Efficacy and Safety of Ruxolitinib in Regularly Transfused Patients with Thalassemia: Results from Single-Arm, Multicenter, Phase 2a Truth Study

Abstract BACKGROUND: Ruxolitinib (RUX) is approved in adult patients (pts) with myelofibrosis (MF), and in pts with polycythemia vera (PV) who are resistant/intolerant to hydroxyurea. Splenomegaly, a key clinical feature in advanced MF/PV, is also common in pts with transfusion-dependent thalassemia (TDT). In pts with TDT, splenomegaly worsens anemia, leading to increased transfusion requirement (TR). Similar to murine models of MF (Ostojic A, 2012), JAK2 inhibition led to a decrease in spleen size in murine models of thalassemia (Musallam KM, 2013). Additionally, thalassemia-related ineffective erythropoiesis was associated with hyperactivation of JAK-STAT pathway in preclinical studies. These findings indicate that RUX treatment (Tx) might benefit pts with TDT and splenomegaly. Present exploratory study aims to evaluate the effect of RUX Tx on TR, spleen volume (SV), and pre-transfusion hemoglobin (Hgb) levels. METHODS: TRUTH is a single-arm, multicenter, phase 2a study exploring the efficacy and safety of RUX in regularly transfused adult pts (N = 30) with thalassemia and splenomegaly, for 30 weeks (core study). Starting dose of RUX was 10 mg twice daily (maximum dose of 25 mg in 5 mg/10 mg increments). Pts were required to receive iron chelation (deferoxamine/deferasirox) for at least 4 week prior to screening and throughout the study. Primary end point was the percent change of red blood cells (RBCs) transfused between week 6 to 30 vs baseline period (BL; defined as period between 24 weeks prior to start of Tx and week 0). Change of SV from BL (by MRI/CT) at week 12 and week 30 was a secondary end point. Other secondary end points included safety (N = 30, safety set) and change of pre-transfusion Hgb level from BL. RESULTS: Of the 30 pts enrolled (median age, 24 years; 60% male), 26 completed the core phase at week 30 and 4 discontinued before week 30 (adverse event [AE], N = 2; withdrew consent, N = 1; subject/guardian decision, N = 1). Of those 26 who completed core Tx, 20 pts continue to receive RUX beyond the core study via other mechanisms. The median duration of exposure during the core phase was 30.2 weeks and median actual dose intensity of RUX was 27.2 mg/day (range, 13.3-39.0 mg/day). Mean hematocrit (HCT) adjusted volume of transfused RBC per 4 weeks was 605 mL for the BL period and 560 mL for the on-Tx period (between week 6-30; N = 27, per protocol set; 3 pts received < 18 weeks of Tx). Mean percent change of transfusion rate was −5.9 (95% CI: −14.7, 2.83). Change of HCT adjusted transfused volume per 4 weeks for on-Tx period vs BL is shown in Figure 1A. The percent change from BL in SV at week 30 is represented in Figure 1B. The mean SV reduction from BL at week 12 (N = 26) and week 30 (N = 25) was −19.7% and −26.8%, respectively. A slight trend for improvement was observed in the median pre-transfusion Hgb levels over time (pre-Tx = 8.4 g/L; end of study [week 24-30] = 8.9 g/L). At BL, 77% (23/30) of pts had Hgb levels below LLN but ≥ 8 g/dL and 20% (6/30) of pts had Hgb levels < 8 g/dL. At BL, 20% (6/30) of pts had a platelet (PLT) count below LLN but > 50 × 109/L, while no pt had PLT counts < 50 × 109/L. Worst post-BL hematologic abnormalities were Hgb (< 8g/dL, [hypo] = 17 pts [57%]), and PLT counts (< 50 × 109/L [hypo] = 1 pt [3%]). The most common AEs (all grade [G], ≥ 5%, regardless of study drug relationship) were upper respiratory tract infection (27%), nausea (20%), and upper abdominal pain/anemia/diarrhea/weight increased [each = 17%]). Overall, 25 pts experienced AEs, 11 pts had G 3 or 4 AEs, and 6 pts had serious AEs (regardless of study drug relationship); while, 13 pts experienced AEs, 5 pts had G 3 or 4 AEs, and 3 pts had serious AEs that were suspected to be related to the study drug. No deaths were reported during the study. AEs led to dose reduction/study Tx interruption in 9 pts (regardless of study drug relationship [≥ 5%]: nausea [all G = 2 pts (7%); G 3 or 4 = 1 pt (3%)] and vomiting [all G = 2 pts (7%); G 3 or 4 = 1 pt (3%)]). CONCLUSION: RUX Tx showed a trend for improvement in transfused red cells and a slight improvement in pre-transfusion Hgb; while, there was a noticeable reduction in SV over time. As per investigator assessment of clinical benefit, a majority of pts continued Tx beyond the core study. RUX was well tolerated in the study population with modest incidences of G 3 or 4 and serious AEs, with no new safety findings. Given the sustained decrease in SV, further studies could be valuable to determine if RUX Tx may be an alternative to splenectomy in pts with TDT. Disclosures Aydinok: Shire: Research Funding; Cerus: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Karakas:Novartis: Research Funding. Siritanaratkul:Jansen-Cilag: Research Funding; Novartis: Research Funding; Roche: Research Funding; Pfizer: Research Funding. Kattamis:Novartis: Honoraria, Research Funding; ApoPharma: Honoraria. Hollaender:Novartis: Employment. Mahuzier:Novartis: Employment. Gadbaw:Novartis: Employment. Taher:Novartis: Honoraria, Research Funding; Celgene: Research Funding.

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Deferasirox Continues to Reduce Iron Overload in Non-Transfusion-Dependent Thalassemia: A One-Year, Open-Label Extension to a One-Year, Randomized, Double-Blind, Placebo-Controlled Study (THALASSA)

Blood ◽

10.1182/blood.v120.21.3258.3258 ◽

2012 ◽

Vol 120 (21) ◽

pp. 3258-3258 ◽

Cited By ~ 1

Author(s):

Ali T Taher ◽

John B Porter ◽

Vip Viprakasit ◽

Antonis Kattamis ◽

Suporn Chuncharunee ◽

...

Keyword(s):

