Ruxolitinib in combination with prednisone and nilotinib exhibit synergistic effects in human cells lines and primary cells from myeloproliferative neoplasms

Abstract

Ruxolitinib is the front-line non-palliative treatment for myelofibrosis (MF). However, a significant number of patients lose or present suboptimal response, are resistant or have unacceptable toxicity. In an attempt to improve response and avoid the adverse effects of this drug, we evaluated the combination of 17 drugs with ruxolitinib in ex vivo models of peripheral blood mononuclear cells from MF patients and cell lines. We found that the combination ruxolitinib and nilotinib had a synergistic effect against MF cells (ΔEC 50 nilotinib, −21.6%). Moreover, the addition of prednisone to combined ruxolitinib/nilotinib improved the synergistic effect in all MF samples studied. We evaluated the molecular mechanisms of combined ruxolitinib/nilotinib/prednisone and observed inhibition of JAK/STAT (STAT5, 69.2+11.8% inhibition) and MAPK (ERK, 29.4+4.5% inhibition) signaling pathways. Furthermore, we found that the triple therapy combination inhibited collagen protein and COL1A1 gene expression in human bone marrow mesenchymal cells. Taken together, we provide evidence that combined ruxolitinib/nilotinib/prednisone is a potential therapy for MF, possibly through the anti-fibrotic effect of nilotinib, the immunomodulatory effect of ruxolitinib and prednisone, and the anti-proliferative effect of ruxolitinib. This combination will be further investigated in a phase Ib/II clinical trial in MF.

Insights from a rare myeloproliferative neoplasm with coexisting BCR‐ABL1 fusion gene, CALR, and TET2 mutations treated with nilotinib and ruxolitinib

“…6,7 Given the overlapping clinical and morphologic features of MPN, it is important to test all of the mutations in JAK2/MPL/CALR and the BCR-ABL1 status in patients suspected of having MPNs. As observed in CML patients 10 and patients with coexistent BCR-ABL1 and JAK2 mutation, 11 combination treatment with TKI and ruxolitinib in our patient was safe and effective, which was also confirmed by three previous patients with coexistent BCR-ABL1 and CALR mutation, one treated with imatinib/dasatinib and ruxolitinib 3 and the others with imatinib and ruxolitinib 4,5 Moreover, recent studies found that the combination of ruxolitinib and nilotinib had a synergistic effect against both CML stem cells 12 and MF cells, 13 so our combination of nilotinib and ruxolitinib may have been better for this patient. However, the CALR mutation allele burden was not decreased and the splenomegaly persisted after 18 months of ruxolitinib therapy.…”

Janus kinase inhibitor ruxolitinib in combination with nilotinib and prednisone in patients with myelofibrosis (RuNiC study): A phase Ib, multicenter study

“…Since MF is a complex disease in which tyrosine-kinase-mediated signaling pathways are involved in the production of hematopoietic clones and with the fibrosis of the bone marrow, the use of drugs in combination against different targets may be beneficial. Previous data have shown that ruxolitinib combined with prednisone and nilotinib exhibits synergistic effects in human cell lines and primary cells from myeloproliferative neoplasms (MPN) [29]. Ruxolitinib showed the ability to diminish or stabilize Ruxolitinib plus nilotinib showed a synergistic behavior that blocked colony formation in patients' primary cells and inhibited the phosphorylation of STAT5 and ERK1/2.…”

“…Ruxolitinib plus nilotinib showed a synergistic behavior that blocked colony formation in patients’ primary cells and inhibited the phosphorylation of STAT5 and ERK1/2. In addition, the combination with prednisone increased this synergy and inhibited the synthesis of collagen in bone marrow mesenchymal cells [ 29 ].…”

Case report: Double L611S/V617L JAK2 mutation in a patient with polycythemia vera originally diagnosed with essential thrombocythemia

“…A recent study confirmed that therapeutic targeting of Y-Box Binding Protein 1 (YBX1)-dependent ERK signaling in combination with JAK2 inhibition could eradicate cells harboring mutations in JAK2 ( 16 ). The ruxolitinib/nilotinib/prednisone combination showed synergistic inhibitory effects on the JAK/STAT and MAPK signaling pathways in MPN cells ( 17 , 18 ). Thus, IFNα combined with JAK2 or MEK inhibition might improve therapeutic efficacy.…”