A Safety Study of Pharmacologic Ascorbate and Ferumoxytol in Addition to Standard of Care Chemoradiation in Glioblastoma

Study Overview
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Brief Summary
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This clinical trial evaluates adding ferumoxytol and pharamcologic ascorbate (vitamin C) to standard of care treatment of glioblastoma multiforme (a type of brain tumor) in adults. All subjects will receive ferumoxytol and pharmacologic ascorbate in addition to the standard treatment.

Detailed Description
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The initial, standard treatment for glioblastoma multiforme (GBM) involves maximum safe surgical resection followed by radiation combined with temozolomide (a chemotherapy pill you take by mouth). Participants in this trial will: receive intravenous (IV) ferumoxytol the day before starting radiation, then around radiation treatments 6, 25, and 31. receive high doses of intravenous (IV) ascorbate three times a week during the combined radiation and chemotherapy phase. provide feedback about how they feel and their quality of life. This is done through short surveys as well as discussing with the study team.

Official Title
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A First-in-Human Clinical Trial of Pharmacologic Ascorbate and Ferumoxytol Combined With Concomitant Temozolomide and External Beam Radiation Therapy for Newly Diagnosed Glioblastoma

Conditions
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Glioblastoma, Glioblastoma Multiforme

Intervention / Treatment
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* Drug: Ferumoxytol injection
* Drug: Pharmacological ascorbate
* Radiation: External beam radiation therapy
* Drug: Temozolomide


