MX2016005294A

Methods of treating and preventing graft versus host disease.

Abstract

Described herein are methods for treating and preventing graft versus host disease using ACK inhibitors. The methods include administering to an individual in need thereof an ACK inhibitor such as ibrutinib for treating and preventing graft versus host disease.

MX2016005294A, drawing sheet 1 — Sheet 1 of 64

Term

9.6 yearsleft in the term

Expires 22 April 2036.

6 claims: 1 independent, 5 dependent

1
NOVEDAD DE LA INVENCIÓN Habiendo descrito la presente invención, se considera como novedad, y por lo tanto se reclama como propiedad lo contenido en las siguientes:REIVINDICACIONES 1. Uso de 1-[(3R)-3-[4-amino-3-(4fenoxifenil)pirazolo[3,4-d]pirimidin-l-il]piperidin-1il]prop-2-en-l-ona (ibrutinib) en la preparación de un medicamento para el tratamiento de enfermedad crónica injerto contra hospedero (GVHD crónica) en un paciente.
2
El uso de conformidad con la reivindicación I, en donde la GVHD crónica es GVHD crónica clásica.
3
El uso de conformidad con la reivindicación 1, en donde la GVHD crónica es GVHD crónica traslapada.
4
El uso de conformidad con la reivindicación 1, en donde la GVHD crónica es GVHD crónica refractaria/dependiente de esferoide.
5
El uso de conformidad con la reivindicación 1, en donde la GVHD crónica es leucemia linfocitica crónica (CLL).
6
El uso de conformidad con la reivindicación 1, en donde la GVHD crónica es GVHD esclerodérmica, GVHD resistente 205 a esferoides, GVHD resistente a ciclosporina, GVHD refractaria, GVHD oral GVHD oral reticular, GVHD erosiva, o GVHD oral ulcerativa. 7 . El uso de conformidad con la reivindicación 1, en donde la GVHD es GVHD esclerodérmica. 8. El uso de conformidad con la reivindicación 1, en donde la GVHD es GVHD resistente a esferoides. 9. El uso de conformidad con la reivindicación 1, en donde la GVHD crónica es GVHD resistente a ciclosporina • 10. El uso de conformidad con la reivindicación 1, en donde la GVHD crónica es GVHD refractaria. 11. El uso de conformidad con la reivindicación I, en donde la GVHD crónica es GVHD oral. 12. El uso de conformidad con la reivindicación I, en donde la GVHD crónica es GVHD oral reticular. 13. El uso de conformidad con la reivindicación I, en donde la GVHD crónica es GVHD erosiva • 14. El ' uso de conformidad con la reivindicación I, en donde la GVHD crónica es GVHD oral ulcerativa. 15. El uso de conformidad con cualquiera de las reivindicaciones 1-14, en donde el paciente es un paciente con trasplante de célula hematopoyética. 206 16. El uso de conformidad con cualquiera de las reivindicaciones 1-15, en donde el compuesto es para administración en una cantidad de 140 mg/día hasta 840 mg/día. 17. El uso de conformidad con cualquiera de las reivindicaciones 1-15, en donde el compuesto es para administración en una cantidad de 40 mg/día, 140 mg/día, 280 mg/día, 420 mg/día, 560 mg/dia o 840 mg/día. 18. El uso de conformidad con la reivindicación 17, en donde el compuesto es para administración en una cantidad de 420 mg/día. 19. El uso de conformidad con la reivindicación 18, en donde los 420 mg del compuesto se administran una vez al día. 20. El uso de conformidad con cualquiera de las reivindicaciones 1-19, en donde el compuesto se administra oralmente. 21. El uso de conformidad con la reivindicación 16, en donde el compuesto es de la estructura:207 22. El uso de conformidad con la reivindicación 18, en donde el compuesto es de la estructura: o 208

Independent claims6

993 paragraphs in 17 sections, as filed

(54) Title: METHODS FOR TREATING AND PREVENTING ILLNESS GRAFT AGAINST GUEST.

(54) Title: METHODS OF TREATING AND PREVENTING GRAFT VERSUS HOST DISEASE.

(57) Summary

Methods for treating and preventing graft-versus-host disease using ACK inhibitors are described herein. Methods include administering to an individual in need thereof an ACK inhibitor such as ibrutinib to treat and prevent graft-versus-host disease.

(57) Abstract

TREATMENT AND PREVENTION METHODS OF GRAFT DISEASE

AGAINST GUEST

CROSS REFERENCE

This application claims the priority benefit of the United States' Provisional Application No. 61/895, 981, filed on October 25, 2013; United States Provisional Application No. 61 / 910,945, filed on December 2, 2013; Provisional Application No. 61 / 973,173, filed on March 31, 2014; and United States Provisional Application No. 61 / 973,176 filed on December 31,

<td>March 2014,</td><td>each of the</td><td>which</td><td>is incorporated into</td><td>this</td>

<td>document by</td><td>reference.</td><td></td><td></td><td></td>

<td></td><td>BACKGROUND OF</td><td colspan="2">THE INVENTION</td><td></td>

<td>The illness</td><td>graft against</td><td>Guest</td><td>chronic (cGVHD)</td><td>is the</td>

most common long-term complication after allogeneic stem cell transplant (SCT), affecting 30-70% of patients who survive beyond the first 100 days. cGVHD and its associated immune deficiency have been identified as a leading cause of relapse-free mortality (NRM) in allogeneic SCT survivors. SCT survivors with cGVHD are 4.7 times more likely to develop serious or life-threatening health conditions compared to healthy siblings and patients with active cGVHD are more likely to report adverse general health, mental health, functional disabilities, limitation of activity, and pain than allo-SCT survivors with no history of cGVHD. Any organ system can be affected, 5 and further morbidity is frequently caused by long-term exposure to corticosteroids and calcineurin inhibitors necessary to treat the condition.

SUMMARY OF THE INVENTION

Methods for preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of occurrence of GVHD in a patient requiring cell transplantation comprising the administration of a therapeutically amount are disclosed herein. An effective ACK inhibitor (eg, an ITK or BTK inhibitor). In some embodiments, methods of reducing the severity of GVHD occurrence in a patient requiring cell transplantation are disclosed herein which comprises the administration of a therapeutically effective amount of an ACK inhibitor (eg, an inhibitor of ITK or BTK). In some embodiments, the ACK inhibitor is a compound of formula (A). In some embodiments, methods for preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of GVHD occurrence in a patient requiring cell transplantation, which comprises administering a therapeutically amount, are disclosed herein. effective of a compound of formula (A) having the structure:

Formula (A);

where:

A is N;

R1 is phenyl-O-phenyl or phenyl-S-phenyl;

R2 and R3 are independently H;

R4 is L3-X-L4-G, where,

L3 is optional, and when present is a bond, optionally substituted or unsubstituted alkyl, optionally substituted or unsubstituted cycloalkyl, optionally substituted or unsubstituted alkenyl, optionally substituted or unsubstituted alkynyl;

X is optional, and when present is a bond, -0, -C (= O) -, -S-, -S (= 0) -, -S (= 0) 2-, -NH-, -NR9 -, -NHC (O) -, C (O) NH-, -NR9C (O) -, -C (O) NR9-, -S (= O) 2NH-, -NHS (= O) 2-, S (= O) 2NR9-, -NR9S (= O) 2-, -OC (O) NH-, -NHC (O) O-, -OC (O) NR9-, NR9C (O) O-, -CH = NO-, -ON = CH-, -NR10C (O) NR10-, heteroaryl-, aryl-, -NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-, OC (= NR11) -, or -C (= NR11) O-;

L4 is optional, and when present is a bond, substituted or unsubstituted alkyl, substituted or unsubstituted cycloalkyl, substituted or unsubstituted alkenyl, substituted or unsubstituted alkynyl, substituted or unsubstituted aryl, substituted or unsubstituted heteroaryl, substituted heterocycle or unsubstituted;

or L3, X and L4 taken together form a nitrogen containing heterocyclic ring;

G is Ryes, where,

R6, R7 and R8 are independently selected from H, halogen, CN, OH, substituted or unsubstituted alkyl or substituted or unsubstituted heteroalkyl or substituted or unsubstituted cycloalkyl, substituted or unsubstituted heterocycloalkyl, substituted or unsubstituted aryl, substituted heteroaryl or not substituted;

each R9 is independently selected from H, substituted or unsubstituted lower alkyl, and substituted or unsubstituted cycloalkyl;

<td>every</td><td>RIVER</td><td>is</td><td>independently H, alkyl</td><td>lower</td>

<td>replaced</td><td>or</td><td>not</td><td>substituted, or cycloalkyl</td><td>lower</td>

<td>replaced</td><td>or not</td><td colspan="2">substituted; or</td><td></td>

<td>two</td><td colspan="2">groups</td><td>RIO can together form a</td><td>ring</td>

<td colspan="2">heterocyclic of</td><td> 5-</td><td>, 6-, 7-, or 8-members; or</td><td></td>

RIO and Rll can together form a 5-, 6-, 7-, or 8-membered heterocyclic ring; or each Rll independently is selected from H or substituted or unsubstituted alkyl; or a pharmaceutically acceptable salt thereof. In some embodiments, L3, X, and L4 taken together form a nitrogen-containing heterocyclic ring. In some embodiments, the nitrogen-containing heterocyclic ring is a group of piperidine. In some embodiments, G is

Formula

In some embodiments, the compound of (A) is

1 - [(3R) -3- [4-amino-3- (46 phenoxyphenyl) pyrazolo [3,4-d] pyrimidin-l-yl] piperidin-1yl] prop-2-en-l-one. In some embodiments, the patient has cancer. In some embodiments, the patient has a hematologic malignancy. In some embodiments, the patient has a relapsed or refractory hematologic malignancy. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the patient has malignant T-cell disease. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a high-risk CLL. In some embodiments, the patient has a deletion of chromosome 17p. In some embodiments, the patient has 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or more CLL as determined by bone marrow biopsy. In some embodiments, the cancer patient is earlier. In one or more agents some embodiments have received, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib,

CAL-101, chlorambucil, cielophosphamide, dexamethasone, docetaxel, doxorubicin, everolimus endostatin, etoposide, fludarabine, fostamatinib, hydroxyunorubicin, ibritumomab, tetanus, leninidomide, mesalazine, ofatumumatin , or a combination thereof. In some embodiments, the anticancer agent is rituximab.

In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR).

In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR).

In some embodiments, the amount of the compound that inhibits

ACK (eg, a compound of Formula (A)) prevents reduces GVHD while maintaining an effective Leukemia Graft Reaction (GVL) to reduce or eliminate the number of cancer cells in the patient's blood. In some embodiments, the cell transplant is a hematopoietic cell transplant. In some embodiments, the GVHD is

Acute GVHD. In some embodiments, the GVHD is chronic GVHD. In some embodiments, the GVHD is sclerodermiform GVHD, steroid resistant GVHD, cyclosporin resistant GVHD, refractory GVHD, oral GVHD, chronic oral GVHD, oral reticular GVHD, erosive GVHD, or ulcerative oral GVHD. In some embodiments, the GVHD is sclerodermiform GVHD. In some embodiments, the GVHD is steroid resistant GVHD. In some embodiments, GVHD is cyclosporine resistant GVHD. In some embodiments, the GVHD is refractory GVHD. In some embodiments, the

GVHD is oral GVHD. In some embodiments, the oral GVHD is reticular oral GVHD. In some embodiments, the oral GVHD is erosive oral GVHD. In some embodiments, the oral GVHD is ulcerative oral GVHD. In some embodiments, the oral GVHD is GVHD of the oral cavity. In some embodiments, the oral GVHD is GVHD of the oropharyngeal region. In some embodiments, Oral GVHD is GVHD of the pharyngeal region. In some embodiments, the oral GVHD is GVHD of the esophagus region. In some embodiments, the oral GVHD is acute oral GVHD. In some embodiments, the oral GVHD is chronic oral GVHD. In some embodiments, the patient exhibits one or more symptoms of GVHD. In some embodiments, the patient has or is to receive an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of

Formula (A)) is administered concurrently with a bone marrow allogeneic or hematopoietic stem cell transplant.

In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to an allogeneic bone marrow transplant or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered subsequent to an allogeneic bone marrow or hematopoietic stem cell transplant.

In some embodiments, the patient is a candidate for receiving HLA-matched hematopoietic stem cells.

In some embodiments, the patient is a candidate to receive hematopoietic stem cells from an unrelated donor, hematopoietic stem cells from the umbilical vein, or peripheral blood stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered orally. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered at a dose between about 0.1 mg / kg per day to about 100 mg / kg per day. In some embodiments, the ACK inhibitor compound (eg, a compound of

Formula (A)) is administered at a dose of about 40 mg / day, about 140 mg / day, about 280 mg / day, about 420 mg / day, about 560 mg / day, or about 840 mg / day. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered in combination with other prophylactic agents. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered from day 1 to about day 120 after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered from day 1 to about day 1000, after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered in combination with one or more additional therapeutic agents. In some embodiments, the additional therapeutic agent is a corticosteroid. In some embodiments, the therapeutic agent is cyclosporine (CSA), mycophenolate mofetil (MMF), or a combination thereof. In some embodiments, the patient has or will receive donor lymphocyte infusions (DLI). In some embodiments, the patient is administered one or more DLI. In some embodiments, two or more DLIs are administered to the patient. In some embodiments, the

DLI comprises CD3 lymphocytes. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered after DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is ibrutinib.

Disclosed herein, in some embodiments, are methods of treating a patient for the relief of bone marrow mediated disease, comprising administering allogeneic hematopoietic stem cells and / or allogeneic T-cells to the patient, and a therapeutically effective amount. of an ACK inhibitor (eg, an ITK or BTK inhibitor). In some embodiments, methods of treating a patient for the relief of bone marrow mediated disease, with the consequent development of graft-versus-host disease (GVHD), comprising administering to the patient, are disclosed herein. allogeneic hematopoietic stem cells and / or allogeneic T-cells, and a therapeutically effective amount of a compound of formula (A):

Formula (A);

where:

A is N;

R1 is phenyl-O-phenyl or phenyl-S-phenyl;

R2 and R3 are independently H;

R4 is L3-X-L4-G, where,

X is optional, and when present is a bond, -0, -C (= O) -, -S-, -S (= O) -, -S (= 0) 2-, -NH-, -NR9 -, -NHC (O) -, C (O) NH-, -NR9C (O) -, -C | (O) NR9-, -S (= O) 2NH-, -NHS (= O) 2-,

S (= O) 2NR9-, -NR9S (= O) 2-, -OC (O) NH-, -NHC (O) O-, -OC (O) NR9-, NR9C (O) O-, -CH = NO-, -ON = CH-, -NR10C (O) NR10-, heteroaryl-, aryl-, -NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-, OC (= NR11) -, or -C (= NR11) O-;

or L3, X and L4 taken together form a nitrogen containing heterocyclic ring;

G is

OR,

, where,

R6, R7 and R8 are independently selected from H, halogen, CN, OH, substituted or substituted or unsubstituted, substituted or unsubstituted or unsubstituted heteroalkyl alkyl or substituted or unsubstituted heterocycloalkyl cycloalkyl, substituted or unsubstituted aryl, substituted heteroaryl or not substituted;

each R9 is independently selected from H, substituted or unsubstituted lower alkyl, and substituted or unsubstituted lower cycloalkyl;

<td>every</td><td>RIVER</td><td>is</td><td>independently H,</td><td>I rent</td><td>lower</td>

<td>replaced</td><td>or</td><td>not</td><td colspan="2">substituted, or cycloalkyl</td><td>lower</td>

<td>replaced</td><td>or not</td><td colspan="2">substituted; or</td><td></td><td></td>

<td>two</td><td colspan="2">groups</td><td>RIO can form</td><td>together a</td><td>ring</td>

<td colspan="2">heterocyclic of</td><td> 5-</td><td>, 6-, 7-, or 8-members;</td><td> 0</td><td></td>

RIO and Rll can together form a 5-, 6-, 7-, or 8-membered heterocyclic ring; or each Rll independently is selected from H or substituted or unsubstituted alkyl; or a pharmaceutically acceptable salt thereof, is administered before, simultaneously with, or after allogeneic hematopoietic stem cells and / or allogeneic T cells. In some embodiments, L3, X, and L4 taken together form a

nitrogen-containing heterocyclic ring. In some embodiments, the nitrogen-containing heterocyclic ring is a group of piperidine. In some embodiments, G is

ORfi

Re. In some embodiments, the compound of Formula (A) is 1 - [(3R) -3- [4-amino-3- (4phenoxyphenyl) pyrazolo [3,4-d] pyrimidin-l-yl] piperidin-1yl] prop -2-in-l-one. In some embodiments, the patient has cancer. In some embodiments, the patient has a hematologic malignancy. In some embodiments, the patient has a relapsed or refractory hematologic malignancy. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a

High-risk CLL. In some embodiments, the patient has a deletion of chromosome 17p. In some embodiments, the patient has 10%, 20%, 30%, 40%, 50%,

60%, 70%, 80%, 90%, or greater of CLL as determined by bone marrow biopsy. In some embodiments, the patient has previously received one or more anticancer agents. In some embodiments, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib, CAL

101, chlorambucil, cyclophosphamide, dexamethasone, docetaxel, doxorubicin everolimus endostatin, etoposide, fludarabine, fostamatinib, hydroxidaunorubicin, ibritumomab ifosfamida, lenalidomide, mesalazine, ofatumumab, paclita, ofatumumab, paclita, ofatumumab, paclita thereof. In some embodiments, the anticancer agent is rituximab. In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR). In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR). In some embodiments, the amount of the ACK inhibitor compound (eg, a compound of Formula (A)) prevents or reduces GVHD while maintaining a leukemia-graft reaction (GVL) effective in reducing or killing the number of cancer cells in the patient's blood. In some embodiments, the cell transplant

<td colspan="2">it's a transplant</td><td>of</td><td colspan="2">cells</td><td>hematopoietic.</td><td>In</td><td>some</td>

<td>achievements,</td><td>the</td><td colspan="2">GVHD</td><td>is</td><td>Acute GVHD.</td><td>In</td><td>some</td>

<td>achievements,</td><td>the</td><td colspan="2">GVHD</td><td>is</td><td>Chronic GVHD.</td><td>In</td><td>some</td>

<td>achievements,</td><td colspan="2">the GVHD</td><td>is</td><td>GVHD</td><td>sclerodermiform</td><td>. In</td><td>some</td>

<td>achievements,</td><td>the</td><td>GVHD</td><td>is</td><td>GVHD</td><td colspan="3">spheroid resistant. In</td>

In some embodiments, GVHD is cyclosporine resistant GVHD. In some embodiments, the GVHD is refractory GVHD. In some embodiments, the GVHD is oral GVHD. In some embodiments, the oral GVHD is reticular oral GVHD. In some embodiments, the oral GVHD is erosive oral GVHD. In some embodiments, the oral GVHD is ulcerative oral GVHD. In some embodiments, the oral GVHD is GVHD of the oral cavity. In some embodiments, the oral GVHD is GVHD of the oropharyngeal region. In some embodiments, the oral GVHD is GVHD of the pharyngeal region. In some embodiments, the oral GVHD is GVHD of the esophagus region. In some embodiments, the oral GVHD is acute oral GVHD. In some embodiments, the oral GVHD is chronic oral GVHD. In some embodiments, the patient exhibits one or more symptoms of GVHD. In some embodiments, the patient has or is to receive an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered concurrently with an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to an allogeneic bone marrow transplant or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered subsequent to an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the patient is a candidate for reception of the incompatible HLA hematopoietic stem cells. In some embodiments, the patient is a candidate to receive hematopoietic stem cells from an unrelated donor, hematopoietic stem cells from the umbilical vein, or peripheral blood stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered at a dose between about 0.1 mg / kg per day to about 100 mg / kg per day. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered at a dose of about 40 mg / day, about 140 mg / day, about 280 mg / day, about 420 mg / day , about 560 mg / day, or about 840 mg / day. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered orally. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered in combination with additional therapeutic agents. In some embodiments, the additional therapeutic agent is a corticosteroid. In some embodiments, the additional therapeutic agent is cyclosporine (CSA), mycophenolate mofetil (MMF), or a combination thereof. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered from day 1 to approximately day 120 after allogeneic transplantation of bone marrow or hematopoietic stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered from day 1 to approximately day 1000 after allogeneic transplantation of bone marrow or hematopoietic stem cells. In some embodiments, the patient has or will be receiving a donor lymphocyte infusion (DLI). In some embodiments, the patient has or will receive two or more donor lymphocyte infusions (DLI). In some embodiments, the patient is administered one or more donor lymphocyte infusions (DLI). In some embodiments, the DLIs comprise CD3 + lymphocytes. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered after DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is ibrutinib.

In some embodiments, methods of reducing the severity of GVHD occurrence in a patient requiring cell transplantation comprising the administration of a therapeutically effective amount of ibrutinib (1 - [(3r) -3-) are disclosed herein. [4-amino-3- (4-phenoxyphenyl) pyrazolo [3,4-d] pyrimidin-l-yl] piperidin-l-yl] prop-2-on-canvas). In some embodiments, the patient has cancer. In some embodiments, the patient has a hematologic malignancy. In some embodiments, the patient has a relapsed or refractory hematologic malignancy. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the patient has malignant T-cell disease. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a high-risk CLL. In some embodiments, the patient has a deletion of chromosome 17p. In some embodiments, the patient has 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or more of CLL as determined by bone marrow biopsy. In some embodiments, the patient has previously received one or more anticancer agents. In some embodiments, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib,

CAL-101, Chlorambucil, Cyclophosphamide, Dexamethasone, Docetaxel, Doxorubicin, Everolimus Endostatin, Etoposide, Fludarabine, Fostamatinib, Hydroxidaunorubicin, Ibritumomaitin, Tetalidinide, Mesalazine, Ofatumumab, , or a combination thereof. In some embodiments, the anticancer agent is rituximab.

In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR).

In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR).

In some embodiments, the amount of ibrutinib prevents reduces GVHD while maintaining a leukemia reaction to reduce or eliminate the number of cancer cells in the blood of the embodiment, the patient cell transplant. In some it is a hematopoietic cell transplant. In some embodiments, the GVHD is

Acute GVHD. In some embodiments, the GVHD is chronic GVHD. In some embodiments, the GVHD is sclerodermiform GVHD. In some embodiments, the GVHD is a spheroid resistant GVHD. In some embodiments, the GVHD is

Cyclosporine resistant GVHD. In some embodiments, the GVHD is refractory GVHD. In some embodiments, the GVHD is oral GVHD. In some embodiments, the oral GVHD is reticular oral GVHD. In some embodiments, the oral GVHD is erosive oral GVHD. In some embodiments, the oral GVHD is ulcerative oral GVHD. In some embodiments, the oral GVHD is GVHD of the oral cavity. In some embodiments, the oral GVHD is GVHD of the oropharyngeal region. In some embodiments, the oral GVHD is GVHD of the pharyngeal region. In some embodiments, the oral GVHD is GVHD of the esophagus region. In some embodiments, the oral GVHD is acute oral GVHD. In some embodiments, the oral GVHD is chronic oral GVHD. In some embodiments, the patient exhibits one or more symptoms of GVHD. In some embodiments, the patient has or is to receive an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, ibrutinib is administered concurrently with an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, ibrutinib is administered prior to a transplant, an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, ibrutinib is administered following an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the patient is a candidate for receiving incompatible HLA hematopoietic stem cells.

