CA2261162A1 - Method for treating tumors having high ldl requirements employing mtp inhibitors - Google Patents

Abstract

A method is provided for treating hematologic tumors and solid tumors, including certain types of leukemias and metastatic tumors, having high LDL
requirements employing a delipidating agent such as an MTP inhibitor to substantially reduce LDL blood levels. In addition, a method is provided for treating tumors of the above types having high LDL requirements, especially hematologic tumors such as certain leukemias, employing a delipidating compound to substantially remove native LDL, and then administering a cytotoxic agent carried in reconstituted LDL.

Description

W O 98/03174 PCTrUS97/12158 METHOD FOR TRr~TING rUMORS HAVING
HIGH LDL REOUIREMENTS FMPLCYING MTP INHIBITORS

Field of the Irvention 5The present invention ~elates to a method for treating cancers having h gh LDL requirements employing a delipidating agen:, which preferably is an MTP inhibitor, alone or in combination with a cytotoxic agent.
Backaround of the Invention It is known that cance:- cells need cholesterol to make new cell me3nbrane. The cholesterol is supplied by either de novo synthesis or from low-density lipoprotein (LDL), or both, Firestone, R.A. et al, "Selective Delivery of Cytotoxic Compounds to Cells ~y the LDL Pathway, J.
Med. Chem., 1984, 27, 1037-1043. Firestone et al describe a series of cytotoxic cornpounds that are compatible with reconstituted LDL and may be delivered with reconstituted LDL against cancers that copiously internalize LDL.
Firestone, R.A., "Low-~ensity Lipoprotein as a Vehicle for Targeting Antitumor Compounds to Cancer Cells", Bioconjugate Ch~mistry, 1994, 5, pp 105-113, at page 105, in the "rntroduction", discusses problems associated ~ith cancer treatment as follows:
"It is difficult to era~icate cancer cells in vivo because they share Wit l normal cells, for the most part, the sarne bioche]nical machinery.
There is no cytotoxic substanc~ that is completely selective for malignant cells, and all those presently in use cause dose-limiting toxic side effects. For this reason ther~ is a growing emphasis on targeting, i.e., selective delivery of W O 98/03174 PCT~US97/12158 drugs to tumors in ways that bypass normal body tissues.
"Among the vehicles that can be used for this purpose is low-density lipoprotein (LDL), a S normal blood constituent that is the body's principal means for delivery of cholesterol to tissues. Cholesterol, a major constituent of m~mm~l ian cell membranes, is obtained by cells either by making it themselves or by picking it up from LDL or both. Cancer cells, like all dividing ones, need large amounts of cholesterol because they are making new membrane. There is ample evidence that many types of cancer cells indeed have unusually great LDL requirements. The evidence is 2-fold: measurements of LDL uptake by tumor cells and depletion of LDL in the blood of cancer patients resulting from high uptake by the tumor ( vide infra) . Thus. if LDL could be made to carry antitumor drugs, it would serve as a targeting vehicle. This concept was proposed in 1981-2 (1,2~ and has been reviewed several times since then ~3-7)."
(1) Gal, D., Ohashi, J., MacDonald, P.C., Buchsbaum, H.J., and Simpson, E.R. (1981) Low-density lipoprotein as a potential vehicle forchemotherapeutic agents and radionucleotides in the management of gynecologic neoplasms. Am. J.
Obstet. Gynecol. 139, 877.

(2) Counsell, R.E., and Pohland, R.C.
(1982) Lipoproteins as potential site-specific delivery systems for diagnostic and therapeutic agents. J. Med. Chem. 25, 1115.
~ 3) van Berkel, T.J.C. (1993) Drug targeting: application of endogenous carriers for site-speci~ic delivery of drugs. J. Controlled Release 24, 145.

WO98103174 PCT~S97/12158 (4) Vitols, S. (1991) Uptake of low-density lipoprotein by malign~nt cell--possible therapeutic applications. Cancer Cells 3, 488.
(5) deSmidt, P.C., ald Van Berkel, T . J . C .
~ 5 (1990) LDL-mediated drug targ~ting. Cri t . Revs .
T~era. Drug Carrier Syst. 7, 39.
(6) Peterson, C., Masquelier, M., Rudling, M., Soderberg, K., and Vitols S. (1991) Lipoproteins, malignancy and ,mticancer agents.
10 Tar~eted Diagn. Ther. (U.S. ) ~, 175.
(7) Catapano, A.L. (:987) Transport of cytotoxic compounds to cells ~ia the LDL receptor pathway. Med . Sci . Res . 15, ~ L 11.
At page 105 under the :opic "LDL
Uptake...", Firestone, supra, lists numerous tumor types that have especially high LDL requirements including acute myeloid leukemia (AML), human monocytic (FAB-M5) and myelomonocytic (FAB-M4) leukemias, chronic myeloid le~kemia in blast crisis, solid tumors such as ~pidermoid cervical cancer EC-50, endometrial aderocarcinoma AC-258, gastric carcinoma and parotid adenoma, G2 heptoma, squamous lung cancer, chorioccrcinoma, brain tumors such as medulloblastoma, oligcdendroglioma, glioma V-251MG, and malignant menigicma, as well as tumor cells that are exceptionally ~etastatic (Schroeder, F., Kier, ~.B. Olson, C.D., and Dempsey, N.E. (1984) Correlation of tumore metastasis with sterol carrier protein and plasma membrane sterol levels. Bioc~em. Biophys. Res.
Commun. 124, 283, and Cambien, F., Ducimetiere, P., and Richard, J. (1980) Total serum cholesterol and cancer mortality in a middle-aged mal~ population. Am. ~.
~pidemiol. 112, 388), tumor cells that are ex-eptionally aggressive (Rudling, M.J., S:ahle, L., Peterson, W O 98/03174 PCT~US97/121S8 C.O., and Skoog, L. (1986) Content of low density lipoprotein receptors in breast cancer tissue related to survival of patients. Bri t . Med. J.
292, 580;
Peterson, C., Vitols, S., Rudling, M., Blomgren, ~., Edsmyr, F., and Skoog, L. (1985) Hypocholesterolemia in cancer patinets may be caused by elevated LDL receptor activities in malignant cells. Med. Oncol. Tumor Pharmacother.
0 2 , 143;
Muller, C.P., Wagner, A.U., Maucher, C., and Steinke, B. (1989) Hypocholesterolemia, an unfavorable feature of prognostic value in chronic myeloid leukemia. Eur. ~. Hematol. 43, 235), and tumor cells that are exceptionally undifferentiated (Ponec, M., Havekes, L., Kempenaar, J., Lavrijsen, S., Wijsman, M., Boonstra, J., and Vermeer, B.J. ~1985) Calcium-mediated regulation of the low density lipoprotein receptor and intracellular cholesterol synthesis in human epidermal keratinocytes. ~. Cell Physiol. 125 98;
Zyada, L.E., Hassan, H.T., Rees, J.K.H., and Ragab, M. H. (1990) The relation between 2~ hypocholesterolemia and degree of maturation in acute myeloid leukemia. ~ematol. Oncol. 8, 65;
Ponec, M., Havekes, L., Kempenaar, J., Lavrisen, S., and Vermeer, B.J. (1984) Defective low-density lipoprotein metabolism in cultured, normal transformed and malignant keratinocytes. ~.
Invest. De~matol. 83, 436) .
Firestone, supra, on page 107 under the topic "Reconstitution of LDL With Cytotoxic Drugs"
states as follows, 3~ "In order to kill tumors with drugs that are targeted in LDL, the drugs must somehow be bound to the LDL in such a way that (1) they cannot W O 98/03174 PCT~US97/12158 escape from it while travelirg in the blood enroute to the tumor, (2) their cytotoxicit~ is chemically or physically masked while L~L-bound, and then restored after entering the target cells, (3) in S cluantity X killing power there is enough drug to kill cancer cells contained i~ the reconstituted - LDL (r-LDL), whose uptake is limited by the number of LDL receptors on the tumor cells and their rate of internalization, and (4) tle presence of Apo B
and its binding power to LDL eceptors are retained. The ability of the drug, once released from its carrier, to escape f~om lysosomes must also be taken in account (76) "
((76) Burton, R., et aL (1975) The permeability properties of ra liver lysosomes to nucleotides. Biochem. Soc. T.-ans. 3, 1251).
On page 109, under the topic "Removal of LDL From the Patient Before Treatment", Firestone, supra, states as follows, "During treatment, drug-bearing r-LDL must compete with native LDL for a(cess to LDL receptors on the tumor cells, recluiring elevated doses of r-LDL. This can be countered b~ removing LDL from the patients' blood (delipidation) prior to treatment ( 139-141 ) . Although restoration of normal LDL levels takes days 1141 ), it might be best to delipidate immediatel~ prior to treatment because it induces upregulaticn of LDL receptors throughout the body (142), anc it is unknown whether upregulation in this ~ay would be greater for tumor or normal cells.~
((139) Franceschini, ~., Busnach, G., Calabresi, L., Chiesa, G., Gianfranceschi, G., Zoppi, F., Minetti, L., and Sirtori, C.R. (1991) Predictability of low-density lipoprotein levels during apheretic treatment of hypercholesterolemia.
Eur. ~. Clin. Invest. 21, 209.

