Leflunomide in Treating Patients With Relapsed or Refractory Multiple Myeloma
Study Details
Study Description
Brief Summary
This phase I/II trial studies the side effects and best dose of leflunomide in treating patients with multiple myeloma that has come back (relapsed) or has not responded to previous treatment (refractory). Leflunomide may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Phase 1/Phase 2 |
Detailed Description
PRIMARY OBJECTIVES: I. To determine the maximum tolerated dose (MTD) and recommended phase II dose (RP2D) of leflunomide, when given as a single agent. (Phase I) II. To assess the safety and tolerability of leflunomide at each dose level by evaluation of toxicities including: type, frequency, severity, attribution, time course and duration. (Phase I) III. To evaluate the anti-myeloma activity of leflunomide, when given as a single agent, as assessed by overall response rate (ORR). (Phase II)
SECONDARY OBJECTIVES: I. To obtain estimates of: response duration, clinical benefit response, overall survival, progression-free survival. (Phase II)
TERTIARY OBJECTIVES: I. To characterize the relationship between serum concentration of the active leflunomide metabolite, teriflunomide (A77 1726), and toxicity. (Phase I/II) II. To assess the relationship between serum concentration of the active leflunomide metabolite, teriflunomide (A77 1726), and disease response. (Phase I/II) III. To explore the relationship between polymorphisms in the CYP1A2, CYP2C19, or DHODH genes and toxicity/response. (Phase I/II) IV. To explore the ex vivo cytotoxicity of leflunomide toward primary multiple myeloma (MM) cells, in order to evaluate whether individual ex vivo leflunomide response might be a useful predictor of therapeutic response. (Phase I/II) V. To explore the potential additive or synergistic effects of combining leflunomide with other classes of Food and Drug Administration (FDA)-approved drugs. (Phase I/II) VI. To generate a preliminary ribonucleic acid (RNA)/microRNA (miRNA) and deoxyribonucleic acid (DNA) methylation signature associated with response of MM cells to leflunomide in vivo (mRNA/miRNA and DNA methylation, phase II only) and teriflunomide ex vivo (messenger RNA [mRNA]/miRNA). (Phase I/II)
OUTLINE: This is a dose-escalation study. Patients receive leflunomide orally (PO) once daily (QD) on days 1-28. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up at 30 days and then every 28 days until disease progression (active follow-up) or every 3 months (long term follow-up).
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Experimental: Treatment (leflunomide) Patients receive leflunomide PO QD on days 1-28. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity. |
Other: Laboratory Biomarker Analysis
Correlative studies
Drug: Leflunomide
Given PO
Other Names:
Other: Pharmacological Study
Correlative studies
|
Outcome Measures
Primary Outcome Measures
- Incidence of toxicity, graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 [Up to 30 days post-treatment]
Observed toxicities will be summarized, for all dose levels, in terms of type (organ affected or laboratory determination), severity, time of onset, duration, serum concentration of the active leflunomide metabolite, probable association with the study treatment and reversibility or outcome.
- MTD, defined as the highest dose in which =< 1/6 patients experience a dose-limiting toxicity, graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 [28 days]
Observed toxicities will be summarized, for all dose levels, in terms of type (organ affected or laboratory determination), severity, time of onset, duration, serum concentration of the active leflunomide metabolite, probable association with the study treatment and reversibility or outcome.
- Best overall response rate, (stringent complete response [sCR]/complete response [CR]/very good partial response [VGPR]/or partial response [PR]), assessed by International Myeloma Working Group (IMWG) criteria [From the start of treatment until disease progression/recurrence, assessed up to 48 months]
Clopper Pearson binomial 95% confidence intervals will be calculated for this estimate.
Secondary Outcome Measures
- Clinical benefit response rate (sCR/CR/VGPR/partial response [PR]/minimal response [MR] or stable disease [SD]), assessed by IMWG criteria [From the start of treatment until disease progression/recurrence, assessed up to 48 months]
Clopper Pearson binomial 95% confidence intervals will be calculated for this estimate.
- Overall survival [From date of first dose of study drug to date of death from any cause, assessed up to 48 months]
Overall survival will be estimated using the product-limit method of Kaplan and Meier.
- Progression-free survival [From date of first dose of study drug to first documented disease relapse, progression or death from any cause, whichever occurs first, assessed up to 48 months]
Progression-free survival will be estimated using the product-limit method of Kaplan and Meier.
- Response duration [From the date of first documented response to documented disease relapse, progression or death, whichever occurs first, assessed up to 48 months]
Time to response will be estimated using the product-limit method of Kaplan and Meier.
Other Outcome Measures
- Combination index (CI) values [Up to 48 months]
CI values will be calculated using the CalcuSyn software program to determine which of the compounds work synergistically.
- DNA methylation [Up to 48 months]
- Germline polymorphisms [Up to 48 months]
All models will be adjusted for risk factors known to be associated with outcomes studies. Multiple comparisons adjustment with false discovery rate (FDR) will be conducted, and variants with FDR =< 0.05 will be considered significant. Will specifically look at DHODH, CYP1A2 and CYP2C19 gene polymorphisms and haplotypes identified in the literature that are associated with leflunomide response-toxicity. Functional annotation of the variants will be performed using ANNOVAR.
