scholarly journals Effect of deferasirox + erythropoietin vs erythropoietin on erythroid response in Low/Int-1-risk MDS patients: Results of the phase II KALLISTO trial

2018 ◽  
Vol 101 (2) ◽  
pp. 208-215 ◽  
Author(s):  
Norbert Gattermann ◽  
Rosa Coll ◽  
Lutz Jacobasch ◽  
Allameddine Allameddine ◽  
Amin Azmon ◽  
...  
Keyword(s):  
Phase Ii ◽  
Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 40-41
Author(s):  
Arshia Akbar ◽  
Waqas Khan ◽  
Zunairah Shah ◽  
Muhammad Yasir Anwar ◽  
Muhammad Ali Aziz ◽  
...  

Background: Low-risk Myelodysplastic Syndromes (MDS) patients commonly present with anemia and may become blood transfusions dependent upon progression. Luspatercept, a targeted drug for an activin receptor ligand has emerged as new anemia treatment in MDS for patients with ring sideroblasts and the patients with SF3B1 mutation. This systemic review highlights the efficacy of luspatercept in MDS patients whom erythropoietin stimulating agents (ESA) are not effective. Methods: We conducted a comprehensive literature search using PubMed, Clinical trial.gov, Embase, Cochrane, and Web of science. Our search strategy included MeSH (Medical Subject Headings) terms and keywords for MDS and luspatercept including trade names and generic names from inception to 29 April 2020. Studies were selected according to PRISMA guidelines. The initial screening revealed 240 articles. After excluding review articles, duplicates, and non-relevant articles, finally we included two clinical trials, which reported transfusion independence (TI), an erythroid response (HI-E) in MDS patients with luspatercept. Proportions along with 95% Confidence Interval (CI) were extracted to compute pooled analysis using the 'meta' package by Schwarzer et al. in the R programming language (version 4.0.2) to report the efficacy of luspatercept. We pooled the results of the experimental arms of the two trials using the inverse variance method and logit transformation. Between studies, variance was calculated using DerSimonian-Laird Estimator. Results: A total of 287 patients were enrolled and evaluated in two phases II/III trials. Platzbecker et al and Fenaux et al reported Erythropoietin stimulating agents (ESA) with one median prior line of therapy (n= 148, n=46). Fenaux et al. also reported iron chelation therapy (n=71) as a prior line of therapy. Patients having ring sideroblast positive <15% (n=172) and SF3B mutation were present in 169 evaluable patients. Low-risk MDS (LR-MDS) patients are classified according to IPSS-R criteria, defined as being of very low (n=19), low (n=135), or intermediate-risk (n=44). Platzbecker et al. (2017) studied luspatercept in MDS patients (n=58) in the PACE phase II trial. Fenaux et al. (2020) studied the efficacy of luspatercept in MDS pts (n=219) in the MEDALIST phase III trial. The baseline Erythropoietin (EPO) levels were: levels <200: n=191, level 200-500: n= 81, level >500: n=57 for both studies. The baseline means hemoglobin (Hb) levels were eight before therapy. TI for more than eight weeks was observed in 38% of patients in both the MEDALIST trial and PACE trial. The erythroid response was 53% and 63% in both trials respectively. In a Phase II study, for LR-MDS patients, the overall erythroid response was higher among patients (n= 69%) having ringed sideroblast status (>15% ring sideroblast) and SF3B mutation (n=77%). The mean increase of Hb was observed in 29 out of 46 and 32 out of 41 pts in MEDALIST and PACE trial, respectively. Luspatercept proved to be efficacious in the pooled analysis i.e transfusion independence (TI): 38%, 95% CI 0.31-0.45; p =0.98, I2 = 0%), and erythroid response (HI-E): 54%, 95% CI 0.48-0.62; p=0.22, I2 = 32%) with an increase in mean Hb of 70% 95%: CI 0.59-0.78; I2 = 56%) (Figure 1). CONCLUSION: In patients with low risk MDS positive ringed sideroblast or SF3B1 mutation status shows good responses with luspatercept treatment, with reduced transfusion dependence, and higher erythroid response. Disclosures Anwer: Incyte Pharmaceuticals: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses, Speakers Bureau; Millennium Pharmaceuticals: Research Funding; Celgene: Research Funding; Astellas Pharma: Research Funding; Acetylon Pharmaceuticals: Research Funding; Seattle Genetics: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses, Speakers Bureau; AbbVie Pharmaceuticals: Research Funding.


Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1451-1451
Author(s):  
Richard Walgren ◽  
Crystal Dao ◽  
Frederieke Kreisel ◽  
Peter Westervelt ◽  
Camille Abboud ◽  
...  

Abstract Rationale: 5-Azacytidine (Aza), a DNA hypomethylating agent, has now been shown in 2 clinical trials involving high-risk MDS patients to provide a survival benefit over supportive/conventional care regimens. While one phase II study used a continuous 7-day IV infusion, Aza was administered subcutaneously (SQ) in most pre-approval studies. However, injection site reactions are not uncommon with SQ dosing, especially in thrombocytopenic patients. Aza given as a short intravenous (IV) infusion is anticipated to be efficacious from pharmacokinetic profiling and is FDA approved, but prospective efficacy data for short IV infusion are lacking. Study aim and design: To determine the efficacy of IV Aza when given as a short infusion, we have undertaken an open-label, single-arm, single-center phase II study of Aza in patients with MDS, either de novo or secondary, defined by FAB classification. Previously treated subjects were ineligible if they had already received Aza or decitabine. Treatment consisted of Aza 75 mg/m2 given as a 20 minute IV infusion once daily on Days 1–5 of a 28-day cycle. Response was evaluated by IWG 2000 criteria. After two cycles at the 75 mg/m2 dose, patients failing to achieve a CR were eligible for an increased dose of 100 mg/m2. After 6 cycles of therapy, patients must have demonstrated at least a hematologic improvement to continue on study. Study endpoints include determination of the complete response (CR) and partial response (PR) rates, and secondary endpoints examined the rates of hematological improvement, time to progression, and cytogenetic response. Results: Accrual began 8/17/06 with a target of 21 subjects. As of 7/31/07, 15 subjects have accrued with a median follow-up of 77 days (range 4 to 246). Subjects consisted of 9 males and 6 females with a median age of 69.6 yr (range 53 to 82). The median time from diagnosis is 213 days (range 0 days to 4 yr). By FAB criteria, subjects consist of 4 RA, 9 RAEB, 1 RAEB-t, and 1 CMML, and subjects are categorized by IPSS risk as 1 Low, 4 Int-1, and 10 Int-2. Two patients had therapy related MDS. The data remain preliminary with subjects having completed a mean of 3 cycles (range 1 to 6). None of the 5 subjects who have completed at least 4 cycles of therapy have achieved a CR. However, 2 (40%) of these subjects achieved a PR. Additionally, 1 (20%) patient had a major erythroid response, while another had a minor erythroid response. Median time to response was 2 months. Ten subjects remain on study, 1 patient withdrew due to progressive disease (in first week of therapy), and 4 deaths have occurred on study (2 due to sepsis, 1 each due to pneumonia and acute MI). No deaths were attributed to study drug. Common adverse events include nausea, emesis, and hematologic toxicities. Grade 2–3 nausea and grade 2–3 emesis each occurred in 5 subjects. Observed grade 3 or 4 hematologic toxicities included: anemia (n=7), thrombocytopenia (n=4), leukopenia (n=3), neutropenia (n=7), and febrile neutropenia (n=1). Hematologic toxicities have resulted in transient treatment delays (< 4 weeks) and dose reduction, but hematologic toxicities have not prevented subsequent treatment on study. Conclusions: Although follow-up is short for assessment of efficacy, this is the first prospective study to report on efficacy and toxicity of short infusional Aza in the treatment of MDS.


Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 224-224 ◽  
Author(s):  
Arjan A. van de Loosdrecht ◽  
Dana A Chitu ◽  
Eline MP Cremers ◽  
Theresia M Westers ◽  
Canan Alhan ◽  
...  

