Venetoclax in Combination with NAMPT Inhibitors Decreases Mitochondrial Bioenergetics through the Impaired AMPK/SIRT/PGC1α Signaling Pathway in CLL

Objective: Chronic lymphocytic leukemia (CLL) is one of the most common types of leukemia in adults. Altered mitochondrial metabolism has been shown to be involved in the pathogenesis of CLL. Nicotinamidephospho-ribosyltransferase (NAMPT) is a key enzyme in the nicotinamide adenine dinucleotide (NAD) salvage pathway. FK866 and GMX1778, chemical inhibitors of NAMPT, deplete cellular NAD and ATP levels and trigger apoptosis in CLL cells, suggesting NAMPT contributes to the prolonged survival of these cells. Venetoclax is an approved therapy for CLL and blocks the anti-apoptotic B-cell lymphoma-2 (Bcl-2) protein, leading to programmed cell death of CLL cells. The adenosine monophosphate-activated protein kinase (AMPK) and peroxisome proliferator-activated receptor γ coactivator-1α (PGC-1α) signaling axis senses the metabolic demands of cells and regulates mitochondrial function. Silent information regulator T1 (SIRT1) is a cytoplasmic enzyme that mediates NAD+-dependent deacetylation of target substrates. The importance of the AMPK/SIRT/PGC1α signaling pathway has to be explored yet in CLL. Venetoclax may trigger a switching off of AMPK and /or SIRT1 signaling leading to impaired PGC-1α expression/activity and diminished mitochondrial activity. The effects of these drugs on mitochondrial bioenergetics profile, cell viability, mitochondrial membrane potential (MMP), reactive oxygen species (ROS) and protein levels of Bcl-2, AMPK, SIRT1, and PGC1α were analyzed. We hypothesize that venetoclax, along with FK866 and GMX1778, will alter CLL mitochondrial bioenergetics profiles and function, cell viability, and ROS levels through the involvement of the AMPK/SIRT/PGC1α signaling pathway and enable lower doses and profound effects for combination therapies rather than single agent therapy. Methods: A high resolution Oroboros Oxygraph 2K (Oroboros Instruments, Innsbruck, Austria), a Clarke-type oxygen electrode is used to measure mitochondrial respiration rates of CLL cells at 370C. Freshly isolated CLL cells (10 mil./ml) were added to the chamber in 2 ml of RPMI. After the measurement of basal respiration rates, the following chemicals were added: oligomycin (2uM), FCCP: carbonyl cyanide p-trifluoromethoxy phenyhydrazone (2.5-12.5 uM), and antimycin A (2 uM). Oxygen consumption rate is expressed in pmol oxygen/s/mil. cells. Protein levels in CLL cell lysates were determined by Western blotting. Cell viability, MMP, and ROS were assessed by Novocyte flow cytometer. Results: Primary CLL cells treated with 1.25 nM of venetoclax for 24 or 48h showed significantly decreased basal respiration rates, maximal respiration rates, and spare respiratory capacity compared to DMSO vehicle control. These parameters were also significantly affected by 1nM of FK866 or 1 nM of GMX1778 except basal respiration rates. The combination treatment of venetoclax with FK866 or GMX1778 for 24 or 48h significantly decreased all these bioenergetics parameters compared to each individual drug. MMP was not affected by these drug treatments and cell viability corresponded to the effect of the mitochondrial bioenergetics profile. ROS levels after 24 hours in venetoclax treated CLL cells were significantly increased compared to DMSO, any single agent or in combination. However, after 48 hours of treatment, increased ROS levels were not statistically significant compared to DMSO. Protein levels of Bcl-2, P-AMPK, AMPK, SIRT1, and PGC1α were decreased by venetoclax alone or in combination with FK866 or GMX1778. Conclusion: Venetoclax, FK866 and GMX1778 affected bioenergetics profiles in CLL cells at doses as low as 1.25 nM, 1nM, and 1 nM, respectively. The combined effect of these drugs on the mitochondrial bioenergetics profiles and cell viability is more profound than each NAMPT inhibitor agent alone. Protein levels of Bcl-2, AMPK, SIRT1, and PGC1α in venetoclax treated samples were reduced compared to DMSO and each single agent NAMPT inhibitor. These novel data suggest the involvement of the AMPK/SIRT/PGC1α signaling pathway to target mitochondrial metabolism and provide rational therapeutic combinations that may lead to reduced toxicity and increased drug efficacy in CLL. Disclosures Banerji: Roche: Other: Unrestricted grant received in the past; Janssen: Other: Unrestricted grant received in the past; Gilead: Other: Unrestricted grant received in the past; Abbvie: Other: Unrestricted grant received in the past; Teva: Other: Unrestricted grant received in the past.

