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Terpos E, Ntanasis-Stathopoulos I, Gavriatopoulou M, Katodritou E, Hatjiharissi E, Malandrakis P, Verrou E, Golfinopoulos S, Migkou M, Manousou K, Delimpasi S, Symeonidis A, Kastritis E, Dimopoulos MA. Efficacy and safety of daratumumab with ixazomib and dexamethasone in lenalidomide-exposed patients after one prior line of therapy: Final results of the phase 2 study DARIA. Am J Hematol 2024; 99:396-407. [PMID: 38298023 DOI: 10.1002/ajh.27206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/16/2023] [Accepted: 12/19/2023] [Indexed: 02/02/2024]
Abstract
The use of lenalidomide in frontline therapy for patients with newly diagnosed multiple myeloma (MM) has increased the number of those who become refractory to lenalidomide at second line. In this context, we assessed the efficacy of daratumumab in combination with ixazomib and dexamethasone (Dara-Ixa-dex) in the prospective phase 2 study DARIA. Eligible patients had relapsed/refractory MM (RRMM) after one prior line with a lenalidomide-based regimen. The primary endpoint was overall response rate (ORR). Secondary endpoints included survival outcomes, safety and changes in biomarkers of bone metabolism. Overall, 50 patients were enrolled (median age 69 years, 56% males). 32 (64%) patients were refractory to lenalidomide, and 17 (34%) had undergone autologous transplant. The ORR was 64% (n = 32); whereas 17 (34%) had a very good partial response or better. The median time to first response was 1.0 month. After a median follow-up of 23.4 months, the median PFS and OS were 8.1 and 39.2 months, respectively. Furthermore, significant changes in markers of bone metabolism became evident as early as at 6 months on treatment. Regarding safety, 21 (42%) patients had ≥1 grade 3/4 adverse event (AE); the most common was thrombocytopenia (n = 9, 18%). 14 (28%) patients had ≥1 serious AE (SAE), the most common being acute kidney injury and pneumonia (n = 2, each). Four patients died due to infections. In conclusion, second-line treatment with Dara-Ixa-dex in patients with RRMM pre-treated with a lenalidomide-based regimen resulted in rapid responses along with a favorable effect on bone metabolism.
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Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eirini Katodritou
- Department of Hematology, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - Evdoxia Hatjiharissi
- First Department of Internal Medicine, Division of Haematology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evgenia Verrou
- Department of Hematology, Theagenio Cancer Hospital, Thessaloniki, Greece
| | | | - Magdalini Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Sosana Delimpasi
- Department of Hematology and Bone Marrow Transplantation Unit, Evangelismos Hospital, Athens, Greece
| | - Argiris Symeonidis
- Hematology Division, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Partanen A, Waage A, Peceliunas V, Schjesvold F, Anttila P, Säily M, Uttervall K, Putkonen M, Carlson K, Haukas E, Sankelo M, Szatkowski D, Hansson M, Marttila A, Svensson R, Axelsson P, Lauri B, Mikkola M, Karlsson C, Abelsson J, Ahlstrand E, Sikiö A, Klimkowska M, Matuzeviciene R, Fenstad MH, Ilveskero S, Pelliniemi TT, Nahi H, Silvennoinen R. Ixazomib, Lenalidomide, and Dexamethasone (IRD) Treatment with Cytogenetic Risk-Based Maintenance in Transplant-Eligible Myeloma: A Phase 2 Multicenter Study by the Nordic Myeloma Study Group. Cancers (Basel) 2024; 16:1024. [PMID: 38473382 DOI: 10.3390/cancers16051024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 02/17/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Scarce data exist on double maintenance in transplant-eligible high-risk (HR) newly diagnosed multiple myeloma (NDMM) patients. This prospective phase 2 study enrolled 120 transplant-eligible NDMM patients. The treatment consisted of four cycles of ixazomib-lenalidomide-dexamethasone (IRD) induction plus autologous stem cell transplantation followed by IRD consolidation and cytogenetic risk-based maintenance therapy with lenalidomide + ixazomib (IR) for HR patients and lenalidomide (R) alone for NHR patients. The main endpoint of the study was undetectable minimal residual disease (MRD) with sensitivity of <10-5 by flow cytometry at any time, and other endpoints were progression-free survival (PFS) and overall survival (OS). We present the preplanned analysis after the last patient has been two years on maintenance. At any time during protocol treatment, 28% (34/120) had MRD < 10-5 at least once. At two years on maintenance, 66% of the patients in the HR group and 76% in the NHR group were progression-free (p = 0.395) and 36% (43/120) were CR or better, of which 42% (18/43) had undetectable flow MRD <10-5. Altogether 95% of the patients with sustained MRD <10-5, 82% of the patients who turned MRD-positive, and 61% of those with positive MRD had no disease progression at two years on maintenance (p < 0.001). To conclude, prolonged maintenance with all-oral ixazomib plus lenalidomide might improve PFS in HR patients.
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Affiliation(s)
- Anu Partanen
- Department of Medicine, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Anders Waage
- Department of Hematology, St. Olavs Hospital, 7030 Trondheim, Norway
| | - Valdas Peceliunas
- Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital, 08661 Vilnius, Lithuania
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Department of Hematology, Oslo University Hospital, 0450 Oslo, Norway
- KG Jebsen Center for B Cell Malignancies, University of Oslo, 0316 Oslo, Norway
| | - Pekka Anttila
- Helsinki University Hospital Cancer Center Hematology, University of Helsinki, 00029 Helsinki, Finland
| | - Marjaana Säily
- Hematology-Oncology Unit, Oulu University Hospital Hematology, 90220 Oulu, Finland
| | - Katarina Uttervall
- Medical Unit Hematology, Karolinska University Hospital, 171 64 Solna, Sweden
- Department of Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Mervi Putkonen
- Department of Medicine, Turku University Hospital, 20521 Turku, Finland
| | - Kristina Carlson
- Department of Hematology, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Einar Haukas
- Stavanger University Hospital, 4011 Stavanger, Norway
| | - Marja Sankelo
- Hematology Unit, Department of Internal Medicine, Tampere University Hospital Hematology, 33520 Tampere, Finland
| | - Damian Szatkowski
- Department of Oncology, Hematology and Palliative Care, Foerde Central Hospital, 6812 Foerde, Norway
| | - Markus Hansson
- Department of Hematology, Skåne University Hospital, 222 42 Lund, Sweden
| | - Anu Marttila
- Department of Medicine, Kymenlaakso Central Hospital, 48210 Kotka, Finland
| | - Ronald Svensson
- Department of Hematology, Linköping University Hospital, 581 85 Linköping, Sweden
| | - Per Axelsson
- Department of Haematology, Helsingborg Hospital, 252 23 Helsingborg, Sweden
| | - Birgitta Lauri
- Department of Hematology, Sunderby Hospital, 971 80 Luleå, Sweden
| | - Maija Mikkola
- Department of Medicine, Päijät-Häme Central Hospital, 15850 Lahti, Finland
| | - Conny Karlsson
- Department of Haematology, Halland Hospital, 302 33 Halmstad, Sweden
| | - Johanna Abelsson
- Department of Hematology, Uddevalla Hospital, 451 53 Uddevalla, Sweden
| | - Erik Ahlstrand
- Department of Medicine, Örebro University Hospital, 701 85 Örebro, Sweden
| | - Anu Sikiö
- Department of Medicine, Central Finland Central Hospital, 40620 Jyväskylä, Finland
| | - Monika Klimkowska
- Department of Clinical Pathology and Cytology, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - Reda Matuzeviciene
- Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Biomedical Sciences Institute, Vilnius University Hospital and Vilnius University Faculty of Medicine, 03101 Vilnius, Lithuania
| | - Mona Hoysaeter Fenstad
- Department of Immunology and Transfusion Medicine, St. Olavs Hospital, 7030 Trondheim, Norway
| | - Sorella Ilveskero
- Clinical Chemistry, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
| | | | - Hareth Nahi
- Hematology Centre, Karolinska University Hospital Huddinge, 141 57 Stockholm, Sweden
| | - Raija Silvennoinen
- Helsinki University Hospital Cancer Center Hematology, University of Helsinki, 00029 Helsinki, Finland
