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Tyrosine Kinase Inhibition to Treat Myeloid Hypereosinophilic Syndrome

Primary Purpose

Eosinophilic Myeloid Neoplasm, Hypereosinophilic Syndrome

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Imatinib
Ruxolitinib
Sponsored by
National Institute of Allergy and Infectious Diseases (NIAID)
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Eosinophilic Myeloid Neoplasm focused on measuring Janus Kinase, Imatinib, Ruxolitinib, Myeloid Neoplasm, Platelet-Derived Growth Factor Receptor Alpha, Hypereosinophilic Syndrome, HES

Eligibility Criteria

2 Years - undefined (Child, Adult, Older Adult)All SexesDoes not accept healthy volunteers

INCLUSION CRITERIA: In order to be eligible to participate in this study, an individual must meet all of the following criteria: Stated willingness to comply with all study procedures and availability for the duration of the study Male or female, at least 2 years of age for imatinib therapy and >=18 years of age for ruxolitinib therapy Documented diagnosis of hypereosinophilic syndrome: eosinophilia > 1,500/mm3 on two occasions, no secondary etiology for the eosinophilia despite careful clinical evaluation, and evidence of end organ damage (histologic evidence of tissue infiltration by eosinophils and/or objective evidence of clinical pathology in any organ system that is temporally associated with eosinophilia and not clearly attributable to another cause). All subjects must fit one of the following four categories: myeloid neoplasm associated with a PDGFRA or PDGFRB rearrangement myeloid neoplasm associated with rearrangement or mutation involving the JAK-STAT pathway presence of >=4 of the following laboratory criteria suggestive of a myeloid disorder: dysplastic eosinophils on peripheral smear serum B12 level >= 1000 pg/ml serum tryptase level >= 12 anemia and/or thrombocytopenia bone marrow cellularity > 80% with left shift in maturation dysplastic (spindle-shaped) mast cells on bone marrow biopsy evidence of fibrosis on bone marrow biopsy dysplastic megakaryocytes on bone marrow biopsy refractory to or intolerant of steroids without evidence of a myeloid disorder Negative serum beta-hCG 24 hours prior to drug administration for women of childbearing potential to exclude early pregnancy Agrees to practice abstinence or effective contraception during administration of imatinib mesylate or ruxolitinib and for 6 months after discontinuation of the drug. Women of childbearing potential who are using hormonal contraceptives and taking ruxolitinib will also be required to use a barrier method. Participation in protocol 94-I-0079 (Activation and function of eosinophils in conditions with blood or tissue eosinophilia) NOTE: Subjects who meet inclusion criteria, but are already receiving imatinib, may be enrolled in the dose de-escalation portion of the study at the investigator s discretion. Subjects who meet inclusion criteria, but are already receiving ruxolitinib, may be enrolled at the investigator s discretion if baseline data is available and they have received ruxolitinib at the dose specified in the protocol for less than 2 months (primary endpoint).. Effective contraception includes the use of hormonal (birth control pills, for example) and/or barrier (condoms and diaphragms, for example) methods by subjects and/or their partners to prevent pregnancy in women of childbearing potential. For women of childbearing potential who use hormonal methods as their primary means of contraception and will be receiving treatment with ruxolitinib, barrier methods will also be required due to possible interference of ruxolitinib with hormonal contraceptives. Although a private physician is not required for inclusion in the study, it is strongly recommended that all subjects have a physician outside the NIH for routine medical care and emergencies. EXCLUSION CRITERIA: An individual who meets any of the following criteria will be excluded from participation in this study: Pregnant or nursing women HIV positivity or other known immunodeficiency D816V KIT-positive systemic mastocytosis Absolute neutrophil count < 1000/mm3 or platelet count <10,000/mm3 or <50,000/m3 with clinical evidence of bleeding. Elevated transaminases (>5 times the upper limit of normal) or elevated bilirubin (>3 times the upper limit of normal) Any condition that, in the investigator s opinion, places the patient at undue risk by participating in the study An individual who meets any of the following criteria will be excluded from participation in the ruxolitinib treatment arm of this study: Evidence of B cell clonality by PCR or flow cytometry Active tuberculosis, acute or chronic active infection with hepatitis B or C Treatment with fluconazole >200 mg daily Subjects with active tuberculosis will be excluded. The most current IDSA guidelines will be followed regarding isoniazid therapy for latent tuberculosis. Subjects who refuse recommended prophylactic therapy for tuberculosis will be counseled regarding the risks of reactivation of tuberculosis during ruxolitinib therapy but will not be systematically excluded. Molecular and serologic tests for hepatitis B and serology for hepatitis C will be performed regardless of vaccination history. Subjects with evidence of active or chronic infection with hepatitis B or positive hepatitis C serology will be excluded from participation in the ruxolitinib arm of the protocol. Specifically, a positive hepatitis B serology indicative of previous immunization (i.e., HBsAb positive and HBc Ab negative) or a fully resolved acute hepatitis B infection is not an exclusion criterion. Patients with an indolent chronic hepatitis B infection (normal ALT, AST, albumin and no radiographic or biopsy evidence of cirrhosis) will be evaluated by NIDDK may be eligible. Patients who choose to remain on study with evidence of prior hepatitis B infection will be counseled regarding the risks of reactivation prior to initiation of ruxolitinib therapy.

