Phase 1 trial of ibrutinib and carfilzomib combination therapy for relapsed or relapsed and refractory multiple myeloma

This phase 1, dose-finding study investigated ibrutinib and carfilzomib ± dexamethasone in patients with relapsed or relapsed/refractory multiple myeloma (≥2 lines of therapy including bortezomib and an immunomodulatory agent). Of 43 patients enrolled, 74% were refractory to bortezomib and 23% had high-risk cytogenetics. No dose-limiting toxicities were observed. The recommended phase 2 dose was ibrutinib 840 mg and carfilzomib 36 mg/m² with dexamethasone. The most common ≥ grade 3 (>10%) treatment-emergent adverse events were hypertension, anemia, pneumonia, fatigue, diarrhea, and thrombocytopenia. Overall response rate was 67% (very good partial response, 21%; stringent complete response, 2%), with an additional 9% minimal response. Median progression-free survival was 7.2 months and was not inferior in refractory nor high-risk patients. Median overall survival was not reached. Ibrutinib plus carfilzomib demonstrated encouraging responses with a manageable safety profile in this advanced population.

Ibrutinib alone or with dexamethasone for relapsed or relapsed and refractory multiple myeloma: phase 2 trial results

Novel therapies with unique new targets are needed for patients who are relapsed/refractory to current treatments for multiple myeloma. Ibrutinib is a first‐in‐class, once‐daily, oral covalent inhibitor of Bruton tyrosine kinase, which is overexpressed in the myeloma stem cell population. This study examined various doses of ibrutinib ± low‐dose dexamethasone in patients who received ≥2 prior lines of therapy, including an immunomodulatory agent. Daily ibrutinib ± weekly dexamethasone 40 mg was assessed in 4 cohorts using a Simon 2‐stage design. The primary objective was clinical benefit rate (CBR; ≥minimal response); secondary objectives included safety. Patients (n = 92) received a median of 4 prior regimens. Ibrutinib + dexamethasone produced the highest CBR (28%) in Cohort 4 (840 mg + dexamethasone; n = 43), with median duration of 9·2 months (range, 3·0–14·7). Progression‐free survival was 4·6 months (range, 0·4–17·3). Grade 3–4 haematological adverse events included anaemia (16%), thrombocytopenia (11%), and neutropenia (2%); grade 3–4 non‐haematological adverse events included pneumonia (7%), syncope (3%) and urinary tract infection (3%). Ibrutinib + dexamethasone produced notable responses in this heavily pre‐treated population. The encouraging efficacy, coupled with the favourable safety and tolerability profile of ibrutinib, supports its further evaluation as part of combination treatment.

Extended Treatment with Single-Agent Ibrutinib at the 420 mg Dose Leads to Durable Responses in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Purpose: Ibrutinib, a first-in-class, once-daily, oral inhibitor of Bruton tyrosine kinase, promotes apoptosis, and inhibits B-cell proliferation, adhesion, and migration. Ibrutinib has demonstrated single-agent efficacy and acceptable tolerability at doses of 420 and 840 mg in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) who were treatment-naïve (TN) or had relapsed/refractory (R/R) CLL after ≥1 prior therapy in a phase Ib/II study (PCYC-1102). Subsequently, the ibrutinib 420 mg dose was approved in CLL.Experimental Design: We report data with 44 months of follow-up on 94 patients with TN and R/R CLL/SLL receiving ibrutinib 420 mg once-daily in PCYC-1102 and the long-term extension study PCYC-1103.Results: Ninety-four CLL/SLL patients (27 TN, 67 R/R) were treated with ibrutinib (420 mg/day). Patients with R/R disease had received a median of four prior therapies (range, 1-12). Responses were rapid and durable and median duration of response was not reached. Best overall response was 91% [85% TN (complete response, CR 26%) and 94% R/R (9% CR)]. Median progression-free survival (PFS) was not reached in either group. The 30-month PFS rate was 96% and 76% for TN and R/R patients, respectively. Ibrutinib was well tolerated with extended follow-up; rates of grade ≥3 cytopenias and fatigue, as well as discontinuations due to toxicities decreased over time.Conclusions: Single-agent ibrutinib at 420 mg once-daily resulted in durable responses and was well tolerated with up to 44 months follow-up in patients with TN and R/R CLL/SLL. Currently, 66% of patients continue on ibrutinib. Clin Cancer Res; 23(5); 1149-55. ©2017 AACR.