Iron Overload ◽

Board Of Directors ◽

Research Funding ◽

Study Drug ◽

Upper Respiratory Tract ◽

Open Label ◽

Advisory Committees ◽

The Core ◽

Core Study ◽

One Year

Abstract Abstract 3258 Background: Despite receiving occasional/no blood transfusions, non-transfusion-dependent thalassemia (NTDT) patients (eg β-thalassemia intermedia, mild/moderate HbE/β-thalassemia, α-thalassemia [HbH disease]) are at risk of iron overload, mainly due to increased intestinal iron absorption. The THALASSA 1-year randomized core study assessing deferasirox for investigational use in NTDT showed deferasirox superiority in reducing iron overload with a similar frequency of overall adverse events (AEs) compared with placebo (PBO). This 1-year extension evaluates continued efficacy/safety of deferasirox in patients receiving deferasirox in the core as well as patients receiving PBO who switched to deferasirox. Methods: Study design/inclusion-exclusion criteria have been described (Taher et al. Blood 2012). In the prospective, open-label, 1-year extension, patients whose LIC decreased ≥30% vs baseline (BL) continued at the same dose received at core end of study (EOS). Patients with LIC 3–15 or >15 mg Fe/g dw received deferasirox 10 or 20 mg/kg/day in the extension, respectively. After 6 months extension, patients with LIC <3 mg Fe/g dw at month 18 interrupted treatment; patients with LIC >7 mg Fe/g dw at month 18 and with LIC reduction <15% compared with core EOS received dose escalation up to a max of 20 mg/kg/day provided no safety issues. If serum ferritin fell <100 ng/mL, drug was withheld. Primary efficacy endpoint was number of patients with LIC <5 mg Fe/g dw by extension end. “Deferasirox” patients refer to combined core + extension. Patients treated with PBO during the core who had the option to enter the extension and be treated with deferasirox are referred to as “PBO/DFX” patients. Results: 166 patients enrolled in the core study (deferasirox: 110; PBO: 56). 133/148 who completed the core entered the extension (deferasirox: 85; 48 PBO/DFX); 15 did not enrol in the extension (mainly due to extension amendment not approved when patients reached core EOS [n=8] and not interested in continuing [n=5]). 130 patients (84 [98.8%] deferasirox; 46 [95.8%] PBO/DFX) completed the extension; 1 patient discontinued in the deferasirox group (due to AE), 2 patients discontinued in the PBO/DFX group (due to AE [n=1], local admin problem [n=1]). Mean actual deferasirox dose was 9.8 ± 3.6 mg/kg/day (median 9.5) in core + extension; 12.6 ± 4.5 mg/kg/day (median 10.8) in the extension (n=82) and 13.7 ± 4.6 mg/kg/day (median 14.0) in patients who crossed over from PBO to deferasirox in the extension, notably higher than those continuing on deferasirox (Figure). Deferasirox group (core + extension n=110) Mean absolute change in LIC from BL to month 24 was –7.14 mg Fe/g dw (Figure). By EOS, 43 (39.1%), 18 (16.4%) and 80 (72.7%) patients achieved a LIC<5, <3 and LIC decrease ≥3 mg Fe/g dw, respectively. In patients with BL LIC>7 mg Fe/g dw, 51/92 (55.4%) achieved LIC ≤7 at EOS. Median change in serum ferritin from BL to EOS was –450 ng/mL. Most common AEs regardless of study drug relationship: upper respiratory tract infection (20.9%), pyrexia (17.3%), diarrhea (13.6%), headache and nausea (both 12.7%), upper abdominal pain, anemia and gastroenteritis (11.8%); serious AEs (>2%): gastroenteritis (6.4%), pyrexia (3.6%), anemia (2.7%). 5 (4.5%) patients had serum creatinine increases >33% above BL and above ULN at ≥2 consecutive visits. One patient had ALT increase >5 × ULN and >2 × BL. PBO/DFX group (core + extension n=56) 21 (37.5%), 6 (10.7%) and 36 (66.1%) patients achieved LIC<5, <3 and LIC decrease ≥3 mg Fe/g dw, respectively. In patients with BL LIC>7 mg Fe/g dw, 17/42 (40.5%) achieved LIC ≤7 at EOS. Patients who crossed over from PBO to deferasirox entered the extension with a higher extension BL LIC than those continuing on deferasirox. Most common AEs regardless of study drug relationship: pyrexia (26.8%), upper respiratory tract infection (25.0%), diarrhea, headache, nausea (21.4%), abdominal pain (16.1%), vomiting, cough (14.3%). Conclusions: In iron-overloaded NTDT patients treated with deferasirox in the core study, LIC continued to decrease in the extension with 39.1% and 16.4% of patients reaching LIC <5 and <3 mg Fe/g dw, respectively, over 2 years. In patients originally randomized to PBO, whose LIC had increased by core EOS, LIC decreased with deferasirox in the extension. Data confirm deferasirox efficacy in reducing iron overload in NTDT, with a safety profile over 2 years consistent with that in the core study. Disclosures: Taher: Novartis: Honoraria, Research Funding. Off Label Use: Exjade is indicated for the treatment of chronic iron overload due to frequent blood transfusions. This abstract describes off-label use of Exjade in patients with non-transfusion-dependent thalassemia syndromes with iron overload. Porter:Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Viprakasit:GPO, Thailand: Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Kattamis:Novartis: Honoraria, Research Funding, Speakers Bureau. Chuncharunee:Novartis: Research Funding. Sutcharitchan:Novartis: Research Funding. Siritanaratkul:Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding. Galanello:Ferrokin: Research Funding; Apopharma: Research Funding, Speakers Bureau; Novartis: Research Funding, Speakers Bureau. Karakas:Novartis: Honoraria. Lawniczek:Novartis: Employment. Habr:Novartis: Employment. Ros:Novartis: Employment. Zhu:Novartis: Employment. Cappellini:Novartis: Speakers Bureau.

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Improvement of Efficacy Outcomes in Patients Who Switched from Sucrose-Formulated rFVIII to BAY 81-8973 Prophylaxis in the LEOPOLD Clinical Trials

Blood ◽

10.1182/blood-2020-137532 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 20-21

Author(s):

Gili Kenet ◽

Thomas Moulton ◽

Erika Soltes Rak ◽

Brian M. Wicklund ◽

Sanjay P Ahuja

Keyword(s):

