Azacitidine and Enasidenib in Treating Patients With IDH2-Mutant Myelodysplastic Syndrome

• ClinicalTrials.gov Identifier: NCT03383575
• Recruitment Status: Recruiting
• First Posted: December 26, 2017
• Last Update Posted: March 14, 2023
• Sponsor: M.D. Anderson Cancer Center
• Collaborators: National Cancer Institute (NCI); Celgene
• Information provided by (Responsible Party): M.D. Anderson Cancer Center

Tracking Information

• First Submitted Date: December 8, 2017
• First Posted Date: December 26, 2017
• Last Update Posted Date: March 14, 2023
• Actual Study Start Date: January 17, 2018
• Estimated Primary Completion Date: February 28, 2025 (Final data collection date for primary outcome measure)

Current Primary Outcome Measures (submitted: July 16, 2019)

• Incidence of adverse events [ Time Frame: Up to 3 years ]
  Will use the Bayesian method by Thall, Simon and Estey for toxicity monitoring. For purpose of toxicity monitoring, toxicity is defined as any grade 3 or higher treatment related-toxicities by Common Terminology Criteria for Adverse Events criteria.
• Overall response rate [ Time Frame: Up to 3 years ]
  Defined as complete response (CR), partial response, and marrow CR assessed by International Working Group criteria. Will be estimated along with the 90% credible interval.

Original Primary Outcome Measures (submitted: December 22, 2017)

• Adverse Events [ Time Frame: Every third cycle of 28 days up to 3 years ]
  Adverse events determined by the overall incidence and severity of all reported adverse events using Common Toxicity Criteria v 4.0.
• Efficacy determined by clinical activity assessed based on Modified IWG Response Criteria for MDS [ Time Frame: Every third cycle of 28 days up to 3 years ]
  Efficacy determined by clinical activity assessed based on Modified IWG Response Criteria for MDS (Cheson et al, 2006).

Current Secondary Outcome Measures (submitted: July 16, 2019)

• Event-free survival (EFS) [ Time Frame: Up to 3 years ]
  The Kaplan-Meier method will be used to estimate the probabilities of EFS. Log-rank tests will be used to compare among subgroups of patients in terms of EFS.
• Overall survival (OS) [ Time Frame: Up to 3 years ]
  The Kaplan-Meier method will be used to estimate the probabilities of OS. Log-rank tests will be used to compare among subgroups of patients in terms of OS.
• Anti-tumor activity [ Time Frame: Up to 3 years ]
  Will be summarized graphically and with descriptive statistics.
• Pharmadynamics (PDn) markers [ Time Frame: Up to 3 years ]
  PDn markers will be summarized graphically and with descriptive statistics.
• Drug exposure levels [ Time Frame: Up to 3 years ]
  Will be summarized graphically and with descriptive statistics.

Original Secondary Outcome Measures (submitted: December 22, 2017)

• Evaluation of Molecular and Cellular Markers That May be Predictive of Antitumor Activity [ Time Frame: Cycle 2 Day 1 and on Cycle 3 Day 1 where each cycle is 28 days ]
  Blood samples to be collected for analysis.
• Overall Survival [ Time Frame: Baseline up to three years ]
  Overall survival determined by death from any cause.
• Event-Free Survival [ Time Frame: Baseline up to 3 years ]
  Event-free survival defined as the number of days from the date of treatment initiation to the date of documented treatment failure, relapses from CR, or death from any cause, whichever occurs first, and calculated for all patients.
• Duration of Response [ Time Frame: Baseline up to 3 years ]
  Duration of response is defined as the number of days from the date of initial response (PR or better) to the date of first documented disease progression/relapse or death, whichever occurs first

Current Other Pre-specified Outcome Measures (submitted: July 16, 2019)

Biomarkers analysis [ Time Frame: Up to 3 years ]

The association between molecular and cellular markers and overall response and/or resistance will be assessed through logistic regression analyses. Paired t-test or Wilcoxon signed rank test will be used to assess the marker change over time.

• Original Other Pre-specified Outcome Measures: Not Provided

Descriptive Information

• Brief Title: Azacitidine and Enasidenib in Treating Patients With IDH2-Mutant Myelodysplastic Syndrome
• Official Title: Targeted Therapy With the IDH2-Inhibitor Enasidenib (AG221) for High-Risk IDH2-Mutant Myelodysplastic Syndrome
• Brief Summary: This phase II trial studies the side effects and how well azacitidine and enasidenib work in treating patients with IDH2-mutant myelodysplastic syndrome. Azacitidine and enasidenib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth.