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Kegyes D, Gulei D, Drula R, Cenariu D, Tigu B, Dima D, Tanase A, Badelita S, Buzoianu AD, Ciurea S, Ghiaur G, Terpos E, Ciechanover A, Einsele H, Tomuleasa C. Proteasome inhibition in combination with immunotherapies: State-of-the-Art in multiple myeloma. Blood Rev 2023; 61:101100. [PMID: 37291017 DOI: 10.1016/j.blre.2023.101100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
Multiple myeloma (MM) is a malignant plasma cell disorder accounting for around 1.8% of all neoplastic diseases. Nowadays, clinicians have a broad arsenal of drugs at their disposal for the treatment of MM, such as proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, bispecific antibodies, CAR T-cell therapies and antibody-drug conjugates. In this paper we briefly highlight essential clinical elements relating to proteasome inhibitors, such as bortezomib, carfilzomib and ixazomib. Studies suggest that the early use of immunotherapy may improve outcomes significantly. Therefore, in our review we specifically focus on the combination therapy of proteasome inhibitors with novel immunotherapies and/or transplant. A high number of patients develop PI resistance. Thus, we also review new generation PIs, such as marizomib, oprozomib (ONX0912) and delanzomib (CEP-18770) and their combinations with immunotherapies.
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Affiliation(s)
- David Kegyes
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Diana Gulei
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Rares Drula
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Diana Cenariu
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Bogdan Tigu
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Alina Tanase
- Department of Hematology and Stem Cell Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Sorina Badelita
- Department of Hematology and Stem Cell Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Anca-Dana Buzoianu
- Department of Clinical Pharmacology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Stefan Ciurea
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, University of California Irvine, CA, United States
| | - Gabriel Ghiaur
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, United States
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Aaron Ciechanover
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania; The Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Haifa, Israel
| | - Hermann Einsele
- Department of Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Ciprian Tomuleasa
- Medfuture Research Center for Advanced Medicine / Department of Hematology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.
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4
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Franz J, Myrus E, Sanchez L, Richter J. No needles needed: All-oral therapy options for relapsed and refractory multiple myeloma. Blood Rev 2023; 57:100993. [PMID: 36137842 DOI: 10.1016/j.blre.2022.100993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 01/28/2023]
Abstract
Immense progress has been made for the treatment of multiple myeloma over the past two decades, with patient outcomes improving dramatically as a result. Patient quality of life, however, is constantly challenged by complications of the disease, side effects of therapy and the overall burden receiving continuous treatment. Compared to parenteral agents, all-oral regimens can provide logistically favorable alternatives and are associated with improved quality of life. Here, we review the currently available and investigational oral therapies for relapsed and refractory multiple myeloma and provide a practical clinical reference tool. We explore the factors that dictate the selection of therapy, such as prior drug refractoriness, disease biology and patient-specific considerations. Regimens with their respective supporting clinical data are organized by the degree of prior treatment, from lenalidomide-sensitive to heavily pretreated patients. We explore common challenges such as renal insufficiency and cytopenias. Lastly, we review investigational oral agents.
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Affiliation(s)
- Joseph Franz
- UPMC Hillman Cancer, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Elizabeth Myrus
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Larysa Sanchez
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joshua Richter
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
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5
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Huo Z, Chen F, Liu P, Luo Z. Ixazomib combined with lenalidomide and dexamethasone chemotherapy for newly diagnosed multiple myeloma in China-Compared with bortezomib/lenalidomide/dexamethasone. Cancer Med 2022; 12:2937-2944. [PMID: 36052569 PMCID: PMC9939219 DOI: 10.1002/cam4.5198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 07/22/2022] [Accepted: 08/23/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To compare the response and safety of Ixazomib/Lenalidomide/Dexamethasone (IRd) and Bortezomib/Lenalidomide/Dexamethasone (VRd) treatment in newly diagnosed multiple myeloma (MM). METHODS This was a single-center retrospective analysis in Xiangtan Central Hospital. A total of 52 newly diagnosed MM patients from June 2019 to June 2021 were enrolled and divided into the IRd (n = 21) and VRd (n = 31) groups. After 4 cycles of chemotherapy, the best response and adverse events were recorded. Moreover, the progression-free survival (PFS) and overall survival (OS) were calculated. RESULTS Patients in IRd group and VRd group showed similar PFS (Log-rank p = 0.70), OS (Log-rank p = 0.61) and overall response rate (83.87% vs 90.48%, p = 0.803). In addition, patients in VRd group showed lower Eastern Cooperative Oncology Group scores (p = 0.047), and higher incidence of peripheral sensory neuropathy (0.00% vs 19.35%, p = 0.032) than that of patients in IRd group. CONCLUSION Compared to VRd regimen, IRd had the similar efficacy, better safety, and may be more convenient for patients with poor basic condition for newly diagnosed MM. This study provides an insight for physicians to use IRd as first-line treatment in MM.
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Affiliation(s)
- Zhongjun Huo
- Department of HematologyCentral Hospital of XiangtanXiangTanChina
| | - Fang Chen
- Department of HematologyCentral Hospital of XiangtanXiangTanChina
| | - Ping Liu
- Department of HematologyCentral Hospital of XiangtanXiangTanChina
| | - Zimian Luo
- Department of HematologyCentral Hospital of XiangtanXiangTanChina
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Rafae A, Ehsan H, Wahab A, Khan SI, Khan I, Ashraf S, Ali S, Khalid F, Neupane K, Valent J, Khouri J, Samaras C, Mazzoni S, Anwer F. Evidence-based recommendations for induction and maintenance treatment of newly diagnosed transplant-ineligible multiple myeloma patients. Crit Rev Oncol Hematol 2022; 176:103744. [PMID: 35717005 DOI: 10.1016/j.critrevonc.2022.103744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 05/23/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022] Open
Abstract
There is increasing evidence regarding the role of various maintenance therapy (MT) strategies after initial induction to treat newly diagnosed transplant-ineligible patients with MM. We reviewed the literature on available regimens for patients with transplant-ineligible newly diagnosed multiple myeloma (NDMM). Lenalidomide (R)-based regimens are still the front-line therapy, but there is an increasing use of bortezomib-based regimens. The MT regimen is mainly based on the initial induction regimen. MT has shown survival benefits compared with patients without maintenance therapy. The most common adverse effects of MT include anemia, neutropenia, thrombocytopenia, infections, and peripheral neuropathy. In conclusion, induction followed by maintenance based on lenalidomide, bortezomib, ixazomib, or daratumumab-based regimens has shown promising results. Therefore, it is essential to conduct more clinical trials to better understand the role of MT in the treatment of NDMM patients who are not candidates for autologous stem cell transplantation.
