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Perl, Alexander E., Richard A. Larson, Nikolai Alexandrovich Podoltsev, Stephen Strickland, Eunice S. Wang, Gary J. Schiller, Giovanni Martinelli, et al. "Follow-up of patients with FLT3-mutated R/R AML in the phase 3 ADMIRAL trial." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): 7013. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.7013.
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7013 Background: The phase 3 ADMIRAL trial demonstrated the superiority of gilteritinib to salvage chemotherapy (SC) in patients (pts) with FLT3-mutated ( FLT3mut+) R/R AML. Aim/Objective: A follow-up of ADMIRAL assessed long-term survivors, transplant (HSCT) outcomes. and gilteritinib safety beyond 1 year. Methods: A data cut was performed on September 20, 2020—2 years after the primary analysis. Patients who were alive without relapse, pts who underwent HSCT, and adverse events of interest (AEIs) in Years 1 (≤12 months) and 2 ( > 12 months) of gilteritinib therapy were evaluated. Results: As of September 20, 2020, 17% (n = 63/371) of pts in the intention-to-treat (ITT) population were alive (gilteritinib, n = 49; SC, n = 14); 16 pts assigned to gilteritinib remained on treatment. After a median follow-up of 37.1 months, 26 of the 49 pts in the gilteritinib arm who were alive were also without relapse; 18 of these 26 pts underwent HSCT, with 16 receiving post-HSCT gilteritinib maintenance therapy. Nineteen of the 26 pts in the gilteritinib arm without relapse continued gilteritinib beyond 1 year and remained in CR. Of the 371 ITT pts, 83 (22%) underwent HSCT during the study (gilteritinib, n = 64; SC, n = 19). Pre-HSCT CRc rates were similar across arms (gilteritinib: n = 40/64; 63%; SC: n = 11/19; 58%); 10 of 11 pts preselected for low-intensity SC achieved pre-HSCT CRc (gilteritinib, n = 9; SC, n = 1). Forty of 64 (63%) transplanted pts in the gilteritinib arm received post-HSCT gilteritinib maintenance after achieving pre-HSCT CRc; the 24-month relapse rate in pts who resumed gilteritinib after pre-HSCT CRc was 19%. Post-HSCT treatment with chemotherapy or other tyrosine kinase inhibitors was administered in 26 pts who received gilteritinib before transplantation. Cumulative 24-month relapse rates in gilteritinib-treated pts who achieved pre-HSCT CR and CRc were 20% and 45%, respectively. Median post-HSCT overall survival (landmarked to HSCT date), was similar across arms (gilteritinib, 16.1 months; SC, 15.3 months; HR = 1.076; 95% CI: 0.536, 2.160). Overall, 10.2% (n = 25/246) had ≥24 months of gilteritinib exposure. Most common AEIs during Years 1 and 2 of gilteritinib therapy were elevated ALT/AST levels. Incidences of all AEIs declined in Year 2. Cardiac AEIs in Year 2 were nonfatal cardiorespiratory arrest (n = 1) and ventricular tachycardia (n = 1). One case of differentiation syndrome and cutaneous squamous cell carcinoma occurred in Years 1 and 2, respectively. Conclusions: A high proportion of gilteritinib-treated R/R FLT3mut+ AML pts who were alive without relapse had received HSCT followed by gilteritinib maintenance. Among all transplanted pts in ADMIRAL, pre-HSCT remission rates and post-HSCT survival were similar across arms. Post-HSCT gilteritinib maintenance may relate to the low post-HSCT relapse rate in the gilteritinib arm. The safety profile of gilteritinib is stable at 2 years with no new or significant safety signals. Clinical trial information: NCT02421939.
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Perl, Alexander E., Giovanni Martinelli, Andreas Neubauer, Ellin Berman, Maria R. Baer, Richard A. Larson, Amir Tahmasb Fathi, et al. "Long-term survivors and gilteritinib safety beyond one year in FLT3-mutated R/R AML: ADMIRAL trial follow-up." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): 7514. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.7514.
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7514 Background: The phase 3 ADMIRAL trial showed that gilteritinib was superior to salvage chemotherapy (SC; median overall survival [OS]: 9.3 vs 5.6 mo, respectively) in FLT3mut+ R/R AML patients (pts; Perl, et al. N Engl J Med. 2019). This follow up (FU) of the ADMIRAL trial assessed long-term (LT) survivors and gilteritinib safety beyond 1 year. Methods: A data cut was performed 1 year after the primary analysis. Response outcomes in LT survivors (OS ≥18 mo) in the gilteritinib arm, and safety during and after 12 mo of gilteritinib therapy were assessed. Results: At 1 year after the primary analysis, median FU for OS was 29.2 mo. Median OS remained longer with gilteritinib (9.3 mo) than with SC (5.6 mo; HR=0.679 [95% CI: 0.527, 0.875], nominal P=0.0026); 18-mo OS rates were 27% and 15%, respectively (Table). Of 49 censored pts in the gilteritinib arm, 20 continued treatment; 13 of these 20 pts underwent transplantation (HSCT) and received gilteritinib post-HSCT. Median gilteritinib exposure was 4.1 mo (IQR, 2.1-8.2) and median average dose was 120 mg/day (range, 43.8-192.3); 12% (n=30/246) of pts had ≥18 mo and 7% (n=17/246) had ≥24 mo of drug exposure. A total of 63 gilteritinib-treated pts had OS ≥18 mo (median exposure, 17.6 mo [IQR, 3.1-25.7 mo]). A high proportion of these LT survivors achieved remission pre-HSCT (Table); median durations of complete remission (CR) or CR with partial hematologic recovery (CRh) have not been reached. After a median of 3.5 mo, 35 of 63 (56%) LT survivors underwent HSCT; 25 of these 35 pts (71%) received post-HSCT gilteritinib therapy. Of 28 pts who did not undergo HSCT, 15 (54%) received gilteritinib for ≥18 mo. Most common grade ≥3 adverse events (AEs) during the first 12 mo of gilteritinib therapy were febrile neutropenia (45%), anemia (40%), and thrombocytopenia (23%); rates of these grade ≥3 AEs decreased to 8%, 10%, and 0, respectively, after 12 mo of treatment. Most common fatal AEs during the first 12 mo of gilteritinib therapy were AML (11%), infections (11%), and cardiac disorders (3%); after 12 mo of treatment, rates of these fatal AEs were 6%, 8%, and 2%, respectively. Conclusions: Results from this ADMIRAL trial FU suggest LT survival in pts receiving gilteritinib is related to ongoing remission, subsequent HSCT, or post-HSCT gilteritinib therapy. The safety profile of gilteritinib beyond 1 year was stable. Clinical trial information: NCT02421939 . [Table: see text]
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Ueno, Yoko, Masamichi Mori, Yoshiteru Kamiyama, Naoki Kaneko, Eriko Isshiki, and Masahiro Takeuchi. "Gilteritinib (ASP2215), a Novel FLT3/AXL Inhibitor: Preclinical Evaluation in Combination with Azacitidine in Acute Myeloid Leukemia." Blood 128, no. 22 (December 2, 2016): 2830. http://dx.doi.org/10.1182/blood.v128.22.2830.2830.
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Abstract Background FMS-like tyrosine kinase 3 (FLT3) is one of the most frequently mutated genes in acute myeloid leukemia (AML). Activating mutations in FLT3 such as internal tandem duplications (ITD) at the juxtamembrane domain are present in approximately 25-30% of newly diagnosed AML cases. Patients with AML harboring the FLT3-ITD mutation have poorer prognosis following the current induction chemotherapy treatment of cytarabine (AraC) and an anthracycline (daunorubicin [DNR] or idarubicin [IDR]). Azacitidine (Aza) is a treatment option for AML patients who are not eligible for intensive chemotherapy. Gilteritinib, a novel, small molecule inhibitor of the tyrosine kinases FLT3/AXL, is in Phase 3 development for treatment of FLT3 mutation-positive AML, including patients with FLT3-ITD mutations. In previous preclinical studies, gilteritinib has demonstrated superior antitumor effects when given in combination with AraC and either DNR or IDR compared with combination chemotherapy. Here, we report preclinical antileukemic activity of gilteritinib in combination with Aza against FLT3-ITD mutation-positive AML. Methods: The antitumor effects of gilteritinib alone and in combination with Aza were investigated in MV4-11 cells harboring the FLT3-ITD mutation. Apoptosis was detected using annexin V staining via flow cytometry; PARP cleavage was evaluated via Western blot analysis. Anti-apoptotic protein expression was evaluated by Western blot. Furthermore, the combination antitumor effects were evaluated in MV4-11-xenografted nude mice administered once-daily, oral gilteritinib at 3 mg/kg for 21 days alone and concomitantly with once-daily intravenous Aza at 3 mg/kg for 5 days. Pharmacokinetic parameters were also investigated in MV4-11 xenografted nude mice. Statistical differences in antitumor effects of combination therapy versus gilteritinib alone and combination therapy versus Aza alone were assessed on Day 21 using the Student's t-test. Results: Gilteritinib treatment for 48h resulted in an induction of apoptosis in MV4-11 cells as determined by an increase in annexin V-positive cells. When used in combination, gilteritinib augmented the Aza-induced increase in annexin V-positive cells. Gilteritinib also decreased the expression of anti-apoptotic proteins such as MCL-1, BCL2L10, and survivin, which are reported to be important in chemotherapy sensitivity, following 24h treatment. In combination with annexin results, an increase in PARP cleavage was also observed in MV4-11 cells following gilteritinib treatment; cells co-treated with gilteritinib and Aza showed a further increase in PARP cleavage. In mice xenografted with MV4-11 cells, oral gilteritinib (3 mg/kg/day) inhibited the tumor growth by 71%; Aza alone did not suppress tumor growth. The tumor volume in the doublet combination group (94% growth inhibition) was significantly smaller than in each single treatment group on Day 21 (Figure). No obvious influences on body weight, behavior, or diarrhea were noted in the combination group. Plasma concentrations for either gilteritinib or Aza were not considerably increased by their use in combination therapy when compared with the concentrations observed with single treatment. Conclusions: Gilteritinib treatment augmented Aza-induced apoptosis in part by reductions of anti-apoptotic protein expressions in vitro. In the non-clinical models used, gilteritinib, in combination with Aza, showed superior antitumor efficacy compared with each single agent alone. These findings support the development of gilteritinib in combination with Aza as a potential treatment of FLT3-ITD mutation-positive AML. Figure Antitumor Effect of Gilteritinib in Combination with Azacitidine in Mice Xenografted with MV4-11 Cells ***P<.001 vs gilteritinib alone; +++P<.001 vs azacitidine alone (Student's t-test). Figure. Antitumor Effect of Gilteritinib in Combination with Azacitidine in Mice Xenografted with MV4-11 Cells. / ***P<.001 vs gilteritinib alone; +++ P<.001 vs azacitidine alone (Student's t-test). Disclosures Ueno: Astellas Pharma Inc: Employment. Mori:Astellas Pharma Inc: Employment. Kamiyama:Astellas Pharma Inc: Employment. Kaneko:Astellas Pharma Inc: Employment. Isshiki:Astellas Pharma Inc: Employment. Takeuchi:Astellas Pharma Inc: Employment.
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Diller, Elizabeth, and Janelle E. Mann. "Gilteritinib (Xospata®)." Oncology Times 41, no. 4 (February 2019): 14. http://dx.doi.org/10.1097/01.cot.0000553980.60791.5c.
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Cortes, Jorge E., Jessica Altman, Ellen K. Ritchie, Richard A. Larson, David Claxton, Mark D. Minden, Alec Goldenberg, et al. "A phase II/III, multicenter, open-label, 3-arm study of gilteritinib, gilteritinib plus azacitidine, or azacitidine alone in the treatment of newly diagnosed FLT3 mutation-positive acute myeloid leukemia (AML) patients ineligible for intensive induction chemotherapy." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): TPS7068. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.tps7068.
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TPS7068 Background: Gilteritinib, a highly selective, potent FLT3/AXL inhibitor, showed antileukemic activity with favorable tolerability in a Phase 1/2 trial of FLT3 mutation-positive (FLT3mut+) relapsed/refractory AML. In FLT3mut+ AML cell lines, gilteritinib plus azacitidine (AZA) inhibited growth, and induced apoptosis and differentiation. This ongoing Phase 2/3 trial will examine the efficacy, safety, and tolerability of gilteritinib alone, gilteritinib plus AZA or AZA alone in newly diagnosed FLT3mut+AML patients ineligible for intensive induction chemotherapy. Methods: This open-label, 3-arm, 2-stage randomized trial (NCT02752035) will enroll ~540 newly diagnosed adults with FLT3mut+ (FLT3-ITD or -TKD) AML; those with APL, BCR-ABL+, or active CNS leukemia will be excluded. Before initiation, the safety and tolerability of gilteritinib plus AZA will be assessed in a Safety Cohort to establish the appropriate gilteritinib dose for combination therapy. Subjects will then be randomized 1:1:1 to receive oral gilteritinib alone (120 mg daily; Days 1–28), AZA alone (75 mg/m2 by subcutaneous injection or intravenous infusion on Days 1–7), or AZA (75 mg/m2; Days 1–7) plus oral gilteritinib (daily on Days 1–28 at the dose determined from the Safety Cohort), and stratified by age ( < 75 vs ≥75 years). Subjects will continue treatment until a discontinuation event occurs. The primary endpoint is overall survival of subjects receiving gilteritinib or gilteritinib plus AZA versus AZA alone; the key secondary endpoint is event-free survival. Additional secondary endpoints: complete remission rate, leukemia-free survival, remission duration, composite remission rate, tolerability, and fatigue. Dose changes and interruptions are allowed in all treatment arms. A formal interim futility analysis by an Independent Data Monitoring Committee is planned when ~50 subjects in each treatment arm have either discontinued therapy or completed 2 treatment cycles. Enrollment began on November 21, 2016; as of January 31, 2017, the Safety Cohort is ongoing. Clinical trial information: NCT02752035.
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Tarver, Theodore C., Jason E. Hill, Leena Rahmat, Alexander E. Perl, Erkut Bahceci, Kenichi Mori, and Catherine C. Smith. "Gilteritinib is a clinically active FLT3 inhibitor with broad activity against FLT3 kinase domain mutations." Blood Advances 4, no. 3 (February 10, 2020): 514–24. http://dx.doi.org/10.1182/bloodadvances.2019000919.
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Abstract Gilteritinib is the first FMS-like tyrosine kinase 3 (FLT3) tyrosine kinase inhibitor (TKI) approved as monotherapy in acute myeloid leukemia with FLT3 internal tandem duplication and D835/I836 tyrosine kinase domain (TKD) mutations. Sequencing studies in patients have uncovered less common, noncanonical (NC) mutations in FLT3 and have implicated secondary TKD mutations in FLT3 TKI resistance. We report that gilteritinib is active against FLT3 NC and TKI resistance-causing mutations in vitro. A mutagenesis screen identified FLT3 F691L, Y693C/N, and G697S as mutations that confer moderate resistance to gilteritinib in vitro. Analysis of patients treated with gilteritinib revealed that 2/9 patients with preexisting NC FLT3 mutations responded and that secondary TKD mutations are acquired in a minority (5/31) of patients treated with gilteritinib. Four of 5 patients developed F691L mutations (all treated at <200 mg). These studies suggest that gilteritinib has broad activity against FLT3 mutations and limited vulnerability to resistance-causing FLT3 TKD mutations, particularly when used at higher doses.
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Knight, Tristan, Xinan Qiao, Jun Ma, Holly Edwards, Lisa Polin, Juiwanna Kushner, Sijana H. Dzinic, et al. "The Combination of CUDC-907 and Gilteritinib Shows Promising Antileukemic Activity in Vitro and In Vivo in Preclinical Models of FLT3-ITD AML." Blood 134, Supplement_1 (November 13, 2019): 1262. http://dx.doi.org/10.1182/blood-2019-123793.
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Introduction FMS-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutations are found in approximately one quarter of acute myeloid leukemia (AML) cases. Its presence results in constitutive activation of the FLT3 receptor tyrosine kinase and its downstream growth/pro-survival pathways including MAPK/ERK, PI3K/AKT, and JAK/STAT, and confers a poor prognosis. Gilteritinib is a selective inhibitor of FLT3 recently approved by the Food and Drug Administration for treatment of patients with relapsed/refractory AML and a FLT3 mutation. However, gilteritinib exposure induces upregulation of FLT3 - a mechanism of resistance. Previously, we showed that CUDC-907, a dual PI3K/histone deacetylase inhibitor, downregulates FLT3 expression (Li X, et al. Haematologica. 2019; epub ahead of print). We therefore hypothesized that combining CUDC-907 with gilteritinib would abrogate FLT3 upregulation and expression, resulting in synergistic antileukemic activities against FLT3-mutated AML. Methods FLT3-ITD AML cell lines and primary patient samples were treated with gilteritinib or CUDC-907, alone or in combination at clinically achievable concentrations, and subjected to annexin V/propidium iodide staining and flow cytometry analysis to quantify apoptosis. Protein levels of FLT3, Bcl-2 family proteins, and key components of the MAPK/ERK, PI3K/AKT, and JAK/STAT pathways were examined using western blotting. The impact of the observed alterations upon apoptosis were confirmed via overexpression, knockdown, and targeted inhibitor experiments. Real-time RT-PCR was used to determine FLT3 transcript levels. The FLT3-ITD AML cell line MV4-11 was used to generate a xenograft mouse model to assess in vivo efficacy of the two agents. Results CUDC-907 and gilteritinib demonstrated potent synergistic antileukemic effects in FLT3-ITD AML cell lines in vitro and patient samples ex vivo, with combined therapy. CUDC-907 abolished gilteritinib-induced expression of FLT3 in both cell lines and primary patient samples. Gilteritinib treatment reduced p-AKT, p-S6, and p-STAT5 and increased p-ERK, while CUDC-907 reduced p-AKT and p-ERK, and upregulated p-STAT5. The combination of gilteritinib and CUDC-907 decreased not only p-AKT and p-S6, but also p-ERK and p-STAT5. Targeted inhibition of ERK and JAK2/STAT5 signaling by SCH772984 and AZD1480, respectively, confirmed their roles in resistance to gilteritinib and CUDC-907 monotherapies, respectively. Combined gilteritinib and CUDC-907 treatment reduced expression of the anti-apoptotic BCL-2 family member Mcl-1 and increased expression of the pro-apoptotic protein Bim. MCL-1 overexpression and BIM knockdown partially rescued FLT3-ITD AML cells upon drug treatment, confirming their role in the antileukemic activity of combined gilteritinib and CUDC-907. To determine in vivo efficacy of the two agents, NSGS mice were injected with MV4-11 cells. Three days later, the mice were randomized into vehicle control (n=5), 40 mg/kg gilteritinib (oral gavage; n=5), 100 mg/kg CUDC-907 (oral gavage; n=5) or combination (40 mg/kg gilteritinib + 100 mg/kg CUDC-907; n=6) groups. CUDC-907 was given daily for 5 days on, 2 days off, for a total of 4 cycles. Gilteritinib was administered daily for 28 days. Both agents were well tolerated; maximal weight loss was 5.5%, 0.9%, and 6.7% in the CUDC-907, gilteritinib, and combination groups, respectively. Median survival of mice in the vehicle control group was 43 days. Median survival in the CUDC-907 monotherapy and gilteritinib monotherapy arm was 40.5 days and 104 days, respectively. One mouse in the combination therapy arm died on day 138, while the remaining 5 mice in the combination therapy arm continue to survive, as of time of writing (day 168), and are asymptomatic (Figure 1). Conclusion We confirmed that the combination of CUDC-907 plus gilteritinib synergistically induces apoptosis in both FLT3-ITD AML cell lines and primary patient samples, and that gilteritinib-induced FLT3 expression is abolished by CUDC-907. Cooperative inhibition of the PI3K-AKT, JAK-STAT, and RAS-RAF pathways, as well as upregulation of Bim/downregulation of Mcl-1 all appear to contribute to this observed antileukemic synergy. Our cell line-derived xenograft mouse model provides strong evidence of in vivo efficacy and robust grounds for clinical translation of this therapeutic combination. Disclosures No relevant conflicts of interest to declare.
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Izumi, Shintaro, Yosuke Minami, Shinichi Masuda, Yoshikazu Utsu, Emiko Sakaida, and Nobuyuki Aotsuka. "Emergence of Natural Killer Cell Large Granular Lymphocytes during Gilteritinib Treatment in Acute Myeloid Leukemia with FLT3-ITD Mutation." Reports—Medical Cases, Images, and Videos 3, no. 3 (September 17, 2020): 25. http://dx.doi.org/10.3390/reports3030025.
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As the potent, selective Fms-Like Tyrosine Kinase 3 (FLT3) inhibitor gilteritinib has only been approved for use for a few years, its efficacy and complications remain incompletely understood. We herein report an elderly patient with FLT3 internal tandem duplications (FLT3-ITD) mutated acute myeloid leukemia (AML) who developed natural killer cell large granular lymphocytes (NK-LGL) in the bone marrow and peripheral blood during gilteritinib treatment. Case: A 79-year-old Japanese female had been diagnosed with FLT3-ITD-mutated AML. The patient received hydroxycarbamide 2000 mg daily for induction chemotherapy but did not achieve remission at day 28 postinduction. The treatment was then changed to gilteritinib 120 mg daily. Although the reduction of blasts in peripheral blood occurred immediately, it was revealed abnormal lymphocytes with large granules developed in bone marrow and peripheral blood. These lymphocytes were analyzed by flow cytometry, which revealed that these cells were NK-LGL because they expressed CD2, CD7, CD16, and CD56 and did not express CD3, CD19, and CD20. The patient achieved partial remission (PR) in a month with gilteritinib treatment. Leukemia eventually could not be controlled, but PR persisted for about 4 months and leukemia was controlled for 4 months after progression disease (PD) with gilteritinib treatment alone. Conclusion: Gilteritinib may induce the NK-LGL. The exact mechanism and effect of LGL in patients with FLT3 mutated AML treated with gilteritinib warrants further investigation.
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Zhu, Ruiqi, Li Li, Bao Nguyen, Amy S. Duffield, and Donald Small. "Gilteritinib and Venetoclax Synergize to Eliminate FLT3/ITD+ Leukemia Cells through BIM." Blood 134, Supplement_1 (November 13, 2019): 2564. http://dx.doi.org/10.1182/blood-2019-131635.
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Gilteritinib and Venetoclax synergize to eliminate FLT3/ITD+ leukemia cells through BIM Abstract Acute myeloid leukemia (AML) is characterized by a clonal proliferation of immature myeloid cells in the bone marrow or other tissues. The most commonly mutated gene in AML is FMS-like tyrosine kinase (FLT3). FLT3 downstream signaling pathways include PI3K/AKT, STAT5 and MAPK, which affect apoptosis, differentiation and cell proliferation. An internal tandem duplication mutation in FLT3 (FLT3/ITD) is identified in approximately 25% of patients with AML, and this mutation is associated with a particularly poor prognosis. A subset of AML also has a point mutation in the tyrosine kinase domain of FLT3 (FLT3/TKD); however, this mutation does not have the same pronounced impact on prognosis as the FLT3/ITD mutation. Since tyrosine kinases are an attractive drug target, tyrosine kinase inhibitors (TKIs) that target FLT3 have been developed, including recent agents that show enhanced specificity, such as Gilteritinib. Despite these advances, TKI monotherapy continues to show limited success, indicating that combination therapy is likely necessary for the effective treatment of FLT3/ITD AML. As FLT3 signaling pathway activity is known to be anti-apoptotic, in this study we investigated the combinatorial effect of a FLT3-selective TKI and the BCL-2 inhibitor Venetoclax. The BCL-2 protein plays a key role in apoptosis, with anti-apoptotic/prosurvival effects. Venetoclax is a selective BCL-2 inhibitor, and is used clinically in the treatment of chronic lymphocytic leukemia and relapsed/refractory AML. We first investigated the combinatorial effect of treatment with Gilteritinb and Venetoclax in a FLT3/ITD+ leukemia cell line (Molm14). Combined treatment with Gilteritinib (20nM) and Venetoclax (80nM) reduced cell proliferation by 83.7%, as compared to Gilteritinib (62.2%, P<0.05) or Venetoclax (37.3%, P<0.05) alone. The drug combination demonstrated synergy (CI=0.42). Combined treatment shows that these agents act synergistically to enhance apoptosis (88.2%), as compared with Gilteritinib (52.1%, P<0.05) or Venetoclax (12.1%, P<0.05) alone. Moreover, the combined treatment also significantly reduced cell proliferation in patient samples with FLT3/ITD+ and FLT3/TKD mutations. Further experiments with cell line (Molm14 cells resistant to 60nM CEP-701) showed that Venetoclax can re-sensitize FLT3 TKI-resistant cell lines to TKI treatment. Western blot analysis indicates that this effect is mediated by inhibiting MAKP pathway-whose reactivation is an important reason for TKI resistance in FLT3/ITD+ patients. These data demonstrate that combined treatment with Gilteritinb and Venetoclax reduces cell proliferation and enhances apoptosis in a FLT3/ITD leukemia cell line. We next investigated the mechanism of action of this drug combination. BCL-2 and other antiapoptotic proteins in this subfamily (i.e. MCL-1, BCL-XL) exert their pro-survival effects by sequestering BIM. BIM is a proapoptotic protein, that, when released by BCL-2, can activate cell death mediators. These cell death mediators include BAX and BAK, which perforate the mitochondrial membrane, resulting in apoptosis. Venetoclax acts by binding to BCL-2 and displacing BIM, freeing BIM to associate with and activate cell death mediators, resulting in apoptosis. We found that in Molm14 cells, Venetoclax not only dissociates BIM from BCL2, but also decreases expression of BIM and enhances the binding of BIM and MCL-1. In contrast, we found that Gilteritinib increases expression of BIM, reduces the binding of BIM with MCL-1 via a reduction of MCL1 expression, and shows enhanced binding of BIM with BCL2. Cells treated with both Venetoclax and Gilteritinib show dissociation of BIM from both BCL2 and MCL-1, though the interaction between BIM and BCL-XL is not affected. Combination treatment also showed increased binding between BIM and the cell death mediator BAX, leading to increased apoptosis. These studies provide evidence that the addition of Venetoclax may enhance TKI therapy in the treatment of FLT3/ITD leukemia. Additionally, these findings suggest that enhanced cell death in FLT3/ITD AML cells treated with combination therapy occurs because Venetoclax mitigates unintentded pro-survival effects of the TKI, including an increase in BIM expression and increased association between BIM and BCL-2. Disclosures Duffield: MedImmune: Consultancy; Boston Biomedical/Sumitomo Dainippon Pharma Co., Ltd.: Consultancy, Membership on an entity's Board of Directors or advisory committees. Small:Pharos I, B & T: Consultancy, Research Funding; InSilico Medicine: Membership on an entity's Board of Directors or advisory committees.