Abstract Purpose: This randomized phase II study (HOVON89) in patients with low/int-1 risk MDS refractory or unlikely to respond to erythropoietin and granulocyte-colony stimulating factor (EPO/G-CSF) assessed efficacy and safety of lenalidomide without (Arm A) or with EPO+/-G-CSF (Arm B) in case of no erythroid response after 4 cycles. Patients and methods: In total 200 patients were randomly 1:1 assigned to either Arm A or Arm B. All patients were treated with lenalidomide (10 mg/day/day 1-21) for a minimum of 6 months in arm A and 12 months in arm B or until loss of response or disease progression. Patients in arm B without hematological improvement-erythroid (HI-E) after 4 cycles received EPO (30,000 IU/wk). In those patients who did not show HI-E after 6 months, EPO was increased to 60,000 IE/wk. G-CSF (3x 300-480 µg/wk) was added if no HI-E was reached at 8 month. The current pre-final evaluation was based on the first180 patients and included 85% non-del5q MDS and15% patients with isolated del5q. The median age was 71years (range 38-89). No differences were observed between both arms regarding sex (55% male), WHO PS, WHO diagnostic subgroup and IPSS, baseline Hb, WBC, platelets, endogenous erythropoietin level, pretreatment with EPO+/-G-CSF (67% of the patients were pretreated) and pre-study transfusions. Patients had received a median of 13 (range 0-72) units of RBC and 4 (range 0-13) within 8 weeks for prior study entry. Results: Adverse events were consistent with the known safety profile of lenalidomide/EPO/G-CSF. HI-E according to IWG criteria was achieved in 38% and 41% of the patients for arm A and B, respectively (p = 0.46). HI-E was significantly lower in non-del5q versus del5q patients (33% vs 78%, respectively). Time-to-HI-E was 3.1 months (median; range 1.6-12.3) for both arms with a median duration of 10 months (range 1 - 76). The median PFS was 14.4 vs 15.4 months in arms A and B (p=0.43). OS was 51.1 and 37.7 months for arm A and B (p=0.09). At 2 years 17% of patients had progressed to AML (no differences between arms). The median FU of patients still alive is 31 months. PFS and OS was significantly longer in those who achieved HI-E, (median 13 vs 19 months, p=0.02 for PFS and median 31 vs 63 months for OS, p<0.001); non-responders vs responders). A Landmark analysis at 12 month confirms a significant prolonged OS in patients who achieved HI-E (28 and 51 months, p<0.002, non-responders vs responders). Endogenous erythropoietin level, pretreatment with EPO/G-CSF, and WHO subgroup did not predict for HI-E, PFS and OS. However, an IPSS of 0 was favorable in comparison to a score of 0.5-1.0 (p=0.02). To better predict response we are currently analyzing baseline flowcytometry and NGS data. Conclusion: Lenalidomide yields sustained HI-E in 33% of patients with non-del5q low/int-1 risk MDS refractory or unlikely to respond on EPO/G-CSF. The addition of EPO/G-CSF did not improve HI-E. Achievement of HI-E significantly improves PFS and OS. Disclosures Ossenkoppele: J&J: Consultancy, Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Roche: Honoraria; Karyopharm: Consultancy, Research Funding; Novartis: Research Funding.


Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 2537-2537
Author(s):  
L. Ades ◽  
H. Mohamed ◽  
D. Vassilief ◽  
E. Berger ◽  
B. Slama ◽  
...  

Abstract Recombinant EPO, when used alone at 60 000 UI/ w, improves anemia in 25 to 30 % of low risk MDS, mainly when serum EPO level is low, and is ineffective on other cytopenias. A previous study (Blood2002,99:1578) suggested that the addition of ATRA to EPO could increase the response rate on anemia, and also improve neutrophils and platelets in some MDS. We report preliminary results of a phase II study of EPO beta and ATRA in lower risk MDS, stratified on serum EPO level, previous results with EPO alone and presence of cytopenias other than anemia. Trial design: Inclusion criteria were MDS with &lt; 10 % marrow blasts anemia requiring transfusions or Hb&lt;10g/dl, or Hb&lt;12g/dl and another cytopenia (neutrophils &lt;1500/mm3 or platelets&lt;50000/mm3) exclusion of other causes of anemia. Patients with EPO level &lt;500 UI/l, previously untreated with EPO and with anemia alone (arm A) were treated with EPO beta alone (20000 UIx3/week). Patients with EPO level &gt;500 UI/l, or unsuccessfully treated by EPO alone or with cytopenia(s) other than anemia (arm B) received the same EPO regimen plus ATRA (45 mg/m2/day, 1 week on, 1 week off). ATRA was escalated to 80 mg/m2/d in case of failure. Responses were evaluated every 12 weeks, based on IWG criteria. Patients: Between Nov 2004 and June 2005, the 99 initially planned pts were included; 48 of them already had a follow up greater than 12 weeks and were evaluable for response (reference date: June 15th, 2005). 14 pts entered arm A, 9 of them had erythroid response (HI-E, major in 7, minor in 2), and this arm will not be further analysed here. 37 patients entered arm B (3 of them after failure of arm A), due to previous failure of EPO alone (n=16), EPO &gt; 500 UI/l (n=12) thrombocytopenia or neutropenia in the absence of the 2 other criteria (n=9). Arm B pts included 23 Males and 14 females, median age 70, 9 RA, 13 RARS, 15 RAEB1; Karyotype was normal in 20 pts, abnormal in 15 pts including 3 pts with del (5q), and a failure in 2 pts. IPSS was low (7pts,), int-1 (20 pts), int-2 (8 pts) and undetermined (2 pts). Treatment results in arm B: 17 (46 %) pts had HI-E after 12 weeks of EPO beta+ATRA, including HI-E major (n=7) and HI-E minor (n=10). 8 of the minor and non responders received 12 further weeks of EPO+ ATRA at 80 mg/m2/d but without improvement. HI-E occurred in 4/12 (33%,) pts with EPO &gt;500 UI/l (all minor responses), 8/16 (50%) pts having failed EPO alone (2 major, 6 minor responses), 5/9 (55 %) pts enrolled in arm B due to neutropenia and/or thrombocytopenia (all major responses). Only 2 of the 19 pts with neutrophils&lt; 1500/mm3 had HI-N (1 major, 1 minor), and none of the 9 pts with platelets&lt;50000/mm3 had HI-P. No major side effects of treatment were observed. Baseline EPO level had significant prognostic value for erythroid response in arm B. Conclusion: Our preliminary findings suggest that the addition of ATRA to EPO improves the erythroid response in about one half of lower risk MDS patients unresponsive to EPO alone, and yields erythroid response in one third of pts with high EPO levels, but most erythroid responses in those 2 patient groups have been minor so far. This combination had very limited effects on neutropenia and thrombocytopenia in MDS. Updated results will be presented.


Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 1506-1506
Author(s):  
Rami S Komrokji ◽  
Najla H Al Ali ◽  
Eric Padron ◽  
Ji-Hyun Lee ◽  
Nancy Hillgruber ◽  
...  

Abstract Introduction Anemia remains the most common management challenge for patients (pts) with lower risk MDS (Low and int-1 International prognostic Scoring System (IPSS) groups). Lenalidomide (LEN) is the treatment of choice for lower risk MDS pts with chromosome 5 deletion (del5q) where 67% of pts on MDS-003 study became red blood cell transfusion independence (RBC-TI). The MDS-002 study reported 26% RBC TI rate in non-del5q MDS pts. Strategies to optimize LEN responses in non-del5q include identifying predictive biomarkers or combination strategies to potentiate erythropoietin receptor signaling. Dexamethasone increases the proliferation of immature erythroid progenitors and in vitro increases erythroid progenitor sensitivity to LEN by enhancing erythropoietin (EPO)-transcriptional response and colony forming capacity (BL Ebert, un-published data). We hypothesize that combination treatment with LEN and prednisone will yield a higher erythroid response rate in patients with non-del (5q) lower risk MDS compared to the historical clinical trial experience with LEN monotherapy (MT). Methods The study was an investigator initiated two- step phase II design. In the first step 25 eligible patients were to be registered. If fewer than 4 of these 25 achieved erythroid hematological response (HI-E), then the study will be terminated early with the conclusion that the regimen does not warrant further investigation. Key eligibility criteria included confirmed MDS diagnosis, low or int-1 IPSS, RBC transfusion-dependent anemia defined as having received ≥4 transfusions of RBCs for Hgb ≤ 9.0 g/dl within 56 days or symptomatic anemia (Hgb ≤ 9.0 g/dl), erythroid stimulating agents failure or endogenous serum epo > 500 mU/ml., absolute neutrophil count (ANC) ≥ 500 /mm≥, platelet count ≥ 50,000 /mm≥, and creatinine Clearance ≥ 30 mL/min. The planned dose of LEN for subjects with a baseline CrCl >60ml/min was 10 mg/day. Prednisone dose was 30 mg po daily cycle 1 tapered by 10 mg after each cycle to 5 mg po every other day for responders beyond cycle 6. The primary objective was best response (HI-E) by IWG 2006 criteria within 24 weeks. Results Twenty five pts were enrolled. Baseline characteristics are summarized in table-1. The HI-E rate was 20% (5/25), and 22% (5/23) of evaluable patients. All responders became RBC TI (5 out of 23). The median time to response was 57 days. The median duration of response was 80 days (95% CI 69-91). Three out of 5 responders did not have hypomethylating agent (HMA) while 14 out of 20 non-responders received prior HMA. No patient transformed to acute myeloid leukemia. At a median follow up of 25 months the median OS was not reached (2 deaths). The most common adverse events deemed related to study drug (>10% of pts) included, neutropenia 54%, thrombocytopenia 40%, anemia 32%, diarrhea 27%, myalgia 20%, edema 24%, rash 20%, infection 12%, fever 12%, and fatigue 12%. Grade III/IV events included anemia (n=8), neutropenia (n=4), thrombocytopenia (n=3), and Cerebrovascular event (n=1). The most common causes for study discontinuation were no response (10 pts), loss of response (4pts), infection (4pts) and rash (4pts). Conclusion Combination treatment with LEN and prednisone did not yield a higher erythroid response rate in patients with non-del (5q) lower risk MDS compared to the historical LEN MT. HI-E rates are less in pts who received HMA compared to MDS-002 study. Toxicity profile was similar to LEN (MT). Disclosures: Komrokji: Celgene: Research Funding, Speakers Bureau. Off Label Use: use of lenalidomide in non del 5q. Lancet:Celgene: Research Funding. List:Celgene: Research Funding.


