NDMM Patients Candidates for ASCT Comparing Extended VRD Plus vs. Isa-VRD vs. Isa-V-Iberdomide (GEM21menos65)
Newly Diagnosed Multiple Myeloma
About this trial
This is an interventional treatment trial for Newly Diagnosed Multiple Myeloma
Eligibility Criteria
Inclusion Criteria:
- Patient is, in the investigator's opinion, willing and able to comply with the protocol requirements.
- Patient must be able to understand the study procedures.
- Patient has given voluntary written informed consent before performance of any studyrelated procedure non part of normal medical care, with the understanding that consent may be withdrawn by the patient at any time without prejudice to their future medical care.
- Newly diagnosed multiple myeloma patient who requires start active treatment according to the 2014 IMWG criteria, namely clonal bone marrow plasma cells ≥10% or biopsy-proven bony or extramedullary plasmacytoma and any one or more of the following myeloma defining events: evidence of end organ damage that can be attributed to the underlying plasma cell proliferative disorder, specifically: Hypercalcaemia, Anaemia, Renal Insufficiency, or Bone lesions (one or more osteolytic lesions on skeletal radiography, CT, or PET-CT), and any one or more of the following biomarkers: clonal BMPC% ≥60%, i/u free light ratio ≥100 or > 1 focal lesions on MRI or PET/CT) [Lancet Oncol. 2014;15(12): e538-e548].
- Patient must have a measurable secretory disease defined as either serum monoclonal protein of ≥ 0,5 g/dl or urine monoclonal (light chain) protein ≥ 200 mg/24 h. For patients whose disease is only measurable by serum FLC, the involved FLC should be ≥ 10mg/dL (100 mg/L), with an abnormal serum FLC ratio.
- Patient must have an Eastern Cooperative Oncology Group (ECOG) performance status of ≤ 2.
- Patient must be ≤ 65 years of age.
Patient must have adequate organ function, defined as follows:
- Absolute neutrophil count (ANC) ≥1.0 X 109/L without G-CSF use in the prior 7 days
- Hemoglobin ≥8.0 g/dL (prior red blood cell (RBC) transfusion or recombinant human erythropoietin use is permitted)
- Platelets ≥ 75 x 109/L in participants in whom <50% of bone marrow nucleated cells are plasma cells and ≥ 50×109/L in participants in whom ≥50% of bone marrow nucleated cells are plasma cells (without transfusion support or thrombopoietin receptor agonist within 7 days before the laboratory test).
- Calcium Corrected serum calcium ≤13.5 mg/dL (≤3.4 mmol/L); or free ionized calcium ≤6.5 mg/dL (≤1.6 mmol/L).
- Total bilirubin ≤2 X ULN
- ALT ≤2.5 X ULN
- AST ≤2.5 X ULN
- Renal: eGFRa: ≥40 mL/min/ 1.73 m2
- Cardiac: LVEF (echo) ≥ 50%
Female patient: contraceptive use should be consistent with local regulations regarding the methods of contraception for those participating in clinical studies. A female patient is eligible to participate if she is not pregnant or breastfeeding, and at least one of the following conditions applies:
- Is not a woman of childbearing potential (WOCBP), i.e., fertile, following menarche and until becoming post-menopausal unless permanently sterile. Permanent sterilization methods include hysterectomy, bilateral salpingectomy and bilateral oophorectomy OR
Is a WOCBP and
- She understands the potential teratogenic risk to the unborn child
- She understands the need for effective contraception as stated in the protocol, without interruption, 28 days before starting study treatment, throughout the entire duration of study treatment, during dose interruptions and for at least 28 days after the last dose of study treatment.
- She understands and agrees to inform the Investigator if a change or stop of method of contraception is needed.
- She must be capable of complying with effective contraceptive measures.
- She is informed and understands the potential consequences of pregnancy and the need to notify her study doctor immediately if there is a risk of pregnancy.
- She understands the need to commence study treatment as soon as it is dispensed following a negative pregnancy test.
- She understands and accepts the need to undergo pregnancy testing based on the frequency outlined in this plan and in the Informed Consent.
- She acknowledges she understands the hazards iberdomide or lenalidomide can cause to an unborn fetus and the necessary precautions associated with the use of study drugs.