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Knight, Tristan, Xinan Qiao, Holly Edwards, Hai Lin, Jeffrey W. Taub, and Yubin Ge. "Novel Therapy for FLT3-ITD Acute Myeloid Leukemia Utilizing the Combination of CUDC-907 and Gilteritinib." Blood 132, Supplement 1 (November 29, 2018): 1427. http://dx.doi.org/10.1182/blood-2018-99-111177.
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Abstract Introduction: FMS-like tyrosine kinase 3 (FLT3) is a receptor tyrosine kinase, and is mutated in approximately one third of acute myeloid leukemia (AML) patients; this mutation confers a poor prognosis. Two FLT3 mutations are commonly seen in AML: internal tandem duplications (ITD) in the juxtamembrane domain (~25% of AML), and point mutations in the receptor tyrosine kinase at codon 835 (D835) (~7% of AML). Both mutations result in constitutive FLT3 activation, causing downstream activation of multiple pathways, in particular, those involved in cell survival including the RAS-RAF-MEK-ERK, JAK-STAT5, and PI3K/AKT pathways. PI3K-AKT may also be activated by AXL, also a tyrosine kinase, via its targets PLC, Grb2, and PI3K. Logically, then, inhibition of FLT3 is a promising pharmacological approach for treating this subtype of AML. Gilteritinib (ASP-2215) is a novel dual inhibitor of FLT3 and AXL, exposure to which results in upregulation of FLT3 as a resistance mechanism. Previously, we found that the novel dual PI3K/histone deacetylase (HDAC) inhibitor CUDC-907 downregulates FLT3 expression in AML cells (Figure 1A). Additionally, inhibition of FLT3 and AXL by gilteritinib may not result in robust inactivation of both the PI3K-Akt and MEK/ERK pathways due to crosstalk between the two pathways. Thus, our hypothesis was that CUDC-907 would sensitize AML cells to gilteritinib, resulting in concurrent inhibition of all the downstream signaling pathways of FLT3 and AXL, leading to synergistic antileukemic activities again FLT3-mutated AML (Figure 1B). Methods: FLT3-ITD AML cell lines (MV4-11 and MOLM-13) and primary patient samples were treated with CUDC-907, gilteritinib, both, or neither for 24 hours, at clinically achievable concentrations. Annexin V/Propidium Iodide (PI) staining and flow cytometry analyses was performed, and combination indexes (CI) calculated; CI<1, CI=1, and CI>1 indicating synergistic, additive, or antagonistic effects, respectively. Western blots were performed after treatment for 0-24 hours to determine protein expression of relevant targets. Results: CUDC-907 and gilteritinib demonstrated potent synergistic antileukemic effects in FLT3-ITD AML cell lines and FLT3-ITD patient samples (AML#171, AML#180), the combination exceeding either in isolation (Figure 1C). These findings were confirmed via western blot, which showed accentuated upregulation of cleaved caspase3 with combination therapy, in both cell lines and one patient sample, demonstrating drug-induced apoptosis. We confirmed that CUDC-907 abolishes gilteritinib-induced expression of FLT3 in a time-dependent fashion in cell lines MV4-11 and MOLM-13 (Figure 1D). Gilteritinib treatment decreased p-AKT, p-S6, and p-STAT5, while inhibition of the ERK pathway, as assessed by p-ERK expression, varied amongst the samples (Figure 1E). CUDC-907 treatment decreased both p-AKT and p-ERK. MOLM-13 cells showed increased p-ERK following gilteritinib treatment and increased p-STAT5 after CUDC-907 treatment. In all samples, combination of gilteritinib with CUDC-907 resulted in decrease of p-STAT5 and p-S6, similar to gilteritinib treatment alone, and further reduction of p-AKT and p-ERK compared to single drug treatments. Gilteritinib treatment also reduced expression of anti-apoptotic protein Mcl-1, which was further decreased in combination treated cells. Subsequently, time-course analysis was performed in both cell lines; findings were consistent with prior observations, and confirmed that protein expression changed over time, in relation to gilteritinib/CUDC-907/combined treatment exposure. Conclusion: We confirmed that CUDC-907 and Gilteritinib synergistically induce apoptosis in both cell lines and primary patient samples derived from patients with FLT3-ITD AML, and that CUDC-907 abolishes Gilteritinib-induced FLT3 expression. Additionally, the combination cooperatively inhibits the PI3K-AKT, JAK-STAT, and RAS-RAF pathways, while preventing escape via alternative pathways. Our results provide a strong foundation for subsequent in vivo murine studies, and eventual clinical evaluation of the combination of gilteritinib and CUDC-907 for the treatment of AML. Figure 1. Figure 1. Disclosures Ge: MEI Pharma: Research Funding.
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Dhillon, Sohita. "Gilteritinib: First Global Approval." Drugs 79, no. 3 (February 2019): 331–39. http://dx.doi.org/10.1007/s40265-019-1062-3.
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McMahon, Christine M., Jonathan Canaani, Bryan Rea, Rachel L. Sargent, Julianne N. Qualtieri, Christopher D. Watt, Jennifer J. D. Morrissette, Martin Carroll, and Alexander E. Perl. "Gilteritinib induces differentiation in relapsed and refractory FLT3-mutated acute myeloid leukemia." Blood Advances 3, no. 10 (May 23, 2019): 1581–85. http://dx.doi.org/10.1182/bloodadvances.2018029496.
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Key Points Gilteritinib induces 2 distinct marrow responses in FLT3-mutated AML: responses with and without differentiation. Ongoing clonal hematopoiesis is ubiquitous during gilteritinib therapy and may promote genetic evolution and drug resistance.
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Zeidan, Amer M., Adrienne M. Gilligan, Santosh Gautam, David L. Grinblatt, Dina Elsouda, Loretta Sullivan, and Bhavik J. Pandya. "Streamline - Retrospective Cohort Study of Relapsed or Refractory (R/R) FLT3-Mutated Acute Myeloid Leukemia (AML): Real-World Treatment, Testing Patterns, and Outcomes." Blood 136, Supplement 1 (November 5, 2020): 30–31. http://dx.doi.org/10.1182/blood-2020-136366.
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Introduction: The past decade in AML research has led to increased emphasis on disease-related mutations and associated targeted therapies. FMS-like tyrosine kinase 3 (FLT3) mutations (FLT3+) are found in about 30% of AML patients and confer a poorer prognosis. Also, the availability of targeted therapies increases the value of testing for FLT3+ AML. A paucity of data exists regarding the real-world FLT3 testing rates in AML patients in both the newly diagnosed and R/R settings. As the treatment landscape for patients with R/R FLT3+ AML expands, it is important to understand how utilization of these therapies and trends in FLT3 testing impact patient outcomes in real-world settings. These updated results examined FLT3 testing trends, treatment patterns, and overall survival (OS) in patients with R/R FLT3+ AML. Patients were grouped based on the FDA approval of the second-generation FLT3 inhibitor gilteritinib (pre-gilteritinib approval vs. post-gilteritinib approval). Methods: This ongoing (01/01/2015-4/17/2020) retrospective study uses electronic medical record data of US patients from a network of 400+ oncology practices maintained in the Definitive Oncology Dataset, including practices affiliated with CancerLinQ. Eligible adult (≥18 years) patients who had a confirmed diagnosis of AML, FLT3+ status, and had ≥1 R/R event between 01/01/2015 and 02/20/2020 were included. FLT3 testing trends included testing performed at initial diagnosis, re-testing performed in the R/R setting, and changes in FLT3 mutation status. Treatment patterns included all systemic anticancer therapies received (including supportive care) for R/R FLT3+ AML. OS was measured from the first R/R event; patients without evidence of death were censored at the last observed visit. Kaplan-Meier analysis was applied to evaluate differences in OS by subsequent hematopoietic stem cell transplant (HSCT) status. Results: Data from 175 patients (50.9% male, n=89) with R/R FLT3+ AML were evaluated (n=124 pre-gilteritinib; n=51 post-gilteritinib). Most patients were White (72.0%; n=126) with a median age of 62 years (range: 20-86) at first R/R event. Median length of follow-up was limited for the post-gilteritinib cohort (9.2 months vs. 15.0 months for pre-gilteritinib, P<0.001). Patients tested for FLT3 mutations at initial AML diagnosis increased from 84.7% (n=105/124) in the pre-gilteritinib cohort to 98.0% (n=50/51) in the post-gilteritinib cohort, and the rates of re-testing increased from 29.5% (n=31/105) to 46.0% (n=23/50) across the two cohorts (Figure 1). After the first R/R event, 18.9% (n=33/175) reported changes in their FLT3 mutation status. Seventy-four different treatment combinations were utilized at the first R/R event. Use of FLT3 tyrosine kinase inhibitors (TKIs), either alone or in combination with chemotherapy, increased from 30.6% (n=38/124) in the pre-gilteritinib cohort to 49.0% (n=25/51) in the post-gilteritinib cohort (Table 1). In the pre-gilteritinib cohort midostaurin (52.6%, n=20/38) and sorafenib (32.4%, n=13/38) were the most commonly prescribed FLT3 TKIs. In the post-gilteritinib cohort, the most common FLT3 TKI was gilteritinib (52.0%, n=13/25). Median OS (95% CI) across all patients at the first R/R event was 13.4 (9.0-17.6) months in the pre-gilteritinib cohort and 12.9 (7.0, NA) months in the post-gilteritinib cohort. Median OS was significantly shorter among patients that did not receive HSCT among all patients and the subset of treated patients (P<0.05 for both values). Median OS for patients with no HSCT was 3.9 months longer in the post-gilteritinib cohort versus the pre-gilteritinib cohort (Table 2). Conclusion: An increase in FLT3 TKI use (both monotherapy and in combination) and a decrease in high-intensity chemotherapy was observed across the two cohorts. In the 18-month post approval period, FLT3 TKI use increased 60% with gilteritinib accounting for more than half of FLT3 TKIs used in the R/R setting. FLT3 re-testing increased by 55% in the R/R setting between the two cohorts; however, re-testing is suboptimal and there is a need to re-test as patients progress. Among pre- and post-treated patients that did not receive HSCT, there was an improvement in OS by almost 4 months, possibly due to increased use of targeted FLT3 TKIs. With recent approval of these targeted therapies, it will be important to continue to monitor FLT3 testing, treatment patterns, and clinical outcomes. Disclosures Zeidan: Celgene / BMS: Consultancy, Honoraria, Research Funding; Daiichi Sankyo: Consultancy, Honoraria; Agios: Consultancy, Honoraria; Ionis: Consultancy, Honoraria; BeyondSpring: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; CCITLA: Other; Astex: Research Funding; Cardinal Health: Consultancy, Honoraria; Trovagene: Consultancy, Honoraria, Research Funding; Seattle Genetics: Consultancy, Honoraria; Leukemia and Lymphoma Society: Other; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Jazz: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Taiho: Consultancy, Honoraria; Aprea: Research Funding; ADC Therapeutics: Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Epizyme: Consultancy, Honoraria; MedImmune/Astrazeneca: Research Funding; Acceleron: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Incyte: Consultancy, Honoraria, Research Funding; Cardiff Oncology: Consultancy, Honoraria, Other. Gilligan:ConcertAI: Current Employment. Grinblatt:Astellas: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Alexion: Speakers Bureau. Elsouda:Astellas: Current Employment. Sullivan:Astellas Pharma: Current Employment. Pandya:Astellas Pharma, Inc.: Current Employment.
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Pandya, Bhavik J., Cynthia Z. Qi, Hongbo Yang, Andy Garnham, Manasee V. Shah, and Amer M. Zeidan. "Comparison of Gilteritinib and Salvage Chemotherapy in FLT3-Mutated Acute Myeloid Leukemia on the Number Needed to Treat for Various Clinical Outcomes: A Secondary Analysis of the Admiral Trial." Blood 136, Supplement 1 (November 5, 2020): 7. http://dx.doi.org/10.1182/blood-2020-136184.
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Introduction/background: FMS-like receptor tyrosine kinase-3 (FLT3) mutations are common in acute myeloid leukemia (AML) and are associated with poor prognosis. Historically, patients with relapsed/refractory (R/R) FLT3 mutation-positive (FLT3mut+) AML experienced dismal survival outcomes. Gilteritinib, a highly potent and selective FLT3 inhibitor, was recently approved as the first targeted therapy for patients with R/R FLT3mut+ AML, and has the potential to bring significant clinical benefits to these patients. The randomized, phase 3 ADMIRAL trial (NCT02421939; Perl, et al. 2019) was the first head-to-head study that evaluated 120-mg/day gilteritinib versus salvage chemotherapy in R/R FLT3mut+ AML patients. The ADMIRAL trial demonstrated that gilteritinib was superior to salvage chemotherapy based on significantly longer median overall survival (OS) and higher response rates, including complete remission/complete remission with partial hematological recovery (CR/CRh), composite CR (CRc), and hematopoietic stem cell transplantation (HSCT) rate. Based on these results, the current study estimated the number needed to treat (NNT) with gilteritinib, compared with salvage chemotherapy, in order to evaluate its clinical benefit with CR/CRh, CRc, 1-year OS, and HSCT rates. Methods: NNT is an established and easily interpretable measure to assess the effectiveness of healthcare interventions. The clinical event estimates (ie, CR/CRh rate, CRc rate, 1-year OS, and HSCT rate) of gilteritinib and salvage chemotherapy among R/R FLT3mut+ AML patients were obtained from the ADMIRAL trial. CR/CRh was defined as the combined rate of CR and CRh. CRc was defined as the combination of CR, CR with incomplete hematologic recovery, and CR with incomplete platelet recovery. OS was defined as time from randomization to death due to any cause. The NNT is calculated as the inverse of the absolute rate difference between the event rates of gilteritinib and salvage chemotherapy. Positive NNT values represent treatment benefit, with lower values indicating greater benefit of gilteritinib over salvage chemotherapy. The 95% confidence interval (CI) of the NNT was derived from the 95% CI of the event rate difference. Results: In the ADMIRAL trial, patients assigned to gilteritinib had significantly higher CR/CRh rates (34.0% vs 15.3%) and CRc rates (54.3% vs 21.8%) than patients assigned to salvage chemotherapy. The NNT for CR/CRh and CRc was 5.35 (95% CI: 3.66, 9.98) and 3.08 (95% CI: 2.38, 4.36), suggesting that treating five and three patients with gilteritinib instead of salvage chemotherapy would result in one additional patient achieving CR/CRh and CRc, respectively. With respect to the survival outcome, patients randomized to gilteritinib had significantly prolonged OS compared to those randomized to salvage chemotherapy (median OS: 9.3 vs 5.6 months; hazard ratio: 0.64); rates of 1-year survival were 37.1% versus 16.7%, respectively. The NNT comparing gilteritinib with salvage chemotherapy was 4.90 (95% CI: 3.29, 9.64) for 1-year OS, which suggests that treating approximately five patients with gilteritinib instead of salvage chemotherapy would lead to one additional survivor at the end of the first year. Lastly, more patients underwent HSCT in the gilteritinib arm versus the salvage chemotherapy arm (25.5% vs 15.3%); the corresponding NNT was estimated at 9.82 (95% CI: 5.40, 54.59) for gilteritinib versus salvage chemotherapy. Conclusion: The results demonstrated that treatment with gilteritinib compared with salvage chemotherapy leads to more R/R FLT3mut+ AML patients achieving CR/CRh, CRc, and proceeding to HSCT, as well as more patients remaining alive at 1 year. This NNT analysis supports the superior clinical benefit of gilteritinib versus salvage chemotherapy in R/R FLT3mut+ AML patients. Disclosures Pandya: Astellas Pharma, Inc.: Current Employment. Qi:BMS: Other: Employee of Analysis Group Inc., which received consulting fees; Astellas Pharma, Inc.: Research Funding. Yang:Analysis Group Inc.: Current Employment; Takeda Pharmaceutical Company Ltd: Research Funding. Garnham:Astellas Pharma, Inc.: Current Employment. Shah:Astellas: Current Employment. Zeidan:Taiho: Consultancy, Honoraria; Celgene / BMS: Consultancy, Honoraria, Research Funding; Cardinal Health: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Abbvie: Consultancy, Honoraria, Research Funding; Trovagene: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria; CCITLA: Other; ADC Therapeutics: Research Funding; Seattle Genetics: Consultancy, Honoraria; Aprea: Research Funding; MedImmune/Astrazeneca: Research Funding; Astex: Research Funding; Daiichi Sankyo: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Acceleron: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Incyte: Consultancy, Honoraria, Research Funding; Jazz: Consultancy, Honoraria; Agios: Consultancy, Honoraria; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Epizyme: Consultancy, Honoraria; Leukemia and Lymphoma Society: Other; Ionis: Consultancy, Honoraria; Takeda: Consultancy, Honoraria, Research Funding; BeyondSpring: Consultancy, Honoraria; Cardiff Oncology: Consultancy, Honoraria, Other.
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Perl, Alexander E., Qiaoyang Lu, Alan Fan, Nahla Hasabou, Erhan Berrak, and Ramon V. Tiu. "Clinical Outcomes Following Treatment with Gilteritinib or Quizartinib in Patients with Relapsed/Refractory FLT3-ITD+ Acute Myeloid Leukemia." Blood 136, Supplement 1 (November 5, 2020): 42–43. http://dx.doi.org/10.1182/blood-2020-136118.
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Background: Gilteritinib is approved for patients (pts) with relapsed/refractory (R/R) FLT3-mutated acute myeloid leukemia (AML), based on findings from the phase 3 ADMIRAL trial (Perl AE, et al. N Engl J Med. 2019). A phase 3 trial, QuANTUM-R, demonstrated the benefit of quizartinib in pts with R/R AML with FLT3 internal tandem duplication (FLT3-ITD) mutations (Cortes JE, et al. Lancet Oncol. 2019). Although eligibility criteria across both studies were similar, QuANTUM-R was more stringent as to prior therapy intensity and remission duration, which potentially enriched for higher-risk pts. We sought to describe outcomes from ADMIRAL among pts who otherwise met eligibility for QuANTUM-R. Methods: In this post-hoc analysis, a subset of pts from ADMIRAL were matched with R/R FLT3-ITD+ AML pts from QuANTUM-R on the basis of baseline characteristics and prior treatment criteria. Matched pts were either refractory to initial anthracycline-based chemotherapy or had relapsed ≤6 mos after achieving composite complete remission (CRc) with an anthracycline-based regimen. Results: Overall, 218 pts with R/R FLT3-ITD+ AML in the ADMIRAL trial (gilteritinib, n=140; salvage chemotherapy [SC], n=78) were matched with the QuANTUM-R intention-to treat (ITT) population (N=367; quizartinib, n=245; SC, n=122). Proportions of pts preselected for high-intensity SC were 66% (n=143/218) in the matched ADMIRAL ITT population and 77% (n=281/367) in the QuANTUM-R ITT populations. Demographic and baseline characteristics of the matched ADMIRAL ITT population and QuANTUM-R ITT population were similar. Median durations of exposure to gilteritinib and quizartinib were 3.8 mos and 3.2 mos, respectively, and median number of treatment cycles received were five and four, respectively. Rates of hematopoietic stem cell transplantation (HSCT) were similar in pts treated with gilteritinib (35%; n=49/140) or quizartinib (32%; n=78/245), as were the proportions of pts who resumed gilteritinib (23%; n=32/140) or quizartinib (20%; n=48/245) therapy post-HSCT. Median overall survival (OS) in pts treated with gilteritinib or quizartinib was longer than that observed with SC. After a median follow-up of 17.4 mos, median OS was 10.2 mos with gilteritinib versus 5.6 mos with SC (hazard ratio [HR]=0.573 [95% CI: 0.403, 0.814]; one-sided nominal P=0.0008). After a median follow-up of 23.5 mos, median OS with quizartinib was 6.2 mos versus 4.7 mos with SC (HR=0.76 [95% CI: 0.58-0.98]; one-sided P=0.02). After censoring for HSCT, median OS was 9.3 mos with gilteritinib versus 5.5 mos with SC (HR=0.525 [95% CI: 0.356-0.775]; nominal one-sided P=0.0005), and 5.7 mos versus 4.6 mos with quizartinib versus SC, respectively (HR=0.79 [95% CI: 0.59, 1.05]; one-sided P=0.05). In both QuANTUM-R and matched ADMIRAL populations, the survival benefits of quizartinib and gilteritinib compared with SC were maintained across multiple subgroups, including high FLT3-ITD allelic ratio subsets. Compared with SC, high CRc rates were observed in pts treated with either gilteritinib (57%; n=80/140) or quizartinib (48%; n=118/245). The complete remission (CR) rate with gilteritinib was 23% (n=32/140), whereas the CR rate with quizartinib was 4% (n=10/245) (Table). Median time to achieve CRc was 1.8 mos with gilteritinib and 1.1 mos with quizartinib, median duration of CRc was 5.5 mos with gilteritinib and 2.8 mos with quizartinib. The safety profiles of gilteritinib and quizartinib were generally similar, though aspartate or alanine aminotransferase elevations (any grade) were more frequent with gilteritinib (41-44%) than quizartinib (≤13%), whereas neutropenia (14% vs 34%, respectively), fatigue (24% vs 39%, respectively), and prolonged QT intervals (9% vs 27%, respectively) were more frequent with quizartinib. Conclusions: In pts with R/R FLT3-ITD+ AML and similar baseline characteristics, both gilteritinib and quizartinib were generally well tolerated and associated with improved survival and treatment response compared with SC. Responses to gilteritinib and quizartinib, as measured by CRc, were similar; blood count recovery varied between the two FLT3 inhibitors. Although cross-study comparisons have substantial limitations, the findings suggest that while remission is achieved faster with quizartinib, response may be more durable and survival potentially longer with gilteritinib. Disclosures Perl: Syndax: Consultancy, Honoraria; Leukemia & Lymphoma Society, Beat AML: Consultancy; Novartis: Honoraria, Other, Research Funding; Agios: Consultancy, Honoraria, Other; Jazz: Honoraria, Other; FORMA Therapeutics: Consultancy, Honoraria, Other; Daiichi Sankyo: Consultancy, Honoraria, Other: Writing/editorial support, travel costs for meetings, Research Funding; FUJIFILM Pharmaceuticals USA, Inc: Research Funding; New Link Genetics: Honoraria, Other; Arog Pharmaceuticals Inc: Other: uncompensated consulting, travel costs for meetings; Actinium Pharmaceuticals Inc: Consultancy, Honoraria, Research Funding; Biomed Valley Discoveries: Research Funding; Astellas: Consultancy, Honoraria, Other: writing/editorial support, travel costs for meeting presentations related to study, Research Funding; Bayer HealthCare Pharmaceuticals: Research Funding; AbbVie Inc: Consultancy, Honoraria, Other, Research Funding; Takeda: Honoraria, Other: Travel costs for meeting; Loxo Oncology Inc, a wholly owned subsidiary of Eli Lilly & Company: Consultancy, Honoraria, Other. Lu:Astellas: Current Employment. Fan:Astellas Pharma: Current Employment. Hasabou:Astellas Pharma: Current Employment. Berrak:Astellas: Current Employment. Tiu:Eli Lilly & Company: Current equity holder in publicly-traded company, Ended employment in the past 24 months; Astellas Pharma Global Development: Current Employment.