In some embodiments, the patient is a candidate to receive hematopoietic stem cells from an unrelated donor, hematopoietic stem cells from the umbilical vein, or peripheral blood stem cells. In some embodiments, ibrutinib is administered orally. In some embodiments, ibrutinib is administered at a dose between about 0.1 mg / kg per day to about 100 mg / kg per day. In some embodiments, ibrutinib is administered at a dose of approximately 40 mg / day,

<td>approximately</td><td> 140</td><td>mg / day,</td>

<td>approximately</td><td> 420</td><td>mg / day,</td>

<td>approximately</td><td> 840</td><td>mg / day.</td>

Ibrutinib is administered at about 280 mg / day, about 560 mg / day, or In some embodiments, the combination with other prophylactic agents. In some embodiments, ibrutinib is administered from day 1 to approximately day 120 after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, ibrutinib is administered from day 1 to about day 1000 after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, ibrutinib is administered in combination with one or more additional therapeutic agents. In some embodiments, the additional therapeutic agent is a corticosteroid. In some embodiments, the therapeutic agent is cyclosporine (CSA), mycophenolate mofetil (MMF), or a combination thereof. In some embodiments, the patient has or will receive donor lymphocyte infusions (DLI). In some embodiments, the patient is administered one or more DLI. In some embodiments, two or more DLIs are administered to the patient. In some embodiments, the DLI comprises CD3 + lymphocytes. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, ibrutinib is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, ibrutinib is administered before DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, ibrutinib is administered after DLI, after allogeneic bone marrow or hematopoietic stem cell transplantation.

Incorporation by reference

All publications, patents and patent applications mentioned in this specification are incorporated herein by reference to the same extent as if each individual publication, patent or patent application is specifically and individually stated to be incorporated by reference.

BRIEF DESCRIPTION OF THE DRAWINGS

The characteristics | Novelties of the invention are set forth with particularity in the appended claims. A better understanding of the features and advantages of the present invention will be obtained by reference to the following detailed description which sets forth illustrative embodiments, in which the principles of the invention are used, and the accompanying drawings of which:

Figures 1A-D illustrate that ibrutinib reduces cGVHD symptoms after allogeneic transplantation. C57BL / 6 mice were grafted with LP / J bone marrow after 850 cGy of lethal irradiation. Mice 25 days after transplantation were randomly assigned to ibrutinib, vehicle, or cyclosporine groups. Figure 1A shows images showing external signs of cGVHD including alopecia, scleroderma, and fibrotic lesions on day 36 after transplantation. The ibrutinib treatment group shows few external signs of cGVHD progression compared to the vehicle or cyclosporine groups. Figure IB shows an analysis of the groups of cGVHD mice using a physical scoring system adapted from Cooke et al., Which incorporates weight, posture, coat condition, skin condition, and mobility. Scoring was performed on day 36 after transplantation. Figure 1C shows the LP / J -> C57BL / 6 cGVHD score. Each category: coat condition, skin condition, weight, posture, mobility, and vitality was scored individually and added together to achieve an overall cGVHD condition score. Scores are taken by an unbiased observer consistent with no knowledge of treatment cohorts. Figure ID provides images of mouse clusters with cGVHD at day 39 post-HSCT. Figure 1E provides images of H&E stained skin preparations of sclerodermiform skin lesions showing levels of dermal fibrosis, epidermal hyperplasia, serocellular crusts, erosion, and lymphohistiocytic infiltration, consistent with cGVHD.

Figures 2A-B illustrate that Tregs are not inhibited by ibrutinib. Figure 2A provides a graph of Foxp3 + CD4 + cells in C57BL / 6 mice treated with ibrutinib (25 mg / kg / day) or vehicle for 9 weeks. The percentage of Foxp3 + CD4 + cells was analyzed by flow cytometry in peripheral blood. Student's t-test indicates that there is no significant difference between the two groups. Figure 2B provides a graph of CD8 T cell division index for various response: suppressor relationships. Purified CD4 + CD25hiCD127dim CD49d-FoxP3 + Tregs were pretreated with ibrutinib bpm or vehicle and mixed with autologous CFSE-labeled CD8 + response cells in the indicated ratio. Anti-CD3 / CD28 / CD2 stimulation beads were added and the stimulation was evaluated by calculated dilution index of CFSE dilution after 6 days. The negative control wells did not contain stimulation beads. N = 7; error bars: sem

Figures 3A-B illustrate that Th2 immunity was inhibited by ibrutinib. Figure 3A provides a graph of normalized intracellular staining analysis of derived CD4 + IL4 cells (open bars n = 6) and IFy (closed bars n = 9) pretreated with ibrutinib and stimulated with anti-CD3 / anti-CD28. Error bars = sem Figure 3B provides a graph of IgGl (Th2) and IgG2c (Thl) subisotype analysis of plasma from 8-month-old C57BL / 6 EpTCLl mice, after 7 consecutive months of administration in the ibrutinib drink (25 mg / kg / day) (n = 12) or vehicle (n = 13).

Figure 4 illustrates that Thl7 immunity was inhibited by ibrutinib. Thl7 cells were magnetically enriched from PBMC from freshly isolated healthy donors using CXCR3-CD4 + CCL6 + isolation. The enriched cells were then treated with ibrutinib or vehicle for 30 minutes before washing the drug. Cells were stimulated with anti-CD3 and anti-CD28 for 12 hours with GOLGISTOP protein transport inhibitor. IL17-producing cells were quantified as a percentage of total living CD4 + T cells and final percentages were normalized with the DMSO group n = 3; error bars: sem

Figures 5A-B illustrate that Ibrutinib inhibited autoimmune symptoms and progression of cGVHD. Figure 5A provides a graph of the weekly blinded analysis of external cGVHD indicators including weight, posture, vitality, mobility, coat, and skin. All cGVHD scores were corrected for individual scores at the start of treatment (day 25). Figure 5B provides a Kaplan Meier progression-free survival graph of cGVHD. Progression is defined as> 2 point increase in cGVHD score on day 25. * = P <0.01 error bars = wk

Figures 6A-D illustrate that ibrutinib therapy combats autoimmune infiltration of internal organs in a cGVHD T cell dependent model. Figure 6A shows representative images of 20x H&E, b220, or stained lung CD3 and kidney tissues from mice sacrificed on day 125 after HSCT. The images were taken by a trained veterinary pathologist who was unaware of the animal cohorts. Figure 6B shows a blinded pathological analysis of H&E stained lung tissues obtained from cGVHD cohorts. Lymphohistiocytic infiltration is rated on a scale of 0-4 for each animal. Figure 6C shows a blinded pathological analysis of H&E stained liver tissues obtained from the cGVHD cohorts. Portal hepatitis and vasculitis were rated on a scale of 0-4 for each animal. Figure 6D shows a Kaplan-Meier graph of cGVHD progression-free survival in an independent experiment that aimed to determine sustained benefits of continued ibrutinib therapy. During the course of the experiment, ibrutinib was withdrawn on day 60 from the animals in the ibrutinib cohort (days 25 to 60 days). ** P <0.001.

Figures 7A-B illustrate that Ibrutinib limits activation of T cells and B cells from patients with active cGVHD. Primary CD4 + T cells were isolated from patients with active cGVHD, pretreated with ibrutinib ΙμΜ (or DMSO), and stimulated with anti-CD3 for 6 hours. Figure 7A shows a graph representing percentage of CD69 + CD4 + T cells for each patient. indicates p <0.05. Figure 7B shows an image of a BTK, ERK, and PLCy2 immunoblot analysis in B cells isolated from cGVHD patients were pretreated ^ with ibrutinib ΙμΜ (or DMSO), and stimulated the use of anti-IgM for 45 minutes. The data is representative of three experiments on three different patients.

Figure 8 illustrates a clinical study of ibrutinib treatment (PCI-32765) of a post-allogeneic HCT transplant patient with refractory CLL with chronic oropharyngeal GVHD. Minimal CLL residual disease (MRD) and CD3 + T cell donor chimerism in blood is shown over time after allogeneic HCT transplantation. Donor lymphocyte infusions (DLI) and initiation of ibrutinib treatment are indicated (see example 5 for example treatment protocol).

Figure 9 shows graphs of deaths due to relapse and acute GVHD after allogeneic transplantation and treatment with ibrutinib, cyclosporine, or vehicle (as indicated in the figure) in a murine model of AML crossed with the transgenic OVA mouse.

Figures 10 AE show graphs representing the percentage change in absolute lymphocyte count (ALC) for 2 patients who received ibrutinib treatment for> 1 year. Spn = number of Stanford patients (Figure 10A); percentage reduction in LN size, as reported by the sum of the product of LN diameters (SPD) for 4 patients after starting ibrutinib (Figure 10B); MRD CLL (reported as a percentage of WBC) and blood donor CD3 T cell levels shown for patient SPN 3975 (Figure 10C); B cells (excluding the CLL clone) as a percentage of the patient's total PBMC SPN 3975, as determined by IgH HTS (Figure 10D); Total IgH molecules and unique IgH clone counts for patient SPN 3975 at different time points (D = day) post alloHCT (Figure 10E).

DETAILED DESCRIPTION OF THE INVENTION

In some embodiments, a method for preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of occurrence of GVHD in a patient requiring cell transplantation is disclosed herein, comprising administering an inhibitor compound. ACK (eg, an ITK or BTK inhibitor compound). In some embodiments, a method of preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of occurrence of GVHD in a patient requiring cell transplantation is disclosed herein, comprising administering an amount therapeutically effective of a compound of Formula (A) having the structure:

N n ^ nr4

Formula (A);

where:

A is N;

R1 is phenyl-O-phenyl or phenyl-S-phenyl;

R2 and R3 are independently H;

R4 is L3-X-L4-G, where,

X is optional, and when present is a bond, -O, -C (= 0) -, -S-, -S (= 0) -, -S (= O) 2-, -NH-, -NR9 -, -NHC (O) -, C (O) NH-, -NR9C (O) -, -C (0) NR9-, -S (= O) 2NH-, -NHS (= O) 2-, S (= O) 2NR9-, -NR9S (= O) 2-, -OC (O) NH-, -NHC (O) O-, -OC (0) NR9-, NR9C (0) 0-, -CH = NO-, -ON = CH-, -NR10C (O) NR10-, heteroaryl-, aryl-, -NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-, OC (= NR11) -, or -C (= NR11) O-;

or L3,

X and L4 taken together form a nitrogen-containing heterocyclic ring;

where,

R7 and R8 are independently selected from

H, halogen, CN, OH, substituted or substituted or unsubstituted, substituted or unsubstituted or unsubstituted heteroalkyl alkyl or substituted or unsubstituted heterocycloalkyl, substituted or unsubstituted aryl, substituted or unsubstituted heteroaryl;

each R9 is independently selected from H, substituted or unsubstituted lower alkyl, and substituted or unsubstituted lower cycloalkyl; I

<td>every</td><td>RIVER</td><td>is</td><td>independently H,</td><td>I rent</td><td>lower</td>

<td>replaced</td><td> 0</td><td>not</td><td colspan="2">substituted, or cycloalkyl</td><td>lower</td>

<td>replaced</td><td>or not</td><td>their</td><td>titled or</td><td></td><td></td>

<td>two</td><td colspan="2">groups</td><td>RIO can form</td><td>together a</td><td>ring</td>

<td colspan="2">heterocyclic of</td><td> 5-</td><td>, 6-, 7-, or 8-members;</td><td>or</td><td></td>

L3, X and L4 taken together form a nitrogen containing heterocyclic ring. In some embodiments, the nitrogen-containing heterocyclic ring is a group of piperidine. In some embodiments, G is

of formula (A) some embodiments, the compound is

1 - [(3r) -3- [4-amino-3- (4phenoxyphenyl) pyrazolo [3,4-d] pyrimidin-l-yl] piperidin-136 yl] prop-2-en-l-one. In some embodiments, the patient has cancer. In some embodiments, the patient has a hematologic malignancy. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the patient has malignant T-cell disease. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a high-risk CLL. In some embodiments, the patient has a deletion of chromosome 17p. In some embodiments, the patient has 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or more of CLL as determined by bone marrow biopsy. In some embodiments, the patient has received one or more previous anticancer agents. In some embodiments, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib, cal101, chlorambucil, cyclophosphamide, dexamethasone, docetaxel, doxorubicin, everolimus endostatin, etoposide, fludarabin, fostamatinib, lenalidomorin, hydrochloride , paclitaxel, pentostatin, prednisone, rituximab, temsirolimus, thalidomide, tositumomab, vincristine, or a combination thereof. In some embodiments, the anticancer agent is rituximab. In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR). In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR). In some embodiments, the amount of the compound of formula (A) prevents or reduces GVHD while maintaining a leukemia reaction against reducing or eliminating the patient's blood count. In some cells it is a transplant of some embodiments, the GVHD

<td>achievements,</td><td>the GVHD</td><td>is</td>

<td>achievements,</td><td>the GVHD is</td><td>GVHD</td>

Graft (GVL) effective for cancer cells in embodiments, transplantation of hematopoietic cells. In is acute GVHD. In some chronic GVHD. In some sclerodermiform. In some resistant to spheroids. In some embodiments, GVHD is cyclosporine resistant GVHD. In some embodiments, the GVHD is refractory GVHD. In some embodiments, the GVHD is oral GVHD. In some embodiments, the oral GVHD is lattice GVHD. In some embodiments, the oral GVHD is erosive oral GVHD. In some embodiments, the oral GVHD is ulcerative oral GVHD. In some embodiments, the oral GVHD is GVHD of the oral cavity. In some embodiments, the oral GVHD is GVHD of the oropharyngeal region. In some embodiments, the GVHD

GVHD of the pharyngeal region. In some embodiments, oral is GVHD from the esophagus region. In oral GVHD is some realizations, the

Oral GVHD is acute oral GVHD. In some embodiments, the

Oral GVHD is chronic oral GVHD. In some embodiments, the patient exhibits one or more symptoms of

GVHD. In some embodiments, the patient has or is to receive an allogeneic bone marrow or hematopoietic stem cell transplant.

In some embodiments, the compound of formula (A) is administered concurrently with an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the compound of formula (A) is administered prior to a transplant an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the compound of formula (A) is administered after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the patient is a candidate for receiving HLA-incompatible hematopoietic stem cells. In some embodiments, the patient is a candidate to receive hematopoietic stem cells from an unrelated donor, hematopoietic stem cells from the umbilical vein, or peripheral blood stem cells. In some embodiments, the compound of formula (A) is administered at a dose between about 0.1 mg / kg per day to about 100 mg / kg per day. In some embodiments, the compound of formula (A) is administered at a dose of about 40 mg / day, about 140 mg / day, about 280 mg / day, about 420 mg / day, about 560 mg / day, or about 840 mg / day. In some embodiments, the compound of formula (A) is administered in combination with additional therapeutic agents. In some embodiments, the additional therapeutic agent is a corticosteroid. In some embodiments, the additional therapeutic agent is cyclosporine (CSA), mycophenolate mofetil (MMF), or a combination thereof. In some embodiments, the compound of formula (A) is administered orally. In some embodiments, the compound of formula (A) is administered from day 1 to approximately day 120 after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is administered from day 1 to about day 1000 after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the patient is administered one or more donor lymphocyte infusions (DLI). In some embodiments, the DLI comprises lymphocytes

CD3 +. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient after an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the compound of formula (A) is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is administered before DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is administered after DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is ibrutinib.

In some embodiments, a method of treating a patient for the relief of bone marrow mediated disease, with the consequent development of graft-versus-host disease (GVHD), is disclosed herein, comprising administering to the patient allogeneic hematopoietic stem cells and / or allogenic T cells, wherein a therapeutically effective amount of a compound of Formula (A):

N

Formula (A);

where:

A is N;

R1 is phenyl-O-phenyl or phenyl-S-phenyl;

R2 and R3 are independently H;

R4 is L3-X-L4-G, where,

X is optional, and when present is a bond, -O, -C (= O) -, -S-, -S (= O) -, -S (= O) 2-, -NH-, -NR9 -, -NHC (O) -, C (O) NH-, -NR9C (O) -, -C (O) NR9-, -S (= O) 2NH-, -NHS (= O) 2-, S (= O) 2NR9-, -NR9S (= O) 2-, -OC (O) NH-, -NHC (O) O-, -OC (O) NR9-, NR9C (O) O-, -CH = NO-, -ON = CH-, -NR10C (O) NR10-, heteroaryl-, aryl-, -NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-, OC (= NR11) -, or -C (= NR11) O-;

or L3, X and L4 taken together form a nitrogen containing heterocyclic ring;

F

R7 and halogen, where,

R8 independently selected from

H

CN,

OH, substituted or unsubstituted alkyl substituted or unsubstituted heteroalkyl or substituted or unsubstituted cycloalkyl, substituted or unsubstituted heterocycloalkyl, substituted or unsubstituted aryl, substituted or unsubstituted heteroaryl;

each R9 is independently selected from H, substituted or unsubstituted lower alkyl, and substituted or unsubstituted lower cycloalkyl; I

<td>every</td><td>RIO is</td><td colspan="2">independently H, alkyl</td><td>lower</td>

<td>replaced</td><td>or not</td><td>substituted,</td><td>or cycloalkyl</td><td>lower</td>

<td>replaced</td><td colspan="2">or unsubstituted; or</td><td></td><td></td>

<td>two</td><td>groups</td><td>RIO can</td><td>together form a</td><td>ring</td>

5-, 6-, 7-, or 8-membered heterocyclic; or

RIO and Rll can together form a 5-, 6-, 7-, or 8-membered heterocyclic ring; or

Each Rll is independently selected from H or substituted or unsubstituted alkyl; or a pharmaceutically acceptable salt thereof, is administered before, simultaneously with, or after administration of allogeneic hematopoietic stem cells and / or allogeneic T-cells. In some embodiments, In some embodiments, L3, X, and L4 taken together form a nitrogen-containing heterocyclic ring. In some embodiments, the nitrogen-containing heterocyclic ring is a group of piperidine. In some embodiments, G is

R8 OR

In some embodiments, the compound of formula (A) is 1 - [(3r) -3- [4-amino-3- (4phenoxyphenyl) pyrazolo [3,4-d] pyrimidin-l-yl] piperidin-1yl] prop -2-in-l-one. In some realizations, the patient has cancer. In some embodiments, the patient as a hematologic malignancy. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the patient has malignant T-cell disease. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a high-risk CLL. In some embodiments, the patient has a deletion of the chromosome the patient has 10%, 20%, embodiments,

17p. In some

<td>determines</td><td>by</td><td>biopsy</td><td>of</td><td>marrow</td><td>that is.</td><td>In</td>

<td colspan="2">achievements,</td><td>the patient</td><td>he has</td><td>received</td><td>one or</td><td>plus</td>

some anticancer agents such as previous ones. In some embodiments, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib, cal-101, chlorambucil, cielofosfamide, dexamethasone, docetaxel, everolimus endostatin, etoposide, fludarabine, fostamatinib, hydroxidaunorubicin, ibritumin, ibritumb , paclitaxel, pentostatin, prednisone, rituximab, temsirolimus, thalidomide, tositumomab, vincristine, or a combination thereof. In some embodiments, the anticancer agent is rituximab.

In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR).

In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR).

In some embodiments, the amount of the compound of formula (A) prevents or reduces GVHD while maintaining an effective Leukemia Graft Reaction (GVL) to reduce or eliminate the number of cancer cells in the patient's blood. In some embodiments, the cell transplant

<td colspan="2">it's a transplant</td><td colspan="2">cell</td><td>hematopoietic.</td><td>In</td><td>some</td>

<td>achievements,</td><td>the</td><td>GVHD</td><td>is</td><td>Acute GVHD.</td><td>In</td><td>some</td>

<td>achievements,</td><td>the</td><td>GVHD</td><td>is</td><td>Chronic GVHD.</td><td>In</td><td>some</td>

<td>achievements,</td><td colspan="2">the GVHD is</td><td>GVHD</td><td>sclerodermiform</td><td>. In</td><td>some</td>

<td>achievements,</td><td>the</td><td>GVHD is</td><td>GVHD</td><td colspan="3">spheroid resistant. In</td>

<td>the compound of</td><td colspan="2">formula (A)</td><td>is administered to</td><td>a</td><td>dose d</td>

<td>approximately</td><td> 40</td><td>mg / day,</td><td>approximately</td><td> 140</td><td>mg / day</td>

<td>approximately</td><td> 280</td><td>mg / day</td><td>approximately</td><td> 420</td><td>mg / day</td>

about 560 mg / day, or about 840 mg / day. In some embodiments, the compound of formula (A) is administered in combination with additional therapeutic agents. In some embodiments, the additional therapeutic agent is a corticosteroid. In some embodiments, the additional therapeutic agent is cyclosporine (CSA), mycophenolate mofetil (MMF), or a combination thereof. In some embodiments, the compound of formula (A) is administered orally. In some embodiments, the compound of formula (A) is administered from day 1 to approximately day 120 after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is administered from day 1 to approximately day 1000 after allogeneic transplantation of bone marrow or hematopoietic stem cells. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient. In some embodiments, the DLI comprises CD3 + lymphocytes. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is administered prior to DLI following allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of formula (A) is administered after DLI after allogeneic transplantation of bone marrow or hematopoietic stem cells. In some embodiments, the compound of formula (A) is ibrutinib.

In some embodiments, uses of a compound of Formula (A) are provided for preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of occurrence of

GVHD in a patient requiring cell transplantation, where the

Formula (A) has the structure:

Formula (A);

where:

A is N;

R1 is phenyl-O-phenyl or phenyl-S-phenyl;

R2 and R3 are independently H;

R4 is L3-X-L4-G, where,

X is optional, and when present is a bond, -0, -C (= O) -, -S-, -S (= 0) -, -S (= O) 2-, -NH-, -NR9 -, -NHC (O) -, C (O) NH-, -NR9C (O) -, | -C (O) NR9-, -S (= O) 2NH-, -NHS (= O) 2- |,

S (= O) 2NR9-, -NR9S (= O) 2-, -OC (O) NH-, -NHC (O) O-, -OC (O) NR9-, NR9C (O) O-, -CH = NO-, -ON = CH-, -NR10C (0) NR10-, heteroaryl-, aryl-, -NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-, OC (= NR11) -, or -C (= NR11) O-;

or L3, X and L4 taken together form a nitrogen containing heterocyclic ring;

OR(

G is

OR

O Ri

where,

R6, R7 and

R8 are independently selected from H, halogen, CN,

OH, substituted or unsubstituted alkyl or substituted or unsubstituted heteroalkyl or substituted or unsubstituted cycloalkyl, substituted or unsubstituted heterocycloalkyl, substituted or unsubstituted aryl, substituted or unsubstituted heteroaryl;

each R9 is independently selected from H, substituted or unsubstituted lower alkyl, and substituted or unsubstituted lower cycloalkyl;

<td>every</td><td>RIVER</td><td>is independently H, alkyl</td><td>lower</td>

<td>replaced</td><td>or</td><td>unsubstituted, or cycloalkyl</td><td>lower</td>

<td>replaced</td><td>or not</td><td>substituted; or</td><td></td>

<td>two</td><td>RIVER</td><td>groups can together form a</td><td>ring</td>

8-members; or heterocyclic 5-, 6-, 7-, or

L3, X and L4 taken together form a nitrogen containing heterocyclic ring.