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Willingness and ability to provide informed consent consistent with Good Clinical Practice (i.e., legally authorized representative will not be used / allowed for this study). Stated willingness to comply with all study procedures for the duration of the study Aged 18 years or older. Newly diagnosed (i.e., within 6 weeks), histologically or molecularly confirmed glioblastoma or diffuse midline glioma. Therapy to begin within 6 weeks of last surgery Able to take oral medication ECOG performance status of 0, 1, or 2 (KPS of >50) Recommended to receive temozolomide and radiation therapy Medically fit, as determined by the prescribing oncologists, to undergo temozolomide and radiation therapy. Agree to use of highly effective contraception from screening until at least 90 days after the last study treatment (study participant should not discontinue contraception until discussing with their treating oncologist(s)). Not have significant co-morbid central nervous system disease, such as multiple sclerosis. Agree to Lifestyle Considerations throughout study duration Exclusion Criteria: Current use of the following drugs and cannot have a drug substitution or decline the drug substitution: warfarin, flecainide, methadone, amphetamines, quinidine, and chlorpropamide. Pharmacologic ascorbic acid may affect urine acidification and, as a result, may affect clearance rates of these drugs. Current use of antiretroviral drugs (e.g., nelfinavir, abacavir, emtricitabine, lamivudine, stavudine, tenofovir disoproxil fumarate, zidovudine). Pharmacologic ascorbate acid is a known CYP450 3A4 inducer, which results in lower serum levels of antiretroviral drugs. Insulin requirement Requires blood glucose monitoring using finger-stick glucose checks. Medical requirement or indication for iron supplementation (including ferumoxytol, ferrous gluconate, ferrous fumarate, or ferrous sulfate). NOTE: Over the counter, patient-elective supplementation is acceptable. Inability to undergo MR imaging. Pregnancy or lactation (note: potential participants should not engage in 'pump & dump' strategy; lactation must be discontinued). Known allergic reactions to ferumoxytol. History of Steven's Johnson Syndrome History of hemochromatosis. Prior radiation treatment that would result in field overlap. For potential participants who have undergone nuclear medicine therapy, including PRRT, the study's radiation oncologist must approve study entry. G6PD (glucose-6-phosphate dehydrogenase) deficiency Platelet count < 100,000 /mm3 within 21 days of first treatment Creatinine ≥ 1.5x the institutional upper limit of normal within 21 days of the first treatment or if creatinine is elevated a creatinine clearance of < 60 mL/(min 1.73 m2) Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection (requiring inpatient admission or a delay to start of therapy), symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements. Treatment with another investigational drug within 30 days prior to study treatment day 1. Imaging trials (including investigational PET or NM tracers) as well as observational trials are acceptable. Clinical trials with an endpoint of treating the patient's cancer, including behavioral, nutritional and/or device human subject studies.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Sequential Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Cohort 1 (starting)<br>Radiation Phase Ascorbate: 87.5 g administered intravenously (IV) three times each calendar week for approximately 8 weeks. Ferumoxytol: 512 g administered intravenously (IV) the day before radiation and then during weeks 5 to 6 of radiation therapy. Radiation: 61.2 Gray (given 1.8 Gray once daily, 5 days per week, for about 7 weeks) or 60 Gray (2.0 Gray once daily for 5 days per week for about 6 weeks) Temozolomide: 75 mg/m2, taken orally, once daily, every day, for up to 49 days or until radiation is completed (whichever comes first). Adjuvant Phase Temozolomide: 150 to 200 mg/m2, taken orally, once daily, for five days out of 28 days (where 28 days is one cycle of chemotherapy) for up to six cycles Ascorbate: 87.5 g administered intravenously (IV) twice each calendar week of the cycle Ferumoxytol: 512 g administered intravenously (IV) the first day of the first cycle of chemotherapy. | Drug: Ferumoxytol injection<br>* Ferumoxytol is an iron replacement product FDA approved for treatment of iron deficiency anemia in adult patients with chronic kidney disease (CKD). This trial uses the FDA approved dosage (512 mg iron) for iron-deficiency anemia in CKD.<br>* Other names: Ferumoxytol;Drug: Pharmacological ascorbate<br>* Intravenous ascorbate<br>* Other names: ascorbic acid;Radiation: External beam radiation therapy<br>* Photon based, focal radiation therapy delivered consistent with national guidelines, standard for treatment of GBM.<br>* Other names: VMAT;Drug: Temozolomide<br>* Temozolomide is a cytotoxic alkylating agent administered orally that penetrates well into the central nervous system. It is a standard-of-care treatment for GBM.<br>* Other names: temozolomide capsule;|
| Experimental: Cohort 2<br>Radiation Phase Ascorbate: 87.5 g administered intravenously (IV) three times each calendar week for approximately 8 weeks. Ferumoxytol: 512 g administered intravenously (IV) the day before radiation, about 1 week after dose 1, during weeks 5 to 6 of radiation therapy, and then a week after that (for a total of 4 ferumoxytol infusions). Radiation: 61.2 Gray (given 1.8 Gray once daily, 5 days per week, for about 7 weeks) or 60 Gray (2.0 Gray once daily for 5 days per week for about 6 weeks) Temozolomide: 75 mg/m2, taken orally, once daily, every day, for up to 49 days or until radiation is completed (whichever comes first). Adjuvant Phase Temozolomide: 150 to 200 mg/m2, taken orally, once daily, for five days out of 28 days (where 28 days is one cycle of chemotherapy) for up to six cycles Ascorbate: 87.5 g administered intravenously (IV) twice each calendar week of the cycle Ferumoxytol: 512 g administered intravenously (IV) the first day of the first cycle of | Drug: Ferumoxytol injection<br>* Ferumoxytol is an iron replacement product FDA approved for treatment of iron deficiency anemia in adult patients with chronic kidney disease (CKD). This trial uses the FDA approved dosage (512 mg iron) for iron-deficiency anemia in CKD.<br>* Other names: Ferumoxytol;Drug: Pharmacological ascorbate<br>* Intravenous ascorbate<br>* Other names: ascorbic acid;Radiation: External beam radiation therapy<br>* Photon based, focal radiation therapy delivered consistent with national guidelines, standard for treatment of GBM.<br>* Other names: VMAT;Drug: Temozolomide<br>* Temozolomide is a cytotoxic alkylating agent administered orally that penetrates well into the central nervous system. It is a standard-of-care treatment for GBM.<br>* Other names: temozolomide capsule;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Determination of recommended phase 2 ferumoxytol dosing regimen | The recommended dose will be determined by incidence of dose limiting toxicities. | From treatment day 1 through 12 weeks after completing radiation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Estimate progression free survival (PFS) | Time (measured in days) to documented disease progression in MRI imaging as described by the RANO criteria. | From treatment day 1 to disease progression, up to 60 months post-treatment | 
| Estimate overall survival (OS) | Time to death from any cause. | Time (measured in days) until death from any cause, up to 20 years post-treatment | 
| Estimate Objective Response Rate (ORR) | Objective response rate, measured using standardized RANO criteria, is a reflection of complete tumor response and partial tumor response. The radiation planning MRI will be used as baseline. | 12 weeks post-radiation | 
| Tumor size | Tumor measurements completed as per RANO criteria and compared to the radiation-planning MRI (baseline) | Baseline and 12 weeks post-radiation | 
| Clinical response | Neurologic assessment in Neuro-Oncology (NANO) composite score evaluating gait, strength, ataxia, sensation, visual fields, facial strength, language, level of consciousness, and behavior and comparing to baseline. | 12 weeks post-radiation | 
| Number of Treatment-Related Adverse Events | Categorize and quantify adverse events using the Common Terminology Criteria for Adverse Events (v5) | Up to 36 months post-radiation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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ascorbate, radiation therapy, temozolomide, ferumoxytol