound is calculated according to the approximate body 45 patients have been enrolled to date. weight or surface area of the patient. Other factors in deter A detailed safety and efficacy evaluation was performed on mining the appropriate dosage can include the stage of the 50 the first 19 patients treated with this combination induction acute myelogenous leukemia or myelodysplastic syndrome regimen and subsequently followed for at least 28 days. There (de novo or relapse), the severity of the disease, the route of were sixteen men and three women enrolled with a median administration and the age, sex and medical condition of the age of 46 years (range, 20 to 60). One, ten, and three patients patient. Further refinement of the calculations necessary to were categorized in favorable-, intermediate- and poor-risk determine the appropriate dosage for treatment involving 55 cytogenetic groups, respectively. Cytogenetic analysis was each of the herein-mentioned formulations is routinely made not available for five patients. Seventeen patients had baseline by those skilled in the art. Dosages can also be determined bone marrow leukemic blast cell determinations with a through the use of known assays for determining dosages median blast percentage of 60% Combination therapy was used in conjunction with appropriate dose-response data. well tolerated and all nineteen patients completed the planned Thus, for example, it is within the scope of the invention that 60 induction therapy. doses of the antineoplastic compounds used in the present Three patients (16%) reported NCI grade 3 fever/chills on invention for treating acute myelogenous leukemia or myelo the day of gemtuzumab ozogamicin infusion. The incidence dysplastic syndrome can be varied to achieve a desired thera of grade 3 AST/ALT elevation was 1.6%; no grade 3 or 4 peutic effect. hyperbilirubinemia was reported. There were no cases of If oral therapeutic administration is an option, the antine 65 hepatic veno-occlusive disease?sinusoidal obstruction syn oplastic compound may be incorporated with excipients and drome. The incidence of grade 3 or 4 infections was 32%. The used in the form of ingestible tablets, buccal tablets, troches, early treatment mortality rate was 0%. Four patients required US 7,727,968 B2 17 18 re-induction for residual AML with cytarabine and daunoru remission with course 1. Hematological recovery was not bicin on approximately day 15. One of these patients was prolonged, but3 patients developed Grade 3 or 4 liver toxicity taken off study and given re-induction with a high-dose cyt of whom 2 developed a VOD-like syndrome from which both arabine (HDAC)-containing regimen on study day 15 and was recovered. A 6 mg/m dose of gemtuzumab ozogamicin was not evaluable for efficacy. not considered feasible. Fifteen of 18 patients (83%) achieved a complete remission Fifteen patients received gemtuzumab ozogamicin in a (CR) characterized by the absence of AML blasts from the dose of 3 mg/m with courses 1 and 2 (DAT 3+10 and DAT peripheral blood, no extramedullary AML, s5% marrow 3+8). ANC recovery was delayed in 5 patients and platelet blasts in a marrow with >20% cellularity, and recovery of recovery in 11, and both in 5 patients. Grade 3 or 4 liver peripheral counts to absolute neutrophil count (ANC)21500/ 10 toxicity was seen in 3 cases of whom 2 developed a VOD-like uL and platelets to 2100,000/uL. No patients were reported syndrome. to have complete remission with incomplete platelet recovery Seventeen patients received gemtuzumab ozogamicin in a (CRp). Of the three non-remission patients, 2 had progressive dose of 3 mg/m with chemotherapy in course 3 with MACE disease and 1 achieved a marrow remission but required (MACE: Amsacarine, AraC, Etoposide, or high dose AraC). radiation therapy for a residual chloroma. Among CR 15 Only one patient developed greater than Grade 2 liver toxic patients, the median time to recover ANC to 21500/uL was ity. Twelve patients received induction in course 1 with gem 38 days and platelets to 2100,000/uL was 30 days. Patients tuzumab ozogamicin in a dose of 3 mg/m and course 3 with have been followed for too short a time to determine duration gemtuzumab