Efficacy of Vorinostat to Induce Fetal Hemoglobin in Sickle Cell Disease

Study Overview
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Brief Summary
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Sickle Cell Disease (SCD) is a hereditary anemia that causes the red blood cells to change their shape from a round and doughnut-like shape to a half-moon/crescent, or sickled shape. People who have SCD have a different type of hemoglobin (protein that carries oxygen). This different type of hemoglobin makes the red blood cells change into a crescent shape under certain conditions. Sickle-shaped cells are a problem because they often get stuck in the blood vessels blocking the flow of blood and can cause inflammation and injury to important areas of the body. All babies are born with hemoglobin called fetal hemoglobin (HbF). Soon after birth, HbF production slows down and another hemoglobin called adult hemoglobin (HbA) is made. Clinical studies have shown that increasing the amount of HbF in the blood may prevent sickling of the red blood cells. Vorinostat has been used in the treatment of cancers and in other research studies and information from those suggests that it may help treat SCD by increasing the amount of HbF in the blood. The purpose of this research study is to determine the effectiveness and safety of vorinostat when used to treat SCD.

Detailed Description
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OBJECTIVES: Primary To determine the efficacy of vorinostat (suberoylanilide hydroxamic acid, SAHA), when administered orally, in a pulsed fashion, once-a-day for 3 consecutive days every week, in inducing a 4% absolute increase or a 100% increase in fetal hemoglobin percent levels (HbF%) in subjects with severe sickle cell disease who have failed prior therapy. To characterize the safety and tolerability. Secondary To assess the effect of vorinostat on F-cell levels. To determine the changes in y-globin, B-globin and E-globin RNA levels during treatment with vorinostat. To describe the dose-response characteristics of vorinostat in inducing fetal hemoglobin in sickle cell disease. Exploratory To determine the extent and duration of global histone acetylation with intermittent vorinostat dosing. To correlate the status of polymorphisms near the BCL11A, c-myb, and HBB gene loci, all of which are associated with levels of fetal hemoglobin, to assess for an association of polymorphism status with therapeutic response to vorinostat. To evaluate red blood cell rheology before and after treatment with vorinostat. STATISTICAL DESIGN: This was a single stage design to evaluate induction of HbF on treatment with target enrollment of 15 patients. A 25% success rate was considered evidence of activity in this patient population while 5% success rate deemed ineffective. If at least 3 patients achieved success, the treatment would be considered promising. With 15 eligible patients, the probability of observing this was 0.76 assuming a true rate of 25% and 0.04 assuming a true rate of 5%.

Official Title
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A Phase II Pharmacodynamic Investigation of the Efficacy of Vorinostat to Induce Fetal Hemoglobin in Adults With Severe Sickle Cell Disease Who Have Not Benefitted From Prior Therapy

Conditions
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Sickle Cell Disease, Sickle Cell Anemia

Intervention / Treatment
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* Drug: vorinostat


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis of sickle cell disease Clinically significant disease defined as at least 1 painful episode per year averaged over the previous 3 years or a history of priapism, stroke, acute chest syndrome, avascular necrosis, multi-organ failure or the need for chronic narcotic medications for pain from sickle cell disease Must have failed a previous attempt at treatment with hydroxyurea defined as the inability to achieve a significant absolute increase in % fetal hemoglobin or the inability to tolerate hydroxyurea treatment due to severe side effects such as but not limited to myelosuppression, gastrointestinal symptoms, edema or hepatic enzyme elevations or have contraindications to hydroxyurea 18 years of age or older Hematologic laboratory values as outlined in the protocol Non-hematologic laboratory values as outlined in the protocol Must agree not to donate blood or other bodily fluid while taking the study drug and for 28 days thereafter Women of child-bearing potential (WCBP) must have a negative serum pregnancy test 72 hours or less prior to starting treatment Women of child-bearing potential and men must agree to use 2 forms of adequate contraception prior to study entry and for the duration of study participation Exclusion Criteria: Subjects with hemoglobin SC or SB+ thalassemia Subjects on chronic transfusion program Subjects who have received RBC transfusions cannot have >15% adult hemoglobin Known positive status for HIV, active hepatitis B or hepatitis C Pregnant or breast feeding women Individuals with a history of malignancy are ineligible except for the following circumstances. Individuals with a history of malignancy are eligible if they have been disease-free for at least 5 years and are deemed by the investigator to be at low risk for recurrence of that malignancy. Individuals with the following cancer are eligible if diagnosed and adequately treated within the past 5 years: cervical or breast cancer in situ, and basal cell or squamous cell carcinoma of the skin Subjects with a history of thrombosis or other reason (other than sickle cell disease) for enhanced thrombotic risk Subjects with unresolved infections Severe or uncontrolled medical conditions that could compromise study participation Subjects on fetal hemoglobin inducing agents Subjects on any other experimental treatment within 90 days of the first dose of study drug or who have not recovered from the side effects of such therapy Known allergic reaction to a histone deacetylase inhibitor Subjects who have received valproic acid for treatment of epilepsy within 30 days of enrollment Subjects who have received any HDAC inhibitors other than valproic acid

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
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Vorinostat<br>Patients received vorinostat in a pulsed fashion, once a day for 3 consecutive days every week to a maximum dose of 400 mg per dose (1200 mg/wk), for 12 to 16 weeks at the maximum dose. The first 3 patients were enrolled in an intrapatient dose escalation schedule of 100 mg/d, then 200 mg/d, each for 3 consecutive days a week for 4 weeks, and then 400 mg/d, 3 consecutive days per week for 16 weeks. The last 2 patients were enrolled to receive 400 mg/d, 3 consecutive days per week for 12 weeks, without an initial dose escalation. | Drug: vorinostat<br> <br> * Other names: SAHA;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percent Fetal Hemoglobin (HbF%) Induction Success Rate | Success will be defined by comparing the maximum HbF% on study drug to the HbF% at baseline. An absolute increase in HbF% of 4% of more, or an increase to 100% or more of baseline in patients with HbF under 4% at baseline will be considered a success. HbF% induction success rate is calculated as the count of successes divided by the count of patients in the analysis population. | HbF% was measured at baseline and weekly on treatment. Median duration of treatment was 3 months. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| F-Cell Percentage Level | F-cell percentage levels were estimated based on established methods. | Measured at baseline and end of treatment, up to 16 weeks. | 
| γ-globin to β-globin Ratio | Levels of peripheral blood γ-globin to β-globin messenger RNA were estimated based on established methods. The ratio of γ-globin to β-globin was then calculated. | Measured at baseline and end of treatment, up to 16 weeks. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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fetal hemoglobin, vorinostat, HDAC inhibitor, SAHA