Detailed Description

PRIMARY OBJECTIVES:

I. To determine the safety and tolerability of enasidenib alone, and enasidenib in combination with azacitidine (AZA), for patients with isocitrate dehydrogenase 2 (IDH2) mutated myelodysplastic syndrome (MDS).

II. To assess the efficacy of the combination of enasidenib + azacitidine in hypomethylating agent (HMA) naive subjects with IDH2-mutated MDS, and to assess the efficacy of enasidenib single-agent in subjects with IDH2-mutated MDS who are relapsed/refractory to HMA therapy.

SECONDARY OBJECTIVES:

I. To evaluate molecular and cellular markers that may be predictive of antitumor activity and/or resistance including evaluation of IDH2 variant allele fraction (VAF) levels during treatment and presence of co-occurring mutations.

II. To assess overall survival, event-free survival and duration of response of enasidenib alone, and enasidenib in combination with azacitidine.

EXPLORATORY OBJECTIVES:

I. To assess changes in cellular differentiation and changes in deoxyribonucleic acid (DNA) methylation profiles in IDH2-mutated MDS treated with enasidenib alone and with enasidenib + azacitidine.

II. To evaluate quality of life (QOL) using an MDS-specific measure.

OUTLINE: Patients are assigned to 1 of 2 arms.

ARM I: Patients who are HMA-naive receive enasidenib orally (PO) once daily (QD) on days 1-28 and azacitidine intravenously (IV) oveer 30-60 minutes or subcutaneously (SC) on days 1-7. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.

ARM II: Patients relapsed and/or refractory to HMA therapy receive enasidenib PO QD on days 1-28. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months for up to 3 years.

• Study Type: Interventional
• Study Phase: Phase 2
• Study Design: Allocation: Non-Randomized; Intervention Model: Parallel Assignment; Masking: None (Open Label); Primary Purpose: Treatment

Condition

• Acute Myeloid Leukemia
• Blasts 20-30 Percent of Bone Marrow Nucleated Cells
• Chronic Myelomonocytic Leukemia
• IDH2 Gene Mutation
• Myelodysplastic Syndrome With Excess Blasts
• Recurrent High Risk Myelodysplastic Syndrome
• Refractory High Risk Myelodysplastic Syndrome

Intervention

• Drug: Azacitidine
  Given IV or SC
  Other Names:

  • 5 AZC
  • 5-AC
  • 5-Azacytidine
  • 5-AZC
  • Azacytidine
  • Azacytidine, 5-
  • Ladakamycin
  • Mylosar
  • U-18496
  • Vidaza
• Drug: Enasidenib
  Given PO
  Other Names:

  • AG-221
  • CC-90007
• Other: Quality-of-Life Assessment
  Ancillary studies
  Other Name: Quality of Life Assessment

Study Arms

• Experimental: Arm I (enasidenib, azacitidine)
  Patients who are HMA-naive receive enasidenib PO QD on days 1-28 and azacitidine IV over 30-60 minutes or SC on days 1-7. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.
  Interventions:

  • Drug: Azacitidine
  • Drug: Enasidenib
  • Other: Quality-of-Life Assessment
• Experimental: Arm II (enasidenib)
  Patients relapsed and/or refractory to HMA therapy receive enasidenib PO QD on days 1-28. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.
  Interventions:

  • Drug: Enasidenib
  • Other: Quality-of-Life Assessment

• Publications *: DiNardo CD, Venugopal S, Lachowiez CA, Takahashi K, Loghavi S, Montalban-Bravo G, Wang X, Carraway HE, Sekeres MA, Sukkur A, Hammond D, Chien KS, Maiti A, Masarova L, Sasaki K, Alvarado Y, Kadia TM, Short NJ, Daver NG, Borthakur G, Ravandi F, Kantarjian HM, Patel BJ, DeZern AE, Roboz GJ, Garcia-Manero G. Targeted therapy with the mutant IDH2 inhibitor enasidenib for high-risk IDH2-mutant myelodysplastic syndrome. Blood Adv. 2022 Aug 16:bloodadvances.2022008378. doi: 10.1182/bloodadvances.2022008378. Online ahead of print.

