Clinical Trials /

ASTX727, Venetoclax, and Gilteritinib for the Treatment of Newly Diagnosed, Relapsed or Refractory FLT3-Mutated Acute Myeloid Leukemia or High-Risk Myelodysplastic Syndrome

NCT05010122

Description:

This phase I/II trial studies the best dose of gilteritinib given together with ASTX727 and venetoclax and the effect of ASTX727, venetoclax, and gilteritinib in treating patients with FLT3-mutated acute myeloid leukemia that is newly diagnosed, has come back (relapsed) or does not respond to treatment (refractory) or high-risk myelodysplastic syndrome. Chemotherapy drugs, such as ASTX727, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Venetoclax may stop the growth of cancer cells by blocking Bcl-2, a protein needed for cancer cell survival. Gilteritinib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Giving ASTX727, venetoclax, and gilteritinib may help to control the disease.

Related Conditions:
  • Acute Myeloid Leukemia
  • Myelodysplastic Syndromes
Recruiting Status:

Recruiting

Phase:

Phase 1/Phase 2

Trial Eligibility

Document

Title

  • Brief Title: ASTX727, Venetoclax, and Gilteritinib for the Treatment of Newly Diagnosed, Relapsed or Refractory FLT3-Mutated Acute Myeloid Leukemia or High-Risk Myelodysplastic Syndrome
  • Official Title: A Phase I/II Study of ASTX727, Venetoclax, and Gilteritinib for Patients With Acute Myeloid Leukemia or High-Risk Myelodysplastic Syndrome With an Activating FLT3 Mutation

Clinical Trial IDs

  • ORG STUDY ID: 2021-0082
  • SECONDARY ID: NCI-2021-06095
  • SECONDARY ID: 2021-0082
  • NCT ID: NCT05010122

Conditions

  • Acute Myeloid Leukemia
  • Myelodysplastic Syndrome
  • Recurrent Acute Myeloid Leukemia
  • Refractory Acute Myeloid Leukemia

Interventions

DrugSynonymsArms
Decitabine and CedazuridineASTX727, C-DEC, CDA Inhibitor E7727/Decitabine Combination Agent ASTX727, Cedazuridine/Decitabine Combination Agent ASTX727, Cedazuridine/Decitabine Tablet, DEC-C, InqoviTreatment (decitabine, cedazuridine, venetoclax, gilteritib)
GilteritinibASP-2215, ASP2215Treatment (decitabine, cedazuridine, venetoclax, gilteritib)
VenetoclaxABT-0199, ABT-199, ABT199, GDC-0199, RG7601, Venclexta, VenclyxtoTreatment (decitabine, cedazuridine, venetoclax, gilteritib)

Purpose

This phase I/II trial studies the best dose of gilteritinib given together with ASTX727 and venetoclax and the effect of ASTX727, venetoclax, and gilteritinib in treating patients with FLT3-mutated acute myeloid leukemia that is newly diagnosed, has come back (relapsed) or does not respond to treatment (refractory) or high-risk myelodysplastic syndrome. Chemotherapy drugs, such as ASTX727, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Venetoclax may stop the growth of cancer cells by blocking Bcl-2, a protein needed for cancer cell survival. Gilteritinib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Giving ASTX727, venetoclax, and gilteritinib may help to control the disease.

Detailed Description

      PRIMARY OBJECTIVES:

      I. To establish the maximum tolerated dose (MTD) of the combination of decitabine and
      cedazuridine (ASTX727), venetoclax and gilteritinib in patients with relapsed/refractory
      FLT3- mutated acute myeloid leukemia (AML) or high-risk myelodysplastic syndrome (MDS).
      (Phase I) II. To determine the complete response (CR)/incomplete hematologic recovery (CRi)
      rate of the regimen in patients with newly diagnosed or relapsed/refractory FLT3-mutated AML
      or high-risk MDS. (Phase II)

      SECONDARY OBJECTIVES:

      I. To assess other efficacy endpoints (CR rate, minimal residual disease negativity by flow
      cytometry, relapse-free survival, overall survival).

      II. To assess proportion of patients proceeding to hematopoietic stem cell transplantation
      (HSCT).

      III. To determine the safety of the combination regimen.

      EXPLORATORY OBJECTIVES:

      I. To evaluate the impact of baseline genomic alterations on response and survival of the
      combination regimen.

      II. To determine the impact of baseline FLT3 allelic ratio on response and survival.

      III. To evaluate clonal evolution from diagnosis to relapse using single-cell sequencing.

      IV. To evaluate potential role of minimal residual disease (MRD) detection by sensitive
      polymerase chain reaction (PCR)/next generation sequencing (NGS) assays for FLT3 mutations.