2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 6523-6523 ◽  
Author(s):  
Claude Gardin ◽  
Sylvain Thépot ◽  
Odile Beyne-Rauzy ◽  
Thomas Prébet ◽  
Sophie Park ◽  
...  

6523 Background: Although anemia of IPSS low and int-1 (LR) MDS initially responds to erythroid stimulating agents (ESA) in 40-50% of patients (pts), response is generally transient. Anemia recurrence with RBC cell transfusion dependency (RBC-TD) is an indicator of poor prognosis, even in absence of progression to higher risk MDS. AZA leads to RBC transfusion independence (RBC-TI) in 30–40% of LR-MDS (Lyons, JCO, 2009), but it has not been prospectively tested in LR-MDS patients resistant to ESA. It also remains unknown if the addition of ESA to AZA would be useful in such pts. Methods: In this randomized phase-II trial (GFMAzaEpo-2008-1 trial, NCT01015352), the Groupe Francophone des Myélodysplasies (GFM) compared AZA 75mg/m2/d for 5 days every 28 days for 6 cycles (AZA arm) to the same treatment plus EPO 60000U/week (AZA+EPO arm). Inclusion criteria were LR-MDS resistant to at least 12 weeks of ESA, with RBC-TD ≥ 4 RBC units in the previous 8 weeks. Responders in both arms were eligible for maintenance up to 12 monthly cycles, unless progression or loss of erythroid response occurred. The primary endpoint was RBC-TI (HI-E major using IWG 2000 criteria) after 6 courses. Results: Between 2009 and 2010, the 98 planned pts were included: M/F 65/28; median age 71y (41-84); 5 pts were excluded (one consent withdrawal, 2 early unrelated events and 2 with exclusion criteria). In the remaining 93 pts, IPSS risk was low in 69 and int-1 in 23 pts, with no imbalance between arms. Five pts received < 4 cycles and 16 received only 4 or 5 cycles, mainly due to toxicity or progression. RBC-TI after 6 courses was observed in 16.7% (8/48) in the AZA arm and 18 % (8/45) in the AZA+EPO arm (P=1), and in 19.5% (8/41) and 26 % (8/31) respectively, in the 72 pts who received ≥ 6 cycles (P=.57). Overall best response rate (at least HI-E minor using IWG 2000 criteria) was 35 and 33% in the AZA and AZA+EPO arms, respectively (P=0.99). Of note, only 9 pts in the AZA+EPO arm required at least one hospitalization for a SAE, compared to 22 pts in the AZA arm (P=0.015). Conclusions: Erythroid response to AZA, in LR MDS with demonstrated ESA resistance, appears lower than expected, with no improved outcome when combined with an ESA. The latter may however improve tolerance of AZA in LR MDS.


2002 ◽  
Vol 118 (1) ◽  
pp. 174-180 ◽  
Author(s):  
Evangelos Terpos ◽  
Athina Mougiou ◽  
Alexandra Kouraklis ◽  
Aria Chatzivassili ◽  
Evridiki Michalis ◽  
...  

2001 ◽  
Vol 120 (5) ◽  
pp. A280-A280
Author(s):  
S HANAUER ◽  
P MINER ◽  
A KESHAVARZIAN ◽  
E MORRIS ◽  
B SALZBERG ◽  
...  

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