W O 98/03174 PCT~US97/12158 (140) Saal, S.D., Parker, T.S., Gordon, B.R., Studebaker, J., Hudgins, L., Ahrens, E.H., Jr., and Rubin, A.L. (1986) Removal of low-density lipoproteins in patients by extracorporeal S immunoadsorption. Am. J. Med. 80, 583.
(141) Parker, T.S., ~ordon, ~.R., Saal, S.D., Rubin, A.L., and Ahrens, E.H., Jr. (1986) Plasma high density lipoprotein is increased in man when low density lipoprotein (LDL) is lowered by LDL-pheresis. Proc. Nat. Acad. Sci . U. S.A. 83, 777.
~ 142) Goldstein, J.L., and Brown M.S.
(1977) The low-density lipoprotein pathway and its relation to atherosclerosis. Annu. Rev. Biochem.
46, 897).
The microsomal triglyceride transfer protein (MTP) catalyzes the transport of triglyceride (TG), cholesteryl ester (CE), and phosphatidylcholine (PC) between small unilamellar vesicles (S W). Wetterau & Zilversmit, Chem. Ph~s.
Li~ids 38, 205-22 ~1985). When transfer rates are expressed as the percent of the donor lipid transferred per time, MTP expresses a distinct preference for neutral lipid transport ~TG and CE), relative to phospholipid transport. The protein from bovine liver has been isolated and characterized. Wetterau & Zilversmit, Chem. Ph~s.
~i~ids 38, 205-22 ~1985). Polyacrylamide gel electrophoresis ~PAGE) analysis of the purified protein suggests that the transfer protein is a complex of two subunits of apparent molecular weights 58,000 and 88,000, since a single band was present when purified MTP was electrophoresed under nondenaturing condition, while two bands of apparent molecular weights 58,000 and 88,000 were identified when electrophoresis was performed in the presence of sodium dodecyl sulfate (S~S).

W O 98/03174 PCT~US97112158 These two polypeptides are hereinafter referred to as 58 kDa and 88 kDa, respectively, or the 58 kDa and the 88 kDa component of Mlrp/ respectively, or the low molecular weight subunit and the high ~ 5 molecular weight subunit of M'~P, respectively.
Characterization of th~ 58,000 molecular - weight component of bovine MT:' indicates that it is the previously characterized multifunctional protein, protein disulfide isomerase (PDI).
Wetterau et al., J. Biol. Chem. 265, 9800-7 ~1990).
The presence of PDI in the trc.nsfer protein is supported by evidence showing that (1) the amino terminal 25 amino acids of th~ bovine 58,000 kDa component of MTP is identical to that of bovine PDI, and (2) disulfide isomercse activity was expressed by bovine MTP follo~ing the dissociation of the 58 kDa - 88 kDa proteir complex. In addition, antibodies raised acainst bovine PDI, a protein which by itself has nc T~ transfer activity, were able to immuno~recipitate bovine TG
transfer activity from a solution containing purified bovine MTP.
PDI normally plays a rcle in the folding and assembly of newly synthesized disulfide bonded proteins within the lumen of t~e endoplasmic reticulum. Bulleid & Freedman, Nature 335, 649-51 (1988). It catalyzes the prop~r pairing of cysteine residues into disulfi~e bonds, thus catalyzing the proper folding ~f disulfide bonded proteins. In addition, PDI ha, been reported to be identical to the beta subunit ~f human prolyl 4-hydroxylase. Koivu et al., J. Biol. Chem. 262, 6447-9 (1987). The role of PD[ in the bovine transfer protein is not clear. It does appear to be an essential component of t,he transfer protein as dissociation of PDI from the 88 kDa component of bovine MTP by either low concentrations of a denaturant (guanidine HC1), a chaotropic agent (sodium perchlorate), or a nondenaturing detergent (octyl glucoside) results in a loss of transfer activity. Wetterau et al., Biochemistr~ 30, 9728-35 (1991). Isolated bovine PDI has no apparentlipid transfer activity, suggesting that either the 88 kDa polypeptide is the transfer protein or that it confers transfer activity to the protein complex.
The tissue and subcellular distribution of MTP activity in rats has been investigated.
Wetterau & Zilversmit, Biochem. Bioph~s. Acta 875, 610-7 (1986). Lipid transfer activity was found in liver and intestine. Little or no transfer activity was found in plasma, brain, heart, or kidney. Within the liver, MTP was a soluble protein located within the lumen o~ the microsomal fraction. Approximately equal concentrations were found in the smooth and rough microsomes.
Abetalipoproteinemia is an autosomal recessive disease characterized by a virtual absence of plasma lipoproteins which contain apolipoprotein B (apoB). Kane & Havel in The Metabolic Basis of Inherited Disease, Sixth edition, 1139-64 (1989). Plasma TG levels may be as low as a few mg/dL, and they fail to rise after fat ingestion. Plasma cholesterol levels are often only 20-45 mg~dL. These abnormalities are the result of a genetic defect in the assembly and/or secretion of very low density lipoproteins (VLDL) in the liver and chylomicrons in the intestine.
The molecular basis for this defect has not been previously determined. In subjects examined, triglyceride, phospholipid, and cholesterol synthesis appear normal. At autopsy, subjects are free of atherosclerosis. Schaefer et al., Clin.
Chem. 34, B9-12 ~1988). A link between the apoB

W O 98/03174 PCT~US97112158 gene and abetalipoproteinemia has been excluded in several families. Talmud et al., J. Clin. Invest.
82, 1803-6 (1988) and Huang e al., Am. J. Hum.
Genet. 46, 1141-8 ~lg90).
S Subjects with abetalipoproteinemia are afflicted with numerous malad:es. Kane & Havel, ~ su~ra. Subjects have fat malabsorption and TG
accumulation in their enteroc~tes and hepatocytes.
Due to the absence of TG-rich plasma lipoproteins, there is a defect in the trancport of fat-soluble vit~m; n~ such as vitamin E. r'his results in acanthocytosis of erythrocytec, spinocerebellar ataxia with degeneration of the fasciculus cuneatus and gracilis, peripheral neurcpathy, degenerative pigmentary retinopathy, and c~roid myopathy.
Treatment of abetalipoprotein~mic subjects includes dietary restriction of fat intake and dietary supplementation with vitamins A, E and K.
In vitro, MTP catalyzec the transport of lipid molecules between phosp~olipid membranes.
Presumably, it plays a similar role in vivo, and thus plays some role in lipid metabolism. The subcellular (lumen of the micr~somal fraction) and tissue distribution (liver and intestine) of MTP
have led to speculation that it plays a role in the assembly of plasma lipoprotein~, as these are the sites of plasma lipoprotein as,embly. Wetterau &
Zilversmit, Biochem. Bio~h~s. ~cta 875, 610-7 (1986). The ability of MTP to catalyze the transport of TG between membra~es is consistent with this hypothesis, and sugg~sts that MTP may catalyze the transport of TG f-om its site of synthesis in the endoplasmic r~ticulum ~ER) membrane to nascent lipoproteil particles within the lumen of the ER.
Olofsson and colleagues have studied lipoprotein assembly in HepG2 cells. Bostrom et CA 0226ll62 1999-01-22 W O 98/03174 PCT~US97/12158 al., J. Biol. Chem. 263, 4434-42 (1988). Their results suggest small precursor lipoproteins become larger with time. This would be consistent with the addition or transfer of lipid molecules to S nascent lipoproteins as they are assembled. MTP
may play a role in this process. In support of this hypothesis, Howell and Palade, J. Cell Biol.
92, 833-45 (1982), isolated nascent lipoproteins from the hepatic Golgi fraction of rat liver.
There was a spectrum of sizes of particles present with varying lipid and protein compositions.
Particles of high density lipoprotein (HDL) density, yet containing apoB, were found. Higgins and Hutson, J. Li~id Res. 25, 1295-1305 (1984), reported lipoproteins isolated from Golgi were consistently larger than those from the endoplasmic reticulum, again suggesting the assembly of lipoproteins is a progressive event. However, there is no direct evidence in the prior art demonstrating that MTP plays a role in lipid metabolism or the assem.bly of plasma lipoprotein.
Recent reports (Science, Vol. 258, page 999, 1992; D. Sharp et al, Nature, Vol. 365, page 65, 1993) demonstrate that the defect causing abetalipoproteinemia is in the MTP gene, and as a result, the MTP protein. Individuals with abetalipoproteinemia have no MTP activity, as a result of mutations in the MTP gene, some of which have been characterized. These results indicate that MTP is required for the synthesis of apoB
containing lipoproteins, such as VLDL, the precursor to LDL. It therefore follows that inhibitors of MTP would inhibit the synthesis of VLDL and LDL, thereby lowering VLDL levels, LDL
levels, cholesterol levels, and triglyceride levels in ~n;m~ls and man.

