Ponatinib is a tyrosine kinase inhibitor (TKI) directed against BCR-ABL1 which is successfully used in patients with BCR-ABL1 T315I+ chronic myeloid leukemia (CML). However, BCR-ABL1 compound mutations may develop during therapy in these patients and may lead to drug resistance. Asciminib is a novel drug capable of targeting most BCR-ABL1 mutant-forms, including BCR-ABL1T315I, but remains ineffective against most BCR-ABL1T315I+ compound mutation-bearing sub-clones. We demonstrate that asciminib synergizes with ponatinib in inducing growth-arrest and apoptosis in patient-derived CML cell lines and murine Ba/F3 cells harboring BCR-ABL1 T315I or T315I-including compound mutations. Asciminib and ponatinib also produced cooperative effects on CRKL phosphorylation in BCR-ABL1-transformed cells. The growth-inhibitory effects of the drug combination 'asciminib+ponatinib' was further enhanced by hydroxyurea (HU), a drug which has lately been described to suppresses the proliferation of BCR-ABL1 T315I+ CML cells. Cooperative drug effects were also observed in patient-derived CML cells. Most importantly, we were able to show that the combinations 'asciminib+ponatinib' and 'asciminib+ponatinib+HU' produce synergistic apoptosis-inducing effects in CD34+/CD38- CML stem cells obtained from patients with chronic phase CML or BCR-ABL1 T315I+ CML blast phase. Together, asciminib, ponatinib and HU synergize in producing anti-leukemic effects in multi-resistant CML cells, including cells harboring T315I+ BCR-ABL1 compound mutations and CML stem cells. The clinical efficacy of this TKI combination needs to be evaluated within the frame of upcoming clinical trials.

Children's Cancer Research Institute Vienna Austria

Department of Internal Medicine 1 Division of Hematology and Hemostaseology Medical University of Vienna Austria

Department of Internal Medicine 3 Division of Gastroenterology and Hepatology Medical University of Vienna Austria

Department of Internal Medicine Hematology and Oncology Faculty of Medicine Masaryk University Brno Czech Republic

Department of Internal Medicine Hematology and Oncology University Hospital Brno Czech Republic

Ludwig Boltzmann Institute for Hematology and Oncology Medical University of Vienna Austria

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Druker BJ, Guilhot F, O’Brien SG, Gathmann I, Kantarjian H, Gattermann N, Deininger MW, Silver RT, Goldman JM, Stone RM, Cervantes F, Hochhaus A, Powell BL, Gabrilove JL, Rousselot P, Reiffers J, Cornelissen JJ, Hughes T, Agis H, Fischer T, Verhoef G, Shepherd J, Saglio G, Gratwohl A, Nielsen JL, Radich JP, Simonsson B, Taylor K, Baccarani M, So C, Letvak L, Larson RA IRIS Investigators. Five-year follow-up of patients receiving imatinib for chronic myeloid leukemia. N Engl J Med. 2006;355:2408–2417. PubMed

Castagnetti F, Gugliotta G, Breccia M, Stagno F, Iurlo A, Albano F, Abruzzese E, Martino B, Levato L, Intermesoli T, Pregno P, Rossi G, Gherlinzoni F, Leoni P, Cavazzini F, Venturi C, Soverini S, Testoni N, Alimena G, Cavo M, Martinelli G, Pane F, Saglio G, Rosti G, Baccarani M GIMEMA CML Working Party. Long-term outcome of chronic myeloid leukemia patients treated frontline with imatinib. Leukemia. 2015;29:1823–1831. PubMed

Baccarani M, Cortes J, Pane F, Niederwieser D, Saglio G, Apperley J, Cervantes F, Deininger M, Gratwohl A, Guilhot F, Hochhaus A, Horowitz M, Hughes T, Kantarjian H, Larson R, Radich J, Simonsson B, Silver RT, Goldman J, Hehlmann R European LeukemiaNet. Chronic myeloid leukemia: an update of concepts and management recommendations of European LeukemiaNet. J. Clin. Oncol. 2009;27:6041–6051. PubMed PMC