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Affiliation(s)
- Abdul Rafae
- Department of Internal Medicine, McLaren Flint-Michigan State University, Flint, MI, USA.
| | | | - Ahsan Wahab
- Internal Medicine/Hospital Medicine Department, University of Alabama at Birmingham, Montgomery, AL, USA
| | - Sana Irfan Khan
- SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | | | - Sara Ashraf
- Sharif Medical and Dental College, Lahore, Pakistan
| | - Sundas Ali
- Department of Internal Medicine, Ascension St. Agnes Hospital, Baltimore, MD, USA
| | - Farhan Khalid
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Karun Neupane
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Christy Samaras
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Sandra Mazzoni
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
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Schwartz G, Shee K, Romo B, Marotti J, Kisselev A, Lewis L, Miller T. Phase Ib Study of the Oral Proteasome Inhibitor Ixazomib (MLN9708) and Fulvestrant in Advanced ER+ Breast Cancer Progressing on Fulvestrant. Oncologist 2021; 26:467-e924. [PMID: 33641211 PMCID: PMC8176977 DOI: 10.1002/onco.13733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/10/2021] [Indexed: 12/28/2022] Open
Abstract
LESSONS LEARNED Fulvestrant is a selective estrogen receptor (ER)-downregulating antiestrogen that blocks ER transcriptional activity and is approved for ER-positive breast cancer. Fulvestrant also induces accumulation of insoluble ER and activates an unfolded protein response; proteasome inhibitors have been shown to enhance these effects in preclinical models. BACKGROUND Fulvestrant is a selective estrogen receptor (ER)-downregulating antiestrogen that blocks ER transcriptional activity and is approved for ER-positive (+) breast cancer. Fulvestrant also induces accumulation of insoluble ER and activates an unfolded protein response; proteasome inhibitors have been shown to enhance these effects in preclinical models. METHODS This is a single-center phase Ib study with a 3+3 design of fulvestrant and the proteasome inhibitor ixazomib (MLN9708) in patients with advanced ER+ breast cancer that was progressing on fulvestrant. A dose-escalation design allowed establishment of the ixazomib maximum tolerated dose (MTD). Secondary objectives included progression-free survival, pharmacokinetics, and tumor molecular analyses. RESULTS Among nine evaluable subjects, treatment was well-tolerated without dose-limiting toxicities The MTD of ixazomib was 4 mg in combination with fulvestrant. Plasma concentrations of the active form of ixazomib (MLN2238) in the 4-mg dose cohort had a median (range) maximal concentration (Cmax ) of 155 (122-171) ng/mL, time of maximal concentration (Tmax ) of 1 (1-1.5) hour, terminal elimination half-life of 66.6 (57.3-102.6) hour after initial dose, and area under the curve (AUC) of 5,025 (4,160-5,345) ng*h/mL. One partial response was observed, and median progression-free survival was 51 days (range, 47-137). CONCLUSION This drug combination has a favorable safety profile and antitumor activity in patients with fulvestrant-resistant advanced ER+ breast cancer that justifies future testing.
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Affiliation(s)
- Gary Schwartz
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Kevin Shee
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Bianca Romo
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Jonathan Marotti
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | | | - Lionel Lewis
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Todd Miller
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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Delforge M, Vlayen S, Kint N. Immunomodulators in newly diagnosed multiple myeloma: current and future concepts. Expert Rev Hematol 2021; 14:365-376. [PMID: 33733978 DOI: 10.1080/17474086.2021.1905513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Impressive therapeutic progress is being made in the management of multiple myeloma (MM). his progress is related to the introduction of several new classes of therapeutic agents including proteasome inhibitors, immunomodulatory drugs (IMiDs) and monoclonal antibodies (MoAbs).Areas covered: In this manuscript, the role of the IMiDs thalidomide and lenalidomide in the management of newly diagnosed MM is discussed. The mode of action of IMiDs and their role in the management of newly diagnosed MM patients is highlighted. In addition, clinical data on how MoAbs such as the anti-CD38 antibody daratumumab can further increase the efficacy of IMiD-based first-line anti-myeloma regimens are provided. A database search in PubMed was carried out.Expert Opinion: Immunomodulation has become an indispensable part of successful anti-myeloma regimens both at relapse and at diagnosis. The combination of lenalidomide plus dexamethasone with an anti-CD38 MoAb such as daratumumab and a proteasome inhibitor such as bortezomib is currently one of the most potent first-line treatment regimens for MM. A better understanding on how IMiDs synergize with existing and new anti-myeloma treatments can further improve the outcome for patients. Optimal first-line therapy will continue to benefit the long-term outcome of a growing population of young and elderly MM patients.
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Affiliation(s)
- Michel Delforge
- Department of Hematology, University of Leuven and Leuven Cancer Institute, Leuven, Belgium
| | - Sophie Vlayen
- Department of Regeneration and Development, University of Leuven, Leuven, Belgium
| | - Nicolas Kint
- Department of Hematology, University of Leuven and Leuven Cancer Institute, Leuven, Belgium
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9
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Oral ixazomib, lenalidomide, and dexamethasone for transplant-ineligible patients with newly diagnosed multiple myeloma. Blood 2021; 137:3616-3628. [PMID: 33763699 PMCID: PMC8462404 DOI: 10.1182/blood.2020008787] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/05/2021] [Indexed: 01/14/2023] Open
Abstract
Addition of ixazomib to Rd in nontransplant NDMM patients resulted in a nonstatistically significant increase in PFS (HR, 0.830; P = .073). Ixazomib-Rd is a feasible and tolerable all-oral triplet regimen in this setting, with a well-characterized and manageable safety profile.
Continuous lenalidomide-dexamethasone (Rd)-based regimens are among the standards of care in transplant-ineligible newly diagnosed multiple myeloma (NDMM) patients. The oral proteasome inhibitor ixazomib is suitable for continuous dosing, with predictable, manageable toxicities. In the double-blind, placebo-controlled TOURMALINE-MM2 trial, transplant-ineligible NDMM patients were randomized to ixazomib 4 mg (n = 351) or placebo (n = 354) plus Rd. After 18 cycles, dexamethasone was discontinued and treatment was continued using reduced-dose ixazomib (3 mg) and lenalidomide (10 mg) until progression/toxicity. The primary endpoint was progression-free survival (PFS). Median PFS was 35.3 vs 21.8 months with ixazomib-Rd vs placebo-Rd, respectively (hazard ratio [HR], 0.830; 95% confidence interval, 0.676-1.018; P = .073; median follow-up, 53.3 and 55.8 months). Complete (26% vs 14%; odds ratio [OR], 2.10; P < .001) and ≥ very good partial response (63% vs 48%; OR, 1.87; P < .001) rates were higher with ixazomib-Rd vs placebo-Rd. In a prespecified high-risk cytogenetics subgroup, median PFS was 23.8 vs 18.0 months (HR, 0.690; P = .019). Overall, treatment-emergent adverse events (TEAEs) were mostly grade 1/2. With ixazomib-Rd vs placebo-Rd, 88% vs 81% of patients experienced grade ≥3 TEAEs, 66% vs 62% serious TEAEs, and 35% vs 27% TEAEs resulting in regimen discontinuation; 8% vs 6% died on study. Addition of ixazomib to Rd was tolerable with no new safety signals and led to a clinically meaningful PFS benefit of 13.5 months. Ixazomib-Rd is a feasible option for certain patients who can benefit from an all-oral triplet combination. This trial was registered at www.clinicaltrials.gov as #NCT01850524.