ozogamicin in a dose of 3 mg/m. This appears of remission (median follow-up 193 days). to be feasible but further study of this regimen is ongoing. The combination of cytarabine 100 mg/m/day, daunoru The overall Survival of all patients receiving gemtuzumab bicin 45 mg/m, and gemtuzumab ozogamicin 6 mg/m was ozogamicin in a dose of 3 mg/m with course 1 at 6 months is well tolerated with low hepatotoxicity and resulted in an 73% and at 12 months is 68%. For the patient receiving increase in the CR rate to 83%. Historical control data from non-Thioguanine induction with 3 mg/m of gemtuzumab the Southwest Oncology Group (SWOG) shows a 60% CR ozogamicin, the 6 month survival is 91%. rate with standard therapy of 100 mg/m/day of cytarabine for 25 What is claimed is: seven days and 45 mg/m of daunorubicin for three days. The 1. A method of treating acute leukemia or myelodysplastic combination of cytarabine 100 mg/m/day, daunorubicin 45 syndrome consisting essentially of administering to a patient mg/m, and gemtuzumab ozogamicin 6 mg/m resulted in a in need of treatment thereof: (a) gemtuzumab ozogamicin in markedly improved rate of CR compared to standard therapy. an amount of about 3 mg/m to about 9 mg/m per day; (b) 30 daunorubicin in an amount of about 45 mg/m to about 60 Example 2 mg/m per day; and (c) cytarabine in an amount of about 100 The feasibility of combining gemtuzumab ozogamicin mg/m to about 200 mg/m per day. 2. The method according to claim 1, wherein the amount of with intensive chemotherapy for induction and/or consolida gemtuzumab ozogamicin is 6 mg/m per day. tion was evaluated in 67 patients in a safety study in the 35 United Kingdom prior to the start of the Medical Research 3. The method according to claim 1, wherein the daunoru Center AML 15 trial. The aim was to combine gemtuzumab bicin is daunorubicin hydrochloride. oZogamicin with chemotherapy planned in the trial, (DAT; 4. The method according to claim 1 or 3, wherein the Daunorubicin, AraC. Thioguanine, or DA; Daunorubicin amount of daunorubicin is 45 mg/m per day. AraC; or FLAG-IDA. Fludarabine, AraC, G-CSF, Idarubicin) 40 5. The method according to claim 1, wherein the amount of as course 1. Course 1 was given using gemtuzumab ozogami cytarabine is 100 mg/m per day. cin in an amount of 3 mg/m on day 1 of chemotherapy in 55 6. A method of treating acute leukemia or myelodysplastic patients. Thirty-three patients received gemtuzumab ozo syndrome consisting essentially of administering to a patient gamicin with DAT. Eight patients received gemtuzumab ozo in need of treatment thereof: (a) gemtuzumab ozogamicin in gamicin with DA. Fourteen patients received gemtuzumab 45 an amount of about 3 mg/m to 9 mg/m for one day; (b) ozogamicin with FLAG-Ida. Of the 55 patients treated, 41 daunorubicin in an amount of about 45 mg/m to 60 mg/m (85%) entered complete remission with course 1 broken per day for three days; and (c) cytarabine in an amount of down as follows: (19) DAT=26/32; (2) DA-7/8; and (3) about 100 mg/m to 200 mg/m per day for at least seven days. FLAG-Ida=8/8. Prior experience in a separate trial desig 7. The method according to claim 6, wherein the daunoru nated MRC AML12 where 720 patients were treated with 50 bicin is administered to the patient on the first three days that H-DAT alone in course 1, 64% of those patients achieved cytarabine is administered to the patient. complete remission. In the present study, the median time to 8. The method according to claim 6 or 7, wherein the ANC recovery (1x10/1) was 27 days (range 9-54) and plate gemtuzumab ozogamicin is administered to the patient on the lets >100x10/1 was 30 (range 21-48) which is within the fourth day that cytarabine is administered to the patient. mean+ISD of the 720 patients treated with H-DAT alone in 55 9. The method according to claim 6, wherein the cytarabine the MRC AML 12 trial. Non-hemopoietic toxicity was con is administered for ten days. fined to the liver. Overall the maximum toxicity was Grade 10. The method according to claim 8, wherein the cytara 1 =5 patients, Grade 2–22 patients, Grade 3=13 patients and bine is administered by continuous infusion, the daunorubi Grade 4=10 patients. Of