In some embodiments, the nitrogen-containing heterocyclic ring is a group of piperidma. In some embodiments, G is

In some embodiments, the compound of Formula (A) is 1 - [(3R) -3- [4-amino-3- (4phenoxyphenyl) pyrazolo [3,4-d] pyrimidin-l-yl] piperidin-1yl] prop -2-in-l-one. In some embodiments, the patient has cancer. In some embodiments, the patient has a hematologic malignancy. In some embodiments, the patient has a relapsed or refractory hematologic malignancy. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the patient has malignant T-cell disease. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a high-risk CLL. In some embodiments, the patient has a deletion of the chromosome

<td>17p.</td><td>In</td><td>some</td><td colspan="2">achievements,</td><td>the patient is 10</td><td> %, 20%,</td>

<td colspan="3">determined by</td><td>biopsy</td><td>of</td><td>bone marrow. In</td><td>some</td>

embodiments, the patient has previously received one or more anticancer agents. In some embodiments, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib, CAL-101, chlorambucil, cyclophosphamide, dexamethasone, docetaxel, doxorubicin, everolimus endostatin, mesalamide, flutarabin, ibidine, hydroxidaunorubin paclitaxel, pentostatin, prednisone, rituximab, temsirolimus, thalidomide, tositumomab, vincristine, or a combination thereof. In some embodiments, the anticancer agent is rituximab. In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR). In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR). In some embodiments, the amount of the compound that inhibits

ACK (eg, a compound of Formula (A)) prevents or reduces GVHD while maintaining an effective Leukemia Graft Reaction (GVL) to reduce or eliminate the number of cancer cells in the patient's blood. In some embodiments, the cell transplant is a hematopoietic cell transplant. In some embodiments, the GVHD is acute GVHD. In some embodiments, the GVHD is chronic GVHD. In some embodiments, the GVHD is sclerodermiform GVHD. In some embodiments, the GVHD is a spheroid resistant GVHD. In some embodiments, GVHD is cyclosporine resistant GVHD. In some embodiments, the GVHD is refractory GVHD. In some embodiments, the GVHD is oral GVHD. In some embodiments, the oral GVHD is reticular oral GVHD. In some embodiments, the oral GVHD is erosive oral GVHD. In some embodiments, the oral GVHD is ulcerative oral GVHD. In some embodiments, the oral GVHD is GVHD of the oral cavity. In some embodiments, the oral GVHD is GVHD of the oropharyngeal region. In some embodiments, the oral GVHD is GVHD of the pharyngeal region. In some embodiments, the oral GVHD is GVHD of the esophagus region. In some embodiments, the oral GVHD is acute oral GVHD. In some embodiments, the oral GVHD is chronic oral GVHD. In some embodiments, the patient exhibits one or more symptoms of GVHD. In some embodiments, the patient has or is to receive an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered concurrently with an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to transplantation by an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered subsequent to an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the patient is a candidate for receiving incompatible HLA hematopoietic stem cells. In some embodiments, the patient is a candidate to receive hematopoietic stem cells from an unrelated donor, hematopoietic stem cells from the umbilical vein, or peripheral blood stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered orally. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered at a dose between about 0.1 mg / kg per day to about 100 mg / kg per day.

In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered at a dose of about 40 mg / day, about 140 mg / day, about 280 mg / day, about 420 mg / day , about 560 mg / day, or about 840 mg / day. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered in combination with other therapeutic agents. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered from day 1 to about day 120 after allogeneic transplantation of bone marrow or hematopoietic stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered from day 1 to about day 1000 after allogeneic transplantation of bone marrow or hematopoietic stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered in combination with one or more additional therapeutic agents.

In some embodiments, the additional therapeutic agent is a corticosteroid. In some embodiments, the therapeutic agent is cyclosporine (CSA), mycophenolate mofetil (MMF), or a combination thereof. In some embodiments, the patient has or will receive donor lymphocyte infusions (DLI). In some embodiments, the patient is administered one or more DLI. In some embodiments, two or more DLIs are administered to the patient. In some embodiments, the DLI comprises CD3 + lymphocytes. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments , the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered after DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is ibrutinib.

In some embodiments, uses of a compound of Formula (A) are provided with allogeneic hematopoietic stem cells and / or allogenic T cells for the treatment of a patient for the relief of bone marrow mediated disease, with the consequent relief development of graft-versus-host disease (GVHD), wherein the compound of Formula (A) has the structure:

Formula (A);

where:

A is N;

R1 is phenyl-O-phenyl or phenyl-S-phenyl;

R2 and R3 are independently H;

R4 is L3-X-L4-G, where,

X is optional, and when present is a bond, -0, -C (= O) -, -S-, -S (= 0) -, -S (= O) 2-, -NH-, -NR9 -, -NHC (O) -, C (O) NH-, -NR9C (O) -, -C (O) NR9-, -S (= O) 2NH-, -NHS (= O) 2-, S (= O) 2NR9-, -NR9S (= O) 2-, -OC (O) NH-, -NHC (O) O-, -OC (O) NR9-, NR9C (O) O-, -CH = NO-, -ON = CH-, -NR10C (0) NR10-, heteroaryl-, aryl-, -NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-, 59

OC (= NR11) -, or -C (= NR11) O-;

L4 is optional, and when present is a bond, substituted or unsubstituted alkyl, substituted or unsubstituted cycloalkyl, substituted alkenyl or substituted or unsubstituted alkynyl | or, unsubstituted, substituted or unsubstituted aryl, substituted or unsubstituted heteroaryl, substituted or unsubstituted heterocycle;

or L3,

X and L4 taken together form a nitrogen-containing heterocyclic ring;

R7

R8 independently select from substituted substituted heteroalkyl where, or unsubstituted or

H, unsubstituted or

OH, alkyl

substituted or unsubstituted cycloalkyl halogen, substituted or unsubstituted heterocycloalkyl, substituted or unsubstituted aryl, substituted or unsubstituted heteroaryl;

each R9 is independently selected from H, substituted or unsubstituted lower alkyl, and substituted or unsubstituted lower cycloalkyl;

<td>every</td><td>RIVER</td><td>is independently H, alkyl</td><td>lower</td>

<td>replaced</td><td>or</td><td>unsubstituted, or cycloalkyl</td><td>lower</td>

<td>replaced</td><td>or not</td><td>substituted; or</td><td></td>

<td>1 two</td><td>RIVER</td><td>groups can form 1 together a</td><td>ring</td>

5-, 6-, 7-, or 8-membered heterocyclic; or

RIO and Rll can together form a 5-, 6-, 7-, or 8-membered heterocyclic ring; or each Rll independently is selected from H or substituted or unsubstituted alkyl; or a pharmaceutically acceptable salt thereof, and is administered before, simultaneously with, or after administration of allogeneic hematopoietic stem cells and / or allogeneic T cells. In some embodiments, L3, X, and L4 taken together form a nitrogen-containing heterocyclic ring.

In some embodiments, the nitrogen-containing heterocyclic ring is a group of piperidine

In some embodiments,

In some embodiments, the compound of Formula (A) is 1 - [(3R) —3— [4— amino-3- (4-phenoxyphenyl) pyrazolo [3,4-d] pyrimidin-1 yl] piperidin-l- il] prop-2-en-l-onea. In some embodiments, the patient has cancer. In some embodiments, the patient has a hematologic malignancy.

In some embodiments, the patient has a relapsed or refractory hematologic malignancy.

In some embodiments, B cells. In the patient has malignant disease of some embodiments, the patient has malignant T cell disease. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a high-risk CLL. In some embodiments, the patient has a deletion of chromosome 17p. In some embodiments, the patient has 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or more of CLL as determined by bone marrow biopsy. In some embodiments, the patient has previously received one or more anticancer agents.

In some embodiments, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib, CAL101, chlorambucil, cyclophosphamide, dexamethasone, docetaxel, doxorubicin everolimus endostatin, etoposide, fludarabin, fostamatinib, lenalidomorubin, hydrochloride, hydrochloride , pentostatin, prednisone, rituximab, temsirolimus, thalidomide tositumomab, vincristine, or a combination thereof. In some embodiments, the anticancer agent is rituximab. In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR). In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR). In some embodiments, the amount of the ACK inhibitor compound (eg, a compound of Formula (A)) prevents or reduces GVHD while maintaining a leukemia-graft reaction (GVL) effective in reducing or killing the number of cancer cells in the patient's blood. In some embodiments, the cell transplant is a cell transplant

<td>achievements,</td><td>the</td><td>GVHD</td><td>is</td>

<td colspan="2">hematopoietic.</td><td>In</td><td>some</td>

<td>GVHD</td><td>acute.</td><td>In</td><td>some</td>

<td>GVHD</td><td>chronicle.</td><td>In</td><td>some</td>

embodiments, the GVHD is spheroid resistant GVHD. In some embodiments, GVHD is cyclosporine resistant GVHD. In some embodiments, the GVHD is refractory GVHD. In some embodiments, the GVHD is oral GVHD. In some embodiments, the oral GVHD is reticular oral GVHD. In some embodiments, the oral GVHD is erosive oral GVHD. In some embodiments, the oral GVHD is ulcerative oral GVHD. In some embodiments, the oral GVHD is GVHD of the oral cavity. In some embodiments, the oral GVHD is GVHD of the oropharyngeal region. In some embodiments, the oral GVHD is GVHD of the pharyngeal region. In some embodiments, the oral GVHD is GVHD of the esophagus region. In some embodiments, the oral GVHD is acute oral GVHD. In some embodiments, the oral GVHD is chronic oral GVHD. In some embodiments, the patient exhibits one or more symptoms of GVHD. In some embodiments, the patient has or is to receive an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered concurrently with an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to transplantation by an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered subsequent to an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the patient is a candidate for receiving the incompatible HLA hematopoietic stem cells. In some embodiments, the patient is a candidate to receive hematopoietic stem cells from an unrelated donor, hematopoietic stem cells from the umbilical vein, or peripheral blood stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered orally. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered at a dose between about 0.1 mg / kg per day to about 100 mg / kg per day. In some embodiments, the ACK inhibitor compound (eg, a compound of

Formula (A)) is administered at a dose of approximately 40 mg / day, approximately 140 mg / day, approximately 280 mg / day, approximately 420 mg / day, approximately 560 mg / day, or approximately

840 mg / day. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered in combination with other prophylactic agents. In some embodiments, the ACK inhibitor compound (eg, a compound of

Formula (Ά)) is administered from day 1 to approximately day 120 after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered from day 1 to about day 1000 after allogeneic transplantation of bone marrow or hematopoietic stem cells. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered in combination with one or more additional therapeutic agents. In some embodiments, the additional therapeutic agent is a corticosteroid. In some embodiments, the therapeutic agent is cyclosporine (CSA), mycophenolate mofetil (MMF), or a combination thereof. In some embodiments, the patient has or will receive donor lymphocyte infusions (DLI).

In some embodiments, one more DLI is administered to the patient. In some embodiments, two or more DLIs are administered to the patient.

In some embodiments, the

DLI comprises CD3 lymphocytes

In some embodiments, one more donor lymphocyte infusion (DLI) is administered to the patient after an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered prior to DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is administered after DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the ACK inhibitor compound (eg, a compound of Formula (A)) is ibrutinib. <

Certain terminology

It should be understood that the foregoing general description and the following detailed description are by way of example only and explanatory and are not restrictive of any claimed subject matter. In this application, the use of the singular includes the plural unless specifically stated otherwise. It should be noted that, as used in the specification and the appended claims, the singular forms un, one and the include plural referents unless the context clearly indicates otherwise. In this application, the use of or means and / or unless

<td>indicate what</td><td>contrary.</td><td>On the other hand, the</td><td>wear</td><td>of the term</td>

<td>including</td><td>, as well as</td><td>other forms such</td><td>how</td><td>include,</td>

<td>It includes,</td><td>included,</td><td>it is not limiting.</td><td></td><td></td>

<td>How</td><td>used</td><td>in this document,</td><td>ACK</td><td>and kinase</td>

cysteine | accessible are synonyms. They signify a kinase with an accessible cysteine residue. ACKs include, but are not limited to, BTK, ITK, Bmx / ETK, TEC, EFGR, HER4, HER4, LCK, BLK, C-src, FGR, Fyn, HCK, Lyn, YES, ABL, Brk, CSK, FER , JAK3, SYK. In some embodiments, ACK is a kinase of the TEC family. In some embodiments, the ACK is HER4. In some embodiments, the ACK is BTK. In some embodiments, the ACK is ITK.

As used in this document, improvement refers to decreased severity, delayed onset, slowed growth, slowed metastasis, or shortened duration of HER2-amplified breast cancer, either permanent or temporary. , durable or transient that can be attributed to, or associated with the administration of the compound or composition.

The term Bruton tyrosine kinase, as used herein, refers to Bruton tyrosine kinase from Homo sapiens, as disclosed in, for example,

United States No. 6,326,469 (GenBank accession number

0000_000052).

The term Bruton tyrosine kinase homolog, as used herein, refers to Bruton tyrosine kinase orthologs, eg, mouse orthologs (GenBank Accession No. AAB47246), dog (Accession No. GenBank XP_549139.), Rat (GenBank Accession No. NP_001007799), chicken (GenBank Accession No. NP_989564), or zebrafish (No. access code GenBank XP_698117), and fusion proteins of any of the above that show kinase activity towards one or more Bruton tyrosine kinase substrates (eg, a peptide substrate having the amino acid sequence AVLESEEELYSSARQ SEQ ID NO: 1) .

The term HER4, also known as ERBB4, also known as erythroblastic V-erb-a leukemia viral homolog 4 means either (a) the nucleic acid sequence encoding a receptor tyrosine kinase that is a member of the receptor subfamily epidermal growth factor, or (b) the protein thereof. For the nucleic acid sequence comprising the human HER4 gene see GenBank Accession No. NM_001042599. For the amino acid sequence comprising the human HER4 protein see GenBank Accession No. NP_001036064.

The term homologous cysteine, as used herein, refers to a cistern residue found within a sequence position that is homologous to that of Bruton tyrosine kinase cistern 481, as defined herein. For example, cistern 482 is the homologous cistern of the rat ortholog of Bruton tyrosine kinase; cistern 479 is the homologated cistern of the chicken ortholog; and cistern 481 is the homologated cistern in the zebrafish ortholog. In another example, the homologous cistern of TXK, a member of the Tec kinase family is related to Bruton's tyrosine, is Cys 350.

The term irreversible BTK inhibitor, as used herein, refers to a BTK inhibitor that can form a covalent bond with a BTK amino acid residue. In one embodiment, the irreversible BTK inhibitor can form a covalent bond with a Cys residue from BTK; In particular embodiments, the irreversible inhibitor may form a covalent bond with a Cys 481 residue (or a homolog thereof) of BTK or a cysteine residue at the homologous corresponding position of another tyrosine kinase, as shown in Figure 7.

As used herein, the term pERK refers to Thr202 / Tyr 204 phosphorylated ERK1 and ERK2 as detected by commercially available phospho-specific antibodies (eg, cell signaling technologies #

4377) .

<td>The</td><td>term individual, patient and subject is</td>

<td>they use</td><td>indistinctly. These terms refer to a</td>

<td>mammal</td><td>(for example, an i human being), which is the object of</td>

treatment, or observation. The term should not be construed as requiring the supervision of a physician (eg, physician, physician's assistant, nurse, nurse, or hospice worker).

The terms treat, treat or treat, as used herein, include decreased severity of GVHD, delayed GVHD onset, triggered GVHD regression, relief of a condition caused by GVHD, or stopping symptoms that result from the GVHD. The

<td>terms</td><td>treat, which treats or treatment, include,</td>

<td>but no</td><td>are limited to prophylactic treatments and / or</td>

therapeutic.

As used herein, oral GVHD refers to the local manifestation of GVHD in the oral cavity, oropharynx, pharynx, or esophageal regions.

Graft-versus-host disease

Methods for preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of occurrence of GVHD in a patient requiring cell transplantation are described herein, comprising administering to the patient a composition comprising a therapeutically amount effective of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as ibrutinib). In some embodiments, the patient requires hematopoietic cell transplantation. In some embodiments, the patient requires peripheral blood stem cell transplantation. In some embodiments, the patient requires a bone marrow transplant. In some embodiments, the ACK inhibitor compound is administered prior to administration of the cell transplant. In some embodiments, the ACK inhibitor compound is administered after administration of the cell transplant. In some embodiments, the ACK inhibitor compound is administered simultaneously with the administration of the cell transplant. In some embodiments, the patient exhibits one or more symptoms of GVHD. In some embodiments, the patient exhibits one or more symptoms of acute GVHD. In some embodiments, the patient exhibits one or more symptoms of chronic GVHD. Example symptoms of GVHD include, but are not limited to, skin rash or reddened areas of the skin, raised skin, blistering, thickening or hardening of the skin, yellow discoloration of the skin and / or eyes, abnormal blood test results, nausea, vomiting, diarrhea, abdominal swelling, abdominal cramps, increased dryness or irritation of the eyes, vision changes, dry mouth, white spots inside the mouth, pain or sensitivity to spicy food, difficulty breathing, difficulty swallowing, pain swallowing, weight loss, fatigue, muscle weakness, muscle pain, increased urinary frequency, burning or bleeding when urinating, vaginal dryness or hardening, or penile dysfunction.

In some embodiments, the patient exhibits one or more symptoms of oral GVHD. In some embodiments, the patient exhibits one or more symptoms of acute oral GVHD. In some embodiments, the patient exhibits one or more symptoms of chronic oral GVHD. Example symptoms of

Oral GVHD includes, but is not limited to, oral tissue inflammation, dry mouth, stippled or generalized mucosal erythema, white streaks or papules on the oral mucosa and lips, erosion-peeling-ulceration of the

<td>mucosa, pain or</td><td>sensitivity to spicy foods,</td>

<td>difficulty</td><td>swallowing, pain when swallowing, stenosis</td>

pharyngoesophageal, xerostomia, lichen planus, poor bolus control, pharyngeal retention, excessive mucus secretion, inflammation of oral tissues, and ulceration. In some embodiments, the patient suffers from refractory GVHD. In some embodiments, the oral GVHD is reticular oral GVHD. In some embodiments, the oral GVHD is erosive oral GVHD. In some embodiments, the oral GVHD is ulcerative oral GVHD.

In some embodiments, the patient suffers from spheroid resistant GVHD. In some embodiments, the spheroid resistant GVHD is acute GVHD. In some embodiments, the spheroid resistant GVHD is chronic GVHD. In some embodiments, the patient suffers from cyclosporine resistant GVHD.

Methods for preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of occurrence of GVHD in a patient requiring stem cell transplantation, comprising administering to the patient a composition comprising a therapeutically effective amount, are described herein. of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib). In some embodiments, the patient requires a hematopoietic stem cell transplant. In some embodiments, the patient requires peripheral blood stem cell transplantation. In some embodiments, the patient requires a bone marrow transplant. In some embodiments, the ACK inhibitor compound is administered prior to administration of the stem cell transplant. In some embodiments, the ACK inhibitor compound is administered after administration of the stem cell transplant. In some embodiments, the ACK inhibitor compound is administered concurrently with administration of the stem cell transplant.

In some embodiments, the ACK inhibitor compound is administered before, after, or simultaneously with the administration of allogeneic hematopoietic stem cells and / or allogeneic T cells.

Also described in this document are methods of treating a patient for the relief of a disease mediated by bone marrow, with the relief of the consequent development of graft-versus-host disease (GVHD), which includes administering hematopoietic stem cells to the patient. allogeneic and / or allogenic T cells, wherein a therapeutically effective amount of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as, ibrutinib) is administered before, after, or simultaneously with the administration of allogeneic hematopoietic stem cells and / or allogeneic T cells.

Treatment of proliferative blood disorders such as leukemia, lymphoma, and myeloma generally involves one or more forms of chemotherapy and / or radiation therapy. These treatments destroy malignant cells, but they also destroy healthy blood cells. Allogeneic hematopoietic cell transplantation is an effective therapy for the treatment of many hematologic malignancies, including, for example, B-cell and T-cell malignancies. In allogeneic hematopoietic cell transplantation, bone marrow (or, in some cases, peripheral blood) from an unrelated donor or a related donor (but not identical twin) is used to replace the destroyed healthy blood cells in the cancer patient. The bone marrow (or peripheral blood) contains stem cells, which are the precursors to all the different types of cells (for example, red blood cells, phagocytes, platelets, and lymphocytes) found in the blood. Allogeneic hematopoietic cell transplantation is known to have both a restorative and a curative effect. The reparative effect arises from the ability of stem cells to repopulate the cellular components of the blood. The healing properties of an allogeneic hematopoietic cell transplant are largely derived from a graft-versus-leukemia (GVL) effect. Transplanted hematopoietic cells from the donor (specifically, T lymphocytes) attack cancer cells, enhancing the suppressive effects of other forms of treatment. In essence, the effect of GVL comprises an attack on the cancer cells of the blood cells derived from the transplant, making it less likely that the malignancy will return after the transplant. Controlling the GVL effect prevents escalation of the GVL effect on the GVHD. A similar effect against tumors is also known (graft-versus-tumor).

Allogeneic hematopoietic cell transplantation is often toxic to the patient. This toxicity stems from the difficulty in dissociating the GVL or GVT effect from graft-versus-host disease (GVHD), an often lethal complication of allogeneic BMT.

GVHD is one of the main complications of allogeneic hematopoietic cell transplantation (HCT). GVHD is a donor graft-initiated T-cell inflammatory disease that recognizes histocompatibility and other host tissue antigens, and GVHD is mediated by a variety of effector cells and inflammatory cytokines. GVHD occurs in both acute and chronic forms. The most common symptomatic organs are the skin, liver, and gastrointestinal tract, including the oral cavity and the oropharyngeal regions. GVHD can involve other organs such as the lung. GVHD treatment is generally only 5075% successful; the rest of the patients generally do not survive. The risk and severity of this immune-mediated condition are directly related to the degree of mismatch between a host and the donor of hematopoietic cells. For example, GVHD develops in up to 30% of human leukocyte antigen (HLA) matched sibling bone marrow recipients, in up to 60% of matched unrelated donor HLA bone marrow recipients, and in a higher percentage of HLA-incompatible bone marrow receptor. Patients with mild intestinal GVHD have anorexia, nausea, vomiting, abdominal pain, and diarrhea, while patients with severe GVHD are disabled from these symptoms. If not treated, the symptoms of intestinal GVHD persist and often progress; Spontaneous remissions are unusual. In its most severe form, GVHD leads to necrosis and exfoliation of most epithelial cells of the intestinal lining, a condition that is often fatal. Symptoms of acute GVHD are usually present within 100 days of the transplant. Symptoms of chronic GVHD usually appear somewhat later, up to three years after allogeneic HCT, and are often preceded by the history of acute GVHD.

Oral manifestations of GVHD are seen in both acute GVHD (aGVHD) and chronic GVHD (cGVHD). Oral involvement varies between 33% and 75% for patients with aGVHD and up to approximately 80% in those with cGVHD. Involvement of the salivary glands can cause dryness of the oral mucosa and oral pain may be the first presenting symptom. Oral lesions in GVHD may be lichenoid or lupus-like in appearance. Oral findings of aGVHD include painful desquamative, erythematous, and ulcerative mucosal lesions. In cGVHD, they are lichenoid with erythema and associated ulcerations; Furthermore, they may be associated with the sicca syndrome characterized by xerostomia and progressive salivary gland atrophy. Oral complications include pain due to changes in the mucosa, altered or reduced taste, and can have a potential impact on speech, swallowing, and use of oral prostheses (when present). Oral infection, mainly due to Candida species, and dental demineralization and caries can also occur. Oral manifestations of cGVHD can significantly affect the quality of life of patients through discomfort and impaired oral intake leading to malnutrition and increased morbidity.

Conventional treatment of oral cGVHD consists of systemic immunosuppressive therapies combined with proper oral hygiene and the judicious use of topical spheroids. However, for patients with oral cGVHD, as the most important clinical finding, the use of systemic immunosuppressants may result in host immunosuppression with concomitant systemic complications. Furthermore, some patients experience considerable and refractory oral complications, even with maximum doses of systemic immunosuppressants.

The first-line therapy for GVHD is mostly systemic in nature, consisting of cyclosporine and spheroids. The most common rescue treatments for cGVHD are thalidomide, tacrolimus, mycophenolate mofetil, T-cell depletion by Campath-1, and phototherapy. Oral GVHD is often refractory to conventional treatment and therefore complementary topical treatment is required. Various agents are currently used for local treatments, such as palliative rinses, topical immunosuppressive agents, thalidomide, retinoids, and phototherapy for oral GVHD.