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Bal S, Giri S, Godby KN, Costa LJ. New regimens and directions in the management of newly diagnosed multiple myeloma. Am J Hematol 2021; 96:367-378. [PMID: 33393136 DOI: 10.1002/ajh.26080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/19/2020] [Accepted: 12/20/2020] [Indexed: 12/20/2022]
Abstract
The introduction of novel agents over the last decade has rapidly expanded the therapeutic landscape of multiple myeloma (MM) for both transplant-eligible and transplant-ineligible patients. The assessment of minimal residual disease (MRD) by next-generation flow cytometry or next-generation sequencing is established as a powerful predictor of long-term outcomes. The use of MRD in response-adapted clinical trials may provide opportunities to identify candidates for treatment escalation and de-escalation. Agents with proven activity in the relapsed and refractory setting are being studied in the management of high-risk newly diagnosed MM (NDMM). Here, we summarize the most recent clinical trials that have led to the current paradigms in the management of NDMM. We also discuss how novel agents could be incorporated in the newly diagnosed setting and potential clinical trial designs that could leverage MRD information with the goal of treatment optimization.
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Affiliation(s)
- Susan Bal
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
| | - Smith Giri
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
| | - Kelly N. Godby
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
| | - Luciano J. Costa
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
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11
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Alsina M, Landgren O, Raje N, Niesvizky R, Bensinger WI, Berdeja JG, Kovacsovics T, Vesole DH, Fang B, Kimball AS, Siegel DS. A phase 1b study of once-weekly carfilzomib combined with lenalidomide and dexamethasone in patients with newly diagnosed multiple myeloma. Am J Hematol 2021; 96:226-233. [PMID: 33125764 PMCID: PMC7898514 DOI: 10.1002/ajh.26041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 12/31/2022]
Abstract
Twice‐weekly carfilzomib with lenalidomide‐dexamethasone (Rd) is an effective regimen for newly diagnosed multiple myeloma (NDMM). Here we evaluated once‐weekly carfilzomib with Rd (once‐weekly KRd) in NDMM patients. The NDMM patients were enrolled regardless of transplant eligibility. Patients received carfilzomib on days 1, 8, and 15; lenalidomide 25 mg on days 1‐21; and dexamethasone 40 mg on carfilzomib days (also day 22 for cycles 1‐8) for ≤18, 28‐day cycles. Enrollment initiated in a carfilzomib 20/70 mg/m2 (20 mg/m2 on cycle one, day 1; 70 mg/m2 thereafter) NDMM dose‐expansion arm, which was suspended because of serious adverse events. After evaluation of dose‐limiting toxicities in a two‐step‐up dose‐evaluation cohort, an NDMM dose‐expansion arm (carfilzomib 20/56 mg/m2) was opened. Fifty‐one NDMM patients were enrolled in dose‐finding and dose‐expansion cohorts. Results are presented for the carfilzomib 56 mg/m2 NDMM dose‐expansion arm (n = 33). The grade ≥ 3 treatment‐emergent AE (TEAE) rate was 63.6%. Twenty‐five patients underwent stem cell collection; 18 proceeded to auto stem cell transplant, and five resumed KRd on study after autoSCT. The overall response rate (ORR) based on best overall response by cycle four was 97.0% (≥very good partial response [VGPR], 69.7%) in the NDMM 20/56 mg/m2 cohort. In patients who did not receive autoSCT (n = 15), the median number of cycles was 16.0; ORR was 93.3% (≥VGPR, 80.0%). At a median follow‐up of 8.1 months, median progression‐free survival was not reached. Once‐weekly KRd (carfilzomib 56 mg/m2) had a favorable safety profile and promising activity in NDMM, supporting the use of this regimen in this setting.
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Affiliation(s)
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center New York New York USA
| | - Noopur Raje
- Massachusetts General Hospital Cancer Center Boston Massachusetts USA
| | - Ruben Niesvizky
- Weill Cornell Medicine New York Presbyterian Hospital New York New York USA
| | | | | | - Tibor Kovacsovics
- Huntsman Cancer Institute at the University of Utah School of Medicine Salt Lake City Utah USA
| | - David H. Vesole
- John Theurer Cancer Center at Hackensack University Medical Center Hackensack New Jersey USA
- Medstar Georgetown University Hospital Washington District of Columbia USA
| | - Belle Fang
- Amgen, Inc. Thousand Oaks California USA
| | | | - David S. Siegel
- John Theurer Cancer Center at Hackensack University Medical Center Hackensack New Jersey USA
- Medstar Georgetown University Hospital Washington District of Columbia USA
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12
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Becnel MR, Lee HC. The role of belantamab mafodotin for patients with relapsed and/or refractory multiple myeloma. Ther Adv Hematol 2020; 11:2040620720979813. [PMID: 33403093 PMCID: PMC7739070 DOI: 10.1177/2040620720979813] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022] Open
Abstract
Belantamab mafodotin (belamaf) is a first-in-class anti-B-cell maturation antigen (BCMA) antibody-drug conjugate (ADC) that recently gained regulatory approval for the treatment of relapsed and/or refractory multiple myeloma (RRMM) patients who have received at least four prior therapies including an anti-CD38 monoclonal antibody (mAb), a proteasome inhibitor (PI), and an immunomodulatory drug (IMiD). As the first BCMA-targeted therapy to be approved in multiple myeloma along with its "off-the-shelf" outpatient administration, belamaf addresses a significant unmet need in RRMM that is refractory to IMiD, PI, and anti-CD38 mAb therapy, otherwise known as triple-class refractory myeloma. Belamaf is also associated with frequent corneal ocular adverse events, which represents a unique toxicity in multiple myeloma therapeutics, and its administration requires a multidisciplinary approach with oncologists and eye care specialists to safely and effectively manage patients on belamaf therapy. In this review, we discuss the preclinical and clinical data leading to the regulatory approval of belamaf, the monitoring and mitigation strategies of corneal ocular adverse events, and its current and future role in the RRMM treatment landscape.