W O 98103174 PCTrUS97112158 Canadian Patent Application No. 2,091,102 published March 2, 1994 (corr~sponding to U.S.
application Serial No. 117,36~, filed September 3, 1993 (file DC21b)) which is ircorporated herein by reference), reports MTP inhibitors which also block the ipoproteins in a human hepatic cell line (HepG2 cells). This provides further support for the proposal that an MTP inhi~itor would lower apoB
conta; n i ng lipoprotein and liFid levels i v'vo.
This Canadian patent application discloses a method for identifying the MTP inhibitors ¢~1 {~N ~

which has the name 2-[1-(3, 3-~iphenylpropyl)-4-piperidinyl]-2, 3-dihydro-3-ox~-lH-isoindole hydrochloride and ~ N J OCH3 which has the name 1-[3-(6-fluoro-1-tetralanyl)-methyl]-4-O-methoxyphenyl pipe:-azine.

Description of the rnvention In accordance with the present invention, a method is provided for treatin(~ tumors having high LDL requirements which method :,ncludes the step of administering to a mammalian species in need of treatment a therapeutically efi'.ective amount of a delipidating agent to substant'.ally reduce LDL
blood levels.
In the above method, th~ delipidating agent may be optionally administered in combination with a cytotoxic agent.

W O 98/03174 PCTrUS97/12158 In addition, in accordance with the present invention, a method is provided for treating tumors having high LDL requirements, especially hematologic tumors, which method includes the steps of administering to a mammalian species in need of treatment a therapeutically effective amount of a delipidating agent to substantially remo~e LDL
~that is, native LDL~, and administering a cytotoxic agent carried in reconstituted LDL (rLDL-drug conjugate).
The delipidating compound to be employed inthe methods of the invention may be an LDL lowering compound which lowers LDL down to less than 20% of normal (that is less than 20~ of 150 mg/dl that is 30 mg/dl), preferably down to less than 10% of normal (that is less than 15 mg/dl) and most ' preferably to substantially zero LDL. Examples of delipidating agents which may ~e employed herein include MTP inhibitors, statins, fibrates and resins or combinations thereof, with MTP inhibitors being preferred.
The reconstituted LDL (employed as a carrier for the cytotoxic agent in the above method~ may be prepared according to the procedures described in the review article Firestone, R.A., Low-Density Lipoprotein as a Vehicle for Targeting Antitumor Compounds to Cancer Cells, Bioconjugate Chemistry, 1994, 5, 105-113, such as disclosed in the following references cited by Firestone, supra:
(78) Krieger, M., Brown, M.S., Faust, J.R., and Goldstein, J.L. (1978) Replacement of endogenous cholesteryl esters of low density lipoprotein with exogenous cholesteryl linoleate, J. Biol. Chem. 253, 4093.
~79) Krieger, M., McPhaul, J.J., Goldstein, J.L., and Brown, M.S. (1979) Replacement of neutral lipids of low density lipoprotein with esters of W O 98/03174 PCTrUS97/12158 long chain unsaturated fatty lcids, J. Biol. Chem.
254, 3845.
(104) Lundberg, B. (1937) Preparation of drug-low density lipoprotein complexes for delivery of antitumoral drugs via the .ow density lipoprotein pathway, Cancer Res . 47, 4105, and ~ Gene M. Dubowchik and :~aymond A. Firestone, Tet. Lett. 35, 4523, 1994.
The cytotoxic agent mar be incorporated in the reconstituted LDL to form an LDL drug conjugate following the procedure descr:.bed in the Firestone review article, supra, especially as described in cited reference (104) Lundber~-, supra.
MTP inhibitors to be employed in the methods of the invention include MTP inhibitors disclosed in Canadian Patent ~pplication No.
2,091,102 described hereinbefcre (corresponding to U.S. Application Serial No. 117,362), U.S.
Application Serial No. 472,06~, filed June 6, 1995 (file DC21e), U.S. Applicatio~ Serial No. 548,811 (file DC21h), U.S. provisional application No.
60/017,224, (file HX79a*), U.C. provisional application No. 60/017,253, (file HX82*) and U.S.
provisional application No. 60/017,254, (file HX84*).
All of the above U.S. applications are incorporated herein by referen-e.
The MTP inhibitors disclosed in U.S.
Application Serial No. 472,067, filed June 6, 1995 (file DC21e) are piperidine conpounds of the structure ~~

or W O 98103174 PCT~US97/12158 ~C4~ ~

or Rs~Q ~ ~ R

or Rs,Q

or 3~ y,N

O O
" ..
whereQis -c- or -S- ;
o Xis:CHR8, - c- ,-cH- CH- or -c=c-;
~ R9 Rl~ R9 R10 R8, R9 and R10 are independently hydrogen, alkyl, alkenyl, alkynyl, aryl, arylalkyl, heteroaryl, heteroarylalkyl, cycloalkyl, or cycloalkylalkyl;
Y i5 - (CH2)m- or --lC~--wherein m is 2 or 3;
R1 is alkyl, alkenyl, alkynyl, aryl, heteroaryl, arylalkyl wherein alkyl has at least 2 carbons, diarylalkyl, arylalkenyl, diarylalkenyl, arylalkynyl, diarylalkynyl, diarylalkylaryl, heteroarylalkyl wherein alkyl has at least 2 carbons, cycloalkyl, or cycloalkylalkyl wherein alkyl has at least 2 carbons, all optionally substituted through available carbon atoms with 1, 2, 3 or 4 groups selected from halo, haloalkyl, alkyl, alkenyl, alkoxy, aryloxy, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, cyclo-4 PCT~S97/12158 alkylalkyl, heteroaryl, fluorenyl, heteroarylalkyl, hydroxy or oxo;
or R1 is a fluorenyl-t ~e group of the structure -R~ -Rl~-z1~ Rls Rl2 ~ R12--z2 ~ R12--z2 ~

R13/~\ R14 Rl3 \ Rl4 R~Rl4 R~Rl5 --Rll_zl R12_ z2~

R1 is an indenyl-type croup of the structure - Rll- Z~ ~R

(a = 2,3 or 4) Rl3 _ R11_ z~R14 _ R11 _ Z1 ~ ;
Rl2_ Z2 R16a Rl'--Z2~ Rl6a R15a ~cH2)a R15a G ~L

zl and z2 are the same or different and are independently a bond, O, S, S , S\ , --NH-C-- ,--N C-- , --C-- or --C--~ (~~2 O alkyl O o OH
with the proviso that with respect to B, at least one Of zl and z2 will be other than a bond; Rll is S a bond, alkylene, alkenylene or alkynylene of up to 10 carbon atoms; arylene or mixed arylene-alkylene;
R12 is hydrogen, alkyl, alkenyl, aryl, haloalkyl, trihaloalkyl, trihaloalkylalkyl, heteroaryl, heteroarylalkyl, arylalkyl, arylalkenyl, cyclo-alkyl, aryloxy, alkoxy, arylalkoxy or cycloalkyl-alkyl, with the provisos that (1) when R12 is H, aryloxy, alkoxy or --NH- C-- , --N C-- --C--arylalkoxy, then z2 is ~ alkyl O ~ o or a bond and (2) when z2 is a bond, F~12 cannot be heteroaryl or heteroarylalkyl;
Z is bond, 0, S, N-alkyl, N-aryl, or alkylene or alkenylene from 1 to 5 carbon atoms;
R13, R14, Rl5, and R16 are independently hydrogen, alkyl, halo, haloalkyl, aryl, cycloalkyl, cycloheteroalkyl, alkenyl, alkynyl, hydroxy, alkoxy, nitro, amino, thio, alkylsulfonyl, arylsulfonyl, alkylthio, arylthio, aminocarbonyl, alkylcarbonyloxy, arylcarbonylamino, alkylcarbonylamino, arylalkyl, heteroaryl, heteroarylalkyl or aryloxy;
R15a and R15a are independently hydrogen, alkyl, halo, haloalkyl, aryl, cycloalkyl, cyclo-heteroalkyl, alkenyl, alkynyl, alkoxy, alkyl-sulfonyl, arylsulfonyl, alkylthio, arylthio, amino-carbonyl, alkylcarbonyloxy, arylcarbonylamino, alkylcarbonylamino, arylalkyl, heteroaryl, heteroarylalkyl, or aryloxy;
or Rl is a group of the structure W O 98103174 PCTrUS97/121S8 Rl7 (CH2)~

wherein p is 1 to 8 and Rl7 a~d Rl8 are each independently H, alkyl, alken~l, aryl, arylalkyl, heteroaryl, heteroarylalkyl, ~ycloalkyl or cycloalkylalkyl at least one of Rl7 and R18 being other than H;
or Rl is a group of th~ structure _ R1g~

