Novel RNA Polymerase I and Cyclin Dependent Kinase combination therapy for the treatment of aggressive Acute Myeloid Leukemia.

Despite advances in therapy, specific subtypes Acute Myeloid Leukaemia (AML) remains largely incurable. The first-in-class RNA Polymerase I (Pol I) inhibitor, CX-5461, has demonstrated promising activity in both haematological malignancies and solid tumours by selectively inhibiting ribosome biogenesis to induce nucleolar stress, a critical vulnerability in rapidly proliferating cancer cells. CX-5461 has undergone clinical trials for the treatment of both solid and haematological malignancies, and 2nd generation Pol I inhibitor PMR-116 has also entered clinical trials, underscoring the translational potential of drugs that target RNA Polymerase I. To enhance the therapeutic efficacy of Pol I inhibition and prevent the emergence of resistance, we conducted a cell line-based unbiased screen of FDA-approved drugs to identify compounds that might synergise with CX-5461. This screen revealed that the pan-CDK inhibitors Dinaciclib and Flavopiridol enhance nucleolar stress pathway (NSP) activation and are strong candidates for combinatorial therapy with CX-5461. Further analysis showed that the combination of CX-5461 and Dinaciclib acts synergistically across a genetically diverse panel of human AML cell lines. This synergy is dependent on an intact NSP, with both agents independently stabilising p53, but with distinct phenotypic outcomes: Dinaciclib induces rapid apoptosis, whereas CX-5461 primarily enforces cell cycle arrest. This functional complementarity results in efficient tumour cell clearance and likely accounts for the delayed onset of therapy resistance. Importantly, combination treatment with CX-5461 and Dinaciclib significantly improved survival in murine models of AML and reduced colony formation in primary human AML samples. Together these findings provide preclinical evidence for a novel combination treatment strategy that leverages nucleolar stress and cell cycle control to enhance treatment outcomes in AML, paving the way for clinical translation of Pol I-CDK co-targeting therapies.