Research Funding ◽

Hemophilia A ◽

Study Drug ◽

Study Cohort ◽

Efficacy And Safety ◽

Old Patients ◽

On Demand ◽

Adults And Children ◽

Previously Treated ◽

Bleeding Episodes

Background BAY 81-8973 (Kovaltry®) is a full-length, unmodified, recombinant factor VIII (FVIII), indicated for on-demand treatment and control of bleeding episodes, perioperative management of bleeding and routine prophylaxis to reduce the frequency of bleeding episodes in adults and children with hemophilia A. It has the same amino acid sequence as sucrose formulated FVIII (FVIII-FS; Kogenate® FS/Helixate® FS). Pharmacokinetic comparisons confirmed BAY 81-8973 to have a longer half-life and lower clearance than FVIII-FS. The objective of this analysis was to assess the efficacy and safety outcomes of patients with hemophilia A who were receiving FVIII-FS prior to enrolling into the LEOPOLD clinical studies receiving BAY 81-8973. Methods LEOPOLD I (NCT01029340) Part B and LEOPOLD Kids (NCT01311648) were Phase 3, multinational, open-label studies that included male patients with severe hemophilia A receiving on-demand or prophylactic therapy, with ≥50 exposure days to any FVIII product and no history of FVIII inhibitors. Patients in LEOPOLD I were >12 years old and received 20-50 IU/kg BAY 81-8973 prophylaxis twice-weekly (2×W) or three times a week (3×W) for up to one year. Patients in LEOPOLD Kids were ≤12 years old and received 25-50 IU/kg BAY 81-8973 ≥2×W for six months. Dosing regimens for both studies were assigned by the investigator. In this analysis, efficacy and safety are assessed in the subset of patients in LEOPOLD I Part B and LEOPOLD Kids who were previously treated with FVIII-FS. Results In LEOPOLD I, 22 (35.5%) patients were previously treated with FVIII-FS with a median age of 27.0; in LEOPOLD Kids, 24 (47.1%) patients were previously treated with FVIII-FS with a median age of 5.0 (Table 1). In general, these switch cohorts had similar patient demographics to the whole study cohort (Table 1) and any differences did not affect the final analysis. Most patients did not change their dosing frequency when starting treatment with BAY 81-8973 but most increased their dose (FVIII-FS dose is 25 IU/kg 3×W [adults] or every other day [EOD; children]; BAY 81-8973 dose is 25-40 IU/kg 2×W or 3×W [>12 years] or 25-50 IU/kg 2×W, 3×W or EOD [≤12 years]). Switching from FVIII-FS to BAY 81-8973 resulted in lower median annualized bleeding rates (ABRs) in the LEOPOLD studies. In LEOPOLD I, median (Q1; Q3) total ABR decreased from 2.5 (0.0; 9.0) in the 12 months of FVIII-FS treatment prior to study entry, to 1.0 (0.0; 6.8) (Figure 1). In LEOPOLD Kids, median total ABR decreased from 3.0 (1.0; 12.0) to 2.0 (0.0; 6.0) for 0-<6 year old patients (n = 13) and from 4.0 (0.0; 10) to 0.0 (0.0; 2.1) for 6-12 year old patients (n = 11) after switching from FVIII-FS to BAY 81-8973 (Figure 1). Joint and spontaneous median ABRs were zero for <12 year old patients treated with BAY 81-8973. There were no study-drug-related adverse events (AEs) or serious AEs (SAEs) reported in patients switching from FVIII-FS to BAY 81-8973 in either LEOPOLD I Part B or LEOPOLD Kids (Table 2). One patient in the LEOPOLD Kids main study discontinued BAY 81-8973 due to a central venous catheter-related infection after six months of treatment, which was not considered study-drug-related. No FVIII inhibitors developed in any patients in either study. Conclusions Switching from FVIII-FS to BAY 81-8973 resulted in improved bleeding control in adults and children with hemophilia A and was well-tolerated. Disclosures Kenet: PI Healthcare, CSL Behring: Honoraria; Bayer, Pfizer, Takeda, BioMarin, Novo Nordisk: Speakers Bureau; Bayer, Pfizer, Roche, Alnylam (Sanofi), Shire: Research Funding; Bayer, Pfizer, BioMarin, Takeda, Roche, Novo Nordisk, Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Moulton:Bayer: Current Employment. Soltes Rak:Bayer: Other: Employee of Belcan, contracted with Bayer. Wicklund:Genentech: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Shire (Takeda): Consultancy, Honoraria; Novo Nordisk: Consultancy, Honoraria. Ahuja:Genentech: Consultancy, Honoraria; Sanofi Genzyme: Consultancy, Honoraria; XaTek, Inc.: Consultancy, Patents & Royalties, Research Funding.

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A multicenter phase II study of Q3 week or weekly paclitaxel in combination with bevacizumab for the treatment of metastatic or unresectable angiosarcoma

Rare Tumors ◽

10.1177/2036361318771771 ◽

2018 ◽

Vol 10 ◽

pp. 203636131877177 ◽

Cited By ~ 9

Author(s):

Nam Bui ◽

Nikhil Kamat ◽

Vinod Ravi ◽

Sant Chawla ◽

Marti Lohman ◽

...

Keyword(s):

Median Overall Survival ◽

Progression Free Survival ◽

Weekly Paclitaxel ◽

Comparable Efficacy ◽

Progression Rate ◽

Efficacy And Safety ◽

Free Survival ◽

Multicenter Phase ◽

Grade 3 ◽

To Receive

Paclitaxel (P) and bevacizumab (B) are agents that provide clinical benefit in advanced angiosarcoma (AS). The objective of this study was to assess the efficacy and safety of P-B in two different scheduled regimens. Patients were to receive P 200mg/m2 IV with B 15mg/kg IV every 21 days (Regimen A) or P 90mg/m2 IV weekly D1, 8, 15 with B 15mg/kg IV D1 of a 28 day cycle (Regimen B) x6 cycles. Maintenance B followed at a dose of 15 mg/kg intravenously once every 21 days. The primary end point was 4 month non-progression rate (NPR). A total of 16 patients were enrolled. 4 month NPR was 62.5% with median overall survival 16 months and median progression free survival 5.06 months. 11 patients made it to cycle 3 and were evaluable for response with 1 CR (9%), 4 PR (36%), 2 SD (18%), and 6 PD (36%). There were ten grade 3 toxicities and four grade 4 toxicities. The breakdown between the two regimens revealed comparable efficacy and safety. Paclitaxel and Bevacizumab is an active regimen in angiosarcoma. Q3 week and weekly paclitaxel appear similar in efficacy and safety.

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Efficacy and Safety of Nilotinib in Elderly Patients with Imatinib-Resistant or -;Intolerant Chronic Myeloid Leukemia (CML) in Chronic Phase (CP): A Sub-Analysis of the ENACT (Expanding Nilotinib Access in Clinical Trials) Study.

Blood ◽

10.1182/blood.v114.22.3286.3286 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3286-3286 ◽

Cited By ~ 5

Author(s):

Philipp D. le Coutre ◽

Anna Turkina ◽

Dong-Wook Kim ◽

Bernadeta Ceglarek ◽

Giuliana Alimena ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Kinase Inhibitor ◽

