1
|
Oliva EN, Riva M, Niscola P, Santini V, Breccia M, Giai V, Poloni A, Patriarca A, Crisà E, Capodanno I, Salutari P, Reda G, Cascavilla N, Ferrero D, Guarini A, Tripepi G, Iannì G, Russo E, Castelli A, Fattizzo B, Beltrami G, Bocchia M, Molteni A, Fenaux P, Germing U, Ricco A, Palumbo GA, Impera S, Di Renzo N, Rivellini F, Buccisano F, Stamatoullas-Bastard A, Liberati AM, Candoni A, Delfino IM, Arcadi MT, Cufari P, Rizzo L, Bova I, D'Errigo MG, Zini G, Latagliata R. Eltrombopag for Low-Risk Myelodysplastic Syndromes With Thrombocytopenia: Interim Results of a Phase II, Randomized, Placebo-Controlled Clinical Trial (EQOL-MDS). J Clin Oncol 2023; 41:4486-4496. [PMID: 37294914 PMCID: PMC10552995 DOI: 10.1200/jco.22.02699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/16/2023] [Accepted: 05/01/2023] [Indexed: 06/11/2023] Open
Abstract
PURPOSE In myelodysplastic syndromes (MDS), severe thrombocytopenia is associated with poor prognosis. This multicenter trial presents the second-part long-term efficacy and safety results of eltrombopag in patients with low-risk MDS and severe thrombocytopenia. METHODS In this single-blind, randomized, placebo-controlled, phase-II trial of adult patients with International Prognostic Scoring System low- or intermediate-1-risk MDS, patients with a stable platelet (PLT) count (<30 × 103/mm3) received eltrombopag or placebo until disease progression. Primary end points were duration of PLT response (PLT-R; calculated from the time of PLT-R to date of loss of PLT-R, defined as bleeding/PLT count <30 × 103/mm3 or last date in observation) and long-term safety and tolerability. Secondary end points included incidence and severity of bleeding, PLT transfusions, quality of life, leukemia-free survival, progression-free survival, overall survival and pharmacokinetics. RESULTS From 2011 to 2021, of 325 patients screened, 169 patients were randomly assigned oral eltrombopag (N = 112) or placebo (N = 57) at a starting dose of 50 mg once daily to maximum of 300 mg. PLT-R, with 25-week follow-up (IQR, 14-68) occurred in 47/111 (42.3%) eltrombopag patients versus 6/54 (11.1%) in placebo (odds ratio, 5.9; 95% CI, 2.3 to 14.9; P < .001). In eltrombopag patients, 12/47 (25.5%) lost the PLT-R, with cumulative thrombocytopenia relapse-free survival at 60 months of 63.6% (95% CI, 46.0 to 81.2). Clinically significant bleeding (WHO bleeding score ≥ 2) occurred less frequently in the eltrombopag arm than in the placebo group (incidence rate ratio, 0.54; 95% CI, 0.38 to 0.75; P = .0002). Although no difference in the frequency of grade 1-2 adverse events (AEs) was observed, a higher proportion of eltrombopag patients experienced grade 3-4 AEs (χ2 = 9.5, P = .002). AML evolution and/or disease progression occurred in 17% (for both) of eltrombopag and placebo patients with no difference in survival times. CONCLUSION Eltrombopag was effective and relatively safe in low-risk MDS with severe thrombocytopenia. This trial is registered with ClinicalTrials.gov identifier: NCT02912208 and EU Clinical Trials Register: EudraCT No. 2010-022890-33.
Collapse
Affiliation(s)
- Esther Natalie Oliva
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Marta Riva
- Dipartimento di Ematologia, Ospedale Niguarda Ca' Granda, Milano, Italy
| | | | - Valeria Santini
- U.O. di Ematologia, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | - Massimo Breccia
- Dipartimento di Ematologia Policlinico Umberto I, Università La Sapienza, Roma, Italy
| | - Valentina Giai
- S.C. a Direzione Universitaria di Ematologia A.O., SS. Antonio e Biagio e Cesare Arrigo Alessandria, Alessandria, Italy
| | - Antonella Poloni
- Clinica di Ematologia Azienda Ospedaliera Universitaria—Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Elena Crisà
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy
| | - Isabella Capodanno
- U.O. di Ematologia, A.U.S.L.-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Prassede Salutari
- Dipartimento Oncologico-Ematologico, Ospedale Civile Spirito Santo, Pescara, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Cascavilla
- U.O. Ematologia Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Dario Ferrero
- Dipartimento Biotecnologie Molecolari, Ematologia Universitaria A.O.U. Citta' della Salute e della Scienza di Torino, Turin, Italy
| | - Attilio Guarini
- U.O. Ematologia I.R.C.C.S. Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Giovanni Tripepi
- IFC-CNR Institute of Clinical Physiology, Reggio Calabria, Italy
| | | | - Emilio Russo
- Department of Pharmacology, University of Germaneto Catanzaro, Catanzaro, Italy
| | | | - Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Oncologia ed Emato-Oncologia, Università degli Studi di Milano, Milan, Italy
| | - Germana Beltrami
- U.O. Ematologia e terapie cellulari, IRCCS Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Monica Bocchia
- UOC Ematologia, Università di Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Pierre Fenaux