Hochhaus A, Erben P, Ernst T, Mueller MC. Resistance to targeted therapy in chronic myelogenous leukemia. Semin Hematol. 2007;44:S15–S24. PubMed

Hehlmann R, Müller MC, Lauseker M, Hanfstein B, Fabarius A, Schreiber A, Proetel U, Pletsch N, Pfirrmann M, Haferlach C, Schnittger S, Einsele H, Dengler J, Falge C, Kanz L, Neubauer A, Kneba M, Stegelmann F, Pfreundschuh M, Waller CF, Spiekermann K, Baerlocher GM, Ehninger G, Heim D, Heimpel H, Nerl C, Krause SW, Hossfeld DK, Kolb HJ, Hasford J, Saußele S, Hochhaus A. Deep molecular response is reached by the majority of patients treated with imatinib, predicts survival, and is achieved more quickly by optimized high-dose imatinib: results from the randomized CML-study IV. J. Clin. Oncol. 2014;32:415–423. PubMed

Quintás-Cardama A, Cortes J. Therapeutic options against BCR-ABL1 T315I-positive chronic myelogenous leukemia. Clin Cancer Res. 2008;14:4392–4399. PubMed

Rinke J, Hochhaus A, Ernst T. CML - Not only BCR-ABL1 matters. Best Pract Res Clin Haematol. 2020;33:101194. PubMed

Shah NP, Nicoll JM, Nagar B, Gorre ME, Paquette RL, Kuriyan J, Sawyers CL. Multiple BCR-ABL kinase domain mutations confer polyclonal resistance to the tyrosine kinase inhibitor imatinib (STI571) in chronic phase and blast crisis chronic myeloid leukemia. Cancer Cell. 2002;2:117–125. PubMed

Balabanov S, Braig M, Brümmendorf TH. Current aspects in resistance against tyrosine kinase inhibitors in chronic myelogenous leukemia. Drug Discov Today Technol. 2014;11:89–99. PubMed

Jabbour EJ, Cortes JE, Kantarjian HM. Resistance to tyrosine kinase inhibition therapy for chronic myelogenous leukemia: a clinical perspective and emerging treatment options. Clin Lymphoma Myeloma Leuk. 2013;13:515–529. PubMed PMC

O’Hare T, Shakespeare WC, Zhu X, Eide CA, Rivera VM, Wang F, Adrian LT, Zhou T, Huang WS, Xu Q, Metcalf CA 3rd, Tyner JW, Loriaux MM, Corbin AS, Wardwell S, Ning Y, Keats JA, Wang Y, Sundaramoorthi R, Thomas M, Zhou D, Snodgrass J, Commodore L, Sawyer TK, Dalgarno DC, Deininger MW, Druker BJ, Clackson T. AP24534, a pan-BCR-ABL inhibitor for chronic myeloid leukemia, potently inhibits the T315I mutant and overcomes mutation-based resistance. Cancer Cell. 2009;16:401–412. PubMed PMC

Cortes JE, Kim DW, Pinilla-Ibarz J, le Coutre P, Paquette R, Chuah C, Nicolini FE, Apperley JF, Khoury HJ, Talpaz M, DiPersio J, DeAngelo DJ, Abruzzese E, Rea D, Baccarani M, Müller MC, Gambacorti-Passerini C, Wong S, Lustgarten S, Rivera VM, Clackson T, Turner CD, Haluska FG, Guilhot F, Deininger MW, Hochhaus A, Hughes T, Goldman JM, Shah NP, Kantarjian H PACE Investigators. A phase 2 trial of ponatinib in Philadelphia chromosome-positive leukemias. N Engl J Med. 2013;369:1783–1796. PubMed PMC

Valent P, Hadzijusufovic E, Schernthaner GH, Wolf D, Rea D, le Coutre P. Vascular safety issues in CML patients treated with BCR/ABL1 kinase inhibitors. Blood. 2015;125:901–906. PubMed

Mayer K, Gielen GH, Willinek W, Müller MC, Wolf D. Fatal progressive cerebral ischemia in CML under third-line treatment with ponatinib. Leukemia. 2014;28:976–977. PubMed

