Clinical Trials /

Venetoclax + Azacitidine vs. Induction Chemotherapy in AML

NCT04801797

Description:

This research is being done to assess the therapeutic activity of a promising combination (azacitidine and venetoclax) versus conventional cytotoxic chemotherapy in induction-eligible patients with acute myeloid leukemia. This study involves the following: - Venetoclax and azacitidine (investigational combination) - Cytarabine and idarubicin or daunorubicin (per standard of care) or Liposomal daunorubicin and cytarabine (per standard of care)

Related Conditions:
  • Acute Myeloid Leukemia
  • Secondary Acute Myeloid Leukemia
Recruiting Status:

Recruiting

Phase:

Phase 2

Trial Eligibility

Document

Title

  • Brief Title: Venetoclax + Azacitidine vs. Induction Chemotherapy in AML
  • Official Title: A Phase 2 Randomized Study Comparing Venetoclax and Azacitidine to Induction Chemotherapy for Newly Diagnosed Fit Adults With Acute Myeloid Leukemia

Clinical Trial IDs

  • ORG STUDY ID: 21-113
  • NCT ID: NCT04801797

Conditions

  • Acute Myeloid Leukemia

Interventions

DrugSynonymsArms
CytarabineAra-C, ArabinosylcytosineStandard of Care (Conventional Induction)
IdarubicinStandard of Care (Conventional Induction)
DaunorubicinStandard of Care (Conventional Induction)
Liposomal daunorubicin and cytarabineVyxeosStandard of Care (Conventional Induction)
VenetoclaxVenclextaInvestigational (Venetoclax and Azacitidine)
AzacitidineVidazaInvestigational (Venetoclax and Azacitidine)

Purpose

This research is being done to assess the therapeutic activity of a promising combination (azacitidine and venetoclax) versus conventional cytotoxic chemotherapy in induction-eligible patients with acute myeloid leukemia. This study involves the following: - Venetoclax and azacitidine (investigational combination) - Cytarabine and idarubicin or daunorubicin (per standard of care) or Liposomal daunorubicin and cytarabine (per standard of care)

Detailed Description

      This is an open-label, multicenter, phase II randomized clinical trial to compare the
      therapeutic activity of conventional induction chemotherapy (7+3 regimen or liposomal
      daunorubicin and cytarabine) to the combination of venetoclax and azacitidine among fit,
      traditionally induction-eligible adults with newly diagnosed acute myeloid leukemia (AML).

      The U.S. Food and Drug Administration (FDA) has approved the combinations of liposomal
      daunorubicin and cytarabine as well as cytarabine and idarubicin or daunorubicin as treatment
      options for acute myeloid leukemia (AML)

      The FDA has approved the combination of venetoclax and azacitidine for people with acute
      myeloid leukemia (AML) that are over the age of 75 or who have comorbidities that preclude
      intensive induction chemotherapy.

      Venetoclax may interact with BCL-2 (a protein that initiates tumor growth, disease
      progression, and drug resistance) and inhibit BLC-2 which can lead to cancer cell death.
      Azacitidine may cause cell death in rapidly dividing cells, which may lead to cancer cell
      death since cancer cells do not grow at a normal rate. Induction Chemotherapy which includes
      the drugs idarubicin or daunorubicin, cytarabine, and liposomal daunorubicin and cytarabine
      is the standard of care chemotherapy treatment for someone with acute myeloid leukemia (AML).

      The research study procedures include screening for eligibility and study treatment,
      including evaluations and follow up visits.

      Participants will receive study treatment for as long as they and their doctor believe they
      are benefitting from the study drugs. Participants will then be followed for 3 years or until
      they withdraw their consent to be contacted.

      It is expected that about 172 people will take part in this research study.

      AbbVie, a biopharmaceutical company, is supporting this research study by providing funding
      for the study, including one of the study drugs.
    