A Descriptive Analysis of Obinutuzumab Usage in a Single Canadian Centre

Background:Chronic lymphocytic leukemia (CLL) is the most prevalent leukemia in North America with the majority of patients being over the age of 70 (Goede et al, 2014). CLL is a heterogeneous disease with some patients undergoing treatment at time of diagnosis, while others follow along a more indolent, asymptomatic course. When indicated, the choice of treatment is based on the patient's functional status, renal function and other comorbidities (Shanafelt, 2013). Previous studies have shown that unfit patients treated with Obinutuzumab plus Chlorambucil have shown prolongation of progression free survival and higher rates of complete response compared to other monoclonal based regimens (Goede et al, 2014). The aim of this study is to investigate the clinical use and uptake of Obinutuzumab in combination with Chlorambucil in a Canadian based population. Methods:All patients receiving Obinutuzumab were identified using the CLL CAISIS database. Then a retrospective chart review was conducted for patients approved for first-line antibody treatment with Obinutuzumab from January 1, 2014 to December 31, 2017. Data including patient characteristics, patterns of treatment, reported toxicities, response rates and survival data were collected and analyzed. This data was used to determine the overall safety and efficacy of this treatment regimen. Results: There were a total of 66 patients that met the inclusion criteria for this study. This cohort consisted of 54.5% males and 45.5% females, with a median age at diagnosis of 68 years (range: 46-94). Within this population 47 patients underwent florescence in situ hybridization testing, which identified 32 patients with chromosomal abnormalities. The immunoglobulin heavy chain variable region gene mutation was also tested in 41 patients, and identified 22 patients that were unmutated. At the time of treatment the median age was 73 (range: 55-98) with a median Cumulative Illness Rating Scale (CIRS) score of 8 (range: 3-15). Of the 66 patients who started treatment with Obinutuzumab, 50 patients (76%) achieved a partial response and 5 patients (8%) had no response. Of note, 21 patients (31.8%) discontinued treatment prior to completion of all six cycles due to cytopenias (4), other comorbidities (4), progression of CLL (2), decline in functional/mental status (2), patient request (2) and other (7). In regards to their treatment there was a high incidence of infusion related reactions (IRRs) on the first day of treatment, with 30 patients (45.5%) requiring intervention. There was a subset of 15 patients that had received low dose Chlorambucil prior to treatment with Obinutuzumab which resulted in a lower average lymphocyte count (38.1) and lower rate of IRRs (33%) compared to those with no prior Chlorambucil (average lymphocyte count: 66.5, rate of IRR: 42%). Due to toxicity and tolerability of Chlorambucil, dose reduction was observed in 37 patients (56%) throughout all six cycles of treatment. In the end, only 18 patients (27.3%) received all doses of Obinutuzumab and Chlorambucil while 37 patients (56%) received all doses of Obinutuzumab. Within the entire cohort, 12 patients have relapsed and 9 of these patients have required additional therapy. This relapse rate can be attributed to lack of response to Obinutuzumab (3), a 17p del (1), poor prognostic markers (5), and inadequate Obinutuzumab (1). Conclusion:In this current study, our results demonstrate that the majority of patients in this cohort were able to complete treatment with Obinutuzumab. Although our demographics were similar to previous studies, we found higher partial response rates (76%) likely due to differences in standards of practice, such as imaging studies after treatment. Disclosures Whiteside: Roche: Membership on an entity's Board of Directors or advisory committees, Other: teaching sessions. Dawe:AstraZeneca: Membership on an entity's Board of Directors or advisory committees; Merck: Membership on an entity's Board of Directors or advisory committees. Johnston:Roche: Other: unrestricted grant received in the past; Abbvie: Other: unrestricted grant received in the past; Teva: Other: unrestricted grant received in the past; Gilead: Other: unrestricted grant received in the past; Janssen: Other: unrestricted grant received in the past. Banerji:Roche: Other: Unrestricted grant received in the past; Janssen: Other: Unrestricted grant received in the past; Abbvie: Other: Unrestricted grant received in the past; Gilead: Other: Unrestricted grant received in the past; Teva: Other: Unrestricted grant received in the past.