wherein Rl9 is aryl or heteroaryl;
R20 is aryl or heteroaryl;
R2l is H, alkyl, aryl, alkylaryl, arylalkyl, aryloxy, arylalkoxy, heteroar~l, heteroarylalkyl, heteroarylalkoxy, cycloalkyl, cycloalkylalkyl or cycloalkylalkoxy;
R2, R3, R4 are indepen~ently hydrogen, halo, alkyl, alkenyl, alkoxy, aryloxy, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, cycloalkylalkyl, heteroaryl, heteroarylalkyl, hydroxy or haloalkyl;
R5 is independently alk~l, alkenyl, alkynyl, aryl, alkoxy, aryloxy, arylalk~xy, heteroaryl, arylalkyl, heteroarylalkyl, cy~loalkyl, cycloalkyl-alkyl, polycycloalkyl, polycycloalkylalkyl, cycloalkenyl, cycloheteroalkyl, heteroaryloxy, cycloalkenylalkyl, polycycloal~enyl, polycyclo-alkenylalkyl, heteroarylcarbon~l, amino, alkylamino, arylamino, heteroa-ylamino, cycloalkyloxy, cycloalkylamino, all optionally substituted through available -arbon atoms with 1, 2, 3 or 4 groups selected from hydrogen, halo, alkyl, haloalkyl, alkoxy, haloalkoxy, alkenyl, alkynyl, cycloalkyl, cycloalkyLalkyl, cycloheteroalkyl, cycloheteroa!kylalkyl, aryl, heteroaryl, arylalkyl, arylcyc.o-alkyl, W O 981~3174 PCT~US97/12158 arylalkenyl, arylalkynyl, aryloxy, aryloxyalkyl, arylalkoxy, arylazo, heteroaryloxo, hetero-arylalkyl, heteroarylalkenyl, heteroaryloxy, hydroxy, nitro, cyano, amino, substituted amino, thiol, alkylthio, arylthio, heteroarylthio, arylthioalkyl, alkylcarbonyl, arylcarbonyl, arylaminocarbonyl, alkoxycarbonyl, aminocarbonyl, alkynylaminocarbonyl, alkylaminocarbonyl, alkenylaminocarbonyl, alkylcarbonyloxy, arylcarbonyloxy, alkylcarbonylamino, arylcarbonylamino, arylsulfinyl, arylsulfinylalkyl, arylsulfonyl, alkylsulfonyl, arylsulfonylamino, heteroarylcarbonylamino, heteroarylsulfinyl, heteroarylthio, heteroarylsulfonyl, alkylsulfinyl;
R6 is hydrogen or Cl-~4 alkyl or Cl-C4 alkenyl; all optionally substituted with 1, 2, 3 or 4 groups which may independently be any of the substituents listed in the definition of R5 set out above;
R7 is alkyl, aryl or arylalkyl wherein alkyl by itself or as part of arylalkyl is optionally ~ O
substituted with oxo \ ~

J~,S J'~S J~S

are the same or different and are independently selected from heteroaryl containing 5- or 6-ring members; and N-oxides ~ thereof; and pharmaceutically acceptable salts thereof;
with the provisos that where in the first formula X is CH2, and R2, R3 and R4 are each H, then Rl will be other than 3,3-diphenylpropyl, and in the fifth formula, where one of R2, R3 and R4 is W O 98/03174 PCT~US97/12158 6-fluoro, and the others are ~, R7 will be other than 4-(2-methoxyphenyl).
The MTP inhibitors disclosed in U.S.
application Serial No. 548,811 filed January 11, 1996 (file DC2lh), have the structure (~ o ~ C-N-CH2-CF3 R
;)=~ ( CH2 ) X--N~ - N--C--R5 x2 including the piperidine N-oxi~e thereof or a pharmaceutically acceptable salt thereof, wherein Z
is a bond, O or S;
xl and x2 are independently selected from H
or halo;
x is an integer from 2 to 6i R5 is heteroaryl, aryl, heterocycloalkyl or cycloalkyl, each R5 group bein~ optionally substituted with 1, 2, 3 or 4 ,ubstituents which may be the same or different.
The MTP inhibitors disclosed in U.S.
provisional application No. 60'017,224, filed May 9, 1996 (file HX79a*) have the structure R2~ L~A ~ B~ L~ Rl R2~ ,S~
I or I~ or Is including pharmaceutically acc~ptable salts thereof, wherein q is 0, 1 or I;
A is (1) a bond;
(2) -O- ; or --N
(3) R

W O 98/03174 PCT~US97112158 where R5 is H or lower alkyl or R5 together with R2 forms a carbocyclic or heterocyclic ring system containing 4 to 8 members in the ring.
B is a fluorenyl-type group of the structure:

or ~\~ R4~
or ~1~ \~ (the above B is also ref~r.ed to as a R3~\X 4 fluorenyl- type ring or moiety); or B is an indenyl-type group of the structure or ~S~ R

R3a (CH a R3b ,~ R3b or (a = 2,3 or 4) R3a R3a (CH2)a ~, R3' ~,~ (the above B is also referred to as R3b an indenyl-type ring or moiety);
R3a Rx is H, alkyl or aryl;
Rl is alkyl, alkenyl, alkynyl, alkoxyl, (alkyl or aryl)3Si (where each alkyl or aryl group is independent), cycloalkyl, cycloalkenyl, substituted alkylamino, substituted arylalkylamino, aryl, arylalkyl, arylamino, aryloxy, heteroaryl, heteroarylamino, heteroaryloxy, arylsulfonylamino, heteroarylsulfonylamino, arylthio, arylsulfinyl, arylsulfonyl, alkylthio, alkylsulfinyl, W O 98/0317~ PCTrUS~7tl2158 alkylsulfonyl, heteroarylthio, heteroarylsulfinyl, heteroarylsulfonyl, -Po(R13)(R14) (where R13 and R14 are independently alkyl, aryl, alkoxy, aryloxy, heteroaryl, heteroarylalkyl, ~eteroaryloxy, heteroarylalkoxy, cyclohetero~lkyl, cycloheteroalkylalkyl, cycloh~teroalkoxy, or ~ cycloheteroalkylalkoxy); R1 cim also be aminocarbonyl (where the amin~ may optionally be substituted with one or two a:-yl, alkyl or heteroaryl groups); cyano, l, -(alkoxyl or aryloxy)2alkyl (where the two aryl or alkyl substituents can be independently defined, or linked to one another to form a ring, such as l,3-dioxane or 1,3-dioxolane, connected to L1 (or L2 in the case of R2) at the 2-position); l,3-dioxane or l,3-dioxolane connected to ~1 (or L2 in the case of ~ ~2) at the 4-position.
The R1 group may have irom one to four substituents, which can be an~ of the R3 groups or R1 groups, and any of the preferred R1 substituents set out below.
R1 may be substituted ~ith the following preferred substituents: alky~carbonylamino, cyclo-alkylcarbonylamino, arylcarborylamino, heteroaryl-carbonylamino, alkoxycarbonylcmino,aryloxycarbonylamino, heteroaryloxylcarbonylamino, uriedo (where the uriedo nitrcgens may be substituted with alkyl, aryl cr heteroaryl), heterocyclylcarbonylamino (wh~re the heterocycle is connected to the carbonyl group via a nitrogen or carbon atom), alkylsulfonyla~ino, arylsulfonylamino, heteroarylsulfonylamino, R21 _ ~c4,ON_ . .

W O98103174 PCT~US97/12158 where J i~: CHR23, --C-- ,-7H--CH- or -c=c-~ R24 R2s R24 R25 R23, R24 and R25 are independently hydrogen, alkyl, alkenyl, alkynyl, aryl, arylalkyl, heteroaryl, heteroarylalkyl, cycloalkyl, or cycloalkylalkyl;
S R20, R21, R22 are independently hydrogen, halo, alkyl, alkenyl, alkoxy, aryloxy, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, cycloalkylalkyl, heteroaryl, heteroarylalkyl, hydroxy or haloalkyl; and these preferred substituents may either be directly attached to R1, or attached via an alkylene chain at an open position.
R2 is the same or different from R1 and is independently any of the groups set out for R1, H, polyhaloalkyl ~such as CF3C~2, CF3CF2CH2 or CF3) or cycloheteroalkyl, and may be substituted with one to four of any of the groups defined for R3, or any of the substituents preferred for R1-L1 is a linking group containing from 1 to 10 carbons in a linear chain (including alkylene,alkenylene or alkynylene), which may contain, within the linking chain any of the following: one or two alkenes, one or two alkynes, an oxygen, an amino group optionally substituted with alkyl or aryl, an oxo groupi and may be substituted with one to five alkyl or halo groups (preferably F).
L2 may be the same or different from L1 and may independently be any of the L1 groups set out above or a singe bond.
R3, R3 , R4 and R4 may be the same or different and are independently selected from ~, halogen, CF3, haloalkyl, hydroxy, alkoxy, alkyl, aryl, alkenyl, alkenyloxy, alkynyl, alkynyloxy, alkanoyl, nitro, amino, thiol, alkylthio, alkyl-sulfinyl, alkylsulfonyl, carboxy, alkoxycarbonyl, aminocarbonyl, alkylcarbonyloxy, alkylcarbonylamino, cyclohete~oalkyl, cycloheteroalkylalkyl, cyano, Ar, Ar-alkyl, ArO, Ar-amino, Ar-thio, Ar-sulfiny], Ar-sulfonyl, Ar-carbonyl, Ar-carbonyloxy or A~-carbonylamino, wherein Ar is aryl or heteroa~yl and Ar may optionally include 1, 2 or 3 cdditional rings fused ~ to Ar;
R3a and R3b are the same or different and are independently any of the F3 groups except hydroxy, nitro, amino or thio;

~ , ~ and ~
are the same or different and independently represent a 5 or 6 membered heteroaryl ring which may contain 1, 2, 3 or 4 heteroatoms in the ring which are independently N, S or O; and including N-oxides.
X (in the fluorenyl ty~e ring) is a bond, or is one of the following groaps:

