Myeloma-Developing Regimens Using Genomics (MyDRUG)

Study Overview
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Brief Summary
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The MyDRUG study is a type of Precision Medicine trial to treat patients with drugs targeted to affect specific genes that are mutated as part of the disease. Mutations in genes can lead to uncontrolled cell growth and cancer. Patients with a greater than 25% mutation to any of the following genes; CDKN2C, FGFR3, KRAS, NRAS, BRAF V600E, IDH2 or T(11;14) can be enrolled to one of the treatment arms. These arms have treatments specifically directed to the mutated genes. Patients that do not have a greater than 25% mutation to the genes listed can be enrolled to a non-actionable treatment arm. The genetic sequencing of the patient's tumor is required via enrollment to the MMRF002 study: Clinical-grade Molecular Profiling of Patients with Multiple Myeloma and Related Plasma Cell Malignancies. (NCT02884102).

Detailed Description
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The study will enroll 228 patients enrolled to one of eight treatment arms. The study is open to patients relapsing with relapsed refractory multiple myeloma, who have received at least one prior but no more than 3 prior therapies exposed to both a PI and an IMiD had early relapse after initial treatment. Relapse is defined as the IMWG uniform response criteria (Kumar et al, 2016). Early relapse as defined by at least one of the following: Relapse within 3 years post autologous stem cell transplantation (ASCT) on maintenance, or 18 months if unmaintained Relapse within 18 months of initial non-ASCT based therapy

Official Title
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Myeloma-Developing Regimens Using Genomics (MyDRUG) (Genomics Guided Multi-arm Trial of Targeted Agents Alone or in Combination With a Backbone Regimen)

Conditions
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Relapsed Refractory Multiple Myeloma

Intervention / Treatment
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* Drug: Abemaciclib, dexamethasone, ixazomib, pomalidomide
* Drug: Enasidenib, dexamethasone, ixazomib, pomalidomide
* Drug: Cobimetinib, dexamethasone, ixazomib, pomalidomide
* Drug: Erdafitinib, dexamethasone, ixazomib, pomalidomide
* Drug: Venetoclax, dexamethasone, ixazomib, pomalidomide
* Drug: Daratumumab, dexamethasone, ixazomib, pomalidomide
* Drug: Belantamab mafodotin, dexamethasone, ixazomib, pomalidomide
* Drug: Selinexor, dexamethasone, ixazomib, pomalidomide


