1
|
Bruzzese A, Martino EA, Labanca C, Mendicino F, Lucia E, Olivito V, Zimbo A, Fragliasso V, Neri A, Morabito F, Vigna E, Gentile M. Momelotinib in myelofibrosis. Expert Opin Pharmacother 2024; 25:521-528. [PMID: 38623844 DOI: 10.1080/14656566.2024.2343780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/12/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Myelofibrosis (MF) is a hematologic disease characterized by bone marrow fibrosis, cytopenias, splenomegaly, and constitutional symptoms. Recent years have seen the emergence of novel therapeutic agents, notably ruxolitinib and fedratinib, which target the Janus kinases (JAK) pathway. However, their myelosuppressive effect coupled with the persistence, and even worsening anemia remains a significant challenge, leading usually to treatment discontinuation. AREAS COVERED This review focuses on Momelotinib (MMB), a unique JAK inhibitor that has shown promise in MF treatment, particularly in improving anemia. MMB inhibits type 1 kinase activin A receptor or activin receptor-like kinase-2 (ACVR1/ALK2), with consequent rebalancing of the SMAD pathways and reduced transcription of hepcidin. Moreover, it seems that MMB could reduce the serum levels of several inflammatory cytokines responsible for anemia. Clinical trials have demonstrated MMB's efficacy in reducing spleen size, alleviating symptoms, and improving anemia, with a favorable safety profile compared to other JAK inhibitors, both in treatment-naïve and in pre-treated patients. EXPERT OPINION Due to its mechanism of action, MMB represents a valuable therapeutic option in MF, addressing the clinical challenge of anemia and potentially improving outcomes for patients with hematologic malignancies. Ongoing research explores MMB's potential in acute myeloid leukemia and combination therapies.
Collapse
Affiliation(s)
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Annamaria Zimbo
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- UOC Laboratorio Analisi Cliniche, Biomolecolari e Genetica, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Valentina Fragliasso
- Laboratorio di Ricerca Traslazionale Azienda USL-IRCSS Reggio Emilia, Emilia-Romagna, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, Reggio Emilia, EmiliaRomagna, Italy
| | | | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
| |
Collapse
|
2
|
Kong T, Gaudin N, Gordon K, Cox MJ, Zhou AW, Oh ST. A phase I trial of pevonedistat in combination with ruxolitinib for the treatment of myelofibrosis. Ther Adv Hematol 2024; 15:20406207241237607. [PMID: 38481947 PMCID: PMC10935761 DOI: 10.1177/20406207241237607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
Janus kinase 2 (JAK2) inhibitors such as ruxolitinib have become standard-of-care therapy for patients with myeloproliferative neoplasms (MPNs); however, activation of alternate oncogenic pathways including nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) has limited durable response as single-agent therapy. With the rationale of targeting both pathways, we conducted a phase I dose escalation trial of pevonedistat in combination with ruxolitinib for the treatment of patients with myelofibrosis (NCT03386214). The primary objective was to assess the safety and tolerability of combination therapy with additional objectives of treatment efficacy and alterations of biomarkers. There were no dose-limiting toxicities observed with most adverse events being limited to grades 1/2. In secondary measures, anemia response was observed in two patients. Pro-inflammatory cytokines and iron parameters were longitudinally assessed, which revealed suppression of interleukin-6 and interferon-gamma in a dose-dependent manner across a subset of patients. These results suggest that combination therapy targeting both JAK2 and NFκB may hold clinical merit for MPN patients.
