A Phase III Multi-center, Open-label, Randomized Study of the Efficacy of Nilotinib Versus Imatinib in Adult Patients With Ph+ CML in Early CP Who Have a Suboptimal Molecular Response to Imatinib
18 Years
N/A
Both
Chronic Myeloid Leukemia
Trial Information
A Phase III Multi-center, Open-label, Randomized Study of the Efficacy of Nilotinib Versus Imatinib in Adult Patients With Ph+ CML in Early CP Who Have a Suboptimal Molecular Response to Imatinib
Imatinib mesylate (imatinib) binds to the inactive conformation of Bcr-Abl tyrosine kinase
suppressing the Ph+ clone in CML (Giles et al, 2005). It is effective in CML and is a major
advance in therapy. With standard dose imatinib, the MMR and complete molecular response
(CMR) rates are 35% to 40% and 6% to 10% respectively at 12 months. These surrogate
endpoints have been associated with high long term survival rates (Kantarjian et al, 2004).
For patients who had a CCyR and MMR (defined as a reduction in Bcr-Abl transcript levels of
at least 3 log at 12 months following imatinib therapy), the probability of remaining
progression-free was 100 percent at 24 months, compared with 95% for patients achieved a
CCyR but no MMR and 85% for patients who did not achieve a CCyR (P<0.001) (Hughes et al,
2003/Druker et al, 2006).
With continued doses of imatinib 400 mg/day, MMR at 24 months is 54% (IRIS SmPC data),
however with high dose imatinib 800 mg/day, MMR may be 70%. Higher doses of imatinib
improved the CCyR rates to 90% both in patients who failed prior IFN-alfa therapy and in
those previously untreated (Cortes et al, 2005). Higher doses are expected to yield higher
MMR rates at 24 months (Cortes et al, ASH 2004 poster). There is also a continued increase
in the cumulative major/complete cytogenetic and molecular response rates with therapy, even
after 2 years (Kantarjian 2004).
Nilotinib is a novel, oral tyrosine kinase inhibitor with improved potency compared with
imatinib. In pre-clinical models of imatinib-sensitive CML cell lines, nilotinib was 20-50
times more potent than imatinib, and 3-7 times more potent in imatinib-resistant cell lines.
In a Phase I dose-escalation trial [Study CAMN107A2101], 119 imatinib-resistant Ph+ CML and
ALL patients were treated with single oral doses of nilotinib ranging from 50-1200 mg daily
or 400 mg and 600 mg given twice daily. Nilotinib produced high hematologic and cytogenetic
response rates of 92% and 53%, respectively (CCyR in 35%), in patients with chronic phase
CML, who were resistant to imatinib. Nilotinib was found to have an acceptable tolerability
profile (Kantarjian et al, 2005). Preliminary results from an ongoing Phase II study appear
to confirm the efficacy and safety profile of nilotinib (Kantarjian et al, 2006).
Achievement of a major molecular response is an important short-term goal in CML therapy as
it appears to predict for long-term event-free survival. This study is designed to compare
the efficacy of nilotinib 400 mg twice daily with patients' maximum tolerated doses of
imatinib (optimally 800 mg/day) in producing a major molecular response after 12 months of
treatment in individuals previously not in major molecular remission. It will also examine
the rates of major molecular and complete molecular response in each of the treatment arms,
as achievement of these endpoints may also be of prognostic significance.
Inclusion Criteria:
- Male or female patients ≥ 18 years of age
- ECOG 0, 1, or 2
- Diagnosis of Ph+ CML in CP
- Patients with suboptimal molecular response defined as:
- Patients must achieve a CCyR at 12 months and must maintain CCyR until study
entry (0% Ph+ chromosomes). Cytogenetic confirmation of Ph+ (9;22 translocation)
is required on a minimum of 20 metaphases. FISH analysis will not be accepted.
- at least 18 months and up to 24 months (≥18 to ≤24 months) of treatment with
imatinib as first line therapy, at a dose of 400 mg daily, without achieving a
MMR (<0.1% IS of Bcr-Abl transcript by RQ- PCR).
- The following laboratory results must be present:
- Total bilirubin <1.5 x ULN
- SGOT and SGPT <2.5 x ULN
- Creatinine <1.5 x ULN
- Serum amylase and lipase ≤ 1.5 x ULN
- Alkaline phosphatase ≤ 2.5 x ULN unless considered tumor related.
- Serum potassium, magnesium and calcium ≥ LLN or correctable with supplements to
within normal limits prior to the first dose of study medication.
- Ability to provide written informed consent prior to any study related screening
procedures being performed.
Exclusion Criteria:
- Late CP who started imatinib more than 6 months after diagnosis
- Prior accelerated phase or blast phase CML
- Rare hereditary problems of galactose intolerance, severe lactase deficiency or
glucose galactose malabsorption
- Hypersensitivity to nilotinib or any of the excipients.
- Previously documented T315I mutations.
- Intolerance to imatinib 400 mg daily defined as the inability to maintain at least
400 mg daily for the previous 3 months.
- Patients treated with imatinib more than 400mg daily
- Achieved prior MMR or CCyR on imatinib and lost response to entering the study.
- Previous treatment with interferon or any other tyrosine kinase inhibitor except
imatinib (however, allow hydroxyurea or anagrelide before initial imatinib start)
- Impaired cardiac function
- Treatment with inhibitors of CYP3A4 or medications well documented to prolong the QT
interval are contraindicated
- Impaired gastrointestinal (GI) function or GI disease
- History of acute pancreatitis within 1 year of study entry or past medical history of
chronic pancreatitis.
- Known cytopathologically confirmed CNS infiltration (in absence of suspicion of CNS
involvement, lumbar puncture not required).
- Any other malignancy that is clinically significant or requires active intervention.
- Severe or uncontrolled medical conditions (i.e. uncontrolled diabetes, acute or
chronic liver disease, pancreatic, or severe renal disease unrelated to tumor, active
or uncontrolled infection).
- History of significant congenital or acquired bleeding disorder unrelated to cancer.
- Previous radiotherapy to ≥ 25% of the bone marrow.
- Major surgery within 4 weeks prior to Day 1 of study or who have not recovered from
prior surgery.
- Use of therapeutic coumarin derivatives (i.e. warfarin, acenocoumarol,
phenprocoumon).
- Treatment with other investigational agents within 30 days of Day 1.
- History of non-compliance to medical regimens or inability to grant consent.
- Women who are pregnant, breast feeding, or of childbearing potential without a
negative serum or urine pregnancy test at baseline.
Type of Study:
Interventional
Study Design:
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Crossover Assignment, Masking: Open Label, Primary Purpose: Treatment
Outcome Measure:
the cumulative rate of MMR
Outcome Description:
To evaluate the cumulative rate of MMR at 12 months of nilotinib compared to imatinib in adult patients with Ph+ CML in early CP who have suboptimal molecular response to imatinib
Outcome Time Frame:
12 months
Safety Issue:
No
Principal Investigator
Dong-Wook Kim, MD, PhD
Investigator Role:
Principal Investigator
Investigator Affiliation:
Seoul St. Mary's Hospital
Authority:
Korea: Food and Drug Administration
Study ID:
CAMN107AKR01T
NCT ID:
NCT01400074
Start Date:
January 2009
Completion Date:
June 2014
Related Keywords:
- Chronic Myeloid Leukemia
- Leukemia
- Leukemia, Myeloid
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive
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