Trial Arms

NameTypeDescriptionInterventions
Standard of Care (Conventional Induction)ExperimentalRandomized participants will receive cytarabine and idarubicin [or daunorubicin) per standard of care as follows: Induction: cytarabine on days 1-7 and idarubicin (or daunorubicin) on days 1-3 of induction. Second Induction (if needed): Cytarabine on days 1-5 and idarubicin (or daunorubicin) on days 1-2 of re-induction. Consolidation (if needed): If < 60 years, cytarabine days 1,3,5 of consolidation cycles, and if ≥60 years, cytarabine days 1-5 of consolidation cycles Those with secondary or therapy-related AML can receive liposomal daunorubicin and cytarabine (Vyxeos) per standard of care as follows: Induction: Liposomal daunorubicin and cytarabine (Vyxeos) on Days 1,3, 5 of induction. Second Induction (if needed): Liposomal daunorubicin and cytarabine (Vyxeos) on days 1,3 of re-induction Consolidation (if needed): liposomal daunorubicin and cytarabine (Vyxeos) on days 1,3 of consolidation cycles
  • Cytarabine
  • Idarubicin
  • Daunorubicin
  • Liposomal daunorubicin and cytarabine
Investigational (Venetoclax and Azacitidine)ExperimentalParticipants will receive azacitidine on days 1-7 and venetoclax daily for up to (3) three 28-day study cycles and evaluated for response or benefit. If benefit/response is achieved, azacitidine on days 1-7 and venetoclax on days 1-28 (or less if deemed necessary per protocol) will be given in repeating 28-day cycles until benefit/response is no longer achieved or until patient proceeds to transplantation.
  • Venetoclax
  • Azacitidine

Eligibility Criteria

        Inclusion Criteria:

          -  Age ≥ 18 years

          -  Participants must have pathologically confirmed, newly diagnosed acute myeloid
             leukemia (AML). The AML may be either:

               -  De Novo: AML in patients with no clinical history of prior myelodysplastic
                  syndrome (MDS), myeloproliferative disorder, or exposure to potentially
                  leukemogenic therapies or agents

               -  Secondary AML (sAML): refers to an acute leukemic process (1) evolving from known
                  prior myelodysplasia, myeloproliferative disorder, or aplastic anemia with or
                  without treatment or; (2) as a product of previous exposure to a proven
                  leukemogenic chemotherapeutic agent

          -  Eligible for intensive induction chemotherapy, according to their treating physician

          -  ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A)

          -  Left ventricular ejection fraction > 50% as measured by echocardiogram or MUGA scan

          -  Must not have received systemic prior antineoplastic therapy for treatment for the
             newly diagnosed AML, including radiation therapy, except hydroxyurea for the purposes
             of cytoreduction. Patients may also have received all-trans retinoic acid (ATRA) if
             there is an early suspicion of acute promyelocytic leukemia (APL, M3-AML), although if
             confirmed to have APL these patients will be excluded from the study.

          -  Adequate hepatic function per local laboratory reference ranges as follows:

               -  Aspartate transaminase (AST) and alanine transaminase (ALT) ≤ 3.0X ULN

               -  Total bilirubin ≤ 2.0 x ULN (unless bilirubin rise is known to be due to
                  Gilbert's syndrome or of non-hepatic origin)

          -  The effects of venetoclax on the developing human fetus are unknown. For this reason
             and because other chemotherapeutic agents are known to be teratogenic, 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 and for the duration
             of study participation. Should a woman become pregnant or suspect she is pregnant
             while she or her partner is participating in this study, she should inform her
             treating physician immediately. Women should use contraceptives for at least 30 days
             following the last dose of venetoclax. Men treated or enrolled on this protocol must
             also agree to use adequate contraception prior to the study, for the duration of study
             participation, and 4 months after completion of therapy.

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

        Exclusion Criteria:

          -  Diagnosis of Acute promyelocytic leukemia (APL) or AML with favorable cytogenetics
             [t(8;21), inv(16), t(16;16)]

          -  Patients < 60 years old with NPM1-mutated AML:

          -  Patients with FLT3-mutated AML (TKD or ITD).

          -  Patients with acute leukemia with ambiguous lineage or mixed phenotype

          -  Patients that have received strong and/or moderate CYP3A inducers within 7 days prior
             to the initiation of study treatment.

          -  Subject has consumed grapefruit, grapefruit products, Seville oranges (including
             marmalade containing Seville oranges) or Starfruit within 3 days prior to the
             initiation of study treatment.

          -  Patients who have had prior systemic cytotoxic chemotherapy or radiotherapy for AML
             (excluding patients with therapy-related AML), except for hydroxyurea or 6-MP as
             noted. Empiric intrathecal chemotherapy during a diagnostic lumbar puncture is
             allowed, as long as CNS disease is not suspected.

          -  Patients treated with prior hypomethylating therapy (such as azacitidine or
             decitabine).

          -  Patients who will exceed a lifetime anthracycline exposure of >550 mg/m2 daunorubicin
             or equivalent (or >400 mg/m2 daunorubicin or equivalent in the event of prior
             mediastinal radiation) if they receive the maximum potential exposure to
             anthracyclines per protocol (including both induction and consolidation cycles.

