Subject Eligibility In order to participate in this study a subject must meet all of the
eligibility criteria outlined below.
Inclusion Criteria. 1. Written informed consent obtained to participate in the study and Health Insurance
Portability and Accountability Act (HIPAA) authorization for release of personal
health information (PHI). Consent must be obtained before performance of any
study-related procedure not part of normal medical care, with the understanding that
consent may be withdrawn by the subject at any time without prejudice to future
medical care.
2. Willing and able to adhere to the study visit schedule and other protocol requirements
based on the judgement of the investigator or protocol designee.
3. Predicted high risk for severe toxicity from intensive induction regimens, such as
standard (full-dose) Bortezomib, cyclophosphamide, dexamethasone (VCD), lenalidomide,
bortezomib, and dexamethasone (RVD), or lenalidomide and weekly dexamethasone (Rd) as
each regimen was published. (Such regimens often use, for example, twice-weekly
bortezomib or lenalidomide at 25 mg.) High-risk is defined as one of the following:
1. Score ≥ 2 (indicating "frail") on the International Myeloma Working Group
instrument (IMWG; Palumbo et al. [Blood 2015]),
2. Karnofsky Performance Status (KPS) ≤ 70,
3. Felt not to be candidate for full-intensity induction by treating clinician due
to comorbidities, performance status, or other factors not otherwise captured by
the Palumbo system or performance status. The reason for the subject's
non-candidacy for full-intensity therapy should be described in the clinical
documentation.
Subjects qualifying for enrollment by criterion C should be discussed with the Medical
Monitor before enrollment, to ensure uniform application of this criterion across
participating sites.
4. Measurable MM diagnosed according to the following standard criteria. Criteria A and B
must be met, in addition to C and/or D:
1. Monoclonal plasma cells in bone marrow ≥ 10% and/or presence of biopsy-proven
plasmacytoma. 2. Monoclonal protein (M-protein) present in serum and/or urine, defined as serum
M-protein of ≥ 1 g/dL (0.5 g/dL for Immunoglobulin A (IgA) MM) OR urine M-protein
of ≥ 200 mg/24 hours. Subjects lacking an M-protein meeting those criteria must
have a serum free light chain assay with an involved light chain ≥ 10 mg/dL (100
mg/L) and an abnormal serum free light chain ratio.
3. One or more MM-related organ dysfunction findings such as hypercalcemia, renal
insufficiency, anemia, and bone lesions (CRAB) criteria listed below:
- - Calcium elevation in blood (serum calcium 1 mg/dL ≥ upper limit of normal or
> 11 mg/dL)
- Renal insufficiency (creatinine clearance < 40 ml/min or serum creatinine >
2 mg/dL)
- Anemia (hemoglobin < 10 g/dL or ≥ 2 g/dL below normal)
- Bone lesions (lytic bone lesions) on x-rays, computerized tomography (CT),
Magnetic resonance imaging (MRI) or Positron emission tomography (PET)
4.
Myeloma-related biomarker of malignancy (1 or more should be fulfilled):
- - ≥ 60% bone marrow plasmacytosis.
- - Serum involved / uninvolved free light chain ratio of ≥ 100, provided
absolute level of involved light chain is at least 100 mg/L (10 mg/dL)
- More than one focal lesion on MRI ≥ 5 mm in size.
5. No prior systemic anti-myeloma therapy lasting more than 28 days (generally one
cycle). Any prior therapy must be completed a minimum of 14 days before starting study
drugs.
6. Subjects who require radiotherapy (which must be localized in its field size) may be
treated during screening but initiating study therapy should be deferred until the
radiotherapy is completed and 14 days have elapsed since the last date of
radiotherapy.
7. Demonstrate adequate organ function and laboratory values as defined in below.
Hematological.
- - Hemoglobin (Hgb) ≥ 8 g/dL Transfusion of packed red blood cells or use of
erythropoietin or analogs is permitted, if clinically appropriate, to achieve
this threshold.
- - Absolute Neutrophil Count (ANC) ≥ 1.0 x 109/L Use of growth factors is permitted
to fulfill this criterion, particularly if low ANC is felt to be due to MM by
treating clinician.
If low ANC is felt to be due to non-MM causes, such as
myelodysplasia or other bone marrow disorders unrelated to MM, then subject
should not be enrolled on the study.
- - Platelets ≥ 50 × 109/L if < 50% of bone marrow nucleated cells are plasma cells,
and.
- - ≥ 30 × 109/L if ≥ 50% of BM (Bone Marrow) nucleated cells are plasma cells.