Sites / Locations

  • National Institutes of Health Clinical CenterRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Experimental

Arm Label

Imatinib

Ruxolitinib

Arm Description

open label imatinib mesylate treatment

open label ruxolitinib treatment

Outcomes

Primary Outcome Measures

peripheral blood absolute eosinophil count.
The percentage of subjects who reach an eosinophil count in the normal range

Secondary Outcome Measures

peripheral blood eosinophil count
The % of subjects who reach an eosinophil count in the normal range
peripheral blood eosinophil count
The % of subjects who reach an eosinophil count below 1500/mm3
abnormal tyrosine kinase (i.e., FIP1L1-PDGFRA, JAK2 V617F)
The % of subjects who achieve molecular remission on therapy
clinical, hematologic and molecular remission
The duration of remission following cessation of therapy

Full Information

First Posted
August 24, 2002
Last Updated
October 20, 2023
Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)
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1. Study Identification

Unique Protocol Identification Number
NCT00044304
Brief Title
Tyrosine Kinase Inhibition to Treat Myeloid Hypereosinophilic Syndrome
Official Title
Efficacy of Tyrosine Kinase Inhibition in Reducing Eosinophilia in Patients With Myeloid and/or Steroid-Refractory Hypereosinophilic Syndrome
Study Type
Interventional

2. Study Status

Record Verification Date
August 8, 2023
Overall Recruitment Status
Recruiting
Study Start Date
September 26, 2002 (Actual)
Primary Completion Date
January 1, 2025 (Anticipated)
Study Completion Date
January 1, 2026 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No