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Levis, Mark J., Alexander E. Perl, Giovanni Martinelli, Jorge E. Cortes, Andreas Neubauer, Ellin Berman, Pau Montesinos, et al. "Effect of gilteritinib on survival in patients with FLT3-mutated (FLT3mut+) relapsed/refractory (R/R) AML who have common AML co-mutations or a high FLT3-ITD allelic ratio." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): 7000. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.7000.
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7000 Background: The FLT3 inhibitor, gilteritinib, showed superior response and overall survival (OS) compared with salvage chemotherapy (SC) in patients (pts) with FLT3mut+ R/R AML in the phase 3 ADMIRAL study. We analyzed the impact of baseline co-mutations and FLT3-ITD allelic ratio (AR) on response and OS. Methods: A total of 37 recurrently mutated genes in AML (Archer Core Myeloid Panel) were analyzed by next-generation sequencing; the cutoff for co-mutation positivity (co-mut+) was ≥0.027. Baseline FLT3-ITD AR ( FLT3-ITD to FLT3 wild-type DNA) was measured by the LeukoStrat CDx FLT3 Mutation Assay. The median FLT3-ITD AR value of 0.77 was used to define high (≥0.77) vs low (<0.77) FLT3-ITD AR. Results: Analysis of 361 FLT3mut+ pts identified four major co-mutation cohorts, each with ≥10% of pts: NPM1 (n=173; 47.9%), DNMT3A (n=115; 31.9%), DNMT3A/NPM1 (n=86; 23.8%) , and WT1 (n=65; 18.0%). In addition, seven pts (1.9%) had all three co-mutations (ie, NPM1, DNMT3A, and WT1). The gilteritinib arm had superior response rates and OS across all four major co-mutation cohorts, with the greatest survival benefit in pts with DNMT3A/NPM1 co-mut+ (Table). In FLT3-ITD AR analyses (n=335), gilteritinib conferred longer OS than SC in pts with a high or low FLT3-ITD AR (gilteritinib: high FLT3-ITD AR, 7.1 mos vs low FLT3-ITD AR, 10.6 mos; SC: high FLT3-ITD AR, 4.3 mos vs low FLT3-ITD AR, 6.9 mos). In both arms, OS was longer in the low FLT3-ITD AR cohort than the high FLT3-ITD AR cohort but the difference in the gilteritinib arm was not statistically significant (gilteritinib: HR=1.341, P=0.0712; SC: HR=2.01, P=0.0021). Conclusions: The ADMIRAL trial shows that the clinical benefit of gilteritinib in FLT3mut+ R/R AML is maintained regardless of NPM1, DNMT3A, DNMT3A/ NPM1, or WT1 co-mut+ or high FLT3-ITD AR. Clinical trial information: NCT02421939. [Table: see text]
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Grinblatt, David L., Bhavik J. Pandya, Wei Han, Loretta Sullivan, Qi Feng, and Nancy Hedlund. "Real-World Use of FLT3-TKIs in R/R FLT3-Mutated AML in the United States." Blood 136, Supplement 1 (November 5, 2020): 24–25. http://dx.doi.org/10.1182/blood-2020-136391.
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Background: Targeted inhibition of the FLT3 tyrosine kinase is a treatment strategy for patients with relapsed or refractory, FLT3 mutation-positive acute myeloid leukemia (R/R FLT3mut+ AML). While the multikinase inhibitors, sorafenib and midostaurin, were not approved specifically for R/R AML, they are used off-label as treatment. Since FDA approval on 11/28/2018, gilteritinib has become the first globally approved targeted therapy for the treatment of R/R FLT3mut+ AML in adults. This study aims to understand the treatment landscape for R/R FLT3mut+ AML patients following the introduction of a new therapeutic agent. Aim/Objective: To describe the characteristics and treatment patterns of patients initiating FLT3 tyrosine kinase inhibitors (TKIs) for R/R FLT3mut+ AML in the real-world setting. Methods: This US-based retrospective cohort study was conducted using two separate closed-claims databases (MarketScan, 1/1/2007-2/29/2020; IQVIA, 1/1/2006-4/30/2020) and a specialty-pharmacy claims database (ProMetrics, 12/6/2018-3/12/2020). Patients ≥18 years of age, with an AML diagnosis and newly initiated FLT3-TKI (ie, gilteritinib, midostaurin, or sorafenib) therapy for R/R diagnosis or episode ("R/R AML") on or after gilteritinib market availability were eligible for inclusion. Patients were indexed on the first newly initiated FLT3-TKI for R/R AML observed on or after 12/1/2018. Patients' baseline clinical and demographic characteristics, AML-related treatments preceding FLT3-TKI initiation for R/R AML, and concomitant therapies (defined as any AML-related treatment overlapping with FLT3-TKI use after R/R AML) were identified. Because individual patients could have received more than one FLT3-TKI during the study period, treatment sequencing was analyzed by FLT3-TKI-containing regimens. Given the larger sample size available within the ProMetrics Specialty Pharmacy database, gilteritinib dose patterns and treatment duration were analyzed using de-identified dispensed prescription data from a separate gilteritinib-only cohort for greater precision. Descriptive statistics were used to evaluate all study outcomes, except for treatment duration, which was estimated using Kaplan-Meier life table analysis. Results: A total of 52 and 51 patients initiating FLT3-TKIs for R/R AML were identified in the MarketScan and IQVIA databases, respectively. The mean age of patients was 53.1 (MarketScan) and 52.3 years (IQVIA); patients had a mean ± SD Quan-Charlson Comorbidity Index of 3.6 ± 2.4 (MarketScan) and 3.7 ± 2.2 (IQVIA). Most patients treated with FLT3-TKIs for R/R AML during the study period were first initiated on gilteritinib (MarketScan: n=35 [67.3%], IQVIA: n=36 [70.6%]); sorafenib was the second most common FLT3-TKI (MarketScan: n=9 [17.3%], IQVIA: n=8 [15.7%]), followed by midostaurin (MarketScan: n=8 [15.4%], IQVIA: n=7 [13.7%]). During the study period, 61 and 55 FLT3-TKI-containing regimens among 52 and 51 R/R AML patients were identified across the MarketScan and IQVIA databases, respectively. Most FLT3-TKI-containing regimens for R/R AML included gilteritinib (MarketScan: n=43 [70.5%], IQVIA: n=38 [69.1%]). Prior exposure to other FLT3-TKIs for new onset and/or R/R AML indications was observed in up to 63% of gilteritinib-, 56% of sorafenib-, and 13% of midostaurin-containing regimens (Table). Following onset of R/R AML, gilteritinib was given without concomitant chemotherapy in 47% (Marketscan: 20/43) to 55% (IQVIA: 21/38) of gilteritinib regimens; in a smaller sample of sorafenib regimens, sorafenib was given without concomitant chemotherapy in up to 56% (IQVIA: 5/9) of regimens. Of 748 patients identified in the ProMetrics database with gilteritinib claims, 714 (95%) patients were initiated on a 120-mg daily dose, with less than 5% (n=34) incurring a downward dosage titration. The median treatment duration was 150 days (95% CI: 129-172 days). Conclusions: Among FLT3-TKI-containing regimens initiated for R/R AML after gilteritinib market approval, close to 70% included gilteritinib, an agent approved for R/R FLT3mut+ AML. Sample sizes for midostaurin- and sorafenib-containing regimens limited characterization of treatment patterns. Gilteritinib was given without concomitant chemotherapy in approximately 50% of regimens prescribed; the dose and treatment durations were similar to those previously reported by the ADMIRAL trial. Disclosures Grinblatt: Astellas: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Alexion: Speakers Bureau. Pandya:Astellas Pharma, Inc.: Current Employment. Sullivan:Astellas Pharma: Current Employment. Feng:Astellas: Current Employment. Hedlund:Astellas: Current Employment.
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Sidaway, Peter. "Gilteritinib improves outcomes in AML." Nature Reviews Clinical Oncology 17, no. 2 (November 19, 2019): 69. http://dx.doi.org/10.1038/s41571-019-0305-2.
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Zeidan, Amer M., Cynthia Z. Qi, Bhavik J. Pandya, Andy Garnham, Hongbo Yang, and Manasee V. Shah. "Cost-Effectiveness Analysis of Gilteritinib Versus Salvage Chemotherapy (SC) for the Treatment of Relapsed or Refractory (R/R) FLT3-Mutated (FLT3mut+) Acute Myeloid Leukemia (AML)." Blood 134, Supplement_1 (November 13, 2019): 3859. http://dx.doi.org/10.1182/blood-2019-123819.
Full textAbstract:
Introduction: FLT3 is a frequently mutated gene in approximately one-third of AML cases and is associated with a poor prognosis. Few effective therapeutic options exist for patients with R/R FLT3mut+ AML. In 2018, gilteritinib was approved in the US as the first targeted therapy indicated for R/R FLT3mut+ AML. The efficacy of gilteritinib was established in the ADMIRAL trial, a phase 3 randomized trial, in comparison with SC (i.e., low-dose cyctarbine [LDAC], azacitidine, mitoxantrone + etoposide + cytarabine [MEC], and fludarabine + cytarabine + granulocyte colony stimulating factor + idarubicin [FLAG-IDA]). The results from the trial indicated that gilteritinib significantly improved overall survival (OS) compared to SC with 1-year survival rates of 37% vs. 17%. To inform the value of gilteritinib, this study aimed to assess the cost-effectiveness of gilteritinib for the treatment of R/R FLT3mut+ AML from a US third-party payer's perspective. Methods: A cost-effectiveness analysis (CEA) model was developed using monthly cycles and a 3% discount rate to assess the incremental cost effectiveness of gilteritinib compared to SC over a lifetime horizon. The model structure comprised a decision tree followed by two three-state partitioned survival models. The decision tree component stratified patients based on whether they received allogeneic hematopoietic stem cell transplantation (HSCT) following treatment initiation. The partitioned survival components included three health states: event-free survival (EFS), alive and post-event, and death. The selected model structure was chosen because HSCT is a key clinical event that has a significant impact on treatment outcomes for the target population. The efficacy inputs (OS and EFS) varied by HSCT status. The efficacy inputs for OS and EFS without HSCT were estimated based on the ADMIRAL trial. The efficacy inputs for OS and EFS with HSCT were assumed to be the same for both gilteritinib and SC and were based on available literature (Evers 2018). Parametric survival models or HRs were used to predict probabilities of being in different health states until year 3. Afterwards, all patients who remained alive were considered long-term survivors and their mortality risk was twice that of the general population based on literature. Treatment costs (drug, administration, and hospitalization), adverse event (AE) costs, subsequent HSCT costs, medical costs for each health state, FLT3 mutation testing, post-progression treatment, and terminal care costs were obtained from public databases and literature. For SC, the same regimen composition (i.e., LDAC, azacitidine, MEC, and FLAG-IDA) as the ADMIRAL trial was considered to estimate the treatment costs. All costs were inflated to 2018 US dollar (USD). Utilities for each health state were derived from the ADMIRAL trial and disutilities for AEs were derived from the literature. Total incremental costs, total incremental LYs, and total incremental QALYs were calculated. Incremental cost-effectiveness ratios (ICERs), defined as the incremental cost per additional gain in health effect (i.e., LY and QALY), were used to assess the economic value of gilteritinib relative to SC. Deterministic sensitivity analyses (DSA) and probabilistic sensitivity analyses (PSA) were also performed to test the robustness of the base-case results. Results: Over a lifetime horizon, the base-case model estimated that treatment with gilteritinib led to an increase of 1.55 discounted LYs and an increase of 1.29 discounted QALYs at an additional cost of $141,097 relative to SC; the corresponding incremental cost per LY gained was $90,761, and incremental cost per QALY gained was $109,741. Cost-effectiveness was most sensitive to gilteritinib cost, HSCT rate, and discount rate. In the PSA, the estimated probability that gilteritinib is cost-effective was 93.5% at an acceptable willingness-to-pay threshold of $150,000/QALY. Conclusions: Gilteritinib demonstrated greater LY and QALY improvements compared with SC. With an ICER of $109,741/QALY, gilteritinib is a cost-effective strategy from a US third-party payer's perspective, based on the $150,000/QALY threshold recommended by the US Institute for Clinical and Economic Review. Compared to SC, gilteritinib represents a new active treatment option for R/R FLT3mut+ AML patients that provides better health outcomes with a favorable cost-effectiveness profile. Disclosures Zeidan: Trovagene: Consultancy, Honoraria, Research Funding; Medimmune/AstraZeneca: Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Ariad: Honoraria; Novartis: Honoraria; Astellas: Honoraria; Daiichi Sankyo: Honoraria; Cardinal Health: Honoraria; Seattle Genetics: Honoraria; BeyondSpring: Honoraria; Incyte: Consultancy, Honoraria, Research Funding; Acceleron Pharma: Consultancy, Honoraria, Research Funding; Celgene Corporation: Consultancy, Honoraria, Research Funding; Abbvie: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria, Research Funding; Agios: Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; ADC Therapeutics: Research Funding; Jazz: Honoraria. Qi:Astellas: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Astellas for the conduct of this study; Analysis Group, Inc.: Employment. Pandya:Astellas Pharmaceuticals: Employment. Garnham:Astellas: Employment. Yang:Analysis Group, Inc.: Employment; Astellas: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Astellas for the conduct of this study. Shah:Astellas: Employment.
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Esteve, Jordi, Rik Schots, Teresa Bernal Del Castillo, Je-Hwan Lee, Eunice S. Wang, Shira Dinner, Mark D. Minden, et al. "Multicenter, Open-Label, 3-Arm Study of Gilteritinib, Gilteritinib Plus Azacitidine, or Azacitidine Alone in Newly Diagnosed FLT3 Mutated (FLT3mut+) Acute Myeloid Leukemia (AML) Patients Ineligible for Intensive Induction Chemotherapy: Findings from the Safety Cohort." Blood 132, Supplement 1 (November 29, 2018): 2736. http://dx.doi.org/10.1182/blood-2018-99-110976.
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Abstract Background: Gilteritinib, a highly selective, potent FLT3/AXL inhibitor, showed antileukemic activity with favorable tolerability in a phase 1/2 trial of patients (pts) with FLT3mut+ relapsed/refractory AML (Perl AE, et al. Lancet Oncol. 2017). Gilteritinib plus azacitidine (AZA) synergistically induced apoptosis and inhibited growth in the MV4-11 cell line and in MV4-11 tumors (Ueno Y, et al. Blood. 2016). The safety, tolerability, and efficacy of gilteritinib alone, gilteritinib plus AZA, or AZA alone is being evaluated in pts with newly diagnosed FLT3mut+ AML ineligible for intensive induction chemotherapy; this abstract presents data from the Safety Cohort which evaluated only gilteritinib plus AZA. Methods: Adults with newly diagnosed FLT3mut+ (FLT3-ITD or FLT3-TKD) AML are being enrolled in this ongoing clinical trial (NCT02752035). Prior to initiation of the randomized portion of the study, the appropriate gilteritinib dose for combination therapy was assessed in a Safety Cohort. Patients enrolled in this cohort received escalating doses of oral gilteritinib (80 or 120 mg/day) on Days 1-28 in combination with subcutaneous or intravenous AZA (75 mg/m2/day) on Days 1-7. Observations of dose-limiting toxicities (DLTs) were collected through Cycle 1; treatment was continued in 28-day cycles until lack of clinical benefit or unacceptable toxicity. Safety and tolerability were the primary endpoints of the Safety Cohort; antileukemic response rates (ie, complete remission [CR], CR with incomplete platelet recovery [CRp], CR with incomplete hematological recovery [CRi], partial remission [PR], and overall response rate [ORR]) were also assessed. Results: A total of 15 adult pts (median age, 76 [range: 65-86]) were enrolled into the Safety Cohort (n=9, 80 mg gilteritinib; n=6, 120 mg gilteritinib); 14 pts were FLT3mut+ (ITD alone, n=10; TKD alone, n=3; ITD and TKD, n=1) and 1 pt had no FLT3 mutation. As of 25 June 2018, more than half (n=8/15; 56%, Figure) of the pts had a treatment duration of >6 mo, while 9 pts discontinued treatment (death, n=4; relapse; adverse event [AE]; physician decision; sponsor decision; subject withdrawal, n=1 each) and 6 pts remained on treatment. During the DLT observation period, 1 DLT (tumor lysis syndrome) was observed in a pt who received 80 mg gilteritinib plus AZA; no DLTs were reported in pts who received 120 mg gilteritinib plus AZA. One or more AEs were seen in all 15 pts; 12 (80%) experienced AEs considered at least possibly related to treatment. Adverse events occurring in ≥25% of pts were anemia (n=7), febrile neutropenia and nausea (n=6 each), increased ALT and AST, constipation, diarrhea, neutropenia, thrombocytopenia, and pyrexia (n=5 each), and decreased appetite, fatigue, increased blood creatinine, and hypocalcemia (n=4 each). Grade ≥3 AEs occurring in ≥25% of pts were febrile neutropenia (n=6), anemia and neutropenia (n=5 each), and thrombocytopenia (n=4). Serious AEs occurring in >2 pts were febrile neutropenia (n=5), and anemia and pyrexia (n=3 each). Of the 8 pts with fatal AEs, none of which were related to treatment, 3 occurred early in treatment: septic shock (Day 2), respiratory failure (Day 6), and cerebral hemorrhage in the setting of acute kidney injury and uremia (Day 17). None of the 13 pts with post-baseline lab data had any potentially clinically significant AST/ALT (>3 X ULN) and total bilirubin (>2 X ULN) values; none of the pts had a maximum post-baseline QTcF interval >500 msec. Across the Safety Cohort, a composite complete remission rate of 67% (n=10/15) was observed; 4 pts achieved a best overall response of CR and 6 achieved CRi (Figure). Two additional pts (13%) achieved a best overall response of PR, giving an ORR of 80%. One DLT from the 11 DLT evaluable pts (defined as pts who experienced a DLT, or in the absence of DLT, received at least 23 of 28 doses of gilteritinib and at least 5 of 7 doses of AZA during the DLT observation period) informed the decision to proceed to the randomized portion at a dose of 120 mg gilteritinib for the combination treatment arm. Conclusions: Gilteritinib and AZA were generally well tolerated with no unexpected AEs. This combination therapy induced antileukemic responses in newly diagnosed FLT3mut+ AML pts unfit to receive standard induction chemotherapy. Based on these results, pts are being enrolled into the randomized portion of the study with a dose of 120 mg gilteritinib for the combination treatment arm. Disclosures Wang: Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz: Speakers Bureau; Jazz: Speakers Bureau; Amgen: Consultancy; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Speakers Bureau; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Speakers Bureau; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy. Laribi:Amgen: Other: Personal fees; Takeda: Other: Grant and personal fees; Sandoz: Other: Grant; Novartis: Other: Grant and personal fees; Teva: Other: Grant; Gilead: Other: Personal fees; Hospira: Other: Grant; Roche: Other: Grant. Montesinos:Daiichi Sankyo: Consultancy, Speakers Bureau; Novartis: Research Funding, Speakers Bureau. Liu:Astellas Pharma: Employment. Rich:Astellas Pharma: Employment. Bahceci:Astellas Pharma: Employment.
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Pratz, Keith, Mohamad Cherry, Jessica K. Altman, Brenda W. Cooper, Jose Carlos Cruz, Joseph G. Jurcic, Mark J. Levis, et al. "Preliminary Results from a Phase 1 Study of Gilteritinib in Combination with Induction and Consolidation Chemotherapy in Subjects with Newly Diagnosed Acute Myeloid Leukemia (AML)." Blood 130, Suppl_1 (December 7, 2017): 722. http://dx.doi.org/10.1182/blood.v130.suppl_1.722.722.
Full textAbstract:
Abstract Background: Gilteritinib is a novel, potent, highly-selective oral fms -like tyrosine kinase 3 (FLT3)/AXL inhibitor with clinical activity in relapsed/refractory (R/R) AML with activating FLT3-ITD and -TKD mutations. In such patients, once-daily gilteritinib ≥80 mg/day, as a single agent, elicited a response rate of 52% and median overall survival (OS) of 31 weeks (Perl AE, et al. Lancet Oncol . 2017.). Here we examined the safety/tolerability and antitumor activity of gilteritinib combined with front-line intensive chemotherapy in newly diagnosed AML patients. Methods: The primary objective of this open-label, dose-escalation/expansion Phase 1 study (NCT02236013) was to assess the safety/tolerability profile (including dose-limiting toxicities [DLTs] and maximum tolerated dose [MTD]) of gilteritinib when combined with 7+3 induction and high-dose cytarabine (HiDAC) consolidation, and administered as single-agent maintenance therapy in subjects aged ≥18 years with newly diagnosed AML. Assessment of antitumor effects of this combination therapy was an exploratory objective. Dose escalation followed a 3+3 design where successive cohorts of 3-6 subjects received gilteritinib doses of 40, 80, or 120 mg/day. Dose-escalation decisions were made based on DLTs that occurred during remission induction. A DLT was defined as any grade ≥3 non-hematologic or extramedullary toxicity (with exceptions) or hematologic toxicity that occurred after the first gilteritinib dose and did not resolve by Day 42 of the last induction cycle or before initiation of consolidation therapy. Subjects received up to 2 cycles of a 7+3 induction regimen (cytarabine 100 mg/m2/day, days 1-7 plus idarubicin 12 mg/m2/day, days 1-3) plus once-daily oral gilteritinib, which was initially administered on days 1-14 but was subsequently changed to administration on days 4-17 at the designated dose. During consolidation, subjects received cytarabine (1.5 g/m2 every 12 hours, days 1, 3, and 5) and once-daily gilteritinib (days 1-14) at the induction dose, for up to 3 cycles. Subjects in the dose-expansion cohort, received gilteritinib at the recommended expansion dose established during dose escalation. After consolidation, subjects received maintenance therapy with once-daily gilteritinib (28-day cycles; up to 26 cycles). Results: As of July 9, 2017, 50 subjects had been enrolled (n=17, dose-escalation cohort; n=33, dose-expansion cohort); 49 had received at least 1 dose of gilteritinib. Most subjects were male (67.3%; n=33); median age was 59 years (range, 23-77 years). Of the 48 subjects with known FLT3 mutation status, 23 (47.9%) were FLT3mut+, of whom 15 (65.2%) had internal tandem duplications. During dose-escalation, 2 subjects in the 40 mg/day cohort who had received gilteritinib on days 1-14 experienced DLTs (neutropenia, thrombocytopenia, and decreased ejection fraction). After gilteritinib induction schedule modification, no additional DLTs were observed. The MTD was not reached; gilteritinib 120 mg/day was chosen as the recommended expansion dose. Grade ≥3 treatment-emergent adverse events (TEAEs) occurring in ≥10% of subjects were febrile neutropenia (53.1%), thrombocytopenia (18.4%), neutropenia (16.3%), decreased platelet count (12.2%), sepsis (10.2%), and decreased white blood cell count (10.2%). Serious drug-related TEAEs occurring in >1 subject were febrile neutropenia (16.3%), sepsis (6.1%), and decreased ejection fraction (4.1%). The end of treatment investigator-reported composite complete remission (CRc) rate for all subjects was 71.4% and 57.1% achieved complete remission (Table). In FLT3mut+ and FLT3 mutation-negative (FLT3mut−) subjects, end-of-treatment CRc rates were 91.3% and 56%, respectively. Among subjects who received ≥80 mg/day gilteritinib (n=40), end-of-treatment CRc rates were 90% (n=18/20) for FLT3mut+ and 60% (n=12/20) for FLT3mut− subjects. Median OS and duration of response have not been reached. For the total study population, median event-free survival (EFS) was 327 days and median disease-free survival (DFS) was 297 days; FLT3mut+ subjects had a longer median EFS (327 days) and DFS (134 days) than FLT3mut− subjects (EFS, 80 days; DFS, not estimable). Conclusions: In subjects with newly diagnosed AML, gilteritinib combined with intensive chemotherapy was well tolerated (MTD >120 mg/day) with seemingly high response rates in FLT3mut+ subjects. Disclosures Cherry: Pfizer: Membership on an entity's Board of Directors or advisory committees; Astellas: Research Funding; Incyte: Membership on an entity's Board of Directors or advisory committees; Ariad: Membership on an entity's Board of Directors or advisory committees. Altman: NCCN: Other: Educational speaker; Syros: Consultancy; BMS: Consultancy; Celgene: Consultancy; Astellas: Consultancy; Ceplene: Consultancy; Janssen Pharmaceuticals: Consultancy; Novartis: Consultancy; ASH: Other: Educational speaker. Cooper: Novartis: Research Funding. Jurcic: Syros Pharmaceuticals: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy; Kura Oncology: Research Funding; Incyte: Consultancy; Genentech: Research Funding; Forma Therapeutics: Research Funding; Celgene: Research Funding; Alexion Pharmaceuticals: Consultancy; Seattle Genetics: Consultancy, Research Funding; Actinium Pharmaceuticals, Inc.: Membership on an entity's Board of Directors or advisory committees, Research Funding; Daiichi-Sankyo: Research Funding; Astellas Pharma, Inc: Research Funding; Amgen: Consultancy. Levis: Astellas Pharma Us: Consultancy, Research Funding; Daiichi Sankyo, Inc.: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Research Funding; FujiFilm: Research Funding. Lin: Jazz Pharmaceuticals: Consultancy. Perl: Arog Pharmaceuticals: Consultancy; Asana Biosciences: Other: Scientific advisory board; Astellas: Consultancy; Daiichi Sankyo: Consultancy; Pfizer: Other: Advisory Board; Novartis: Other: Advisory Board; Actinium Pharmaceuticals: Other: Scientific Advisory Board; Seattle Genetics: Other: Advisory board. Podoltsev: Alexion: Consultancy; CTI biopharma/Baxalta: Consultancy; Incyte: Consultancy; Ariad: Consultancy. Schiller: Celator/Jazz: Research Funding. Liu: Astellas Global Pharma, Inc.: Employment. Bahceci: Astellas Pharma Global Development: Employment.