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Affiliation(s)
- Melody R Becnel
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hans C Lee
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 429, Houston, TX, 77030, USA
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13
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Zweegman S, Stege CA, Haukas E, Schjesvold FH, Levin MD, Waage A, Leys RB, Klein SK, Szatkowski D, Axelsson P, Do TH, Knut-Bojanowska D, van der Spek E, Svirskaite A, Klostergaard A, Salomo M, Blimark C, Ypma PF, Mellqvist UH, Poddighe PJ, Stevens-Kroef M, van de Donk NW, Sonneveld P, Hansson M, van der Holt B, Abildgaard N. Ixazomib-Thalidomide-low dose dexamethasone induction followed by maintenance therapy with ixazomib or placebo in newly diagnosed multiple myeloma patients not eligible for autologous stem cell transplantation; results from the randomized phase II HOVON-126/NMSG 21.13 trial. Haematologica 2020; 105:2879-2882. [PMID: 33256392 PMCID: PMC7716358 DOI: 10.3324/haematol.2019.240374] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Claudia A.M. Stege
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Einar Haukas
- Stavanger University Hospital-Rogaland Hospital, Stavanger, Norway
| | | | | | - Anders Waage
- St Olavs Hospital and Norwegian University of Science, Trondheim, Norway
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Pino J. Poddighe
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Niels W.C.J. van de Donk
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Pieter Sonneveld
- Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands and
| | | | | | - Niels Abildgaard
- Hematology Research Unit and Academy of Geriatric Cancer Research, Odense University Hospital and University of Southern Denmark, Denmark
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14
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Kazandjian D, Mo CC, Landgren O, Richardson PG. The role of high-dose melphalan with autologous stem-cell transplant in multiple myeloma: is it time for a paradigm shift? Br J Haematol 2020; 191:692-703. [PMID: 32501533 PMCID: PMC8505046 DOI: 10.1111/bjh.16764] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023]
Abstract
Recent advances in multiple myeloma include numerous approvals of novel therapies with unprecedented efficacy, a rapid and sustained tempo of new drug development, and further refinements to prognostication to include minimal residual disease (MRD) testing and improved risk stratification. The upfront use of immunomodulatory drug and proteasome inhibitor combinations followed by maintenance has resulted in transformative clinical benefit. Four-drug regimens incorporating monoclonal antibodies are reporting unprecedented rates of complete response and MRD negativity in the absence of intensification. In the context of these advances, the added value of high-dose melphalan with autologous stem-cell transplant (HDM-ASCT) is a key question. From a safety standpoint, HDM-ASCT is associated with both acute toxicities that reduce quality of life and long-term toxicities that may limit life expectancy for some patients. The present review discusses the recent advances in induction therapy, the impact of these advances on HDM-ASCT, the evolving role of MRD testing and the short- and long-term risks of HDM-ASCT. Recognising that prospective data remains limited, we suggest that HDM-ASCT not be considered mandatory for eligible newly diagnosed patients who are treated with highly efficacious regimens and achieve deep responses, but rather be held in reserve without early exposure to the clinical and genomic toxicity inherent to this approach.
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Affiliation(s)
- Dickran Kazandjian
- Multiple Myeloma Program, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Clifton C. Mo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Multiple Myeloma Center, Boston, MA
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Paul G. Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Multiple Myeloma Center, Boston, MA, USA
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15
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Three Drug Combinations in the Treatment of Fit Elderly Multiple Myeloma Patients. J Clin Med 2020; 9:jcm9113554. [PMID: 33158277 PMCID: PMC7694236 DOI: 10.3390/jcm9113554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 01/06/2023] Open
Abstract
The multiple myeloma (MM) non transplant eligible (NTE) population is growing in line with the aging of the population in Western countries. Historically, this population has been known for having a greater risk of treatment related toxicity, and therefore drug development was slow and rather oriented towards the improvement of safety profile than the optimization of disease control. However, NTE MM patients, at least for the fit/non frail patients in recent years, seemed to have benefited more from a less palliative care to improve the depth of response and then prolong survival. NTE MM being a quite heterogeneous population, there are still a number of groups of patients that are in need of more efficient therapy, avoiding unnecessary toxicity, particularly for the frail patients. The use of triplet regimen with a melphalan-prednisone (MP) backbone has long been the standard of care for NTE MM, often dedicated to non-frail patients. New standards of care, triplet, and even quadruplet combinations, are emerging on the basis of the MP backbone but also on the more recently approved lenalidomide-dexamethasone (Rd) backbone. These developments were largely possible in line with the development of antibody-based immunotherapies (IT) in MM. The objective to improve outcomes with an acceptable safety profile will see other key therapeutic developments such as the dropping of dexamethasone early in the disease course or various attempts to allow permanent treatment discontinuation with a prolonged disease control. In that context, it is possible that immunomonitoring, minimal residual disease (MRD), and genomic risk-adaptation will become key elements of the treatment decisions on triplet-based regimens.
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16
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Ling Y, Li R, Zhong J, Zhao Y, Chen Z. Ixazomib-associated cardiovascular adverse events in multiple myeloma: a systematic review and meta-analysis. Drug Chem Toxicol 2020; 45:1443-1448. [PMID: 33108916 DOI: 10.1080/01480545.2020.1835945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Prolonged survival and expanded treatment options in myeloma patients have led to adverse events associated with treatment getting increased attention. This systematic review and meta-analysis aimed to determine the incidence of ixazomib-associated cardiovascular adverse events (CVAEs) and to compare the rates of ixazomib-associated CVAEs and related therapies. CVAEs were defined as heart failure, hypertension, ischemia, and arrhythmia. All-grade and high-grade CVAEs and study characteristics were recorded. A total of 266 potentially relevant articles were identified, and 246 were excluded after review. Twenty studies of 1715 patients with multiple myeloma were thus considered in this study. The estimated rates of all-grade and high-grade ixazomib associated CVAEs were 11.2 and 3.7%, respectively. Subgroup analysis showed that median age ≥65 years, none phase 1 trial and combination regimen were associated with higher rates of high-grade ixazomib associated CVAEs. Ixazomib was association with increased high-grade CVAEs risk (RR = 1.679, 95% CI: 1.078-2.615, P = 0.022). Ixazomib was associated with a significant rate of high-grade CVAEs. Future studies are needed to identify patients at high risk for high-grade CVAEs.
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Affiliation(s)
- Yiwen Ling
- Department of Hematology, First People's Hospital of Foshan, Foshan, China
| | - Rui Li
- Department of Internal Medicine, Foshan Maternal and Child Health Hospital, Foshan, China
| | - Jiankai Zhong
- Department of Cardiology, Shunde Hospital, Southern Medical University, Guangdong, China
| | - Ying Zhao
- Department of Hematology, First People's Hospital of Foshan, Foshan, China
| | - Zhuowen Chen
- Department of Hematology, First People's Hospital of Foshan, Foshan, China
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17
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Tundo GR, Sbardella D, Santoro AM, Coletta A, Oddone F, Grasso G, Milardi D, Lacal PM, Marini S, Purrello R, Graziani G, Coletta M. The proteasome as a druggable target with multiple therapeutic potentialities: Cutting and non-cutting edges. Pharmacol Ther 2020; 213:107579. [PMID: 32442437 PMCID: PMC7236745 DOI: 10.1016/j.pharmthera.2020.107579] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 01/10/2023]
Abstract
Ubiquitin Proteasome System (UPS) is an adaptable and finely tuned system that sustains proteostasis network under a large variety of physiopathological conditions. Its dysregulation is often associated with the onset and progression of human diseases; hence, UPS modulation has emerged as a promising new avenue for the development of treatments of several relevant pathologies, such as cancer and neurodegeneration. The clinical interest in proteasome inhibition has considerably increased after the FDA approval in 2003 of bortezomib for relapsed/refractory multiple myeloma, which is now used in the front-line setting. Thereafter, two other proteasome inhibitors (carfilzomib and ixazomib), designed to overcome resistance to bortezomib, have been approved for treatment-experienced patients, and a variety of novel inhibitors are currently under preclinical and clinical investigation not only for haematological malignancies but also for solid tumours. However, since UPS collapse leads to toxic misfolded proteins accumulation, proteasome is attracting even more interest as a target for the care of neurodegenerative diseases, which are sustained by UPS impairment. Thus, conceptually, proteasome activation represents an innovative and largely unexplored target for drug development. According to a multidisciplinary approach, spanning from chemistry, biochemistry, molecular biology to pharmacology, this review will summarize the most recent available literature regarding different aspects of proteasome biology, focusing on structure, function and regulation of proteasome in physiological and pathological processes, mostly cancer and neurodegenerative diseases, connecting biochemical features and clinical studies of proteasome targeting drugs.
