Phase 2 study of clarithromycin, pomalidomide, and dexamethasone in relapsed or refractory multiple myeloma

No needles needed: All-oral therapy options for relapsed and refractory multiple myeloma

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.

How to Manage Patients with Lenalidomide-Refractory Multiple Myeloma

Although lenalidomide-based combinations, such as lenalidomide plus a proteasome inhibitor or an anti-CD38 monoclonal antibody, improve the overall response rate, progression-free survival, and overall survival of patients with relapsed/refractory multiple myeloma (RRMM), there is a tendency to use these regimens as a frontline treatment. This strategy has led to the development of refractoriness early in the disease course, usually after the patient's first treatment. Since lenalidomide-free regimens have so far shown limited efficacy in lenalidomide-refractory patients, there is an unmet need for other treatment options. In this review, we discuss the therapeutic options available to treat the general population of lenalidomide-refractory patients (mono, double and triple refractory) and the subpopulation of patients with other high-risk features such as renal failure, extramedullary disease, and high-risk cytogenetics. Moreover, new promising individual therapies and the possible impact of immunotherapy in RRMM patients are debated.

Delivering macrolide antibiotics to heal a broken heart - And other inflammatory conditions

Drug carriers to deliver macrolide antibiotics, such as azithromycin, show promise as antibacterial agents. Macrolide drug carriers have largely focused on improving the drug stability and pharmacokinetics, while reducing adverse reactions and improving antibacterial activity. Recently, macrolides have shown promise in treating inflammatory conditions by promoting a reparative effect and limiting detrimental pro-inflammatory responses, which shifts the immunologic setpoint from suppression to balance. While macrolide drug carriers have only recently been investigated for their ability to modulate immune responses, the previous strategies that deliver macrolides for antibacterial therapy provide a roadmap for repurposing the macrolide drug carriers for therapeutic interventions targeting inflammatory conditions. This review describes the antibacterial and immunomodulatory activity of macrolides, while assessing the past in vivo evaluation of drug carriers used to deliver macrolides with the intention of presenting a case for increased effort to translate macrolide drug carriers into the clinic.

Current status of drug repositioning in hematology

INTRODUCTION

Drug repositioning (DR) is defined as determining new therapeutic applications for existing drugs. This approach is advantageous over de novo drug discovery in accelerating clinical development, in terms of lower costs, a shortened development period, a well-known action mechanism, a feasible dosage, and an acceptable safety profile.

AREAS COVERED

This work was aimed at reviewing agents with successful DR in hematology.

EXPERT OPINION

Thalidomide and plerixafor have been successfully repositioned for treating multiple myeloma and harvesting peripheral blood stem cells, respectively. The former was originally developed as a sedative and the latter as an anti-HIV drug. Currently, the feasibility of repositioning various agents is being explored (e.g. an anti-influenza virus drug oseltamivir for primary immune thrombocytopenia, an anti-HIV drug abacavir for adult T-cell leukemia, and a macrolide antibiotic clarithromycin for multiple myeloma). Furthermore, bosutinib for chronic myeloid leukemia or the antiplatelet drug cilostazol have been suggested to have clinical benefits for the management of amyotrophic lateral sclerosis and ischemic stroke, respectively. To promote DR, effective application of artificial intelligence or stem cell models, comprehensive database construction shared between academia and pharmaceutical companies, suitable handling of drug patents, and wide cooperation in the area of specialty are warranted.

The evolving role and utility of off-label drug use in multiple myeloma

The treatment landscape for multiple myeloma (MM) has dramatically changed over the last three decades, moving from no US Food and Drug Administration approvals and two active drug classes to over 19 drug approvals and at least eight different active classes. The advances seen in MM therapy have relied on both a structured approach to obtaining new labels and cautious off-label drug use. Although there are country and regional differences in drug approval processes, many of the basic principles behind off-label drug use in MM can be summarized into four main categories: 1) use of a therapy prior to the current approval regulations; 2) widespread use of a therapy following the release of promising clinical trial results but prior to drug approval; 3) use of a cheap therapy supported by clinical safety and efficacy data but without commercial backing; and 4) niche therapies for small well-defined patient populations where large clinical trials with sufficient power may be difficult to perform. This review takes a historical approach to discuss how off-label drug use has helped to shape the current treatment approach for MM.

Lenalidomide and dexamethasone with or without clarithromycin in patients with multiple myeloma ineligible for autologous transplant: a randomized trial

Although case-control analyses have suggested an additive value with the association of clarithromycin to continuous lenalidomide and dexamethasone (Rd), there are not phase III trials confirming these results. In this phase III trial, 286 patients with MM ineligible for ASCT received Rd with or without clarithromycin until disease progression or unacceptable toxicity. The primary endpoint was progression-free survival (PFS). With a median follow-up of 19 months (range, 0–54), no significant differences in the median PFS were observed between the two arms (C-Rd 23 months, Rd 29 months; HR 0.783, p = 0.14), despite a higher rate of complete response (CR) or better in the C-Rd group (22.6% vs 14.4%, p = 0.048). The most common G3–4 adverse events were neutropenia [12% vs 19%] and infections [30% vs 25%], similar between the two arms; however, the percentage of toxic deaths was higher in the C-Rd group (36/50 [72%] vs 22/40 [55%], p = 0.09). The addition of clarithromycin to Rd in untreated transplant ineligible MM patients does not improve PFS despite increasing the ≥CR rate due to the higher number of toxic deaths in the C-Rd arm. Side effects related to overexposure to steroids due to its delayed clearance induced by clarithromycin in this elderly population could explain these results. The trial was registered in clinicaltrials.gov with the name GEM-CLARIDEX: Ld vs BiRd and with the following identifier NCT02575144. The full trial protocol can be accessed from ClinicalTrials.gov. This study received financial support from BMS/Celgene.

Phase I/II trial of bendamustine, ixazomib, and dexamethasone in relapsed/refractory multiple myeloma

In this phase I/II trial, BID, bendamustine (70, 80, or 90 mg/m²), ixazomib (4 mg), and dexamethasone (40 mg), was administered to 28 patients with relapsed and/or refractory multiple myeloma (RRMM) exposed to bortezomib and lenalidomide and refractory to at least one. A 3 + 3 dose escalation based on dose-limiting toxicities (DLTs) was employed in phase I (total 15); 2/6 patients developed DLTs (neutropenia and thrombocytopenia) at dose level 3 establishing the recommended phase II dose as bendamustine 80 mg/m², ixazomib 4 mg, and dexamethasone 40 mg. The median age was 67 years (range, 42–72), and 43% were females. Patients received a median of 4 (range, 4–9) prior lines of therapy, of which ~50% were double refractory. In phase II, total 19 patients were treated. With a median follow-up of 17 months, 11% achieved very good partial response, 50% achieved partial response, and 27% achieved stable disease. Median progression free (PFS) and overall (OS) survival were 5.2 months (95% CI, 1.96–8.3) and 23.2 months (95% CI 16.3–30.07). The most frequent adverse events were anemia, thrombocytopenia, leukopenia, nausea, diarrhea, and infections. Peripheral neuropathy was infrequent. BID is a well-tolerated and effective combination therapy for patients with RRMM.