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Altman, Jessica K., Alexander E. Perl, Jorge E. Cortes, Catherine Choy Smith, Mark Robert Litzow, Jason E. Hill, Richard A. Larson, et al. "Deep molecular response to gilteritinib to improve survival in FLT3 mutation-positive relapsed/refractory acute myeloid leukemia." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): 7003. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.7003.
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7003 Background: Gilteritinib, a highly selective FLT3/AXL inhibitor, has displayed antileukemic activity in FLT3 mutation-positive (FLT3mut+) relapsed/refractory (R/R) AML in the CHRYSALIS Phase I/II study (NCT02014558), specifically at doses ≥80 mg/d. This exploratory analysis assessed molecular response to gilteritinib in a CHRYSALIS subpopulation. Methods: Molecular response was assessed from bone marrow aspirates obtained at baseline and at ≥1 additional time point from FLT3mut+ patients (≥18 y) treated with 120 or 200 mg/d gilteritinib. These doses were identified due to their ability to induce consistent, potent FLT3 inhibition and high clinical response rates. FLT3-ITD and total FLT3 were quantified by NGS to assess molecular response. A Cox regression model of overall survival (OS) by Kaplan-Meier estimation established a FLT3-ITD:total FLT3 ratio (ITD signal ratio) of 10−2as the threshold for improved survival. Results: Of 147 FLT3-ITDmut+ patients who received gilteritinib 120 or 200 mg/d, 80 were included in this analysis. Composite response rate for these 80 patients was 55%. During response, 20 patients (25%) had an ITD signal ratio of ≤10−2. Of these 20 patients, 18 had a ratio of ≤10−3 (major molecular response [MMR]) and 13 had a ratio of ≤10−4 (minimal residual disease [MRD] negative). Median time to achieve minimum signal ratio was 54 days. Elimination of morphologic leukemia was observed in 80% of patients with ITD signal ratios <10−2. Patients who had a signal ratio ≤10−2, MMR, or were MRD negative had significantly longer median OS than those who did not (Table). Conclusions: Molecular responses to gilteritinib in FLT3-ITDmut+ R/R AML correlated with clinical response and improved OS. This is the first demonstration of molecular response to a FLT3 inhibitor in AML. These data suggest ITD signal ratio may predict durable clinical benefit of gilteritinib. Clinical trial information: NCT02014558. [Table: see text]
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Perl, Alexander E. "Availability of FLT3 inhibitors: how do we use them?" Blood 134, no. 9 (August 29, 2019): 741–45. http://dx.doi.org/10.1182/blood.2019876821.
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Abstract The natural history of FLT3-mutated AML is changing after the approval of midostaurin for frontline therapy and gilteritinib for relapsed or refractory patients. Recently reported, positive randomized trials of the drugs gilteritinib, quizartinib, and sorafenib predict even wider use of FLT3 inhibitors going forward. FLT3 inhibitors now emerge as an important, if not indispensable, part of therapy for a large subset of high-risk patients.
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Kuravi, Sudhakiranmayi, Janice Cheng, Kishore Polireddy, Gabrielle Fangman, Roy A. Jensen, Tara L. Lin, Siddhartha Ganguly, Joseph P. McGuirk, and Ramesh Balusu. "Preclinical Evaluation of Gilteritinib on NPM1-ALK Driven Anaplastic Large Cell Lymphoma Cells." Blood 134, Supplement_1 (November 13, 2019): 2865. http://dx.doi.org/10.1182/blood-2019-130633.
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Anaplastic large cell lymphoma (ALCL) is an aggressive type of non-Hodgkin's lymphoma (NHL) comprising 2-8% of adult and 10-20% of pediatric and adolescent NHL. More than three-fourths of anaplastic lymphoma kinase (ALK)-positive ALCL express (nucleophosmin1) NPM1-ALK fusion gene as a result of t(2;5) chromosomal translocation. The self-dimerization of fusion kinase NPM1-ALK mediates constitutive activation of the chimeric tyrosine kinase activity leading to downstream signaling pathways responsible for lymphoma cell proliferation and survival. The current standard treatment regimen for ALK+ ALCL is CHOP (cyclophosphamide, hydroxy doxorubicin, vincristine, prednisone) chemotherapy. Oftentimes, resistance and failure of remission occur with CHOP therapy, making it a suboptimal treatment regimen for many patients. Therefore, an alternative therapeutic approach is warranted to better address the needs of the ALK+ ALCL population. Gilteritinib is a recently FDA approved tyrosine kinase inhibitor for the treatment of FMS-like tyrosine kinase (FLT3) mutation-positive acute myeloid leukemia. Along with inhibition of FLT3, gilteritinib also inhibits other tyrosine kinases such as AXL and ALK. In this study, for the first time, we demonstrated gilteritinib mediated growth inhibitory effects on NPM1-ALK driven ALCL cells. We have used a total of five cell lines in our study: NPM1-ALK endogenously expressing human ALCL cell lines (SUDHL-1, SUP-M2, SR-786, and DEL), and our laboratory generated ectopically overexpressing Ba/F3-FG-NPM1-ALK, a murine cell line. Gilteritinib treatment (5-20 nM) inhibited NPM1-ALK fusion kinase phosphorylation, which resulted in downregulation of downstream survival signaling pathways including AKT, ERK1/2, and STAT3 leading to induced apoptosis and decreased clonogenic survival. Gilteritinib mediated apoptosis was associated with caspase 3/9 and poly (ADP-ribose) polymerase cleavage with increased pro-apoptotic protein BAD and decreased anti-apoptotic protein MCL-1. Increased expression of c-Myc is associated with ALK-positive ALCL and gilteritinib treatment decreased c-Myc levels in a dose dependent manner. Cell cycle analysis demonstrated gilteritinib treatment induced cell cycle arrest at the G0/G1 phase with a concomitant decrease in G2/M and S phases. In summary, our preclinical results suggest gilteritinib has therapeutic potential for the treatment of ALCL cells expressing NPM1-ALK and other ALK /ALK-fusion driven hematologic or solid malignancies. Disclosures Lin: Jazz Pharmaceuticals: Honoraria; Pfizer: Membership on an entity's Board of Directors or advisory committees. Ganguly:Daiichi Sankyo: Research Funding; Seattle Genetics: Speakers Bureau; Janssen: Honoraria, Other: Advisory Board; Kite Pharma: Honoraria, Other: Advisory Board. McGuirk:ArticulateScience LLC: Other: Assistance with manuscript preparation; Juno Therapeutics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bellicum Pharmaceuticals: Research Funding; Astellas: Research Funding; Novartis: Research Funding; Fresenius Biotech: Research Funding; Pluristem Ltd: Research Funding; Gamida Cell: Research Funding; Kite Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.
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Newman, Matthew, Sunil K. Joshi, Daniel Bottomly, Shannon McWeeney, Brian J. Druker, Evan Lind, and Elie A. Traer. "High dimensional mapping of temporal evolution within the marrow microenvironment in response to FLT3 inhibitor therapy." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): 7020. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.7020.
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7020 Background: The advent of genomic sequencing technologies has revealed underlying genetic alterations, such as FLT3 mutations, that can be targeted in acute myeloid leukemia (AML). However, development of resistance limits the durability of response. Recent data has implicated that factors from the bone marrow microenvironment mediate initial resistance to FLT3 inhibitors (FLT3i) in AML. We combined high dimensional characterization techniques, time-of-flight mass cytometry (CyTOF) and RNA sequencing, to examine sequential marrow stromal samples from a subset of patients with FLT3 mutated AML treated with the FLT3i gilteritinib. Here, we report on the heterogeneity and evolution of cell surface and secreted factors over time. Methods: RNA sequencing of primary FLT3-ITD stromal samples (N = 29) from pre-study and on-treatment patients enabled prioritization of candidate targets for CyTOF. Target-specific purified antibodies were purchased pre-conjugated to metal lanthanides or conjugated in house according to manufacturer protocols (after validation via traditional flow cytometry). Primary stromal cells were cultured ex vivo until confluent and were harvested and stained according to a standardized protocol, and subsequently run on a Helios (Fluidigm) mass cytometer. A computational approach was employed to compensate and visualize data via the CATALYST R package. A total of four pre-treatment and four post-gilteritinib timepoint isolates (N = 8) were analyzed. Results: A 36-target mass cytometry panel revealed protein level differences in patients before and after gilteritinib therapy. Dimensional reduction techniques such as MDS and UMAP showed that samples taken from later timepoints clustered together compared to their earlier counterparts with respect to global protein expression. Inflammatory mediators such as IL1-beta and MCP-1 were upregulated in patient stroma soon after gilteritinib treatment and therefore potentially contribute to early resistance. Novel markers previously implicated in early resistance to targeted therapies in AML such as FGF2 and FGFR1 similarly peaked earlier in treatment, mimicking the clinical course of expression observed in marrow stroma of patients treated with another FLT3 inhibitor quizartinib (Traer et al. Cancer Res. 2016). Conclusions: Our findings show that primary marrow stroma evolves during gilteritinib treatment, and that stromal proteins previously reported to promote early resistance to FLT3i are also upregulated during gilteritinib resistance. The heterogeneity of stromal cell isolates detected by mass cytometry highlights the utility of high dimensional tracking of disease course in patients, and may enable a better understanding of how the temporal evolution of the marrow microenvironment contributes to development of resistance to targeted therapies such as gilteritinib and other FLT3i over time.
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Cai, Jiayi, Honghui Huang, Xiaoli Hu, Wenjing Lang, Wanbin Fu, Lan Xu, Zilong Qiu, Hua Zhong, and Fangyuan Chen. "Homoharringtonine Synergized with Gilteritinib Results in the Downregulation of Myeloid Cell Leukemia-1 by Upregulating UBE2L6 in FLT3-ITD-Mutant Acute Myeloid (Leukemia) Cell Lines." Journal of Oncology 2021 (September 21, 2021): 1–11. http://dx.doi.org/10.1155/2021/3766428.
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FMS-like tyrosine kinase 3 (FLT3) mutant acute myeloid leukemia (AML) occurs in approximately 30% of all AML patients and still has a poor prognosis. This study is directed to investigate gilteritinib in combination with homoharringtonine (HHT) on FLT3-ITD-mutant AML cell lines. In our study, we found that cell proliferation was dramatically suppressed by the combination of gilteritinib and HHT. This combination therapy decreased the mitochondrial membrane potential, finally inducing apoptosis. We demonstrated that gilteritinib downregulated the expression of FLT3 and downstream signaling, further decreased the mRNA level of myeloid cell leukemia-1 (Mcl-1). HHT and combination therapy could upregulate UBE2L6, which induced the degradation of Mcl-1 via ubiquitin-proteasome system. Knockdown of UBE2L6 could protect Mcl-1 from deprivation through the ubiquitin-proteasome system. These findings may provide a novel theoretical basis for the treatment of AML patients with FLT3-ITD mutations.
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Facharztmagazine, Redaktion. "r/r AML: Neues zu Gilteritinib." InFo Hämatologie + Onkologie 23, no. 12 (December 2020): 62. http://dx.doi.org/10.1007/s15004-020-8327-6.
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Pratz, Keith W., Mohamad Cherry, Jessica K. Altman, Brenda Cooper, Jose Carlos Cruz, Joseph G. Jurcic, Mark J. Levis, et al. "Updated Results from a Phase 1 Study of Gilteritinib in Combination with Induction and Consolidation Chemotherapy in Subjects with Newly Diagnosed Acute Myeloid Leukemia (AML)." Blood 132, Supplement 1 (November 29, 2018): 564. http://dx.doi.org/10.1182/blood-2018-99-110975.
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Abstract Introduction: Gilteritinib is a novel, potent, highly-selective oral fms-like tyrosine kinase 3 (FLT3)/AXL inhibitor. Once-daily single-agent gilteritinib doses of ≥80 mg/day elicited antileukemic responses in FLT3 mutation-positive (FLT3mut+) subjects with relapsed/refractory AML (Perl AE, et al. Lancet Oncol. 2017). We examined the safety/tolerability and antitumor activity of gilteritinib plus front-line intensive chemotherapy in newly diagnosed AML patients. Methods: This ongoing open-label, dose-escalation/expansion phase 1 study (NCT02236013) assesses the safety/tolerability and antitumor effects of gilteritinib combined with 7+3 induction and high-dose cytarabine consolidation, and as single-agent maintenance therapy in subjects aged ≥18 years with newly diagnosed AML (excluding core-binding factor translocations). Dose escalation followed a 3+3 design; successive cohorts of 3-6 subjects received 40, 80, 120, or 200 mg/day gilteritinib. Subjects received ≤2 cycles of a 7+3 induction regimen (cytarabine 100 mg/m2/day, Days 1-7 plus idarubicin 12 mg/m2/day, Days 1-3 [dose-escalation and dose-expansion cohorts], and once-daily gilteritinib on Days 4-17 [Schedule 1]). After completion of the dose-expansion cohort using Schedule 1, a new cohort of patients were enrolled. In this cohort of six patients, gilteritinib administration was changed to Days 8-21 (Schedule 2) in preparation for phase 3 studies and daunorubicin 90 mg/m2/day, administered on Days 1-3, was used as an alternative anthracycline to idarubicin. During consolidation, subjects received cytarabine (1.5 g/m2 every 12 hours, Days 1, 3, and 5) and once-daily gilteritinib (Days 1-14) at the induction dose for ≤3 cycles. Subjects in the dose-expansion cohort received gilteritinib at the recommended expansion dose established during dose escalation. Transplantation was allowed for responding subjects. After consolidation or transplantation with stable engraftment, subjects received maintenance therapy with once-daily gilteritinib (28-day cycles; ≤26 cycles). Results: As of July 2, 2018, 62 subjects have been enrolled; 60 are included in the safety analysis set. Most subjects were male (66.7%; median age, 59.5 years [range, 23-77]) and 32 (53.3%) had FLT3 mutations (FLT3-ITD, n=23). During dose-escalation, two subjects in the 40 mg/day cohort who had received gilteritinib on Days 1-14 experienced dose-limiting toxicities (DLTs; neutropenia, thrombocytopenia, decreased ejection fraction). After the gilteritinib induction schedule change, no more DLTs occurred at this dose. Two subjects in the 200 mg/day cohort experienced DLTs (neutropenia, neutropenic enterocolitis). The maximum tolerated dose and the recommended expansion dose were established at 120 mg/day. Grade ≥3 adverse events (AEs) in ≥10% of patients were febrile neutropenia (63.3%), thrombocytopenia (18.3%), decreased platelet count (16.7%), neutropenia (15.0%), bacteremia (10.0%), sepsis (10.0%), and decreased white blood cell count (10.0%). Serious drug-related AEs in >1 subject were febrile neutropenia (n=9), small intestinal obstruction, lung infection, sepsis, and decreased ejection fraction (all n=2). The end-of-treatment investigator-reported rate of composite complete remission (CRc) for response evaluable FLT3mut+ subjects receiving gilteritinib 120 mg on Schedule 1 (n=17) was 100%. The CRc rate in FLT3mut+ subjects receiving Schedule 2 induction with daunorubicin was also 100% (Table). Enrollment in the Schedule 2 cohort receiving idarubicin is ongoing; the two subjects in this cohort have not been assessed for response. Among subjects who received ≥80 mg/day gilteritinib (n=47), CRc rates for FLT3mut+ subjects were 88.9% (n=24/27). Median overall survival has not been reached. Median disease-free survival was 297 days (95% CI: 112, not reached). Assessment of minimum residual disease in FLT3-ITD patients using a next-generation sequencing-based assay is ongoing; results will be available at the time of presentation. Conclusions: Gilteritinib can be safely combined with intensive chemotherapy, and given as single-agent maintenance therapy in subjects with newly diagnosed AML. Treatment was well tolerated. High response rates were observed in FLT3mut+ subjects after treatment with either idarubicin or daunorubicin in combination with two different gilteritinib administration schedules. Disclosures Pratz: Millenium/Takeda: Research Funding; AbbVie: Consultancy, Research Funding; Agios: Research Funding; Astellas: Consultancy, Research Funding; Boston Scientific: Consultancy. Altman:Astellas Pharma: Other; Agios: Other: Payment to the institution to conduct the trial ; Epizyme: Other: payment to the institution to conduct clinical trial work; BMS: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Pfizer: Other: payment to the institution to conduct clinical trial work; Cyclacel: Other: payment to the institution to conduct clinical trial work; Celator: Other: payment to the institution to conduct clinical trial work; Ariad: Other: payment to the institution to conduct clinical trial work; Bayer: Other: payment to the institution to conduct clinical trial work; Genetech: Other: Payment to the institution to conduct clinical trial work; FujiFilm: Other: payment to the institution to conduct clinical trial work; Incyte: Other: payment to the institution to conduct clinical trial work; Celgene: Membership on an entity's Board of Directors or advisory committees, Other: payment to the institution to conduct clinical trial work; Boeringer Ingelheim: Other: payment to the institution to conduct clinical trial work; Syros: Membership on an entity's Board of Directors or advisory committees; GSK: Other: payment to the institution to conduct clinical trial work; Janssen Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Immune Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Cruz:Takeda: Speakers Bureau. Jurcic:Kura Oncology: Research Funding; Forma Therapeutics: Research Funding; Celgene: Research Funding; Daiichi-Sankyo: Research Funding; Incyte: Consultancy; Actinium Pharmaceuticals, Inc: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees; Syros Pharmaceuticals: Research Funding; Genetech: Research Funding; AbbVie: Consultancy, Research Funding; Astellas: Research Funding. Lin:Jazz Pharmaceuticals: Honoraria. Perl:AbbVie: Membership on an entity's Board of Directors or advisory committees; Actinium Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Daiichi Sankyo: Consultancy; Novartis: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Arog: Consultancy; NewLink Genetics: Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy. Podoltsev:Pfizer: Membership on an entity's Board of Directors or advisory committees; Astellas Pharma: Research Funding; LAM Therapeutics: Research Funding; Astex Pharmaceuticals: Research Funding; Genentech: Research Funding; Boehringer Ingelheim: Research Funding; Sunesis Pharmaceuticals: Research Funding; Daiichi Snakyo: Research Funding; Celator: Research Funding; Celgene: Research Funding; Pfizer: Research Funding. Schiller:bluebird bio: Research Funding; Astellas Pharma: Membership on an entity's Board of Directors or advisory committees, Research Funding. Liu:Astellas Pharma: Employment. Bahceci:Astellas Pharma: Employment.
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Smith, Catherine C. "The growing landscape of FLT3 inhibition in AML." Hematology 2019, no. 1 (December 6, 2019): 539–47. http://dx.doi.org/10.1182/hematology.2019000058.
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Abstract Midostaurin and gilteritinib are FLT3 inhibitors that have been recently approved for use in FLT3-mutant acute myeloid leukemia (AML). These approved drugs represent a new standard of care for patients with FLT3 mutations in both the first-line and salvage settings. The success of midostaurin used in combination with induction chemotherapy has prompted exploration of newer, more potent and targeted inhibitors (including gilteritinib) in the first-line setting in combination with chemotherapy. At the same time, the success of gilteritinib and other newer FLT3 inhibitors as monotherapy in the salvage setting has been tempered by the development of resistance because of diverse mechanisms. Investigational strategies that incorporate FLT3 inhibitors in combination with hypomethylating agents and as maintenance therapy after allogeneic stem cell transplantation have shown promise. Other novel combination strategies are also undergoing clinical investigation. In this article, we review the current landscape of approved and investigational FLT3 inhibitors in AML, including the current standard of care and investigational strategies.
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Perl, Alexander E., Jessica K. Altman, Naoko Hosono, Pau Montesinos, Nikolai A. Podoltsev, Giovanni Martinelli, Catherine C. Smith, et al. "Clinical Outcomes in Patients with Relapsed/Refractory Acute Myeloid Leukemia Treated with Gilteritinib Who Received Prior Midostaurin or Sorafenib." Blood 136, Supplement 1 (November 5, 2020): 22–23. http://dx.doi.org/10.1182/blood-2020-136395.