The Investigator must ensure that a WOCBP: i) Complies with the conditions of the pregnancy prevention plan, including confirmation that she has an adequate level of understanding. ii) Acknowledges the aforementioned requirements.
A WOCBP must have a negative highly sensitive serum pregnancy test (as required by local regulations) within 72 hours before the first dose of study drug.
Nonchildbearing potential is defined as follows (by other than medical reasons):
- Has not achieved menarche at some point.
- Has undergone a hysterectomy or bilateral oophorectomy.
- Has been naturally postmenopausal (amenorrhea following cancer therapy does not rule out childbearing potential) for at least 24 consecutive months (ie, has had menses at any time in the preceding 24 consecutive months).
Male patient: contraceptive use should be consistent with local regulations regarding the methods of contraception for those participating in clinical studies.
Male patient is eligible to participate if he agrees to the following from the time of first dose of study until 6 months after the last dose of iberdomide or lenalidomide to allow for clearance of any altered sperm:
- Understand the potential teratogenic risk if engaged in sexual activity with a pregnant female or a WOCBP.
- Understand the need for the use of a condom even if he has had a vasectomy, if engaged in sexual activity with a pregnant female or a FCBP
- Understand the potential teratogenic risk, so the subject should not donate semen or sperm.. Understand that the effects on fertility are currently unknown, therefore all family planning options and/or alternatives should be thoroughly discussed with the study doctor prior to receiving iberdomide.
- All prior treatment-related toxicities (defined by National Cancer Institute- Common Toxicity Criteria for Adverse Events (NCI-CTCAE), version 5.0 must be ≤ Grade 1 at the time of enrolment except for alopecia.
Exclusion Criteria:
- Patient has a diagnosis of primary amyloidosis, monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), plasma cell leukemia or active POEMS syndrome at the time of screening.
- Patient has had clinical evidence of central nervous system (CNS) or pulmonary leukostasis, disseminated intravascular coagulation, or CNS multiple myeloma.
- Prior history of malignancies, other than multiple myeloma (except for basal or squamous cell carcinoma of the skin, carcinoma in situ of the cervix or the breast), unless the patient has been free of the disease for ≥ 5 years.
- Any serious medical condition that places the subject at an unacceptable risk if he or she participates in this study; subjects with conditions requiring chronic steroid or immunosuppressive treatment, such as rheumatoid arthritis, multiple sclerosis and/or lupus, that likely need additional steroid or immunosuppressive treatments in addition to the study treatment.
- Pregnant or breastfeeding females.
- Men and women of reproductive potential who are not using effective contraceptive methods (double barrier method, intrauterine device, oral contraception).
- Patient is simultaneously enrolled in other interventional clinical trial.
- Patient has used an investigational drug within 28 days or five half-lives, whichever is longer, preceding the first dose of study drug.
- Patient must not have received prior radiotherapy (except localized palliative radiotherapy for pain, palliation or fracture) within 2 weeks of start of study therapy. Participants must have recovered from all radiation-related toxicities, not require corticosteroids, and not have had radiation pneumonitis.
- Major surgery (except kyphoplasty) ≤ 4 weeks prior to initiating protocol therapy.
- Patient has peripheral neuropathy or neuropathic pain grade 1 with pain or ≥2, as defined by the National Cancer Institute Terminology Criteria for Adverse Events (NCI CTCAE) Version 5.0.
Patient evidence of cardiovascular risk including any of the following:
- Myocardial infarction within 6 months before randomization, or an unstable or uncontrolled disease/condition related to or affecting cardiac function (eg, unstable angina, congestive heart failure, New York Heart Association Class III-IV).
- Uncontrolled cardiac arrhythmia.
- Screening 12-lead ECG showing a baseline interval QTcF> 470 msec (exception: subjects with pacemaker).
- Patients with uncontrolled hypertension.
- Patients who have current unstable liver or biliary disease defined by the presence of ascites, encephalopathy, coagulopathy, hypoalbuminemia, esophageal or gastric varices, persistent jaundice, or cirrhosis. Note: Stable chronic liver disease (including Gilbert's syndrome or asymptomatic gallstones) or hepatobiliary involvement of malignancy is acceptable if otherwise meets entry criteria.
- Presence of active renal condition (infection, requirement for dialysis or any other condition that could affect patient's safety). Participants with isolated proteinuria resulting from MM are eligible, provided they fulfil inclusion criteria.