Jain P, Kantarjian H, Jabbour E, Gonzalez GN, Borthakur G, Pemmaraju N, Daver N, Gachimova E, Ferrajoli A, Kornblau S, Ravandi F, O’Brien S, Cortes J. Ponatinib as first-line treatment for patients with chronic myeloid leukaemia in chronic phase: a phase 2 study. Lancet Haematol. 2015;2:e376–e383. PubMed PMC

Khorashad JS, Kelley TW, Szankasi P, Mason CC, Soverini S, Adrian LT, Eide CA, Zabriskie MS, Lange T, Estrada JC, Pomicter AD, Eiring AM, Kraft IL, Anderson DJ, Gu Z, Alikian M, Reid AG, Foroni L, Marin D, Druker BJ, O’Hare T, Deininger MW. BCR-ABL1 compound mutations in tyrosine kinase inhibitor-resistant CML: frequency and clonal relationships. Blood. 2013;121:489–498. PubMed PMC

Gibbons DL, Pricl S, Posocco P, Laurini E, Fermeglia M, Sun H, Talpaz M, Donato N, Quintás-Cardama A. Molecular dynamics reveal BCR-ABL1 polymutants as a unique mechanism of resistance to PAN-BCR-ABL1 kinase inhibitor therapy. Proc Natl Acad Sci U S A. 2014;111:3550–3555. PubMed PMC

Zabriskie MS, Eide CA, Tantravahi SK, Vellore NA, Estrada J, Nicolini FE, Khoury HJ, Larson RA, Konopleva M, Cortes JE, Kantarjian H, Jabbour EJ, Kornblau SM, Lipton JH, Rea D, Stenke L, Barbany G, Lange T, Hernández-Boluda JC, Ossenkoppele GJ, Press RD, Chuah C, Goldberg SL, Wetzler M, Mahon FX, Etienne G, Baccarani M, Soverini S, Rosti G, Rousselot P, Friedman R, Deininger M, Reynolds KR, Heaton WL, Eiring AM, Pomicter AD, Khorashad JS, Kelley TW, Baron R, Druker BJ, Deininger MW, O’Hare T. BCR-ABL1 compound mutations combining key kinase domain positions confer clinical resistance to ponatinib in Ph chromosome-positive leukemia. Cancer Cell. 2014;26:428–442. PubMed PMC

Byrgazov K, Lucini CB, Valent P, Hantschel O, Lion T. BCR-ABL1 compound mutants display differential and dose-dependent responses to ponatinib. Haematologica. 2018;103:e10–e12. PubMed PMC

Yeung DT. Compound mutations in CML-imaginary bogeyman or real arch-nemesis? Leuk Res. 2019;81:102–104. PubMed

Shah NP, Skaggs BJ, Branford S, Hughes TP, Nicoll JM, Paquette RL, Sawyers CL. Sequential ABL kinase inhibitor therapy selects for compound drug-resistant BCR-ABL mutations with altered oncogenic potency. J Clin Invest. 2007;117:2562–2569. PubMed PMC

Schneeweiss-Gleixner M, Byrgazov K, Stefanzl G, Berger D, Eisenwort G, Lucini CB, Herndlhofer S, Preuner S, Obrova K, Pusic P, Witzeneder N, Greiner G, Hoermann G, Sperr WR, Lion T, Deininger M, Valent P, Gleixner KV. CDK4/CDK6 inhibition as a novel strategy to suppress the growth and survival of BCR-ABL1T315I+ clones in TKI-resistant CML. EBioMedicine. 2019;50:111–121. PubMed PMC

Gleixner KV, Sadovnik I, Schneeweiss M, Eisenwort G, Byrgazov K, Stefanzl G, Berger D, Herrmann H, Hadzijusufovic E, Lion T, Valent P. A kinase profile-adapted drug combination elicits synergistic cooperative effects on leukemic cells carrying BCR-ABL1T315I in Ph+ CML. Leuk Res. 2019;78:36–44. PubMed PMC