          -  Individuals with a history of a different malignancy are ineligible except for the
             following circumstances. Individuals with a history of other malignancies are eligible
             if they have been disease-free for at least 3 years and are deemed by the investigator
             to be at low risk for recurrence of that malignancy. Individuals with the following
             cancers are eligible if diagnosed and treated within the past 3 years: cervical cancer
             in situ, breast DCIS, and basal cell or squamous cell carcinoma of the skin.

          -  Current clinical central nervous system (CNS) symptoms deemed by the investigator to
             be related to leukemic CNS involvement (no lumbar puncture required, clinical
             assessment per investigator's judgment is sufficient).

          -  Prior bone marrow transplantation for a myeloid malignancy

          -  Participants who are receiving any other investigational agents within the prior 14
             days.

          -  Currently clinically active hepatitis C or hepatitis B infection, as suggested by
             serology or viral load.

          -  Human immunodeficiency virus (HIV)-infected participants. Patients with no detectable
             viral load on a stable anti-viral regimen may be eligible, after discussion with the
             study overall PI.

          -  Current or history of congestive heart failure New York Heart Association (NYHA) class
             3 or 4, or any history of documented diastolic or systolic dysfunction (LVEF <50%, as
             measured by MUGA scan or echocardiogram). Prior to study entry, any ECG abnormality at
             screening has to be documented by the investigator as not medically relevant.

          -  Known hypersensitivity to the trial drugs or other contraindication to standard "7+3"
             induction chemotherapy.

          -  WBC > 25 x 109/L. Note: hydroxyurea is permitted to meet this criterion

          -  Patients who might refuse to receive blood products and/or have a hypersensitivity to
             blood products

          -  Patients with clinically significant persistent electrolyte abnormalities such as
             hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and
             hypermagnesemia of Grade > 1 per NCI CTCAE, v5.0. Treatment for correction of above
             electrolyte imbalances is permitted during screening to meet eligibility.

          -  Uncontrolled intercurrent illness including, but not limited to, clinically ongoing or
             active infection requiring intravenous antibiotics (IV antibiotics are allowed if
             infection is deemed to be controlled), symptomatic congestive heart failure, unstable
             angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that
             would limit compliance with study requirements.

          -  Known GI disease or GI procedures that could interfere with the oral absorption or
             tolerance of the study drugs. Examples include, but are not limited to partial
             gastrectomy, history of small intestine surgery, and celiac disease.

          -  Pregnant women are excluded from this study because venetoclax and azacitidine, along
             with standard induction chemotherapy, carries the potential for teratogenic or
             abortifacient effects. Because there is potential risk for adverse events in nursing
             infants secondary to treatment of the mother with venetoclax as well as azacitidine,
             cytarabine, daunorubicin and idarubicin, breastfeeding should be avoided. Confirmation
             that the subject is not pregnant must be established by a negative serum ß-human
             chorionic gonadotropin (ß-hCG) pregnancy test result obtained during screening.
             Pregnancy testing is not required for post-menopausal or surgically sterilized women.

          -  Patients with psychological, familial, social, or geographic factors that otherwise
             preclude them from giving informed consent, following the protocol, or potentially
             hamper compliance with study treatment and follow-up.

          -  Patients who are otherwise felt unable to comply with the protocol, in the opinion of
             the investigator.
      
Maximum Eligible Age:N/A
Minimum Eligible Age:18 Years
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Event free survival
Time Frame:From the time from randomization to time for up to 3 years, per protocol.
Safety Issue:
Description:Primary endpoint is event-free-survival of patients treated with venetoclax and azacitidine compared to patients treated with standard induction with either 7+3 regimen or liposomal daunorubicin and cytarabine Events are described in the protocol and will include Progressive Disease as defined above Any change in therapy due to leukemic persistence. Transition to hospice Relapse following CR, CRi, or CRh Any death Assessments of differences in EFS between the randomized arms will be made with the log-rank test; modeling will employ the Cox proportional hazards model. We also plan to assess the difference in estimated EFS at one year, using Kaplan-Meier estimates with standard deviation calculated by Greenwood's formula. EFS will be assessed using the Kaplan-Meier method. EFS will be assessed with the log-rank test, and cox proportional hazards model when appropriate.