      V. To evaluate leukemia stem cell populations over the course of treatment with the
      combination regimen.

      VI. To determine the impact of baseline apoptotic protein levels as assessed by mass
      cytometry (CyTOF) on response and resistance to the regimen.

      OUTLINE: This is a phase I, dose-escalation study of gilteritinib followed by a phase II
      study.

      INDUCTION (CYCLE 1): Patients receive decitabine and cedazuridine orally (PO) once daily (QD)
      on days 1-5, venetoclax PO QD on days 1-28, and gilteritinib PO QD on days 1-28 in the
      absence of disease progression or unacceptable toxicity

      CONSOLIDATION (CYCLES 2-24): Patients receive decitabine and cedazuridine PO QD on days 1-5,
      gilteritinib PO QD on days 1-28, and venetoclax PO QD on days 1-21. Treatment repeats every
      28 days for up to 23 cycles in the absence of disease progression or unacceptable toxicity.

      MAINTENANCE (CYCLES 24+): Patients receive gilteritinib PO QD on days 1-28. Cycles repeat
      every 28 days in the absence of disease progression or unacceptable toxicity.

      After completion of study treatment, patients are followed up at 30 days, then every 6 months
      thereafter.
    

Trial Arms

NameTypeDescriptionInterventions
Treatment (decitabine, cedazuridine, venetoclax, gilteritib)ExperimentalINDUCTION (CYCLE 1): Patients receive decitabine and cedazuridine PO QD on days 1-5, venetoclax PO QD on days 1-28, and gilteritinib PO QD on days 1-28 in the absence of disease progression or unacceptable toxicity CONSOLIDATION (CYCLES 2-24): Patients receive decitabine and cedazuridine PO QD on days 1-5, gilteritinib PO QD on days 1-28, and venetoclax PO QD on days 1-21. Treatment repeats every 28 days for up to 23 cycles in the absence of disease progression or unacceptable toxicity. MAINTENANCE (CYCLES 24+): Patients receive gilteritinib PO QD on days 1-28. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.
  • Decitabine and Cedazuridine
  • Gilteritinib
  • Venetoclax

Eligibility Criteria

        Inclusion Criteria:

          -  Diagnosis:

               -  Phase I cohort: Adults >= 18 years with relapsed/refractory FLT3-mutated AML or
                  myelodysplastic syndrome (MDS) that is intermediate-2 or high-risk by the
                  International Prognostic Scoring System

               -  Phase II cohort A: Adults >= 18 years with newly diagnosed FLT3-mutated AML.
                  Patients should meet the following criteria:

                    -  Confirmed newly diagnosed AML with FLT3 mutation

                    -  Ineligible for induction therapy defined as

                         -  Either age >= 75

                         -  Or 18-74 with at least one comorbidity (congestive heart failure [CHF]
                            requiring therapy or ejection fraction [EF] =< 50%, diffusion capacity
                            of the lung for carbon monoxide [DLCO] =< 65% or forced expiratory
                            volume in 1 second [FEV1] =< 65%, or Eastern Cooperative Oncology Group
                            [ECOG] 2 or 3, or other significant co-morbidity precluding use of
                            cytotoxic chemotherapy as approved by the principal investigator (PI)

               -  Phase II cohort B: Adults >= 18 years with relapsed/refractory FLT3-mutated AML
                  or MDS that is intermediate-2 or high-risk by the International Prognostic
                  Scoring System who have received 1 prior therapy

               -  For all cohorts, patients with either FLT3-ITD or FLT3 D835 mutations will be
                  eligible

          -  Performance status =< 3 (Eastern Cooperative Oncology Group [ECOG] scale)

          -  Total serum bilirubin =< 2.5 x upper limit of normal (ULN), unless due to Gilbert's
             syndrome, hemolysis or the underlying leukemia approved by the PI

          -  Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) =< 3 x ULN, unless
             due to the underlying leukemia approved by the PI

          -  Creatinine clearance >= 30 mL/min

          -  Ability to swallow

          -  Signed informed consent

          -  Hydroxyurea or one dose of cytarabine up to 1000 mg is allowed to reduce the white
             blood cell (WBC) to less than 25 x 10^9/L prior to initiation of study treatment

        Exclusion Criteria:

          -  Prior therapies

               -  Phase I cohort: No restriction based on prior therapies

               -  Phase II cohort A: Patients with prior therapy for AML are not eligible. Prior
                  therapy for antecedent hematologic disorder is allowed including prior
                  hypomethylating agent (HMA) therapy for MDS. Prior hydroxyurea or cytarabine
                  given for purposes of cytoreduction is also allowed. Prior all trans-retinoic
                  acid given for presumed acute promyelocytic leukemia is also allowed