(~) n~
(2) -O--(3) --N

(4) "c~

R9 Rl~R9~ ~Rll' (6) c c-R9 RlO
(7) ,c~ Y -R9 Rlo CA 0226ll62 l999-0l-22 W O 98/03174 PCT~US97/12158 wherein Y is O, N-R6 or S;
n' is 0, l or 2;
R6 is H, lower alkyl, aryl, -C(O)-Rll or S -C(O)-O-Rll;
R7 and R8 are the same or different and are independently H, alkyl, aryl, halogen, -O-Rl2, or R7 and R8 together can be oxygen to form a ketone;
R9 Rl0 R9' and Rl0' are the same or different and are independently H, lower alkyl, aryl or -O-Rll;
R9" and Rl~ are the same or different and are independently ~, lower alkyl, aryl, halogen or -O-Rll;
Rll is alky or aryl;
Rl2 is H, alkyl or aryl.
The following provisos apply to formula I
compounds:
(a) when Rl is unsubstituted alkyl or unsubstituted arylalkyl, Ll cannot contain amino;
(b) when Rl is alkyl, Ll cannot contain amino and oxo in adjacent positions (to form an amido group);
(c) when R2L2A- is H2M-, RlLl cannot contain amino;
(d) when Rl is cyano, Ll must have more than 2 carbons;
(e) RlLl must contain at least 3 carbons.
With respect to compounds IA and IB, R2L2 cannot have an O or N atom directly attached to S=(O)q or CRX(OH), and for IA, R2L2 cannot be H.
With respect to compounds IA and IB, where Rl is cycloheteroalkyl, Rl is exclusive of l-piper-idinyl, l-pyrrolidinyl, l-azetidinyl or l-(2-oxo-pyrrolidinyl).

W O 98/03174 PCT~US97112158 The MTP inhibitors disclosed in U.S.
provisional application No. 6C/017,253, filed May 10, 1996, (file HX82*) are pyrrolidine compounds and have the structure S

R3. ~ N ~ ; or R4 w II

5, Q~
R6 ~ N-W

whereQis -C- or - S- ;
o W is H,H or Oi Xis:CHR8, -C- ,-cH- cH- or -C=C-;
~ R9 R10 R9 R1 0 R8, R9 and R10 are independent y hydrogen, alkyl, lS alkenyl, alkynyl, aryl, arylalkyl, heteroaryl, heteroarylalkyl, cycloalkyl, or cycloalkylalkyl;
Rl is alkyl, alkenyl, alkynyl, aryl, heteroaryl, arylalkyl (wherein alkyl preferably has at least 2 carbons, more preferably at least 3 carbons), diarylalkyl, arylalk~nyl, diarylalkenyl, arylalkynyl, diarylalkynyl, di~rylalkylaryl, heteroarylalkyl (wherein alkyl preferably has at least 2 carbons, more preferably at least 3 carbons), cycloalkyl, or cyclo~lkylalkyl (wherein alkyl preferably has at least 2 carbons, more preferably at least 3 carbons); all of the aforementioned Rl groups being optionally substituted through available ~arbon atoms with 1, 2, 3 or 4 groups selected from halo, haloalkyl, alkyl, alkenyl, alkoxy, aryloxy, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, W098/03174 PCT~S97/12158 cycloalkylalkyl, heteroaryl, fluorenyl, heteroarylalkyl, hydroxy or oxo; or R1 is a fluorenyl-type group of the structure or ~ -R11_z1 ~

R13 \ R14 R13 \ R14 3 R14 B C

_R11_Z1 or R12_ Z2 ~ Z

R13 ; or R1 is an indenyl-type group of the structure hl~. R14 R13' R14 _ R11_ z1 ~or --R11_ z1 ~ or R12_ Z2~ CH~ R R12' E- (a=2~30r4) E

_ R~ or _ R11_ z1 ~ ;
R12_ Z2 R16a R12_ Z2 ~ R16a R1sa (CH2)a R15~
G H
zl and z2 are the same or different and are independently a bond, 0, S, W O 98103174 PCT~US97/12158 S , /S~ , --NH-C-- , --N C-- . --C-- or --C--~ ~~)2 O alkyl O O OH
with the proviso that with respect to B, at least one of zl and z2 will be other than a bond;
R11 is a bond, alkylene, alkenylene or alkynylene of up to 10 carbon atoms, arylene (for example or mixed arylene-alkylene (for example ~--(CH2)n where n is 1 to 6;
R12 is hydrogen, alkyl, alkenyl, aryl, halo-alkyl, trihaloalkyl, trihaloal:;ylalkyl, heteroaryl, heteroarylalkyl, arylalkyl, ar~lalkenyl, cyclo-alkyl, aryloxy, alkoxy, aryla:koxy or cycloalkyl-lS alkyl; with the provisos that '1) when R12 is H, aryloxy, alkoxy or arylalkox~y, then z2 is --NH- C-- , --N--C-- --C--o alkyl O ~ O or a bond;
and (2) when z2 is a bond, R12 cannot be heteroaryl or heteroarylalkyl;
Z is a bond, 0, S, N-al{yl, N-aryl, or alkylene or alkenylene of from 1 to 5 carbon atoms;
R13 R14, R15, and R16 a-e independently hydrogen, alkyl, halo, haloalkyl, aryl, cycloalkyl, cycloheteroalkyl, alkenyl, alkynyl, hydroxy, alkoxy, nitro, amino, thio, al];ylsulfonyl, aryl-sulfonyl, alkylthio, arylthio, aminocarbonyl, alkylcarbonyloxy, arylcarbonylamino, alkylcarbonyl-amino, arylalkyl, heteroaryl, heteroarylalkyl, or aryloxy;
R15a and R15a are indepeldently any of the R15 or R16 groups except hydroxy, nitro, amino or thio;
or Rl is W O 98/03174 PCTrUS97/12158 ( CH2 ) 1?--<

wherein p is 1 to 8 and R17 and R18 are each independently H, alkyl, alkenyl, aryl, arylalkyl, heteroaryl, heteroarylalkyl, cycloalkyl or cycloalkylalkyl, at least one of Rl7 and R18 being other than H;
or Rl is --R1g~, wherein Rl9 is aryl or heteroaryl R20 is aryl or heteroaryl;
R2l is H, alkyl, aryl, alkylaryl, arylalkyl, aryloxy, arylalkoxy, heteroaryl, heteroarylalkyl, heteroarylalkoxy, cycloalkyl, cycloalkylalkyl or cyc~oalkylalkoxy;
~2, R3, R4 are independently hydrogen, halo, alkyl, alkenyl, alkoxy, aryloxy, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, cycloalkylalkyl, heteroaryl, heteroarylalkyl, hydroxy or haloalkyl;
R5 is alkyl , alkenyl, alkynyl, aryl, alkoxy, aryloxy, arylalkoxy, heteroaryl, arylalkyl, heteroarylalkyl, cycloalkyl, cycloheteroalkyl, heteroaryloxy, cycloalkylalkyl, polycycloalkyl, polycycloalkylalkyl, cycloalkenyl, cycloalkenyl-alkyl, polycycloalkenyl, polycycloalkenylalkyl, heteroarylcarbonyl, amino, alkylamino, arylamino, heteroarylamino, cycloalkyloxy, cycloalkylamino, all of the R5 substituents and R6 substituents (set out hereinafter) being optionally substituted through available carbon atoms with 1, 2, 3 or 4 groups selected from hydrogen, halo, alkyl, haloalkyl, alkoxy, haloalkoxy, alkenyl, alkynyl, cycloalkyl, cycloalkylalkyl, cycloheteroalkyl, cycloheteroalkylalkyl, aryl, heteroaryl, arylalkyl, arylcycloalkyl, arylalkenyl, arylalkynyl, aryloxy, W O98103174 PCTrUS97/12158 aryloxyalkyl, arylalkoxy, ary:.azo, heteroaryloxo, heteroarylalkyl, heteroarylal];enyl, heteroaryloxy, hydroxy, nitro, cyano, amino, substituted amino (wherein the amino includes l or 2 substituents ~ 5 which are alkyl, aryl or hete~oaryl, or any of the other aryl compounds mentionecL in the definitions), thiol, alkylthio, arylthio, h~teroarylthio, arylthioalkyl, alkylcarbonyl, arylcarbonyl, arylaminocarbonyl, alkoxycarbcnyl, aminocarbonyl, alkynylaminocarbonyl, alkylaminocarbonyl, alkenylaminocarbonyl, alkylcarbonyloxy, arylcarbonyloxy, alkylcarbonylamino, arylcarbonylamino, arylsulfin~l, arylsulfinylalkyl, arylsulfonyl, alkylsulfonyl, arylsulfonylamino, heteroarylcarbonylamino, heteroarylsulfinyl, heteroarylthio, heteroarylsulf~nyl, or alkylsulfinyl. Where R5 is ph~nyl, aryl, heteroaryl or cycloalkyl; this group preferably includes an ortho hydrophobic ~ubstituent such as alkyl, haloalkyl (with up to 5 halo groups), alkoxy, haloalkoxy (with up to 5 halo groups), aryl, aryloxy or arylalkyl;
R6 is hydrogen or Cl-C4 alkyl or Cl-C4 alkenyl;