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Affiliation(s)
- G R Tundo
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy.
| | | | - A M Santoro
- CNR, Institute of Crystallography, Catania, Italy
| | - A Coletta
- Department of Chemistry, University of Aarhus, Aarhus, Denmark
| | - F Oddone
- IRCCS-Fondazione Bietti, Rome, Italy
| | - G Grasso
- Department of Chemical Sciences, University of Catania, Catania, Italy
| | - D Milardi
- CNR, Institute of Crystallography, Catania, Italy
| | - P M Lacal
- Laboratory of Molecular Oncology, IDI-IRCCS, Rome, Italy
| | - S Marini
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - R Purrello
- Department of Chemical Sciences, University of Catania, Catania, Italy
| | - G Graziani
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - M Coletta
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy.
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18
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Abstract
INTRODUCTION The survival of multiple myeloma patients is increasing due to new medications, the widespread implementation of autologous stem cell transplantation and better supportive treatments. The controversy surrounding post-transplant treatment is debated due to a lack of large randomized trials comparing the different treatment modalities. The questions for each proposed treatment are whether it improves outcomes, has low cumulative toxicities and is easy to administer. Areas covered: In this review, we have summarized the current data on maintenance therapy in newly diagnosed MM patients undergoing ASCT, focusing on bortezomib, thalidomide and lenalidomide as well as newer agents Expert opinion: Maintenance treatment has been shown to deepen and prolong responses and increase PFS and OS. Lenalidomide is approved for maintenance and guidelines recommend its use post ASCT. Ixazomib has recently been reported to improve PFS.
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Affiliation(s)
- Iuliana Vaxman
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA.,b Institute of Hematology, Davidoff Cancer Center , Rabin Medical Center Petah , Tikva , Israel.,c Israel Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Morie Gertz
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
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19
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Abstract
PURPOSE OF REVIEW While the traditional gold standard for demonstrating clinical benefit of a therapy has been to show prolongation of overall survival (OS), there are multiple factors which can hinder the use of OS as a primary endpoint in randomized clinical trials (RCTs). Here, we analyze recent myeloma RCTs and evaluate the issues relevant to current and future myeloma RCT design. RECENT FINDINGS A review of recent phase III RCTs that led to approval of new agents/combinations reveals that none were designed with OS as the primary endpoint, but instead utilized time to progression (TTP) or progression-free survival (PFS). These studies illuminate the inherent difficulties of designing trials with the primary endpoint of OS/PFS in a disease characterized by increasingly prolonged survival times, availability of effective salvage therapies, and competing events such as co-morbid conditions. Alternative primary endpoints other than OS or PFS need to be developed for future myeloma RCTs. Validated surrogate endpoints with novel clinical trial designs will help improve the feasibility of conducting comparative clinical trials in a timely manner.
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Optimizing Immunomodulatory Drug With Proteasome Inhibitor Combinations in Newly Diagnosed Multiple Myeloma. ACTA ACUST UNITED AC 2020; 25:2-10. [PMID: 30694854 DOI: 10.1097/ppo.0000000000000348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In the modern era of multiple myeloma therapeutics, proteasome inhibitor (PI) and immunomodulatory drugs (IMiDs) have replaced chemotherapy regimens for newly diagnosed multiple myeloma patients. Treatment combinations that comprise both first- and next-generation PIs, including bortezomib, carfilzomib, and ixazomib and IMiDs, including thalidomide and lenalidomide, have been evaluated in phases II and III clinical trials and have shown significant efficacy with manageable toxicity profiles. Bortezomib or carfilzomib with lenalidomide and dexamethasone (VRD and KRD) are the most promising regimens resulting in significant survival improvement. Disease and patient characteristics should lead the individualization of treatment, with the eligibility for autologous transplant being of principal importance. The addition of a monoclonal antibody to PI with IMiD combinations is currently under clinical investigation and may lead to further treatment optimization.
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21
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Dimopoulos MA, Jakubowiak AJ, McCarthy PL, Orlowski RZ, Attal M, Bladé J, Goldschmidt H, Weisel KC, Ramasamy K, Zweegman S, Spencer A, Huang JSY, Lu J, Sunami K, Iida S, Chng WJ, Holstein SA, Rocci A, Skacel T, Labotka R, Palumbo A, Anderson KC. Developments in continuous therapy and maintenance treatment approaches for patients with newly diagnosed multiple myeloma. Blood Cancer J 2020; 10:17. [PMID: 32054831 PMCID: PMC7018731 DOI: 10.1038/s41408-020-0273-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/13/2019] [Accepted: 09/18/2019] [Indexed: 12/30/2022] Open
Abstract
The evolving paradigm of continuous therapy and maintenance treatment approaches in multiple myeloma (MM) offers prolonged disease control and improved outcomes compared to traditional fixed-duration approaches. Potential benefits of long-term strategies include sustained control of disease symptoms, as well as continued cytoreduction and clonal control, leading to unmeasurable residual disease and the possibility of transforming MM into a chronic or functionally curable condition. "Continuous therapy" commonly refers to administering a doublet or triplet regimen until disease progression, whereas maintenance approaches typically involve single-agent or doublet treatment following more intensive prior therapy with autologous stem cell transplant (ASCT) or doublet, triplet, or even quadruplet induction therapy. However, the requirements for agents and regimens within these contexts are similar: treatments must be tolerable for a prolonged period of time, should not be associated with cumulative or chronic toxicity, should not adversely affect patients' quality of life, should ideally be convenient with a minimal treatment burden for patients, and should not impact the feasibility or efficacy of subsequent treatment at relapse. Multiple agents have been and are being investigated as long-term options in the treatment of newly diagnosed MM (NDMM), including the immunomodulatory drugs lenalidomide and thalidomide, the proteasome inhibitors bortezomib, carfilzomib, and ixazomib, and the monoclonal antibodies daratumumab, elotuzumab, and isatuximab. Here we review the latest results with long-term therapy approaches in three different settings in NDMM: (1) maintenance treatment post ASCT; (2) continuous frontline therapy in nontransplant patients; (3) maintenance treatment post-frontline therapy in the nontransplant setting. We also discuss evidence from key phase 3 trials. Our review demonstrates how the paradigm of long-term treatment is increasingly well-established across NDMM treatment settings, potentially resulting in further improvements in patient outcomes, and highlights key clinical issues that will need to be addressed in order to provide optimal benefit.