Vorinostat in Combination With Lenalidomide and Dexamethasone in Lenalidomide-Refractory Multiple Myeloma

BACKGROUND

This is a retrospective chart review to evaluate the efficacy of the addition of vorinostat to lenalidomide and dexamethasone in patients with multiple myeloma relapsed/refractory to lenalidomide and dexamethasone.

METHODS

Charts from 26 consecutive patients able to obtain commercial vorinostat were analyzed for response and safety data.

RESULTS

The overall response rate was 31%, and the clinical beneficial rate was 50%. The median duration of response was 3 months, and the median overall survival was 28.5 months. The most common grade 3 and 4 toxicities were hematologic and metabolic, including neutropenia (44%), thrombocytopenia (53%), and transaminase elevations (aspartate aminotransferase 9% and alanine aminotransferase 6%). No thromboembolic events or febrile neutropenia were observed.

CONCLUSION

These observations demonstrate that the addition of vorinostat to patients with lenalidomide- and dexamethasone-refractory multiple myeloma was associated with moderate response and was well-tolerated, warranting further assessment in a larger prospective study.

Abstract CT132: Long-term treatment with single-agent ibrutinib 420 mg leads to durable responses including complete responses in CLL

Background: Ibrutinib (ibr), a first-in-class, once-daily, oral, covalent inhibitor of Bruton's tyrosine kinase, has single-agent efficacy and acceptable toxicity in treatment-naïve (TN) [Lancet Oncology 2013] and previously-treated chronic lymphocytic leukemia (CLL)/small lymphocytic leukemia (SLL) patients (pts) [NEJM 2014]. Ibrutinib (Imbruvica®) is indicated for treatment of pts with CLL receiving one prior therapy and for pts with del17p CLL. We present efficacy and safety data with up to 45 months of follow-up for pts receiving ibr at the approved 420 mg dose.

Methods: Analysis included all pts receiving ibr 420 mg/day, dosed until disease progression in the phase I/IIb study PCYC-1102, and the PCYC-1103 extension study. Best overall response rate (ORR), including partial response with lymphocytosis (PR-L) was assessed by investigator using iwCLL criteria. Adverse event (AE) collection focused on ≥grade 3 and serious AEs.

Results: Of 94 CLL/SLL pts (27 TN, 67 relapsed/refractory [R/R]) receiving ibr, median age was 68 years (range, 37-84), with 44 (47%) pts aged ≥70 years. 25 (27%) pts (2 TN, 23 R/R) had del17p and 22 (23%, all R/R) had del11q. R/R pts had a median of 4 (range, 1-12) prior therapies. Best ORR was 91% including 14% complete responses (CR) for all pts (CR 26% TN, 9% R/R). Median DOR and PFS were not reached for all pts. Median time on treatment was 25 mos (range, 0-45) for all pts (30 mos TN, 22 mos R/R). The most common ≥grade 3 AEs reported over this follow-up were hypertension (23%), pneumonia (15%), neutropenia (13%), atrial fibrillation (7%), and diarrhea (7%). 50 (53%) pts (22 [81%] TN, 28 [42%] R/R) remained on treatment for >2 years. At analysis, 22 (81%) TN and 40 (60%) R/R pts continued on ibrutinib. During follow-up, 12 pts discontinued treatment due to disease progression and 12 due to an AE.

Conclusions: Single-agent ibrutinib led to durable responses including 14% CRs in pts with TN or R/R CLL/SLL, with up to 45 months of follow-up.