~S ~S ~S

are the same or different and are independently selected from heteroaryl conta:.ning 5- or 6-ring members; and including N-oxides of the formulae I and II
compounds, that is - ~ ~nd W O 98/03174 PCTrUS97/12158 including pharmaceutically acceptable salts thereof.
The MTP inhibitors disclosed in U.S.
provisional application No. 60/017,254, filed May 10, 1996, (file HX84*) are azetidine compounds which have the structure I

R3 R~\~N--~CH )--CN--PI1 ; or I I
Rs I--(C~2),.~N - R

O O
,. ,.
whereQis -C- or -S- ;
o Xis:CHR~, -C~ H- CH- or ~C=C-;
~ R9 R10 Rg Rl n is 0 or 1;
lS R8, Rg and R10 are independently hydrogen, alkyl, alkenyl, alkynyl, aryl, arylalkyl, heteroaryl, heteroarylalkyl, cycloalkyl, or cycloalkylalkyl;
R1 is alkyl, alkenyl, alkynyl, aryl, heteroaryl, arylalkyl (wherein alkyl preferably has at least 2 carbons, more preferably at least 3 carbons~, diarylalkyl, arylalkenyl, diarylalkenyl, arylalkynyl, diarylalkynyl, diarylalkylaryl, heteroarylalkyl (wherein alkyl preferably has at least 2 carbons, more preferably at least 3 carbons), cycloalkyl, or cycloalkylalkyl (wherein alkyl preferably has at least 2 carbons, more preferably at least 3 carbons); all of the aforementioned R1 groups being optionally substituted through available carbon atoms with 1, 2, 3 or 4 groups selected from halo, haloalkyl, alkyl, alkenyl, alkoxy, aryloxy, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, W O 98/03174 PCT~US97/12158 cycloalkylalkyl, heteroaryl, f]uorenyl, heteroaryl-alkyl, hydroxy or oxo; or R1 is a fluorenyl-type croup of the structure S

R13 \ Rl4 R13~'='\ R1~l Rl4 a B C

--R11_z1 or R12_ z2 ~ Z

R1 is an indenyl-type g:-oup of the structure hl~ R14 l~13 R14 _R11_z1 ~ or_R11_ z1 ~ or ZR15a (CH2~ R12_ z2 (a=2,3or4) --R11_~ R14 _ R11 _ Z1 Ç~ ;
Rl2_ Z2 R16a R12-Z2 ~ R16a R15a (CH2)a G ~! R15a zl and z2 are the same or different and are independently a bond, O, S, W O 98103174 PCTrUS97112158 S , S ,--NH- C-- , --N C-- , --C-- or --C--~ (~)2 O alkyl O O OH
with the proviso that with respect to B, at least one Of zl and z2 will be other than a bond;
Rll is a bond, alkylene, alkenylene or S alkynylene of up to 10 carbon atoms, arylene (for example ~ ) or mixed arylene-alkylene (for example ~--(CH2)~ ) where q is 1 to 6;
R12 is hydrogen, alkyl, alkenyl, aryl, halo-alkyl, trihaloalkyl, trihaloalkylalkyl, heteroaryl, heteroarylalkyl, arylalkyl, arylalkenyl, cyclo-alkyl, aryloxy, alkoxy, arylalkoxy or cycloalkyl-alkyl; with the provisos that (l) when R12 is H, aryloxy, alkoxy or arylalkoxy, then z2 is --NH- C-- , --N C-- --C--O alkyl O ' ~ or a bondi and (2) when z2 is a bond, R12 cannot be heteroaryl or heteroarylalkyl;
Z is a bond, 0, S, N-alkyl, N-aryl, or alkylene or alkenylene of from 1 to 5 carbon atoms;
R13 R14, R15, and R16 are independently hydrogen, alkyl, halo, haloalkyl, aryl, cycloalkyl, cycloheteroalkyl, alkenyl, alkynyl, hydroxy, alkoxy, nitro, amino, thio, alkylsulfonyl, arylsulfonyl, alkylthio, arylthio, aminocarbonyl, alkylcarbonyloxy, arylcarbonylamino, alkylcarbonylamino, arylalkyl, heteroaryl, heteroarylalkyl, or aryloxy;
R15a and R16a are independently any o~ the R15 or R16 ~roups except hydroxy, nitro, amino or thioi or Rl is W O 98103174 PCT~US97/121S8 --(CH2)~
~18 wherein p is 1 to 8 and Rl7 anc R~8 are each independently H, alkyl, alkeny:., aryl, arylalkyl, heteroaryl, heteroarylalkyl, cycloalkyl or cycloalkylalkyl, at least one of R17 and R18 being other than H;
or Rl is F~~
_R1g~

wherein Rl9 is aryl or heteroatyl;
R20 is aryl or heteroaryl;
R21 is H, alkyl, aryl, alkylaryl, arylalkyl, aryloxy, arylalkoxy, heteroaryL, heteroarylalkyl, heteroarylalkoxy, cycloalkyl, cycloalkylalkyl or cycloalkylalkoxy;
R2, R3, R4 are independ~ntly hydrogen, halo, alkyl, alkenyl, alkoxy, arylox~, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, cycloalkylalkyl, heteroaryl, h~teroarylalkyl, hydroxy or haloalkyl;
R5 is alkyl , alkenyl, alkynyl, aryl, alkoxy, aryloxy, arylalkoxy, h~teroaryl, arylalkyl, heteroarylalkyl, cycloalkyl, c!cloheteroalkyl, heteroaryloxy, cycloalkylalkyl, polycycloalkyl, polycycloalkylalkyl, cycloalkelyl, cycloalkenylalkyl, polycycloalcenyl, polycycloalkenylalkyl, heteroarylcarbonyl, amino, alkylamino, arylamino, heteroarylamino, cycloalkyloxy, cycloalkylamino, all of the R5 substituents and R6 substituen s ~set out hereinafter~ being optionally ,ubstituted through available carbon atoms with 1, 2, 3 or 4 groups selected from hydrogen, halo, ~lkyl, haloalkyl, alkoxy, haloalkoxy, alkenyl, alkynyl, cycloalkyl, cycloalkylalkyl, cycloheteroalkyl, 3~ cycloheteroalkylalkyl, aryl, heteroaryl, arylalkyl, W O 98/03174 PCTfUS97112158 arylcycloalkyl, arylalkenyl, arylalkynyl, aryloxy, aryloxyalkyl, arylalkoxy, arylazo, heteroaryloxo, heteroarylalkyl, heteroarylalkenyl, heteroaryloxy, hydroxy, nitro, cyano, amino, substituted amino (wherein the amino includes l or 2 substituents which are alkyl, aryl or heteroaryl, or any of the other aryl compounds mentioned in the definitions), thiol, alkylthio, arylthio, heteroarylthio, arylthioalkyl, alkylcarbonyl, arylcarbonyl, arylaminocarbonyl, alkoxycarbonyl, aminocarbonyl, alkynylaminocarbonyl, alkylaminocarbonyl, alkenylaminocarbonyl, alkylcarbonyloxy, arylcarbonyloxy, alkylcarbonylamino, arylcarbonylamino, arylsulfinyl, arylsulfinylalkyl, arylsulfonyl, alkylsulfonyl, arylsulfonylamino, heteroarylcarbonylamino, heteroarylsulfinyl, heteroarylthio, heteroarylsulfonyl, or alkylsulfinyl. Where R5 is phenyl, aryl, heteroaryl or cycloalkyl; this group preferably includes an ortho hydrophobic substituent such as alkyl, haloalkyl ~with up to 5 halo groups), alkoxy, haloalkoxy (with up to 5 halo groups), aryl, aryloxy or arylalkyl;
R6 is hydrogen or Cl-C4 alkyl or Cl-C4 alkenyl;

~ , ~ and ~
are the same or different and are independently selected from heteroaryl containing 5- or 6-ring members; and including N-oxides of the formulae I and II
compounds, that is ~ _ o ; and Rl including pharmaceuticaLly acceptable salts thereof.
Compounds disclosed as ?referred in each of the above applications are pre-erred for use in the present invention.
Most preferred MTP inhi~itors to be employed in accordance with the present invention include preferred MTP inhibito:-s as set out in U.S.
patent application Serial No. ;48,811, filed January 11, 1996 (file DC21h) ,md in U.S.
provisional application No. 60'017,224, filed May 9, 1996 (file HX79a*).
Thus, preferred compoun~s in U.S. patent application Serial No. 548,811 (file DC21h) for use herein are compounds where Z is a bond;
xl and x2 are H;
R5 is aryl such as phenyl subs ituted with ~ ~ CF3 ~
(1) aryl such as phenyl, , Cl, S ~ N

(2) heteroaryl such as (3) halo such as Cl R5 is heteroaryl such as s ~ or substituted with -Ic~
(1) aroyl such as -s~ ~1 (2) arylthio such as wherein the R5 substituent is preferably in the 1o, position adjacent to the carbo~ linked to c CA 0226ll62 l999-0l-22 W O 98/03174 PCT~US97/121S8 (CH2)X is -(CH2)4- or F
Most preferred is 9-~4-[4-[[2-(2,2,2-Trifluoroethoxy)benzoyl]amino]-1 -piperidinyllbutyl~-N-(2,2,2-trifluoroethyl)-gH fluorene-9-carboxamide N I ' Preferred compounds in U.S. provisional application No. 60/017,224 (file HX79a*) for use herein are MTP inhibitor compounds of formula I
that is R2 ~ ~ AJ~ B ~ ~ R
wherein A is NH, B is Ri ~ R4 X is a bond, oxygen or sulfur; R3 and R4 are independently H or F.
Preferred Rl groups are aryl, preferably phenyl, heteroaryl, preferably imidazoyl or pyridyl (preferably substituted with one of the preferred Rl substituents: arylcarbonylamino, heteroarylcarbonylamino, cycloalkylcarbonylamino, alkoxycarbonylamino, alkylsulfonylamino, arylsulfonylamino, heteroarylsulfonylamino), PO(OAlkyl)2, heteroarylthio, benzthi-azole-2-thio, .,, . ~ . . ...

