Clinical Trials /

A Phase 1B Clinical Trial of Trametinib Plus Digoxin in Patients With Unresectable or Metastatic BRAF Wild-type Melanoma

NCT02138292

Description:

The study is a prospective, single-arm, one-site therapeutic trial of the combination of trametinib plus digoxin for advanced melanoma. endpoints are toxicities assessed by nCi CTCae v4.1 within the first 8 weeks, responses measured by ReCiST v1.1 criteria every 8 weeks with scans and exams, tumor sensitivity to the drug combination quantified by tumor regressions in nSG mice, and correlations of response with tumor sensitivity, BRaF status, MaPK inhibitor exposure history, and tumor sodium pump expression. Treatment Dosage and administration Study Drugs: 1. Trametinib (2mg) will be administered orally on a daily basis. 2. Digoxin (0.25mg) will be administered orally on a daily basis. on a 8-week cycle, duration of treatment can last from 8 to 104 weeks. endpoints 1. Toxicities will be assessed via nCi's CTCae v4.1 toxicity criteria. DLTs will be defined based on the rate of drug-related (definitely or probably) grade 3-5 adverse events experienced within the first 8 weeks of study treatment. The MTD will be exceeded if more than 20% of patients on the study experience DLTs. 2. Responses will be measured by ReCiST v1.1 every 8 weeks. Response duration will be defined as time from first documented response until disease progression. PFS is time from treatment until disease progression. 3. Patient tumor sensitivity to the drug combination will be quantified by the amount of subcutaneous established tumor growth inhibition in nSG mice by 5d/week oral gavage with drugs. 4. Tumor nRaS status will be determined by tumor Dna extraction, PCR amplification of exons and Sanger sequencing of nRaS. 5. History of prior MaPK inhibitor therapies will document MeK inhibitor exposures. 6. Sodium pump subunit expression will be analyzed by pretreatment tumor immunohistochemistry and a qualitative 0 to 3+ grading system.

Related Conditions:
  • Melanoma
Recruiting Status:

Completed

Phase:

Phase 1

Trial Eligibility

Document

Title

  • Brief Title: A Phase 1B Clinical Trial of Trametinib Plus Digoxin in Patients With Unresectable or Metastatic BRAF Wild-type Melanoma
  • Official Title: A Phase 1B Clinical Trial of Trametinib Plus Digoxin in Patients With Unresectable or Metastatic BRAF Wild-type Melanoma

Clinical Trial IDs

  • ORG STUDY ID: STU 012014-007
  • NCT ID: NCT02138292

Conditions

  • Melanoma

Interventions

DrugSynonymsArms
Trametinib (2mg)/Digoxin (.25mg)Trametinib (2mg)/Digoxin (0.25mg)

Purpose

The study is a prospective, single-arm, one-site therapeutic trial of the combination of trametinib plus digoxin for advanced melanoma. endpoints are toxicities assessed by nCi CTCae v4.1 within the first 8 weeks, responses measured by ReCiST v1.1 criteria every 8 weeks with scans and exams, tumor sensitivity to the drug combination quantified by tumor regressions in nSG mice, and correlations of response with tumor sensitivity, BRaF status, MaPK inhibitor exposure history, and tumor sodium pump expression. Treatment Dosage and administration Study Drugs: 1. Trametinib (2mg) will be administered orally on a daily basis. 2. Digoxin (0.25mg) will be administered orally on a daily basis. on a 8-week cycle, duration of treatment can last from 8 to 104 weeks. endpoints 1. Toxicities will be assessed via nCi's CTCae v4.1 toxicity criteria. DLTs will be defined based on the rate of drug-related (definitely or probably) grade 3-5 adverse events experienced within the first 8 weeks of study treatment. The MTD will be exceeded if more than 20% of patients on the study experience DLTs. 2. Responses will be measured by ReCiST v1.1 every 8 weeks. Response duration will be defined as time from first documented response until disease progression. PFS is time from treatment until disease progression. 3. Patient tumor sensitivity to the drug combination will be quantified by the amount of subcutaneous established tumor growth inhibition in nSG mice by 5d/week oral gavage with drugs. 4. Tumor nRaS status will be determined by tumor Dna extraction, PCR amplification of exons and Sanger sequencing of nRaS. 5. History of prior MaPK inhibitor therapies will document MeK inhibitor exposures. 6. Sodium pump subunit expression will be analyzed by pretreatment tumor immunohistochemistry and a qualitative 0 to 3+ grading system.

Detailed Description

      Primary Objectives:

        -  To describe the toxicities and estimate the frequency of dose limiting toxicities (DLTs)
           of digoxin in combination with trametinib in advanced melanoma patients and estimate the
           frequency of DLTs.

        -  To measure the response rate, response duration and progression free survival (PFS) of
           digoxin plus trametinib in advanced melanoma.

      Secondary Objectives:

        -  To correlate NSG xenograft sensivity to the drug combination with clinical response in
           the same patient.

        -  To compare response rates in MAPK inhibitor naive versus refractory patients and NRAS
           mutant versus wild-type patients and for sodium pump 3 subunit high tumor expression
           versus low tumor expression patients.