Secondary Outcome Measures

Measure:Rate of response
Time Frame:From the time from randomization to time for up to 6 months.
Safety Issue:
Description:Evaluated overall and separately for patients with primary and secondary AML, comparisons will be based on the Fisher exact test. CR and CRi will be assessed. Study also includes CRh as a possible response, CRh aims to describe marrow blast clearance and evidence of partial hematologic recovery not captured by current CR or CRi, criteria.
Measure:Treatment-related toxicity
Time Frame:Enrollment to end of treatment duration for up to 12 months.
Safety Issue:
Description:Assessed using CTCAE 5
Measure:Rate of Minimal Residual Disease (MRD) negativity
Time Frame:From time of enrollment until up to the first 6 months.
Safety Issue:
Description:Assessed by flow cytometry and next-generation sequencing
Measure:30-day mortality
Time Frame:From the time of start of therapy until through the first 30 days.
Safety Issue:
Description:Analyzed using the Kaplan Meier method.
Measure:60-day mortality
Time Frame:From the time of start of therapy until through the first 60 days.
Safety Issue:
Description:Analyzed using the Kaplan Meier method.
Measure:Overall survival (OS)
Time Frame:Overall Survival (OS) is defined as the time from randomization (or registration) to death due to any cause, or censored at date last known alive, or for up to 3 years.
Safety Issue:
Description:Survival will be summarized using the method of Kaplan Meier, and assessed using the log rank test and Cox proportional hazards when appropriate.
Measure:Rate of stem cell transplantation (SCT) following induction
Time Frame:From time of enrollment until up to 3 years following start of treatment.
Safety Issue:
Description:The proportion of patients that receive a hematopoietic stem cell transplant following induction therapy or consolidation/continuation therapy.
Measure:Patient reported quality of life (QOL)
Time Frame:up to one year
Safety Issue:
Description:To compare quality of life between the two groups using the Functional Assessment of Cancer Therapy-Leukemia (FACT-Leuk). the FACT-Leukemia ranges from 0-176 with higher scores indicating better quality of life
Measure:Patient-reported depression symptoms
Time Frame:up to one year
Safety Issue:
Description:To compare depression symptoms between the two groups using the Hospital Anxiety and Depression Scale (HADS-Depression). the HADS-depression ranges from 0 (no distress) to 21 (maximum distress) with higher scores indicating worse depression symptoms
Measure:Patient-reported anxiety symptoms
Time Frame:up to one year
Safety Issue:
Description:To compare anxiety symptoms between the two groups using the Hospital Anxieyt and Depression Scale (HADS-Anxiety). the HADS-Anxiety ranges from 0 (no distress) to 21 (maximum distress) with higher scores indicating worse anxiety symptoms
Measure:Patient-reported symptom burden
Time Frame:up to one year
Safety Issue:
Description:To compare symptom burden between the two groups using the Edmonton Symptom Assessment Scale (ESAS-revised). ESAS ranges from 0-100 with higher scores indicating worse symptom burden
Measure:Patient-reported post-traumatic stress symptoms
Time Frame:up to one year
Safety Issue:
Description:To compare post-traumatic stress (PTSD) symptoms between the two groups using the PTSD-Checklist-Civilian Version. The PTSD-Checklist ranges from 17-85 with higher scores indicating worse PTSD symptoms
Measure:Health care utilization - hospitalizations
Time Frame:up to 1 year
Safety Issue:
Description:To compare number of hospitalizations between the two groups using linear regression (and adjusting for any potential imbalances between the groups
Measure:Health care utilization - days alive and out of the hospital
Time Frame:up to 1 year
Safety Issue:
Description:To compare days alive and out of the hospital between the two groups using linear regression (and adjusting for any potential imbalances between the groups)
Measure:Health care utilization - Intensive care unit admissions
Time Frame:up to 1 year
Safety Issue:
Description:To compare intensive care unit admissions (yes vs. no) between the two groups using logistic regression (and adjusting for any potential imbalances between the groups)
Measure:Cost of care
Time Frame:up to 1 year
Safety Issue:
Description:To compare cost of care between the two groups using parametric and non-parametric tests based on distribution of the data
Measure:Incidence of neutropenic infections
Time Frame:Up to 8 weeks
Safety Issue:
Description:Number of patients that experience neutropenic fever during induction cycles (up to 2 cycles).
Measure:100-Day post-transplant mortality
Time Frame:From date of transplantation through 100 days following transplantation.
Safety Issue:
Description:Assessed using the Kaplan Meier method
Measure:Incidence of grade 3 or greater acute graft versus host disease (GVHD)
Time Frame:Patients that receive a SCT will be followed post-SCT through up to 100 days.
Safety Issue:
Description:Assessed among patients that receive HSCT following induction.

Details

Phase:Phase 2
Primary Purpose:Interventional
Overall Status:Recruiting
Lead Sponsor:Massachusetts General Hospital

Trial Keywords

  • Acute Myeloid Leukemia

Last Updated

June 22, 2021