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Affiliation(s)
- Meletios A Dimopoulos
- Hematology & Medical Oncology, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | | | | | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michel Attal
- Hematology Department, University Hospital Purpan, Toulouse, France
| | - Joan Bladé
- Hematology Department, Hospital Clinic, Institut de Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Medical Hospital and National Center of Tumor Diseases, University of Heidelberg, Heidelberg, Germany
| | - Katja C Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Sonja Zweegman
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health-Monash University, Melbourne, Australia
| | | | - Jin Lu
- Department of Hematology, Peking University People's Hospital and Peking University Institute of Hematology, Beijing, China
| | - Kazutaka Sunami
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Wee-Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, and Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Sarah A Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Alberto Rocci
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, School of Medical Science, Division of Cancer Science, University of Manchester, Manchester, UK
| | - Tomas Skacel
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Richard Labotka
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Antonio Palumbo
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
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22
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Chakraborty R, Bin Riaz I, Malik SU, Marneni N, Mejia Garcia A, Anwer F, Khorana AA, Rajkumar SV, Kumar S, Murad MH, Wang Z, Khan SU, Majhail NS. Venous thromboembolism risk with contemporary lenalidomide-based regimens despite thromboprophylaxis in multiple myeloma: A systematic review and meta-analysis. Cancer 2020; 126:1640-1650. [PMID: 31913498 DOI: 10.1002/cncr.32682] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/23/2019] [Accepted: 11/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Thromboprophylaxis is routinely used with lenalidomide-based regimens in multiple myeloma because of a substantial risk of venous thromboembolism (VTE). However, little is known about the incidence of VTE with contemporary lenalidomide-based regimens. The objective of the current study was to estimate the incidence of VTE despite thromboprophylaxis with currently used lenalidomide-based regimens in patients with myeloma. METHODS The Ovid MEDLINE, Embase, and Cochrane databases were queried from study inception to January 2019 for keywords to cover the following concepts: "lenalidomide," "venous thromboembolism," and "multiple myeloma." Phase 1, 2, and 3 clinical trials evaluating lenalidomide-based regimens with thromboprophylaxis were included. The pooled incidence rate of VTE was estimated using a random-effects model. RESULTS The search generated 1372 citations, with 51 clinical trials and 9069 patients included for analysis. The most common thromboprophylaxis agents were aspirin, low-molecular-weight heparin or warfarin, administered either per risk-stratification or at investigators' discretion. The pooled incidence of VTE in trials of patients who had newly diagnosed and relapsed/refractory myeloma was 6.2% (95% CI, 5.4%-7.1%) over median treatment durations ranging from 2 to 34 cycles, which translated into 1.2 VTE events per 100 patient-cycles (95% CI, 0.9-1.7 VTE events per 100 patient-cycles). Among contemporary regimens, the risk of VTE was low with combined lenalidomide and low-dose dexamethasone (0.2 [95% CI, 0.1-0.6] events/100 patient-cycles) and lenalidomide maintenance (0.0 [95% CI, 0.0-0.7] events per 100 patient-cycles). VTE risk was higher with combined lenalidomide and low-dose dexamethasone plus proteasome inhibitors (1.3 [95% CI, 0.7-2.3] events per 100 patient-cycles). CONCLUSIONS Despite adequate thromboprophylaxis, lenalidomide-based regimens have a substantial risk of VTE in controlled clinical trial settings. Further studies are needed on new thromboprophylaxis strategies with regimens that have a high VTE risk.
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Affiliation(s)
| | - Irbaz Bin Riaz
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Saad Ullah Malik
- Department of Hematology and Oncology, University of Arizona, Tucson, Arizona
| | | | | | - Faiz Anwer
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Alok A Khorana
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Zhen Wang
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Safi U Khan
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
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23
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Baljevic M, Orlowski RZ. Pharmacodynamics and pharmacokinetics of proteasome inhibitors for the treatment of multiple myeloma. Expert Opin Drug Metab Toxicol 2019; 15:459-473. [PMID: 31104525 PMCID: PMC10393465 DOI: 10.1080/17425255.2019.1621839] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/17/2019] [Indexed: 12/18/2022]
Abstract
Introduction: Multiple myeloma (MM) is the second most commonly diagnosed hematologic malignancy and has an increasing incidence and prevalence globally, and proteasome inhibitors (PIs) form the backbone of some of our most effective regimens for all phases of this disease in fit and frail patients. Areas covered: Strong understanding of the proteasome complex is increasingly important as the rapid development of new PIs and innovative myeloma therapies complicate the use of old and new combination regimens. We focus herein on the pharmacodynamics and pharmacokinetics of the approved PIs and others in development, including their safety and efficacy in corresponding clinical studies. Expert opinion: Advancements such as the first oral PI, ixazomib, with a more convenient route of administration and improved toxicity profile led to an improved quality of life, patient compliance, and all-oral combination regimens which are efficacious for long-term management of standard and high-risk MM. Novel pan-PIs, such as marizomib, hold the promise of superior clinical activity due to irreversible targeting of all multicatalytic proteinase complex subunits. Development of clinically validated biomarkers of PI sensitivity/resistance is required to inform utilization of the most optimal and effective, rationally targeted PI treatments for all MM patients.
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Affiliation(s)
- Muhamed Baljevic
- The University of Nebraska Medical Center, Division of Hematology and Oncology, Omaha, NE, USA
| | - Robert Z. Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Paul B, Lipe B, Ocio EM, Usmani SZ. Induction Therapy for Newly Diagnosed Multiple Myeloma. Am Soc Clin Oncol Educ Book 2019; 39:e176-e186. [PMID: 31099624 DOI: 10.1200/edbk_238527] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The frontline therapy for newly diagnosed multiple myeloma (MM) has continued to evolve over the last 10 years. There has been a growing emphasis on achieving the best depth of response in the context of minimal residual disease negativity, given its prognostic correlation with superior overall survival. Another important area of emphasis has been to improve prognostication and staging by including information on disease biology. There also a growing appreciation of global differences in drug access and patterns of care. The current review explores each of these areas and how best to incorporate the emerging induction regimens in to schema of MM therapy.
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Affiliation(s)
| | - Brea Lipe
- 2 Wilmont Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | - Enrique M Ocio
- 3 University Hospital Marqués de Valdecilla (IDIVAL), University of Cantabria, Santander, Spain
| | - Saad Z Usmani
- 4 Plasma Cell Disorders Division, Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC
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25
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Dimopoulos MA, Laubach JP, Echeveste Gutierrez MA, Grzasko N, Hofmeister CC, San-Miguel JF, Kumar S, Labotka R, Lu V, Berg D, Byrne C, Teng Z, Liu G, van de Velde H, Richardson PG. Ixazomib maintenance therapy in newly diagnosed multiple myeloma: An integrated analysis of four phase I/II studies. Eur J Haematol 2019; 102:494-503. [PMID: 30943323 DOI: 10.1111/ejh.13231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of maintenance therapy with the oral proteasome inhibitor ixazomib in patients with newly diagnosed multiple myeloma (NDMM) not undergoing transplantation. METHODS Data were pooled from four NDMM phase I/II studies; patients received induction therapy with once- or twice-weekly ixazomib plus lenalidomide-dexamethasone (IRd), melphalan-prednisone (IMP), or cyclophosphamide-dexamethasone (ICd), followed by single-agent ixazomib maintenance, given at the last tolerated dose during induction, until disease progression, death, or unacceptable toxicity. RESULTS A total of 121 patients achieved stable disease or better after induction (weekly IRd, n = 25; twice-weekly IRd, n = 18; weekly or twice-weekly IMP, n = 35; weekly ICd, n = 43) and received ≥ 1 dose of ixazomib maintenance. Grade ≥ 3 drug-related adverse events occurred in 24% of patients during maintenance; each event was reported in ≤2% of patients. Rates of complete response were 22% after induction and 35% after maintenance. A total of 28 patients (23%) improved their response during maintenance. CONCLUSIONS Ixazomib maintenance following ixazomib-based induction is associated with deepening of responses and a positive safety profile with no cumulative toxicity in patients with NDMM not undergoing transplantation, suggesting that ixazomib is feasible for long-term administration. Phase III investigation of ixazomib maintenance is ongoing.