Efficacy parameterTNR/R(n = 27)(n = 67)ORR23 (85%)63 (94%)CR7 (26%)6 (9%)PR/PR-L16 (59%)57 (85%)DOR, mos (95% Cl)NR (NE, NE)NR (36, NE)30-mo PFS (95% Cl)96% (74, 99)76% (63, 85)30-mo OS rate (95% Cl)96% (78, 99)87% (76, 93)DOR, duration of response; NE, not estimated; NR, not reached; PFS, progression-free survival; OS, overall survival

Citation Format: Steven Coutre, Richard Furman, Ian Flinn, Jan Burger, Kristie Blum, Jeff Sharman, Jeffrey Jones, William Wierda, Weiqiang Zhao, Nyla Heerema, Amy Johnson, Anh Tran, Cathy Zhou, Elizabeth Bilotti, Danelle James, John Byrd, Susan O'Brien. Long-term treatment with single-agent ibrutinib 420 mg leads to durable responses including complete responses in CLL. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr CT132. doi:10.1158/1538-7445.AM2015-CT132

Phase I study of carfilzomib, lenalidomide, vorinostat, and dexamethasone in patients with relapsed and/or refractory multiple myeloma

Research has shown that proteasome inhibitors (e.g., carfilzomib), immunomodulatory agents (e.g., lenalidomide), histone deacetylase inhibitors (e.g., vorinostat) and corticosteroids (e.g., dexamethasone) have synergistic anti-multiple myeloma (MM) activity. This phase I dose-escalation study evaluated a regimen combining carfilzomib, lenalidomide, vorinostat and dexamethasone (QUAD) in patients with relapsed and/or refractory MM. Seventeen patients received carfilzomib (15, 20, or 20/27 mg/m(2) ; 30-min infusion; days 1, 2, 8, 9, 15, 16), lenalidomide (15 or 25 mg; days 1-21), vorinostat (300 or 400 mg; days 1-7, 15-21), and dexamethasone (40 mg; days 1, 8, 15, 22) in 28-d cycles. No dose-limiting toxicities were observed; the maximum tolerated dose was not reached. The maximum administered dose was carfilzomib 20/27 mg/m(2) , lenalidomide 25 mg, vorinostat 400 mg, and dexamethasone 40 mg. Common grade ≥3 adverse events included neutropenia (53%), thrombocytopenia (53%) and anaemia (41%). The overall response rate was 53%: 12% of patients achieved a very good partial response (PR) and 41% of patients achieved a PR. At a median follow-up of 10 months, median progression-free survival was 12 months and median overall survival was not reached. Treatment with QUAD was feasible and had encouraging activity in patients with relapsed and/or refractory MM.

Carfilzomib: a next-generation proteasome inhibitor for multiple myeloma treatment

Although the incidence of multiple myeloma (MM) is increasing, the median overall survival and the number of agents in the pipeline for treating MM also are increasing. Response rates higher than 80% are not uncommon in the frontline setting when the novel agents thalidomide, lenalidomide, and bortezomib are used in combination. Response rates and survival also have improved in disease that has relapsed after treatment with conventional therapies. The focus of research has now shifted to improving survival and disease response in patients refractory to current treatment paradigms. New agents are targeting new pathways, as well as existing mechanisms known to be effective, but with different safety profiles. Carfilzomib is a potent, selective, irreversible inhibitor of the ubiquitin-proteasome pathway. The drug is a next-generation proteasome inhibitor found to be safe and effective for patients with relapsed and refractory MM, where treatment options are limited. As with any newly approved agent, one should recognize that drugs within the same class will be administered differently and often cause dissimilar treatment-related toxicities. Oncology nurses are crucial to the successful administration of chemotherapeutic agents such as carfilzomib, and an understanding of management techniques is paramount to quality patient care.

Novel agents for the treatment of multiple myeloma: proteasome inhibitors and immunomodulatory agents

The integration of novel agents into the treatment of multiple myeloma (MM) has shifted the focus from an incurable disease to one that is chronic, with a realistic hope of someday achieving a cure. Proteasome inhibitors and immunomodulatory agents are the backbone of novel therapies for MM. These agents are particularly important for patients with relapsed or refractory disease, a fate faced by the majority of myeloma patients over the course of their disease. Review of recent clinical trial data for the proteasome inhibitors and immunomodulatory agents, including clinical efficacy and safety information, will assist the advanced practitioner in oncology with integrating these data into the current treatment guidelines for MM.