Recruitment Information

• Recruitment Status: Recruiting
• Estimated Enrollment (submitted: December 22, 2017): 105
• Original Estimated Enrollment: Same as current
• Estimated Study Completion Date: February 28, 2025
• Estimated Primary Completion Date: February 28, 2025 (Final data collection date for primary outcome measure)

Eligibility Criteria

Inclusion Criteria:

• Signed, informed consent must be obtained prior to any study specific procedures
• Subjects with a histologically confirmed diagnosis of MDS, including both MDS and refractory anemia with excess blasts in transformation (RAEB-T) (acute myeloid leukemia [AML] with 20-30% blasts and multilineage dysplasia by French-American-British [FAB] criteria) by World Health Organization (WHO), and chronic myelomonocytic leukemia (CMML) are eligible
• Subjects must have an IDH2 gene mutation (IDH2-R140 or R172) as determined by local laboratory result
• (Arm A only): Subject must be hypomethylating agent naive (i.e. prior azacitidine, decitabine, SGI-110 is exclusionary). Receipt of other MDS-directed therapy such as lenalidomide is allowed
• (Arm A only): Subjects with high-risk MDS (i.e. International Prostate Symptom Score [IPSS] intermediate-2 or high-risk; or revised [R]-IPSS high or very-high risk). Patients with intermediate-1 risk by IPSS or intermediate risk by R-IPSS with high-risk molecular features including TP53, ASXL1, EZH2, and/or RUNX1 mutations are also eligible
• (Arm B only): Subject must be relapsed or refractory to prior hypomethylating agent therapy, defined as prior receipt of 6 cycles of HMA therapy with failure to attain a response, or relapse after prior response to HMA therapy
• Eastern Cooperative Oncology Group (ECOG) performance status of 0-2
• Serum bilirubin =< 2 x the upper limit of normal (ULN) (except for patients with Gilbert's disease)
• Alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) =< 3 x the laboratory ULN
• Serum creatinine =< 2 x the ULN
• Able to understand and voluntarily sign a written informed consent, and willing and able to comply with protocol requirements
• Resolution of all clinically significant treatment-related, non-hematological toxicities, except alopecia, from any previous cancer therapy to =< grade 1 prior to the first dose of study treatment
• Female patients of childbearing potential must have a negative serum or urine pregnancy test within 7 days of the first dose of study drug and agree to use dual methods of contraception during the study and for a minimum of 3 months following the last dose of study drug. Post-menopausal females (> 45 years old and without menses for > 1 year) and surgically sterilized females are exempt from these requirements. Male patients must use an effective barrier method of contraception during the study and for a minimum of 3 months following the last dose of study drug if sexually active with a female of childbearing potential

Exclusion Criteria:

• Any prior or coexisting medical condition that in the investigator's judgment will substantially increase the risk associated with the subject's participation in the study
• Subject has received a prior targeted IDH2 inhibitor
• Psychiatric disorders or altered mental status precluding understanding of the informed consent process and/or completion of the necessary study procedures
• Active uncontrolled infection at study enrollment including known diagnosis of human immunodeficiency virus or chronic active hepatitis B or C infection
• Clinically significant gastrointestinal conditions or disorders that may interfere with study drug absorption, including prior gastrectomy
• Patients with known active central nervous system (CNS) disease, including leptomeningeal involvement
• Impaired cardiac function, uncontrolled cardiac arrhythmia, or clinically significant cardiac disease including the following: a) New York Heart Association grade III or IV congestive heart failure, b) myocardial infarction within the last 6 months
• Subjects with a corrected QT (QTc) > 480 ms (QTc > 510 msec for subjects with a bundle branch block at baseline
• Nursing or pregnant women
• Subjects with known hypersensitivity to study drugs or their excipients

Sex/Gender

• Sexes Eligible for Study: All

• Ages: 12 Years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No

Contacts

Contact: Courtney DiNardo, MD; 713-794-1141; cdinardo@mdanderson.org

• Listed Location Countries: United States

Administrative Information

• NCT Number: NCT03383575
• Other Study ID Numbers: 2016-0981; NCI-2018-00987 ( Registry Identifier: CTRP (Clinical Trial Reporting Program) ); 2016-0981 ( Other Identifier: M D Anderson Cancer Center ); P30CA016672 ( U.S. NIH Grant/Contract )
• Has Data Monitoring Committee: No

U.S. FDA-regulated Product

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

• IPD Sharing Statement: Not Provided
• Current Responsible Party: M.D. Anderson Cancer Center
• Original Responsible Party: Same as current
• Current Study Sponsor: M.D. Anderson Cancer Center
• Original Study Sponsor: Same as current

Collaborators

• National Cancer Institute (NCI)
• Celgene

Investigators

• Principal Investigator: Courtney DiNardo; M.D. Anderson Cancer Center

• PRS Account: M.D. Anderson Cancer Center
• Verification Date: September 2022