- Half maximal inhibitory concentration values for teriflunomide in MM cells [Up to 48 months]
Will be calculated suing Prism software (GraphPad). These values will be used for correlation analysis to determine the strength and linearity of the relationship between the ex vivo response and the response characteristics in vivo. These results will also be compared to responses from cell lines.
- miRNA/mRNA expression profile [Up to 48 months]
- Potential new pathways to complement leflunomide treatment [Up to 48 months]
Will compare the miRNA/mRNA/methylation profiles between responders and non-responders. Differentially expressed genes will be used to identify pathways that are activated in non-responders, which will provide insights into possible complementary therapy. Gene ontology and KEGG pathways will be analyzed using DAVID and GSEA. Pathway and gene ontology that are activated in non-responders will be sorted by their multiple comparison adjusted p-value. Potential miRNA targets will be identified using TargetScan and the enrichment of gene ontology and pathways will be identified as well.
- Total and free teriflunomide levels [At 2 and 4 weeks]
Descriptive statistics will be used to characterize possible inter-patient variability and relationship to dose, toxicity and response for future studies. Additional testing and analysis will be done on collected samples to assess, in an exploratory manner, the potential association between germline polymorphisms in the DHODH gene and either toxicity or response.
Eligibility Criteria
Criteria
Inclusion Criteria:
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All subjects must have the ability to understand and the willingness to sign a written informed consent
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Patients must have a life expectancy of > 3 months
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Patients must exhibit an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2
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Patients must have a diagnosis of multiple myeloma
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Serum M-protein >= 0.5 g/dL
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Urine M-protein >= 200 mg/24 hr
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Serum free light chain >=10 mg/dL provided the free light chain (FLC) ratio is abnormal
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10% plasma cells in bone marrow
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Patients must be relapsed or are refractory to at least 3 prior lines of therapy, including both a proteasome inhibitor an immunomodulatory drug (IMiD), and for whom a transplant is not recommended (induction therapy and stem cell transplant +/- maintenance will be considered as one regimen)
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At least 2 weeks from prior therapy to time of start of treatment; prior therapy includes steroids (except prednisone or equivalent - up to 10 mg per day is allowed)
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Platelet count >= 50,000/uL; platelet transfusions are not allowed within 14 days of platelet assessment
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Absolute neutrophil count (ANC) >= 1000/mm^3; growth factor is not permitted within 14 days of neutrophil assessment
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Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.0 x upper limit of normal (ULN)
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Total Bilirubin < 1.5 x ULN
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Calculated creatinine clearance (CrCl) >= 30 mL/min per 24 hour urine collection or the Cockcroft-Gault formula
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Negative serum or urine beta-human chorionic gonadotropin (B-HCG) test (female patient of childbearing potential* only), to be performed locally within the screening period
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Negative for tuberculosis antigen (e.g. T-Spot test)
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Negative for hepatitis A, B, or C infection
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Adequate pulmonary function as defined by forced vital capacity (FVC) and diffusing capacity of the lung for carbon monoxide (DLCO) >= 50% of predicted by pulmonary function testing
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Agreement by females of childbearing potential* and sexually active males to use an effective method of contraception (hormonal or barrier method of birth control or abstinence) prior to study entry and for three months following duration of study participation; should a woman become pregnant or suspect that she is pregnant while participating on the trial, she should inform her treating physician immediately * A female of childbearing potential is defined as a sexually mature woman who: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months
Exclusion Criteria:
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Prior treatment with leflunomide
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Current or planned use of other investigational agents, or concurrent biological, chemotherapy, or radiation therapy during the study treatment period
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Current or planned growth factor or transfusion support until after initiation of treatment; if growth factor or transfusion support is provided between screening and start of treatment, the participant will no longer be eligible
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Prior diagnosis of rheumatoid arthritis
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Prior allogenic transplant
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Acute active infection requiring systemic therapy within 2 weeks prior to enrollment
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Pre-existing liver disease
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Known human immunodeficiency virus (HIV) infection
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History of allergic reactions attributed to compounds of similar chemical or biologic composition to leflunomide or cholestyramine
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Non-hematologic malignancy within the past 3 years aside from the following exceptions:
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Adequately treated basal cell or squamous cell skin cancer
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Carcinoma in situ of the cervix
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Prostate cancer < Gleason grade 6 with a stable prostate specific antigen (PSA)
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Successfully treated in situ carcinoma of the breast
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Clinically significant medical disease or condition that, in the investigator's opinion, may interfere with protocol adherence or the patient's ability to give informed consent
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Pregnant women and women who are lactating; breastfeeding should be discontinued if the mother is enrolled on this study
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Any other condition that would, in the investigator's judgment, contraindicate the patient's participation in the clinical study due to safety concerns or compliance with clinical study procedures, e.g., infection/inflammation, intestinal obstruction, unable to swallow medication, social/ psychological issues, etc
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NONCOMPLIANCE: Prospective participants who, in the opinion of the investigator, may not be able to comply with all study procedures (including compliance issues related to feasibility/logistics)
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | City of Hope Medical Center | Duarte | California | United States | 91010 |
Sponsors and Collaborators
- City of Hope Medical Center
- National Cancer Institute (NCI)
Investigators
- Principal Investigator: Michael Rosenzweig, City of Hope Medical Center
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- 15140
- NCI-2015-01181
- 15140