Chronic Phase ◽

Study Drug ◽

Cytogenetic Response ◽

Efficacy And Safety ◽

Advisory Committees ◽

Imatinib Resistant ◽

Grade 3

Abstract Abstract 3286 Poster Board III-1 Introduction: Nilotinib, a potent and highly selective BCR-ABL kinase inhibitor, is approved for the treatment of patients (pts) with Philadelphia chromosome-positive chronic myelogeneous leukemia (Ph+ CML) in chronic phase (CML-CP) and accelerated phase (CML-AP) who are resistant or intolerant to prior therapy including imatinib. The ENACT study is a Phase IIIb, open-label, multicenter study that evaluated the efficacy and safety of nilotinib in adult pts with imatinib-resistant or intolerant CML in a clinical practice setting outside of a registration program. It is the largest single source of efficacy and safety information of any available tyrosine kinase inhibitor (TKI) in CML, particularly among the elderly. Methods: The present is a sub-analysis of the ENACT study on the efficacy and safety of 400 mg twice daily nilotinib in elderly (aged =60 years) pts initiating treatment in CML-CP who were resistant and/or intolerant to imatinib. Results: Of the 1,422 CML-CP pts enrolled in the ENACT study between January 2006 and October 2008, 452 (32%) were elderly (=60 years) at study initiation and 165 (37%) of these pts were =70 years [10 (2%) were =80 years]. Countries that enrolled =20 elderly pts include France, Italy, USA, Germany, UK, Spain, Canada, and Brazil. At study initiation, elderly pts had longer median durations of CML (<60: 51.1 months; =60: 69.3; =70: 66.6) and higher proportions with CML duration >5 years (<60: 43%; =60: 56%; =70: 52%). Besides imatinib, prior CML treatments received by elderly pts included dasatinib (=60: 20%; =70: 19%), cytarabine (=60: 23%; =70: 19%), busulfan (=60: 10%; =70: 7%), and interferons (=60: 50%; =70: 42%). Elderly pts were previously treated with imatinib for longer median durations (<60: 27.4 months; =60: 32.7; =70: 29.9), with higher proportions treated for >5 years (<60: 12%; =60: 19%; =70: 18%). The proportion of imatinib-intolerant to resistant elderly pts was about 1:1, which was higher than the proportion among <60 pts at about 0.6:1, such that relatively few elderly pts had prior highest imatinib dose >800 mg (<60: 34%; =60: 26%; =70: 21%). While response rates to prior imatinib were similar, among pts who required therapy after failing imatinib, elderly pts had lower cytogenetic response rates (<60: 22%; =60: 17%; =70: 19%) to prior dasatinib. During ENACT, less than 50% of elderly pts experienced nilotinib dose interruptions (=60: 46%; =70: 41%) and reductions (=60: 7%; =70: 6%) lasting >5 days, which was consistent with the overall ENACT dataset. The median duration of dose interruptions and reductions was 15 (=70: also 15) and 41 (=70: 32) days, respectively. The main reason for dose interruptions and reductions was adverse events (AEs). The median duration of nilotinib exposure was 227 days (=70: 219) and the median dose intensity was 749 mg/day (=70: 775). Efficacy was similar among elderly pts, with 39% (=70: 35%) of pts achieving complete hematologic response (CHR), 41% (=70: 39%) achieving major cytogenetic response (MCyR) and 31% (=70: 33%) achieving complete cytogenetic response (CCyR). MCyR rate was also similar among elderly hematologic responders (=60: 64%; =70: 65%). Among elderly pts requiring nilotinib therapy after both imatinib and dasatinib, and therefore have more resistant CML, CHR rate was 39% (=70: 32%), MCyR rate was 28% (=70: 29%) and CCyR rate was 20% (=70: 16%). Safety was likewise similar among elderly pts, with grade 3/4 study drug-related AEs occurring in 56% of pts (=70: 53%). The most frequent of these AEs were thrombocytopenia (=60: 24%; =70: 21%) and neutropenia (=60: 14%; =70: 11%). The most common method of managing these AEs was brief dose interruptions and/or reductions [thrombocytopenia (=60:86/108 pts; =70: 30/35), neutropenia (=60: 42/62 pts; =70: 9/18)]. Among elderly pts with prior dasatinib, 53% (=70: 58%) experienced grade 3/4 study drug-related AEs, while 7 out of 8 pts with pleural effusion on dasatinib no longer had it on nilotinib. Conclusions: In ENACT, pts aged =60 years at study initiation appear to have longer durations of CML, be more heavily pre-treated and more intolerant to imatinib than the younger cohort. Nonetheless, nilotinib induced comparable clinical responses in CML-CP pts regardless of age. Importantly, the safety profile of nilotinib is maintained in elderly pts. Disclosures: le Coutre: Novartis: Honoraria, Research Funding; BMS: Honoraria. Turkina:Novartis Pharmaceuticals: Honoraria. Kim:Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Wyeth: Research Funding. Ceglarek:Novartis Pharmaceuticals: Honoraria. Shen:Novartis Pharmaceuticals: Honoraria. Smith:Novartis Pharmaceuticals: Honoraria. Rizzieri:Novartis Pharma: Honoraria, Research Funding, Speakers Bureau. Szczudlo:Novartis: Employment. Berton:Novartis Pharmaceuticals: Employment. Wang:Novartis Pharmaceuticals: Employment. Wang:Novartis Pharmaceuticals: Research Funding. Nicolini:Novartis Pharma: Consultancy, Honoraria, Research Funding, Speakers Bureau; Bristol Myers Squibb: Consultancy, Honoraria, Research Funding, Speakers Bureau; Chemgenex: Honoraria, Speakers Bureau.

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Rationale and Design of a Phase 3b Multicenter, Randomized, Double-Blind Placebo-Controlled, Parallel-Group Trial with an Open-Label Extension Phase to Evaluate the Efficacy and Safety of Avatrombopag for the Treatment of Pediatric Patients with Immune Thrombocytopenia

Blood ◽

10.1182/blood-2021-144873 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 4211-4211

Author(s):

Rachael F. Grace ◽

Xiaoqiang Xue ◽

Brian Jamieson

Keyword(s):

Research Funding ◽

Immune Thrombocytopenia ◽

Pediatric Patients ◽

Previous Treatment ◽

Open Label ◽

The Core ◽

Age Cohort ◽

Open Label Extension ◽

Insufficient Response ◽

Core Phase

Abstract Background: Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by low platelet counts (PCs) caused by a combination of both impaired platelet production and increased peripheral platelet destruction. ITP in children often resolves on its own, but it may become chronic and symptomatic in a proportion of children affected. After failure of first-line therapies (e.g. corticosteroids or immunoglobulin), treatment options for children include immunosuppressants, such as rituximab, and thrombopoietin receptor agonists (TPO-RAs). Avatrombopag (AVA) is an orally administered small molecule TPO-RA. It binds the human c-Mpl at a different site than endogenous TPO, stimulating signal transduction mimicking the biological effects of endogenous TPO in a non-competitive manner. In a phase 3 trial (NCT01438840) in adults with ITP, the primary efficacy endpoint of cumulative number of weeks with PC ≥50×10 9/L during 6 months of treatment in the absence of rescue therapy, was statistically significant favoring AVA over placebo. The most common treatment-emergent adverse events (AEs) in the phase 2 and 3 trials in adults (n=128) were headache, fatigue, and contusion. AVA has no significant hepatotoxicity, is administered with food, and has no restrictions on meal composition. AVA is approved by FDA and EMA for treatment of primary chronic ITP in adult patients with an insufficient response to a previous treatment. For pediatric patients with ITP, there is an unmet need for new treatment options, given the difficult administration requirements and variable, transient response, frequent relapse, and associated toxicities of available treatments. Study Design and Methods: Described here is the rationale and design of a phase 3b multicenter, randomized, double-blind placebo-controlled, parallel-group trial with an open-label extension phase (NCT04516967), evaluating the efficacy and safety of AVA for the treatment of pediatric patients with ITP for ≥6 months with an insufficient response to a previous treatment. Main inclusion criteria (Core phase) include: Age ≥1 and <18 years; informed consent; primary ITP for ≥6 months duration and an insufficient response to previous treatment; an average of 2 PCs <30×10 9/L, with no single count >35×10 9/L. Main exclusion criteria: secondary ITP; inherited thrombocytopenia; history of arterial or venous thrombosis, myelodysplastic syndrome; or congenital heart abnormalities or arrhythmias. Subjects will be randomized to blinded therapy of AVA or placebo (3:1 ratio) for 12 weeks, stratified by age cohort and baseline PC (Figure). AVA or placebo will be administered as an oral tablet (20 mg, age cohort 1 and 2) or as an age-appropriate pediatric formulation (10 mg, age cohort 3). Subjects who complete the Core Phase and are eligible may continue to the open label extension phase (2 years). The primary endpoint is durable platelet response, defined by the proportion of subjects achieving ≥6 out of 8 weekly PCs ≥50×10 9/L during the last 8 weeks of the 12 week treatment period in the Core Phase, in the absence of rescue medication. Secondary endpoints include proportion of subjects with ≥2 consecutive PCs ≥50×10 9/L during the Core Phase (12 weeks) in the absence of rescue medication; percentage of weeks with PC ≥50×10 9/L, and between ≥50×10 9/L and ≤150×10 9/L, during Core Phase (12 weeks) in the absence of rescue therapy; proportion of subjects with PC ≥50×10 9/L at day 8, proportion of subjects who require rescue medications during Core Phase; incidence and severity of bleeding symptoms; safety and PK/PD parameters. Statistics: The primary endpoint will be tested using the Cochran-Mantel-Haenszel 2-sided test at α=0.05, adjusting for age cohort and baseline PC (≤15×10 9/L vs >15×10 9/L), or the Fisher's exact test, when data is sparse. In addition, the numbers and percentages of responders in each treatment group, the associated 95% confidence intervals (CI), and the 95% CI for the difference between AVA and placebo will be estimated. Study Status: This global study is currently enrolling patients and aims to include at least 72 patients in total, at approximately 62 sites. Figure 1 Figure 1. Disclosures Grace: Principia: Membership on an entity's Board of Directors or advisory committees; Dova: Membership on an entity's Board of Directors or advisory committees, Research Funding; Agios: Research Funding; Novartis: Research Funding. Xue: Dova Pharmaceuticals, a Sobi company: Current Employment. Jamieson: Sobi, Inc.: Current Employment. OffLabel Disclosure: Avatrombopag is an orally administered thrombopoietin receptor agonist (TPO-RA) that mimics the biologic effects of TPO in stimulating the development and maturation of megakaryocytes, resulting in increased platelet count. It is approved by the European Medicines Agency (EMA) and the US Food & Drug Administration (FDA) for the treatment of thrombocytopenia in adult patients with chronic liver disease who are scheduled to undergo a procedure, and for the treatment of thrombocytopenia in adult patients with chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment.