Full textAbstract:
Background: Gilteritinib is a FLT3 inhibitor with demonstrated efficacy and safety in patients with FLT3-mutated relapsed or refractory (R/R) AML. The efficacy of gilteritinib in patients with prior tyrosine kinase inhibitor (TKI) therapy is not clearly defined. The phase 1/2 CHRYSALIS trial demonstrated the safety and antileukemic activity of gilteritinib in a FLT3-mutation-enriched R/R AML population (Perl AE, et al. Lancet Oncol. 2017). The phase 3 ADMIRAL trial demonstrated the superiority of gilteritinib to salvage chemotherapy (SC) in FLT3-mutated patients based on longer median overall survival (OS) with gilteritinib (9.3 vs 5.6 months; hazard ratio [HR]=0.64 [95% CI: 0.49, 0.83]; P<0.001) (Perl AE, et al. N Engl J Med. 2019). We sought to determine whether prior TKI therapy affected response and survival in these two trials. Methods: We retrospectively analyzed clinical outcomes in patients with R/R AML previously treated with TKIs midostaurin or sorafenib, before receiving 120- or 200-mg gilteritinib in the CHRYSALIS trial, or before receiving 120-mg gilteritinib in the ADMIRAL trial. Patients randomized to SC in the ADMIRAL trial were also assessed. Patients in the CHRYSALIS trial had received at least one line of prior AML therapy; patients in the ADMIRAL trial received only one line of prior AML therapy. Results: Of the 145 FLT3-mutation-enriched patients who received 120- or 200-mg gilteritinib in the CHRYSALIS trial, 33 (23%; 120 mg, n=15; 200 mg, n=18) had received a prior TKI (all received sorafenib). Baseline characteristics among patients who received (n=33) or did not receive prior TKIs (n=112) were similar; median age was 56 and 61 years, respectively. Across both dose groups, FLT3 mutation types in prior TKI-treated and non-treated patients were: FLT3-ITD (88% vs 84%, respectively), FLT3-TKD (0 vs 8%, respectively), FLT3-ITD and -TKD (12% vs 6%, respectively), and unknown or missing (0 vs 2%, respectively). Rates of composite complete remission (CRc) were similar in patients who received prior TKIs (42%; n=14/33) and in those who did not (43%; n=48/112). Among patients who received prior TKIs, rates of CRc were 53% (n=8/15) in the 120-mg dose group and 33% (n=6/18) in the 200-mg dose group (Table 1); rates of CRc in patients who did not receive prior TKIs were similar across both the 120- and 200-mg dose groups (44% [n=18/41] and 42% [n=30/71], respectively). Among patients treated with prior TKIs across the 120- or 200-mg dose groups (n=33), most (73%; n=24) had received ≥3 lines of any prior AML therapy. In the phase 3 ADMIRAL trial, 31 of 247 (13%) R/R FLT3-mutated AML patients in the gilteritinib arm and 14 of 124 (11%) patients in the SC arm had received prior TKIs. Demographic and baseline characteristics were well balanced between treatment arms and were also similar between prior TKI-treated (n=45) and non-treated patients (n=326); median age was 57 and 62 years, respectively. Among prior TKI-treated and non-treated patients, FLT3 mutation types in gilteritinib and SC arms were: FLT3-ITD (71% vs 93% and 89% vs 91%, respectively), FLT3-TKD (16% vs 7% and 7% vs 8%, respectively), and FLT3-ITD and -TKD (13% vs 0 and 1% vs 0, respectively). FLT3 mutation type was unconfirmed in 5 of 326 (2%) patients who did not receive prior TKIs (gilteritinib vs SC, 2% vs 1%, respectively). In the gilteritinib arm, CRc rates were comparable in patients who received (48%; n=15/31) and did not receive prior TKIs (55%; n=119/216); lower CRc rates were observed in the SC arm in both TKI-treated and non-treated groups (21% [n=3/14] and 22% [n=24/110], respectively) (Table 2). Median OS in patients treated with prior TKIs, albeit not statistically significant, remained high in patients treated with gilteritinib compared with those treated with SC (6.5 vs 4.7 months, respectively; HR=0.671 [95% CI: 0.328, 1.376]) (Table 2). In patients who did not receive prior TKIs, median OS was 9.6 months in the gilteritinib arm and 6.0 months in the SC arm (HR=0.625 [95% CI: 0.474, 0.824]). Conclusions: Patients with R/R AML who received prior TKIs (midostaurin or sorafenib) were able to achieve remission with gilteritinib. High response rates with gilteritinib were observed in heavily pre-treated FLT3-mutation-enriched patients in the CHRYSALIS trial who received prior TKIs. Higher response rates with gilteritinib than with SC were observed in prior TKI-treated patients with FLT3 mutations in the ADMIRAL trial. Disclosures Perl: Takeda: Honoraria, Other: Travel costs for meeting; Syndax: Consultancy, Honoraria; Leukemia & Lymphoma Society, Beat AML: Consultancy; Agios: Consultancy, Honoraria, Other; FUJIFILM Pharmaceuticals USA, Inc: Research Funding; AbbVie Inc: Consultancy, Honoraria, Other, Research Funding; Astellas: Consultancy, Honoraria, Other: writing/editorial support, travel costs for meeting presentations related to study, Research Funding; Novartis: Honoraria, Other, Research Funding; Loxo Oncology Inc, a wholly owned subsidiary of Eli Lilly & Company: Consultancy, Honoraria, Other; Arog Pharmaceuticals Inc: Other: uncompensated consulting, travel costs for meetings; Actinium Pharmaceuticals Inc: Consultancy, Honoraria, Research Funding; New Link Genetics: Honoraria, Other; Bayer HealthCare Pharmaceuticals: Research Funding; FORMA Therapeutics: Consultancy, Honoraria, Other; Daiichi Sankyo: Consultancy, Honoraria, Other: Writing/editorial support, travel costs for meetings, Research Funding; Jazz: Honoraria, Other; Biomed Valley Discoveries: Research Funding. Altman:Cancer Expert Now: Consultancy; ASH: Consultancy; PeerView: Consultancy; Bristol-Myers Squibb: Consultancy; Fujifilm: Research Funding; AbbVie: Other: advisory board, Research Funding; BioSight: Other: No payment but was reimbursed for travel , Research Funding; Theradex: Other: Advisory Board; Immune Pharmaceuticals: Consultancy; Syros: Consultancy; Janssen: Consultancy; Kartos: Research Funding; Celgene: Research Funding; Boehringer Ingelheim: Research Funding; ImmunoGen: Research Funding; Amgen: Research Funding; Aprea: Research Funding; Amphivena: Research Funding; Genentech: Research Funding; Novartis: Consultancy; Kura Oncology: Other: Scientific Advisory Board - no payment accepted, Research Funding; Daiichi Sankyo: Other: Advisory Board - no payment but was reimbursed for travel; Agios: Other: advisory board, Research Funding; Glycomimetics: Other: Data safety and monitoring committee; Astellas: Other: Advisory Board, Speaker (no payment), Steering Committee (no payment), Research Funding; PrIME Oncology: Consultancy; France Foundation: Consultancy. Montesinos:Celgene, Pfizer, Abbvie: Consultancy; Pfizer, Abbvie, Daiichi Sankyo: Research Funding; Astellas, Novartis, Janssen: Speakers Bureau. Podoltsev:Blueprint Medicines: Consultancy, Honoraria; Astellas Pharma: Research Funding; AI Therapeutics: Research Funding; Samus Therapeutics: Research Funding; Novartis: Consultancy, Honoraria; Bristol-Myers Squib: Consultancy, Honoraria; Alexion: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Agios Pharmaceuticals: Consultancy, Honoraria; Daiichi Sankyo: Research Funding; Genentech: Research Funding; CTI biopharma: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Boehringer Ingelheim: Research Funding; Sunesis Pharmaceuticals: Research Funding; Jazz Pharmaceuticals: Research Funding; Astex Pharmaceuticals: Research Funding; Incyte: Consultancy, Honoraria; Kartos Therapeutics: Research Funding; Arog Pharmaceuticals: Research Funding. Martinelli:Celgene: Consultancy, Speakers Bureau; Amgen: Consultancy; AbbVie: Consultancy, Research Funding; Janssen: Consultancy; Roche: Consultancy; Pfizer: Consultancy, Research Funding, Speakers Bureau; Daichii Sankyo: Consultancy, Research Funding; Incyte: Consultancy; Jazz: Consultancy. Smith:FujiFilm: Other: Research support, Research Funding; Abbvie: Other: Research Support, Research Funding; Revolution Medicines: Other: Research Support, Research Funding; Daiichi Sanyko: Consultancy, Honoraria; Sanofi: Honoraria; Astellas Pharma: Honoraria, Other: Research Support, Research Funding. Levis:Amgen: Honoraria; Menarini: Honoraria; FujiFilm: Honoraria, Research Funding; Astellas: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria. Röllig:Abbvie, Novartis, Pfizer: Consultancy, Research Funding; Amgen, Astellas, BMS, Daiichi Sankyo, Janssen, Roche: Consultancy. Groß-Langenhoff:Astellas: Current Employment. Hasabou:Astellas Pharma: Current Employment. Lu:Astellas: Current Employment. Tiu:Astellas Pharma Global Development: Current Employment; Eli Lilly & Company: Current equity holder in publicly-traded company, Ended employment in the past 24 months.
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Ishikawa, Yuichi, Koichi Saito, Naomi Kawashima, Michie Morimoto, Hidetoshi Murao, Daisuke Terada, Takeshi Yamaura, Shinji Hagiwara, and Hitoshi Kiyoi. "FF-10101 Retains Potent Inhibitory Activities Against Resistant Mutations to FLT3 Inhibitors, Newly Identified in Random Mutagenesis Screens." Blood 134, Supplement_1 (November 13, 2019): 2672. http://dx.doi.org/10.1182/blood-2019-124632.
Full textAbstract:
Background: FLT3-internal tandem duplication (FLT3-ITD) mutation is a poor prognostic factor for acute myeloid leukemia (AML). Several second-generation FLT3-targeted tyrosine kinase inhibitors with high selectivity and potency have been developed to date. Recently, gilteritinib was approved for the FLT3 mutation-positive relapsed or refractory AML patients. However, acquired mutations at the F691 residue in FLT3 kinase domain were identified in the patients who had disease progression after the treatment with gilteritinib, as with quizartinib treatment that caused resistant mutations at F691 and D835 residues. Therefore, it is very important to clarify the potencies of each FLT3 inhibitors against acquired FLT3 mutations for clinically selecting an appropriate FLT3 inhibitor according to the mutation type. In this study, we explored the resistant mutations against FLT3 inhibitors by random mutagenesis analysis and evaluated the cross-reactivity of FLT3 inhibitors against each resistant mutation. Methods: For random mutagenesis assay, 32D cells were infected with retroviruses encoding randomly mutagenized human FLT3-ITD. FLT3-ITD dependent 32D cells were established without an addition of IL-3, and then treated with FLT3 inhibitors, gilteritinib, FF-10101 and quizartinib, at concentrations of GI95 and 3 x GI95. Two weeks after treatment, full length FLT3-ITD sequences of viable clones were analyzed. The identified mutated FLT3-ITDs were introduced into 32D cells to confirm the resistance to FLT3 inhibitors. For cell growth assay, 32D transfectants were incubated with 5 FLT3 inhibitors (gilteritinib, FF-10101, quizartinib, crenolanib and midostaurin) for 3 days followed by determination of cell viability. Results: We identified the gilteritinib-resistant mutation (FLT3-ITD+D698N), quizartinib-resitant mutation (FLT3-ITD+N676T), and FF-10101-resistant mutation (FLT3-ITD+C695W) (Table). Inhibitory activity of gilteritinib against FLT3-ITD+D698N-expressing 32D cells (GI50, 27 nM) was decreased by 12-fold as compared with that against original FLT3-ITD-expressing 32D cells (GI50, 2.3nM). FF-10101 (GI50, 0.73 nM), quizartinib (GI50, 0.99 nM) and crenolanib (GI50, 19 nM) retained potency against FLT3-ITD+D698N, while midostaurin (GI50, 47 nM) did not have a potency. In FLT3-ITD+N676T-expressing 32D cells, inhibitory activities of quizartinib and midostaurin were decreased by 11 and 15-fold (GI50, 6.6 nM and 83 nM, respectively), while FF-10101 (GI50, 0.73 nM), gilteritinib (GI50, 6.6 nM) and crenolanib (GI50, 19 nM) retained potency. In FF-10101-resistant mutation (FLT3-ITD+C695W)-expressing 32D cells, the other inhibitors retained growth inhibitory activity. Conclusions: Resistant mutations to gilteritinib and quizartinib were newly identified in FLT3 kinase domain by random mutagenesis analysis. FF-10101 retained potent inhibitory activities against FLT3-ITD+N676T conferring resistance to quizartinib and midostaurin, and FLT3-ITD+D698N resistant to gilteritinib and midostaurin, although FF-10101 was vulnerable to FLT3-ITD+C695W substituted for C695 residue which forms covalent bond with FF-10101. These results indicated that FF-10101 was a promising agent for the treatment of patients with AML with FLT3 inhibitor-resistant mutations newly identified in this study. Disclosures Ishikawa: Bristol-Myers Squibb: Honoraria; Abbvie GK.: Honoraria; Celgene Co., Ltd.: Honoraria; Kyowa Hakko Kirin Co., Ltd.: Honoraria. Saito:FUJIFILM Corporation: Employment. Morimoto:FUJIFILM Corporation: Employment. Murao:FUJIFILM Corporation: Employment. Terada:FUJIFILM Corporation: Employment. Yamaura:FUJIFILM Corporation: Employment. Hagiwara:FUJIFILM Coporation: Employment. Kiyoi:Daiichi Sankyo Co., Ltd: Research Funding; Takeda Pharmaceutical Co., Ltd.: Research Funding; Sumitomo Dainippon Pharma Co., Ltd.: Research Funding; FUJIFILM Corporation: Research Funding; Pfizer Japan Inc.: Honoraria; Bristol-Myers Squibb: Research Funding; Perseus Proteomics Inc.: Research Funding; Otsuka Pharmaceutical Co.,Ltd.: Research Funding; Chugai Pharmaceutical Co., Ltd.: Research Funding; Eisai Co., Ltd.: Research Funding; Kyowa Hakko Kirin Co., Ltd.: Research Funding; Zenyaku Kogyo Co., Ltd.: Research Funding; Astellas Pharma Inc.: Honoraria, Research Funding; Nippon Shinyaku Co., Ltd.: Research Funding.
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Perl, Alexander E., Jorge E. Cortes, Stephen Anthony Strickland, Ellen K. Ritchie, Andreas Neubauer, Giovanni Martinelli, Tomoki Naoe, et al. "An open-label, randomized phase III study of gilteritinib versus salvage chemotherapy in relapsed or refractory FLT3 mutation-positive acute myeloid leukemia." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): TPS7067. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.tps7067.
Full textAbstract:
TPS7067 Background: FLT3 mutations occur in 30% of patients with acute myeloid leukemia (AML), most often as internal tandem duplications (FLT3-ITD) or point mutations at codon D835. FLT3-ITDs are associated with high relapse rates, short remission duration, and poor overall survival (OS); FLT3-D835 can confer resistance to other tyrosine kinase inhibitors (TKIs). Gilteritinib is a highly selective FLT3/AXL TKI with activity against both FLT3-ITD and FLT3-D835 mutations. A recent phase 1/2 study of gilteritinib (20–450 mg/d) in relapsed/refractory (R/R) AML showed favorable tolerability at doses ≤300 mg/d, and consistent, potent FLT3 inhibition at doses ≥80 mg/d. Patients with FLT3 mutation-positive (FLT3mut+) AML receiving doses ≥80 mg/d had an ORR of 52% (CR/CRp/CRi = 41%, PR = 11%) and longer OS than historic experience in R/R AML with combination cytotoxic chemotherapy or other FLT3 TKIs as monotherapy. Given these results, we initiated a phase 3 trial of once-daily (QD) 120 mg gilteritinib. Methods: This randomized, open-label phase 3 study (NCT02421939) will enroll 369 adults with FLT3mut+ AML in first relapse or refractory to front-line therapy. Patients who have not previously received FLT3 inhibitors, except sorafenib and midostaurin, will be randomized 2:1 to either 120 mg gilteritinib QD or the investigator’s pre-randomization specified salvage chemotherapy choice (LoDAC, Aza, MEC, FLAG-IDA), and stratified by prior chemotherapy response and salvage chemotherapy intensity. Gilteritinib or low-intensity chemotherapy cohorts will receive continuous 28-day treatment cycles until a discontinuation event occurs; the high-intensity chemotherapy cohort will receive ≤2 treatment cycles before response measurement. Primary objective is OS; key secondary objectives are event-free survival and CR rate. Other secondary objectives: leukemia-free survival, remission duration, composite CR rate, subsequent transplantation rate, patient-reported fatigue, and safety. A formal interim analysis is planned when ~50% of planned death events have occurred. Study enrollment began on Oct 23, 2015; as of Jan 20, 2017, 167 subjects have been randomized. Clinical trial information: NCT02421939.
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Cella, David, Ellen Ritchie, Arnaud Pigneux, Yoshinobu Kanda, Cristina Ivanescu, Bhavik J. Pandya, and Manasee V. Shah. "Pain and Opioid Use in Patients with FLT3 Mutation-Positive Relapsed/Refractory AML: A Subanalysis of Patient-Reported Outcomes from the Admiral Trial." Blood 136, Supplement 1 (November 5, 2020): 25–26. http://dx.doi.org/10.1182/blood-2020-134389.
Full textAbstract:
Background: Despite widespread interest in pain management and opioid use across the United States, information on pain and opioid utilization in patients with relapsed or refractory acute myeloid leukemia (R/R AML) is lacking. Better understanding of patient-reported outcomes (PROs) specific to pain could be used to identify strategies to improve the quality of life in patients with R/R AML. Aim/Objective: To describe pain and opioid use in patients with FLT3 mutation-positive (FLT3mut+)R/R AML receiving either gilteritinib or salvage chemotherapy (SC) using PRO data collected from the ADMIRAL study (NCT02421939). Methods: ADMIRAL was a phase 3, open-label, multicenter, active-controlled randomized study comparing the efficacy and safety of gilteritinib to SC in patients with FLT3mut+ R/R AML. Pain was assessed using selected items from the Functional Assessment of Cancer Therapy - Leukemia (FACT-Leu; GP4 item: "I have pain") and the EuroQol 5-Dimension 5-Level Questionnaire (EQ-5D-5L; Pain/Discomfort domain). Data for these instruments were collected at baseline (BL), Day 1 of every treatment cycle, and end of treatment (EOT). A modified EOT (mEOT) was defined as the last PRO assessment before patient discontinuation, study data cut-off date, or patient death. Patients on high-intensity chemotherapy (HIC) were treated for up to two cycles depending on treatment response; as such, only changes from BL to Cycle 2 were evaluated. Opioid utilization, including percentage of patients using any opioid medication, specific medications, duration of use, and use by transfusion dependence, was also described. Analyses of the intention-to-treat population using analysis of covariance, including BL score, response to first-line AML therapy, and investigator-preselected SC as covariates, were conducted to estimate least squares mean (LSM) and compare the differences in pain question responses between treatment arms. Descriptive statistics were used to describe opioid utilization. Results: Of 371 eligible patients, 247 were randomized to gilteritinib and 124 to SC. The median age for both groups was 62 years and slightly more patients were female (gilteritinib, 53.0%; SC, 56.5%). Improvements at the mEOT from BL in the Fact-Leu GP4 item were observed in both gilteritinib (LSM -0.3) and SC (LSM -0.1). Scores also changed on the EQ-5D-5L at the mEOT from BL for both groups (gilteritinib, LSM 0.2; SC, LSM 0.3). No treatment differences were observed between gilteritinib vs SC on the change from BL to Cycle 2 or mEOT on the Fact-Leu GP4 item (LSM [95% CI] of -0.1 [-0.65, 0.38]; P=0.6016 and -0.2 [-0.53, 0.21]; P=0.3902, respectively) or on the EQ-5D-5L Pain/Discomfort domain (LSM [95% CI] of 0.2 [-0.21, 0.62]; P=0.3255 and -0.1 [-0.38, 0.23]; P=0.6288, respectively). During Cycles 1 and 2, no differences were identified between gilteritinib or SC on the percentage of patients using opioids (Cycle 1: 49.8% vs 55.6%; Cycle 2: 58.9% vs 62.7%, respectively) or the time-averaged duration of use (Cycle 1: 12.4 days vs 14.1 days; Cycle 2: 15.0 days vs 17.2 days, respectively). Patients on gilteritinib were less likely to use opioids during the first two cycles compared with patients on HIC, when stratified by chemotherapy intensity (Cycle 1: 49.0% vs 72.0%, P<0.05; Cycle 2: 58.2% vs 74.1%, P<0.05). Conversely, patients on gilteritinib were more likely to use opioids compared with patients on low-intensity chemotherapy during the first two cycles (Cycle 1: 51.0% vs 30.6%, P<0.05; cycle 2: 60.0% vs 33.3%, P<0.05). In patients using opioids across the first two cycles (Table), opioids used most frequently were oxycodone (Cycle 1: 45.3%; Cycle 2: 44.6%) and tramadol (Cycle 1: 43.2%; Cycle 2: 42.5%). In patients on gilteritinib, those dependent on transfusions were generally more likely to use opioids, and for more days (time-averaged) during each cycle than patients independent of transfusions. Conclusions: Patients with FLT3mut+ R/R AML receiving gilteritinib or SC demonstrated modest changes in responses to pain-related assessments at EOT compared with BL values. Opioids were used more frequently by patients receiving HIC regimens and transfusion-dependent patients receiving gilteritinib. These data suggest that treatments for FLT3mut+ R/R AML may impact opioid use; further study should be done to determine the relationships between these factors and their potential impact on overall quality of life. Disclosures Cella: DSI: Consultancy, Research Funding; Evidera: Consultancy; Ipsen: Consultancy, Research Funding; Mei Pharma: Consultancy; Oncoquest: Consultancy; ASAHI KASEI PHARMA CORP.: Consultancy; BMS: Consultancy, Research Funding; IDDI: Consultancy; Kiniksa: Consultancy; Novartis: Consultancy; Pfizer: Consultancy, Research Funding; Apellis: Consultancy; Alexion: Research Funding; Clovis: Research Funding; Janssen: Research Funding; Pled Pharma: Research Funding; PROMIS Health Org: Membership on an entity's Board of Directors or advisory committees, Other; BlueNote: Consultancy; Astellas: Consultancy, Honoraria; FACIT.org: Membership on an entity's Board of Directors or advisory committees, Other: President; Abbvie: Consultancy, Research Funding. Ritchie:Abbvie: Honoraria; Sierra Oncology: Honoraria; Novartis: Honoraria; Pfizer: Honoraria, Research Funding; Jazz pharmaceuticals: Honoraria, Research Funding; Incyte: Speakers Bureau. Kanda:Pfizer: Honoraria, Research Funding; Astellas Pharma: Honoraria, Research Funding; Janssen: Honoraria; Shionogi: Research Funding; Chugai Pharma: Honoraria, Research Funding; Otsuka: Honoraria, Research Funding; Celgene: Honoraria; Sumitomo Dainippon Pharma: Honoraria; Eisai: Honoraria, Research Funding; Novartis: Honoraria; Kyowa Kirin: Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria; Takeda Pharmaceuticals: Honoraria; Alexion Pharmaceuticals: Honoraria; Shire: Honoraria; Daiichi Sankyo: Honoraria; Ono Pharmaceutical: Honoraria; Nippon Shinyaku: Honoraria, Research Funding; Mochida Pharmaceutical: Honoraria; Mundipharma: Honoraria; Sanofi: Honoraria, Research Funding; Meiji Seika Kaisha: Honoraria; Merck Sharp & Dohme: Honoraria. Ivanescu:Astellas: Other: IQVIA employee which is a contracted by Astellas. Pandya:Astellas Pharma, Inc.: Current Employment. Shah:Astellas: Current Employment.
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Numan, Yazan, Zaid Abdel Rahman, Justin Grenet, Stephanie Boisclair, Jan Philipp Bewersdorf, Dylan Barth, Amer M. Zeidan, et al. "Gilteritinib Remains Clinically Active in Relapsed/Refractory FLT3 Mutated AML Previously Treated with FLT3 inhibitors." Blood 136, Supplement 1 (November 5, 2020): 5–7. http://dx.doi.org/10.1182/blood-2020-137251.
