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.
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
Drug | Synonyms | Arms |
---|
Decitabine and Cedazuridine | ASTX727, C-DEC, CDA Inhibitor E7727/Decitabine Combination Agent ASTX727, Cedazuridine/Decitabine Combination Agent ASTX727, Cedazuridine/Decitabine Tablet, DEC-C, Inqovi | Treatment (decitabine, cedazuridine, venetoclax, gilteritib) |
Gilteritinib | ASP-2215, ASP2215 | Treatment (decitabine, cedazuridine, venetoclax, gilteritib) |
Venetoclax | ABT-0199, ABT-199, ABT199, GDC-0199, RG7601, Venclexta, Venclyxto | Treatment (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
Name | Type | Description | Interventions |
---|
Treatment (decitabine, cedazuridine, venetoclax, gilteritib) | Experimental | INDUCTION (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