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Long-Term Efficacy and Safety of the Oral Pyruvate Kinase Activator Mitapivat in Adults with Non-Transfusion-Dependent Alpha- or Beta-Thalassemia

Blood ◽

10.1182/blood-2021-150386 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 576-576

Author(s):

Kevin H.M. Kuo ◽

D. Mark Layton ◽

Ashutosh Lal ◽

Hanny Al-Samkari ◽

Joy Bhatia ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Study Drug ◽

Publicly Traded ◽

Ineffective Erythropoiesis ◽

Advisory Committees ◽

The Core ◽

Grade 3 ◽

Hb Concentration ◽

Extension Period

Abstract Background: The thalassemias are a group of red blood cell (RBC) disorders in which ineffective erythropoiesis and hemolysis occur due to imbalanced production and precipitation of globin chains. Thalassemic RBCs have insufficient levels of ATP to meet increased energy demands associated with globin chain imbalance, protein degradation, and cellular oxidative stress responses. Mitapivat (AG-348) is a first-in-class, small-molecule, oral activator of RBC pyruvate kinase (PKR), a key enzyme regulating ATP production via glycolysis. In a phase 2, open-label trial of mitapivat in adults with α- or β-non-transfusion-dependent (NTD) thalassemia (NCT03692052), 80.0% (16/20) of patients (pts) met the primary endpoint of a hemoglobin (Hb) response (increase ≥ 1.0 g/dL from baseline at 1 or more assessments between Wks 4-12, inclusive). Improvements in markers of hemolysis and erythropoiesis were also observed in pts and mitapivat was generally well tolerated. Methods: Pts aged ≥ 18 (yrs) with a known medical history of α- or β-thalassemia, Hb concentration of ≤ 10.0 g/dL, and ≤ 5 RBC units transfused in prior 24 wks and none in 8 wks prior to study drug were eligible for the study. All pts started mitapivat at 50 mg twice daily (BID), escalating to 100 mg BID based on individual safety and Hb assessments. After completion of the 24-wk core period, pts were continued on mitapivat treatment in the extension period if they had achieved a Hb response, or a delayed Hb response (Hb increase of ≥ 1.0 g/dL at ≥ 1 assessment after Wk 12), with no ongoing grade ≥ 3 treatment-emergent adverse events (AE) related to study drug. Eligible pts continued mitapivat at the dose received at their Wk 24 visit. Study visits are conducted every 12 wks and will continue for up to 10 yrs. The extension period of the study is ongoing, here we report data up to Wk 72 visit (data cutoff March 27, 2021). Results: Of the 19 pts who completed the core period, 17 entered the extension period. During the extension period, 16 pts received 100 mg BID mitapivat and 1 received 50 mg BID. As of the cutoff date, 1 pt had discontinued (patient decision). Median (range, in wks) duration of mitapivat treatment for pts who entered the extension period was 70.9; (54.7, 105.6), with 8 of 17 pts receiving 72 wks or more of treatment as of the cutoff date for this analysis. The Median age of pts who entered the extension period was 44 yrs (range 29, 67). Mean baseline (standard deviation [SD]) Hb, total bilirubin and lactate dehydrogenase (LDH) was 8.1 (1.2) g/dL, 40.1 (26.2) μmol/L and 272.4 (121.7) U/L, respectively. Median baseline erythropoietin (EPO) was 70.5 (range 15, 11191) IU/L. Improvements in Hb concentration achieved in the core period were sustained in the extension study (n = 8 at Wk 72; Figure 1). Mean Hb (SD) increase from baseline to Wk 60 (which includes 4 pts with α- and 9 with β-thalassemia) and Wk 72 (which includes 8 pts with β-thalassemia) were 1.5 (0.4) g/dL and 1.7 (0.5) g/dL, respectively. Improvements in markers of hemolysis and ineffective erythropoiesis observed in the core period were maintained in the extension period up to Wk 72 (mean [SD] bilirubin and LDH, -15.8 [16.6] μmol/L and -63.6 [216.0] U/L, respectively; median [range] EPO, -33.0 [-72.0, -16.0] IU/L). The safety profile was consistent with that observed during the core period. AEs occurring in ≥ 15% of pts during the extension period were headache (5/17) and back pain (3/17), none of which were grade ≥ 3. No notable trends for changes in bone mineral density were observed (Figure 2). There were no treatment-related serious AEs during the extension period. Conclusions: In pts with either α- or β-thalassemia, a favorable efficacy-safety profile was observed with long-term treatment with mitapivat. Results show sustained improvements in Hb, hemolysis and ineffective erythropoiesis - despite the globin genotypic heterogeneity of the cohort - and no new safety findings. Mitapivat, through its unique mechanism of action, may represent a novel therapeutic approach for this condition. Two phase 3 trials of mitapivat in α- and β-thalassemia, one in pts who are NTD and one in pts who are transfusion-dependent, will be initiated in 2021. Figure 1 Figure 1. Disclosures Kuo: Bluebird Bio: Consultancy; Alexion: Consultancy, Honoraria; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria; Apellis: Consultancy; Pfizer: Consultancy, Research Funding; Bioverativ: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy. Layton: Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Cerus: Membership on an entity's Board of Directors or advisory committees. Lal: Chiesi: Consultancy; Agios Pharmaceuticals: Consultancy; bluebird bio, Inc.: Research Funding; La Jolla Pharmaceutical Company: Research Funding; Terumo Corporations: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Insight Magnetics: Research Funding; Protagonist Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Research Funding. Al-Samkari: Dova/Sobi: Consultancy, Research Funding; Moderna: Consultancy; Argenx: Consultancy; Rigel: Consultancy; Amgen: Research Funding; Novartis: Consultancy; Agios: Consultancy, Research Funding. Bhatia: Agios Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Kosinski: Agios Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Tong: Agios Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Lynch: Agios Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Uhlig: Agios Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Vichinsky: Agios Pharmaceuticals: Consultancy, Research Funding; Bluebird Bio: Consultancy, Research Funding; Global Blood Therapeutics: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding.