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Willing to be registered into the pomalidomide (POMALYST®) Risk Evaluation and Mitigation Strategy (REMS®) program Enrolled in the MMRF002 Molecular Profiling Protocol (NCT02884102) with report less than 120 days old Disease free of prior malignancies for ≥ 3 years with exception of currently treated basal cell, squamous cell carcinoma of the skin, carcinoma in situ of the cervix or breast, or prostate cancer not requiring therapy High risk patients with relapsed refractory multiple myeloma (RRMM), who have: received at least one prior but no more than 3 prior therapies exposed to both a PI and an IMiD had early relapse after initial treatment Early relapse as defined by at least one of the following: (Relapse is defined as the IMWG uniform response) Relapse within 3 years of initiation of induction chemo therapy for post autologous stem cell transplantation (ASCT) followed by maintenance, or 18 months if unmaintained after ASCT Within 18 months of initial non-ASCT based therapy Patients must have progressed after their most recent treatment and require therapy for myeloma Females of reproductive potential must have a negative pregnancy test at baseline, be non-lactating, and willing to adhere to scheduled pregnancy testing Females of reproductive potential and males must practice and acceptable method of birth control Laboratory values obtained ≤ 14 days prior to registration: Absolute neutrophil count (ANC) ≥ 1000/ul Hemoglobin (Hgb) ≥ 8 g/dl Platelet (PLT) ≥ 75,000/ul Total bilirubin <1.5 x upper limit of normal (ULN) or if total bilirubin is >1.5 x ULN, the direct bilirubin must be ≤ 2.0 mg/dL Aspartate aminotransferase (AST) <3 x ULN Creatinine Clearance ≥ 30 mL/min Measurable disease of Multiple Myeloma (MM) as defined by at least one of the following: Serum monoclonal protein ≥ 0.5 g by protein electrophoresis ≥200 mg of monoclonal protein in the urine on 24-hour electrophoresis Serum immunoglobulin free light chain (FLC) ≥10 mg/dL AND abnormal serum immunoglobulin kappa to lambda FLC ratio Monoclonal bone marrow plasmacytosis ≥30% (evaluable disease) Eastern Cooperative Oncology Group (ECOG) Performance Status 0, 1, or 2 Ability to take aspirin, warfarin, or low molecular weight heparin Sub-Protocol Inclusion Criteria: Refer to each respective Sub Protocol for additional inclusion criteria. Exclusion Criteria: Patients will be ineligible for this study if they meet any one of the following criteria: Aggressive multiple myeloma requiring immediate treatment as defined by: Lactate dehydrogenase (LDH) > 2 times ULN Presence of symptomatic extramedullary disease or central nervous system involvement Hypercalcemia >11.5 mg/dl Acute worsening of renal function (CrCl < 30 ml/min) directly related to myeloma relapse Any neurological emergency related to myeloma Clinical symptoms of hyperviscosity related to monoclonal protein Involved serum free light chain > 100 mg/dL (1000 mg/L) in the setting of prior diagnosis of cast nephropathy Infection requiring systemic antibiotic therapy or other serious infection within 14 days of enrolment Known hypersensitivity or development of erythema nodosum if characterized by a desquamating rash while taking thalidomide, lenalidomide, pomalidomide or similar drug. Known allergy to any of the study medications, their analogues, or excipients in the various formulations of the agents Prior Ixazomib/Pomalidomide/Dexamethasone combination therapy Pregnant or breast-feeding females Serious medical or psychiatric illness, active alcoholism, or drug addiction that may hinder or confuse compliance, interfere in the completion of treatment per protocol, or follow-up evaluation Active hepatitis A, B or C viral infection or known human immunodeficiency virus (HIV) infection Concurrent symptomatic amyloidosis or plasma cell leukemia POEMS syndrome [plasma cell dyscrasia with polyneuropathy, organomegaly, endocrinopathy, monoclonal protein (M-protein) and skin changes] Residual side effects to previous therapy > Grade 1 prior to initiation of therapy (Alopecia any grade and/or neuropathy Grade 2 without pain are permitted) Prior allogeneic or ASCT within 12 weeks of initiation of therapy. Prior allogeneic stem cell transplant with active graft-versus-host disease (GVHD) Prior experimental therapy within 14 days of protocol treatment or 5 half-lives of the investigational drug, whichever is longer Prior anticancer therapy within 14 days of initiation of protocol therapy (Dexamethasone/ 40mg/day) for a maximum of 4 days before screening is allowed Prior major surgical procedure or radiation therapy within 4 weeks of the initiation of therapy (this does not include limited course of radiation used for management of bone pain within 7 days of initiation of therapy). Known to have dysphagia, short-gut syndrome, gastroparesis, or other conditions that limit the ingestion or Gastro Intestinal (GI) absorption of drugs administered orally Evidence of current uncontrolled cardiovascular conditions, including uncontrolled hypertension, uncontrolled cardiac arrhythmias, symptomatic congestive heart failure, unstable angina, or myocardial infarction within the past 6 months Other co-morbidity, which would interfere with patient's ability to participate in trial or that confounds the ability to interpret data from the study Sub-Protocol Exclusion Criteria: Refer to each respective Sub Protocol for additional exclusion criteria.