- Evidence of active mucosal or internal bleeding.
- Any serious medical condition or psychiatric illness that would interfere in understanding of the informed consent form.
- Uncontrolled endocrine diseases (i.e. diabetes mellitus, hypothyroidism or hyperthyroidism) (i.e. requiring relevant changes in medication within the last month, or hospital admission within the last 3 months).
- Patient with acute diffuse infiltrative pulmonary disease and/or pericardial disease.
- Patient with severe chronic obstructive pulmonary disease (COPD) or asthma with forced expiratory volume in the first minute (FEV1) less than 50%.
- History of interstitial lung disease or ongoing interstitial lung disease.
- Subject has gastrointestinal disease that may significantly alter the absorption of iberdomide and/or other oral study treatment.
- Patient has an active infection requiring systemic antibiotic, antiviral, or antifungal treatment at the time of starting treatment.
- Patient has known HIV infection.
- Patient has positive hepatitis B surface antigen (HBsAg), or hepatitis B core antibody (HBcAb) at screening or within 3 months prior to first dose of study treatment.
- Patient has positive hepatitis C antibody test result or positive hepatitis C RNA test result at screening or within 3 months prior to first dose of study treatment. Note: Participants with positive Hepatitis C antibody due to prior resolved disease can be enrolled, only if a confirmatory negative Hepatitis C RNA test is obtained. Note: Hepatitis RNA testing is optional and participants with negative Hepatitis C antibody test are not required.
- Patient require concurrent administration of a strong inhibitor or inducer of cytochrome P450 (CYP3A4/5) (including within 14 days of initiating study treatment).
- Patient has a known immediate or delayed hypersensitivity reaction or idiosyncratic reactions to iberdomide or drugs chemically related to iberdomide.
- Patient has a known immediate or delayed hypersensitivity reaction or idiosyncratic reactions to isatuximab or drugs chemically related to isatuximab, hypersensitivity reactions, or idiosyncratic reactions to other molecular antibodies.
- Patient has a known immediate or delayed hypersensitivity reaction or idiosyncratic reactions to lenalidomide or dexamethasone or drugs chemically related to lenalidomide or dexamethasone.
Sites / Locations
- Hospital Principe de Asturias
- Hospital Universitario Quirón Salud Madrid
- Clinica Universidad Navarra (CUN)
- Hospital General Universitario de Albacete
- Hospital Germans Trias i Pujol (ICO BADALONA)
- Hospital Clinic i Provincial de Barcelona
- Hospital de la Santa Creu i Sant Pau
- Hospital Universitari Vall d´Hebron
- ICO L´Hospitalet
- Hospital Universitario de Cruces
- Hospital Universitario de Burgos
- Complejo Hospitalario de Cáceres
- Hospital Universitario de Cabueñes
- Hospital Universitari Dr. Josep Trueta (ICO Girona)
- Hospital Universitario Virgen de las Nieves
- Hospital Universitario de Guadalajara
- H.Universitario de Jerez de la Frontera
- Hospital Universitario de Canarias
- Complejo Asistencial Universitario de León
- Hospital Arnau de Vilanova (Lleida)
- Hospital San Pedro
- Complejo Hospitalario Lucus Augusti
- Fundación Jiménez Díaz-Ute
- Hospital General Universitario Gregorio Marañón
- Hospital HLA Universitario Moncloa
- Hospital Universitario 12 de octubre
- Hospital Universitario Clínico San Carlos
- Hospital Universitario de Fuenlabrada
- Hospital Universitario de la Princesa
- Hospital Universitario Fundación Alcorcón
- Hospital Universitario HM Sanchinarro