Methods for preventing the occurrence of graft-versus-host disease (GVHD) or reducing the severity of occurrence of GVHD in a patient requiring cell transplantation comprising administering to the patient a composition comprising a therapeutically effective amount are described herein. of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib). In some embodiments, the patient requires hematopoietic cell transplantation. Methods of treating a patient for the relief of bone marrow mediated disease, with the consequent development of graft-versus-host disease (GVHD), comprising administering stem cells to the patient, are further described herein. allogeneic hematopoietic and / or allogenic T cells, wherein a therapeutically effective amount of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as ibrutinib) is administered before, simultaneously with, or after allogeneic hematopoietic stem cells and / or allogeneic T cells. In some embodiments, the patient has cancer. In some embodiments, the patient has a hematologic malignancy. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the patient has malignant T-cell disease. In some embodiments, the patient has leukemia, lymphoma, or myeloma. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL. In some embodiments, the patient has a high-risk CLL. In some embodiments, the patient has a deletion of chromosome 17p. In some embodiments, the patient has 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or more of CLL as determined by bone marrow biopsy. In some embodiments, the patient has previously received one or more anticancer agents. In some embodiments, the anticancer agent is selected from alemtuzumab, bendamustine, bortezomib, CAL-101, chlorambucil, cyclophosphamide, dexamethasone, docetaxel, everolimus endostatin, etoposide, fludarabine hydroxidaunorubicin, ibritumomab, ifosfamide, ifosfamide, ifosfamide, ifosfamide , paclitaxel pentostatin, prednisone, rituximab, temsirolimus, thalidomide, tositumomab, vincristine, or a combination thereof. In some embodiments, the anticancer agent is rituximab. In some embodiments, the anticancer agent is alemtuzumab. In some embodiments, the anticancer agent is fludarabine, cyclophosphamide, and rituximab (FCR). In some embodiments, the anticancer agent is oxaliplatin, fludarabine, cytarabine, rituximab (OFAR). In some embodiments, a compound disclosed herein prevents or reduces GVHD while maintaining an effective Leukemia Graft Reaction (GVL) to reduce or eliminate the number of cancer cells in the patient's blood. In some embodiments, the GVHD is acute GVHD. In some embodiments, the GVHD embodiments, the GVHD is embodiments, the oral GVHD is chronic GVHD. In some

Oral GVHD. In some

GVHD of the oral cavity. In some embodiments, the oral GVHD is GVHD of the oropharyngeal region. In some embodiments, the oral GVHD is GVHD of the pharyngeal region. In some embodiments, the oral GVHD is GVHD of the esophagus region. In some embodiments, the oral GVHD is acute oral GVHD. In some embodiments, the oral GVHD is chronic oral GVHD. In some embodiments, the patient has or is to receive an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, an ACK inhibitor compound disclosed herein is administered concurrently with an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, an ACK inhibitor compound disclosed herein is administered prior to allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, an ACK inhibitor compound disclosed herein is administered subsequent to an allogeneic bone marrow or hematopoietic stem cell transplant. In some embodiments, the patient is a candidate for receiving HLA-incompatible hematopoietic stem cells. In some embodiments, the patient is a candidate to receive hematopoietic stem cells from an unrelated donor, hematopoietic stem cells from the umbilical vein, or peripheral blood stem cells. In some embodiments, an ACK inhibitor compound disclosed herein is subsequently administered to a patient presenting with one or more symptoms of oral GVHD, where the patient has an allogeneic bone marrow or hematopoietic stem cell transplant.

In some embodiments, donor lymphocyte infusions (DLI) are administered to the patient. A donor lymphocyte infusion is an infusion of blood cells into which the original stem donor CD3 + lymphocytes are infused, after transplantation, to enhance an anti-tumor immune response or to ensure that the donor stem cells remain grafted. These donated white blood cells contain cells of the immune system that can recognize and destroy cancer cells. In some embodiments, the therapy induces remission of the patient's cancer by a graft-versus-tumor effect (GVT). In some embodiments, donor T cells can attack and control the growth of residual cancer cells that provide the GVT effect. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient. In some embodiments, the DLI comprises CD3 + lymphocytes. In some embodiments, one or more donor lymphocyte infusions (DLI) are administered to the patient after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of Formula (A) is administered concurrently with a DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of Formula (A) is administered before DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of Formula (A) is administered after DLI after allogeneic bone marrow or hematopoietic stem cell transplantation. In some embodiments, the compound of Formula (A) is ibrutinib.

In some embodiments, the patient has non-Hodgkin lymphoma. In some embodiments, the patient has Hodgkin lymphoma. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), diffuse large B-cell lymphoma Activated B (ABC-DLBCL), diffuse germ center B cell lymphoma (GCB DLBCL), primary mediastinal B cell lymphoma (PMBL), Burkitt lymphoma, immunoblastic large cell lymphoma, Precursor B-cell lymphoblastic lymphoma, mantle cell lymphoma (MCL), B-cell prolymphocytic leukemia, lymphoplasmocytic lymphoma, Waldenstrbm macroglobulinemia, marginal zone splenic lymphoma, plasmacytoma, marginal zone extranodal B-cell lymphoma , B-cell lymphoma, marginal nodal zone, large B-cell lymphoma of the mediastinum (thymus), cell lymphoma

Large intravascular B, primary cavity lymphoma, or lymphomatoid granulomatosis. In some embodiments, the patient has malignant T-cell disease. In some embodiments, the malignant T-cell disease is peripheral T-cell lymphoma not otherwise specified (PTCL-NOS), anaplastic large cell lymphoma, angioimmunoblastic lymphoma, cutaneous T-cell lymphoma, leukemia / T-cell lymphoma. adults (ATLL), blastic NK-cell lymphoma, enteropathy-type T-cell lymphoma, hemato-splenic gamma-delta T-cell lymphoma, lymphoblastic lymphoma, nasal T / NK-cell lymphomas, or treatment-related T-cell lymphomas. In some embodiments, the subject has multiple myeloma.

In some embodiments, the patient has a relapsed or refractory hematologic cancer. In some embodiments, the relapsed or refractory hematologic cancer is a leukemia, a lymphoma, or a myeloma. In some embodiments, the relapsed or refractory hematologic cancer is non-Hodgkin lymphoma.

In some embodiments, the relapsed or refractory hematologic cancer is Hodgkin lymphoma.

In some embodiments, refractory relapsed hematologic cancer is a malignant cell disease

In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), diffuse large B-cell lymphoma and cell Activated B (ABC-DLBCL), diffuse germ center large B-cell lymphoma (GCB DLBCL), primary mediastinal B-cell lymphoma (PMBL), Burkitt lymphoma, immunoblastic large cell lymphoma, Precursor B-cell lymphoblastic lymphoma, mantle cell lymphoma (MCL), B-cell prolymphocytic leukemia, lymphoplasmocytic lymphoma, Waldenstrom macroglobulinemia, B-cell splenic lymphoma, plasma cell myeloma, marginal zone lymphoma B-cell lymphoma, B-cell nodal marginal zone lymphoma, large B-cell lymphoma of the mediastinum (thymus), intravascular large B-cell lymphoma, primary effusion lymphoma, or lymphomatoid granulomatosis.

In some embodiments, relapsed or refractory hematologic cancer is a malignant T-cell disease. In some embodiments, malignant T-cell disease is otherwise unspecified peripheral T-cell lymphoma (PTCL-NOS), anaplastic large cell lymphoma, angioimmunoblastic lymphoma, cutaneous T-cell lymphoma, adult T-cell leukemia / lymphoma (ATLL), Blastic NK Cell Lymphoma, Enteropathy-type T-Cell Lymphoma, Hemato-splenic Gamma-Delta Cell Lymphoma, Lymphoblastic Lymphoma, Cell Lymphomas

Nasal T / NK, or treatment-related T-cell lymphomas. In some embodiments, the subject has a relapsed or refractory multiple myeloma. In some embodiments, the patient has malignant B-cell disease. In some embodiments, the malignant B-cell disease is non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is chronic lymphocytic leukemia (CLL). In some embodiments, the B-cell malignancy is a relapsed or refractory B-cell malignant disease. In some embodiments, the malignant B-cell disease is a relapsed or refractory non-Hodgkin lymphoma. In some embodiments, the malignant B-cell disease is a relapsed or refractory CLL.

In some embodiments, the patient exhibits one or more symptoms of hematologic cancer. In some embodiments, the subject exhibits one or more symptoms of malignant B-cell disease. In some embodiments, the subject exhibits one or more symptoms of leukemia, lymphoma, or myeloma. In some embodiments, the subject exhibits one or more symptoms such as, but not limited to, abnormal B cell function, abnormal B cell shape or size, abnormal B cell count, fatigue, fever, night sweats, frequent infection , enlarged lymph nodes, paleness, anemia, easy bleeding, bruising, loss of appetite, weight loss, bone or joint pain, headaches, and petechiae.

In some embodiments, the subject is at high risk for cancer recurrence. In some embodiments, the subject is a mammal, such as, but not limited to, a human, non-human primate, mouse, rat, rabbit, goat, dog, cat, or cow. In some embodiments, the mammal is a human. In some embodiments, a high risk of cancer recurrence is determined based on the expression or the presence of a biomarker. In some embodiments, the biomarker includes heterozygous PMSB1 P11A G / C, CD68, cytokine signaling suppressor 1 (SOCS1), LIM domain only 2 (LMO2), CD137, or a combination thereof.

Combination therapies

In some embodiments, the additional therapeutic agent is an anti-GVHD therapeutic agent. In some embodiments, the anti-GVHD therapeutic agent is an immunosuppressive drug. In some embodiments, the immunosuppressive drug includes cyclosporine, tacrolimus, methotrexate, mycophenolate mofetil, corticosteroids, azathioprine, or antithymocytic globulin (ATG). In some embodiments, the immunosuppressive drug is a monoclonal antibody (eg, anti-CD3, anti-CD5, and anti IL-2 antibodies). In some embodiments, the immunosuppressive drug is mycophenolate mofetil, alemtuzumab, antithymocytic globulin (ATG), sirolimus, tacrolimus, thalidomide, daclizumab, infliximab, or clofazimine for use in the treatment of chronic GVHD. In some embodiments, the additional therapeutic agent is denileukin diftitox, defibrotide, budesonide, beclomethasone dipropionate, or pentostatin.

In some embodiments, the additional therapeutic agent is an IL-6 receptor inhibitor. In some embodiments, the additional therapeutic agent is an IL-6 receptor antibody.

In some embodiments, the additional therapeutic agent is a TLR5 agonist.

In some embodiments, the patient undergoes additional therapy such as extracorporeal photopheresis or infusion of mesenchymal stem cells or donor lymphocytes.

In some embodiments, the additional therapeutic agent is a topically active corticosteroid (CAT).

In some embodiments, the

TAC is Beclomethasone Dipropionate, Alciomethasone Dipropionate, Budesonide, Budesonide

22S, budesonide

22R, beclomethasone-17- monopropionate, betamethasone, clobetasol propionate, dexamethasone, diflorasone diacetate, flunisolide, fluocinonide, flurandrenolide propionate, halokethasone propionate, halcinocide furoate, mometasone furoate .

In some embodiments, the additional therapeutic agent is an antifungal agent. In some embodiments, the additional therapeutic agent is nystatin, clotrimazole, amphotericin, itraconazole, fluconazole, or a combination thereof.

In some embodiments, the additional therapeutic agent is a sialologist. In some embodiments, the additional therapeutic agent is cevimeline, pilocarpine, betanecol, or a combination thereof.

In some embodiments, the additional therapeutic agent is a topical anesthetic. In some embodiments, the additional therapeutic agent is lidocaine, diclonin, diphenhydramine, doxepin, or a combination thereof.

In the methods described herein, any appropriate technique for chemotherapy, biotherapy, immunosuppression, and radiation therapy known in the art can be used. For example, the chemotherapeutic agent can be any agent that has an oncolytic effect against cancer cells or neoplastic cells of the subject. For example, the chemotherapeutic agent may be, without limitation, an anthracycline, an alkylating agent, an alkyl sulfonate, an aziridine, an ethyleneimine, a methylenelamine, a nitrogen mustard, a nitrosourea, an antibiotic, an antimetabolite, an analog of folic acid, a purine analog, a pyrimidine analog, an enzyme, a podophyllotoxin, a platinum-containing agent, or a cytokine. Preferably, the chemotherapeutic agent is one that is known to be effective against the particular cell type that is cancerous or neoplastic. In some embodiments, the chemotherapeutic agent is effective in the treatment of hematopoietic malignancies, such as thiotepa, cisplatin-based compounds, and cyclophosphamide. Cytokines include interferons, G-CSF, erythropoietin, GM-CSF, interleukins, parathyroid hormone, and the like. Biotherapies include alemtuzumab, rituximab, bevacizumab, vascular disrupting agents, lenalidomide, and the like. Radiosensitizers include nicotinamide, and the like.

In some administered in embodiments, the ACK inhibitor is combined with a chemotherapeutic biological agent selected from an antibody, an inhibitor via B cell receptor, a T cell receptor inhibitor, a PI3K inhibitor, an IAP inhibitor, an inhibitor mTOR, an immunotherapeutic radio, an agent that damages the

DNA, a histone deacetylase inhibitor, a protein kinase inhibitor, a hedgehog inhibitor, an inhibitor of

Hsp90, a telomerase inhibitor, an inhibitor of

Jakl / 2, a protease inhibitor, an IRAK inhibitor, a PKC inhibitor, a PARP inhibitor, an inhibitor of

CYP3A4, an inhibitor of AKT, an inhibitor of

Erk, a proteasome inhibitor, an alkylating agent, an anti-metabolite, a plant alkaloid, a terpenoid, a cytotoxin, a topoisomerase inhibitor, or a combination thereof. In some embodiments, the B cell receptor pathway inhibitor is a CD79A inhibitor, a CD79B inhibitor, a CD19 inhibitor, a Lyn inhibitor, a Syk inhibitor, a PI3K inhibitor, a Blnk inhibitor, a PLCy inhibitor, an inhibitor of

ΡΚΟβ, a CD22 inhibitor, a Bcl-2 inhibitor, an IRAK-4 inhibitor, a JAK inhibitor (eg ruxolitinib, baricitinib, | CYT387, lestauritinib, pacritinib,

TG101348, SAR302503, tofacitinib (Xeljanz), etanercept (Enbrel), GLPG0634, R256), a microtubule inhibitor, a Topo II inhibitor, anti-TWEAK antibody, bispecific anti-IL17 antibody, a CK2 kinase inhibitor of lymphoma (ALK) and c-Met inhibitors, inhibitors of the enzyme demethylase such as demethylase, HDM,

LSDI and KDM, fatty acid synthase inhibitors such as spirocyclic piperidine derivatives, glucocorticosteroid receptor agonist, anti-CD19 fusion conjugate cytotoxic agent, antimetabolite, p70S6K inhibitor, immunomodulators, AKT / PKAC-3 activator -1, BRAF inhibitor, lactate dehydrogenase A (LDH-A) inhibitor, CCR2 inhibitor, CXCR4 inhibitor, chemokine receptor antagonists, double-stranded DNA break repair inhibitors, NOR202, GA-101, TLR2 inhibitor, or a combination thereof. In some embodiments, the T cell receptor inhibitor is Muromonab-CD3. In some embodiments, the chemotherapeutic agent is selected from rituximab (Rituxan), carfilzomib, fludarabine, cyclophosphamide, vincristine, prednisalone, chlorambucil, ifosfamide, doxorubicin, mesalazine, thalidomide, revimid, lenalidomide, temsirin, lenalidomide, temsir , dexamethasone, bendamustine, prednisone, CAL-101, ibritumomab, tositumomab, bortezomib, pentostatin, endostatin, ritonavir, ketoconazole, an anti-VEGF antibody, herceptin, cetuximab, cisplatin, carboplatin, docetaxel, erlotinib, etoposide, 5fluorouracil, gemcitabine, ifosfamide, imatinib (Gleevec) mesylate, gefitinib, erlotinib, procarbazine, irinotecan, meucovorin, meucovorin, meucovorin, leucovorin , topotecan, vinblastine, GA-1101, dasatinib, Sipuleucel-T, disulfiram, epigallocatechin-3-gallate, salinosporamide A, ONX0912, CEP18770, MLN9708, R-406, lenalinomide, spirocyclic piperidine derivatives, azetidine compounds quinazoline carboxamide, thiotepa, DWA2114R, NK121, IS 3 295, 254-S, alkyl sulfonates, such as busulfan, improsulfan and piposulfan; aziridines such as benzodepa, carboquinone carbocuone, meturedepa and uredepa; ethyleneimine, methylmelamines such as altretamine, triethylenemelamine, triethylenephosphoramide, triethylenethiophosphoramide and trimethylmelamine; chlornafazine; estramustine; ifosfamide;

mechlorethamine; hydrochloride oxide; novobiocin; fenesterin;

prednimustine; trophosphamide; uracil mustard; nitrosoureas such as carmustine, chlorozotocin, fotemustine, lomustine, nimustine, ranimustine;

antibiotics such as rincinomycin, actinomycin, anthramycin, azaserine, bleomycin, cactinomycin, calicheamycin, carubicin, carminomycin, carzinophilin, chromomycin, dactinomycin, daunorubicin, detorubicin,

6-diazo-5-oxo-L-norleucine, doxorubicin, epirubicin, esorubicin, idarubicin, marcelomycin, mitomycin, mycophenolic acid, nogalamycin, olivomycin, peplomycin, puromycin, chelamycin, rodorubicin, streptonrine, streptonine, streptonine , zorubicin;

antimetabolites such as methotrexate and

FU); folic acid analogs such as denopterin, methotrexate, pteropterin, trimetrexate;

purine analogs such as fludarabine,

6-mercaptopurine, tiamiprine, thioguanine;

pyrimidine analogs such as ancitabine, azacitidine,

6-azauridine, carmofur, cytarabine, dideoxyuridine, doxifluridine, enocitabine, floxuridine;

androgens such as calusterone, dromostanolone propionate, epitiostanol, mepitiostane, testolactone; anti-adrenals such as aminoglutethimide, mitotane, trilostane; folic acid enhancer such as folinic acid;

aceglatone;

aldosophosphamide glucoside;

aminolevulinic acid;

amsacrine;

bestrabucilo;

bisantrene;

edatrexate;

defosphamide;

demecolcin;

diazicuone;

eflornithine; eliptinium acetate; ethoglucid;

gallium nitrate; hydroxyurea; slow lonidamine;

mitoguazone;

mitoxantrone;

mopidamol; nitracrine; pentostatin; fenamet;

pyrarubicin;

podophyllic acid;

2-ethylhydrazide;

procarbazine;

polysaccharide-K;

razoxane;

sizofirán;

spirogermanium;

tenuazonic acid;

triazicuone;

trichlorothriethylamine; urethane;

vindesine;

dacarbazine;

manomustine;

mitobronitol;

mitolactol;

pipobromano;

gacytosine;

cytosine arabinoside; taxoids, for example, paclitaxel and docetaxel; 6-thioguanine; mercaptopurine;

methotrexate;

platinum analogs; platinum; etoposide (VP-16);

ifosfamide;

mitomycin C; mitoxantrone;

vincristine;

vinorelbine;

Navelbine; Novantrone; teniposide; daunomycin;

aminopterin;

Xeloda; ibandronate; CPT1

one; topoisomerase inhibitor

RFS 2000; difluoromethylornitine (DMFO) retinoic acid;

spiramycins;

Capecitabine;

pharmaceutically acceptable salts, acids or derivatives of anti-hormonal agents, such as antiestrogens including for example tamoxifen, raloxifene, 4 (5) -imidazoles, aromatase inhibitors, 4-hydroxytamoxyphene, trioxifene, keoxifen,

LY117018, onapristone and toremifene (Fareston); antiandrogens such as flutamide, nilutamide, bicalutamide, leuprolide, and goserelin;

ACK inhibitors like AVL-263 (Avila

Therapeutics / Celgene

Corporation),

AVL-292 (Avila

Therapeutics / Celgene

Corporation),

AVL-291 (Avila

Therapeutics / Celgene

Squibb), BMS-509744

Corporation), BMS-488516 (Bristol-Myers Squibb), (Bristol-Myers

CGI-1746 (CGI

Pharma / Gilead Sciences), CTA-056, GDC-0834 (Genentech), HY11066 (also, CTK4I7891, HMS3265G21, HMS3265G22,

HMS3265H21, HMS3265H22, 439574-61-5, AG-F-54930), ONO-4059 (Ono Pharmaceutical Co., Ltd.), ONO-WG37 (Ono Pharmaceutical Co., Ltd.), PLS-123 (Peking University ), RN486 (HoffmannLa Roche), HM71224 (Hanmi Pharmaceutical Company Limited) or a combination thereof.

When an additional agent is co-administered with an ACK inhibitor, the additional agent and ACK inhibitor do not have to be administered in the same pharmaceutical composition, and are optionally, due to different physical and chemical characteristics, administered by different routes. Initial administration is performed, for example, according to established protocols, and then, based on observed effects, the dosage, modes of administration, and times of administration are modified.

100

By way of example only, if a side effect experienced by an individual on ACK inhibitor reception is nausea, then it is appropriate to administer an anti-emetic agent in combination with the ACK inhibitor.

<td>0, so</td><td>of example</td><td>only the</td><td colspan="2">effectiveness</td>

<td>therapeutics of a</td><td>inhibitor</td><td>ACK is described</td><td>in</td><td>this</td>

<td>document looks</td><td>enhanced by</td><td>the administration</td><td>of</td><td>a</td>

adjuvant (ie, by itself the adjuvant has minimal therapeutic benefit, but in combination with another therapeutic agent, the overall therapeutic benefit to the patient is enhanced). Or, by way of example only, the benefit experienced by an individual is increased by administration of an ACK inhibitor described herein with another therapeutic agent (which also includes a therapeutic regimen) which also has therapeutic benefit. In any case, regardless of the

<td>disease,</td><td>disorder</td><td>what i</td><td>is being treated,</td><td>the</td><td>benefit</td>

<td colspan="2">global experienced</td><td>by</td><td>the patient is</td><td>in</td><td>some</td>

<td>realizations</td><td colspan="2">simply</td><td>additive of</td><td>two</td><td>agents</td>

<td>therapeutic</td><td>or in</td><td>others</td><td>achievements,</td><td>the</td><td>patient</td>

experiences a synergistic benefit.

The particular choice of compounds used

101 It will depend on the diagnosis of the attending physicians and their judgment of the patient's condition and the appropriate treatment protocol.

The compounds are optionally administered at the same time (eg, simultaneously, essentially simultaneously within the same protocol depending on the nature of the disorder, the condition of the patient, and the actual choice of compounds used. The determination of the order of administration, and the number of repetitions of administration of each therapeutic agent during a treatment protocol, is based on an evaluation of the disease being treated and the condition of the patient.

In some embodiments, therapeutically effective doses vary when the drugs are used in treatment combinations. Methods for experimentally determining therapeutically agent doses for use in combination are described in effective drug and other treatment regimens in the literature. For example, the use of metronome dosing, i.e. providing lower, more frequent doses, in order to minimize toxic side effects, combination therapy has been widely described in the literature, further includes periodic treatments that start and stop on several occasions to help with the clinical management of the patient.

102

For the combination therapies described herein, dosages of the co-administered compounds will of course vary depending on the type of co-drug used, the specific drug used, the disease being treated, and so on. Furthermore, when co-administered with an additional therapeutic agent, an ACK inhibitor described herein is administered simultaneously with the additional therapeutic agent, or sequentially. If administered sequentially, the treating physician will decide on the appropriate protein administration sequence in combination with the biologically active agent (s).

If the additional therapeutic agent and ACK inhibitor are administered simultaneously, the multiple therapeutic agents are optionally provided in a single, unified, or multiple form (by way of example only, either as a single pill or as two separate pills ). In some embodiments, one of the therapeutic agents is given in multiple doses, or both are given in multiple doses. If not simultaneous, the time between multiple doses is from about more than zero weeks to less than about four weeks. Furthermore, combination methods, compositions and formulations should not be limited to the use of only two agents; the use of

103 Multiple therapeutic combinations are also envisioned.

It is understood that the dosage regimen to treat, prevent, or improve the condition (s) for which relief is sought may be modified according to a variety of factors. These factors include the disorder the subject is suffering from, as well as the subject's age, weight, sex, diet and medical condition. Therefore, the dosage regimen currently employed can vary widely and therefore may deviate from the dosage regimens set forth herein.

In some embodiments, the pharmaceutical agents that make up the combination therapy disclosed herein are administered in a combined dosage form or in separate dosage forms intended for substantially simultaneous administration. In some embodiments, the pharmaceutical agents that make up the combination therapy are administered sequentially, either with the compound or therapeutic that is administered by a regimen that requires two-stage administration. In some embodiments, the two-stage administration regimen requires sequential administration of the active agents or spaced administration of the separate active agents. The period of time between the administration of

104 Multiple stages vary from a few minutes to several hours, depending on the properties of each pharmaceutical agent, such as potency, solubility, bioavailability, plasma half-life and kinetic profile of the pharmaceutical agent. In some embodiments, the circadian variation in the target molecule concentration determines the optimal dose range.