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Affiliation(s)
- Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Norbert Grzasko
- Department of Hematology, St. John's Cancer Center and Medical University of Lublin, Lublin, Poland
| | - Craig C Hofmeister
- The Ohio State University, Columbus, Ohio.,Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jesus F San-Miguel
- Clinica Universidad de Navarra, Centro Investigación Medica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona, Spain
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Vickie Lu
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
| | - Deborah Berg
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
| | | | - Zhaoyang Teng
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
| | - Guohui Liu
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
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26
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Smolewski P, Rydygier D. Ixazomib: an investigational drug for the treatment of lymphoproliferative disorders. Expert Opin Investig Drugs 2019; 28:421-433. [DOI: 10.1080/13543784.2019.1596258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Piotr Smolewski
- Department of Experimental Hematology, Medical University of Lodz, Lodz,
Poland
| | - Dominika Rydygier
- Department of Experimental Hematology, Medical University of Lodz, Lodz,
Poland
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27
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Gupta N, Hanley MJ, Xia C, Labotka R, Harvey RD, Venkatakrishnan K. Clinical Pharmacology of Ixazomib: The First Oral Proteasome Inhibitor. Clin Pharmacokinet 2019; 58:431-449. [PMID: 30117017 PMCID: PMC6397141 DOI: 10.1007/s40262-018-0702-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Ixazomib, the first oral proteasome inhibitor, is approved in combination with lenalidomide and dexamethasone for the treatment of patients with multiple myeloma (MM) who have received at least one prior therapy. Ixazomib is a selective, potent, and reversible inhibitor of the 20S proteasome, and preferentially binds to and inhibits the β5 chymotrypsin-like proteolytic site. Ixazomib absorption is rapid, with a median time to reach maximum plasma concentration of approximately 1 h post-dose. Ixazomib pharmacokinetics (PK) are adequately described by a three-compartment model (terminal half-life of 9.5 days) with first-order linear absorption (oral bioavailability of 58%). Plasma exposures of ixazomib increase in a dose-proportional manner. A high-fat meal decreases both the rate and extent of ixazomib absorption, supporting administration on an empty stomach. Population PK analyses demonstrated that no dose adjustment is required based on age, body size/weight, race, sex, mild-to-moderate renal impairment, or mild hepatic impairment. Results from dedicated studies indicate that a reduced starting dose (from 4 to 3 mg) is appropriate for patients with severe renal impairment, end-stage renal disease requiring dialysis, or moderate-to-severe hepatic impairment. Non-cytochrome P450 (CYP)-mediated metabolism appears to be the major clearance mechanism for ixazomib. Drug-drug interaction studies have shown no meaningful effects of strong inhibitors of CYP3A on ixazomib PK; however, the strong inducer rifampin caused a clinically relevant reduction in ixazomib exposure, supporting the recommendation to avoid concomitant administration of ixazomib with strong CYP3A inducers. Exposure-response analyses of data from the phase III TOURMALINE-MM1 registrational study demonstrate a favorable benefit-risk profile for the approved dose and regimen of weekly ixazomib 4 mg on days 1, 8, and 15 of each 28-day cycle.
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Affiliation(s)
- Neeraj Gupta
- Millennium Pharmaceuticals, Inc., a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, 40 Landsdowne Street, Cambridge, MA, 02139, USA.
| | - Michael J Hanley
- Millennium Pharmaceuticals, Inc., a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, 40 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Cindy Xia
- Millennium Pharmaceuticals, Inc., a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, 40 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Richard Labotka
- Millennium Pharmaceuticals, Inc., a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, 40 Landsdowne Street, Cambridge, MA, 02139, USA
| | - R Donald Harvey
- Departments of Hematology and Medical Oncology and Pharmacology, Emory University School of Medicine, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Karthik Venkatakrishnan
- Millennium Pharmaceuticals, Inc., a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, 40 Landsdowne Street, Cambridge, MA, 02139, USA
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28
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Baz R, Naqvi SMH, Lee JH, Brayer J, Hillgruber N, Fridley BL, Shain KH, Sullivan DM, Alsina M. Lenalidomide-based response-adapted therapy for older adults without high risk myeloma. Br J Haematol 2018; 184:735-743. [PMID: 30548250 DOI: 10.1111/bjh.15700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/15/2018] [Indexed: 11/29/2022]
Abstract
Combined lenalidomide and dexamethasone is a standard-of-care therapy for the treatment of older adults with multiple myeloma. Lenalidomide monotherapy has not been evaluated in newly diagnosed myeloma patients. We conducted a phase II study, evaluating a response-adapted therapy for older adults newly diagnosed with multiple myeloma without high-risk features who were ineligible for high-dose therapy and stem cell transplant. Patients were started on single-agent lenalidomide, and low-dose dexamethasone was added in the event of progressive disease, in a response-adapted approach. The primary endpoint was progression-free survival (PFS), and the International Myeloma Working Group's uniform response criteria were used to assess response and progression. Twenty-seven patients were enrolled, and 20 (74%) experienced a partial response or better to this response-adapted therapy. After a median follow-up of 69 months, the median PFS was 36 months [95% confidence interval (CI), 29·8 to not reached], and the median overall survival was 65 months (95% CI, 35·3 to not reached). Grade 3/4 adverse events were mainly haematological in nature. This response-adapted therapy in this patient population is feasible and results in durable responses that compare favourably with concurrent lenalidomide and dexamethasone. These results should be validated in prospective studies.
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Affiliation(s)
- Rachid Baz
- Department of Malignant Haematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Jae-Hoon Lee
- Hematology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jason Brayer
- Department of Malignant Haematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nancy Hillgruber
- Department of Malignant Haematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brooke L Fridley
- Department of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kenneth H Shain
- Department of Malignant Haematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Daniel M Sullivan
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Melissa Alsina
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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29
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Richardson PG, Zweegman S, O’Donnell EK, Laubach JP, Raje N, Voorhees P, Ferrari RH, Skacel T, Kumar SK, Lonial S. Ixazomib for the treatment of multiple myeloma. Expert Opin Pharmacother 2018; 19:1949-1968. [DOI: 10.1080/14656566.2018.1528229] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Paul G. Richardson
- Division of Hematologic Malignancy, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Jacob P. Laubach
- Division of Hematologic Malignancy, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Noopur Raje
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Renda H. Ferrari
- Global Medical Affairs, Millennium Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Tomas Skacel
- Global Medical Affairs, Millennium Pharmaceuticals, Inc, Cambridge, MA, USA
| | | | - Sagar Lonial
- Hematology & Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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