Should We Change A New Standard of Care to Carfilzomib?

Nuchanan Areethamsirikul, M.D.Wattanosoth Hospital

Carfilzomib

• Second-generation proteasome inhibitor• Tetrapeptide Epoxyketone • Highly selective and irreversible proteasome binding• Minimal off-target effect less neurotoxicity

Kortuem KM et al. Blood 2013.7;121(6):893-7.

Single Agent Carfilzomib Pivotal Trial : 003-A1

Carfilzomib20 mg/m2 days 1, 2, 8, 9, 15, 16

every 28 daysN = 46

MM: Progressive disease> 2 prior therapy lines

including bortezomib, thalidomide or lenalidomide,

an alkylating agent, and anthracycline alone or in

combination

CarfilzomibDose escalation to 27 mg/m2

after cycle 1 up to 12 cyclesN = 266

Phase II; N= 266; Median of 5 prior therapiesPrimary Endpoint: ORR 23.7%, ≥VGPR 5.3%Secondary Endpoints: • Clinical benefit rate (≥minimal response) 37%• Median DOR 7.8 months• Median PFS 3.7 months• Median OS 15.6 months

Siegel DS, et al. Blood. 2012;120:2817-25.

ASPIRE : KRd vs Rd in Relapsed MM

Stewart AK et al. N Engl J Med. 2015 Jan 8;372(2):142-52.

Phase 3open label,

multicenter, RCT

N = 792

Prior Rx 1-3 lines

KRdCarfilzomib 20/27 mg/m2 D 1, 2, 8, 9, 15 , 16

Len 25 mg D1-21Dex 40 mg D 1, 8, 15, 22

After cycle 12, K given on D 1,2,15,16After cycle 18, K discontinued

RdLen 25 mg D1-21

Dex 40 mg D 1, 8, 15, 22

ASPIRE : Treatment Responses

Stewart AK et al. N Engl J Med. 2015 Jan 8;372(2):142-52.

ASPIRE : Progression Free Survival

Stewart AK et al. N Engl J Med. 2015 Jan 8;372(2):142-52.

ASPIRE : Overall Survival

Stewart AK et al. N Engl J Med. 2015 Jan 8;372(2):142-52.

ENDEAVOR : Kd vs Vd in Relapsed MM

N = 929

• Prior Rx 1-3 lines

• Prior Rx with V or K was allowed if

- PR to prior Rx- 6 mo PI-free

interval- Not D/C due to

toxicity

KdCarfilzomib 20/56 mg/m2 D 1, 2, 8, 9, 15, 16

Infusion in 30 minsDex 20 mg D 1, 2, 8, 9, 15, 16, 22,23

q 28 days until PD

VdBortezomib 1.3 mg/m2 D 1, 4, 8, 11

Dex 20 mg D 1, 2, 8, 9, 11, 12q 21 days until PD

Dimopoulos MA et al. EHA meeting 2015. Abstract LB2071.

ENDEAVOR: Treatment Response

Dimopoulos MA et al. EHA meeting 2015. Abstract LB2071.

ENDEAVOR: PFS and OS

Dimopoulos MA et al. EHA meeting 2015. Abstract LB2071.

• Double median PFS in Kd arm compared to Vd• Subgroup analysis, favor Kd in all subgroups – high ISS, prior

bortezomib and IMIDs exposure, high risk cytogenetics, age≥75 yo

Carfilzomib in Renal Insufficiency Patient• Phase II PX-171-005, single agent carfilzomib in RRMM• Dose : 15/20/27 mg/m2 ; n = 50• No difference in carfilzomib clearance among patients with

various degree of renal impairment• Carfilzomib is predominantly cleared through extra-renal

pathway

Badros AZ et al. Leukemia. 2013;27(8):1707-14.