In some embodiments, the ACK inhibitor compound and the additional therapeutic agent are administered in a unit dosage form. In some embodiments, the ACK inhibitor compound and the additional therapeutic agent are administered in separate dosage forms. In some embodiments, the ACK inhibitor compound and the additional therapeutic agent are administered simultaneously or sequentially.

Administration

105 example ibrutinib).

Additionally, the methods for reducing the severity of GVHD occurrence in a patient requiring cell transplantation comprising | administering to the patient a composition comprising a therapeutically effective amount of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib).

Also described in this document are methods of treating a patient for the relief of a disease mediated by bone marrow, with the relief of the consequent development of graft-versus-host disease (GVHD), which includes administering to the patient the hematopoietic stem cells allogeneic and / or allogenic T cells, wherein a therapeutically effective amount of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered before or simultaneously with allogeneic hematopoietic stem cells and / or allogeneic T cells. In some embodiments, the ACK inhibitor compound is (R) —1- (3- (4 amino-3- (4-phenoxyphenyl) -lH-pyrazolo [3,4-d] pyrimidin-1yl) piperidin-l-yl) prop-2-en-l-ona (ie, PCI32765 / ibrutinib).

106

The ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered before, during or after the development of GVHD. In some embodiments, the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is used as a prophylactic treatment and is administered continuously to subjects with a propensity to develop GVHD (eg , allogeneic transplant recipients). In some embodiments, the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as, for example, ibrutinib) is administered to an individual during or as soon as possible after the development of GVHD. In some embodiments, administration of the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as, for example, ibrutinib) begins within the first 48 hours of symptom onset, within the first 6 hours of onset of symptoms, or within 3 hours of onset of symptoms. In some embodiments, the initial administration of the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is via any practical route, such as, for example, an intravenous injection, an injection of bolus, infusion for 5 minutes to about 5 hours, one pill, one capsule, one tablet, one patch

107 transdermal, oral delivery, and the like, or a combination thereof. The ACK inhibitor compound (for example, an ITK or BTK inhibitor, such as for example ibrutinib) should be administered as soon as possible after a disorder is detected or suspected, and for a length of time required for treatment of the disease, such as, for example, from about 1 month to about 3 months. The duration of treatment can vary for each subject, and the duration can be determined using known criteria. In some embodiments, the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered for at least 2 weeks, between about 1 month to about 5 years, or from about 1 month to about 3 years.

Therapeutically effective amounts will depend on the severity and course of the disease, previous therapy, the patient's health status, weight, and response to the drugs, and the judgment of the treating physician. Prophylactically effective amounts depend on the patient's health status, weight, severity and course of disease, previous therapy, response to drugs, and judgment of the attending physician.

108

In some embodiments, the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered to the patient on a regular basis, eg, three times a day, twice a day, once daily, every other day or every 3 days. In other embodiments, the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered to the patient intermittently, eg, twice a day followed by once a day followed by three times a day; or the first two days of each week; or the first, second and third day of a week. In some embodiments, intermittent administration is as effective as the regular dose. In additional or alternative embodiments, the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered only when the patient exhibits a particular symptom, eg, the onset of pain, or the onset fever, or

<td colspan="2">appearance</td><td>of</td><td>an inflammation, or</td><td>the appearance of</td><td>a</td>

<td>disorder</td><td>of</td><td>the</td><td>skin. Schemes of</td><td>dosage of</td><td>every</td>

<td>compound</td><td colspan="2">can</td><td>depend on the</td><td>another, or you can</td><td>to be</td>

independent of the other.

In the case where the patient's condition does not improve, at the discretion of the doctor, the compounds can be administered chronically, that is, for a period

109 prolonged period of time, including throughout the duration of the patient's life in order to improve or otherwise control or limit the symptoms of the patient's disorder.

In the case where the patient's condition improves, at the discretion of the physician the compounds can be administered continuously; alternatively, the dose of the drug being administered can be temporarily reduced or temporarily suspended for a certain period of time (ie, a drug break). The duration of the drug rest can vary between 2 days and 1 year, including by way of example only, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 10 days, 12 days, 15 days, 20 days, 28 days, 35 days, 50 days, 70 days, 100 days, 120 days, 150 days, 180 days, 200 days, 250 days, 280 days, 300 days, 320 days, 350 days or 365 days. The dose reduction during a drug break may be 10% -100%, including, by way of example only, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45% , 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100%.

Once improvement of the patient's conditions has occurred, a maintenance regimen is administered if necessary. Subsequently, the dose or frequency of administration, or both, of the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as, for example,

110 ibrutinib) can be reduced, as a function of symptoms, to a level at which the individual's improved condition is maintained. People may, however, require long-term intermittent treatment for any recurrence of symptoms.

The amount of the ACK inhibitor compound (for example, an ITK inhibitor or

BTK, such as for example ibrutinib) will vary depending on factors such as the particular compound, disorder and its severity, identity or host in need of treatment, and is determined according to the particular circumstances surrounding the case, including, for example , the specific agents being administered, the routes of administration, and the subject or host being treated.

In general, however, the doses used for adult human treatment will generally be in the range of

0.02

1500 mg per day.

intervals

5000 mg approximately to

The per day, or simultaneously (or single dose or

<td>dose</td><td>desired</td><td colspan="2">can be presented in a</td>

<td>how</td><td>dose</td><td>divided</td><td>administered</td>

<td>in a</td><td>short</td><td>period of</td><td>time) or</td>

<td>5, for</td><td>example,</td><td>comfortable,</td><td>three, four or</td>

more sub-doses per day.

In some embodiments, the therapeutic amount of the

111 ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is 100 mg / day up to, and including, up to, and including, 2000 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is from 140 mg / day to, and including, 840 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is from 420 mg / day to, and including, 840 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 40 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 140 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 280 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 420 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 560 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an inhibitor of

112

ITK or BTK, such as for example ibrutinib) is approximately 700 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 840 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 980 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 1120 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 1260 mg / day. In some embodiments, the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is approximately 1,400 mg / day. In some embodiments, a compound of Formula (A) is administered at a dose between about 0.1 mg / kg per day to about 100 mg / kg per day.

In some embodiments, the dose of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as, for example, ibrutinib) is scaled over time. In some embodiments, the ACK inhibitor dose (eg, an ITK or BTK inhibitor, such as ibrutinib, for example) is scaled, for example, from or about 1.25 mg / kg / day to or

113 approximately 12.5 mg / kg / day for a specified period of time. In some embodiments the predetermined time period is more than 1 month, more than 2 months, more than 3 months, more than 4 months, more than 5 months, more than 6 months, more than 7 months, more than 8 months, more 9 months, more than 10 months, more than 11 months, more than 12 months, more than 18 months, more than 24 months or more.

The ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) can be formulated into unit dosage forms appropriate for single administration of precise doses. In unit dosage form, the formulation is divided into unit doses containing appropriate amounts of one or both compounds. The unit dose may be in the form of a container containing discrete amounts of the formulation. Non-limiting examples are packaged tablets or capsules, and powders in vials or ampoules. Aqueous suspension compositions can be packaged in single dose containers and cannot be resealed. Alternatively, multi-dose reclosable containers may be used, in which case it is typical to include a preservative in the composition. By way of example only, formulations for parenteral injection may be presented in unit dosage form, including,

114 but they are not limited to ampoules, or in multi-dose containers, with an added preservative.

It is understood that a dosage regimen will be determined by a medical professional in accordance with a variety of factors. These factors include the subject's severity of GVHD, as well as the subject's age, weight, sex, diet, and medical condition.

Compounds

115 a therapeutically effective amount of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered prior to or simultaneously with allogeneic hematopoietic stem cells and / or allogeneic T cells.

In the following description of the irreversible BTK compounds appropriate for use in the methods described in this document, the definitions of referring to standard chemistry terms can be found in reference works (unless otherwise defined in this document), including Carey and Sundberg Advanced Organic Chemistry 4th Ed. Vols. A (2000) and B (2001), Plenum Press, New York. Unless otherwise indicated, conventional methods of mass spectroscopy, NMR, HPLC, protein chemistry, biochemistry, recombinant DNA techniques, and pharmacology are employed within the ordinary skill of the art. Furthermore, nucleic acid sequences

<td colspan="4">and amino acids for</td><td>BTK</td><td>(by</td><td>example,</td><td>BTK</td><td>human)</td><td>I know</td>

<td>know</td><td>in</td><td>the</td><td>technique</td><td colspan="3">as revealed in,</td><td>by</td><td>example,</td><td>the</td>

<td>Patent</td><td>of</td><td>the</td><td>state</td><td>United</td><td>No.</td><td> 6, 326,469</td><td>. TO</td><td>less than</td><td>I know</td>

provide specific definitions, nomenclature used in relation to, and laboratory, analytical chemistry, synthetic organic chemistry, pharmaceutical and medicinal chemistry procedures and techniques described in this document.

116 are those known in the art. Standard techniques can be used for chemical synthesis, chemical analysis, pharmaceutical preparation, formulation, and administration, and treatment of patients.

The co:

BTK inhibitors described herein are selective for BTK and kinases that have a cysteine residue at a position in the amino acid sequence of tyrosine kinase that is homologous to the position of the cysteine 481 amino acid sequence in BTK. In general, an irreversible BTK inhibitor compound used in the methods described herein is identified or characterized in an in vitro assay, eg, an acellular biochemical assay or a cellular functional assay. Such assays are useful in determining an IC50 in vitro for an irreversible BTK inhibitor compound.

For example, an acellular kinase assay can be used to determine BTK activity after kinase incubation in the absence or presence of a range of concentrations of an irreversible candidate BTK inhibitor compound. If the candidate compound is, in fact, an irreversible BTK inhibitor, BTK kinase activity will not be recovered by repeated washing with inhibitor-free medium. See, eg, JB Smaill, et al.

117 (1999), J. Med. Chem. 42 (10): 1803-1815. Furthermore, the formation of the covalent complex between BTK and a candidate irreversible BTK inhibitor is a useful indicator of irreversible BTK inhibition that can be readily determined by a number of methods known in the art (eg, mass spectrometry). For example, some irreversible BTK inhibitor compounds can form a covalent bond with BTK Cys 481 (eg, via a Michael reaction).

Cellular functional assays for BTK inhibition include measurement of one or more cell endpoints in response to stimulation of a BTK-mediated pathway in a cell line (eg, BCR activation in Ramos cells) in the absence or presence of a range of concentrations of a candidate irreversible BTK inhibitor compound. Useful endpoints for determining a response to BCR activation include, for example, BTK autophosphorylation, phosphorylation of a BTK target protein (eg, PLC-γ), and cytoplasmic calcium flux.

High throughput assays for many acellular biochemical assays (eg, kinase assays) and cellular functional assays (eg, calcium flux) are well known to those of ordinary skill in the art.

118

Additionally, high-performance screening systems are commercially available (see, for example, Zymark Corp., Hopkinton, MA; Air Technical Industries, Mentor, OH; Beckman Instrumente, Inc. Fullerton, CA; Precision Systems, Inc., Natick , MA, etc.). These systems generally automate comprehensive procedures that include all reagent and sample pipetting, liquid dispensing, timed incubations, and final microplate readings in appropriate detector (s) for the assay. Automated systems thus allow the identification and characterization of a large number of irreversible BTK compounds without undue effort.

In some embodiments, the BTK inhibitor is selected from the group consisting of a small organic molecule, a macromolecule, a peptide, or a non-peptide.

In some embodiments, the BTK inhibitor provided herein is a reversible or irreversible inhibitor. In certain embodiments, the BTK inhibitor is an irreversible inhibitor.

In some embodiments, the irreversible BTK inhibitor forms a covalent bond with a Bruton tyrosine kinase cysteine side chain, a Bruton tyrosine kinase homolog, or a tyrosine kinase homolog.

119 BTK cistern.

The irreversible BTK inhibitor compounds can be used for the manufacture of a medicament to treat any of the above conditions (eg, autoimmune diseases, | inflammatory diseases, allergic disorders, B-cell proliferative disorders, or thromboembolic disorders).

In some embodiments, the irreversible BTK inhibitor compound used for the methods described herein inhibits BTK or a BTK homologous kinase activity with an in vitro IC50 of less than 10 µΜ (eg less than 1 µΜ, less than 0.5 µΜ, less than 0.4 µΜ, less than 0.3 µΜ, less than 0.1, less than 0.08 µΜ, less than 0.06 µΜ, less than 0.05 µΜ, less than 0.04 µΜ, less than 0.03 µΜ, less than less than 0.02 µΜ, less than 0.01, less than 0.008 μΜ, less than 0.006 μΜ, less than 0.005 μΜ, less than 0.004 µΜ, less than 0.003 µΜ, less than less than 0.002 µΜ, less than 0.001, less than 0.00099 µΜ, less than 0.00098 µΜ, less than 0.00097 µΜ, less than 0.00096 µΜ, less than 0.00095 µΜ, less than 0.00094 µΜ , less than 0.00093 μΜ, less than 0.00092, or less than 0.00090 μΜ).

In some embodiments, the irreversible BTK inhibitor compound is selected from ibrutinib (PCI-32765), PCI

120

45292, PCI-45466, AVL-101, AVL-291, AVL-292, or ONO-GT-37. In some embodiments, the irreversible BTK inhibitor compound is ibrutinib.

In one embodiment, the selective and irreversible irreversible BTK inhibitor compound inhibits an activated form of its target tyrosine kinase (eg, a phosphorylated form of tyrosine kinase). For example, activated BTK is phosphorylated at tyrosine 551. Therefore, in these embodiments, the irreversible BTK inhibitor inhibits the target kinase in cells only once the target kinase is activated by signaling events.

In other embodiments, the BTK inhibitor used in the methods described herein has the structure of any of Formula (A). Also described herein are pharmaceutically acceptable salts, pharmaceutically acceptable solvates, pharmaceutically active metabolites, and pharmaceutically acceptable prodrugs of such compounds. Pharmaceutical compositions are provided that include at least one such compound or a pharmaceutically acceptable salt, pharmaceutically acceptable solvate, pharmaceutically active metabolite, or pharmaceutically acceptable prodrug of such compound.

Definition of standard chemistry terms is

121 found in

Sundberg Advanced reference works, including Carey and

Organic Chemistry 4th Ed. Vols. A (2000) and B (2001), Plenum

Press, New York. Unless otherwise indicated, conventional mass spectroscopy methods are employed,

NMR,

HPLC, protein chemistry, biochemistry, techniques

Recombinant DNA pharmacology, within the experience of the technique.

Unless specific definitions are provided, the nomenclature employed in connection with, and the procedures and techniques of, analytical chemistry, organic synthesis chemistry, and medical and pharmaceutical chemistry described in this laboratory document are those known in the art. Standard techniques are optionally used for chemical synthesis, chemical analysis, pharmaceutical preparation, formulation, and delivery, and patient treatment. Optionally, standard techniques are used for recombinant DNA, oligonucleotide synthesis, and tissue culture and transformation (eg, electroporation, lipofection). Reactions and purification techniques are carried out using documented methodologies or as described in this document.

It should be understood that the methods and compositions described in this document are not limited to the particular methodology, protocols, cell lines, constructs, and

122 reagents described in this document and, as such, optionally, vary. It should also be understood that the terminology used in this document is for the purpose of describing only particular embodiments, and is not intended to limit the scope of the methods and compositions described in this document, which will be limited only by the appended claims.

Unless otherwise indicated, the terms used for complex structural units (ie, multiple chains of structural units) are to be read equivalently, either left to right or right to left. For example, the alkylenecycloalkylene group refers to either an alkylene group, followed by a cycloalkylene group, or a cycloalkylene group followed by an alkylene group.

<td>The</td><td colspan="3">suffix eno attached</td><td colspan="3">to a group indicates that said</td>

<td>group is</td><td>a dirradical.</td><td colspan="3">Only by way</td><td>of</td><td>example a</td>

<td>methylene</td><td>is a dirradical</td><td>of</td><td>a</td><td>methyl group,</td><td>is</td><td>say it's a</td>

<td colspan="2">group -CH2-; and an ethylene</td><td>is</td><td>a</td><td>dirradical of</td><td>a</td><td>ethyl group,</td>

<td>A</td><td>alkyl group</td><td>I know</td><td colspan="3">refers to a group</td><td>hydrocarbon</td>

aliphatic. The alkyl structural unit includes a saturated alkyl group, which means that it does not contain any

123 alkene or alkyne structural unit. The alkyl structural unit also includes an unsaturated alkyl structural unit, meaning that it contains at least one alkene or alkyne structural unit. An alkene structural unit refers to a group having at least one carbon-carbon double bond, and an alkyne structural unit refers to a group having at least one carbon-carbon triple bond. The alkyl structural unit, whether saturated or unsaturated, includes linear, branched, or cyclic chain structural units. Depending on the structure, an alkyl group includes a monoradical or a dirradical (ie, an alkylene group), and whether a lower alkyl has 1 to 6 carbon atoms.

As used in this document, Cl-Cx includes C1-C2, ClC3 ... Cl-Cx.

The alkyl structural unit at 10 carbon atoms (always document, a numerical range such every integer in the carbon atoms range means select from a structural unit as that given,

<td colspan="3">optionally has</td>

<td>than</td><td colspan="2">appears in this</td>

<td>1 a</td><td>10 refers</td><td>to</td>

<td>by</td><td>example the</td><td> 10</td>

<td colspan="2">the alkyl group</td><td>I know</td>

carbon, etc., carbon, 2 carbon atoms, 3 atoms up to and including carbon atoms, although the present

124 definition also covers the occurrence of the term alkyl, where no numerical range is designated). The alkyl group of the compounds described in this document can be designated as C1-C4 alkyl or similar designations. By way of example only, C1-C4 alkyl indicates that there are one to four carbon atoms in the alkyl chain, ie, the alkyl chain is selected from methyl, ethyl, propyl, iso-propyl, n-butyl, iso butyl, sec-butyl and t-butyl. Therefore, C1-C4 alkyl includes C1-C2 alkyl and ClC3 alkyl. The alkyl groups are optionally substituted or unsubstituted.

Typical alkyl groups include, but are in no way limited to, methyl, ethyl, propyl, isopropyl, butyl, isobutyl, tertiary butyl, pentyl, hexyl, ethenyl, propenyl, butenyl, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and the like. .

The term alkenyl refers to a type of alkyl group in which the first two atoms of the alkyl group form a double bond that is not part of an aromatic group. That is, an alkenyl group beginning with atoms C (R) = C (R) -R, where R refers to the remaining portions of the alkenyl group, which are either the same or different. The alkenyl structural unit is straight-chain or optionally branched, cyclic (in which case, it is also known as a cycloalkenyl group). Depending on the

125 structure, an alkenyl group includes a monoradical or a dirradical (ie, an alkenylene group). Alkenyl groups are optionally substituted. Non-limiting examples of an alkenyl group include -CH = CH2, -C (CH3) = CH2, CH = CHCH3, -C (CH3) = CHCH3. Alkenylene groups include, but are not limited to, -CH = CH-, -C (CH3) = CH-, -CH = CHCH2-, CH = CHCH2CH2- and -C (CH3) = CHCH2-. Alkenyl groups optionally have 2 to 10 carbons, and if lower alkenyl have 2 to 6 carbon atoms.

The term "alkynyl" refers to a type of alkyl group in which the first two atoms of the alkyl group form a triple bond. That is, an alkynyl group beginning with the atoms of -C ^ CR, where R refers to the remaining portions of the alkynyl group, which is either the same or different. The R portion of the alkynyl structural unit can be straight chain, branched, or cyclic. Depending on the structure, an alkynyl group includes a monoradical or a di-radical (ie, an alkynylene group). Alkynyl groups are optionally substituted. Non-limiting examples of an alkynyl group include, but are not limited to, -C = CH, -C ^ CCH3, -C ^ CCH2CH3, -C = C-, and C ^ CCH2-. Alkynyl groups optionally have 2 to 10 carbon atoms, and if a lower alkynyl have 2 to 6 carbon atoms.

126

An alkoxy group refers to an (alkyl) O- group, where alkyl is as defined herein.

Hydroxyalkyl refers to an alkyl radical, as defined herein, substituted with at least one hydroxy group.

Non-limiting examples of a hydroxyalkyl include, but are not limited to, hydroxymethyl,

2hydroxyethyl,

2-hydroxypropyl,

3-hydroxypropyl,

1 (hydroxymethyl)

-2-methylpropyl,

2-hydroxybutyl,

3-hydroxybutyl,

4-hydroxybutyl,

2,3-dihydroxypropyl,

1 (hydroxymethyl) -2-hydroxyethyl,

2,3-dihydroxybutyl,

3,4-dihydroxybutyl and 2- (hydroxymethyl) -3-hydroxypropyl.

Alkoxyalkyl refers to an alkyl radical, as defined herein, substituted with an alkoxy group, as defined herein.

The term "alkylamine" refers to the group N (alkyl) xHy, where x and y are selected from x = 1, y = 1 and x = 2, y = 0. When x = 2, the alkyl groups, taken together with the N atom at which are attached, optionally form a cyclic ring system.

"Alkylaminoalkyl" refers to an alkyl radical, as defined herein, substituted with an alkylamine, as defined herein.

127

Hydroxyalkylaminoalkyl refers to an alkyl radical, as defined herein, substituted with an alkylamine, and alkylhydroxy, as defined herein.

| Alkoxyalkylaminoalkyl refers to an alkyl radical, as defined herein, substituted with an alkylamine and substituted with an alkylalkoxy, as defined herein.

An amide is a chemical structural unit with the formula -C (O) NHR or -NHC (O) R, where R is selected from alkyl, cycloalkyl, aryl, heteroaryl (linked through one ring carbon) and heteroalicyclic (linked through a carbon ring). In some embodiments, an amide structural unit forms a bond between an amino acid or a peptide molecule and a compound described herein, thereby forming a prodrug. Any amine, or carboxyl side chain in the compounds described herein can be transformed into an amide. Specific procedures and groups for making such amides are found in sources such as Greene and Wuts, Protective Groups in Organic Synthesis, 3rd Ed., John Wiley & Sons, New York, NY, 1999, which is incorporated herein by reference herein. divulgation.

128

The term ester refers to a chemical structural unit with the formula -COOR, where R is selected from alkyl, cycloalkyl, aryl, heteroaryl (linked through one ring carbon) and heteroalicyclic (linked through one ring carbon) . Any hydroxy, or carboxyl side chain in the compounds described herein can be esterified. Specific procedures and groups for making such asters are found in sources

<td colspan="2">such as Greene</td><td>and</td><td colspan="2">Wuts, Protective</td><td>Groups i:</td><td colspan="2">n Organic</td>

<td>Synthesis, 3to</td><td>Ed.,</td><td>John</td><td>Wiley & Sons,</td><td>New</td><td>York, NY,</td><td> 1999,</td><td>than</td>

<td>is incorporated</td><td>in</td><td>this</td><td>document</td><td>by</td><td>reference</td><td>for</td><td>the</td>

present disclosure.

As used herein, the term ring refers to any closed covalent structure. Rings include, for example, carbocycles (eg, aryls and cycloalkyls), non-heterocycles (eg, heteroaryls and aromatics), aromatics (eg, aryl and heteroaryls), and nonaromatic (eg, cycloalkyls and heterocycles) rings may be optionally substituted.

The rings can be monocyclic or polycyclic.

As used herein, the term ring system refers to one or more than one ring.

129

The term member ring can encompass any cyclic structure. The term members is intended to indicate the number of atoms in the skeleton that make up the ring. Thus, for example, cyclohexyl, pyridine, pyran, and thiopyran are 6-membered rings and cyclopentyl, pyrrole, furan, and thiophene are 5-membered rings.

The term fused refers to structures in which two or more rings share one or more bonds.

The term carbocyclic or carbocycle refers to a ring where each of the atoms that make up the ring is a carbon atom. Carbocycle includes aryl and cycloalkyl. Thus, the term distinguishes carbocycle from heterocycle (heterocyclic) in that the ring skeleton contains at least one atom that is different from carbon (ie, a heteroatom). Heterocycle includes heteroaryl and heterocycloalkyl. Carbocycles and heterocycles can be optionally substituted.