the Grade 3 and 4 toxicities, 7 were cin is administered by intravenous bolus, and the gemtu felt to be definitely associated with gemtuzumab ozogamicin 60 Zumab ozogamicin is administered by 2-hour infusion. therapy. A possible contributory factor was the inclusion of 11. The method according to claim 8, wherein the cytara Thioguanine. Of the 39 recipients where Thioguanine was bine is administered in an amount of 100 mg/m/day, the included in the schedules, 22 developed Grade 3 or 4 liver daunorubicin is administered in an amount of 45 mg/m, and toxicity compared with 1 for 16 recipients of non-Thiogua the gemtuzumab ozogamicin is administered in an amount of nine Schedules. 65 6 mg/m. Nine additional patients received H-DAT with 6 mg/m 12. The method according to claim 6, wherein the dauno gemtuzumab ozogamicin and 8 patients achieved complete rubicin is daunorubicin hydrochloride. US 7,727,968 B2 19 20 13. A pharmaceutical combination for enhanced induction essentially of: (i) gemtuzumab ozogamicin in an amount of of remission in a patient having acute leukemia or myelodys about 3 mg/m to about 9 mg/m per day for one day; (ii) plastic syndrome consisting essentially of gemtuzumab ozo daunorubicin in an amount of about 45 mg/m to about 60 gamicin in an amount of about 3 mg/m to about 9 mg/m. mg/m per day for up to three days; and (iii) cytarabine in an daunorubicin in an amount of about 45 mg/m to about 60 amount of about 100 mg/m to about 200 mg/m per day for mg/m, and cytarabine in an amount of about 100 mg/m to up to ten days; and (c) administering a third course of therapy about 200 mg/m. to a patient in need of treatment consisting essentially of: (i) 14. The pharmaceutical combination of claim 13, wherein daunorubicin in an amount of about 45 mg/m to about 60 the daunorubicin is daunorubicin hydrochloride. mg/m per day for up to three days; and (ii) cytarabine in an 15. The pharmaceutical combination of claim 13 wherein 10 amount of about 100 mg/m to about 200 mg/m per day for the gemtuzumab ozogamicin is in an amount of about 6 up to ten days. mg/m. 20. A method of treating acute myelogenous leukemia or 16. The pharmaceutical combination of claim 13 or 14, myelodysplastic syndrome consisting essentially of: (a) wherein the daunorubicin is in an amount of about 45 mg/m. administering a first course of therapy to a patient in need of 17. The pharmaceutical combination of claim 13, wherein 15 treatment consisting essentially of: (i) gemtuzumab ozogami the cytarabine is in an amount of 100 mg/m. cin in an amount of 6 mg/m per day for one day; (ii) dauno 18. A pharmaceutical combination for enhanced induction rubicin in an amount of 45 mg/m per day for up to three days; of remission in a patient having acute leukemia or myelodys and (iii) cytarabine in an amount of 100 mg/m to about 200 plastic syndrome consisting essentially of gemtuzumab ozo mg/m per day for up to ten days; (b) administering a second gamicin in an amount of 6 mg/m, daunorubicin in an amount course of therapy to a patient in need of treatment consisting of 45 mg/m, and cytarabine in an amount of 100 mg/m. essentially of: (i) gemtuzumab ozogamicin in an amount of 6 19. A method of treating acute myelogenous leukemia or mg/m per day for one day; (ii) daunorubicin in an amount of myelodysplastic syndrome consisting essentially of: (a) 45 mg/m to per day for up to three days; and (iii) cytarabine administering a first course of therapy to a patient in need of in an amount of 100 mg/m per day for up to ten days; and (c) treatment consisting essentially of: (i) gemtuzumab ozogami 25 administering a third course of therapy to a patient in need of cin in an amount of about 3 mg/m to about 9 mg/m per day treatment consisting essentially of: (i) daunorubicin in an for one day; (ii) daunorubicin in an amount of about 45 mg/m amount of 45 mg/m per day for up to three days; and (ii) to about 60 mg/m per day for up to three days; and (iii) cytarabine in an amount of 100 mg/m per day for up to ten cytarabine in an amount of about 100 mg/m to about 200 days. mg/m per day for up to ten days; (b) administering a second 30 course of therapy to a patient in need of treatment consisting