Valent P, Herndlhofer S, Schneeweiß M, Boidol B, Ringler A, Kubicek S, Gleixner KV, Hoermann G, Hadzijusufovic E, Müllauer L, Sperr WR, Superti-Furga G, Mannhalter C. TKI rotation-induced persistent deep molecular response in multi-resistant blast crisis of Ph+ CML. Oncotarget. 2017;8:23061–23072. PubMed PMC

Rea D, Lang F, Kim D, Cortes JE, Hughes TP, Minami H, Breccia M, Deangelo DJ, Hochhaus A, Talpaz M, Goh YT, le Coutre P, Deininger MW, Etienne G, Sondhi M, Mishra , Aimone P, Ng-Sikorski J, Mauro MJ. Asciminib, a specific allosteric BCR-ABL1 inhibitor, in patients with chronic myeloid leukemia carrying the T315I mutation in a phase 1 trial. Blood. 2018;132:792.

Hantschel O, Grebien F, Superti-Furga G. The growing arsenal of ATP-competitive and allosteric inhibitors of BCR-ABL. Cancer Res. 2012;72:4890–4895. PubMed PMC

Wylie AA, Schoepfer J, Jahnke W, Cowan-Jacob SW, Loo A, Furet P, Marzinzik AL, Pelle X, Donovan J, Zhu W, Buonamici S, Hassan AQ, Lombardo F, Iyer V, Palmer M, Berellini G, Dodd S, Thohan S, Bitter H, Branford S, Ross DM, Hughes TP, Petruzzelli L, Vanasse KG, Warmuth M, Hofmann F, Keen NJ, Sellers WR. The allosteric inhibitor ABL001 enables dual targeting of BCR-ABL1. Nature. 2017;543:733–737. PubMed

Schoepfer J, Jahnke W, Berellini G, Buonamici S, Cotesta S, Cowan-Jacob SW, Dodd S, Drueckes P, Fabbro D, Gabriel T, Groell JM, Grotzfeld RM, Hassan AQ, Henry C, Iyer V, Jones D, Lombardo F, Loo A, Manley PW, Pellé X, Rummel G, Salem B, Warmuth M, Wylie AA, Zoller T, Marzinzik AL, Furet P. Discovery of asciminib (ABL001), an allosteric inhibitor of the tyrosine kinase activity of BCR-ABL1. J Med Chem. 2018;61:8120–8135. PubMed

Hughes TP, Mauro MJ, Cortes JE, Minami H, Rea D, DeAngelo DJ, Breccia M, Goh YT, Talpaz M, Hochhaus A, le Coutre P, Ottmann O, Heinrich MC, Steegmann JL, Deininger MWN, Janssen JJWM, Mahon FX, Minami Y, Yeung D, Ross DM, Tallman MS, Park JH, Druker BJ, Hynds D, Duan Y, Meille C, Hourcade-Potelleret F, Vanasse KG, Lang F, Kim DW. Asciminib in chronic myeloid leukemia after ABL kinase inhibitor failure. N Engl J Med. 2019;381:2315–2326. PubMed PMC

Garcia-Gutiérrez V, Luna A, Alonso-Dominguez JM, Estrada N, Boque C, Xicoy B, Giraldo P, Angona A, Alvarez-Larrán A, Sanchez-Guijo F, Ramírez MJ, Mora E, Vélez P, Rosell A, Colorado Araujo M, Cuevas B, Sagüés M, Cortes M, Encinas MP, Casado Montero LF, Moreno Vega M, Serrano L, Gomez V, Garcia-Hernandez C, Lakhwani S, Paz Coll A, de Paz R, Suarez-Varela S, Fernandez-Ruiz A, Perez Lopez R, Ortiz-Fernández A, Jiménez-Velasco A, Steegmann-Olmedillas JL, Hernández-Boluda JC. Safety and efficacy of asciminib treatment in chronic myeloid leukemia patients in real-life clinical practice. Blood Cancer J. 2021;11:16. PubMed PMC

Manley PW, Barys L, Cowan-Jacob SW. The specificity of asciminib, a potential treatment for chronic myeloid leukemia, as a myristate-pocket binding ABL inhibitor and analysis of its interactions with mutant forms of BCR-ABL1 kinase. Leuk Res. 2020;98:106458. PubMed