The term aromatic refers to a flat ring that has a delocalized π-electron system containing 4n + 2 π electrons, where n is an integer. Aromatic rings can be formed from five, six, seven, eight, nine, or more than nine atoms. The aromatics can be optionally substituted. The aromatic term

130 it includes both carbocyclic aryl (eg, phenyl) and heterocyclic aryl (or heteroaryl or heteroaromatic) groups (eg, pyridine). The term includes monocyclic or polycyclic groups of fused rings (ie, rings that share adjacent pairs of carbon atoms).

As used herein, the term "aryl" refers to an aromatic ring where each of the ring-forming atoms is a carbon atom. Aryl rings can be made of five, six, seven, eight, nine, or more than nine carbon atoms. Aryl groups can be optionally substituted. Examples of aryl groups include, but are not limited to phenyl, naphthalenyl, phenanthrenyl, anthracenyl, fluorenyl, and indenyl. Depending on the structure, an aryl group can be either a monoradical or a dirradical (ie, an arylene group).

An aryloxy group refers to an (aryl) O- group, where aryl is as defined herein.

The term carbonyl, as used in this document

<td>refers to a</td><td>group containing a structural unit</td>

<td>selected from</td><td>group consisting of -C (O) -, -S (O) -,</td>

<td>S (O) 2-, and -C (S) -,</td><td>including, but not limited to, groups that</td>

contain at least one ketone group, and / or at least one group

131 aldehyde, and / or at least one ester group, and / or at least one carboxylic acid group, and / or at least one thioester group. Such carbonyl groups include ketones, aldehydes, carboxylic acids, esters, thioesters.

In some embodiments, these groups are a linear, branched, or cyclic part of molecules.

The term cycloalkyl refers to a monocyclic or polycyclic radical that contains only carbon and hydrogen, and is optionally saturated, partially unsaturated, or fully unsaturated. Cycloalkyl groups include groups having 3 to 10 ring atoms. Illustrative examples of cycloalkyl groups include the following structural units:

of and the like. Depending on the structure, a cycloalkyl group is either a

132 monoradical or a dirradical (eg, a cycloalkylene group), and whether a lower cycloalkyl having 3 to 8 carbon atoms.

Cycloalkylalkyl means an alkyl radical, as defined herein, | substituted with a cycloalkyl group. Non-limiting cycloalkylalkyl groups include cyclopropylmethyl, cyclobutylmethyl, cyclopentylmethyl, cyclohexylmethyl, and the like.

The term heterocycle refers to heteroaromatic and heteroalicyclic groups containing from one to four heteroatoms, each selected from 0, S and N, where each heterocyclic group has from 4 to 10 atoms in its ring system, and with the condition of that the ring of said group does not contain two adjacent 0 or S atoms. In this document, whenever the number of carbon atoms in a heterocycle is indicated (eg, C1-C6 heterocycle), at least one other atom (the heteroatom) must be present in the ring. Designations such as C1-C6 heterocycle refer only to the number of carbon atoms in the ring and do not refer to the total number of atoms in the ring. It is understood that the heterocyclic ring may have additional heteroatoms in the ring. Designations such as 4-6 membered heterocycle refer to the total number of

133 atoms that are contained in the ring (ie, a four, five, or six-membered ring, in which at least one atom is a carbon atom, at least one atom is a heteroatom, and the remaining two to four atoms are already be it carbon atoms or heteroatoms). In heterocycles having two or more heteroatoms, these two or more heteroatoms may be the same or different from each other. Heterocycles can be optionally substituted. Binding to a heterocycle can be at a heteroatom or through a carbon atom. Non-aromatic heterocyclic groups include groups that have only 4 atoms in their ring system, but aromatic heterocyclic groups must have at least 5 atoms in their ring system. Heterocyclic groups include benzo-fused ring systems. An example of a 4-membered heterocyclic group is azetidinyl (derived from azetidine). An example of a 5-membered heterocyclic group is thiazolyl. An example of a 6-membered heterocyclic group is pyridyl, and an example of a 10-membered heterocyclic group is quinolinyl. Examples of non-aromatic heterocyclic groups are pyrrolidinyl, tetrahydrofuranyl, dihydrofuranyl, tetrahydrothienyl, tetrahydropyranyl, dihydropyranyl, tetrahydrothiopyranyl, piperidino, morpholino, thiomorpholino, thioxanyl, piperazinyl, azetidinyl, oxethanil, tietanyl, tietanyl, tietanyl, oxethanyl, tietanyl, tienethyl, tietanyl, oxethanyl, tietanyl, tienethyl, oxethanyl

134 oxepanil, tiepanil, oxazepinil, diazepinil, thiazepinil,

1,2,3,6-tetrahydropyridinyl, 2-pyrrolinyl, 3-pyrrolinyl, indolinyl, 2H-pyranyl, 4H-pyranyl, dioxanyl, 1,3dioxolanyl, pyrazolinyl, dithianyl, dithiolanyl, dihydropyranyl, dihydrothienyl, dihydrofuranyl, pyrazolidinyl, imidazolidinyl, 3-azabicyclo [3.1.0] hexanyl, 3-azabicyclo [4.1.0] heptanyl, 3H-indolyl, and quinolizinyl. Examples of aromatic heterocyclic groups are pyridinyl, imidazolyl, pyrimidinyl, pyrazolyl, triazolyl, pyrazinyl, tetrazolyl, furyl, thienyl, isoxazolyl, thiazolyl, oxazolyl, isothiazolyl, pyrrolyl, quinolinyl, isoquinolinyl, indolyl, benzimidazolyl, benzofuranyl, cinnolinyl, indazolyl, indolizinyl , phthalazinyl, pyridazinyl, triazinyl, isoindolyl, pteridinyl, purinyl, oxadiazolyl, thiadiazolyl, furazanil, benzofurazanil, benzothiophenyl, benzothiazolyl, benzoxazolyl, quinazolinyl, quinoxalinyl, naphthyridinyl, and furopyridinyl. The above groups, as derivatives of the groups mentioned above, are optionally C-linked or N-linked when possible. For example, a group derived from pyrrole includes pyrrole-l-yl (linked to N) or pyrrole-3-yl (C-linked). Furthermore, a group derived from imidazole includes imidazol-l-yl or imidazol-

3-yl (both N-linked) or imidazol-2-yl, imidazol-4-yl

135 or imidazol-5-yl (all attached to C). Heterocyclic groups include benzo-fused ring systems and ring systems substituted with one or two oxo (= O) structural units such as pyrrolidin-2-one. Depending on the structure, a heterocycle group can be a monoradical (ie, a heterocycle group) or a dirradical.

The terms heteroaryl or, alternatively, heteroaromatic refer to an aromatic group that includes one or more ring heteroatoms selected from nitrogen, oxygen, and sulfur. An N-containing heteroaromatic or heteroaryl structural unit refers to an aromatic group in which at least one of the ring skeleton atoms is a nitrogen atom. Illustrative examples of heteroaryl groups include the following structural units:

136

and the like. Depending on the structure, a heteroaryl group can be a monoradical or a dirradical (ie, a heteroaryl group ^ no).

As used herein, the term "non-aromatic heterocycle, heteroalicyclic heterocycloalkyl" refers to a non-aromatic ring where one or more ring-forming atoms is a heteroatom. A non-aromatic heterocycle group or

"Heterocycloalkyl" refers to a cycloalkyl group that includes at least one heteroatom selected from nitrogen, oxygen and sulfur. In some embodiments, the radicals are fused with a heteroaryl aryl. Heterocycloalkyl rings can be made up of three, four, five, six, seven, eight, nine or more than nine atoms. Heterocycloalkyl rings can be optionally substituted. In certain embodiments, the non-aromatic heterocycles contain one or more carbonyl or thiocarbonyl groups, such as, for example, oxo- and thio- containing groups. Examples of heterocyclicalkyls include, but are not limited to, lactams, lactones, cyclic imides.

cyclic thioimides, cyclic carbamates, tetrahydrothiopyran,

137

4H-pyran, tetrahydropyran, piperidine, 1,3-dioxin, 1,3-dioxane, 1,4 dioxin, 1,4-dioxane, piperazine, 1,3-oxathian,

1,4-oxatiin, 1,4-oxatian, tetrahydro-1,4-thiazine, 2H-1,2oxazine, maleimide, succinimide, barbituric acid, thiobarbituric acid, dioxopiperazine, hydantoin, dihydrouracil, morpholine, trioxane, hexahydro-1, 3,5-triazine, tetrahydrothiophene, tetrahydrofuran, pyrroline, pyrrolidine, pyrrolidone, pyrrolidione, pyrazoline, pyrazolidine, imidazoline, imidazolidine, 1,3-dioxol, 1,3-dioxolane, 1,3-dithiol, 1,3-dithiolane, isoxazoline, isoxazolidine, oxazoline, oxazolidine, oxazolidinone, thiazoline, thiazolidine, and 1,3 oxathiolane. Illustrative examples of heterocycloalkyl groups, also referred to as non-aromatic heterocycles, include:

138 or

and the like. The term heteroalicyclic also includes all forms of carbohydrate rings including, but not limited to monosaccharides, disacchari

and the oligosaccharides.

Depending on the structure, a heterocycloalkyl group can be a monoradical or a dirradical (ie, a heterocycloalkylene group)

The term halo or, alternatively, halogen or halide means fluoro, chloro, bromo, and iodo.

The term haloalkyl refers to alkyl structures in which at least one hydrogen is replaced with a halogen atom. In certain embodiments where two or more hydrogen atoms are replaced with halogen atoms, the halogen atoms are all the same to each other. In other embodiments where two or more hydrogen atoms are replaced with halogen atoms, the halogen atoms are not all the same as the others.

The term fluoroalkyl, as used herein, refers to an alkyl group in which at least one hydrogen is replaced with a fluorine atom. Examples of fluoroalkyl groups include, but are not limited to, -CF3,

139

-CH2CF3, -CF2CF3, -CH2CH2CF3 and the like.

As used herein, the term "heteroalkyl" refers to optionally substituted alkyl radicals in which one or more atoms in the chain of the [skeleton is a heteroatom, eg, oxygen, nitrogen, sulfur, silicon, phosphorus, or combinations of the themselves. The heteroatom (s) are placed at any position within the heteroalkyl group or at the position where the heteroalkyl group is attached to the rest of the molecule. Examples include, but are not limited to, -CH2-O-CH3, CH2-CH2-O-CH3, -CH2-NH-CH3, -CH2-CH2-NH-CH3, -CH2-N (CH3) -CH3 ,

-CH2-CH2-NH-CH3, -CH2-CH2-N (CH3) -CH3, -CH2-S-CH2-CH3, -CH2-

<td>CH2-CH = N-OCH3,</td><td>and -CH = CH-N (CH3) -CH3. Furthermore, in some</td>

<td>achievements,</td><td>up to two heteroatoms are consecutive, such</td>

as, by way of example, -CH2-NH-OCH3 and -CH2-O-YES (CH3) 3.

The term heteroatom refers to an atom other than carbon or hydrogen. Heteroatoms are generally independently selected from oxygen, sulfur, nitrogen, silicon, and phosphorus, but are not limited to these atoms. In embodiments where two or more heteroatoms are present, the two or more heteroatoms may all be the same to each other, or some or all of the two or more

140 Heteroatoms can each be different from the others.

The term bond or single bond refers to a chemical bond between two atoms, or two structural units when the atoms bonded to the bond are considered part of the larger substructure. |

The term structural unit refers to a specific segment or functional group of a molecule. Chemical structural units are often recognized as chemical entities embedded in or attached to a molecule.

A thioalkoxy or alkylthio group refers to an alkyl group -S.

An SH group is also referred to as either a thiol group or a sulfhydryl group.

The term optionally substituted or substituted means that the group referred to may be substituted with one or more group (s) individually and independently selected from alkyl, cycloalkyl, aryl, heteroaryl, heteroalicyclic, hydroxy, alkoxy, aryloxy, alkylthio, arylthio, alkylsulfoxide, arylsulfoxide, alkylsulfone, arylsulfone, cyano, halo, acyl, nitro, haloalkyl, fluoroalkyl, amino, including mono and di substituted amino groups, and the protected derivatives of the

141 themselves. By way of example, optional substituents may be LsRs, where each of Ls is independently selected from a bond -O-, -C (= O) -, -S-, —S (= O) -,

S (= O) 2-, -NH-, -NHC (O) -, -C (O) NH-, S (= O) 2NH-, -NHS (= O) 2, OC (O) NH-, -NHC (O) O-, - (substituted or unsubstituted C1-C6 alkyl), or (substituted or unsubstituted C2-C6 alkenyl); and each RS is independently selected from H, (substituted or unsubstituted C1-C4 alkyl), (substituted or unsubstituted C3-C6 cycloalkyl), heteroaryl or heteroalkyl. Protective groups that form the protective derivatives of the above substituents include those found in sources such as Greene and Wuts, supra.

ACK inhibitor compounds

Also described in this document are methods of treating a patient for the relief of a disease

142 mediated by the bone marrow, with the relief of the consequent development of graft-versus-host disease (GVHD), which comprises administering to the patient allogeneic hematopoietic stem cells and / or allogenic T cells, where a therapeutically effective amount of a compound that inhibits ACK (eg, an ITK or BTK inhibitor, such as, for example, ibrutinib) is administered before or simultaneously with allogeneic hematopoietic stem cells and / or allogeneic T cells.

The ACK inhibitor compounds described herein are selective for kinases that have an accessible cysteine that is capable of forming a covalent bond with a Michael acceptor structural unit in the inhibitor compound. In some embodiments, the cysteine residue is accessible or becomes accessible when the structural unit of the irreversible inhibitor binding site binds to the kinase. That is, the structural unit of the irreversible inhibitor binding site binds to an active ACK site and the Michael acceptor structural unit of irreversible inhibitor gains access (in one embodiment the binding step leads to a conformational change in ACK. , thereby exposing the cysteine) or is otherwise exposed to the cysteine residue of the ACK; as a result a covalent bond is formed between the S of the cysteine residue and the

143 Michael acceptor of the irreversible inhibitor. Consequently, the structural unit of the irreversible inhibitor binding site remains attached or otherwise blocks the active ACK site.

In some embodiments, the ACK is BTK, a counterpart to | BTK or a tyrosine kinase that has a cysteine residue at a position in the amino acid sequence that is homologous to the position in the cysteine 481 amino acid sequence in BTK. In some embodiments, the ACK is ITK. In some embodiments, the ACK is HER4. Inhibitor compounds described herein include a Michael acceptor structural unit, a binding site structural unit, and a linker that binds the binding site structural unit and the Michael acceptor structural unit (and in some embodiments, the linker structure provides a conformation, or otherwise directs the Michael acceptor structural unit, in order to improve selectivity of the irreversible inhibitor for a particular ACK). In some embodiments, the inhibitor inhibits ACK ITK and BTK.

In some embodiments, the ACK inhibitor is a compound of Formula (A)

144

formula (A) where

A is independently selected from N or CR5;

R1 is H, L2- (substituted or unsubstituted alkyl), L2 (substituted or unsubstituted cycloalkyl), L2- (substituted or unsubstituted alkenyl), L2- (substituted or unsubstituted cycloalkenyl), L2- (substituted or unsubstituted heterocycle) substituted), L2- (substituted or unsubstituted heteroaryl), or L2- (substituted or unsubstituted aryl), where L2 is a bond, 0, S, S (= 0), -S (= O) 2, C ( = O), - (substituted or unsubstituted C1-C6 alkyl), or - (substituted or unsubstituted C2-C6 alkenyl);

R2 and R3 are independently selected from H, lower alkyl, and substituted lower alkyl;

R4 is L3-X-L4-G, where,

L3 is optional, and when present is a bond, optionally substituted or unsubstituted alkyl, optionally substituted or unsubstituted cycloalkyl, optionally substituted or unsubstituted alkenyl, alkynyl

145 optionally substituted or unsubstituted;

X is optional, and when present is a bond, O, -C (= O), S, -S (= O), -S (= O) 2, -NH, -NR9, -NHC (O), -C (O) NH, NR9C (O), -C (O) NR9, -S (= O) 2NH, -NHS (= O) 2, -S (= O) 2NR9-,

NR9S (= O) 2, -OC (O) NH-, -NHC (O) O-, ^ OC (O) NR9-, -NR9C (O) O-, CH = NO-, -ON = CH-, -NR10C (O) NR10-, heteroaryl, aryl,

NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-,

OC (= NR11) -, or -C (= NR11) O-;

or L3, X and L4 taken together form a nitrogen containing heterocyclic ring;

G is or

z R ^ 8, where,

R6, R7 and R8 are independently selected from H, lower alkyl or substituted lower alkyl, heteroalkyl

146 lower or substituted lower heteroalkyl, substituted or unsubstituted lower cycloalkyl, and substituted or unsubstituted lower heterocycloalkyl;

R5 is H, halogen, -L6- (substituted or unsubstituted C1-C3 alkyl), -L6- (C2-C4 alkenyl | substituted or unsubstituted), -L6- (substituted or unsubstituted heteroaryl), or

<td>-L6- (aryl</td><td colspan="2">substituted or unsubstituted)</td><td>, where L6 is a</td>

<td>every</td><td>R9 independently</td><td>I know</td><td>select from H,</td>

substituted or unsubstituted lower alkyl, and substituted or unsubstituted lower cycloalkyl;

<td>every</td><td>RIVER</td><td>is</td><td>independently H,</td><td>I rent</td><td>lower</td>

<td>replaced</td><td> 0</td><td>not</td><td colspan="2">substituted, or cycloalkyl</td><td>lower</td>

<td>replaced</td><td>or not</td><td colspan="2">substituted; or</td><td></td><td></td>

<td>two</td><td colspan="2">groups</td><td>RIO can form</td><td>together a</td><td>ring</td>

<td colspan="2">heterocyclic of</td><td> 5-</td><td>, 6-, 7-, or 8-members;</td><td> 0</td><td></td>

RIO and Rll can together form a 5-, 6-, 7-, or 8-membered heterocyclic ring; or each Rll independently is selected from H or alkyl; and pharmaceutically active metabolites, pharmaceutically acceptable solvates, pharmaceutically salts

147 acceptable, or pharmaceutically acceptable prodrugs thereof.

In some embodiments, the compound of Formula (A) is a BTK inhibitor. In some embodiments, compound | of Formula (A) is an inhibitor of I1 | K. In some embodiments, the compound of Formula (A) inhibits ITK and BTK.

In some embodiments, the compound of Formula (A) has the structure:

Formula (A);

where:

A is N;

<td>R1</td><td>is phenyl-O-phenyl</td><td>or phenyl-S-phenyl;</td><td>and</td><td></td>

<td>R4</td><td>is L3-X-L4-G, in</td><td>where,</td><td></td><td></td>

<td>L3</td><td>is optional, and</td><td colspan="2">when it is present it is</td><td>a link,</td>

<td>I rent</td><td>optionally</td><td>substituted or</td><td>not</td><td>substituted,</td>

<td colspan="3">optionally substituted cycloalkyl</td><td>or not</td><td>substituted,</td>

148 optionally substituted or unsubstituted alkenyl, optionally substituted or unsubstituted alkynyl;

X is optional, and when present is a bond, O, -C (= O), S, -S (= 0), -S (= O) 2, -NH, -NR9, -NHC (O), -C (O) NH, NR9C (O), -C (O) N | R9, -S (= O) 2NH, -NHS (= O) 2, -S (= O) 2 ^ R9-,

NR9S (= O) 2, -OC (O) NH-, -NHC (O) O-, -OC (O) NR9-, -NR9C (O) O-, CH = NO-, -ON = CH-, -NR10C (O) NR10-, heteroaryl, aryl, NR10C (= NR11) NR10-, -NR10C (= NR11) -, -C (= NR11) NR10-, OC (= NR11) -, or -C (= NR11 ) O ~;

or L3, X and L4 taken together form a nitrogen containing heterocyclic ring;

G is

O R <

OR

, where,

R6, R7 and R8 are independently selected from H,

149 lower alkyl or substituted lower alkyl, lower heteroalkyl or substituted lower heteroalkyl, substituted or unsubstituted lower cycloalkyl, and substituted or unsubstituted lower heterocycloalkyl.

In some embodiments, the ACK inhibitor is (R) - | L (3- (4-amino-3- (4-phenoxyphenyl) -lH-pyrazolo [3,4-d] pyrimidin-1yl) piperidin-l-yl ) prop-2-en-l-ona (ie PCI-32765 / ibrutinib)

Ibrutinib.

In some embodiments, the ACK inhibitor is AVL263 (Avila Therapeutics / Celgene Corporation), AVL-292 (Avila Therapeutics / Celgene Corporation), AVL-291 (Avila Therapeutics / Celgene Corporation), BMS-488516 (Bristol-Myers Squibb), BMS-509744 (Bristol-Myers Squibb), CGI-1746 (CGI Pharma / Gilead Sciences), CTA-056, GDC-0834 (Genentech), HY150

11066 (also, CTK4I7891, HMS3265G21, HMS3265G22,

HMS3265H21, HMS3265H22, 439574-61-5, AG-F-54930), ONO-4059 (Ono Pharmaceutical Co., Ltd.), ONO-WG37 (Ono Pharmaceutical Co., Ltd.), PLS-123 (Peking University) , RN486 (Hoffmann-La

Roche), or HM71224 (Hanmi Pharmaceutical Company Limited).

In some embodiments, the ACK inhibitor is 4 (tert-butyl) -N- (2-methyl-3- (4-methyl-6 - ((4-morpholine-4carbonyl) phenyl) amino) -5-oxo-4 , 5-dihydropyrazin-2yl) phenyl) benzamide (CGI-1746); 7-benzyl-l- (3- (piperidin-1yl) propyl) -2- (4- (pyridin-4-yl) phenyl) -1H-imidazo [4,5—

G] quinoxalin-6 (5H) -one (CTA-056); (R) -N- (3- (6- (4- (1,4-dimethyl-3-oxopiperazin-2-yl) phenylamino) -4-methyl-5-oxo-4,5dihydropyrazin-2-yl) - 2-methylphenyl) -4,5,6,7tetrahydrobenzo [b] thiophene-2-carboxamide (GDC-0834); 6-cyclopropyl-8-fluoro-2- (2-hydroxymethyl-3- {l-methyl-5- [5— (4— methyl-piperazin-l-yl) -pyridin-2-ylamino] -6-oxo-l, 6-dihydropyridin-3-yl} -phenyl) -2H-isoquinolin-l-one (RN-486); N— [5— [5— (4-acetylpiperazine-l-carbonyl) -4-methoxy-2-methylphenyl] sulfanyl-1,3-thiazol-2-yl] -4 - [(3,3-dimethylbutan-2-amino-methyl) ] benzamide (BMS-509744, HY-11092); or N- (5 - ((5 (4-Acetylpiperazine-l-carbonyl) -4-methoxy-2-methylphenyl) thio) thiazol-2-yl) -4 - (((3-methylbutan-2yl) amino) methyl) benzamide (HY11066).

151

In some embodiments, the ACK inhibitor is:

152

153

154

In some embodiments, ACK inhibitor is an ITK inhibitor.

In some embodiments the inhibitor

ITK is an ITK inhibitor compound described in

W02002 / 0500071, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02005 / 07 0420, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02005 / 079791, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in

155

W02007 / 076228, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02007 / 058832, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02004 / 016610, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02004 / 016611, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02004 / 016600, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02004 / 016615, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02005 / 026175, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02006 / 065946, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02007 / 027594, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in

156

W02007 / 017455, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02008 / 025820, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02008 / 025821, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in WO2008 / 025822, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in W02011 / 017219, which is incorporated by reference in its entirety. In some embodiments , the ITK inhibitor is an ITK inhibitor compound described in W02011 / 090760, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in WO2009 / 158571, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in WO2009 / 051822, which is incorporated by reference in its entirety. In some embodiments, the ITK inhibitor is an ITK inhibitor compound described in US 13/177657, which is incorporated by reference in its entirety.