W O 98/03174 PCT~US97112158 imidazole-2-thio, alkyl, or al];enyl, cycloalkyl such as cyclohexyl, or l,3-dio,:an-2-yl.
Preferred R2 groups are alkyl, polyfluoroalkyl (such as l,l,l-trifluoroethyl), alkenyl, aryl or heteroaryl ~p:-eferably substituted with one of the preferred Rl substituents above), or PO(OAlkyl)2-If R2 is al~yl, l,l,l-t:-ifluoroethyl, or alkenyl, it is preferred that ]~l is other than alkyl or alkenyl.
It is preferred that 1l contains l to 5 atoms in the linear chain and ,2 is a bond or lower alkylene.
Preferred e3nnbodiments oE formula IA and formula IB compounds of the in~ention include those where B, Ll, L2, Rl and R2 are as set out with respect to the preferred embodLments of the formula I compounds, q is 0 or 2 and ~x is H.
Examples of other delipidating agents which may be employed herein include statins such as pravastatin, lovastatin, simva,tatin, atorvastatin, cerivastatin and fluvastatin, with pravastatin and atorvastatin being preferred, -ibrates such as clofibrate, fenofibrate, bezafLbrate, gemfibrozil, ciprofibrate, and clinofibrate as well as nicotinic acid, probucol and resins such as cholestyramine, colestipol, and DEAE-Sephadex, and/or combinations of two or more thereof, and/or co3~binations thereof with an MTP inhibitor.
The delipidating agent, for example MTP
inhibitor employed in accordan~e with the present invention can be administered o various mammalian species, such as dogs, cats, hlmans, etc., in need of treatment. These agents can be administered systemically, such as orally o- parenterally.
The delipidating agent, for example MTP
inhibitor can be incorporated Ln a conventional CA 0226ll62 l999-0l-22 W O 98/03174 PCTrUS97/12158 systemic dosage form, such as a tablet, capsule, elixir or injectable formulation. The above dosage forms will also include the necessary physiologically acceptable carrier material, excipient, lubricant, buffer, antibacterial, bulking agent (such as mannitol), anti-oxidants (ascorbic acid or sodium bisulfite) or the like.
Oral dosage forms are preferred, although parenteral forms are quite satisfactory as well.
The dose administered must be carefully adjusted according to the age, weight, and condition of the patient, as well as the route of administration, dosa~e form and regimen, and the desired result. In general, the dosage forms described above may be administered containing amounts of MTP inhibitor of from about 5 to about 500 mg per day preferably from about l0 to about 400 mg per day, in single or divided doses of one to four times daily.
The other delipidating agents will be employed in amounts set out in the latest edition of the Physician's Desk Reference (PDR).
Cytotoxic agents which may be employed in conjunction with the delipidating agent, for example with MTP inhibitors, in accordance with the present invention, are preferably lipophilic or rendered lipophilic by addition of LDL anchors such as oleoyl groups either as oleic acid derivatives or oleyl alcohol derivatives, linoleyl derivatives, retinyl derivatives or cholesteryl derivatives (as disclosed at page 107 of the Firestone review article, supra) so that the cytotoxic agent may be more easily constituted with LDL. Cytotoxic agents approved by the FDA such as those listed in the Physicians Desk Reference 50th Ed. 1996, may be employed including doxorubicin, doxorubicin valerate, idarubicin HCl, mitomycin, paclitaxel, taxotere, teniposide, etoposide, carboplatin, busulfan, megestrol acetate, mitotane, altretamine, lomustine, carmustine, estramustine phosphate sodium, procarbazine hydrochloride, cytarabine, and the like.
Preferred cytotoxic agerts include 9-methoxyellipticine, N-methylellipticinium, compounds 25, 1 and 2 disclosec in Firestone review article, supra, at page 107, t~at is ~ (cH2) ~ ~ ocON (cH2cH2cl ) 2 Oleoyl~ ,~ ,~J
"Cpd 25": n=l, R=H
1 : n=l, R=CH20CON(CH2CH2Cl)2 2 : n-3, R=CH2OCON(CH2CH2Cl)2 prednimustine, WB4291 (l-~bis(~-chloroethyl)amino]-3-methylnaphthalene), daunomycin and vincristine.
Preferred cytotoxic agents to be employed herein will depend upon the pa~ticularly neoplastic disease to be treated as follo~s.

WO98/03174 PCT~S97/12158 Cytotoxic Agent Tarqet (absorbs LDL~ to be Em~loved (1) acute myeloid leukemia compounds 25, l,2 and the other preferred compounds listed above (2) human monocytic (FAB-M5) and myelomonocytic (FAB-M4) leukemias and chronic myeloid leukemia in blast crisis (3) epidermoid cervical cancer (4) endometrial adenocarcinoma (5) gastric carcinoma (6) parotid adenoma (7) brain tumors including medulloblastoma, oligoden-droglioma, and malignant meningioma (8) squamous and small cell lung tumors (9) glioma (lO) G2 hepatoma (ll) choriocarcinoma (12) metastatic tumors (13) lymphoma (14) bladder cancer (15) breast carcinoma The dosages and formulations for the MTP
inhibitor delipidating agent will be as disclosed in the various patents and applications discussed above.

W O 98lO3174 PCTrUS97/12158 The dosages and formulltions for the delipidating agent and cytoto:~ic agent to be employed, where applicable, w:11 be as set out in the latest edition of the Physicians' Desk Reference.
Dosages for the LDL-drl~g conjugate are as follows: from about 10 to about lO00 mg/day, preferably from about 50 to about 250 mg/day, when the patient is at least 90% d~lipidated, in single IO or divided doses (2 to 4 timec/day). The reconstituted LDL portion wil~ comprise about 50%
of the conjugate.
The LDL-drug conjugate may be formulated for intravenous administration employing conventional pharmaceutical pr~ctices.

Claims (29)

What is Claimed is:

1. A method for treating a cancer having a high LDL requirement, which comprises administering to a mammalian species in need of treatment a therapeutically effective amount of a delipidating compound to substantially reduce LDL blood level.

2. The method as defined in Claim 1 wherein the LDL blood level is reduced to at least 20% of normal LDL blood level.

3. The method as defined in Claim 1 wherein the LDL blood level is reduced to substantially zero.

4. The method as defined in Claim 1 wherein the delipidating compound is an MTP
inhibitor alone or in combination with another type of cholesterol lowering drug.

5. The method as defined in Claim 4 wherein the MTP inhibitor has the structure including the piperidine N-oxide thereof or a pharmaceutically acceptable salt thereof, wherein Z
is a bond, O or S;
X1 and X2 are independently selected from H
or halo;
x is an integer from 2 to 6;
R5 is heteroaryl, aryl, heterocycloalkyl or cycloalkyl, each R5 group being optionally substituted with 1, 2, 3 or 4 substituents which may be the same or different.

6. The method as defined in Claim 5 where in the MTP inhibitor z is a bond.

7. The method as defired in Claim 5 where the MTP inhibitor is a piperiaine N-oxide.

8. The method as defired in Claim 5 where in the MTP inhibitor (CH2)x is optionally substituted with 1, 2 or 3 substituents which are the same or different and are alkyl or halo.

9. The method as defined in Claim 5 where in the MTP inhibitor R5 is sub;tituted with 1, 2, 3 or 4 substituents which may be the same or different and are halogen, monocyclic heteroaryl, bicyclic heteroaryl, heteroarylalkyl, cycloheteroalkyl, alkyl, alkoxy, cycloalkyl, aryl, aryloxy, substituted aryl, arylalkyloxy, heteroaryloxy, amino, alkylamilo, alkyl(aryl)amino, heteroarylamino, arylamino, alkylthio, arylthio, arylthioalkyl, heteroarylthio, arylsulfinyl or acyl.

10. The method as defined in Claim 9 where in the MTP inhibitor the R5 includes a substituent attached to a carbon in the position adjacent to the carbon linked to .