- - Platelet transfusions are permitted to reach entry criteria.
If low platelets are
felt to be due to non-MM causes, such as myelodysplasia or other bone marrow
disorders unrelated to MM, then subject should not be enrolled on the study.
Renal. • Calculated or measured glomerular filtration rate (GFR):Any GFR as long as not
currently dialysis-dependent. 8. Females of childbearing potential (FCBP)* must have a negative serum or urine
pregnancy test with a sensitivity of at least 25 mIU/mL within 10
- - 14 days prior to
and again within 24 hours of starting lenalidomide and must either commit to continued
abstinence from heterosexual intercourse or begin two acceptable methods of birth
control, one highly effective method and one additional effective method at the same
time, at least 28 days before she starts taking lenalidomide through 30 days after the
last dose of lenalidomide and 5 months after the last dose of isatuximab.
FCBP must
also agree to ongoing pregnancy testing during the entire duration of treatment and
monthly for 5 months after the last dose of isatuximab. Men must agree to use a latex
or synthetic condom during sexual contact with a FCBP even if they have had a
vasectomy from the time of signing the informed consent form through 30 days after the
last dose of lenalidomide and 5 months after the last dose of isatuximab. These same
subjects must not donate sperm. All subjects must be counseled at a minimum of every
28 days about pregnancy precautions and risks of fetal exposure. All subjects enrolled
into this trial, must be registered in and must comply with all requirements of the
REVLIMID Risk Evaluation and Mitigation Strategy (REMS) program.
- - A female of childbearing potential (FCBP) is a sexually mature female who: 1) has
not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been
naturally postmenopausal for at least 24 consecutive months (i.e., has had menses
at any time in the preceding 24 consecutive months).
Exclusion Criteria. 1. Active infection requiring systemic antibiotics or other serious infection within 14
days prior to study treatment.
2. Subjects felt to not be candidates by treating physician for any systemic therapy due
to excessive comorbidities, frailty, impaired performance status, or other severe
limitations. Such limitations can be conceptualized generally as making subjects
exceedingly high-risk for any systemic treatment for their MM. These limitations often
stem from medical comorbidities unrelated to MM and they are hence unlikely to improve
with MM therapy. The reasons for exclusion will be documented.
3. Any clinically significant, uncontrolled medical conditions that, in the
Investigator's opinion, would expose excessive risk to the subject or may interfere
with compliance or interpretation of the study results.
4. Light-chain (AL) amyloidosis. Subjects with secondary amyloidosis due to MM are
eligible, if the amyloidosis is not felt to be a clinically significant issue (e.g.,
amyloid found incidentally on bone marrow core biopsy without evidence of
amyloid-mediated organ compromise).
5. Myocardial infarction within 3 months prior to study treatment or has New York Heart
Association (NYHA) Class III or IV heart failure, uncontrolled angina, severe
uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute
ischemia or active conduction system abnormalities.
6. Known allergy to any of the study medications, their analogues, or excipients in the
various formulations of any agent.
7. Hypersensitivity or history of intolerance to steroids, mannitol, pregelatinized
starch, sodium stearyl fumarate, histidine (as base and hydrochloride salt), arginine
hydrochloride, poloxamer 188, sucrose or any of the other components of study therapy
that are not amenable to premedication with steroids and H2 blockers or would prohibit
further treatment with these agents.
8. Known gastrointestinal (GI) disease that could interfere with the oral absorption or
tolerance of dexamethasone or lenalidomide including difficulty swallowing.
9. Serious medical or psychiatric illness likely to interfere with participation in this
clinical study.
10. Patients with a history of prior or concurrent second primary malignancy whose natural
history or treatment does not have the potential to interfere with the safety or
efficacy assessment of the investigational treatment should generally be eligible.
11. Receiving other investigational agents less than 14 days or 5 half-lives of first dose
of therapy on this protocol, whichever is longer.
12. Concurrent use of other anti-cancer agents or treatments with possible exception of
agents with low likelihood of affecting outcome of this study, such as adjuvant
hormonal therapy for remote history of breast cancer.
13. Known to be HIV+ or have active infection with hepatitis A, B, or C; or tuberculosis.
14. Chronic daily corticosteroids for other, non-MM-related medical conditions exceeding
low-dose (e.g., prednisone ≥ 10 mg daily or equivalent).
15. Subject is receiving prohibited medications or treatments as listed in the protocol
that cannot be discontinued/replaced by an alternative therapy.
