Iadademstat in combination with gilteritinib for patients with mutated FLT3 relapsed/refractory acute myeloid leukemia.
Authors: Fathi Amir Tahmasb , Arévalo Mabel , Gutierrez Sonia , Molero Antonieta , Sacilotto Natalia , Limon Ana E. , Faller Douglas V. 
Published: June 2023

TPS7075 Background: Epigenetic dysregulation is a hallmark of acute myeloid leukemia (AML) and is caused by recurrent translocations and/or mutations in chromatin regulators and transcription factors, resulting in myeloid differentiation blockade and leukemic stem cell renewal. Accordingly, about 70% of recurring mutations in AML patients (pts) target regulators of gene expression, underscoring the potential of epigenetic therapies to change the disease natural history. Iadademstat (iada/ORY-1001) is a specific, oral, potent, covalent inhibitor of the epigenetic Lysine-Specific Demethylase 1 (LSD1/KDMA1) enzyme. In preclinical and clinical studies iada decreased leukemic stem cell survival and induced macrophage/monocytic differentiation of blasts. ALICE, a Ph2 study of iada in combination with azacitidine (aza), showed high complete remission (CR/CRi) rates and durable responses in treatment naïve, unfit AML pts without exacerbating the toxicity profile of aza (Salamero et al., Oral at ASH 2022). Despite improvements in AML therapy, relapsed and refractory (R/R) cases are frequent and contribute to the death of more than 50% of pts, particularly in those subpopulations with higher risk genetics, the largest of which (up to 30-40% AML pts) harbors fms-like tyrosine kinase 3 mutations (FLT3mut+). Use of the FLT3 inhibitor (FLT3i) gilteritinib as monotherapy for R/R pts resulted in improved outcomes but the duration of remission achieved is transient and often brief (CR rate: 20%; EFS: 2.8 months) per the ADMIRAL Ph3 study (Perl, et al., NEJM 2019). Preclinically, iada has marked synergy with FLT3i, particularly gilteritinib, in FLT3 wild-type and FLT3 mut+ AML cells and in derived cell lines resistant to venetoclax, azacitidine and FLT3is. Methods: Adult pts with ECOG 0-2 and FLT3 mut+ R/R AML, after 1 or 2 prior lines of therapy, will be enrolled. In escalation (3+3), up to 18 pts will receive iada at 75 to 150 ug, orally, in 5 days ON-2 days OFF schedule, with gilteritinib SoC. Up to approximate 14 pts will be expanded from pharmacologically active dose/s (per Project OPTIMUS). Primary endpoints of the study are safety and RP2D determination. Bayesian posterior probability efficacy monitoring will be performed periodically for each dose cohort. Bayesian efficacy futility and early stopping boundary will be applied. Posterior probability criterion (Prob (CR > 0.3) ≥ 0.60) at the end of the study will warrant further research. Safety in expansion will be evaluated continuously with a Bayesian stopping rule. Secondary endpoints include OS, EFS, CR, CR/CRh, ORR, TTR, DoR, and transfusion rate. Exploratory endpoints include PK, PD, MRD and gene mutational analysis. The study will run in 15 US sites. Additional sites will be added for a subsequent Phase 2 randomized controlled double-blinded FRIDA 2 study to assess the efficacy of this combination in R/R FLT3 mut+ AML. Clinical trial information: NCT05546580 .