Towards Successful Implementation of Pharmacokinetic-Guided Prophylactic Dosing of Clotting Factor Concentrate in Hemophilia; The Do’s and Don’ts after Discrete Choice Experiment Analysis

Background: Patients’, parents’ and providers’ preferences with regard to medical interventions may have a major impact on the implementation of innovations, often delaying initiation significantly. Illustratively, as early as 1997, Carlsson et al. suggested that a 30% reduction of consumption of clotting factor concentrate in prophylactic treatment could be attained by dosing based on an individual pharmacokinetic (PK) profile, with a concomitant cost reduction. Therefore, we aim to evaluate do’s and don’ts in hemophilia patients, parents and professionals with regard to individualized dosing according to PK-profile of prophylaxis with clotting factor concentrate. This in order to successfully implement this intervention when imperative. Methods: In this study we included patientswith hemophilia currently or previously on prophylactic treatment with clotting factor concentrate (n=114) and parents of patients aged 12-18 years (n=19) from five Dutch Academic Hemophilia Treatment Centers, and hemophilia professionals attending the World Federation of Haemophia congress 2012 from throughout the world (n=91). Data were analysed using a Discrete Choice Experiment. Patients’, parents’ and professionals’ preferences with regard to the intervention, are measured by specific attributes with varying levels: ‘number of blood samples necessary to construct individual PK-profile’, ‘advised frequency of prophylactic infusions’, ‘frequency of repetitive PK-profiling’, ‘risk of bleeding’, ‘estimated cost reduction of treatment with benefit for society’. Results: For patients and parents (response rate 64%), a higher dosing frequency e.g. daily dosing was an important barrier. They were however willing to infuse more frequently, if bleeding was consequently reduced. ‘Reduction of costs for society’ by implementation of individualized dosing according to PK profile was found relevant and motivating to implement PK-guided dosing. For professionals the most important attributes driving implementation were an acceptable ‘advised frequency of prophylactic infusions’ and reduction of ‘risk of bleeding’. Conclusions: When anticipating implementation of a medical intervention, defining of preferences of those involved is of importance. In case of PK-guided prophylactic dosing in hemophilia conclusions are: realise the impact of daily dosing of clotting factor concentrate, use frequent bleeding as a motivator to initiate PK-guided dosing and actively discuss costs of treatment with those undergoing treatment and the cost reduction that may result from PK-guided dosing. Identification of these preferences will secure successful implementation in the near future. Disclosures Lock: ZonMW: Research Funding; Baxter: Research Funding. Laros-van Gorkum:Sanquin: speakers fee Other; Baxter: Unrestricted educational grant was provided to the Hemophilia Treatment Center of the Radboud university medical center, Unrestricted educational grant was provided to the Hemophilia Treatment Center of the Radboud university medical center Other; CSL Behring: Unrestricted educational grant was provided to the Hemophilia Treatment Center of the Radboud university medical center, Unrestricted educational grant was provided to the Hemophilia Treatment Center of the Radboud university medical center Other. Driessens:Baxter: unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work Other; Bayer Schering Pharma: unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work, unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work Other; CSL Behring: unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work, unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work Other; Eurocept: unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work, unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work Other; Novo Nordisk: unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work Other; Pfizer: unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work Other; Sanquin: unrestricted grant for meetings and educational courses with hemophilia patients and members of the Netherlands Hemophilia Patient Society, outside the submitted work Other. Fijnvandraat:Baxter: Member of the European Hemophilia Treatment and Standardisation Board sponsored by Baxter Other; CSL Behring: Research Funding; Pfizer: Has given lectures at educational symposiums organised by Pfizer, Has given lectures at educational symposiums organised by Pfizer Other, Research Funding; Bayer Schering Pharma: Has given lectures at educational symposiums organised by Bayer Schering Pharma, Has given lectures at educational symposiums organised by Bayer Schering Pharma Other, Research Funding. Leebeek:CSL Behring: has served on advisory boards of CSL Behring, outside the submitted work Other, Research Funding; Baxter: has served on advisory boards of Baxter, outside the submitted work, has served on advisory boards of Baxter, outside the submitted work Other. Cnossen:Pfizer: Educational funding Other, Research Funding; Bayer Schering Pharma: Educational funding and travel support, Educational funding and travel support Other, Research Funding; Baxter: Educational funding and travel support, Educational funding and travel support Other, Research Funding; Novo Nordisk: Educational funding, Educational funding Other, Research Funding; Novartis: Educational funding and travel support Other, Research Funding.