Full textAbstract:
Background: Gilteritinib is approved for the treatment of relapsed/refractory (R/R) AML and FLT3-mutation (FLT3mut+). However, the gilteritinib phase 3 ADMIRAL study (Perl et al NEJM 2019) enrolled prior to widespread adoption of either midostaurin as a component of standard intensive induction and consolidation or post-transplant FLT3inhibitor (FLT3i) maintenance. Some mechanisms of drug resistance can be shared across FLT3i's, suggesting response to gilteritinib might differ in patients treated with frontline FLT3i. A better understanding of how prior therapy modulates response to gilteritinib is necessary to clarify this novel agent's role in the current FLT3-mutated AML treatment algorithm. Methods: This is an ongoing multi-institutional analysis from 13 US centers identifying patients who received gilteritinib alone or as combination therapy for the treatment of R/R FLT3mut+ AML. Patients who received gilteritinib as a part of an ongoing trial were excluded. Response criteria were identical to the ADMIRAL trial. For patients with available data and a composite complete remission (CRc), we defined clinically measurable residual disease (cMRD) negative status by bone marrow flow cytometry using a cutoff of <1 x 10x105 cells as well as polymerase chain reaction (PCR) for FLT3 mutation with a minimum sensitivity of 5%. Survival from the time of gilteritinib initiation was recorded. Multivariate analysis included all variables collected to determine interaction with patient outcome (CR and survival data). Kaplan-Meier curves and log rank test were used for survival analysis after gilteritinib initiation. Results: 72 patients treated with prior FLT3i exposure received gilteritinib for treatment of R/R FLT3mut+ AML. Patient characteristics are presented in table-1 with 46 (64%) previously receiving midostaurin, 19 (26%) sorafenib, and 7 (10%) other FLT3i. 8 (11%) received more than one prior TKI. NGS at diagnosis were available in 66 patients (92%) and co-mutations in DNMT3A, NPM1 and NRAS were observed in more than 10% of patients. Average duration of gilteritinib therapy was 5.7 months (range: 0.2-25 months). 27 (37.5%) received stem cell transplant (SCT) before gilteritinib and 15 (21%) underwent SCT after gilteritinib. The composite CR rate (CRc, defined as CR + CRi + CRp) was 51.4% (n= 37 patients). With regard to specific FLT3i's, we found no significant difference in median survival (7.1 months and 6.4 months for midostaurin and sorafenib, respectively) or remission rates (CRc 54% and 47% for prior midostaurin and sorafenib, respectively). The CRc rate for patients who received only prior 7+3 and midostaurin with or without consolidation was 58% with a median survival of 7.8 months. A trend toward higher CRc rate was noted in patients treated with gilteritinib in combination regimens rather than as a single agent (64% vs 43%, respectively, p=0.09 using Chi-square test). No survival advantage for combination therapy was seen over single agent. Survival was longest in patients who obtained a CR, particularly a cMRD negative response; this remained significant after censoring at the time of SCT (figures 1&2). Patients who received SCT after gilteritinib had significantly longer survival than non-transplanted patients (9.3 months vs 5.6 months, respectively, HR 0.44, 95% CI 0.2-0.8)(figure-3). Patients with concurrent mutations of NPM1/DNMT3A had a trend toward a higher CRc compared to FLT3 mutation alone (71% vs 50%, p= 0.2) but similar survival. With regard to mutations associated with drug resistance to other FLT3i's, patients with both FLT3-ITD and FLT3-D835 mutation had similar response and survival to FLT3-ITD alone. However, patients with MAPK pathway activating mutations (e.g. NRAS and PTPN11) had lower CRc (37.5% vs 59.5%) and poorer median survival than other patients (3.3 months vs 7.5 months) (HR 2.2- 95% CI 1.1-4.4) p value <0.01(figure-4). Conclusions: In this multi-center, retrospective analysis, gilteritinib remains a clinically active agent after treatment failure of prior FLT3i's (midostaurin or sorafenib). Mutations activating MAPK pathway have been implicated in secondary gilteritinib resistance but are seldom co-mutated at initial FLT3mut+ AML diagnosis. While further study is required, we hypothesize that their detection after frontline FLT3i therapy may represent treatment-emergent clones with propensity for pan-FLT3i resistance. Disclosures Zeidan: Cardiff Oncology: Consultancy, Honoraria, Other; Trovagene: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Celgene / BMS: Consultancy, Honoraria, Research Funding; Jazz: Consultancy, Honoraria; Daiichi Sankyo: Consultancy, Honoraria; BeyondSpring: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria; Taiho: Consultancy, Honoraria; Cardinal Health: Consultancy, Honoraria; Acceleron: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Aprea: Research Funding; ADC Therapeutics: Research Funding; MedImmune/Astrazeneca: Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Ionis: Consultancy, Honoraria; Epizyme: Consultancy, Honoraria; Astex: Research Funding; CCITLA: Other; Leukemia and Lymphoma Society: Other; Agios: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Incyte: Consultancy, Honoraria, Research Funding. Yilmaz:Pint Pharma: Honoraria; Pfizer: Research Funding; Daicho Sankyo: Research Funding. Foran:Agios: Honoraria, Research Funding; H3Biosciences: Research Funding; Xencor: Research Funding; Trillium: Research Funding; Takeda: Research Funding; Kura Oncology: Research Funding; Aptose: Research Funding; Aprea: Research Funding; Actinium: Research Funding; Boehringer Ingelheim: Research Funding; Abbvie: Research Funding; BMS: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Revolution Medicine: Consultancy. Daver:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Daiichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Syndax: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; KITE: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Karyopharm: Research Funding; Servier: Research Funding; Genentech: Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novimmune: Research Funding; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Trovagene: Research Funding; Fate Therapeutics: Research Funding; ImmunoGen: Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz: Consultancy, Membership on an entity's Board of Directors or advisory committees; Trillium: Consultancy, Membership on an entity's Board of Directors or advisory committees. Perl:Novartis: Honoraria, Other, Research Funding; Agios: Consultancy, Honoraria, Other; Biomed Valley Discoveries: Research Funding; Jazz: Honoraria, Other; FORMA Therapeutics: Consultancy, Honoraria, Other; Syndax: Consultancy, Honoraria; Actinium Pharmaceuticals Inc: Consultancy, Honoraria, Research Funding; AbbVie Inc: Consultancy, Honoraria, Other, Research Funding; Loxo Oncology Inc, a wholly owned subsidiary of Eli Lilly & Company: Consultancy, Honoraria, Other; Bayer HealthCare Pharmaceuticals: Research Funding; New Link Genetics: Honoraria, Other; Astellas: Consultancy, Honoraria, Other: writing/editorial support, travel costs for meeting presentations related to study, Research Funding; Daiichi Sankyo: Consultancy, Honoraria, Other: Writing/editorial support, travel costs for meetings, Research Funding; Leukemia & Lymphoma Society, Beat AML: Consultancy; Arog Pharmaceuticals Inc: Other: uncompensated consulting, travel costs for meetings; FUJIFILM Pharmaceuticals USA, Inc: Research Funding; Takeda: Honoraria, Other: Travel costs for meeting. Altman:Kartos: Research Funding; Celgene: Research Funding; Boehringer Ingelheim: Research Funding; ImmunoGen: Research Funding; Amgen: Research Funding; Aprea: Research Funding; Amphivena: Research Funding; Genentech: Research Funding; Novartis: Consultancy; Syros: Consultancy; Janssen: Consultancy; Immune Pharmaceuticals: Consultancy; ASH: Consultancy; Bristol-Myers Squibb: Consultancy; Glycomimetics: Other: Data safety and monitoring committee; Daiichi Sankyo: Other: Advisory Board - no payment but was reimbursed for travel; Kura Oncology: Other: Scientific Advisory Board - no payment accepted, Research Funding; BioSight: Other: No payment but was reimbursed for travel , Research Funding; AbbVie: Other: advisory board, Research Funding; Agios: Other: advisory board, Research Funding; Theradex: Other: Advisory Board; Astellas: Other: Advisory Board, Speaker (no payment), Steering Committee (no payment), Research Funding; PrIME Oncology: Consultancy; PeerView: Consultancy; Cancer Expert Now: Consultancy; France Foundation: Consultancy; Fujifilm: Research Funding. OffLabel Disclosure: Some of the patients we are reporting on received gilteritinib in combination with other agents which is off-label use.
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Zeidan, Amer M., Bhavik J. Pandya, Cynthia Z. Qi, Andy Garnham, Hongbo Yang, and Manasee V. Shah. "Cost-Effectiveness Analysis of Gilteritinib Versus Best Supportive Care (BSC) for the Treatment of Relapsed or Refractory (R/R) FLT3 Mutation-Positive (FLT3mut+) Acute Myeloid Leukemia (AML)." Blood 134, Supplement_1 (November 13, 2019): 5085. http://dx.doi.org/10.1182/blood-2019-123811.
Full textAbstract:
Introduction: AML is an aggressive hematopoietic malignancy, and ~30% of patients have mutations in the FLT3 gene. Historically, patients with R/R FLT3mut+ AML experienced dismal survival outcomes. The approval of FLT3-targeted agents has resulted in a paradigm change in the management of these patients. In 2018, gilteritinib was approved as the first targeted agent for R/R FLT3mut+ AML based on results of the phase 3 ADMIRAL trial, showing significantly improved median overall survival (OS) of 9.3 months. Historically, due to limited effective options and tolerability concerns, 11-40% of patients with R/R FLT3mut+ AML received BSC (defined as no active leukemia-directed therapy). Patients managed by BSC still incur substantial resource use and have poor outcomes. The estimated median OS was 2-3 months, with the majority of patients (> 90%) dying within one year. To quantify the incremental benefit and economic value of gilteritinib over BSC, a cost-effectiveness analysis (CEA) model was constructed to model disease trajectory, quality of life impact, and economic impact. Methods: A CEA was developed to compare the costs and effectiveness of gilteritinib and BSC from a US third-party payer's perspective over a lifetime horizon. The model used a 1-month cycle and 3% discount rate and comprised a decision tree followed by a three-stage partitioned survival model. In the decision tree stage, patients were first classified based on whether they received allogeneic hematopoietic stem cell transplantation (HSCT). Following stratification, patients were distributed among three health states: event-free survival (EFS), alive and post-event, and death. Due to the palliative nature of BSC, all patients in the BSC arm were assumed to start in the alive and post-event state and were not eligible to receive subsequent HSCT based on clinical inputs. For patients in the gilteritinib arm, the efficacy inputs were based on the ADMIRAL trial for patients without HSCT or literature (Evers 2018) for those with HSCT. For patients in the BSC arm, the efficacy inputs were based on available literature (Sarkozy 2013). Parametric survival models or hazard ratios were used to predict probabilities in different health states until year 3. After year 3, all patients who remained alive were considered cured with a two-fold increase in mortality risk compared to the general population. Treatment costs (drug, administration, and hospitalization), adverse event (AE) costs, subsequent HSCT costs, medical costs for health states, FLT3 testing, post-progression treatment, and terminal care costs were obtained from public databases and literature. Patients managed by BSC were assumed not to incur any costs related to treatment, AEs, or HSCT. All costs were inflated to 2018 US dollar (USD). Utilities for each health state were derived from the ADMIRAL trial and disutilities for AEs were derived from the literature. The model calculated total costs, and total effectiveness measured by life years (LYs) and quality-adjusted life years (QALYs) for gilteritinib and BSC, respectively. Incremental cost-effectiveness ratios (ICERs), defined as the incremental cost per additional gain in health effect (i.e., LY and QALY), were estimated comparing gilteritinib to BSC. To test the robustness of the results, deterministic sensitivity analyses (DSA) and probabilistic sensitivity analyses (PSA) were performed. Results: Over a lifetime horizon, treatment with gilteritinib, compared to BSC, was associated with an incremental LY gain of 2.82 and QALY gain of 2.32, respectively. With an additional cost of $239,623 relative to BSC, the ICER per one LY gained was $84,922, and ICER per one QALY gained was $103,110. The results were most sensitive to discount rate, cure assumptions, and gilteritinib cost. PSA showed 100% probability of being cost-effective at an acceptable willingness-to-pay threshold of $150,000/QALY in the US. Conclusions: Gilteritinib led to substantial clinical benefit compared to BSC for treatment of R/R FLT3mut+ AML. Despite the large cost difference, the ICER is still within a reasonable range of less than $150,000/QALY, as established by the US Institute for Clinical and Economic Review. Gilteritinib fulfills an important unmet need in the treatment landscape and represents a potential paradigm shift in the current management of R/R FLT3mut+ AML for patients who otherwise would not have received active therapy. Disclosures Zeidan: BeyondSpring: Honoraria; Acceleron Pharma: Consultancy, Honoraria, Research Funding; Celgene Corporation: Consultancy, Honoraria, Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Trovagene: Consultancy, Honoraria, Research Funding; Incyte: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; ADC Therapeutics: Research Funding; Abbvie: Consultancy, Honoraria, Research Funding; Cardinal Health: Honoraria; Otsuka: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Jazz: Honoraria; Ariad: Honoraria; Agios: Honoraria; Novartis: Honoraria; Astellas: Honoraria; Daiichi Sankyo: Honoraria; Medimmune/AstraZeneca: Research Funding; Seattle Genetics: Honoraria. Pandya:Astellas Pharmaceuticals: Employment. Qi:Astellas: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Astellas for the conduct of this study; Analysis Group, Inc.: Employment. Garnham:Astellas: Employment. Yang:Analysis Group, Inc.: Employment; Astellas: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Astellas for the conduct of this study. Shah:Astellas: Employment.
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Smith, Catherine C., Mark J. Levis, Alexander E. Perl, Giovanni Martinelli, Andreas Neubauer, Ellin Berman, Pau Montesinos, et al. "Emerging Mutations at Relapse in Patients with FLT3-Mutated Relapsed/Refractory Acute Myeloid Leukemia Who Received Gilteritinib Therapy in the Phase 3 Admiral Trial." Blood 134, Supplement_1 (November 13, 2019): 14. http://dx.doi.org/10.1182/blood-2019-122620.
Full textAbstract:
Introduction: The phase 3 ADMIRAL trial demonstrated that gilteritinib, a novel, potent, oral FLT3 inhibitor, significantly prolonged overall survival and resulted in higher remission rates compared with salvage chemotherapy in patients with FLT3-mutation-positive (FLT3mut+) relapsed/refractory (R/R) acute myeloid leukemia (AML; Perl AE, et al. AACR 2019), even in the presence of common co-occurring AML mutations (DNMT3A, NPM1, and WT1) (Levis MJ, et al. J Clin Oncol. 2019;37[suppl 15]:7000). However, as with other FLT3 inhibitors, patients often develop resistance after an initial response to gilteritinib. Evidence suggests that expansion of leukemic clones containing mutations in Ras/MAPK pathway genes NRAS and KRAS mediates secondary resistance to gilteritinib in patients with FLT3mut+ R/R AML, and confirms that cells with Ras/MAPK pathway mutations are FLT3mut+ (McMahon CM, et al. Cancer Discov. 2019; doi: 10.1158/2159-8290). We evaluated emerging mutations in patients who relapsed while receiving gilteritinib therapy in the ADMIRAL trial. Methods: Blood or bone marrow samples were available for 361 patients at baseline (97.3% of the intention-to-treat population [N=371]) and for 40 patients who relapsed on gilteritinib treatment. Samples were analyzed by next-generation sequencing using the Archer Core Myeloid Panel. Data were analyzed using Archer Analysis software; the variant allele frequency (VAF) cutoff was ≥2.7%. Results: Of 371 patients enrolled in the ADMIRAL trial, 247 were assigned to 120-mg/day gilteritinib and 75 (30.5%) relapsed during the study. Most relapses (n=72/75; 96.0%) occurred ≤4 weeks from the last gilteritinib dose. Forty patients who had samples available at baseline also had samples at relapse for comparison. No samples were available from patients who relapsed on chemotherapy. At relapse, 27/40 patients (67.5%) had new mutations, including mutations in Ras/MAPK pathway genes (n=18), FLT3 (n=6), WT1 (n=3), IDH1 (n=1), and GATA2 (n=1) (Table). Thirteen patients (32.5%) had no new mutations. Of the 18 patients with Ras/MAPK pathway gene mutations at relapse, 11 (61.1%) had >1 new mutation at relapse (range, 2-6). The most frequently mutated Ras/MAPK pathway gene was NRAS (n=11). Patients were also assessed for Ras/MAPK gene pathway mutations prior to gilteritinib therapy. Among all FLT3mut+ patients analyzed for co-mutated genes at baseline (n=361), 25 (6.9%) had Ras/MAPK pathway gene mutations detected (gilteritinib, n=18; salvage chemotherapy, n=7; median VAF, 13% [range, 3.4%-50%]). In contrast to the 12.0% of patients (n=3/25) who had >1 Ras/MAPK pathway gene mutation at baseline, 61.1% (n=11/18) had >1 Ras/MAPK pathway gene mutation at relapse. Notably, a considerable number of gilteritinib-treated patients who had Ras/MAPK pathway gene mutations at baseline achieved remission: the rate of CRc (ie, composite complete remission: complete remission [CR] or CR with incomplete hematologic/platelet recovery) was 38.9% (n=7/18); the rate of CR/CRh (ie, CR or CR with partial hematologic recovery) was 27.8% (n=5/18). Six patients acquired new FLT3 mutations at relapse. Five of these six patients acquired a F691L gatekeeper mutation; one of these five patients also acquired a FLT3 juxtamembrane domain point mutation. Of the three patients who acquired a WT1 mutation at relapse, one also acquired a FLT3 F691L gatekeeper mutation. The acquisition of Ras/MAPK pathway gene mutations and FLT3 F691L gatekeeper mutations at relapse was mutually exclusive. Conclusions: In patients with FLT3mut+ R/R AML who relapsed on gilteritinib therapy, Ras/MAPK pathway gene mutations and FLT3 F691L gatekeeper mutations were the most common mutational events. The presence of a Ras/MAPK pathway gene mutation at baseline did not preclude benefit from gilteritinib therapy, possibly due to fewer Ras/MAPK pathway gene mutations per patient at baseline than at relapse. The acquisition of multiple Ras/MAPK pathway gene mutations at relapse likely mediates continued engagement of Ras/MAPK signaling in patients with FLT3mut+ R/R AML receiving gilteritinib. The frequency of emergent FLT3 F691 gatekeeper mutations at relapse in patients who received 120-mg/day gilteritinib in the ADMIRAL study was similar to that observed in relapsed patients who received 20- to 450-mg/day gilteritinib (Levis MJ, et al. Blood. 2017;130[suppl 1]:2705). Table Disclosures Smith: Revolution Medicines: Research Funding; Astellas Pharma: Research Funding; fujiFilm: Research Funding; Abbvie: Research Funding. Levis:Astellas: Consultancy, Research Funding; FUJIFILM: Consultancy, Research Funding; Menarini: Consultancy, Honoraria; Novartis: Consultancy, Research Funding; Agios: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Daiichi Sankyo Inc: Consultancy, Honoraria. Perl:Astellas: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings as well as a medical writing company that assisted with manuscript preparation/submission and slide deck assembly for academic meeting presentations of trial data., Research Funding; BioMed Valley Discoveries: Research Funding; Daiichi Sankyo: Consultancy, Honoraria, Other, Research Funding; Arog: Consultancy, Other: Non-financial support included travel costs for advisory board meetings.; AbbVie: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; Actinium Pharmaceuticals: Consultancy, Honoraria, Other: Clinical Advisory Board member, Research Funding; Agios: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Non-financial support included travel costs for advisory board meetings.; Jazz: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; NewLink Genetics: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; Takeda: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; Bayer: Research Funding; FujiFilm: Research Funding; Novartis: Honoraria, Other: Advisory board, Non-financial support included travel costs for advisory board meetings as well as a medical writing company that assisted with manuscript preparation/submission and slide deck assembly for academic meeting presentations of the data., Research Funding. Martinelli:Daiichi Sankyo: Consultancy, Honoraria; Roche: Consultancy, Other: trial grant; Ariad: Consultancy, Other: trial grant; Janssen: Consultancy, Other: trial grant; Amgen: Consultancy, Other: trial grant; Pfizer: Consultancy, Other: trial grant; Abbvie: Consultancy, Honoraria, Other: trial grant; Celgene: Consultancy, Honoraria, Other: trial grant; Novartis: Consultancy, Other: trial grant; Incyte: Consultancy, Other: trial grant. Berman:Astellas: Membership on an entity's Board of Directors or advisory committees, Research Funding. Montesinos:Karyopharm: Membership on an entity's Board of Directors or advisory committees, Other: Research support; Pfizer: Membership on an entity's Board of Directors or advisory committees, Other: Research support, Research Funding, Speakers Bureau; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Research support, Speakers Bureau; Teva: Membership on an entity's Board of Directors or advisory committees, Other: Research support, Research Funding, Speakers Bureau; Abbvie: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Other: Research support, Research Funding, Speakers Bureau; Daiichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Research support, Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Other: Research support, Research Funding, Speakers Bureau; Incyte: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Baer:Abbvie: Research Funding; Astellas: Research Funding; Al Therapeutics: Research Funding; Forma: Research Funding; Incyte: Research Funding; Kite: Research Funding; Takeda: Research Funding. Larson:Celgene: Consultancy; Agios: Consultancy; Novartis: Honoraria, Other: Contracts for clinical trials. Yokoyama:Astellas: Other: Travel expenses. Recher:Incyte: Honoraria; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sunesis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Jazz: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Macrogenics: Consultancy, Membership on an entity's Board of Directors or advisory committees. Yoon:MSD: Consultancy; Kyowa Hako Kirin: Research Funding; Janssen: Consultancy; Genentech, Inc.: Research Funding; Amgen: Consultancy, Honoraria; Yuhan Pharma: Research Funding; Novartis: Consultancy, Honoraria. Hill:Astellas: Employment; Ligacept, LLC.: Other: Stock, Patents & Royalties. Rosales:Astellas: Employment. Bahceci:Astellas: Employment, Patents & Royalties.
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Mikesch, Jan-Henrik, and Christoph Schliemann. "Gilteritinib in der Therapie der r/r AML." InFo Hämatologie + Onkologie 23, no. 7-8 (August 2020): 27–28. http://dx.doi.org/10.1007/s15004-020-8154-9.
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Levis, Mark, and Alexander E. Perl. "Gilteritinib: potent targeting of FLT3 mutations in AML." Blood Advances 4, no. 6 (March 24, 2020): 1178–91. http://dx.doi.org/10.1182/bloodadvances.2019000174.
Full textAbstract:
Abstract Since the discovery of FMS-like tyrosine kinase-3 (FLT3)–activating mutations as genetic drivers in acute myeloid leukemia (AML), investigators have tried to develop tyrosine kinase inhibitors that could effectively target FLT3 and alter the disease trajectory. Giltertinib (formerly known as ASP2215) is a novel compound that entered the field late, but moved through the developmental process with remarkable speed. In many ways, this drug’s rapid development was facilitated by the large body of knowledge gained over the years from efforts to develop other FLT3 inhibitors. Single-agent gilteritinib, a potent and selective oral FLT3 inhibitor, improved the survival of patients with relapsed or refractory FLT3-mutated AML compared with standard chemotherapy. This continues to validate the approach of targeting FLT3 itself and establishes a new backbone for testing combination regimens. This review will frame the preclinical and clinical development of gilteritinib in the context of the lessons learned from its predecessors.
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Pratz, Keith W., Mohamad Cherry, Jessica K. Altman, Brenda W. Cooper, Jose Carlos Cruz, Joseph G. Jurcic, Mark Levis, et al. "A Phase 1 Study of Gilteritinib in Combination with Induction and Consolidation Chemotherapy in Patients with Newly Diagnosed AML: Final Results." Blood 136, Supplement 1 (November 5, 2020): 16–17. http://dx.doi.org/10.1182/blood-2020-137685.