               -  Phase II cohort B: Patients with >= 3 prior lines of therapy are not eligible.
                  Stem cell transplantation, treatment given only for cytoreductive purposes (e.g.
                  hydroxyurea), and growth factors do not count as lines of therapy for this
                  purpose. Prior therapy with venetoclax is allowed

          -  Prior treatment with gilteritinib

          -  Patients suitable for and willing to receive intensive induction chemotherapy (for
             Phase II cohort A only)

          -  Congenital long QT syndrome or corrected QT (QTc) > 450 msec. Repeat
             electrocardiograms (EKGs) after correction of electrolytes or discontinuation of QT
             prolonging medications are allowed to meet entry criteria

          -  Active serious infection not controlled by oral or intravenous antibiotics (e.g.
             persistent fever or lack of improvement despite antimicrobial treatment)

          -  Active grade III-V cardiac failure as defined by the New York Heart Association
             Criteria

          -  Active central nervous system leukemia

          -  Known history of human immunodeficiency virus (HIV) seropositive

          -  Known hepatitis B surface antigen seropositive or known or suspected active hepatitis
             C infection

               -  Note: Patients who have isolated positive hepatitis B core antibody (i.e., in the
                  setting of negative hepatitis B surface antigen and negative hepatitis B surface
                  antibody) must have an undetectable hepatitis B viral load. Patients who have
                  positive hepatitis C antibody may be included if they have an undetectable
                  hepatitis C viral load

          -  Patients with a prior or concurrent malignancy whose natural history or treatment is
             not anticipated to interfere with the safety or efficacy assessment of the
             investigational regimen may be included only after discussion with the PI

          -  Consumed strong inducer of CYP3A or p-glycoprotein within 3 days of study enrollment.
             Agents include but are not limited to: carbamazepine, phenytoin, rifampin, and St.
             John's wart

          -  Treatment with any investigational antileukemic agents or chemotherapy agents in the
             last 7 days before study entry, unless full recovery from side effects has occurred or
             patient has rapidly progressive disease judged to be life-threatening by the
             investigator. Prior recent treatment with corticosteroids, hydroxyurea and/or
             cytarabine (given for cytoreduction) permitted. Use of hydroxyurea or one dose
             cytarabine to reduce WBC below 25 prior to initiation of study treatment is
             recommended

          -  Pregnant women will not be eligible; women of childbearing potential should have a
             negative pregnancy test prior to entering on the study and be willing to use effective
             methods of contraception throughout the study period and for at least 6 months after
             the last dose of study drugs. Women do not have childbearing potential if they have
             had a hysterectomy or are postmenopausal without menses for 12 months. In addition,
             men enrolled on this study should understand the risks to any sexual partner of
             childbearing potential and should practice an effective method of birth control
             throughout the study period and for at least 4 months after the last dose of study
             drugs. Lactating women (or those planning to breastfeed) should not breastfeed during
             treatment of gilteritinib and for at least 2 months after the last dose of
             gilteritinib
      
Maximum Eligible Age:N/A
Minimum Eligible Age:18 Years
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Maximum tolerated dose (Phase I)
Time Frame:Up to 28 days
Safety Issue:
Description:Will estimate the OR for the combination treatment (defined as the proportion of patients achieving complete response (CR) or incomplete hematologic recovery (CRi) within 2 cycles of treatment), along with the 95% credible interval.

Secondary Outcome Measures

Measure:Complete response rate
Time Frame:Up to 2 years
Safety Issue:
Description:Will also be estimated along with 95% credible interval.
Measure:To assess minimal residual disease negativity by flow cytometry
Time Frame:Up to 2 years
Safety Issue:
Description:Will also be estimated along with 95% credible interval.
Measure:Relapse-free survival
Time Frame:From the date of response to the date of documented relapses from CR or death from any cause, whichever occurs first, assessed up to 2 years
Safety Issue:
Description:Will be estimated using the method of Kaplan and Meier.
Measure:Overall survival
Time Frame:From treatment start till death or last follow-up, assessed up to 2 years
Safety Issue:
Description:Will be estimated using the method of Kaplan and Meier.
Measure:Proportion of patients proceeding to hematopoietic stem cell transplantation
Time Frame:Up to 2 years
Safety Issue:
Description:Will also be estimated along with 95% credible interval.
Measure:Incidence of adverse events
Time Frame:Up to 30 days post-treatment
Safety Issue:
Description:

Details

Phase:Phase 1/Phase 2
Primary Purpose:Interventional
Overall Status:Recruiting
Lead Sponsor:M.D. Anderson Cancer Center

Last Updated

August 18, 2021