5. Study Description

Brief Summary
The purpose of this study is to evaluate the safety and efficacy of the tyrosine kinase inhibitor, imatinib mesylate (Gleevec ) in reducing peripheral blood eosinophilia in patients with the myeloid form of hypereosinophilic syndrome (HES). Patients with the hypereosinophilic syndrome who meet a set of criteria designed to select patients with the myeloid form of the disease, as well as patients without myeloid disease who are refractory to standard therapy for HES, will be admitted on this protocol. A thorough clinical evaluation will be performed with emphasis on potential sequelae of eosinophil-mediated tissue damage. A baseline bone marrow will be obtained to exclude leukemia or lymphoma and to assess the degree and nature of eosinophilopoiesis. Bone marrow, blood cells and/or serum will also be collected to test for the presence of a recently described mutation that is associated with imatinib-responsiveness in HES, and to provide reagents (such as DNA, RNA, and specific antibodies) and for use in the laboratory to address issues related to the mechanism of action of imatinib mesylate in HES. Imatinib mesylate will be initiated at a dose of 400 mg daily, the FDA-approved dose for the treatment of chronic myelogenous leukemia. In patients who demonstrate a complete clinical and hematologic response to imatinib therapy and who do not have life-threatening disease, the dose will be decreased gradually to 100mg daily and then discontinued. In order to minimize bone marrow suppression, other myelosuppressive agents will be tapered and discontinued during the first week of therapy with imatinib mesylate. Complete blood counts will be performed weekly for the first month and biweekly thereafter. Clinical assessments will be performed every three months to assess progression of end organ damage. In patients who demonstrate a complete clinical and hematologic response to imatinib therapy and who do not have life-threatening disease, the dose will be decreased gradually to 100 mg daily and then discontinued. In the event of clinical, hematologic or molecular relapse during the taper, the imatinib dose will be increased to a maximum of 600 mg daily to achieve a second remission. Laboratory monitoring will be performed as above except for molecular monitoring which will be monitored monthly if drug is discontinued or molecular relapse occurs. Once a stable dosing regimen is achieved for greater than or equal to 6 months in subjects who have undergone dose descalation or greater than or equal to 2 years in subjects receiving 300-400 mg of imatinib daily who did not qualify for dose de-escalation, the frequency of NIH visits and end organ assessments will be decreased to 6 months, with molecular monitoring every 3 months and monthly routine laboratory assessments.
Detailed Description
This study will evaluate the safety and effectiveness of imatinib mesylate in reducing the number of eosinophils (a type of white blood cell) in patients with hypereosinophilic syndrome (HES). Patients with HES have elevated counts of eosinophils in the blood and body tissues, which can cause damage to these tissues. Although HES can involve any tissues, the heart, nerves, and skin are most often affected. Several drugs, including steroids, interferon, and hydroxyurea can lower eosinophil counts; however, these drugs have drawbacks in that they do not work in all patients with HES, or they may work only temporarily, or patients may develop side effects that require stopping the drugs. Imatinib mesylate is a new drug approved to treat gastrointestinal tumors and chronic myelogenous leukemia. Some data suggest that imatinib mesylate may be useful in treating a subgroup of patients with HES. Patients with HES who are 18 years of age and older may be eligible for this study. Candidates will be screened with a medical history, physical examination, blood tests, electrocardiogram (EKG), echocardiogram (ultrasound examination of the heart), pulmonary (lung) function tests, eye exam and a bone marrow examination to determine if they fall into the subgroup of patients likely to respond to this therapy. For the bone marrow procedure, an area of skin and bone is numbed and a very sharp needle is inserted into the bone to draw out a sample of bone marrow for evaluation under the microscope. Patients enrolled in the study will take imatinib mesylate daily. Any other drugs they may be taking for HES, as well as other drugs they are taking that may interact with imatinib mesylate, will be tapered and stopped. If it is not possible to stop taking certain drugs for other conditions, their dosages may be adjusted. Patients will be monitored weekly with laboratory testing during the first month of treatment and whenever neutrophil counts drop below 1500/mm3 or platelets fall below 100,000/mm3. If blood counts remain high enough, monitoring will be reduced to every 2 weeks for 3 months and once a month after that. Patients will have a clinic visit at NIH 1 month after beginning the drug for a clinical and laboratory evaluation, including a repeat bone marrow examination. Patients whose eosinophil counts are not lowered after 4 weeks of treatment will leave the study. Those who respond to therapy will return to NIH every 3 months for a history and physical examination, laboratory tests, EKG, echocardiogram, and pulmonary function testing to determine how treatment is affecting disease progression. In some participants with stable disease where an optimal dose of imatinib mesylate has been identified, visits may be extended to every six months. In addition, the following procedures will be done solely for research purposes: Blood tests to determine the effects of imatinib mesylate on immune cells, including eosinophils. Leukapheresis to study the effects of imatinib mesylate on eosinophils: For this procedure, whole blood is collected through a needle in an arm vein, similar to donating blood. The blood circulates through a machine that separates it into its components, and the white cells are removed. The rest of the blood is returned to the body, either through the same needle or through another needle in the other arm. Bone marrow examinations will be done during the screening tests and again 1 month after starting treatment to look at newly developing cells in the bone marrow. Genetic testing to determine how imatinib mesylate is able to lower eosinophil counts in patients with HES.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Eosinophilic Myeloid Neoplasm, Hypereosinophilic Syndrome
Keywords
Janus Kinase, Imatinib, Ruxolitinib, Myeloid Neoplasm, Platelet-Derived Growth Factor Receptor Alpha, Hypereosinophilic Syndrome, HES