Full textAbstract:
Background: Gilteritinib, an oral FMS-like tyrosine kinase 3 (FLT3) inhibitor, demonstrated antileukemic responses in patients with FLT3-mutated (FLT3mut+) relapsed/refractory acute myeloid leukemia (AML). We report final results from a phase 1 study of once-daily oral gilteritinib plus intravenous (IV) chemotherapy in patients with newly diagnosed AML. Methods: This 4-part, open-label, phase 1 study (NCT02236013) assessed the safety/tolerability and antileukemic effects of gilteritinib plus 7+3 induction and high-dose cytarabine consolidation chemotherapy, and as single-agent maintenance therapy in adults with newly diagnosed AML. In part 1, successive cohorts of 3-6 patients received 40-200 mg/d gilteritinib (Days 4-17) and ≤2 cycles of induction (cytarabine 100 mg/m2/d IV, Days 1-7; idarubicin 12 mg/m2/d IV, Days 1-3). In part 2, patients (n=33, of which at least 15 were FLT3mut+) received the recommended 120 mg/d gilteritinib expansion dose and ≤2 cycles of the part 1 induction schedule. In part 3, patients were stratified into 2 cohorts: one receiving treatment from part 2 (n=7) and the other receiving treatment that replaced idarubicin with daunorubicin (90 mg/m2/d IV, Days 1-3; n=7). In part 4, patients (n=12) received the same induction as the part 3/daunorubicin cohort (with a reduction in cycle 2 to daunorubicin 45 mg/m2/d). During consolidation, patients received ≤3 cycles of cytarabine (1.5 g/m2 every 12 hours; Days 1, 3, and 5) and gilteritinib (Days 1-14 for parts 1-3; Days 1-56 for part 4) at the induction dose. Gilteritinib was given once daily in 28-day cycles for up to 26 cycles as maintenance therapy (maintenance phase is still ongoing). Patients achieving composite complete remission (CRc) or partial remission could undergo hematopoietic stem cell transplant (HSCT) and resume maintenance gilteritinib treatment post-HSCT. Results: As of 23 June 2020, 80 patients were allocated to treatment (safety analysis set, n=79); median age was 59.0 y (range, 23-77) and most were male (62.0%). Median follow-up for overall survival (OS) was 35.8 mo. Dose-limiting toxicities are provided in Table 1. The maximum tolerated dose was 120 mg/d. Serious treatment-related adverse events (AEs) and AEs leading to discontinuation of gilteritinib occurred in 12.7% (n=10) and 5.1% (n=4) of patients, respectively. One (1.3%) death occurred across all treatment phases. Grade ≥3 nonhematologic AEs (≥10% of patients) were increased alanine aminotransferase (13.9%), pneumonia (13.9%), sepsis (11.4%), and bacteremia (11.4%). At the end-of-induction time point, there were 44 (55.7%) total FLT3mut+ patients across all dose groups and 38 (48.1%) patients who received gilteritinib 120 mg/d. Investigator-reported CRc was achieved by 81.8% of patients across all dose groups (n=36) and 81.6% among patients who received gilteritinib 120 mg/d (n=31; Table 2). Anthracycline choice had no clear impact on CRc rate, although the number of patients in these cohorts was low. In FLT3mut+ patients who achieved CRc in any dose group, median (95% CI) duration of CRc and disease-free survival were 14.1 (4.0-29.9) and 15.3 (9.8-not reached) mo, respectively. Median OS for FLT3mut+ patients has not been reached. The survival probability (95% CI) in all FLT3mut+ patients at weeks 8, 12, 26, 52, and 104 were 97.7% (84.6%-99.7%), 95.3% (82.5%-98.8%), 92.9% (79.6%-97.7%), 83.1% (67.7%-91.5%), and 71.8% (54.6%-83.4%), respectively. In patients with FLT3 internal tandem duplication (ITD)-positive AML achieving CRc, mutational clearance (summed FLT3 ITD signal ratio of ≤10-4 after induction or consolidation) was achieved by 70% (n/N=16/23) of patients receiving a gilteritinib dose of ≥120 mg. HSCT occurred in 30.4% of the total population (n/N=24/79). Analysis of plasma inhibitory activity and pharmacokinetics of gilteritinib will be available at presentation. Conclusions: Gilteritinib plus induction and consolidation chemotherapy is well tolerated in patients with newly diagnosed AML. Favorable antileukemic responses were observed in FLT3mut+ patients regardless of anthracycline type or gilteritinib administration schedule, with a mutational clearance rate of 70.0%. Based on these results, randomized clinical trials of induction and consolidation chemotherapy plus gilteritinib vs midostaurin in FLT3mut+ AML patients have been initiated. Disclosures Pratz: AbbVie: Other: Scientific Advisory Board, Research Funding; Astellas: Other: Scientific Advisory Board, Research Funding; Boston BioMedical: Consultancy; Celgene: Other: Scientific Advisory Board; Agios: Other: Scientific Advisory Board, Research Funding; Jazz Pharmaceutical: Consultancy; Millennium: Research Funding; Daiichi Sankyo: Research Funding. Cherry:Pfizer: Other: Advisory Board; BMS: Other: Advisory Board; Kite: Other: Advisory Board. Altman:PeerView: Consultancy; ASH: Consultancy; Syros: Consultancy; Janssen: Consultancy; Genentech: Research Funding; Amphivena: Research Funding; Amgen: Research Funding; Aprea: Research Funding; ImmunoGen: Research Funding; Celgene: Research Funding; Boehringer Ingelheim: Research Funding; PrIME Oncology: Consultancy; Immune Pharmaceuticals: Consultancy; Novartis: Consultancy; Glycomimetics: Other: Data safety and monitoring committee; Daiichi Sankyo: Other: Advisory Board - no payment but was reimbursed for travel; Kura Oncology: Other: Scientific Advisory Board - no payment accepted, Research Funding; Kartos: Research Funding; AbbVie: Other: advisory board, Research Funding; Fujifilm: Research Funding; BioSight: Other: No payment but was reimbursed for travel , Research Funding; Bristol-Myers Squibb: Consultancy; Astellas: Other: Advisory Board, Speaker (no payment), Steering Committee (no payment), Research Funding; Cancer Expert Now: Consultancy; Agios: Other: advisory board, Research Funding; Theradex: Other: Advisory Board; France Foundation: Consultancy. Cruz:Takeda: Speakers Bureau. Jurcic:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Consultancy, Research Funding; Daiichi-Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Arog Pharmaceuticals: Research Funding; Astellas: Research Funding; Forma Therapeutics: Research Funding; Genentech: Research Funding; Kura Oncology: Research Funding; PTC Therapeutics: Research Funding; Syros Pharmaceuticals: Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Levis:Menarini: Honoraria; Amgen: Honoraria; FujiFilm: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria; Astellas: Honoraria, Research Funding. Lin:Pfizer: Research Funding; Bio-Path Holdings: Research Funding; Abbvie: Research Funding; Seattle Genetics: Research Funding; Tolero Pharmaceuticals: Research Funding; Ono Pharmaceutical: Research Funding; Prescient Therapeutics: Research Funding; Incyte: Research Funding; Genetech-Roche: Research Funding; Gilead Sciences: Research Funding; Aptevo: Research Funding; Celyad: Research Funding; Celgene: Research Funding; Astellas Pharma: Research Funding; Mateon Therapeutics: Research Funding; Jazz: Research Funding; Trovagene: Research Funding. Perl:Bayer HealthCare Pharmaceuticals: Research Funding; Syndax: Consultancy, Honoraria; Jazz: Honoraria, Other; Arog Pharmaceuticals Inc: Other: uncompensated consulting, travel costs for meetings; Biomed Valley Discoveries: Research Funding; Agios: Consultancy, Honoraria, Other; FUJIFILM Pharmaceuticals USA, Inc: Research Funding; AbbVie Inc: Consultancy, Honoraria, Other, Research Funding; Loxo Oncology Inc, a wholly owned subsidiary of Eli Lilly & Company: Consultancy, Honoraria, Other; Takeda: Honoraria, Other: Travel costs for meeting; Astellas: Consultancy, Honoraria, Other: writing/editorial support, travel costs for meeting presentations related to study, Research Funding; Leukemia & Lymphoma Society, Beat AML: Consultancy; New Link Genetics: Honoraria, Other; Daiichi Sankyo: Consultancy, Honoraria, Other: Writing/editorial support, travel costs for meetings, Research Funding; FORMA Therapeutics: Consultancy, Honoraria, Other; Actinium Pharmaceuticals Inc: Consultancy, Honoraria, Research Funding; Novartis: Honoraria, Other, Research Funding. Podoltsev:Arog Pharmaceuticals: Research Funding; Astex Pharmaceuticals: Research Funding; Jazz Pharmaceuticals: Research Funding; Sunesis Pharmaceuticals: Research Funding; Boehringer Ingelheim: Research Funding; Daiichi Sankyo: Research Funding; Astellas Pharma: Research Funding; CTI biopharma: Consultancy, Honoraria, Research Funding; Bristol-Myers Squib: Consultancy, Honoraria; Genentech: Research Funding; Novartis: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Samus Therapeutics: Research Funding; Agios Pharmaceuticals: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Incyte: Consultancy, Honoraria; Blueprint Medicines: Consultancy, Honoraria; Alexion: Consultancy, Honoraria; Kartos Therapeutics: Research Funding; AI Therapeutics: Research Funding. Schiller:Abbvie: Research Funding; Actinium: Research Funding; Ariad: Research Funding; Amgen: Consultancy, Current equity holder in publicly-traded company, Research Funding, Speakers Bureau; AstraZeneca: Consultancy; Incyte: Consultancy, Research Funding, Speakers Bureau; Novartis: Consultancy, Research Funding; Ono Pharma: Consultancy; Kite Pharma: Research Funding; Stemline: Speakers Bureau; Gilead: Speakers Bureau; Celgene: Research Funding, Speakers Bureau; Sanofi: Speakers Bureau; Agios: Consultancy, Research Funding, Speakers Bureau; DeltaFly: Research Funding; Deciphera: Research Funding; Daiichi Sankyo: Research Funding; Cyclacel: Research Funding; Constellation: Research Funding; Celator: Research Funding; Astellas Pharma: Honoraria, Research Funding; Bristol-Myers Squibb: Current equity holder in publicly-traded company, Research Funding; Forma: Research Funding; FujiFilm: Research Funding; Gamida: Research Funding; Genentech-Roche: Research Funding; Geron: Research Funding; Jazz Pharmaceuticals: Research Funding; Karyopharm: Research Funding; Mateon: Research Funding; MedImmune: Research Funding; Onconova: Research Funding; Pfizer: Current equity holder in publicly-traded company, Research Funding; Regimmune: Research Funding; Samus: Research Funding; Sangamo: Research Funding; Tolero: Research Funding; Trovagene: Research Funding; Kaiser Permanente: Consultancy; Johnson & Johnson: Current equity holder in publicly-traded company. Hill:Targeted Molecular Diagnostics: Patents & Royalties: US7862995; Astellas: Current Employment; Ligacept, LLC: Current equity holder in publicly-traded company, Patents & Royalties: US9051388, US9683222. James:Astellas: Current Employment. Lu:Astellas: Current Employment. Tiu:Astellas Pharma Global Development: Current Employment; Eli Lilly & Company: Current equity holder in publicly-traded company, Ended employment in the past 24 months. OffLabel Disclosure: New Indication
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Cucchi, David G. J., Barbara Denys, Gertjan J. L. Kaspers, Jeroen J. W. M. Janssen, Gert J. Ossenkoppele, Valérie de Haas, C. Michel Zwaan, et al. "RNA-based FLT3-ITD allelic ratio is associated with outcome and ex vivo response to FLT3 inhibitors in pediatric AML." Blood 131, no. 22 (May 31, 2018): 2485–89. http://dx.doi.org/10.1182/blood-2017-12-819508.
Full textAbstract:
Key Points FLT3-ITD-AR measurement based on RNA, but not DNA, is predictive for survival with a cutoff point of 0.5. FLT3-ITD-AR is associated with an ex vivo response to FLT3 inhibition with gilteritinib.
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Ha, You Na, Sungmi Song, Barbora Orlikova-Boyer, Claudia Cerella, Christo Christov, Anake Kijjoa, and Marc Diederich. "Petromurin C Induces Protective Autophagy and Apoptosis in FLT3-ITD-Positive AML: Synergy with Gilteritinib." Marine Drugs 18, no. 1 (January 16, 2020): 57. http://dx.doi.org/10.3390/md18010057.
Full textAbstract:
Treatment of acute myeloid leukemia (AML) remains inefficient due to drug resistance and relapse, particularly in patients with FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication (ITD). Marine-derived natural products have recently been used for drug development against AML. We show in this study that petromurin C, which was isolated from the culture extract of the marine-derived fungus Aspergillus candidus KUFA0062, isolated from the marine sponge Epipolasis sp., induces early autophagy followed by apoptotic cell death via activation of the intrinsic cell death pathway concomitant with mitochondrial stress and downregulation of Mcl-1 in FLT3-ITD mutated MV4-11 cells. Moreover, petromurin C synergized with the clinically-used FLT3 inhibitor gilteritinib at sub-toxic concentrations. Altogether, our results provide preliminary indications that petromurin C provides anti-leukemic effects alone or in combination with gilteritinib.
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Chew, Serena, Melissa C. Mackey, and Elias Jabbour. "Gilteritinib in the treatment of relapsed and refractory acute myeloid leukemia with a FLT3 mutation." Therapeutic Advances in Hematology 11 (January 2020): 204062072093061. http://dx.doi.org/10.1177/2040620720930614.
Full textAbstract:
Acute myeloid leukemia (AML) is a malignancy of uncontrolled proliferation of immature myeloid blasts characterized by clonal evolution and genetic heterogeneity. FMS-like tyrosine kinase 3 (FLT3) mutations occur in up to a third of AML cases and are associated with highly proliferative disease, shorter duration of remission, and increased rates of disease relapse. The known impact of activating mutations in FLT3 in AML on disease pathogenesis, prognosis, and response to therapy has led to the development of tyrosine kinase inhibitors targeting FLT3. Gilteritinib is a potent, second generation inhibitor of both FLT3 and AXL, designed to address the limitations of other FLT3 inhibitors, particularly in targeting mechanisms of resistance to other drugs. In this review, we present comprehensive data on recent and ongoing studies evaluating the role of gilteritinib in the relapsed and refractory FLT3 mutated AML setting.
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Perl, Alexander E., Naval G. Daver, Keith W. Pratz, Joseph Maly, Wan-Jen Hong, Erkut Bahceci, Bo Tong, Tian Tian, and Kimberley Dilley. "Venetoclax in Combination with Gilteritinib in Patients with Relapsed/Refractory Acute Myeloid Leukemia: A Phase 1b Study." Blood 134, Supplement_1 (November 13, 2019): 3910. http://dx.doi.org/10.1182/blood-2019-127416.
Full textAbstract:
BACKGROUND: The FLT3 tyrosine kinase inhibitor (TKI) gilteritinib improves the survival of patients with relapsed/refractory (R/R) FLT3 mutated (FLT3mut+) acute myeloid leukemia (AML) compared to standard salvage chemotherapy; however, single agent TKI therapy is not curative and long-term survival remains low. Combination therapy with agents that induce apoptosis may enhance cytotoxicity against FLT3mut+ and WT clones and potentially delay or prevent drug resistance. Preclinical data demonstrate that the combination of venetoclax with a FLT3 tyrosine kinase inhibitor is highly synergistic, and BCL-2 inhibition by venetoclax directly triggers apoptosis, which may help overcome resistance to FLT3-targeted therapy. Therefore, we sought to define the safety and activity of venetoclax plus gilteritinib in R/R AML. METHODS: This is a multicenter, open-label, phase 1b clinical trial (NCT03625505) evaluating the safety and efficacy of venetoclax in combination with gilteritinib for patients with relapsed or refractory (R/R) AML. Patients had to have R/R AML and an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2. Here, we present data in patients that had either wild type (WT) or mutated FLT3, and were treated with 400 mg venetoclax in combination with 80 mg or 120 mg gilteritinib daily, from the dose escalation portion of the study. For study purposes, gilteritinib was administered alone for one day. On day two venetoclax was initiated in a three-day ramp-up from 100 to 200 to 400 mg; thereafter, target doses of each were administered, daily, in 28-day cycles unless venetoclax was shortened for cytopenia recovery. Interruptions of venetoclax or both drugs simultaneously were permitted for adverse events (AEs). RESULTS: Data cutoff was July 10, 2019. Of 15 patients enrolled and treated, 5 had WT FLT3 and 10 had mutant FLT3 (8 ITD, 1 TKD, and one with both included with the ITD group). The median age for all patients was 58 (range: 23-81). Both patients with WT or mutant FLT3 had a median of 2.0 prior lines of therapy, with ranges of 2-4 and 1-4 prior lines, respectively. Six (60%) of the FLT3 mutant patients had previously received a FLT3 blocking TKI (2 of those receiving both midostaurin and sorafenib), and 5 (50%) had prior stem cell transplant (SCT). None of the patients with WT FLT3 were FLT3 inhibitor-experienced, and one patient had prior stem cell transplant. Key treatment emergent grade ≥3 AEs across all patients were: febrile neutropenia (47%), anemia (27%), thrombocytopenia (7%) and neutropenia (7%). One patient receiving 80 mg of gilteritinib had a protocol-defined dose limiting toxicity of prolonged neutropenia, and one receiving 120 mg of gilteritinib was still within the protocol-defined count recovery period at analysis. Seven (47%) patients had venetoclax interrupted, the majority due to neutropenia; 3 (20%) patients had gilteritinib interrupted. No cases of tumor lysis syndrome were observed. Pharmacokinetic studies showed comparable drug levels to those observed with single agent use of each drug. Key efficacy results are shown in the Table. Fifty percent of patients with mutant FLT3 achieved CRc, and another 40% of patients achieved morphologic leukemia free state, for an ORR of 90% (9/10). The ORR in patients with WT FLT3 was 20% (1/5). 0-32); this patient had WT FLT3. Among the 5 patients who achieved CRc, 2 had relapse after documented CRi (at 2.6 months and 1.6 months). Patient monitoring is ongoing, and enrollment in an expansion cohort has also commenced (FLT3 mutant patients treated with 400 mg venetoclax plus 120 mg of gilteritinib); results will be updated for the presentation. CONCLUSIONS: Venetoclax in combination with gilteritinib was well tolerated and demonstrated blast clearance in 90% of patients with FLT3 mutated AML. The high overall rate of response in patients with FLT3 mutated AML, particularly in patients with previous FLT3 TKI exposure, suggests venetoclax in combination with gilteritinib may be a highly effective treatment option for AML patients with FLT3mut+, even in patients with relapsed/refractory AML. Disclosures Perl: Bayer: Research Funding; AbbVie: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; Takeda: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; NewLink Genetics: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; FujiFilm: Research Funding; Novartis: Honoraria, Other: Advisory board, Non-financial support included travel costs for advisory board meetings as well as a medical writing company that assisted with manuscript preparation/submission and slide deck assembly for academic meeting presentations of the data., Research Funding; BioMed Valley Discoveries: Research Funding; Actinium Pharmaceuticals: Consultancy, Honoraria, Other: Clinical Advisory Board member, Research Funding; Agios: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Non-financial support included travel costs for advisory board meetings.; Daiichi Sankyo: Consultancy, Honoraria, Other, Research Funding; Astellas: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings as well as a medical writing company that assisted with manuscript preparation/submission and slide deck assembly for academic meeting presentations of trial data., Research Funding; Jazz: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; Arog: Consultancy, Other: Non-financial support included travel costs for advisory board meetings.. Daver:Otsuka: Consultancy; Immunogen: Consultancy, Research Funding; Forty-Seven: Consultancy; Genentech: Consultancy, Research Funding; Agios: Consultancy; Agios: Consultancy; Otsuka: Consultancy; Sunesis: Consultancy, Research Funding; Celgene: Consultancy; BMS: Consultancy, Research Funding; Daiichi Sankyo: Consultancy, Research Funding; Servier: Research Funding; Incyte: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Abbvie: Consultancy, Research Funding; Glycomimetics: Research Funding; Astellas: Consultancy; Jazz: Consultancy; Jazz: Consultancy; Daiichi Sankyo: Consultancy, Research Funding; Hanmi Pharm Co., Ltd.: Research Funding; Sunesis: Consultancy, Research Funding; NOHLA: Research Funding; Karyopharm: Consultancy, Research Funding; Celgene: Consultancy; Pfizer: Consultancy, Research Funding; Abbvie: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Incyte: Consultancy, Research Funding; Hanmi Pharm Co., Ltd.: Research Funding; Forty-Seven: Consultancy; Servier: Research Funding; Genentech: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Immunogen: Consultancy, Research Funding; Glycomimetics: Research Funding; Karyopharm: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; NOHLA: Research Funding; Astellas: Consultancy. Pratz:Astellas Pharma: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Boston Biomedical: Consultancy; Millenium/Takeda: Research Funding. Hong:Genentech Inc.: Employment, Equity Ownership; Roche: Equity Ownership. Bahceci:Astellas: Employment, Patents & Royalties. Tong:AbbVie: Employment, Other: stock or options. Tian:AbbVie, Inc.: Employment, Other: stock or options. Dilley:AbbVie, Inc.: Employment, Other: stock or options.
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Cella, David, Ellen K. Ritchie, Francesco Fabbiano, Arnaud Pigneux, Yoshinobu Kanda, Cristina Ivanescu, Bhavik J. Pandya, and Manasee V. Shah. "The Relationship between Transplant Status and Patient-Reported Outcomes in Patients with FLT3-Mutated Relapsed/Refractory (R/R) Acute Myeloid Leukemia (AML): Results from the Phase 3 Admiral Study." Blood 134, Supplement_1 (November 13, 2019): 3850. http://dx.doi.org/10.1182/blood-2019-123790.
Full textAbstract:
INTRODUCTION: Standard chemotherapy regimens for AML are not effective in many patients (pts), necessitating the use of targeted therapies. FMS-like tyrosine kinase 3 (FLT3), a cytokine receptor tyrosine kinase expressed in early hematopoietic precursor cells, regulates the proliferation and differentiation of these cells. FLT3 mutations resulting in constitutive signaling are common in AML (~30% of pts), including internal tandem duplication (ITD) in the juxtamembrane (~25%) and point mutations in the tyrosine kinase domain (TKD; ~5%). Hematopoietic stem cell transplantation (HSCT) remains the best chance for a cure, especially in pts with R/R AML; however, data suggest that HSCT can affect the quality of life of pts, both negatively and positively (Wood, 2016; Wong, 2016). While data regarding the relationship between pt-reported outcomes (PRO) and transplant status exist, data from controlled clinical trials, especially trials focused on pts with AML, are scarce. Gilteritinib is an orally administered, potent, selective FLT3 inhibitor with single-agent activity in R/R FLT3-mutation-positive (FLT3mut+) AML. Results from ADMIRAL, a global, randomized, phase 3 study (NCT02421939), demonstrated that gilteritinib improves response and survival compared with salvage chemotherapy (SC) in pts with FLT3mut+ R/R AML. The objective of this analysis was to examine the relationship between PROs and transplant status in pts with FLT3mut+ R/R AML using data collected from ADMIRAL. METHODS: ADMIRAL was a phase 3, open-label, multicenter, randomized study that compared the efficacy and safety of gilteritinib therapy to SC in pts with FLT3mut+ R/R AML. In this study, pts who had a stem cell donor identified and achieved a response allowing them to undergo HSCT could do so without leaving the study. PRO instruments used in this study included the EuroQol Five Dimension Five Level Scale Questionnaire (EQ-5D-5L), Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu), Brief Fatigue Inventory (BFI), Functional Assessment of Chronic Illness Therapy - Dyspnea (FACIT-Dys), and two leukemia-specific items (dizziness and mouth sores). BFI was completed at baseline (BL), Day 1, 8, and 15 of Cycle 1, Day 1 and 15 of Cycle 2, Day 1 of every treatment cycle thereafter, and end of treatment (EOT). All other instruments were completed at BL, Day 1 of every treatment cycle, and EOT. In this analysis, time-to-definitive-deterioration (TDD) values were compared between gilteritinib pts who did or did not undergo HSCT during the study period. In this study, pts in the SC arm who received HSCT were required to leave the study, though they were followed for OS outcomes; as such, PRO data for SC pts were not considered here. TDD was defined as the duration of time from the date of randomization to death or deterioration of ≥1 change threshold unit compared with BL. Change threshold units connote a clinically meaningful change to a pt and were obtained from literature, if published, or from a distribution-based method when no threshold was available from the literature. Kaplan-Meier curves with two-sided 95% confidence intervals were used to estimate the distribution of TDD. RESULTS: A total of 371 pts (n=247, gilteritinib; n=124, SC) were randomized and included in the intent-to-treat population. Of 247 gilteritinib-treated pts, 63 (25.5%) underwent HSCT; 55.6% (n=35/63) of these pts achieved complete remission (CR) or CR with partial hematologic recovery (CRh). Gilteritinib-treated pts who underwent HSCT were found to have significantly improved TDD scores across all EQ-5D-5L (n=43), FACT-Leu (n=40), and BFI (n=41) measures compared with gilteritinib-treated pts who did not undergo HSCT (P<0.001; Table 1). Furthermore, gilteritinib-treated pts who underwent HSCT were more likely to experience improved/maintained PRO scores at EOT across all EQ-5D-5L, FACT-Leu (except for the Social Well-Being subscale), and BFI measures compared with gilteritinib-treated pts who did not undergo HSCT (Table 2). CONCLUSIONS: Results demonstrate that undergoing HSCT is associated with significantly longer TDD. Specifically, median TDD values associated with all measures of fatigue, disease symptomology, and quality of life assessed in this study were significantly longer in pts who underwent HSCT compared with pts who did not. This shows HSCT significantly improved QOL in pts with FLT3mut+ R/R AML in the ADMIRAL trial. Disclosures Cella: FACIT.org: Equity Ownership. Ritchie:Celgene, Novartis: Other: travel support; Jazz Pharmaceuticals: Research Funding; Celgene: Other: Advisory board; Pfizer: Other: Advisory board, travel support; agios: Other: Advisory board; Tolero: Other: Advisory board; Genentech: Other: Advisory board; AStella, Bristol-Myers Squibb, Novartis, NS Pharma, Pfizer: Research Funding; Ariad, Celgene, Incyte, Novartis: Speakers Bureau; Celgene, Incyte, Novartis, Pfizer: Consultancy. Pigneux:Novartis: Honoraria; Pfizer: Honoraria; Astellas: Honoraria; Roche: Honoraria; Jazz: Honoraria; Amgen: Honoraria; Abbvie: Honoraria; Daichi: Honoraria; F. Hoffmann-La Roche Ltd: Honoraria. Kanda:Pfizer: Research Funding; MSD: Research Funding; Chugai: Consultancy, Honoraria, Research Funding; Pfizer: Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria; Chugai: Consultancy, Honoraria, Research Funding; Shionogi: Consultancy, Honoraria, Research Funding; Ono: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Research Funding; Takara-bio: Consultancy, Honoraria; Nippon-Shinyaku: Research Funding; Takeda: Consultancy, Honoraria, Research Funding; MSD: Research Funding; Mochida: Consultancy, Honoraria; Shionogi: Consultancy, Honoraria, Research Funding; Nippon-Shinyaku: Research Funding; Alexion: Consultancy, Honoraria; CSL Behring: Research Funding; Kyowa-Hakko Kirin: Consultancy, Honoraria, Research Funding; CSL Behring: Research Funding; Novartis: Research Funding; Kyowa-Hakko Kirin: Consultancy, Honoraria, Research Funding; Astellas: Consultancy, Honoraria, Research Funding; Asahi-Kasei: Research Funding; Eisai: Consultancy, Honoraria, Research Funding; Tanabe Mitsubishi: Research Funding; Otsuka: Research Funding; Novartis: Research Funding; Dainippon Sumitomo: Consultancy, Honoraria, Research Funding; Sanofi: Research Funding; Astellas: Consultancy, Honoraria, Research Funding; Taisho-Toyama: Research Funding; Eisai: Consultancy, Honoraria, Research Funding; Taiho: Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Otsuka: Research Funding; Celgene: Consultancy, Research Funding; Dainippon Sumitomo: Consultancy, Honoraria, Research Funding; Mochida: Consultancy, Honoraria; Sanofi: Research Funding; Alexion: Consultancy, Honoraria; Takara-bio: Consultancy, Honoraria; Taisho-Toyama: Research Funding; Taiho: Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria; Tanabe Mitsubishi: Research Funding; Ono: Consultancy, Honoraria, Research Funding; Asahi-Kasei: Research Funding. Ivanescu:Astellas: Consultancy. Pandya:Astellas Pharmaceuticals: Employment. Shah:Astellas: Employment.