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: Parallel Assignment
Interventional Model Description: Eight Arms with 38 patients per arm
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Sub-Protocol A1<br>Patients with CDK activating alteration receive Abemaciclib in combination with ixazomib, pomalidomide and dexamethasone (IPd) | Drug: Abemaciclib, dexamethasone, ixazomib, pomalidomide<br>* Patients with relapsed Multiple Myeloma will receive Abemaciclib and Dexamethasone for the first 2 cycles. Abemaciclib, Dexamethasone, Ixazomib and Pomalidomide from cycle 3 forward. Each cycle is 28 days long.<br>* Other names: pomalidomide: Pomalyst;|
| Experimental: Sub-Protocol B1<br>Patients with IDH2 activating mutation receive Enasidenib in combination with ixazomib, pomalidomide and dexamethasone (IPd) | Drug: Enasidenib, dexamethasone, ixazomib, pomalidomide<br>* Patients with relapsed Multiple Myeloma will receive Enasidenib and Dexamethasone for the first 2 cycles. Enasidenib, Dexamethasone, Ixazomib and Pomalidomide from cycle 3 forward. Each cycle is 28 days long.<br>* Other names: pomalidomide: Pomalyst;|
| Experimental: Sub-Protocol C1<br>Patients with the presence of RAF/RAS mutation receive Cobimetinib in combination with ixazomib, pomalidomide and dexamethasone (IPd) | Drug: Cobimetinib, dexamethasone, ixazomib, pomalidomide<br>* Patients with relapsed Multiple Myeloma will receive Cobimetinib and Dexamethasone for the first 2 cycles. Cobimetinib, Dexamethasone, Ixazomib and Pomalidomide from cycle 3 forward. Each cycle is 28 days long.<br>* Other names: pomalidomide: Pomalyst;|
| Experimental: Sub-Protocol D1<br>Patients with presence of FGFR3 activating mutations receive Erdafitinib in combination with ixazomib, pomalidomide and dexamethasone (IPd) | Drug: Erdafitinib, dexamethasone, ixazomib, pomalidomide<br>* Patients with relapsed Multiple Myeloma will receive Erdafitinib and Dexamethasone for the first 2 cycles. Erdafitinib, Dexamethasone, Ixazomib and Pomalidomide from cycle 3 forward. Each cycle is 28 days long.<br>* Other names: pomalidomide: Pomalyst;|
| Experimental: Sub-Protocol E1<br>Patients with t(11;14) translocation will be enrolled in arm E1 and randomized to the venetoclax or the IPd control arm. Patients with relapsed Multiple Myeloma will receive Venetoclax, Ixazomib, Pomalidomide and Dexamethasone every cycle. Each cycle is 28 days long. | Drug: Venetoclax, dexamethasone, ixazomib, pomalidomide<br>* Patients with t(11;14) translocation will be enrolled in arm E1 and randomized to the venetoclax or the IPd control arm. Patients with relapsed Multiple Myeloma will receive Venetoclax, Ixazomib, Pomalidomide and Dexamethasone every cycle. Each cycle is 28 days long.<br>* Other names: pomalidomide: Pomalyst;|
| Experimental: Sub-Protocol Y1<br>Patients with Non-Actionable Genetic Abnormality receive Daratumumab in combination with ixazomib, pomalidomide and dexamethasone (IPd) | Drug: Daratumumab, dexamethasone, ixazomib, pomalidomide<br>* Patients with relapsed Multiple Myeloma will receive Daratumumab, Ixazomib, Pomalidomide and Dexamethasone every cycle. Each cycle is 28 days long.<br>* Other names: pomalidomide: Pomalyst;|
| Experimental: Sub-Protocol Y2<br>Patients with Non-Actionable Genetic Abnormality receive Belantamab mafodotin in combination with ixazomib, pomalidomide and dexamethasone (IPd) | Drug: Belantamab mafodotin, dexamethasone, ixazomib, pomalidomide<br>* Patients with relapsed Multiple Myeloma will receive Belantamab mafodotin, Ixazomib, Pomalidomide and Dexamethasone every cycle. Each cycle is 28 days long.<br>* Other names: Belantamab mafodotin: BLENREP, GSK2857916;|
| Experimental: Sub-Protocol Y3<br>Patients with Non-Actionable Genetic Abnormality receive Selinexor in combination with ixazomib, pomalidomide and dexamethasone (IPd) | Drug: Selinexor, dexamethasone, ixazomib, pomalidomide<br>* Patients with relapsed Multiple Myeloma will receive Selinexor, Ixazomib, Pomalidomide and Dexamethasone every cycle. Each cycle is 28 days long.<br>* Other names: Selinexor: XPOVIO;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall Response Rate - Actionable Genetic Alteration | • To evaluate the overall response rate (ORR) with targeted agents used in combination with backbone regimen ixazomib, pomalidomide and dexamethasone (IPd) in patients with an actionable genetic alteration per the International Myeloma Working Group [IMWG] consensus criteria (Kumar et al, 2016) | Patients will be evaluated monthly for response from the start of the study until the date of documented disease progression, assessed up to 2 years | 
| Overall Response Rate - Non-Actionable Genetic Alteration | • To evaluate the ORR with agents used in combination with backbone (or IPd) regimen in patients with no actionable genetic alteration per IMWG consensus criteria (Kumar et al, 2016). | Patients will be evaluated monthly for response from the start of the study until the date of documented disease progression, assessed up to 2 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Multiple Myeloma, Relapsed Refractory, Multiple Myeloma Research Consortium (MMRC), Genomic Profile, My Drug, Multiple Myeloma Research Foundation