Type: Oral
Session: 637. Myelodysplastic Syndromes: Clinical and Epidemiological: Defining and Treating Low Risk MDS
Hematology Disease Topics & Pathways:
Research, Clinical trials, MDS, Clinical Research, Chronic Myeloid Malignancies, Diseases, Myeloid Malignancies
The therapeutic landscape of lower risk MDS has recently changed with the approval of Luspatercept to treat anemia in transfusion-dependent patients with ring sideroblast (RS)-positive LR-MDS who are refractory/intolerant to ESAs, following the phase 3 MEDALIST study. More recently, the COMMANDS study has challenged the place of ESA as a first-line treatment for low-risk MDS with or without RS ,showing a superiority of luspatecept over ESA, at least in RS-MDS. To better understand the role of luspatercept in non-RS MDS, we carried out a study evaluating the combination of luspatecept and ESA to assess the safety of the combination and to determine the best doses for the combination in a LR non-RS MDS population having failed ESA, before comparing luspatercept to this combo in a randomized trial (COMBOLA-Part B).
Patients & Methods
A two-part Phase 1/2 study (Phase 2 ongoing) is being conducted by the GFM in patients with LR-MDS (IPSS low risk and Int-1) without RS or del(5q) and ineligible or having failed to achieve a response (or subsequently relapsed) after ESA without disease progression, and with hemoglobin < 9 g/dl. The primary objective of this dose-finding part of the trial was to determine the optimal dose in terms of both toxicity and efficacy for luspatercept + ESA, for selection in the randomized part B of the trial. Luspatercept was administered subcutaneously every 21 days at dose concentrations ranging from 0.8 to 1.75 mg/kg. Based on a TITE-BOIN-ET design, Epoetin alfa was administered weekly at dose concentrations ranging from 30 000UI to 60 000 UI. Four dose levels were tested: Dose level 1 (n=3): Luspatercept 0.8 mg/kg/21d and EPO alpha 30.000 UI/w; Dose level 2 (n=3): Luspatercept 1.33 mg/kg/21d and EPO alpha 30.000 UI/w; Dose Level 3 (n=3) : Luspatercept 1.75 mg/kg/21d and EPO alpha 30.000 UI/W; Dose Level 4 (n=15): Luspatercept 1.75 mg/kg/21d and EPO alpha60.000 UI/w. The assessment window for efficacy was d-21 days, and for toxicity d-42.
Results
Thirty-five patients were screened and 24 patients from 10 French centers were included between May 2022 and November 2023. Median age at inclusion was 77.7 y [71.4;84.1] and male/female ratio was 18/6. According to 2016-WHO, 18 had refractory cytopenia with multilineage dysplasia, 2 refractory cytopenia with unilineage dysplasia, and 4 had MDS-EB1. According to historical IPSS, 2 and 22 patients had low and intermediate-1 risk, respectively. According to IPSS-R, 5, 15 and 4 patients had low, intermediate risk and high risk respectively. All patients had resistance to ESA and 7 had also received Revlimid (n=3), IDH inhibitors (n=2), Thalidomide (n=1), AZA (n=1). Six (25%) had low transfusion burden, 16 (67%) had high transfusion burden (according to IWG 2018 criteria) and 2 were non-transfusion dependent.
D-42 Tolerance and D21-efficacy have been assessed after treatment initiation for all patients. At these timepoints, No DLT was observed, and efficacy was only reported in one patient treated at the dose level 4 (Luspatercept 1.75 mg/kg/21d and EPO 60 000 UI/w)). At week 25, 7 (29 %) patients had achieved an erythroid response , 2/3 at dose level 2, and 5/15 at dose level 4. Moreover, 2 patients achieved platelet response and 1 neutrophil response. According to transfusion burden, ½, 2/6 and 4/16 achieved Erythroid response in the non-transfusion dependent, Low TD and High TD cohorts, respectively. Among the 7 patients who achieved an erythroid response, 3 were still responders at the time of the present analysis and the median duration of response was 9.2 (95%CI 0.85-NA) months. During the first 6 months, 45 adverse events were observed including 16 serious adverse events (all grade >2) including 3 infections, 2 cardiac events, 2 GI disorders, 1 worsening of general condition and 8 others. Overall, 6 (25 %) patients had an AML evolution (n=2) or died in the 6 months after treatment initiation leading to a 6-month PFS of 74.8% [59.2-94.5] and a 6-month OS of 78.9% [64.1-97.2], with no differences across the different cohorts.
Conclusions: In this difficult to treat population, one third achieved erythroid response with the combination of Luspatercept and ESA. Based on the results of this Phase 1 study, the dosing schedule Luspatercept 1.75 mg/kg/21d and EPO 60 000 UI/w, that balanced clinical efficacy and safety profile was selected as the RP2D. This regimen is being compared to Luspatercept 1.75 mg/kg/21d in the ongoing randomized Phase 2 study.
Disclosures: Ades: BMS: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Takeda: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding. Cluzeau: Incyte: Speakers Bureau; Servier: Consultancy, Speakers Bureau; Syros: Speakers Bureau; Keros: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS: Consultancy, Speakers Bureau; Takeda: Speakers Bureau; Amgen: Speakers Bureau; Pfizer: Other: International Congress; Jazz Pharma: Consultancy, Research Funding, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Abbvie: Consultancy, Research Funding, Speakers Bureau. Meunier: Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy; Alexion: Consultancy; BMS: Membership on an entity's Board of Directors or advisory committees; GSK: Speakers Bureau. Gyan: BMS, Sandoz: Research Funding; AstraZeneca, Abbvie, Janssen, Roche, BMS, Sanofi, Kephren Publishing, Recordati, Novartis, Incyte, Axonal, Servier, Gilead Kite: Honoraria. Thépot: BMS, Gilead, Abbvie: Honoraria. Sebert: Abbvie: Honoraria; Servier: Honoraria, Research Funding; BMS: Honoraria; Jazz Pharmaceutical: Honoraria; Gilead: Honoraria. Fenaux: Astex: Research Funding; Servier: Research Funding; Novartis: Research Funding; AbbVie: Honoraria, Research Funding; Janssen: Research Funding; Jazz Pharmaceuticals: Honoraria, Research Funding; Agios: Research Funding; BMS: Honoraria, Research Funding.
OffLabel Disclosure: combining ESA and Luspatercept in MDS is not approved