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The Commands Trial: A Phase 3 Study of the Efficacy and Safety of Luspatercept Versus Epoetin Alfa for the Treatment of Anemia Due to IPSS-R Very Low-, Low-, or Intermediate-Risk MDS in Erythropoiesis Stimulating Agent-Naive Patients Who Require RBC Transfusions

Blood ◽

10.1182/blood-2020-140284 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 1-2

Author(s):

Matteo Della Porta ◽

Uwe Platzbecker ◽

Valeria Santini ◽

Guillermo Garcia-Manero ◽

Rami S. Komrokji ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Efficacy And Safety ◽

Epoetin Alfa ◽

Phase 3 ◽

Advisory Committees ◽

Starting Dose ◽

To Receive ◽

Stimulating Factor ◽

Rbc Transfusion

Introduction: Anemia is the predominant cytopenia observed in patients with myelodysplastic syndromes (MDS), with many patients requiring regular red blood cell (RBC) transfusions. Erythropoiesis-stimulating agents (ESAs) remain a standard of care among patients with lower-risk MDS (LR-MDS), defined by International Prognostic Scoring System-Revised (IPSS-R) as Very Low-, Low-, or Intermediate-risk MDS, and endogenous serum erythropoietin (sEPO) levels ≤ 500 U/L. Recent studies of epoetin alfa and darbepoetin alfa have demonstrated efficacy among patients with LR-MDS, but the patient population in whom a clinically significant effect is seen may be limited (Fenaux P, et al. Leukemia 2018;32:2648-2658; Platzbecker U, et al. Leukemia 2017;31:1944-1950). A novel therapeutic option that increases the frequency of response and the duration of RBC transfusion independence (TI) in patients with LR-MDS would provide an important clinical benefit in this patient population. Luspatercept is a first-in-class erythroid maturation agent with a mechanism of action distinct from ESAs (Suragani RNVS, et al. Nat Med 2014;20:408-414). It is now approved in both the US and EU for patients with LR-MDS with ring sideroblasts (RS) who require RBC transfusions and are refractory, intolerant, or ineligible to receive ESAs on the basis of results from a phase 3 study (Fenaux P, Platzbecker U, et al. N Engl J Med 2020;382:140-151). Luspatercept may also be beneficial in treating anemia in patients with ESA-naive, LR-MDS who require RBC transfusions. In a phase 2 study in anemic patients with LR-MDS, 63% of patients receiving luspatercept (0.75-1.75 mg/kg) achieved a modified hematologic improvement - erythroid (mHI-E) response (Platzbecker U, et al. Lancet Oncol 2017;18:1338-1347); when analyzed by RS status, 69% of patients with ≥ 15% RS and 43% of patients with < 15% RS achieved mHI-E response. Study Design and Methods: The COMMANDS trial is a phase 3, open-label randomized study to compare the efficacy and safety of luspatercept versus epoetin alfa in anemic patients with IPSS-R defined LR-MDS, either with or without ≥ 15% RS, who are ESA naive, and who require regular RBC transfusions. Eligible patients must be aged ≥ 18 years at time of consent, have a documented diagnosis of IPSS-R defined LR-MDS with < 5% blasts in the bone marrow, have sEPO levels < 500 U/L, and require RBC transfusions (defined as an average transfusion requirement of 2-6 RBC units/8 weeks for ≥ 8 weeks immediately prior to randomization). Exclusion criteria include prior use of ESAs (≤ 2 doses of prior epoetin alfa permitted if ≥ 8 weeks from randomization date and sEPO confirmed as ≤ 500 U/L), granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF), unless given for the treatment of febrile neutropenia; disease-modifying agents (e.g. lenalidomide), or hypomethylating agents; and presence of del(5q) cytogenetic abnormality. A total of approximately 350 eligible patients will be randomized in a 1:1 ratio to receive either luspatercept (starting dose 1.0 mg/kg with titration up to 1.75 mg/kg) subcutaneously (SC) once every 3 weeks or epoetin alfa (starting dose 450 IU/kg with titration up to 1,050 IU/kg) SC once every week, for a minimum of 24 weeks (Figure). Best supportive care, including RBC transfusions, may be used in combination with study treatment in both arms. Randomization will be stratified by baseline RBC transfusion burden (< 4 vs ≥ 4 RBC units per 8 weeks), RS status (with RS+ defined as RS ≥ 15%, or ≥ 5% [but < 15%] if SF3B1 mutation is present), and baseline sEPO level (≤ 200 U/L versus > 200 U/L). In addition, ≥ 40% and ≤ 60% of randomized patients will be RS+, and ≥ 25% will have sEPO > 200 U/L. The primary endpoint is the proportion of patients who achieve RBC-TI for 12 weeks within the first 24 weeks on study, with a concurrent mean hemoglobin (Hb) increase of ≥ 1.5 g/dL compared with baseline. Key secondary endpoints include duration of RBC-TI, change in Hb levels, achievement of HI-E response per International Working Group (IWG) 2006 criteria, and safety. The COMMANDS trial is registered at ClinicalTrials.gov (NCT03682536) and EudraCT (number 2017-003190-34). Disclosures Platzbecker: Takeda: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Geron: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria; Amgen: Honoraria, Research Funding; BMS: Consultancy, Honoraria. Santini:Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Johnson & Johnson: Honoraria; Acceleron: Consultancy; Takeda: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Menarini: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Takeda: Membership on an entity's Board of Directors or advisory committees. Garcia-Manero:Celgene: Consultancy, Honoraria, Research Funding; Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Acceleron Pharmaceuticals: Consultancy, Honoraria; H3 Biomedicine: Research Funding; AbbVie: Honoraria, Research Funding; Helsinn Therapeutics: Consultancy, Honoraria, Research Funding; Amphivena Therapeutics: Research Funding; Astex Pharmaceuticals: Consultancy, Honoraria, Research Funding; Novartis: Research Funding; Jazz Pharmaceuticals: Consultancy; Bristol-Myers Squibb: Consultancy, Research Funding; Onconova: Research Funding; Merck: Research Funding. Komrokji:Geron: Honoraria; Novartis: Honoraria; Incyte: Honoraria; JAZZ: Honoraria, Speakers Bureau; AbbVie: Honoraria; Agios: Honoraria, Speakers Bureau; Acceleron: Honoraria; BMS: Honoraria, Speakers Bureau. Ito:BMS: Current Employment, Current equity holder in publicly-traded company. Fenaux:BMS: Honoraria, Research Funding; Jazz: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding.

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Efficacy and Safety of Bimagrumab in Sporadic Inclusion Body Myositis

Neurology ◽

10.1212/wnl.0000000000011626 ◽

2021 ◽

Vol 96 (12) ◽

pp. e1595-e1607

Author(s):

Anthony A. Amato ◽

Michael G. Hanna ◽

Pedro M. Machado ◽

Umesh A. Badrising ◽

Hector Chinoy ◽

...