      Rationale: Having established cell culture and xenograft systems for studying patient
      melanoma samples, the researchers were able to grow tumors in vitro and in vivo from single
      cells and found a correlation of tumor metastatic behavior in immunocompromised mice and in
      patients. Recently they have extended the experiments to examine melanoma sensitivity to
      novel compounds. In screens of FDA approved drugs, they found several cardenolides including
      digoxin that reproducibly exhibited greater toxicity to primary human melanomas as compared
      to a range of normal human cells. They then examined the anti-tumor efficacy against primary
      human melanomas growing in vivo as xenografts. While trametinib, vemurafenib, and digoxin and
      digitoxin individually slowed the growth of human melanomas xenografts, they did not cause
      tumor regression. However, the combination of digoxin or digitoxin and trametinib caused
      substantial tumor regression using melanomas obtained from multiple patients, some with BRAF
      mutations and some without. The effects were dramatically better than trametinib, digoxin,
      digitoxin or vemurafenib alone. No difference in efficacy for the combination was seen in
      BRAF mutant and BRAF wild-type samples.
    

Trial Arms

NameTypeDescriptionInterventions
Trametinib (2mg)/Digoxin (0.25mg)ExperimentalTrametinib (2mg) will be administered orally on a daily basis. Digoxin (0.25mg) will be administered orally on a daily basis. On a 8-week cycle, duration of treatment can last from 8 to 104 weeks.
  • Trametinib (2mg)/Digoxin (.25mg)

Eligibility Criteria

        Inclusion Criteria:

          -  1. Histologic diagnosis of unresectable or metastatic melanoma. For unknown primary
             disease, diagnosis of metastatic disease by cytology FNA is not acceptable. BRAF
             wild-type confirmed, and NRAS mutation assessed.

             2. Age > 18 years.

             3. Any number of prior systemic therapeutic regimens for unresectable stage III or
             stage IV melanoma. This includes chemotherapy, immunotherapy, pathway inhibitors,
             biochemotherapy, or investigational treatments. Patients may also have received
             therapies in the adjuvant setting.

             4. ECOG Performance status 0-2.

             5. Adequate organ and marrow function as defined below:

          -  leukocytes ≥ 2,000/mcL

          -  absolute neutrophil count ≥ 1,000/mcL

          -  platelets ≥ 75,000/mcl

          -  total bilirubin < 3 x institutional upper limit of normal

          -  AST(SGOT)/ALT(SPGT) ≤ 2.5 X institutional upper limit of normal

          -  creatinine < 1.5 mg/dL

          -  cardiac ejection fraction > 50%

          -  QTc < 480msec

             6. Women of child-bearing potential and men must agree to use adequate contraception
             (hormonal or barrier method of birth control; abstinence) prior to study entry, for
             the duration of study participation, and for 90 days following completion of therapy.
             Should a woman become pregnant or suspect she is pregnant while participating in this
             study, she should inform her treating physician immediately. A female of child-bearing
             potential is any woman (regardless of sexual orientation, having undergone a tubal
             ligation, or remaining celibate by choice) who meets the following criteria: Has not
             undergone a hysterectomy or bilateral oophorectomy; or Has not been naturally
             postmenopausal for at least 12 consecutive months (i.e., has had menses at any time in
             the preceding 12 consecutive months).

             7. All sites of disease must be evaluated within 4 weeks prior to beginning therapy.
             Patients must have measurable disease as defined by RECIST v1.1.

             8. Ability to understand and the willingness to sign a written informed consent.

             9. Patients must be willing to undergo tumor biopsy pretreatment and at relapse.

        Exclusion Criteria:

          1. Subjects who have had chemotherapy or radiotherapy or any systemic therapy for
             melanoma within 2 weeks prior to entering the study or those who have not recovered
             from adverse events due to agents administered more than 2 weeks earlier. No
             concomitant therapy is allowed including IL2, interferon, ipilimumab, anti-PD-1 or
             anti-PD-L1 antibody, cytotoxic chemotherapy, immunosuppressive agents, or other
             investigational therapies.

          2. Active infection with hepatitis B or C or HIV.

          3. Subjects with active CNS disease are excluded. Patient with brain metastases
             previously treated with surgery or radiation therapy and with confirmed SD for >4
             weeks are allowed.

          4. Patients are excluded if they have a history of any other malignancy from which the
             patient has been disease-free for less than 2 years, with the exception of adequately
             treated and cured basal or squamous cell skin cancer, superficial bladder cancer or
             carcinoma in situ of the cervix.

          5. Uncontrolled inter-current illness including, but not limited to, ongoing or active
             infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
             arrhythmia, or psychiatric illness/social situations that would limit compliance with
             study requirements. Cardiac symptoms or events within 24 weeks.

          6. History of predisposition to retinal vein occlusion or central serous retinopathy.

          7. Inability to assess BRAF or NRAS mutation status. Hypersensitivity to digoxin.

          8. Wolff-Parkinson White syndrome or AV block or sinus node dysfunction.
      
Maximum Eligible Age:N/A
Minimum Eligible Age:19 Years
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Dose Limiting Doxicities (DLTs)
Time Frame:within the first 8 weeks of study treatment
Safety Issue:
Description:To describe the toxicities and estimate the frequency of dose limiting toxicities (DLTs) of digoxin in combination with trametinib in advanced melanoma patients and estimate the frequency of DLTs.

Secondary Outcome Measures

Measure:Response Rate
Time Frame:up to 104 weeks
Safety Issue:
Description:Responses will be measured by RECIST v1.1 every 8 weeks. Response duration will be defined as time from first documented response until disease progression. PFS is time from treatment until disease progression.

Details

Phase:Phase 1
Primary Purpose:Interventional
Overall Status:Completed
Lead Sponsor:University of Texas Southwestern Medical Center

Last Updated

May 15, 2018