Impact of a Patient-Access Program with Integrated Distress Screening on Resource Utilization and Psychosocial Distress Levels in Patients with Multiple Myeloma

Background: There is growing awareness of the importance in integrating psychosocial care into routine practice in oncology. A new American College of Surgeons Commission on Cancer accreditation standard requires psychosocial distress screening for patients with cancer as part of an initiative to treat the “whole patient” and ensure quality care. Distress screening at pivotal transition points along the disease continuum can identify problems before a crisis event occurs, allow patients to voice concerns and gain information, and improve the use of healthcare resources. The value of distress screening in patients with multiple myeloma (MM) or by industry patient access programs, however, has received relatively little attention to date. The Cancer Support Community (CSC), in collaboration with Onyx Pharmaceuticals, Inc., an Amgen subsidiary, established an integrated patient assistance program (Onyx 360) to screen and refer patients/caregivers facing advanced MM for psychosocial services. As part of this program, distress screening was performed at baseline and after patients engaged with Onyx 360 resources. Herein, we report results evaluating the impact of distress screening on the utilization of resources offered by Onyx 360 and the effect of these resources on patient distress levels over time. Methods: The Onyx 360 program was initiated in 2012 and distress screening was introduced in the program in late December 2013. Patients are asked 4 distress screening questions by an Onyx 360 Oncology Nurse Advocate during an initial phone call: 1.) overall level of distress today; 2.) level of concern about practical issues such as home care, transportation, finances, etc.; 3.) level of concern about family, work, or home life; and 4.) level of concern about emotional issues or coping with MM. For each question, patients gauged their level of distress on a scale from 0 to 10 (0-lowest level of distress and 10-highest level of distress). Patients were then offered enrollment in Onyx 360 services, which include reimbursement and clinical support, transportation assistance, and real-time referrals to key resources including the Chronic Disease Fund, the International Myeloma Foundation, the Multiple Myeloma Research Foundation, and the Cancer Support Community. Consenting patients/caregivers were transferred to CSC, whose licensed mental health professionals conducted further distress screening and offered patients/caregivers free supportive counseling, resource referral, group support, and treatment decision counseling. Patients were rescreened with the 4 questions 30 days after the initial call. Results: Between March 4, 2014 and July 11, 2014, a total of 227 patients in the Onyx 360 program were screened for baseline distress levels. For each screening question, 70%–80% of patients expressed some level of distress (i.e., distress level of ≥1). A total of 172 patients (76%) responded with a distress level of ≥4 for ≥1 of the screening questions; of these patients who were also new to Onyx 360 at the time of the initial call, 86% subsequently enrolled in ≥1 Onyx 360 service including 72% enrolling in transportation services and 27% enrolling in copay assistance. Referral rates to the CSC increased when distress screening was performed compared with when it was not. A total of 145 (64%) patients completed a follow-up call; 74% reported lower levels of distress for ≥1 question since the initial call. Among patients who initially reported a distress level of ≥4 on ≥1 of the screening questions, 79% reported lower levels of distress for ≥1 question since the initial call. Conclusion: Through a brief distress screening measure, the Onyx 360 program identified patients with psychosocial distress and connected them to a variety of resources and community programs. Patients utilized these resources at a higher rate when distress screening was implemented compared with when it was not. Distress levels decreased after patients engaged with these resources and services; moreover, the decrease in distress levels was greatest in patients who initially had higher levels of distress. These results demonstrate that an integrated patient-centered standard of care improves psychosocial outcomes in patients with advanced MM. Further research is needed to determine whether reduced levels of distress will translate into increased duration of therapy and increase in value to the patient and healthcare system. Disclosures Kennedy: Onyx Pharmaceuticals: Unrestricted grant funding Other. Buzaglo:Onyx Pharmaceuticals: Unrestricted grant funding Other. Goldberger:Onyx Pharmaceuticals: Unrestricted grant funding Other.