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Sequential Assignment
Masking
None (Open Label)
Allocation
Non-Randomized
Enrollment
60 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Imatinib
Arm Type
Experimental
Arm Description
open label imatinib mesylate treatment
Arm Title
Ruxolitinib
Arm Type
Experimental
Arm Description
open label ruxolitinib treatment
Intervention Type
Drug
Intervention Name(s)
Imatinib
Intervention Description
The dosing regimen to be used initially (400 mg po qd in adults and 260 mg/m2/day in children with food and a glass of water) is identical to that recommended by the FDA for the treatment of the chronic phase of chronic myelogenous leukemia (CML) (Prod Info Gleevec ). In patients with ANC <1500/mm3, platelet counts < 75,000mm3 or abnormal liver function tests (ALT or AST > 2.5 or bilirubin > 3 times the upper limit of normal), the starting dose will be reduced to 300 mg po qD.
Intervention Type
Drug
Intervention Name(s)
Ruxolitinib
Intervention Description
The dosing regimen to be used initially (15 mg po bid) is identical to that recommended by the FDA for the treatment of myelofibrosis with platelet counts of 100-200,000/mm3 (Prod Info ruxolitinib). In patients with platelet counts <100,000/mm3, moderate renal impairment (CrCl <60 mL/min) or abnormal liver function tests (ALT or AST > 2.5 or bilirubin > 3 times the upper limit of normal), the starting dose will be reduced to 10 mg bid. The recommended guidelines for dose adjustment during therapy and discontinuation of therapy in myelofibrosis will be followed.
Primary Outcome Measure Information:
Title
peripheral blood absolute eosinophil count.
Description
The percentage of subjects who reach an eosinophil count in the normal range
Time Frame
one month (for imatinib) and 3 months (for ruxolitinib).
Secondary Outcome Measure Information:
Title
peripheral blood eosinophil count
Description
The % of subjects who reach an eosinophil count in the normal range
Time Frame
3,6,9 and 12 months
Title
peripheral blood eosinophil count
Description
The % of subjects who reach an eosinophil count below 1500/mm3
Time Frame
1, 3, 6, 9, and 12 months
Title
abnormal tyrosine kinase (i.e., FIP1L1-PDGFRA, JAK2 V617F)
Description
The % of subjects who achieve molecular remission on therapy
Time Frame
every 3 months for 5 years
Title
clinical, hematologic and molecular remission
Description
The duration of remission following cessation of therapy
Time Frame
every 3 months for 5 years

10. Eligibility

Sex
All
Minimum Age & Unit of Time
2 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
INCLUSION CRITERIA: In order to be eligible to participate in this study, an individual must meet all of the following criteria: Stated willingness to comply with all study procedures and availability for the duration of the study Male or female, at least 2 years of age for imatinib therapy and >=18 years of age for ruxolitinib therapy Documented diagnosis of hypereosinophilic syndrome: eosinophilia > 1,500/mm3 on two occasions, no secondary etiology for the eosinophilia despite careful clinical evaluation, and evidence of end organ damage (histologic evidence of tissue infiltration by eosinophils and/or objective evidence of clinical pathology in any organ system that is temporally associated with eosinophilia and not clearly attributable to another cause). All subjects must fit one of the following four categories: myeloid neoplasm associated with a PDGFRA or PDGFRB rearrangement myeloid neoplasm associated with rearrangement or mutation involving the JAK-STAT pathway presence of >=4 of the following laboratory criteria suggestive of a myeloid disorder: dysplastic eosinophils on peripheral smear serum B12 level >= 1000 pg/ml serum tryptase level >= 12 anemia and/or thrombocytopenia bone marrow cellularity > 80% with left shift in maturation dysplastic (spindle-shaped) mast cells on bone marrow biopsy evidence of fibrosis on bone marrow biopsy dysplastic megakaryocytes on bone marrow biopsy refractory to or intolerant of steroids without evidence of a myeloid disorder Negative serum beta-hCG 24 hours prior to drug administration for women of childbearing potential to exclude early pregnancy Agrees to practice abstinence or effective contraception during administration of imatinib mesylate or ruxolitinib and for 6 months after discontinuation of the drug. Women of childbearing potential who are using hormonal contraceptives and taking ruxolitinib will also be required to use a barrier method. Participation in protocol 94-I-0079 (Activation and function of eosinophils in conditions with blood or tissue eosinophilia) NOTE: Subjects who meet inclusion criteria, but are already receiving imatinib, may be enrolled in the dose de-escalation portion of the study at the investigator s discretion. Subjects who meet inclusion criteria, but are already receiving ruxolitinib, may be enrolled at the investigator s discretion if baseline data is available and they have received ruxolitinib at the dose specified in the protocol for less than 2 months (primary endpoint).. Effective contraception includes the use of hormonal (birth control pills, for example) and/or barrier (condoms and diaphragms, for example) methods by subjects and/or their partners to prevent pregnancy in women of childbearing potential. For women of childbearing potential who use hormonal methods as their primary means of contraception and will be receiving treatment with ruxolitinib, barrier methods will also be required due to possible interference of ruxolitinib with hormonal contraceptives. Although a private physician is not required for inclusion in the study, it is strongly recommended that all subjects have a physician outside the NIH for routine medical care and emergencies. EXCLUSION CRITERIA: An individual who meets any of the following criteria will be excluded from participation in this study: Pregnant or nursing women HIV positivity or other known immunodeficiency D816V KIT-positive systemic mastocytosis Absolute neutrophil count < 1000/mm3 or platelet count <10,000/mm3 or <50,000/m3 with clinical evidence of bleeding. Elevated transaminases (>5 times the upper limit of normal) or elevated bilirubin (>3 times the upper limit of normal) Any condition that, in the investigator s opinion, places the patient at undue risk by participating in the study An individual who meets any of the following criteria will be excluded from participation in the ruxolitinib treatment arm of this study: Evidence of B cell clonality by PCR or flow cytometry Active tuberculosis, acute or chronic active infection with hepatitis B or C Treatment with fluconazole >200 mg daily Subjects with active tuberculosis will be excluded. The most current IDSA guidelines will be followed regarding isoniazid therapy for latent tuberculosis. Subjects who refuse recommended prophylactic therapy for tuberculosis will be counseled regarding the risks of reactivation of tuberculosis during ruxolitinib therapy but will not be systematically excluded. Molecular and serologic tests for hepatitis B and serology for hepatitis C will be performed regardless of vaccination history. Subjects with evidence of active or chronic infection with hepatitis B or positive hepatitis C serology will be excluded from participation in the ruxolitinib arm of the protocol. Specifically, a positive hepatitis B serology indicative of previous immunization (i.e., HBsAb positive and HBc Ab negative) or a fully resolved acute hepatitis B infection is not an exclusion criterion. Patients with an indolent chronic hepatitis B infection (normal ALT, AST, albumin and no radiographic or biopsy evidence of cirrhosis) will be evaluated by NIDDK may be eligible. Patients who choose to remain on study with evidence of prior hepatitis B infection will be counseled regarding the risks of reactivation prior to initiation of ruxolitinib therapy.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Thomas W Brown, R.N.
Phone
(301) 402-7823
Email
browntw@mail.nih.gov
First Name & Middle Initial & Last Name or Official Title & Degree
Amy D Klion, M.D.
Phone
(301) 435-8903
Email
aklion@niaid.nih.gov
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Amy D Klion, M.D.
Organizational Affiliation
National Institute of Allergy and Infectious Diseases (NIAID)
Official's Role
Principal Investigator
Facility Information:
Facility Name
National Institutes of Health Clinical Center
City
Bethesda
State/Province
Maryland
ZIP/Postal Code
20892
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
For more information at the NIH Clinical Center contact Office of Patient Recruitment (OPR)
Phone
800-411-1222
Ext
TTY dial 711
Email
ccopr@nih.gov