11. The method as defined in Claim 9 where in the MTP inhibitor R5 is substituted with 1, 2, 3 or 4 of one or more of the following I, Cl, F, CF3 where x is 1 to 5 , , , ;

alkyl, phenyl, phenyl substituted with halo, alkyl, CF3O, alkoxy, , CF3, or phenyl;
-~-(CH2)p CF3- where p is 1 to 5, -N(CH3)C6H5;

-S-(CH2)p CF3 where p is 1 to 5, , -S-alkyl, , -O-(CH2)p-CF3, , OCH3;

, ;
cyclohexyl, amino, , , , ;

alkanoyl, alkoxycarbonyl, aroyl, heteroarylaminocarbonyl, arylalkyloxycarbonyl, , ;
-CH2-S-C6H5, , , , .

12. The method as defined in Claim 11 where in the MTP inhibitor R5 is phenyl substituted with haloalkylphenyl or heteroaryl.

13. The method as defined in Claim 12 where in the MTP inhibitor R5 is or .

14. The method as defined in Claim 11 where in the MTP inhibitor is or

15. The method as defined in Claim 4 wherein the MTP inhibitor has the structure or or including pharmaceutically acceptable salts thereof, N-oxides thereof, wherein q is 0, 1 or 2 A is (1) a bond;
(2) -O-; or (3) where R5 is H or lower alkyl, or R5 together with R2 forms a carbocyclic or heterocyclic ring system containing 4 to 8 members in the ring;
B is a fluorenyl-type group of the structure or or or B is an indenyl-type group of the structure or or ;

R x is H, alkyl or aryl;

R1 is alkyl, alkenyl, clkynyl, alkoxyl, (alkyl or aryl)3Si (where each alkyl or aryl group is independent), cycloalkyl, cycloalkenyl, substituted alkylamino, substituted arylalkylamino, aryl, arylalkyl, arylamino, aryloxy, heteroaryl, hetero-arylamino, heteroaryloxy, arylsulfonylamino, heteroarylsulfonylamino, arylthio, arylsulfinyl, arylsulfonyl, alkylthio, alkylsulfinyl, alkylsulfonyl, heteroarylthio, heteroarylsulfinyl, hetero-arylsulfonyl, -PO(R13)(R14), (where R13 and R14 are independently alkyl, aryl, alkoxy, aryloxy, hetero-aryl, heteroarylalkyl, heteroaryloxy, heteroarylalkoxy, cycloheteroalkyl, cycloheteroalkylalkyl, cycloheteroalkoxy, or cycloheteroalkylalkoxy);
aminocarbonyl (where the amino may optionally be substituted with one or two aryl, alkyl or heteroaryl groups); cyano, 1,1-(alkoxyl or aryloxy)2alkyl (where the two aryl or alkyl substituents can be independently defined, or linked to one another to form a ring connected to L1 (or L2 in the case of R2) at the 2-position);
1,3-dioxane or 1,3-dioxolane connected to L1 (or L2 in the case of R2) at the 4-position; the R1 group may optionally be substituted with 1, 2, 3 or 4 substituents, which can be any of the R3 or R1 groups or alkylcarbonylamino, cycloalkylcarbonylamino, arylcarbonylamino, heteroarylcarbonylamino, alkoxycarbonylamino, aryloxycarbonylamino, heteroaryloxylcarbonylamino, uriedo (where the uriedo nitrogens may optionally be substituted with alkyl, aryl or heteroaryl), heterocyclylcarbonylamino (where the heterocycle is connected to the carbonyl group via a nitrogen or carbon atom), alkylsulfonylamino, arylsulfonylamino, heteroarylsufonylamino, , where J is: CHR23, , or ;

R23, R24 and R25 are independently hydrogen, alkyl, alkenyl, alkynyl, aryl, arylalkyl, heteroaryl, heteroarylalkyl, cycloalkyl, or cycloalkylalkyl;
R20, R21, R22 are independently hydrogen, halo, alkyl, alkenyl, alkoxy, aryloxy, aryl, arylalkyl, alkylmercapto, arylmercapto, cycloalkyl, cycloalkylalkyl, heteroaryl, heteroarylalkyl, hydroxy or haloalkyl; and these substituents may either be directly attached to R1, or attached via an alkylene at an open position;
R2 is independently any of the groups set out for R1, H, polyhaloalkyl, or cycloheteroalkyl, and may be optionally substituted with one to four of any of the groups defined for R3 or substituents defined for R1;
L1 is a linking group containing from 1 to 10 carbons in a linear chain including alkylene, alkenylene or alkynylene, which may contain, within the linking chain any of the following: one or two alkenes, one or two alkynes, an oxygen, an amino group, an oxo group, and may be substituted with one to five alkyl or halo groups;
L2 may be the same or different from L1 and may independently be any of the L1 groups set out above or a singe bond;
R3, R3', R4 and R4' may be the same or different and are independently selected from H, halogen, CF3, haloalkyl, hydroxy, alkoxy, alkyl, aryl, alkenyl, alkenyloxy, alkynyl, alkynyloxy, alkanoyl, nitro, amino, thiol, alkylthio, alkylsulfinyl, alkylsulfonyl, carboxy, alkoxycarbonyl, aminocarbonyl, alkylcarbonyloxy, alkylcarbonylamino, cycloheteroalkyl, cycloheteroalkylalkyl, cyano, Ar-, Ar-alkyl, ArO, Ar-amino, Ar-thio, Ar-sulfinyl, Ar-sulfonyl, Ar-carbonyl, Ar-carbonyloxy or Ar-carbonylamino, wherein Ar is aryl or heteroaryl and Ar may optionally include 1, 2 or 3 additional rings fused to Ar;
R3a and R3b are the same or different and are independently any of the R3 groups except hydroxy, nitro, amino or thio;

, and are the same or different and independently represent a 5 or 6 membered heteroaryl ring which contains 1, 2, 3 or 4 heteroatoms in the ring which are independently N, S or O; and including N-oxides;
X is a bond, or is one of the following groups:
;

(2) -o- ;

;

;

;

; or wherein Y is O, N-R6 or S;
n' is 0, 1 or 2;
R6 is H, lower alkyl, aryl, -C(O)-R11 or -C(O)-O-R11;
R7 and R8 are the same or different and are independently H, alkyl, aryl, halogen, -O-R12, or R7 and R8 together can be oxygen to form a ketone;
R9, R10, R9' and R10' are the same or different and are independently H, lower alkyl, aryl or -O-R11;
R9" and R10" are the same or different and are independently H, lower alkyl, aryl, halogen or -O-R11;
R11 is alky or aryl;
R12 is H, alkyl or aryl;
with the following provisos for compound of the structure (a) when R1 is unsubstituted alkyl or unsubstituted arylalkyl, L1 cannot contain amino;
(b) when R1 is alkyl, L1 cannot contain amino and oxo in adjacent positions (to form an amido group);
(c) when R2L2A- is H2N-, R1L1 cannot contain amino;
(d) when R1 is cyano, L1 must have more than 2 carbons;
(e) R1L1 must contain at least 3 carbons;
with respect to compounds of formulas I, IA
and IB, where R1 is cycloheteroalkyl, R1 is exclusive of 1-piperidinyl, 1-pyrrolidinyl, 1-azetidinyl or 1-(2-oxo-pyrrolidinyl);
with respect to the sulfur containing compounds and alcohols, R2L2 cannot have an O or N

atom directly attached to S=(O)q or CR x(OH), and for IA, R2L2 cannot be H.

16. The method as defined in Claim 15 wherein the MTP inhibitor has the structure .

17. The method as defined in Claim 16 wherein A is a bond.

18. The method as defined in Claim 16 wherein A is -O-.

19. The method as defined in Claim 16 wherein A is .

20. The method as defined in Claim 16 wherein B is a fluorenyl-type group.

21. The method as defined in Claim 16 having the formula wherein B is A is NH;
X is a bond, oxygen or sulfur;
R3 and R4 are the same or different and are H or F;
R1 is aryl, phenyl, heteroaryl, imidazolyl, pyridyl, cyclohexyl, PO(R13)(RL4), heteroarylthio, benzthiazole-2-thio, imidazole-2-thio, alkyl, alkenyl or 1,3-dioxan-2-yl, wherein each of the above is optionally substituted;
R2 is alkyl, polyfluorcalkyl, alkenyl, aryl, phenyl, heteroaryl, imidazolyl or pyridyl, wherein each of the above is optionally substituted;
L1 is a chain containing 1 to 5 atoms in a linear chain;

L2 is a bond or lower alkylene.

22. The method as defined in Claim 1 wherein the cancer to be treated is a hematologic tumor.

23. The method as defined in Claim 1 wherein the cancer to be treated is a solid tumor or a metastatic tumor.

24. The method as defined in Claim 1 wherein the cancer treated is acute myeloid leukemia.

25. A method for treating a cancer having a high LDL requirement, which comprises administering to a mammalian species in need of treating a therapeutically effective amount of one or more delipidating agents alone or in combination with a cytotoxic agent.

26. A method for treating cancers having a high LDL requirement, which comprises administering to a mammalian species in need of treatment an LDL
lowering amount of a delipidating compound to substantially remove native LDL, and then administering a cytotoxic agent in reconstituted LDL to said mammalian species.

27. The method as defined in Claim 26 wherein the delipidating compound is an MTP
inhibitor alone or in combination with another cholesterol lowering drug.

28. The method as defined in Claim 26 wherein the cancer to be treated is a hematologic tumor.

29. The method as defined in Claim 26 wherein the cancer to be treated is acute myeloid leukemia.