Safety and Efficacy of Subcutaneous Sarilumab in Improving the Quality of Life in People With Indolent Systemic Mastocytosis

Background:

Mast cells help the body fight disease and heal wounds. People with indolent systemic mastocytosis (ISM) make too many mast cells. This causes pain, tiredness, digestive problems, and other symptoms. Researchers think the drug sarilumab could help.

Objective:

To see if sarilumab is a safe and effective treatment for people with ISM.

Eligibility:

Adults ages 18-75 with ISM who are enrolled in NIH study 02-I-0277

Design:

Participants will be screened with:

* Physical exam
* Medical history
* Blood and urine tests
* Questionnaires
* Bone marrow removed by a needle inserted into the hip bone
* Ultrasound of the abdomen
* Photographs of the skin

Participants will repeat some screening tests at study visits.

Participants will have a baseline visit in the hospital for 3 days. They will:

* Be assigned to get either the study drug or a placebo. They will not know which one they get.
* Have a skin punch biopsy: An instrument will remove a small piece of skin.
* Get their first drug dose injected under their skin

Participants will keep a side effect and medication diary during the study.

Participants will visit the clinic to get a drug dose every 2 weeks, for a total of 8 doses.

Participants will have a visit 2 weeks after their final dose. It will last up to 2 days.

Participants will have another visit 12 weeks later.

Participants may then continue this study for 1 more year. Those who continue will get sarilumab, even if they previously got the placebo, every 2 weeks. They will have visits every 6 weeks, and then every 3 months.

Systemic mastocytosis is a disorder caused by clonal mast cell proliferation and release of mast cell mediators including tryptase. As a result, mast cell numbers may increase and affect target organs including the dermis (maculopapular cutaneous mastocytosis/urticaria pigmentosa, flushing), gastrointestinal tract (abdominal pain, diarrhea), skeletal system (osteoporosis), hematological system (anemia, thrombocytopenia), and spleen and liver (organomegaly). Patients with indolent (non-aggressive) systemic mastocytosis (ISM) are not candidates for cytoreductive therapy and are generally treated with symptomatic therapy that only partly decreases symptoms. There is, however, a documented association between severity of mastocytosis and elevated serum levels of interleukin (IL)-6. Furthermore, mast cells have been shown to double their rate of division and exhibit increased reactivity and release of mediators when cultured in the presence of IL-6. In addition, in an animal model of mastocytosis, anti-IL-6 has been shown to slow disease progression. In this study, adults with ISM will thus be randomized and treated with sarilumab, a recombinant monoclonal antibody directed against the IL-6 receptor, or receive placebo. Sarilumab is marketed in the United States as Kevzara (Sanofi/Genzyme \[Cambridge, Massachusetts, USA \]) and is approved by the Food and Drug Administration for the treatment of rheumatoid arthritis. Binding of sarilumab to the IL-6 receptor inhibits IL-6-associated human mast cell signaling and proliferation with a resultant decrease in proliferation and reactivity (decreased mediator release), and therefore is a rational choice for the treatment of ISM.

In this study, participants will be randomized with approximately half of the participants receiving study drug, which will be administered at 200 mg via subcutaneous (SC) injection once every 2 weeks (Q2W) for a total of 16 weeks. The other participants will receive a placebo administered via SC injection Q2W for 16 weeks. Participants will return for a follow-up visit 2 weeks after the final dose (treatment peak), and then again 12 weeks later. Evaluations at study visits will include quality of life and symptom assessments and measurement of serum tryptase levels. Bone marrow examination will be performed at the onset and conclusion of the study. After the week 28 visit, all participants will have the option to continue sarilumab for 52 more weeks, at 200 mg administered via SC injections. Participants will continue to be monitored on a regular basis for safety concerns, as instructed in the study drug s package insert.

Eligibility Criteria:
* INCLUSION CRITERIA:

Participants must meet all of the following criteria to be enrolled in this study:

1. Male or female participant greater than or equal to 18 and \< 75 years of age at screening.
2. Enrolled on NIAID protocol 02-I-0277.
3. Documented pathologic diagnosis of ISM.
4. Mc-QoL score of at least 25% (which suggests participant is at least somewhat affected by all Mc-QoL questions).
5. Willing and able to undergo a bone marrow biopsy and aspirate.
6. Absolute neutrophil count (ANC) greater than or equal to 2000/mL.
7. Hemoglobin greater than or equal to 12.0 g/dL (males), greater than or equal to 11 g/dL (females).
8. Platelet count greater than or equal to 150,000/microliters.
9. Alanine transaminase (ALT) and aspartate transaminase (AST) \< 1.5 times the upper limit of normal (ULN).
10. Willing to allow storage of blood and bone marrow for future use in medical research.
11. Willing to allow genetic testing on biospecimens.
12. Able to provide informed consent.
13. Participants who can become pregnant must agree to use adequate contraception when engaging in sexual activities that can result in pregnancy. Adequate contraception must be used consistently, beginning at least 1 month before the beginning of dosing and lasting until 3 months after the final dose of study drug. Acceptable methods of contraception include the following:

    * Hormonal contraception (non-oral only).
    * Male or female condom with spermicide.
    * Diaphragm or cervical cap with a spermicide.
    * Intrauterine device.

EXCLUSION CRITERIA:

Individuals meeting any of the following criteria will be excluded from study participation:

1. Any abnormality that would be scored as a Grade 4 toxicity on the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Only clinically significant lab results will deem the subject ineligible
2. Infected with HIV or has other known immunodeficiency.
3. Has an active infection, including localized infection.
4. Active diverticulitis.
5. Active or chronic viral hepatitis.
6. Active or latent tuberculosis.
7. Use of any other anti-IL-6 or anti-IL-6R agent within 1 year prior to the date informed consent was obtained.
8. Use of cytoreductive therapy for mastocytosis within 1 year prior to the date informed consent was obtained.
9. Known lymphoma or advanced and metastatic solid tumors on active therapy (including chemotherapy) within 1 year prior to the date informed consent was obtained
10. Use of chemotherapy within 1 year prior to the date informed consent was obtained.
11. Receipt of any marketed (eg, omalizumab) or investigational biologic or monoclonal antibody reported to affect mast cell activation within 5 half-lives prior to date informed consent was obtained.
12. Receipt of intravenous (IV) immunoglobulin within 30 days prior to the date informed consent was obtained.
13. Receipt of live attenuated vaccines within 30 days prior to the date informed consent was obtained.
14. History of alcohol or drug/abuse within 12 months prior to date informed consent was obtained.
15. Is allergic to any component of the sarilumab formulation.
16. Pregnant or breastfeeding.
17. Any condition that, in the opinion of the investigator, contraindicates participation in this study.