Keyword(s):

Placebo Group ◽

Inclusion Body Myositis ◽

Extension Study ◽

Efficacy And Safety ◽

Treatment Groups ◽

The Core ◽

Core Study ◽

Sporadic Inclusion Body Myositis ◽

Class Iv

ObjectiveTo assess long-term (2 years) effects of bimagrumab in participants with sporadic inclusion body myositis (sIBM).MethodsParticipants (aged 36–85 years) who completed the core study (RESILIENT [Efficacy and Safety of Bimagrumab/BYM338 at 52 Weeks on Physical Function, Muscle Strength, Mobility in sIBM Patients]) were invited to join an extension study. Individuals continued on the same treatment as in the core study (10 mg/kg, 3 mg/kg, 1 mg/kg bimagrumab or matching placebo administered as IV infusions every 4 weeks). The co–primary outcome measures were 6-minute walk distance (6MWD) and safety.ResultsBetween November 2015 and February 2017, 211 participants entered double-blind placebo-controlled period of the extension study. Mean change in 6MWD from baseline was highly variable across treatment groups, but indicated progressive deterioration from weeks 24–104 in all treatment groups. Overall, 91.0% (n = 142) of participants in the pooled bimagrumab group and 89.1% (n = 49) in the placebo group had ≥1 treatment-emergent adverse event (AE). Falls were slightly higher in the bimagrumab 3 mg/kg group vs 10 mg/kg, 1 mg/kg, and placebo groups (69.2% [n = 36 of 52] vs 56.6% [n = 30 of 53], 58.8% [n = 30 of 51], and 61.8% [n = 34 of 55], respectively). The most frequently reported AEs in the pooled bimagrumab group were diarrhea 14.7% (n = 23), involuntary muscle contractions 9.6% (n = 15), and rash 5.1% (n = 8). Incidence of serious AEs was comparable between the pooled bimagrumab and the placebo group (18.6% [n = 29] vs 14.5% [n = 8], respectively).ConclusionExtended treatment with bimagrumab up to 2 years produced a good safety profile and was well-tolerated, but did not provide clinical benefits in terms of improvement in mobility. The extension study was terminated early due to core study not meeting its primary endpoint.Clinical Trial RegistrationClinicaltrials.gov identifier NCT02573467.Classification of EvidenceThis study provides Class IV evidence that for patients with sIBM, long-term treatment with bimagrumab was safe, well-tolerated, and did not provide meaningful functional benefit. The study is rated Class IV because of the open-label design of extension treatment period 2.

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Patterns and Management of Selected Adverse Events of Adult Patients with Imatinib-Resistant or -Intolerant Chronic Myeloid Leukemia (CML) From the ENACT (Expanding Nilotinib Access in Clinical Trials) Study.

Blood ◽

10.1182/blood.v114.22.1115.1115 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1115-1115

Author(s):

Philipp D. le Coutre ◽

Bernadeta Ceglarek ◽

Anna Turkina ◽

Dong-Wook Kim ◽

Giuliana Alimena ◽

...

Keyword(s):

Drug Therapy ◽

Research Funding ◽

Concomitant Medication ◽

Kinase Inhibitor ◽

Study Drug ◽

Efficacy And Safety ◽

Advisory Committees ◽

Imatinib Resistant ◽

First Occurrence ◽

Grade 3

Abstract Abstract 1115 Poster Board I-137 Introduction Nilotinib, a potent and highly selective BCR-ABL kinase inhibitor, is approved for the treatment of patients (pts) with Philadelphia chromosome-positive chronic myelogeneous leukemia (Ph+ CML) in chronic phase (CML-CP) or accelerated phase (CML-AP) who are resistant or intolerant to prior therapy, including imatinib. The ENACT study is a Phase IIIb, open-label, multicenter study that evaluated the efficacy and safety of nilotinib in adult pts with imatinib-resistant or intolerant CML in a clinical practice setting outside of a registration program. It is the largest single source of efficacy and safety information of any available tyrosine kinase inhibitor (TKI) in CML. Data from ENACT are used to characterize the patterns and management of adverse events (AEs) in nilotinib pts with imatinib-resistant or -intolerant CML-CP or -AP. Methods Pts received nilotinib 400 mg twice daily. Safety assessments included monitoring for all AEs and cardiac procedures. The first occurrence of the following AEs were selected on the basis of the following criteria: 1) the most frequently reported hematologic or biochemical laboratory abnormalities; or 2) identified by participating investigators as AEs of interest that may lead to study drug discontinuation: thrombocytopenia, neutropenia, hyperglycaemia, elevated lipase, elevated amylase, hyperbilirubinaemia, elevated alanine transaminase (ALT), and elevated aspartate transaminase (AST). There were no differences observed between the pattern of management between AEs suspected and regardless of study drug relationship as well as all grades vs. grade 3/4. For this reason this analysis covers management of grade 3/4 AEs suspected of study-drug relationship including duration and subsequent management. The following actions taken were reported by the treating physicians: study drug dose adjusted or temporarily interrupted, non-drug therapy given, no action taken, study drug permanently discontinued, concomitant medication taken or hospitalization/ prolonged hospitalization. More than one action was allowed to be selected. Results The AEs experienced by 1,603 pts (1,422 CP and 181 AP) were generally identified during nilotinib treatment and lasted for short durations. The number of the grade 3 and 4 AEs in CP and AP, median time from start of treatment and median duration are reported in Table. For all included AEs, the overall most common action taken for the first occurrence was dose adjustment or temporary interruption with the exception of hyperglycaemia which was most often managed by treatment with concomitant medications (8/11 of hyperglycaemia AEs in CP and 1/2 in AP). In the majority of the biochemical abnormalities other than hyperglycaemia there was no additional action taken. 49/308 (16%) events of thrombocytopenia in CP pts (9 in AP) were managed by non-drug therapy. 31/204 (15%) events of neutropenia in CP pts were managed by concomitant medication (6/33 events in AP). Permanent discontinuation of study drug was infrequently observed (number of pts in CP; AP): thrombocytopenia (25; 7), neutropenia (15; 2), hyperglycaemia (1; 0), elevated lipase (3; 0), elevated amylase (0; no pts), hyperbilirubinaemia (2; 0), elevated ALT (3; 0), and elevated AST (1; 0). Conclusions Based on a large cohort of 1,603 nilotinib pts with CML-CP and CML-AP, nilotinib is well-tolerated. Most study drug-related grade 3/4 AEs could be managed by temporary treatment interruption or dose adjustment, such that permanent discontinuation of study drug due to AEs was infrequent. The only events requiring concomitant medication administration or non-drug therapy were thrombocytopenia, neutropenia, hyperglycaemia and hyperbilirubinaemia. The AE profile observed was predictable and similar to that seen in registration trial. Disclosures le Coutre: Novartis: Honoraria, Research Funding; BMS: Honoraria. Ceglarek:Novartis Pharmaceuticals: Honoraria. Turkina:Novartis Pharmaceuticals: Honoraria. Kim:Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Wyeth: Research Funding. Shen:Novartis Pharmaceuticals: Honoraria. Smith:Novartis Pharmaceuticals: Honoraria. Rizzieri:Novartis Pharma: Honoraria, Research Funding, Speakers Bureau. Szczudlo:Novartis: Employment. Berton:Novartis Pharmaceuticals: Employment. Wang:Novartis Pharmaceuticals: Employment. Dial:Novartis Pharmaceuticals: Research Funding. Nicolini:Novartis Pharma: Consultancy, Honoraria, Research Funding, Speakers Bureau; Bristol Myers Squibb: Consultancy, Honoraria, Research Funding, Speakers Bureau; Chemgenex: Honoraria, Speakers Bureau.