Collapse
Affiliation(s)
- Tim Kong
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Nicole Gaudin
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Karyn Gordon
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Maggie J. Cox
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Amy W. Zhou
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Stephen T. Oh
- Division of Hematology, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8125, St Louis, MO 63110, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA
- Immunomonitoring Laboratory, Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St Louis, MO, USA
| |
Collapse
|
3
|
Caduc MJ, Koschmieder S. Is Treatment for Cytopenic Myelofibrosis Still an Unmet Clinical Need? Hemasphere 2023; 7:e982. [PMID: 37928624 PMCID: PMC10621927 DOI: 10.1097/hs9.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
- Madeline J. Caduc
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| |
Collapse
|
4
|
Oh ST, Mesa RA, Harrison CN, Bose P, Gerds AT, Gupta V, Scott BL, Kiladjian JJ, Lucchesi A, Kong T, Buckley SA, Tyavanagimatt S, Harder BG, Roman-Torres K, Smith J, Craig AR, Mascarenhas J, Verstovsek S. Pacritinib is a potent ACVR1 inhibitor with significant anemia benefit in patients with myelofibrosis. Blood Adv 2023; 7:5835-5842. [PMID: 37552106 PMCID: PMC10561048 DOI: 10.1182/bloodadvances.2023010151] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023] Open
Abstract
In patients with cytopenic myelofibrosis, treatment with the JAK2/IRAK1 inhibitor pacritinib was associated with anemia benefit in the phase 3 PERSIST-2 study. The impact of pacritinib on transfusion independence (TI) has not been previously described, nor has the mechanism by which pacritinib improves anemia been elucidated. Because it has been previously postulated that inhibition of activin A receptor, type 1 (ACVR1)/activin receptor-like kinase-2 improves anemia in patients with myelofibrosis via suppression of hepcidin production, we assessed the relative inhibitory potency of pacritinib compared with other JAK2 inhibitors against ACVR1. Pacritinib inhibited ACVR1 with greater potency (half-maximal inhibitory concentration [IC50] = 16.7 nM; Cmax:IC50 = 12.7) than momelotinib (IC50 = 52.5 nM; Cmax:IC50 = 3.2), fedratinib (IC50 = 273 nM; Cmax:IC50 = 1.0), or ruxolitinib (IC50 > 1000; Cmax:IC50 < 0.01). Pacritinib's inhibitory activity against ACVR1 was corroborated via inhibition of downstream SMAD signaling in conjunction with marked suppression of hepcidin production. Among patients on PERSIST-2 who were not transfusion independent at baseline based on Gale criteria, a significantly greater proportion achieved TI on pacritinib compared with those treated on best available therapy (37% vs 7%, P = .001), and significantly more had a ≥50% reduction in transfusion burden (49% vs 9%, P < .0001). These data indicate that the anemia benefit of the JAK2/IRAK1 inhibitor pacritinib may be a function of potent ACVR1 inhibition.
Collapse
Affiliation(s)
- Stephen T. Oh
- Washington University School of Medicine, St. Louis, MO
| | - Ruben A. Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | | | - Prithviraj Bose
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aaron T. Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | - Alessandro Lucchesi
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori,” Meldola, Italy
| | - Tim Kong
- Washington University School of Medicine, St. Louis, MO
| | | | | | | | | | | | | | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | |
Collapse
|
5
|
Guerra A, Parhiz H, Rivella S. Novel potential therapeutics to modify iron metabolism and red cell synthesis in diseases associated with defective erythropoiesis. Haematologica 2023; 108:2582-2593. [PMID: 37345473 PMCID: PMC10542825 DOI: 10.3324/haematol.2023.283057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/15/2023] [Indexed: 06/23/2023] Open
Abstract
Under normal conditions, iron metabolism is carefully regulated to sustain normal cellular functions and the production of hemoglobin in erythroid cells. Perturbation to the erythropoiesis-iron metabolism axis can result in iron imbalances and cause anemia or organ toxicity. Various congenital and acquired diseases associated with abnormal red cell production are characterized by aberrant iron absorption. Several recent studies have shown that improvements in red blood cell production also ameliorate iron metabolism and vice versa. Many therapeutics are now under development with the potential to improve a variety of hematologic diseases, from β-thalassemia and iron-refractory iron deficiency anemia to anemia of inflammation and polycythemia vera. This review summarizes selected mechanisms related to red cell production and iron metabolism and describes potential therapeutics and their current uses. We also consider the potential application of the discussed therapeutics on various diseases, alone or in combination. The vast repertoire of drugs under development offers new opportunities to improve the clinical care of patients suffering from congenital or acquired red blood cell disorders with limited or no treatment options.