- Groupe Francais desmyélodysplasies (GFM), Paris, France
| | - Ulrich Germing
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Alessandra Ricco
- U.O. Ematologia con Trapianto, Azienda Ospedale Policlinicodi Bari, Bari, Italy
| | - Giuseppe A. Palumbo
- Dipartimento di Scienze Mediche Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”, University of Catania, Catania, Italy
| | - Stefana Impera
- U.O. C. Ematologia, A. O.ad Alta Specializzazione Ospedale Garibaldi Nesima, Catania, Italy
| | | | - Flavia Rivellini
- Divisione Ematologia, P.O. A. Tortora di Pagani-ASL Salerno, Pagani, Italy
| | - Francesco Buccisano
- Divisione di Biopatologia e Diagnostica per Immagini, Policlinico Universitario Tor Vergata, Rome, Italy
| | | | - Anna Marina Liberati
- S.C. Oncoematologia, Università degli Studi di Perugia A.O. Santa Maria, Terni, Italy
| | - Anna Candoni
- Divisione Ematologia, P.O. Santa Maria della Misericordia, A.S.U.F.C di Udine, Udine, Italy
| | - Ilaria Maria Delfino
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Maria Teresa Arcadi
- U.O. Farmacia Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Patrizia Cufari
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Lorenzo Rizzo
- Dipartimento di Ematologia, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Irene Bova
- U.O.S. di Genetica Medica Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Maria Grazia D'Errigo
- U.O.S. di Genetica Medica Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Gina Zini
- Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | |
Collapse
|
3
|
Mittelman M, Platzbecker U, Grosicki S, Lawniczek T, Zhu Z, Selleslag D. Long-Term Safety and Efficacy of Eltrombopag for Advanced Myelodysplastic Syndromes or Acute Myeloid Leukemia and Severe Thrombocytopenia: Results of the ASPIRE Extension Study. Acta Haematol 2023; 146:373-378. [PMID: 37231838 PMCID: PMC10614231 DOI: 10.1159/000531146] [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: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 05/27/2023]
Abstract
ASPIRE, a three-part, international, phase 2 trial (ClinicalTrials.gov identifier: NCT01440374), investigated eltrombopag efficacy and safety in patients with advanced myelodysplastic syndrome or acute myeloid leukemia and grade 4 thrombocytopenia (<25 × 109 platelets/L). Approximately 30-65% of patients in this open-label extension phase experienced clinically relevant thrombocytopenic events; no conclusions could be made regarding long-term efficacy (non-randomized design, no placebo control), and survival rates may simply reflect advanced disease. Long-term safety was consistent with the double-blind phase and contrasted with earlier SUPPORT study findings in higher-risk patients, suggesting that eltrombopag may have a role in treating thrombocytopenia in patients with low-/intermediate-risk myelodysplastic syndrome.
Collapse
Affiliation(s)
- Moshe Mittelman
- The Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Uwe Platzbecker
- Medical Clinic and Polyclinic I, Hematology and Cellular Therapy, University Hospital Leipzig, Leipzig, Germany
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | | | - Zewen Zhu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Dominik Selleslag
- Department of Hematology, AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| |
Collapse
|
4
|
Madanat YF, Xie Z, Zeidan AM. Advances in myelodysplastic syndromes: promising novel agents and combination strategies. Expert Rev Hematol 2023; 16:51-63. [PMID: 36620919 DOI: 10.1080/17474086.2023.2166923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) are heterogeneous group of clonal hematopoietic stem cell neoplasms that have limited approved treatment options. Multiple novel agents are currently being tested in a clinical trial setting. From a therapeutic perspective, MDS is generally divided into lower-risk and higher-risk disease. In this review, we summarize some of the most prominent novel agents currently in development. AREAS COVERED This review focuses on select clinical trials in both lower- and higher-risk MDS, elucidating the mechanisms of action and rationale for drug combinations and summarizing early safety and efficacy data using novel agents in MDS. EXPERT OPINION Advances in understanding the innate immune system, telomere biology, as well as genomic drivers of the disease have led to the development of multiple novel agents that are currently in late stages of clinical development in MDS. Imetelstat is being tested in lower-risk disease and the phase III clinical trial recently completed accrual. Magrolimab, sabatolimab, and venetoclax in addition to novel oral hypomethylating agents (HMA) are being investigated in higher-risk MDS. These advances will hopefully bring better treatment options to patients and lead to a shift in the treatment paradigm. Post HMA therapy remains an area of dire unmet need.