Group Renal function status CrCl (mL/min) ORR1 Normal >80 18%2 Mild impairment 50-80 27%3 Moderate impairment 30-<50 22%

4 Severe Impairment <30 25%5 Chronic dialysis - 38%

Carfilzomib & High Risk Cytogenetics• 27% high risk cytogenetics (del17p, t(4;14), t(14,16) by FISH, del

13 or hypodiploidy by metaphase)• ORR were similar in patient with high- and standard-risk

cytogenetics (26% vs 25%, P=0.85)• Comparable efficacy in patient who had isolated t(4;14) median

OS 16 mo• Del 17p had the greatest negative impact ORR 17%, OS 7 mo• Carfilzomib can at least overcome the adverse impact of t(4;14)

Jakubowiak AJ et al. Leukemia. 2013;27(12):2351a-6.

PFS OS

Carfilzomib & High Risk Cytogenetics• PFS benefit was demonstrated in patient with high risk

cytogenetics who had carfilzomib combination treatment in phase 3 studies• ASPIRE study, median PFS 23.1 vs 13.9 mo; HR 0.70, 95%CI 0.43-1.16;

P=0.083• Endeavor study, HR 0.65, 95% CI 0.45-0.92

Stewart AK et al. N Engl J Med. 2015 Jan 8;372(2):142-52.Dimopoulos MA et al. EHA meeting 2015. Abstract LB2071.

Carfilzomib & Peripheral Neuropathy (PN)

Dimopoulos MA et al. EHA meeting 2015. Abstract LB2071.

• PN is a common side effect of bortezomib, up to 57%• Less PN with weekly bortezomib dosing and subcutaneous

route still ~ 38% experienced PN from phase III study• Very low incidence of PN in carfilzomib (all gr 14-17%,

gr 3-4 1%)• Allow more drug combination option, more tolerable in

elderly patients and allow longer treatment duration

Cardiovascular/Pulmonary toxicities • Multiple factors Multiple comorbidities, age related CV-risk,

chronic anemia, amyloidosis, prior anthracycline Rx• 74% of patient had a history of cardiovascular events• No different overall mortality rate (7%) in patients who had

baseline cardiac risk factor or not• 14% Hypertension (mainly gr 1-2); ≥50% had Hx of HTN• Cardiac failure rate is similar (6-8% in phase II; 5-6% in phase

III) to the rate reported in bortezomib (8%)• Majority of dyspnea was low grade and transient• Dose reduction/treatment discontinuation were uncommon

(1%/4% for cardiac AEs and 1%/1% for pulmonary AEs)

Siegel et al. Haematologica. 2013;98(11):1753-61.Stewart AK et al. N Engl J Med. 2015 Jan 8;372(2):142-52.

Dimopoulos MA et al. EHA meeting 2015. Abstract LB2071.

Ongoing Carfilzomib Studies In Upfront Setting

Study Phase Patient N ORR/≥VGPR PFS/OS Median F/U (mo)

CYKLONE1 Ib/II ASCT 64 91%/59% 2yr PFS 76%2 yr OS 96% 17.5

CMP2 I/II Elderly 72 90%/58%PFS 21 moEstimated

3 yr OS 80%22

KRd3 II ASCT 53 98%/78% - 17

KTd4 II ASCT 91 90%/68% 3yr PFS 72% 23

CLARIONKMP vs VMP III Elderly 882 - - -

1 Mikhael JR et al. Br J Haeatol. 2015;169(2);219-27. 2 Moreau P et al. Blood. 2015;125(20):3100-4.3 Zimmerman TM et al. ASCO 2015. Abstract 8510. 4 Sonneveld P et al. Blood. 2015;125(3);449-56.

Conclusion• Carfilzomib is a potent 2nd generation PI and becoming a

new standard of care in MM treatment• Currently approved by US FDA for 2nd/3rd lines therapies• Highly efficacious with PFS benefit in two phase 3 RCT

superior to bortezomib in ENDEAVOR study• Favorable safety profiles, well tolerated – less PN• Safe to use in patient with renal impairment, includes

those who are on dialysis• Carfizomib can at least overcome the negative impact of

some certain high risk cytogenetics• Promising results from ongoing studies in front line

setting

Thank You