In some embodiments, the ITK inhibitor has a

157 structure selected from the group consisting of:

158

Compos i gifts / Pharmaceutical formulations

Compositions comprising a therapeutically effective amount of an ACK inhibitor compound, and a pharmaceutically acceptable carrier are disclosed herein, in certain embodiments. In some embodiments, the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is a compound of Formula (A). In some embodiments, the ACK inhibitor compound is (R) -1- (3- (4-amino-3- (4phenoxyphenyl) -lH-pyrazolo [3,4-d] pyrimidin-l-yl) piperidin-1yl) prop-2-en-l-ona (ie PCI-32765 / ibrutinib).

Pharmaceutical compositions of the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) are formulated in a conventional manner using one or more physiologically acceptable carriers that include excipients and auxiliaries that facilitate processing of the compounds. active in preparations that can be used pharmaceutically. The appropriate formulation depends on the chosen route of administration. A

159 A summary of the pharmaceutical compositions described herein is found, for example, in Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa .: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, HA and Lachman, L., Eds. , Pharmaceutical Dosage Forms, Marcel Decker, New York, NY, 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkinsl999).

A pharmaceutical composition, as used herein, refers to a mixture of an ACK inhibitor compound (for example, an ITK or BTK inhibitor, such as for example ibrutinib) with other chemical components, such as vehicles, stabilizers, diluents, dispersing agents, suspending agents, thickening agents, and / or excipients.

The pharmaceutical compositions are optionally manufactured in a conventional manner, such as, by way of example only, by conventional mixing, dissolving, granulating, dragee-making, levigating, emulsifying, encapsulating, trapping, or compressing processes.

The pharmaceutical formulations described in this document are administered by any route of administration.

160 appropriate, including, but not limited to, oral, parenteral (eg, intravenous, subcutaneous, intramuscular), intranasal, oral, topical, rectal, or transdermal routes of administration.

The pharmaceutical compositions described in | This document is formulated in any appropriate dosage form, including but not limited to, aqueous oral dispersions, liquids, gels, syrups, elixirs, slurries, suspensions, and the like, for oral ingestion by an individual to be treated, solid forms. oral dosing, aerosols, controlled release formulations, fast melting formulations, effervescent formulations, lyophilized formulations, tablets, powders, pills, dragees, capsules, delayed-release formulations, prolonged-release formulations, pulsatile-release formulations, multiple-particle formulations, and controlled-release and immediate-release mixture formulations. In some embodiments, the compositions are formulated in capsules. In some embodiments, the compositions are formulated in solutions (eg, for IV administration).

The pharmaceutical solid dosage forms described herein include, optionally a

161 compound described herein and one or more pharmaceutically acceptable additives such as a compatible carrier, binder, filler, suspending agent, flavoring agent, sweetening agent, disintegrating agent, dispersing agent, surfactant, lubricant, colorant, diluent, solubilizer, wetting agent, plasticizer, stabilizer, penetration enhancer, a wetting agent, anti-foaming agent, antioxidant, preservative, or one or more combination thereof.

In some embodiments, the use of standard coating procedures, such as those described in Remington's Pharmaceutical Sciences, 20th Edition (2000), a film coating is provided around the compositions. In some embodiments, the compositions are formulated into particulates (eg, for capsule administration) and some or all of the particles are coated. In some embodiments, the compositions are formulated into particulates (eg, for administration by capsule) and some or all of the particles are microencapsulated. In some embodiments, the compositions are formulated into particulates (eg, for administration by capsule) and some or all of the particles are not microencapsulated and uncoated.

162

In some embodiments, the pharmaceutical compositions are formulated such that the amount of the ACK inhibitor (eg, an ITK or BTK inhibitor, such as for example ibrutinib) in each unit dosage form is approximately 140 mg per unit.

Kits / Manufacturing items

Kits are described herein to prevent the occurrence of graft-versus-host disease (GVHD) or to reduce the severity of occurrence of GVHD in a patient requiring cell transplantation comprising a therapeutically effective amount of an ACK inhibitor compound (for example, an ITK or BTK inhibitor, such as for example ibrutinib).

Kits for treating a patient for the relief of bone marrow mediated disease, with the consequent development of graft-versus-host disease (GVHD), comprising a therapeutically effective amount of an inhibitor compound, are further described herein. ACK (eg, an ITK or BTK inhibitor, such as for example ibrutinib), wherein a therapeutically effective amount of an ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as for example ibrutinib) is administered before or simultaneously with

163 allogeneic hematopoietic stem cells and / or allogenic T cells.

For use in the therapeutic applications described herein, kits and articles of manufacture are also described herein, for some embodiments, these kits include a carrier, container, or container that is compartmentalized to receive one or more containers such as vials, tubes, and the like, each of the containers, including one of the separate elements to be used in a method described herein. Appropriate containers include, for example, bottles, vials, syringes, and test tubes. Containers can be formed from a variety of materials such as glass or plastic.

<td>The</td><td>articles</td><td>of</td><td>manufacturing</td><td colspan="3">provided in this</td>

<td>document</td><td>they contain</td><td colspan="2">materials of</td><td>packing.</td><td>Ex emplos</td><td>of</td>

<td>materials</td><td colspan="2">packaging</td><td colspan="2">pharmacists include,</td><td>but no</td><td>I know</td>

limited to, blister packs, bottles, tubes, inhalers, pumps, bags, vials, containers, syringes, bottles, and any packaging material appropriate for a selected formulation and intended mode of administration and treatment. A wide range of formulations of the compounds and compositions provided herein are contemplated as a variety of treatments for

164 Any disorder that benefits from BTK inhibition, or in which BTK is a mediator or contributor to the symptoms or cause.

The container (s) optionally have a sterile access port (for example, the container is an intravenous solution bag or a vial that has a stopper that is pierceable by a hypodermic injection needle). Such kits optionally comprise a compound with an identification or label description or instructions regarding its use in the methods described herein.

A kit will generally include one or more additional containers, each containing one or more of various materials (such as reagents, optionally in concentrated form, and / or devices) desirable from a commercial and user point of view for the use of a compound described in this document. Examples of such non-limiting materials include, but are not limited to, buffers, diluents, filters, needles, syringes, carrier, container, container, vial and / or tube labels of the listed contents and / or instructions for use, and leaflets with instructions for use. A set of instructions is usually included as well.

In some embodiments, a label is on or

165 associated with the container. A label can be on a container when letters, numbers, or other characters that make up the label are attached, molded, or engraved on the container itself; A label can be associated with a container when it is present within a receptacle or holder that also holds the container, for example, as a container insert. A label can be used to indicate that the content is to be used for a specific therapeutic application. The label may also indicate directions for use of the content, such as in the methods described in this document.

In certain embodiments, a pharmaceutical composition comprising the ACK inhibitor compound (eg, an ITK or BTK inhibitor, such as, for example, ibrutinib) is presented in a container or dispensing device that may contain one or more unit dosage forms. The packaging can contains for example a plastic, such as a blister package.

sheet metal or

The container or dispensing device may be accompanied by instructions for administration.

The container or dispensing device may be accompanied by a notice associated with the container as prescribed by a government agency that regulates the manufacture, use, or sale of pharmaceuticals, whose notice reflects the agency's approval of the form of the

166 drug for human consumption or veterinary administration. Such notification, for example, may be the labeling approved by the US Food and Drug Administration, for prescription drugs, or the package leaflet of the approved product. Compositions containing a compound provided herein formulated in a compatible pharmaceutical carrier can also be prepared, placed in an appropriate container, and labeled for treatment of an indicated condition.

EXAMPLES

Example 1: Immune reconstitution and development of cGVHD

The influence of lymphocyte reconstitution on days 30 and 100 after allogeneic SCT on the subsequent development of cGVHD was assessed using a flow cytometric immune assay of a large immune reconstitution, allowing for monitoring of changes in cell activation markers, memory T cell status, Treg subsets, NK cell subsets, and Thl vs. Th2 cell subsets. Patients who developed cGVHD had a higher increase in CD4 + T cells and a lower increase in CD8 + T cells compared to patients who did not develop cGVHD.

167 over time, suggesting selective expansion of CD4 + T cells. Furthermore, a significant decrease in NK cells and a concomitant increase in the percentages of activated B cells were observed. An increase in CD4 + cells is associated with an inflammatory phenotype, and a biased Th2 proinflammatory response may contribute to B cell activation. The presence of a biased Th2 phenotype was supported by the presence of an increase in CD4 + / CD193 + cells among cGVHD patients, since CCR3 is preferentially expressed in Th2 cells.

Example 2: Ibrutinib in a murine model of cGVHD

An established model bone marrow transplant (BMT) system was used for a preclinical test of ibrutinib as a therapy for cGVHD. The LP / J - ♦ C57BL / 6 model is a murine sclerodermiform cGVHD model that develops dermal lesions characterized by hair loss, redness, scaling, crusting, hunched posture, and skin thickening. In this murine model, external symptoms become evident between days 20 and 25 and maximum between days 37 and 47 after hematopoietic stem cell transplantation (HSCT).

C57BL / 6 mice received X-ray irradiation

168 lethal (850cGy) followed by allo-BMT derived from MHC-compatible LP / J mice. A small number of mature spleen cells were included in the transplant to seed the development of cGVHD. The studies showed that approximately 1/3 of the mice survived 25 days after transplantation and at that time began to develop classic external signs of cGVHD including scleroderma, hair loss, stooped posture, weight loss, and dermal fibrosis. Therefore, day 25 after BMT was selected for the time of treatment.

Ibrutinib reduces cGVHD symptoms after allogeneic transplantation

C57BL / 6 mice were grafted with LP / J bone marrow after lethal 850cGy irradiation. mice 25 days after transplantation were randomly assigned to vehicle, cyclosporine, or Ibrutinib cohorts and drug was administered via drinking water or intraperitoneal injection. Scoring was performed on day 36 or day 39 after transplantation using a physical scoring system adapted from Cooke et al., Which incorporates weight, posture, coat condition, skin condition, and mobility.

These studies confirmed a therapeutic response.

169 dramatic to Ibrutinib that allowed complete resolution of scleroderma, alopecia, weight loss, and cGVHD-induced paralysis compared to vehicle or cyclosporine treatment groups (Figures 1A, D). The quality of the therapeutic response was assessed quantitatively using a previously established scoring model for the evaluation of hair loss, scleroderma, weight loss, posture, and mobility in mice suffering from cGVHD (Figure IB). In the scoring model, scores range from 0 (healthy mouse) to 19 (from mouse that has died due to cGVHD) where 18 represents the maximum score for a live mouse with cGVHD (Figure 1C). CGVHD progression was defined as a> 2 point change in the overall cGVHD score from the treatment baseline. Histological preparations of sclerodermiform skin lesions revealed dermal fibrosis, epidermal hyperplasia, serocellular crusting, erosion, and lymphohistiocytic infiltration, consistent with external examination (Figure 1E). Normal dermal histology was observed in mice receiving therapeutic ibrutinib.

Ibrutinib significantly extended the mean time to cGVHD progression by 14 days and 33% (6 of 18) of the ibrutinib-treated mice were kept free of

170 progression compared to 12% (2 of 18) of mice receiving vehicle and 10% (1 of 11) of mice receiving cyclosporine 10 mg / kg / day (p <0.02) (Figure 5). 100% survival was observed in the ibrutinib cohort compared to 82 and 88% survival for the cyclosporine and vehicle groups, respectively. Weekly assessment of mouse body weight revealed little difference between groups with Ibrutinib-treated mice weighing slightly more than average.

Tregs were not inhibited by ibrutinib

In allo-BMT receptors, cGVHD controls Tregs (regulatory T cells), actively suppressing autoreactive T cells within the periphery; Unfortunately, most current therapies disrupt the development or functionality of Treg. To study the effects of ibrutinib on Tregs, C57BL / 6 mice were treated with ibrutinib (25 mg / kg / day) or vehicle for 9 weeks and the percentage FoxP3 + CD4 + cells was analyzed by flow cytometry in peripheral blood. In addition, purified CD4 + CD25hiCD127dim CD49d-FoxP3 + Tregs, were pretreated with ΙμΜ of ibrutinib or vehicle and mixed with autologous CFSE-labeled response CD8 + cells in different response ratios: 1: 0, 1: 1 suppressor,

171

2: 1, 4: 1, 8: 1, and 16: 1 Anti-CD3 / CD28 / CD2 stimulation beads were added and the stimulation was evaluated by calculated dilution division ratio of CFSE (succinimidyl carboxyfluorescein ester) after 6 days. The negative control wells did not contain stimulation beads.

In vivo data showed that ibrutinib did not decrease total number of Treg after 9 weeks of continued ibrutinib therapy (Figure 2A). The in vitro data indicates that the suppressive function of human Tregs was maintained after ibrutinib treatment as tested by an in vitro T cell suppression assay (Figure 2B). The data showed that ibrutinib had the ability to suppress anti-host immunity while preserving Treg function, which is important for the graft-versus-tumor effect.

Th2 immunity was inhibited by ibrutinib

Intracellular staining for IFNy and IL4 was performed on TCR-stimulated CD4 + T cells treated with Ibrutinib. After stimulation, a significant decrease in the IL4-producing Th2 population of CD4 + T cells was identified, while IFNy-producing Thl cells were unaffected (Figure 3A). These data confirmed

172 that a significant divergence of the two cell populations was achieved in a purified T cell culture at doses of Ibrutinib ranging from Ol-ΙμΜ. This dose range was consistent with the serum concentrations observed in vivo, during the pharmacokinetic studies of ibrutinib in both mouse and human trials. To assess the long-term consequences of ibrutinib-induced Thl cytokine bias, IgG subisotype analyzes were performed in a cohort of 8-month-old C57BL / 6 EpTCLl mice. These mice were continuously treated for 7 months with ibrutinib (25 mg / kg / day) or vehicle. The results revealed a significant inversion (p = 0.002) of the Thl / Th2 ratio as measured by the relative levels of IgGl (Th2) and IgG2c (Thl), confirming a Thl bias related to ibrutinib in vivo (Figure 3B ).

Thl7 immunity was inhibited by ibrutinib

In cGVHD, there is a common link in which alloreactive Th2 and Thl7 T cells drive profibrotic pathways and the production of B cell autoantibodies as a result of defective thymic conditioning. Given the role of Thl7 cells, the effect of ibrutinib on this specific T cell subtype was investigated. Healthy donor Thl7 cells were magnetically isolated from freshly isolated PBMC

173 from healthy donors using CXCR3-CD4 + CCL6 + isolation and TCR stimulation for 12 hours after 30 minutes of pretreatment with vehicle or ibrutinib ΙμΜ. The percentage of CD4 + T cells that secrete IL17 was quantified by intracellular cytokine staining and normalized to vehicle treatment (Figure 4). The data indicated that ibrutinib limits TCR-induced activation of Thl7 cells.

Therapeutically controlled cGVHD-induced organ injury by Ibrutinib

In addition to externally measurable cGVHD measurements, it was found that the pulmonary and renal cGVHD model developed LP / J - »C57BL / 6, evident after histological evaluation. Evaluation of H&E stained sections revealed that ibrutinib therapy systemically limited cGVHD-induced aggregates of lymphocytes, plasma cells, and histiocytes surrounding the bronchioles and small-caliber vessels throughout the lung parenchyma and in the renal interstitium. Immunohistochemistry revealed B220 + B cells and pulmonary CD3 + T cell infiltration, in addition to renal CD3 + T cell infiltration in both the vehicle and cyclosporine groups, which was not observed in the Ibrutinib treatment groups (Figure 6A). The analysis

174 Pathology encoded by a trained veterinary pathologist confirmed that ibrutinib improved internal systemic cGVHD in this model (Figures 6B and C).

An additional long-term therapeutic experiment was carried out (Figure 6Dj. Again, Ibrutinib significantly limited the progression of cGVHD compared to vehicle control (P = 0.0019). Withdrawal of therapy in the Day 60 allowed clinical advancement of cGVHD in a single mouse (1 out of 6), however this was not statistically significant A similar trend was observed by external cGVHD scoring. Analysis of internal cGVHD pathology within lung and kidney tissues on day 75 suggests that long-term continuous ibrutinib was more effective in cGVHD control; in particular, the internal pathology of the lung and kidney was not reduced in BM-only recipients, indicating that the true internal cGVHD pathology in this model persists despite the removal of T-cells from the graft similar to that observed in human allo-HSCT receptors. Prophylactic ibrutinib treatment started pre-HSCT on day -2 and ended on day 25 did not give a significant improvement in cGVHD progression, suggesting that ibrutinib will be more effective when T and B cell responses are more fully developed.

175

Example 3: Ibrutinib inhibition of CD4 T-cell and B-cell activation in cells of cGVHD patients

Activation of CD4 + T cells in cGVHD cells inhibited by ibrpitinib

Primary CD4 + T cells were isolated from patients with active cGVHD, pretreated with ibrutinib ΙμΜ (or DMSO), and stimulated with anti-CD3 for 6 hours. Quantification of the percentage of activated T cells for each patient showed a significant decrease in the CD69 + CD4 + T cell population (Figure 7A) in cells pretreated with ibrutinib compared to DMSO.

B cell activation in cGVHD patient cells inhibited by ibrutinib

B cells isolated from cGVHD patients were pretreated with ibrutinib ΙμΜ and stimulated with anti-IgM for 45 minutes. Activation analysis of the B cell receptor pathway using phosphospecific antibodies to pERKl / 2, pBTK, and pPLCy2 revealed that ibrutinib was effective in inhibiting the B cell receptor pathway (Figure 7B). These data confirmed that ibrutinib reduces immune receptor activation in T and B cells.

176 human in the context of active cGVHD.

Example 4:

Clinical Studies of Ibrutinib in CLL and lymphoma

Fifty-six patients,

They were treated in the initial phase, including 16 with CLL, from the ibrutinib study. Seven cohorts were evaluated: 5 cohorts where patients were treated on a 28-day schedule with treatment, 7 days without treatment, and 2 cohorts where patients were treated on a continuous-to-daily dosing schedule or a fixed dose of 560 patients. there were earlier, and the middle ages

8.3 mg / kg was received a

<td colspan="2">median</td><td>of 3</td><td>regimes</td>

<td>of</td><td> 65</td><td>years,</td><td>Being the</td>

the oldest patient maximum dose of 82 years.

It was not tolerated, and only dose-limiting toxicities were observed: a grade 3 allergic hypersensitivity in a patient with a history of drug hypersensitivity; and a suspension of the medication for more than 7 days due to transients of grade 2 neutropenia. The use of a competitive binding assay to assess, ^ 95% BTK occupancy was achieved 4 hours after the dose in all patients who they received 2.5 mg / kg / day. Therefore, 420 mg and 840 mg doses were selected, administered daily in the study. Of the 50 patients evaluable for response

177 tumor, 60% achieved an objective response (CR or PR). The responses were observed in all histologies, including in 11 of the 16 patients with CLL / SLL. All responding CLL patients had rapid reduction in lymphadenopathy during the first cycle accompanied by an increase in absolute lymphocyte count, and all but one had an eventual reduction in ALC to meet the IWCLL criteria for RP. Responses were long-lasting, with progression-free mean survival of

13.6 months.

Based on the impressive responses in patients with CLL seen in the phase I study, a phase Ib / II study was conducted in patients with CLL. Patients were enrolled in one of 5 cohorts evaluating ibrutinib at a fixed dose of 420 mg daily or 840 mg daily. The cohorts evaluated patients who were previously untreated and at or above the age of 65 years, in relapse or refractory after 2 or more previous lines of treatment, including a purine-nucleoside analog, or at high risk, with relapse within 2 years of receiving chemoimmunotherapy, or the presence of dell7p. One hundred and sixteen patients were enrolled: 31 patients without prior treatment, in the relapse / refractory cohorts, and 24 high-risk patients. The

178 Median global follow-up was 16.6 months, with 4 median prior treatments, both in relapse / refractory and high-risk cohorts. The most common adverse events observed were diarrhea, fatigue, upper respiratory tract infection, rash, nausea, and arthralgia, and most were grade 2 or less. Importantly, no evidence of cumulative toxicity has been reported. Responses were observed, regardless of unfavorable risk factors, including advanced disease, an increasing number of previous treatments, increased beta-2microglobulin, or precarious risk cytogenetics, with a PRO of 67% in patients with dell7p in the relapse / refractory cohorts. The estimated 22 months PFS for the 85 patients in the relapse / refractory and high-risk cohorts was 76% and 96% for the 31 patients without prior treatment. The estimated 22-month overall survival for these two groups was, respectively, 85% and 96%. Overall and progression-free survival for any of the cohorts was not met at the time.

Example 5: Clinical study of ibrutinib in patients with chronic refractory or spheroid-resistant graft-versus-host disease (cGVHD)

179 cGVHD and its associated immune deficiency have been identified as a leading cause of relapse-free mortality (MRN) in allogeneic SCT survivors. SCT survivors with cGVHD are 4.7 times more likely to develop serious or life-threatening health conditions compared to healthy siblings and patients with active cGVHD are more likely to report adverse general health, mental health, functional disabilities, limitation of activity, and pain than allo-SCT survivors with no history of cGVHD. However, historical response rates of rituximab, with a number of agents under investigation in spheroid-refractory cGVHD have been around 30%, making this a population of patients with a clear need for effective intervention to reduce dependence on spheroids and improve quality of life and survival. Ibrutinib induces apoptosis in B lymphocytes through inhibition of the BCR pathway and antagonizes multiple cytokine mediated external microenvironmental survival signals such as BAFF, and Th2 polarization can be reversed. Therefore, it has now been shown to be safe in the treatment of patients with B-cell lymphomas. relapsed or refractory and CLL, the most common toxicities being diarrhea, fatigue, upper respiratory infection and rash

180 cutaneous, and being 2 or less degree. Importantly, no cumulative toxicities were observed, allowing for long-term use of the drug. In comparison, the long-term use of spheroids and calcineurin inhibitors used to treat cGVHD is known to cause adverse effects, leading to much of the morbidity and mortality observed in patients with cGVHD. Based on the tolerability of ibrutinib in early phase studies and its mechanism of action, it was expected that this would be a well tolerated and clinically effective agent against cGVHD.

For the primary purposes of evaluating the safety and efficacy of ibrutinib when used for cGVHD, ibrutinib is expected to be well tolerated in patients with refractory / steroid-dependent cGVHD and will improve response at 12 weeks · compared to 30% historical response rate. Furthermore, it is expected that the use of ibrutinib will allow a faster decrease in spheroids and will contribute to a better quality of life at 1 and 2 years compared to historical controls. Given that patients will be exposed to fewer corticosteroids, it is expected that relapse rates of primary disease will improve with ibrutinib, especially in patients receiving a transplant of a lymphoid malignancy, in which ibrutinib has documented efficacy in phase studies. II. Because

181 Since ibrutinib has effects on ITK, it is expected that, compared to institutional controls, the use of ibrutinib in this setting will bias' a Thl phenotype, which will be assessed by serial evaluation of immune reconstitution by flow cytometry. Furthermore, Thl7 cell activation is inhibited, while preserving Tregs number and function, thus preserving the graft-versus-tumor effect, while treating GVHD.