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Luger, Selina M., Zhuoxin Sun, Sanam Loghavi, Hillard M. Lazarus, Jacob M. Rowe, Martin S. Tallman, Keith W. Pratz, and Mark Litzow. "Phase II Randomized Trial of Gilteritinib Vs Midostaurin in Newly Diagnosed FLT3 Mutated Acute Myeloid Leukemia (AML)." Blood 134, Supplement_1 (November 13, 2019): 1309. http://dx.doi.org/10.1182/blood-2019-128377.
Full textAbstract:
Background: The use of midostaurin in combination with standard induction chemotherapy has been shown to improve the outcomes in patients with newly diagnosed FLT3 mutated (FLT3m) AML (Stone et al) and allogeneic transplant is often recommended in first remission. While likely to achieve remission with standard induction, the majority of these patients will relapse and die of their disease. Gilteritinib, a potent FLT3 inhibitor, has been approved for use in patients with relapsed or refractory FLT3 mutated AML. In Phase I/II studies, when used as part of induction therapy, gilteritinib has shown promising CR rates. We have designed a trial comparing the outcomes of induction therapy with gilteritinib to those with midostaurin. The hypothesis is that gilteritinib, when added to induction chemotherapy, will produce more FLT3m negative composite complete remission (CRc). The Ratify trial combined midostaurin with daunorubicin 60 mg/m2/d X 3 days and cytarabine X 7 days Daunorubicin 90 mg/m2/d has however been shown to be superior during induction in patients with newly diagnosed FLT3 ITD mutated AML (Luskin et al, Burnett et al) While improved survival is the ultimate goal of any leukemia regimen, it is known that AML patients who proceed to allogeneic transplant with measurable residual disease (MRD) positive disease fare worse than those with MRD negative disease. As such, our goal is to increase the likelihood of an MRD negative state after induction. Study Design This is a randomized, open-label, multicenter phase II study comparing gilteritinib to midostaurin in combination with cytarabine 100 mg/m2 and daunorubicin 90 mg/m2 in newly diagnosed FLT3 mutated AML patients ages 18-65. Central confirmation of FLT3 mutation and other pretreatment studies are required. In order to identify patients without delay, all patients with suspected AML will be able to be prescreened without enrollment to the randomized treatment trial. Patients will be stratified according to TKD vs. ITD FLT3 mutation. Patients with FLT3-ITD mutation will undergo further stratification with NPM1 mutation status (positive vs. negative) and FLT3 ITD to FLT3 wild type signal ratio (high [≥ 0.5] vs. low [<0.5]). Patients will be randomized to receive standard induction treatment (cytarabine and daunorubicin) with either gilteritinib or midostaurin. Mandatory bone marrow samples are required after Induction and Consolidation. Patients who achieve CR or complete remission with incomplete hematologic recovery (CRi) will be assessed for MRD and be eligible at count recovery to go on to receive standard consolidation treatment of high-dose cytarabine with the study drug received during induction (gilteritinib or midostaurin). Patients may proceed to allogeneic transplant after induction or after 0-4 cycles of chemotherapy consolidation and may participate in BMT CTN 1506. Key Eligibility: Newly diagnosed FLT3m AML Primary Objective To evaluate the FLT3m negative (evaluated by polymerase chain reaction [PCR] and capillary electrophoresis) composite complete response (CRc) (includes CR or CRi)rate of patients with FLT3 mutated AML who receive gilteritinib compared to those who receive midostaurin in addition to standard therapy with cytarabine and daunorubicin during induction. Sample Size and Statistical design The accrual goal of this study will be 179 patients. Patients who achieve remission will be followed for survival and relapse. With an allocation ratio of 1:1 to the two arms, the study will have 80% power to detect an improvement of 20% in the FLT3 mutation negative CRc rate in the gilteritinib arm (i.e. from 40% to 60%) at the one-sided significance level of 0.05 based on Fisher's exact test. This study is conducted through PrECOG and is funded by Astellas Pharma. The study is slated to open in the summer of 2019 at 30 US sites. References: Stone R.M., Mandrekar S.J., Sanford B.L., et al. N Engl J Med 2017; 377:454-464 Luskin MR, Lee JW, Fernandez HF et al. Blood 2016 :blood-2015-07-657403; doi: https://doi.org/10.1182/blood-2015-07-657403 Burnett AK, Russell NH, Hills RK et al. Blood 2016; Blood 2016 128:449-452; doi: https://doi.org/10.1182/blood-2016-04-712091 Figure Disclosures Luger: Genetech: Research Funding; Jazz: Honoraria; Celgene: Research Funding; Pfizer: Honoraria; Kura: Research Funding; Onconova: Research Funding; Agios: Honoraria; Ariad: Research Funding; Biosight: Research Funding; Seattle Genetics: Research Funding; Cyslacel: Research Funding; Daichi Sankyo: Honoraria. Loghavi:MDACC: Employment; GLG Consultants: Consultancy; AlphaSights: Consultancy. Lazarus:Genentech: Speakers Bureau; Pluristem Therapeutics, Inc: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Adaptive Biotechnologies: Consultancy, Honoraria; CSL Behring: Consultancy; Jazz Pharmaceuticals: Consultancy, Honoraria, Speakers Bureau; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; AstraZeneca: Honoraria, Speakers Bureau; Actinium Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Honoraria, Speakers Bureau; Seattle Genetics: Consultancy, Honoraria, Speakers Bureau; Biosight: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Speakers Bureau; Teva Pharmaceuticals: Speakers Bureau. Rowe:BioSight: Consultancy. Tallman:Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Rigel: Consultancy, Membership on an entity's Board of Directors or advisory committees; Biosight: Research Funding; ADC Therapeutics: Research Funding; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; KAHR: Consultancy, Membership on an entity's Board of Directors or advisory committees; Nohla: Consultancy, Membership on an entity's Board of Directors or advisory committees; Oncolyze: Consultancy, Membership on an entity's Board of Directors or advisory committees; BioLineRx: Consultancy, Membership on an entity's Board of Directors or advisory committees; Daiichi-Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees; Delta Fly Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Orsenix: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Cellerant: Research Funding; Tetraphase: Consultancy, Membership on an entity's Board of Directors or advisory committees; UpToDate: Patents & Royalties. Pratz:Astellas Pharma: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Millenium/Takeda: Research Funding; Boston Biomedical: Consultancy. OffLabel Disclosure: In this study gilteritinib is being studies in newly diagnosed AML.
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Joshi, Amogh, Emilee Kurtz, Rebecca Lopes, Tarick Sheikh, Sagar Vadhar, and Paul Corotto. "GILTERITINIB MEDIATED HYPOTHYROIDISM PRESENTING AS A LARGE PERICARDIAL EFFUSION." Journal of the American College of Cardiology 75, no. 11 (March 2020): 2912. http://dx.doi.org/10.1016/s0735-1097(20)33539-7.
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Joshi, Sunil K., Tamilla Nechiporuk, Daniel Bottomly, Paul Piehowski, Julie Reisz, Janét Pittsenbarger, Sara J. Gosline, et al. "Evolution of Gilteritinib Resistance from Residual Disease to Relapse." Blood 136, Supplement 1 (November 5, 2020): 4–5. http://dx.doi.org/10.1182/blood-2020-139084.
Full textAbstract:
Activating mutations in the tyrosine kinase receptor FLT3 are observed in ~35% of all acute myeloid leukemia (AML) cases. Multiple FLT3 inhibitors are currently in clinical development and while most patients initially respond well to FLT3 inhibition, resistance inevitably develops in a period of months. During the initial response to FLT3 inhibitors, residual leukemia cells are able to survive and persist in the marrow microenvironment, which facilitates early resistance. Over time, leukemia cells develop intrinsic mechanisms of resistance, that are not dependent upon the microenvironment, which leads to late resistance and disease relapse. In this study, we utilized a two-step model to study the temporal evolution of gilteritinib resistance. To model initial extrinsic early resistance, we cultured the FLT3-ITD+ AML cell lines, MOLM-14 and MV4;11, with ligands secreted by the marrow microenvironment. We previously reported that fibroblast growth factor 2 (FGF2) is secreted from marrow stromal cells and protects FLT3-ITD+ AML cells from quizartinib, a FLT3 inhibitor. FGF2 binds receptor FGFR1, activates MAPK signaling, and promotes ligand-dependent growth (Traer et al. Cancer Res. 2016). We also used FLT3 ligand (FL), which has been shown to reactivate the FLT3 receptor despite the presence of inhibitor. MOLM14 cells were cultured with 100 nM gilteritinib in media alone, or supplemented with 10 ng/ml FGF2 or FL. After 7 weeks, all cultures supplemented with ligand eventually resumed growth (early resistance), whereas MOLM-14 cells without ligand were unable to resume growth.We then removed ligand, which transiently restored sensitivity to gilteritinib. However, after 2 months the cells resumed exponential growth in the absence of extrinsic factors (late resistance). A similar pattern was observed with MV4;11 cells. We analyzed the mechanisms of early and late resistance using a number of orthogonal tools: whole exome sequencing (WES), genome-wide CRISPR/Cas9, proteomics, metabolomics, and small-molecule inhibitor screening. WES identified NRAS mutations in the majority of late resistant cultures (13/15) and a gatekeeper FLT3 mutation was found in 1, consistent with mutations found in patients treated with gilteritinib on the Admiral trial (McMahon et al., Cancer Discov., 2019). To identify if NRAS mutations were pre-existing, ddPCR was used. NRAS mutations were detected at low level (<0.1%) in early resistant cultures and parental cells, but did not become the dominant mechanism of resistance until the ligand was removed. Moreover, when NRAS mutations were stably expressed in MOLM14 cells, cells remained sensitive to 100 nM gilteritinib and required over a month of continuous culture to become resistant and resume growth, indicating that NRAS mutations alone are not sufficient for gilteritinib resistance. We further analyzed both early and late resistant lines with genome-wide resensitization CRISPR/Cas screening and global and phospho-proteomics. As expected, CRISPR/Cas screening revealed that NRAS was important for late resistance, which was confirmed by proteomics. In contrast, early resistance revealed multiple hits in metabolic and cell cycle pathways by CRISPR/Cas and global and phospho-proteomics. The unique metabolic signatures (lipid signaling in particular) were verified by metabolomic analyses. CDK proteins were significantly decreased in early resistance, as was the cell cycle. Aurora Kinase B protein (AURKB) was also increased in early resistance, and cells were uniquely sensitive to AURKB small molecule inhibitors and genetic deletion. We then evaluated primary leukemia cells from 11 patients before and after 1-2 months of gilteritinib to evaluate early resistance. Leukemia cells were isolated by CD33 and CD34 beads and subjected to a targeted proteomic analysis (Figure 1). In agreement with our cell line model, early resistant cells had a distinct protein profile, with significant alteration of cell cycle and lipid metabolism proteins after gilteritinib treatment. Primary patient samples also demonstrated robust sensitivity to AURKB inhibitors only after gilteritinib exposure. Our results suggest that developing drug combinations that selectively target early resistance can improve the depth of initial response and may block development of later resistance mutations, thus improving the durability of response to gilteritinib. Figure 1 Disclosures Tyner: Incyte: Research Funding; Janssen: Research Funding; Syros: Research Funding; Seattle Genetics: Research Funding; Petra: Research Funding; Agios: Research Funding; AstraZeneca: Research Funding; Gilead: Research Funding; Aptose: Research Funding; Array: Research Funding; Genentech: Research Funding; Constellation: Research Funding; Takeda: Research Funding. Druker:Henry Stewart Talks: Patents & Royalties; Third Coast Therapeutics: Membership on an entity's Board of Directors or advisory committees; Novartis Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding; McGraw Hill: Patents & Royalties; MolecularMD (acquired by ICON): Consultancy, Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees; Millipore (formerly Upstate Biotechnology): Patents & Royalties; Merck & Co: Patents & Royalties; Cepheid: Consultancy, Membership on an entity's Board of Directors or advisory committees; GRAIL: Consultancy, Current equity holder in private company, Membership on an entity's Board of Directors or advisory committees; Dana-Farber Cancer Institute: Patents & Royalties; EnLiven: Consultancy, Research Funding; Gilead Sciences: Consultancy, Membership on an entity's Board of Directors or advisory committees; Vivid Biosciences: Membership on an entity's Board of Directors or advisory committees; Aileron Therapeutics: Membership on an entity's Board of Directors or advisory committees; ALLCRON: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees; Aptose Therapeutics Inc. (formerly Lorus): Consultancy, Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees; ARIAD: Research Funding; Blueprint Medicines: Consultancy, Current equity holder in private company, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Research Funding; Oregon Health & Science University: Patents & Royalties; Patient True Talks: Consultancy; Pfizer: Research Funding; The RUNX1 Research Program: Membership on an entity's Board of Directors or advisory committees; Iterion Therapeutics (formerly Beta Cat Pharmaceuticals): Membership on an entity's Board of Directors or advisory committees; VB Therapeutics: Membership on an entity's Board of Directors or advisory committees; Leukemia & Lymphoma Society: Research Funding. Traer:Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees; Genentech: Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees; Incyte: Research Funding; Notable Labs: Consultancy, Current equity holder in private company; Astellas: Membership on an entity's Board of Directors or advisory committees.
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Lee, Lauren Y., Daniela Hernandez, Trivikram Rajkhowa, Samuel C. Smith, Jayant Ranganathan Raman, Bao Nguyen, Donald Small, and Mark Levis. "Preclinical studies of gilteritinib, a next-generation FLT3 inhibitor." Blood 129, no. 2 (January 12, 2017): 257–60. http://dx.doi.org/10.1182/blood-2016-10-745133.
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Perl, Alexander E., Jessica K. Altman, Jorge E. Cortes, Catherine C. Smith, Mark Litzow, Maria R. Baer, David F. Claxton, et al. "Final Results of the Chrysalis Trial: A First-in-Human Phase 1/2 Dose-Escalation, Dose-Expansion Study of Gilteritinib (ASP2215) in Patients with Relapsed/Refractory Acute Myeloid Leukemia (R/R AML)." Blood 128, no. 22 (December 2, 2016): 1069. http://dx.doi.org/10.1182/blood.v128.22.1069.1069.
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Abstract Background: Gilteritinib (ASP2215) is a novel, highly selective, potent oral FLT3/AXL inhibitor with preclinical activity against FLT3-ITD activating and FLT3-D835 resistance mutations. The objectives of this phase 1/2 study were to assess gilteritinib safety/tolerability, pharmacokinetic (PK) and pharmacodynamic (PD) profiles after single- and multiple-day dosing, and antileukemic effects in patients with R/R AML. Methods: This open-label study (NCT02014558) enrolled patients (≥18 yr) into 1 of 7 dose-escalation cohorts (20-450 mg once daily [QD]) or concomitant dose-expansion cohorts. While confirmed FLT3 mutation was not an inclusion criterion, each expanded dose level enrolled ≥10 patients with FLT3 mutations (FLT3mut+); 120 and 200 mg dose levels were further expanded with ≥40 FLT3mut+ patients. The choice to expand these dose cohorts was based upon FLT3 inhibition in correlative assays and clinical activity seen during dose escalation. Safety and tolerability were primary endpoints; blood samples were drawn from patients in the dose-escalation cohorts to evaluate gilteritinib PK parameters and PD effects. Antileukemic response rates (eg, complete remission [CR], CR with incomplete platelet recovery [CRp], CR with incomplete hematological recovery [CRi], overall response rate [ORR]) were secondary endpoints. Results: Patients (N=252; 129M:123F, median age 62 yr [range: 21-90]) enrolled between October 2013 and August 2015 received ≥1 dose of gilteritinib. The study population was heavily pretreated: 70% (n=177) had ≥2 prior AML therapies, 29% (n=73) had a prior stem cell transplant, and 25% (n=63) had prior TKI treatment with sorafenib most commonly used. Across the study, 194 patients had a locally confirmed FLT3 mutation (ITD, n=159; D835, n=13; ITD-D835, n=16; other, n=6). For all enrolled patients, progressive disease (n=75), lack of efficacy (n=44), adverse events (n=34), and death (n=29) were the most common reasons for treatment discontinuation. Seven deaths were considered possibly/probably related to treatment: pulmonary embolism, respiratory failure, hemoptysis, intracranial bleed, ventricular fibrillation, septic shock, and neutropenia (all n=1). Maximum tolerated dose was determined to be 300 mg when 2 of 3 patients in the 450 mg cohort experienced diarrhea and/or hepatic transaminase elevation as dose-limiting toxicities. Diarrhea (16%) and fatigue (15%) were the most commonly reported treatment-related adverse events of any grade. Less than 5% of patients (11/252) had a maximum post-baseline QTcF interval >500 msec. Gilteritinib concentrations were generally dose proportional and showed both a long-elimination half-life (45-159 h) and substantial accumulation (3.2-10 fold) by day 15. An exposure-related increase in the inhibition of FLT3 phosphorylation with increasing doses of gilteritinib was also observed. Gilteritinib showed strong antileukemic activity in FLT3mut+ patients (ORR=49%); response was observed less frequently in patients with wild-type FLT3 (ORR=12%). While CR, CRi, and CRp occurred at all doses, responses were enriched among FLT3mut+ patients with gilteritinib steady-state trough concentrations ≥100 ng/mL, which correlated with potent FLT3 inhibition in PD assays and corresponded to doses ≥80 mg. The ORR in 169 FLT3mut+ patients receiving ≥80 mg was 52% (Table); median overall survival in this patient population was ~31 wk (range: 1.7-61; Figure) and median duration of response was 20 wk (range: 1.1-55). Clinical responses occurred in FLT3mut+ patients with -ITD, -D835, and both mutations (ORR: 55%, 17%, and 62%, respectively) as well as in FLT3mut+ patients with or without prior TKI treatment (ORR: 42% vs 56%, respectively). Conclusions: This PD-driven, first-in-human study shows that gilteritinib was well tolerated and generated frequent, prolonged, clinically important responses in FLT3mut+ patients with R/R AML. Antileukemic responses were enriched in FLT3mut+ patients treated at doses that consistently and potently inhibited FLT3 phosphorylation. The survival of these patients appears better than expected for this patient population when treated with standard therapy. Our data suggest that FLT3 inhibition may improve survival in patients with FLT3mut+R/R AML; as such, phase 3 testing of oral gilteritinib 120 mg QD in patients with FLT3mut+R/R AML after first-line therapy is underway (NCT02421939). Disclosures Perl: Astellas US Pharma Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees; Daichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees; Asana Biosciences: Consultancy, Membership on an entity's Board of Directors or advisory committees; Arog Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Actinium Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees. Altman:Janssen: Other: advisory board; BMS: Membership on an entity's Board of Directors or advisory committees; Spectrum: Other: advisory board; Ariad: Other: advisory board; Seattle Genetics: Other: advisory board; Syros: Other: advisory board. Cortes:ARIAD: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Teva: Research Funding. Smith:Astellas: Research Funding. Erba:Jannsen: Consultancy, Research Funding; Millennium Pharmaceuticals, Inc.: Research Funding; Agios: Research Funding; Juno: Research Funding; Incyte: Consultancy, DSMB, Speakers Bureau; Daiichi Sankyo: Consultancy; Ariad: Consultancy; Amgen: Consultancy, Research Funding; Astellas: Research Funding; Gylcomimetics: Other: DSMB; Seattle Genetics: Consultancy, Research Funding; Sunesis: Consultancy; Novartis: Consultancy, Speakers Bureau; Celator: Research Funding; Celgene: Consultancy, Speakers Bureau; Pfizer: Consultancy. Gill:Astellas: Employment. Goldberg:Bristol Myers Squibb, Novartis: Speakers Bureau; Novartis: Consultancy; COTA Inc: Employment; Pfizer: Honoraria; Neostem: Equity Ownership. Jurcic:Astellas: Research Funding. Larson:Astellas: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy. Liu:Astellas: Employment. Ritchie:Celgene: Consultancy, Other: Travel, Accomodations, Expenses, Speakers Bureau; Incyte: Consultancy, Speakers Bureau; Novartis: Consultancy, Other: Travel, Accommodations, Expenses, Research Funding, Speakers Bureau; Ariad: Speakers Bureau; Pfizer: Consultancy, Research Funding; Astellas Pharma: Research Funding; Bristol-Meyers Squibb: Research Funding; NS Pharma: Research Funding. Schiller:Incyte Corporation: Research Funding. Strickland:Celator: Research Funding; Cyclacel: Research Funding; Karyopharm Therapeutica: Research Funding; GlaxoSmithKline: Research Funding; Baxalta: Consultancy; Boehringer Ingelheim: Consultancy, Research Funding; Ambit: Consultancy; Alexion Pharmaceuticals: Consultancy; Astellas Pharma: Research Funding; CTI Biopharma: Consultancy; Daiichi Sankyo: Consultancy; Sunesis Pharmaceuticals: Consultancy, Research Funding; Abbvie: Research Funding; Sanofi: Research Funding. Wang:Incyte: Speakers Bureau; Immunogen: Research Funding. Stuart:Sunesis: Consultancy, Honoraria, Other: Travel, Accomodations, Expenses, Research Funding; Agios: Research Funding; Incyte: Research Funding; Bayer: Research Funding; Celator: Research Funding; Astellas: Research Funding. Martinelli:Ariad: Consultancy, Speakers Bureau; Pfizer: Consultancy, Speakers Bureau; BMS: Speakers Bureau; Roche: Consultancy, Speakers Bureau; MSD: Consultancy; Genentech: Consultancy; Novartis: Speakers Bureau; Celgene: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau. Bahceci:Astellas: Employment. Levis:Millennium: Consultancy, Research Funding; Astellas: Consultancy, Honoraria, Research Funding; Daiichi-Sankyo: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding.
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Liu, Changnian, Bin Liu, Chunping Xu, Pan Zhang, Bin Li, Bin Ji, Bin Zhang, Qingjun Liu, James Zhang, and Chengzhi Yu. "ETH-155008, a Novel Selective Dual Inhibitor of FLT3 and CDK4/6 in Preclinical Treatment of Acute Myeloid Leukemia." Blood 134, Supplement_1 (November 13, 2019): 5141. http://dx.doi.org/10.1182/blood-2019-123589.
Full textAbstract:
Fms-like tyrosine kinase 3 (FLT3) is part of a family of receptor tyrosine kinases (RTKs), and a molecular therapeutic target of acute myeloid leukemia (AML). There are three FTL3 inhibitors, midostaurin, gilteritinib, and quizartinib have been approved for clinical treatment of AML. We have evaluated the inhibition of cell proliferation in vitro and antitumor activity in vivo of ETH-155008, a novel triple inhibitor of FLT3, Pim-3 and CDK4/6. ETH-155008 was found to have a strong inhibitory activity against key target enzymes (FLT3 IC50 at 0.5nM; Flt3 -Itd IC50 at 0.6 nM; CDK4/D1 IC50 at 0.8nM, CDK6/D1 IC50 at 1.4nM), which were more potent than the tested positive controls gilteritinib, quizartinib, and AMG-925. ETH-155008 showed to have highly potent antiproliferative activities against cultured human acute myeloid leukemia cells (MV4-11 and Molm-13) with IC50 at 4.1nM and 12 nM, respectively, and showed remarkable antitumor efficacy in vivo. The in vivo antitumor activity of ETH-155008 was evaluated and compared with midostaurin and gilteritinib in the treatment of the two models with mutant forms in TKD and gatekeeper region, namely BaF3 FLT3-ITD-F691L and BaF3 FLT3-ITD-D835Y, respectively. Treatment with ETH-155008 (40 mg/kg/daily x 18, oral) significantly delayed tumor growth and resulted in a smaller mean tumor size (tumor growth inhibition (TGI) of 86% (p<0.001 compared with the control group) in the BaF3 FLT3-ITD-F691L model, and cured all of the tumor-bearing mice in the BaF3 FLT3-ITD-D835Y model. The antitumor activity of ETH-155008 was comparable to gilteritinib, but much better than midostaurin, the latter showed only mild antitumor activity with ~25% of TGI in the two FLT3 mutant models. We also tested the therapeutic efficacy of ETH-155008 in the human AML xenograft model MV4-11, ETH-155008 cured all of the tumor-bearing mice (mean tumor size at time of treatment 126 mm3), at a dose of 40mg/kg/daily for 14 days, that showed very little toxicity (only 2% body weight loss) which were well below the maximum tolerated dose. ETH-155008 represents a novel dual inhibitor that may yet fulfill the promise of effective AML therapy through dual targeting of FLT3 and CDK4/6. These preclinical results supported the safety and efficacy observed in the preclinical studies and worthy of further clinical evaluation. Disclosures Liu: Euthare LLC: Other: founder. Zhang:shengke therapeutics: Other: cofounder. Yu:shengke Therapeutics: Other: co-founder.