The anion gap and routine serum protein measurements in monoclonal gammopathies

BACKGROUND AND OBJECTIVES

An abnormal anion gap and an increased total protein and globulin are clues to the diagnosis of monoclonal gammopathy. We explored the utility of these markers in IgG, IgA, IgM, and free light chain monoclonal gammopathies.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The anion gap, Na(+) - (Cl(-) + HCO(3)(-)), corrected for hypoalbuminemia, was calculated in patients with monoclonal gammopathies. Exclusion criteria were serum calcium >10.5 mg/dl and/or creatinine >2 mg/dl.

RESULTS

Among 287 patients, 242 remained after applying exclusion criteria (109 IgG, 64 IgA, 21 IgM, and 48 light chain); 36% of 242 patients required correction for hypoalbuminemia. The anion gap was decreased (<10) in 22% of IgG and increased (>15) in 31% of IgA monoclonal gammopathies. IgM did not affect the gap. In light chain gammopathies, the anion gap showed no consistent trend (15% increased, 17% decreased). Mean clonal IgG, IgA, and IgM concentrations were 10-fold higher than mean clonal free light chain concentrations in the respective monoclonal gammopathies (P < 0.001). These paraprotein level disparities were reflected in significantly increased mean serum total protein and globulin concentrations in IgG, IgA, and IgM versus free light chain monoclonal gammopathies, where mean total protein and globulin levels were within normal limits (P < 0.001).

CONCLUSIONS

The anion gap was significantly altered in IgG and IgA monoclonal gammopathies, but it was not a sensitive tool for suspecting the diagnosis. In light chain monoclonal gammopathies, the anion gap, total protein, and globulin did not provide reliable diagnostic clues.

Routine health maintenance in patients living with multiple myeloma: survivorship care plan of the International Myeloma Foundation Nurse Leadership Board

Patients diagnosed with multiple myeloma are living longer because of new therapeutic options. Helping patients with multiple myeloma maintain a good state of health from the time of diagnosis and throughout their therapy leads to better quality of life. However, patients with multiple myeloma are at risk for illnesses experienced by the general population and at additional risk for illnesses related to multiple myeloma and its treatment. Therefore, the International Myeloma Foundation Nurse Leadership Board (NLB) has developed practice recommendations to meet the particular needs of adult patients with multiple myeloma using evidence-based recommendations for screening and disease prevention, as well as nursing experience. The NLB recommendations are designed to address and overcome barriers to health maintenance by educating and empowering nurses and their patients.

Survivorship care guidelines for patients living with multiple myeloma: consensus statements of the International Myeloma Foundation Nurse Leadership Board

Novel therapies approved over the past decade for the management of multiple myeloma have contributed to improved overall survival in patients with newly diagnosed and relapsed disease. Nurses play a key role in educating, advocating for, and supporting patients throughout the continuum of care. Identifying potential and actual comorbid conditions associated directly with multiple myeloma and its treatment is important, as is confirming those that are patient specific so that prompt intervention can take place; therefore, the International Myeloma Foundation Nurse Leadership Board identified the most significant needs of patients diagnosed with multiple myeloma as bone health, health maintenance, mobility and safety, sexual dysfunction, and renal health. The Nurse Leadership Board then developed a survivorship care plan to assist healthcare providers and patients with multiple myeloma, their partners, and their caregivers to identify these needs.

Management of side effects of novel therapies for multiple myeloma: consensus statements developed by the International Myeloma Foundation's Nurse Leadership Board

Nurses play an essential role in managing the care of patients with multiple myeloma, who require education and support to receive and adhere to optimal therapy. The International Myeloma Foundation created a Nurse Leadership Board comprised of oncology nurses from leading cancer centers and community practices. An assessment survey identified the need for specific recommendations for managing key side effects of novel antimyeloma agents. Myelosuppression, thromboembolic events, peripheral neuropathy, steroid toxicities, and gastrointestinal side effects were selected for the first consensus statements. The board developed recommendations for healthcare providers in any medical setting, including grading of side-effect toxicity and strategies for managing the side effects in general, with specific recommendations pertaining to the novel agents.