Study objectives:

one. Primary endpoints:

<td>For</td><td colspan="2">decide</td><td>the</td><td>security of</td><td colspan="2">ibrutinib</td><td>when</td>

<td>administers</td><td>during</td><td>the</td><td>GVHD</td><td>chronic (part</td><td>of the</td><td colspan="2">Phase Ib)</td>

<td>For</td><td>evaluate</td><td>the</td><td>rate</td><td>answer</td><td>(CR +</td><td>PR)</td><td>at 12</td>

weeks using ibrutinib as treatment for chronic refractory or spheroid-resistant GVHD (Phase II part)

2. Secondary endpoints:

To assess the impact of ibrutinib on the spheroid dose at 12 weeks, 6 months, 1 year and 2 years

To assess response at 6 months and 1 and 2 years

To assess overall survival at 1 and 2 years

182

To assess the relapse rate (both in primary disease and in cGVHD symptoms) at 1 year

To assess the incidence of grade infections

3-5 during treatment

To assess the quality of life! at 1 and 2 years

To assess the effect on immune reconstitution a and 2 years

Eligibility criteria:

one. Classic or chronic superimposed GVHD that is resistant or refractory to corticosteroids (equivalent to at least 0.5 mg / kg / day or 1 mg / kg / daily prednisone for at least one month of treatment). Organ-specific topical therapy allowed

2. History of allogeneic stem cell transplantation of hematologic malignancy

<td> 3.</td><td>Age 18-75</td><td>years in the</td><td colspan="2">enrollment time</td><td></td>

<td> 4 .</td><td>Within</td><td>the seven</td><td>days</td><td>of the administration of</td><td>the</td>

<td>first</td><td>dose of</td><td>ibrutinib,</td><td>the</td><td>patient must have</td><td>a</td>

<td colspan="2">appropriate function</td><td>organic</td><td>and the</td><td>functional state of</td><td>the</td>

<td colspan="2">Following way:</td><td></td><td></td><td></td><td></td>

Absolute Neutrophil Count (ANC) 500 / pL

183

Platelets 2 30,000 / pL

Total bilirubin - 2.5 x upper limit of normal less than due to Gilbert's disease that cannot be attributed to cGVHD

I AST (SGOT) 2.5 x institutional normal upper limit that cannot be attributed to cGVHD.

Creatinine removal 40 ml / min

5. ECOG functional status <2

6. Life expectancy 12 weeks

7. Willing and able to participate in all the evaluations and procedures required in this study protocol

8. You are able to understand the purpose and risks of the study and give your informed consent and signed and dated authorization to use protected health information (in accordance with national and local privacy regulations)

Exclusion criteria:

one. New immunosuppression within 4 weeks of starting ibrutinib

184

2. Currently active malignancy, except for adequately treated squamous cell or basal cell skin cancer, cervical cancer in situ, or other cancer for which the subject has been disease free for at least 2 years, other than the primary indication for transplant, or that will not limit survival to less than 2 years

3. A life-threatening disease, medical condition, or organic systemic dysfunction, in the investigator's opinion, could jeopardize the subject's safety or put the study results at undue risk

Four. Active and uncontrolled bacterial, fungal, or viral infection

5. Significant cardiovascular disease, such as uncontrolled or symptomatic arrhythmias, congestive heart failure, or myocardial infarction in the absence of a major predisposing cause (ie, severe autoimmune hemolytic anemia or sepsis) within 6 months of detection, or any heart disease class 3 or 4 as defined by the New York Heart Association Functional Classification

6. Known history of human immunodeficiency virus (HIV) or active infection with hepatitis C (HCV) or virus

185 hepatitis B (HBV) or any active uncontrolled systemic infection.

7. Concurrent antineoplastic therapy after hematopoietic stem cell transplantation

8. Infant ^ or pregnant I

9. They will not agree to use a highly effective method of contraception (eg, condoms, implants, injectables, combination oral contraceptives, some intrauterine devices [IUDs], sexual abstinence, or sterilized partners) during the study and for 30 days after the last study drug dose (Note: applies only to men and women of childbearing potential)

Study design:

one. Overview

This is an open-label, non-randomized phase Ib / II study in patients with chronic refractory or spheroid-resistant graft-versus-host disease (cGVHD), equivalent to at least 0.5 mg / kg / day or 1 mg / kg / each prednisone day for at least one month of treatment, after allogeneic hematologic cancer stem cell transplant. If a patient is on a calcineurin inhibitor and the level is less than 5 ng / ml at baseline

186

<td colspan="2">of the study, will be stopped</td><td colspan="2">. Then</td><td>of</td><td>registration,</td>

<td>patients</td><td>they will start</td><td>with</td><td> 420</td><td>mg</td><td>from Ibrutinib day,</td>

<td>basing</td><td>in the studios</td><td>of</td><td>phase</td><td>I</td><td>and II in neoplasms</td>

Hematologic tests showing that this dose is well tolerated and that 90% of BTK active sites are occupied at this dose. To facilitate documentation and monitoring, a cycle is defined as 28 days. The treatment is oral, and will be administered on an outpatient basis. The first six patients will be subject to a Dose Limiting Toxicity (DLT) evaluation period. The DLT period will be 28 days after the initial administration of the drug, and the sixth patient must complete the DLT period before accumulation can continue. A DLT is defined as the following: acute grade graft-versus-host disease (confirmed by biopsy preferable but not necessary); Grade 4 thrombocytopenia that does not improve to 80% of baseline or better after a 14-day treatment-free period without disease progression; grade 4 febrile neutropenia or infection; grade 3 febrile neutropenia or infection that cannot resolve within 7 days; any grade 4 non-haematological toxicity excluding infection; and grade 4 electrolyte abnormalities if not corrected by optimal replacement therapy.

The initial steroid narrowing may begin to

187 4 weeks after starting ibrutinib, but the spheroid dose may not be less than 50% of the initial dose by the end of the third cycle (12 weeks). Patients will have a physical exam with a comprehensive cGVHD evaluation at the beginning of each cycle. Patients will be evaluated for response at the end of cycle 3, and if there is no improvement in symptoms, then this will be considered a treatment failure and will be withdrawn from the study. In addition, patients requiring additional treatment for cGVHD before assessment of response at the end of cycle 3 will be considered a treatment failure, and these patients will be removed from the study. If patients are on a CR or PR at the 12-week evaluation, they will continue on ibrutinib daily while the spheroids are tapered. Once the spheroids have decreased, ibrutinib can be discontinuous. If patients are obtaining a clinical benefit that allows the reduction of the spheroid dose at the 1-year evaluation point, then they will be allowed to continue the study for up to 24 months. GVHD will be evaluated monthly, and correlative studies, including immune reconstitution, T and B cell activation, serum immunoglobulins, and serum BAFF levels will be evaluated every 3 months. Symptom burden studies

188 and quality of life, including the cGVHD Lee Symptom Scale, 10-point cGVHD activity assessment, the FACT-BMT, SF36, and the profile of human activity will be assessed at 12 weeks, 6 months, 1 year and 2 years.

2. Ibrutinib Therapy |

Ibrutinib is administered daily each day of a 28-day cycle. The first administration of ibrutinib will define C1D1. A fixed dose of 420 mg will be administered. A comprehensive chronic evaluation of the graft against the host according to NIH consensus criterion 35 will be performed baseline in order to determine the overall organ-specific score. The complete evaluation will be repeated at the end of cycle 3. This study will be conducted using a Phase Ib / II study design, in which the Phase II portion will be conducted as an optimal 2-stage Simon design. If no more than 5 of the initial 15 patients, including the 6 enrolled in the phase Ib portion, have evidence of a CR or RP at the 12-week evaluation, the study will be discontinued for futility. At the discretion of the treating physician, the initial set-up of prednisone may begin 2 weeks after starting an ibrutinib if a clinical response is observed. Prednisone cannot taper below 50% of the original dose

189 for the 12-week evaluation period, and an increase in cGVHD symptoms during decreased spheroids requiring an increase in the dose of spheroids to NO MORE than the original dose will not be considered progression. However, if a patient requires a higher spheroid dose than the initial dose or the addition of a new treatment for cGVHD at any point, this is considered evidence of progressive disease and will require removal from the study. Because approximately 66% of cGVHD patients are expected to progress, regardless of therapy, stopping rules will be triggered if more than 75% of patients progress prior to evaluation at the end of cycle 3. Daily ibrutinib will continue until the spheroids have been lowered. There was no specific pyramid schedule for prednisone. Once the spheroids are not present, ibrutinib will continue for an additional 4 weeks, and then stop. Patients can continue on ibrutinib for 2 years, and patients who are able to stop ibrutinib will be followed for 2 years from the start of treatment for secondary variables.

Final Points / Statistical Considerations: This study will be conducted in 2 parts, one phase Ib portion and one phase II portion. Six patients initially

190 be enrolled in the phase Ib portion of the study. Analogous to a maximum tolerated dose (DMT) assessment, the regimen is considered sufficiently tolerable if at most one of these 6 patients experiences DLT during the 28-day observation period, in which case the study will proceed to the phase II part . Using Simon's optimal two-stage phase II design, in order to test the null hypothesis that the overall response rate will be 30% versus the alternative hypothesis that the overall response rate will be 50%, with an error of Type I single-sided 0.1 and 80% power, 32 patients will be needed. Of more than 100 allogeneic transplants performed annually by the inventors, approximately half of them ultimately develop cGVHD. Approximately 50% of them will have the disease that does not respond to initial treatment with spheroids, resulting in approximately 20 incident cases of cGVHD in the state of Ohio annually. The study is expected to accumulate approximately 1 patient per month, resulting in an accumulation period of almost 3 years if conducted at a single institution. Transplant volumes are slightly lower at the University of North Carolina and the University of Chicago, and therefore, with the addition of these 2 sites, they are expected to be able to fully accumulate at approximately 24

191 months. If a maximum of 5 of 15 patients in the first stage respond to the 12-week evaluation point, the study will be terminated. If at most 12 patients respond in general, this treatment will not be considered worthy of further persecution. In general, regardless of treatment, approximately 66% of patients are expected to have progressive disease 6 months after starting treatment. Therefore, stopping rules will be activated if 75% of the patients or more enrolled before the intermediate analysis cut presenting worsening of cGVHD requires escalation of treatment within the first 12 weeks (3 of 4 patients, 6 of 8 patients, and 9 of 12 patients).

<td>The</td><td>answer</td><td colspan="2">will be evaluated by</td><td>the criteria</td><td>of</td>

<td>consensus</td><td>from the NIH for</td><td>the classification</td><td>of</td><td>GVHD.</td><td></td>

<td>The</td><td>answer</td><td>complete (CR)</td><td>I know</td><td>defined as</td><td>the</td>

Complete resolution of symptoms attributable to GVHD.

Partial response (RP) was defined as the presence of an objective response in an involved organ, with no evidence of progression elsewhere and there are no requirements for additional systemic therapy.

The duration of the follow-up will be 24 months, and the

192 Estimated accumulation period will be 2 years.

Patient characteristics are presented as median and range for continuous variables and as frequency and percentage for categorical variables. The laboratory correlations will be summarized at each moment using descriptive statistics. The nonparametric Wilcoxon signed rank procedure will be used to compare the baseline values for correlation studies. For quality of life correlations, a standard deviation change of 0.5 was considered statistically significant. Logistic regression models were adjusted to find correlations that warrant further investigation in future studies. Time course records will be generated for each patient and repeated measures analysis of variance will be used to explore relationships. The κ statistic is used to assess the consensus between the NIH response and clinically significant improvement in the quality of life measures.

Example 6: CLL / GVHD case study

A 52-year-old man with 17p high-risk CLL was originally diagnosed in November 2002. In 2003, he was initially treated with six cycles of fludarabine, cyclophosphamide, and rituximab (FCR) and achieved a response.

193 complete. It was repeated one year later with a right pleural effusion and the mesenteric / retroperitoneal lymph nodes. In December 2006, in situ hybridization peripheral blood fluorescence (FISH) showed that 23 percent of the cells will be 17p removed and CT showed increased lymphadenopathy. In March 2007, her bone marrow was hypercellular and diffusely infiltrated with CLL (62 percent of CD45 + cells). In April 2007, the FCR was restarted and she received four cycles with a partial response (bone marrow showing disease persistence with 44 percent CD45 + cells). Because of his persistent disease and diagnosis pl7, he received Campath (alemtuzumab) for a total of 20 doses and a subsequent bone marrow biopsy in October 2007 showed no CLL and PET / CT was negative.

In November 2007, the patient underwent a nonmyeloablative allogeneic hematopoietic stem cell transplant using total lymphoid irradiation and antithymocytic globulin (TLI / ATG) with infusion of G-CSF mobilized peripheral blood stem cells from his matched matched donor brother ( sister). Her oral graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine (CSA) and mycophenolate mofetil (MMF). He was transplanted into a Stanford research protocol

194 (ΒΜΤ 172) incorporating rituximab 375 mg / m2 infused post-transplant on days 56, 63, 70 and 77.

The patient's post-transplant course was complicated by infectious complications (multi-lobar fungal pneumonia, influenza A, varicella zoster reactivation) and post-transplant lymphoproliferative disorder (PTLD) treated with nine doses of rituximab in 2008. The patient never achieved complete donor chimerism after HCT. In September 2008, approximately nine months after HCT, she was found to have disease progression using flow cytometry and a CT scan that showed some retroperitoneal adenopathy enlargement from the previous study. Due to donor chimerism and progression of the patient's mixed disease, the patient received a total of five donor lymphocyte infusions (DLIs).

The patient's first DLI was given in September 2008 at a dose of 1x107 donor CD3 + cells / kg recipient weight. No GVHD response or disease. She received a second DLI in November 2008 at a dose of 3x107 donor CD3 + cells / kg recipient body weight. It was found that having a decrease in your allele specific oligonucleotide (ASO) quantification results with the reduction of 268,000 clonal IgH sequences per mcg of

195

DNA down to 120. There was also an increase in donor blood T-cell chimerism to 90% in January 2009 with associated mild oropharyngeal chronic GVHD. Bone marrow biopsy in April 2009 showed only 10% CLL. She received a third DLI in May 2009 at a dose of 5x107 CD34-cells from the donor / kg body weight of the recipient. The patient also received one cycle of rituximab (4 doses during this time). Approximately 18 days after her third DLI, she developed oral GVHD with erythema and ulceration associated with a dramatic increase in donor T-cell chimerism from 71 percent on the day of the DLI infusion to 87 percent 11 days later and up to 97 percent 25 days later. It did not require systemic spheroid therapy for GVHD, but it does require local therapy and persisted for approximately one year.

In the summer of 2009, the patient's PET / CT scan showed disease progression with massive chest / abdomen disease and a bone marrow biopsy with 40 to 50 percent CLL. For this persistent disease, the patient was subsequently treated with combination chemotherapy with four OFAR cycles (oxaliplatin, fludarabine, cytarabine, rituximab). In December 2009, the patient received a fourth DLI at a 5x107 dose of donor CD3 + cells / kg recipient weight. GVHD is

196 it flared up when its donor chimerism reached above 95 percent after OFAR. However, his disease persisted, so he was given a fifth DLI in February 2010 at a dose of 1x106 CD3 + cells from the donor / kg body weight of the recipient. Her GVHD requires treatment with local spheroids. Her bone marrow biopsy performed in May still showed 50 percent CLL.

In August 2010, the patient's PET / CT scan showed rapid disease progression and recurrence of massive lymphadenopathy including an abdominal mass up to 12 centimeters in diameter. In September 2010, the patient was enrolled in a clinical trial with ibrutinib (oral BTK inhibitor) through the Stanford hematology group and completed more than three years of therapy on ibrutinib, and

<td colspan="3">got a full answer</td><td>so much</td><td>in</td><td>the marrow</td><td>that is</td><td>how</td>

<td>on CT (see fig.</td><td colspan="2">8). Further,</td><td colspan="3">the symptoms of</td><td>GVHD</td><td>oral</td>

<td colspan="2">they were completely resolved</td><td>and the</td><td>achievement</td><td>a</td><td>chimerism</td><td colspan="2">full</td>

<td>from the durable donor</td><td>(see</td><td>fig.</td><td> 8) .</td><td></td><td></td><td></td><td></td>

<td>In summary,</td><td>this</td><td colspan="2">patient</td><td>with</td><td colspan="2">CLL after</td><td>of the</td>

<td>allogeneic transplant</td><td>HCT</td><td>had</td><td>CLL</td><td colspan="2">refractory</td><td>with</td><td>GVHD</td>

oropharyngeal chronic that resolved with ibrutinib therapy. His CLL was undetectable by B-cell IgH sequencing (CLONOSIGHT minimal residual disease assay

197 (Sequenta, inc.)) And achieved complete donor grafts without

Chronic GVHD.

Example 7: Study in the murine model of the crossed AML with transgenic mouse ova

Stages were carried out using the flt3itdmllptd AML model crossed with the transgenic mouse ova, which develops a transplantable leukemia expressing the immune monitoring protein ova. When the mice reached a leukemic load that did not exceed 20% of total CD45 + cells in the peripheral circulation, they were randomized to Ibrutinib, vehicle, or cyclosporine treatment cohorts. Two days after the start of treatment, they received lethal irradiation and subsequent grafting of bone marrow cells and splenocytes from an incompatible MHC-minor LP / J mouse, along with viable AML leukemic cells. Anti-tumor immunity and relapse were monitored by analysis of ova-tetramer CD8-positive T cells and the presence of circulating leukemic cells. Among mice treated to date, there was a clear sign of fewer relapses in the ibrutinib group compared to the cyclosporine group (Figure 9).

Example 8: Ibrutinib treatment of relapsed CLL after allogeneic transplantation: disease response

198 Sustained and Promising Donor Immune Modulation

This example demonstrates the effects of ibrutinib rescue therapy in 5 CLL patients who relapsed after allogeneic hematopoietic cell transplantation (allo-HCT). In addition to measurements of response minimal residual disease (MRD), cell chimerism

Donor T and donor B cell immune reconstitution after ibrutinib therapy were also evaluated. Five patients with high-risk CLL relapsed 1-8.5 years after allo-HCT. Four patients had never achieved donor CDT3 T-cell chimerism> 95% after a low-intensity transplant. Ibrutinib 420 mg daily was started 1 me-2 years after clinical relapse. Four of the 5 patients remained on ibrutinib with treatment courses ranging from 3-17 months. CLL MRD was measured by IgH high throughput sequencing (HTS), using the clonosight minimal residual disease test (sequenta, inc.), Which has the sensitivity to detect clone 1 CLL per million leukocytes. Lymph node (LN) size was assessed by CT and is expressed as the sum of the B cell reconstitution products quantifying HTS IgH diameters of .LN (SPD). That of donors was determined by total IgH molecules and unique IgH clonotypes. Lymphocytosis was observed in all 5

199 patients after initiation of ibrutinib therapy, consistent with previous reports. In 2 patients who received> 1 year of ibrutinib therapy, lymphocytosis peaked at 3 weeks and 8 weeks after starting treatment and gradually decreased after this, the complete solution within 1 year (Fig. 10A). The 4 patients with pathological lymphadenopathy before treatment experienced dramatic LN reduction (Fig. 10B; average reduction of 68%. in LN size after 3 months with ibrutinib). The longest duration of follow-up was reported for patient SPN 3975, who had a 17p deletion and received ibrutinib for 39 months. Treatment was discontinued after CLL MRD became undetectable using the CLONOSIGHT minimal residual disease test (FIG. 10C). Evidence of T cell donor immune modulation includes achievement of complete donor CD3 chimerism after 1 year and resolution of chronic oral and skin graft-versus-host disease (GVHD) after 6 months. Although this patient has been off ibrutinib> 8 months, complete donor chimerism persisted and CLL MRD remained undetectable (Figure 10C). Before ibrutinib therapy, donor B cells (excluding the patient's CLL clone) accounted for <0.2% of total PBMC as determined by HTS IgH. After the interruption

200 of ibrutinib, the percentage of donor B cells increased within 6 months to> 1% PBMC (Fig. 10D). On the other hand, the recovery of B cells had diverse low frequency IgH clonotypes (Fig. 10E). Taken together, these findings show rapid, sustained, and diverse immune reconstitution without recurrence of CLL after discontinuation of ibrutinib. Ibrutinib provided effective rescue therapy for CLL relapse after allo-HCT. After transplantation, CLL relapse is often extranodal, and our experience shows that ibrutinib is effective in eliminating both nodal and extranodal disease. One of the patients who discontinued treatment after achieving negative MRD maintains the disease undetectable 8 months after ibrutinib discontinuation. Ibrutinib treatment demonstrated donor immune modulation, promising by promoting complete donor chimerism and resolution of chronic GVHD. These data support the use of ibrutinib in patients with relapsed CLL after allo-HCT.

Example 9: Safety and efficacy of ibrutinib in

<td>patients</td><td>with</td><td>The</td><td>leukemia</td><td>lymphocytic</td><td>chronicle</td><td>(CLL)</td>

<td colspan="3">relapse / refractory</td><td colspan="2">(R / R) / lymphocytic lymphoma</td><td>little</td><td>(SLL)</td>

<td>that have</td><td>had</td><td>a</td><td>transplant</td><td>allogenic of</td><td>cells</td><td>mother</td>

201

Patients with CLL who relapse after allogeneic hematopoietic stem cell transplantation (alloHCT) are difficult to treat with chemotherapy due to altered hematopoietic reserve, infections, and concern about graft-versus-host disease (GVHD).

Ibrutinib is approved in the U.S.

for patients with

CLL or LCM who have received prior treatment 1, and for CLL patients with dell7p.

In preclinical studies, ibrutinib reversed

Chronic GVHD (cGVHD) established. The safety and efficacy of ibrutinib in a subset of alloHCT patients were previously evaluated in this example. Data were collected for R / R patients with allogeneic HSCT before enrolling in 1 of 4 clinical trials (PCYC-1102, PCYC-1109,

PCYC-1112, and PCYC-1117). PCYC-1112

PCYC-1117 only patients> 6 months after HCT without GVHD were included.

Efficacy assessments included overall response rate (ORR; iwCLL criteria), duration of response (DOR), progression-free survival (SLP), and overall survival (OS). Safety assessments include adverse events (AE), including

Bass AE (AAG).

clinical trial patients had alloHCT before (mean age, 54.5 y; 16 patients with functional status

ECOG 0 or 1; 10 patients with dell7p, 3 patients with delllq, patients with 4 previous treatments). The median of

202 time since last HCT was 27 months (range, 8-115). Initial neutropenia, anemia, and thrombocytopenia were reported in 31%, 25%, and 38%, respectively. The median ibrutinib time was 18.1 months (range, 0.4-38.8), with 12 patients being treated> 12 months. In the cutoff data, 11 patients were on treatment. Reasons for discontinuation include disease progression (n = 2), AE (n = 2), and consent to withdrawal (n = 1). Investigator-assessed responses include 2 complete responses, 9 partial responses (PR), and 3 PR with lymphocytosis, resulting in a better ORR of 87.5%. The median DOR, PFS, and OS were not reached at a median follow-up of 23 months. The 24-month PFS and OS rates were 77% and 75%, respectively. No SAE grade> 3 derived from treatment were observed in 11 patients and included infections (n = 6), and febrile neutropenia, atrial flutter, colitis, perirenal hematoma, subdural hematoma, bleeding after the procedure, hypercalcemia, bone injury, syncope , hematuria, urinary retention and dyspnea (η = 1 each, some events reported for the same patient). The only adverse event leading to Ibrutinib discontinuation was pneumonia (n = 2); both were fatal events. Two new deaths occurred in the study due to disease progression at 24 and 28 months. Ibrutinib

203 it was well tolerated in patients who had alloHCT before, with a safety profile similar to that observed in the general CLL R / R population. Better ORR (87.5%) was consistent with the results observed in the general / broader population.

Even if! The preferred embodiments of the present invention have been shown and described herein, it will be obvious to those skilled in the art that such embodiments are provided by way of example only. Numerous variations, changes and substitutions will occur to those skilled in the art without departing from the invention. It should be understood that various alternatives the embodiments of the invention described herein can be employed in the practice of the invention. The following claims are intended to define the scope of the invention and that the methods and structures within the scope of these claims and their equivalents are covered by the same.

204

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61895981	United States of America	–	2013-10-25
201361895981	United States of America	P	2013-10-25
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201461973173	United States of America	P	2014-03-31
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2014062277	United States of America	W	2014-10-24

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Methods of treating and preventing graft versus host disease.

Abstract

Term

TREATMENT AND PREVENTION METHODS OF GRAFT DISEASE

AGAINST GUEST

CROSS REFERENCE

SUMMARY OF THE INVENTION

OR,

BRIEF DESCRIPTION OF THE DRAWINGS

DETAILED DESCRIPTION OF THE INVENTION

N

F

H

CN,

OR

CGI-1746 (CGI

NMR,

-CH2-CH2-NH-CH3, -CH2-CH2-N (CH3) -CH3, -CH2-S-CH2-CH3, -CH2-

OR

EXAMPLES

Priority claims9

Members66

Numbers

Titles2

Classification