Collapse
Affiliation(s)
- Amaliris Guerra
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA
| | - Hamideh Parhiz
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA; RNA Institute, University of Pennsylvania, Philadelphia, PA
| | - Stefano Rivella
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA; Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA; RNA Institute, University of Pennsylvania, Philadelphia, PA, USA; Cell and Molecular Biology affinity group (CAMB), University of Pennsylvania, Philadelphia, PA, USA; Raymond G. Perelman Center for Cellular and Molecular Therapeutics-CHOP; Penn Center for Musculoskeletal Disorders, CHOP, Philadelphia, PA, USA; Institute for Regenerative Medicine, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
6
|
Kong T, Yu L, Laranjeira ABA, Fisher DA, He F, Cox MJ, Oh ST. Comprehensive profiling of clinical JAK inhibitors in myeloproliferative neoplasms. Am J Hematol 2023; 98:1029-1042. [PMID: 37203407 PMCID: PMC10525038 DOI: 10.1002/ajh.26935] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 05/20/2023]
Abstract
Small molecule inhibitors targeting JAK2 provide symptomatic benefits for myeloproliferative neoplasm (MPN) patients and are among first-line therapeutic agents. However, despite all having potent capacity to suppress JAK-STAT signaling, they demonstrate distinct clinical profiles suggesting contributory effects in targeting other ancillary pathways. Here, we performed comprehensive profiling on four JAK2 inhibitors either FDA-approved (ruxolitinib, fedratinib, and pacritinib) or undergoing phase 3 studies (momelotinib) to better outline mechanistic and therapeutic efficacy. Across JAK2-mutant in vitro models, all four inhibitors demonstrated similar anti-proliferative phenotypes, whereas pacritinib yielded greatest potency on suppressing colony formation in primary samples, while momelotinib exhibited unique erythroid colony formation sparing. All inhibitors reduced leukemic engraftment, disease burden, and extended survival across patient-derived xenograft (PDX) models, with strongest effects elicited by pacritinib. Through RNA-sequencing and gene set enrichment analyses, differential suppressive degrees of JAK-STAT and inflammatory response signatures were revealed, which we validated with signaling and cytokine suspension mass cytometry across primary samples. Lastly, we assessed the capacity of JAK2 inhibitors to modulate iron regulation, uncovering potent suppression of hepcidin and SMAD signaling by pacritinib. These comparative findings provide insight into the differential and beneficial effects of ancillary targeting beyond JAK2 and may help guide the use of specific inhibitors in personalized therapy.
Collapse
Affiliation(s)
- Tim Kong
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - LaYow Yu
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Angelo B. A. Laranjeira
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A.C. Fisher
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Fan He
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Maggie J. Cox
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephen T. Oh
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Immunomonitoring Laboratory, Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
7
|
Yacoub A, Mesa RA, Oh ST. Long-Term Hematologic Improvement in a Patient With Cytopenic Myelofibrosis Treated With Pacritinib. JCO Precis Oncol 2023; 7:e2200523. [PMID: 36634298 PMCID: PMC9929105 DOI: 10.1200/po.22.00523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/31/2022] [Accepted: 11/21/2022] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Ruben A. Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX
| | - Stephen T. Oh
- Washington University School of Medicine, St Louis, MO
| |
Collapse
|
8
|
Abstract
Myelofibrosis is a myeloproliferative neoplasm characterized by splenomegaly, debilitating constitutional symptoms and bone marrow failure. Disease-related anemia is common and associated with an inferior quality of life and survival. Unfortunately, few therapies exist to improve hemoglobin in myelofibrosis patients. Momelotinib is a JAK1/JAK2 inhibitor that also antagonizes ACVR1, leading to downregulation of hepcidin expression and increased availability of iron for erythropoiesis. In clinical testing, momelotinib has demonstrated a unique ability to improve hemoglobin and reduce transfusion burden in myelofibrosis patients with baseline anemia, while producing reductions in spleen size and symptom burden. This review explores the preclinical rationale, clinical trial data and future role of momelotinib in the evolving therapeutic landscape of myelofibrosis.
Collapse
Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX, USA
| |
Collapse
|