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Efficacy and Safety of Azacitidine (AZA) in Combination with the Anti-PD-L1 Durvalumab (durva) for the Front-Line Treatment of Older Patients (pts) with Acute Myeloid Leukemia (AML) Who Are Unfit for Intensive Chemotherapy (IC) and Pts with Higher-Risk Myelodysplastic Syndromes (HR-MDS): Results from a Large, International, Randomized Phase 2 Study

Blood ◽

10.1182/blood-2019-122896 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 829-829 ◽

Cited By ~ 12

Author(s):

Amer M. Zeidan ◽

James Cavenagh ◽

Maria Teresa Voso ◽

David Taussig ◽

Mar Tormo ◽

...

Keyword(s):

Research Funding ◽

Treatment Cycle ◽

Surface Expression ◽

Efficacy And Safety ◽

Employment Equity ◽

Treatment Groups ◽

End Of Treatment ◽

Phase 2 Study ◽

Equity Ownership ◽

To Receive

Background: Loss of immune surveillance, mediated through immune checkpoint (ICP) interactions, is thought to be a key step in the development of cancers including AML and HR-MDS. AZA is a standard therapy for pts with AML who are unfit for IC and for pts with HR-MDS. AZA can promote immune recognition of tumor cells and potentially increase expression of ICP molecules, which can mediate resistance to AZA. As myeloid cell lines and samples from pts treated with hypomethylating agents demonstrated up-regulation of PD-L1 expression, blockade of the PD-L1 ICP with durva in combination with AZA may enhance antitumor activity and improve clinical outcomes. Here, we report the final results from a large phase 2 study evaluating the efficacy and safety of AZA+durva vs. AZA alone in pts with HR-MDS or AML (NCT02775903). Methods: This randomized, open-label, international, multicenter study enrolled untreated pts in 2 cohorts: 1) MDS (aged ≥18 years; IPSS-R intermediate, high, and very high) and 2) older AML pts (aged ≥65 years) who were ineligible for IC. All pts had ECOG performance status 0-2 and were separately randomized (1:1) to receive SC AZA 75 mg/m2 Days 1-7 and durva 1500 mg IV on Day 1 Q4W (Arm A) or AZA alone (Arm B) and stratified according to cytogenetic risk (MDS, very good/good/intermediate vs. poor/very poor; AML, intermediate vs. poor). Treatment was planned to continue until progression or unacceptable toxicity. Disease status was evaluated every third treatment cycle. Primary MDS endpoints included overall response rate (ORR, defined as complete remission [CR], marrow [m]CR, partial response [PR], or hematologic improvement [HI]) based on IWG 2006 response criteria, while for AML ORR was defined as CR or CR with incomplete blood recovery (CRi) based on modified IWG 2003 response criteria. Secondary endpoints included PFS, OS, and safety. Peripheral blood samples were collected to assess changes in DNA methylation using the EPIC methylation array (Illumina). Bone marrow (BM) aspirates were obtained for quantitation of PD-L1 surface expression by flow cytometry and values are reported as molecules of equivalent soluble fluorochrome. Results: A total of 213 pts, 84 with MDS (each arm, n=42) and 129 with AML (Arm A, n=64; Arm B, n=65) were randomized. As of October 31, 2018, 32 pts (MDS, n=14; AML, n=18) continued to receive trial treatment while 181 (MDS, n=70; AML, n=111) had discontinued. Baseline demographics and disease characteristics were generally balanced across treatment groups in both cohorts. Median number of treatment cycles for AML Arm A vs. B, 6.5 vs. 6.7; for MDS Arm A vs. B, 7.9 vs. 7.0. No statistically significant differences in ORR between treatment arms were observed in either cohort (Tables 1 and 2). In MDS Arm A vs. B, median OS was 11.6 vs. 16.7 months (mo) and PFS was 8.7 vs. 8.6 mo. In the AML cohort, median OS was 13.0 vs. 14.4 mo and PFS was 8.1 vs. 7.2 mo. Caution should be used when interpreting results because >50% of patients were censored. The most frequent TEAEs (≥15%) were hematologic and GI toxicity. In the MDS and AML cohorts, 7 and 17, respectively, immune-mediated AEs were observed; all were treated and resolved. AZA induced similar trends in global hypomethylation, along with focal hypomethylation of PD-L1 and PD-L2 gene loci, at the end of treatment cycle 1 in all treatment groups and cohorts. Mean PD-L1 surface expression in BM immune cells at baseline was highest in monocytes (MDS=1,425; AML=1,536), followed by granulocytes (MDS=550; AML=758) and myeloid blasts (MDS=532; AML=735). Increased surface expression of PD-L1, but not PD-L2, was observed at the end of treatment cycle 3 on BM granulocytes and monocytes from MDS pts and on BM monocytes from AML pts, but no increase was detected on myeloid blasts. Conclusions: To our knowledge, this is the first large randomized trial of AZA with or without ICP blockade in older unfit AML and HR-MDS pts reported to date. No clinically meaningful difference in efficacy was observed between treatments for either cohort. No new safety signals or potential overlapping risks were identified with the combination. While the hypomethylating activity of AZA on PD-L1 gene was confirmed, no treatment-mediated induction of PD-L1 surface expression was observed on myeloid blasts. Disclosures Zeidan: Acceleron Pharma: Consultancy, Honoraria, Research Funding; Celgene Corporation: Consultancy, Honoraria, Research Funding; Abbvie: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Medimmune/AstraZeneca: Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Trovagene: Consultancy, Honoraria, Research Funding; Incyte: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; ADC Therapeutics: Research Funding; Jazz: Honoraria; Ariad: Honoraria; Agios: Honoraria; Novartis: Honoraria; Astellas: Honoraria; Daiichi Sankyo: Honoraria; Cardinal Health: Honoraria; Seattle Genetics: Honoraria; BeyondSpring: Honoraria. Voso:Novartis: Speakers Bureau; Celgene: Research Funding, Speakers Bureau. Taussig:Celgene: Research Funding. Boss:Celgene Corporation: Employment, Equity Ownership. Copeland:Celgene Corporation: Employment, Equity Ownership. Gray:Celgene Corporation: Employment, Equity Ownership. Previtali:Celgene Corporation: Employment, Equity Ownership. O'Connor:Celgene Corporation: Employment, Equity Ownership. Rose:Celgene Corporation: Employment, Equity Ownership. Beach:Celgene Corporation: Employment, Equity Ownership. OffLabel Disclosure: Durvalumab is a PD-L1 blocking antibody indicated for the treatment of patients with 1) locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing chemotherapy, or who have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy, or 2) unresectable, stage 3 NSCLC whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy.

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