Collapse
Affiliation(s)
- Yazan F Madanat
- Simmons Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, New Haven, Connecticut, USA
| |
Collapse
|
6
|
Sternberg A, Boucher R, Coulthard HC, Raghavan M, Culligan D, Jackson A, Cargo C, Dennis M, Metzner M, O'Sullivan J, Moore R, Bowen D, Vyas P. Phase Ib study of eltrombopag and azacitidine in patients with high-risk myelodysplastic syndromes and related disorders (the ELASTIC study). Br J Haematol 2022; 199:222-229. [PMID: 35918828 DOI: 10.1111/bjh.18389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022]
Abstract
Treating adverse risk myelodysplastic syndromes with azacitidine exacerbates thrombocytopenia. We report a study of eltrombopag in combination with azacitidine using a 3 + 3 cohort design. Patients with baseline platelets of <150 × 109 /l received eltrombopag ranging from 25 to 300 mg. An 8-day pre-phase of eltrombopag was followed by two cycles of combined therapy. Amongst 31 patients, there were no dose-limiting toxicities. The maximum tolerated dose (MTD) was 300 mg. Transient increases in bone marrow blasts at day 8 were common but no patient had protocol-defined progression following eltrombopag monotherapy. Marrow response rates after three and six treatment cycles were 32% and 29% respectively. In all, 70% of patients treated below and 36% treated at the MTD achieved a modified International Working Group 2006 platelet response at the end of cycle two. Of the platelet transfusion independent patients at baseline, 67% treated at the MTD became transfusion dependent during the first two cycles of treatment. Apart from lack of disease progression, our findings concur with a previously reported Phase III study (A StUdy of eltromboPag in myelodysPlastic SyndrOmes Receiving azaciTidine [SUPPORT]). We conclude that eltrombopag/azacitidine is safe in terms of conventional measures defined by adverse-event reporting. However, in light of SUPPORT and our own descriptive findings regarding efficacy, further combination studies in high-risk disease should be considered with caution.
Collapse
Affiliation(s)
| | - Rebecca Boucher
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Manoj Raghavan
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Dominic Culligan
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Aimee Jackson
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Catherine Cargo
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Mike Dennis
- Department of Haematology, The Christie Hospital, Manchester, UK
| | - Marlen Metzner
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| | - Jennifer O'Sullivan
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| | - Rachel Moore
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| | - David Bowen
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Paresh Vyas
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
7
|
Bazinet A, Bravo GM. New Approaches to Myelodysplastic Syndrome Treatment. Curr Treat Options Oncol 2022; 23:668-687. [PMID: 35320468 DOI: 10.1007/s11864-022-00965-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT The treatment of myelodysplastic syndromes (MDS) begins with risk stratification using a validated tool such as the International Prognostic Scoring System (IPSS) or its revised version (IPSS-R). This divides patients into lower- and higher- risk categories. Although treatment objectives in lower-risk MDS (LR-MDS) have traditionally been directed at improving cytopenias (usually anemia) as well as quality of life, recent data supports a potential role for early intervention in delaying transfusion dependency. In addition, careful individualized risk stratification incorporating clinical, cytogenetic, and mutational data might help identify patients at higher-than-expected risk for progression. Given the need for supportive care with red blood cell (RBC) transfusions leading to iron overload, iron chelation should be considered for patients with heavy transfusion requirements at risk for end-organ complications. For patients with LR-MDS and isolated anemia, no high-risk features, and endogenous erythropoietin (EPO) levels below 500 U/L, erythropoiesis-stimulating agents (ESAs) can be attempted to improve anemia. Some LR-MDS patient subgroups may also benefit from specific therapies including luspatercept (MDS with ring sideroblasts), lenalidomide (MDS with deletion 5q), or immunosuppressive therapy (hypocellular MDS). LR-MDS patients failing the above options, or those with multiple cytopenias and/or higher-risk features, can be considered for oral low-dose hypomethylating agent (HMA) therapy. Alternatively, these patients may be enrolled on a clinical trial with promising agents targeting the transforming-growth factor beta (TGF-β) pathway, the hypoxia-inducible factor (HIF) pathway, telomerase activity, inflammatory signaling, or the splicing machinery. In higher-risk MDS (HR-MDS), therapy seeks to modify the natural history of the disease and prolong survival. Eligible patients should be considered for curative allogeneic hematopoietic stem cell transplantation (aHSCT). Despite promising novel combinations, the HMAs azacitidine (AZA) or decitabine (DAC) are still the standard of care for these patients, with intensive chemotherapy-based approaches being a potential option in a small subset of patients. Individuals who fail to respond or progress after HMA experience dismal outcomes and represent a major unmet clinical need. Such patients should be treated as part of a clinical trial if possible. Experimental agents to consider include venetoclax, myeloid cell leukemia 1 (MCL-1) inhibitors, eprenetapopt, CPX-351, immunotherapies (directed towards CD47, TIM3, or CD70), interleukin-1 receptor-associated kinase 4 (IRAK4) inhibitors, pevonedistat, seclidemstat, and eltanexor. In this review, we extensively discuss the current landscape of experimental therapies for both LR- and HR-MDS.
Collapse
Affiliation(s)
- Alexandre Bazinet
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Guillermo Montalban Bravo
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA.
| |
Collapse
|