12. IPD Sharing Statement

Citations:
PubMed Identifier
26797802
Citation
Khoury P, Desmond R, Pabon A, Holland-Thomas N, Ware JM, Arthur DC, Kurlander R, Fay MP, Maric I, Klion AD. Clinical features predict responsiveness to imatinib in platelet-derived growth factor receptor-alpha-negative hypereosinophilic syndrome. Allergy. 2016 Jun;71(6):803-10. doi: 10.1111/all.12843. Epub 2016 Mar 2.
Results Reference
background
PubMed Identifier
27887955
Citation
King B, Lee AI, Choi J. Treatment of Hypereosinophilic Syndrome with Cutaneous Involvement with the JAK Inhibitors Tofacitinib and Ruxolitinib. J Invest Dermatol. 2017 Apr;137(4):951-954. doi: 10.1016/j.jid.2016.10.044. Epub 2016 Nov 22. No abstract available.
Results Reference
background
PubMed Identifier
25964669
Citation
Klion AD. How I treat hypereosinophilic syndromes. Blood. 2015 Aug 27;126(9):1069-77. doi: 10.1182/blood-2014-11-551614. Epub 2015 May 11.
Results Reference
background
PubMed Identifier
17709602
Citation
Klion AD, Robyn J, Maric I, Fu W, Schmid L, Lemery S, Noel P, Law MA, Hartsell M, Talar-Williams C, Fay MP, Dunbar CE, Nutman TB. Relapse following discontinuation of imatinib mesylate therapy for FIP1L1/PDGFRA-positive chronic eosinophilic leukemia: implications for optimal dosing. Blood. 2007 Nov 15;110(10):3552-6. doi: 10.1182/blood-2007-07-100164. Epub 2007 Aug 20.
Results Reference
derived
Links:
URL
https://clinicalstudies.info.nih.gov/cgi/detail.cgi?A_2002-I-0286.html
Description
NIH Clinical Center Detailed Web Page

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Tyrosine Kinase Inhibition to Treat Myeloid Hypereosinophilic Syndrome

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