Eide CA, Zabriskie MS, Savage Stevens SL, Antelope O, Vellore NA, Than H, Schultz AR, Clair P, Bowler AD, Pomicter AD, Yan D, Senina AV, Qiang W, Kelley TW, Szankasi P, Heinrich MC, Tyner JW, Rea D, Cayuela JM, Kim DW, Tognon CE, O’Hare T, Druker BJ, Deininger MW. Combining the allosteric inhibitor asciminib with ponatinib suppresses emergence of and restores efficacy against highly resistant BCR-ABL1 mutants. Cancer Cell. 2019;36:431–443. PubMed PMC

Eadie LN, Saunders VA, Branford S, White DL, Hughes TP. The new allosteric inhibitor asciminib is susceptible to resistance mediated by ABCB1 and ABCG2 overexpression in vitro. Oncotarget. 2018;9:13423–13437. PubMed PMC

Elrashedy AA, Ramharack P, Soliman MES. The perplexity of synergistic duality: inter-molecular mechanisms of communication in BCR-ABL1. Anticancer Agents Med Chem. 2019;19:1642–1650. PubMed

Yuan H, Wang Z, Gao C, Chen W, Huang Q, Yee JK, Bhatia R, Chen W. BCR-ABL gene expression is required for its mutations in a novel KCL-22 cell culture model for acquired resistance of chronic myelogenous leukemia. J Biol Chem. 2010;285:5085–5096. PubMed PMC

La Rosee P, Corbin AS, Stoffregen EP, Deininger MW, Druker BJ. Activity of the Bcr-Abl kinase inhibitor PD180970 against clinically relevant Bcr-Abl isoforms that cause resistance to imatinib mesylate (Gleevec, STI571) Cancer Res. 2002;62:7149–7153. PubMed

Byrgazov K, Lucini CB, Berkowitsch B, Koenig M, Haas OA, Hoermann G, Valent P, Lion T. Transposon-mediated generation of BCR-ABL1-expressing transgenic cell lines for unbiased sensitivity testing of tyrosine kinase inhibitors. Oncotarget. 2016;7:78083–78094. PubMed PMC

Chou TC, Talalay P. Quantitative analysis of dose-effect relationships: the combined effects of multiple drugs or enzyme inhibitors. Adv Enzyme Regul. 1984;22:27–55. PubMed

Tan FH, Putoczki TL, Stylli SS, Luwor RB. Ponatinib: a novel multi-tyrosine kinase inhibitor against human malignancies. Onco Targets Ther. 2019;12:635–645. PubMed PMC

Castagnetti F, Pane F, Rosti G, Saglio G, Breccia M. Dosing strategies for improving the risk-benefit profile of ponatinib in patients with chronic myeloid leukemia in chronic phase. Front Oncol. 2021;11:642005. PubMed PMC

Santoro M, Accurso V, Mancuso S, Contrino AD, Sardo M, Novo G, Di Piazza F, Perez A, Russo A, Siragusa S. Management of ponatinib in patients with chronic myeloid leukemia with cardiovascular risk factors. Chemotherapy. 2019;64:205–209. PubMed

Valent P. Emerging stem cell concepts for imatinib-resistant chronic myeloid leukaemia: implications for the biology, management, and therapy of the disease. Br J Haematol. 2008;142:361–378. PubMed

Jiang X, Zhao Y, Smith C, Gasparetto M, Turhan A, Eaves A, Eaves C. Chronic myeloid leukemia stem cells possess multiple unique features of resistance to BCR-ABL targeted therapies. Leukemia. 2007;21:926–935. PubMed

Copland M, Hamilton A, Elrick LJ, Baird JW, Allan EK, Jordanides N, Barow M, Mountford JC, Holyoake TL. Dasatinib (BMS-354825) targets an earlier progenitor population than imatinib in primary CML but does not eliminate the quiescent fraction. Blood. 2006;107:4532–4539. PubMed

Combination therapies with ponatinib and asciminib in a preclinical model of chronic myeloid leukemia blast crisis with compound mutations