A Phase 1b Study of Birinapant in Combination with 5-Azacitadine in Patients with Myelodysplastic Syndrome Who Are Naïve, Refractory or Have Relapsed to 5-Azacitadine
Authors: Borthakur Gautam , Foran James M. , Wang Eunice S. , Rakkar Amol , Minderman Hans , Burns Jennifer , Andreeff Michael , Tibes Raoul 
Published: October 2019

Background: Although 5-azacitidine (5-AZA) is the standard of care for patients with higher-risk patients with Myelodysplastic Syndrome (MDS) almost all patients will fail 5-AZA therapy with the majority of patients progressing within 2 years. Two-year survival for MDS patients refractory to 5-AZA is only 15%. There is a need for more effective therapies for these patients with higher-risk MDS. The Inhibitors of Apoptosis (IAP) Proteins are a family of molecules that suppress apoptotic cell death. Expression of IAPs is dysregulated in MDS, supporting potential as therapeutic targets. SMAC (second mitochondrial activator of caspases) is an IAP antagonist, resulting in caspase activation, inhibition of the pro-survival transcription factor NF-kB and increased apoptosis leading to tumor cell death. Birinapant is a potent bivalent SMAC mimetic in clinical development for the treatment of several cancers. Pre-clinical data support its investigation in myeloid malignancies, specifically MDS.
Methods: This Phase 1b study was designed to determine the MTD and recommended Phase 2 dose and schedule of birinapant in combination with 5-AZA in patients with higher-risk MDS who are naïve to or have relapsed or are refractory to 5-AZA. Secondary objectives included determining the clinical activity of the combination of birinapant plus 5-AZA, and assessing the pharmacokinetics (PK) and exploratory biomarkers.
Results: Twenty-one patients were enrolled, of whom 15 had high/very high risk MDS, with median IPSS score of 3 (range, 1.5-8). Median age (range) was 73 years (48-84 years). Eight patients were therapy-naïve. All patients received 5-AZA, administered either intravenous (IV; 13 patients) or subcutaneous (SC; 8 of whom 4 later switched to IV), at 75 mg/m2 for 7 days of a 28-day cycle in combination with birinapant. Birinapant was administered IV twice weekly (Days 1 and 4) at 13 mg/m2 for either 3 of 4 weeks (15 patients; Cohort 1 and Expansion Cohort) or 4 of 4 weeks (6 patients; Cohort 2) in 28-day cycles.
No cycle 1 dose-limiting toxicities were observed. Adverse events ≥Grade 3 observed in two or more patients were thrombocytopenia (9 patients); pneumonia (including fungal pneumonia; 8); anemia (8); leukopenia (7); febrile neutropenia (7) neutropenia (5); fatigue (4); respiratory failure (3); cellulitis or soft tissue necrosis (3); and nausea, vomiting, or hypoxia (2 patients each). SAEs seen in more than one patient included pneumonia (6 patients, including fungal pneumonia); febrile neutropenia (4); sepsis (3) and cellulitis or soft tissue necrosis (3). Grade 3 abdominal soft tissue necrosis occurred in the area of subcutaneous injections of 5-AZA, and two events of Grade 3 cellulitis were judged related to treatment. These local injection site reactions were more severe than expected with SC 5-AZA, and were not observed with subsequent IV administration. These events were not considered DLTs. Treatment-related suppression of NF-k B activity was evident in circulating blast cells from patients in Cohort 1 suggesting pharmacodynamic activity of birinapant at this dose and schedule. Based on this, the Phase 2 dosing regimen has been recommended as birinapant administered at 13 mg/m2 IV twice weekly for 3 weeks of a 28-day cycle in combination with 5-AZA at 75 mg/m2 IV daily for 7 days of a 28-day cycle.
Although not a primary endpoint, evidence of clinical activity, as demonstrated by significant reduction in marrow blast percentages, was seen, including 3 patients considered relapsed or refractory to prior therapy. Nine patients of 20 evaluable (45%) demonstrated either a ≥50% decrease in marrow blast count, or a blast count of ≤5% at the end of Cycle 1 or 2. Two additional patients (10%) demonstrated hematological improvement in one or more peripheral cell lineages without transfusions. In addition, 2 patients, one of whom had previously received 5-AZA, could be bridged to stem cell transplant subsequent to response with birinapant plus 5-AZA. Several patients remain in active follow-up.
Conclusion: This Phase 1b trial confirms the acceptable safety profile of the combination of birinapant administered with IV 5-AZA. Evidence of clinical activity in both 5-AZA naïve and refractory patients provide the rationale for an ongoing global randomized, blinded Phase 2 study comparing birinapant in combination with 5-AZA vs. 5-AZA alone in patients with higher-risk MDS in the front-line setting.

Disclosures
Wang: Immunogen: Research Funding. Rakkar:TetraLogic Pharmaceuticals: Research Funding. Minderman:TetraLogic Pharmaceuticals: Research Funding. Burns:TetraLogic Pharmaceuticals: Employment. Tibes:TetraLogic Pharmaceuticals: Research Funding.