- Hospital Universitario Infanta Leonor
- Hospital Universitario La Paz
- Hospital Universitario La Zarzuela
- Hospital Universitario Puerta del Hierro
- Hospital Universitario Ramón y Cajal
- H. Morales Meseguer
- H. Un. Virgen de la Arrixaca
- Hospital General Universitario Santa Lucía
- Hospital Costa del Sol
- Hospital Regional de Málaga
- Hospital U Niversitario Virgen de La Victoria
- Hospital Universitario Rey Juan Carlos
- Complejo Hospitalario Universitario de Ourense
- Hospital Universitario Central de Asturias
- Hospital Son Llatzer
- Hospital Universitari Son Espases
- Complejo Hospitalario de Navarra
- Complejo Hospitalario de Pontevedra
- Hospital Clinico Universitario Salamanca
- Hospital Universitario Infanta Sofía
- Hospital Universitario de Donostia
- Complejo Hospitalario Universitario Nuestra Señora de la Candelaria
- H. Universitario Marqués de Valdecilla
- Complejo Hospitalario Santiago (CHUS)
- Hospital General de Segovia
- Complejo Hospitalario Regional Virgen Del Rocío
- H. Universitario de Valme
- Hospital Universitario Reina Sofía
- Hospital Universitari de Tarragona Joan XXIII
- Hospital Universitari Mutua Terrassa
- Complejo Hospitalario de Toledo (Virgen de la Salud)
- Hospital Clínico Universitario de Valencia
- Hospital Universitari i Politecnic la Fe
- Hospital Universitario Dr. Peset Aleixandre
- H. U. Txagorritxu
- Hospital Clinico Universitario Lozano Blesa
- Hospital Universitario Miguel Servet
Arms of the Study
Arm 1
Arm 2
Arm 3
Active Comparator
Experimental
Experimental
Control arm (A)
EXPERIMENTAL ARM (B): Extended VRD and Early Rescue Intervention
EXPLORATORY ARM (C)
INDUCTION: Isatuximab + VRD, 4 cycles. Isatuximab (IV) 10 mg/Kg, 1st cycle D: 1,8,15, 22. Cycles 2-4: D 1,15. Bortezomib (SC) 1.3 mg/m2, D:1, 4, 8, 11. Lenalidomide (PO) 25mg, D:1-21. Dexamethasone (PO) 40 mg, D: 1-4, 9-12. ASCT. The conditioning regimen is melphalan 200 mg/m2. CONSOLIDATION: Isatuximab + VRD, 2 cycles. Isatuximab (IV) 10 mg/Kg. D 1-15. Bortezomib (SC) 1.3 mg/m2, D:1, 4, 8, 11. Lenalidomide (PO) 25mg, D:1-21. Dexamethasone (PO) 40 mg, D: 1-4, 9-12. CONTINUOUS TREATMENT: Lenalidomide and monthly Isatuximab until progression, unacceptable toxicity, patient withdrawal, loss to follow up or death. During continuous treatment, dexamethasone 40 mg is used as a standardized premedication for Isatuximab.
INDUCTION: Includes two experimental lines: VRD extended to 18 cycles: Induction (VRDx6): Bortezomib (SC) 1.3 mg/m2, D: 1, 4, 8, and 11 (Q4W). Lenalidomide 25 mg (PO), D: 1-21 (Q4W). Dexamethasone 40 mg (PO) D 1 to 4 and 9 to 12 (Q4W). Isatuximab (IV) 10 mg/kg, D: 1, 8, 15, and 22 (Q4W) and D: 1-15 in subsequent cycles. Early detection of treatment failure and Early Rescue Intervention (ERI): Isatuximab-Iberdomide-Dexamethasone in continuous treatment. Isatuximab (IV) 10mg/kg Cycle 1: Days 1, 8, 15, and 22 (Q4W). Cycles 2 onwards: Days 1 and 15 (Q4W). Isatuximab will be infused monthly after 1 year treatment (Day 1 Q4W) including ASCT. Iberdomide (PO) 1,6 mg. D: 1-21 (Q4W). Dexamethasone (PO) 40 mg. D: 1, 8, 15, and 22 (Q4W). ASCT. The conditioning regimen is melphalan 200 mg/m2. CONSOLIDATION (VRDx2)- Extended VRD: VDx10, followed by lenalidomide plus dexamethasone maintenance. CONTINUOUS TREATMENT: Lenalidomide 15 mg, D: 1-21, and dexamethasone 20 mg, D: 1-4 (Q4W).
INDUCTION: Iberdomide plus Isatuximab, bortezomib and dexamethasone (four cycles). Isatuximab (IV) 10 mg/kg D 1, 8, 15, and 22 in the first Q4W; and days 1-15 in subsequent cycles. Iberdomide (PO) at 1.6 mg on days 1-21 of every 4-week cycle. Bortezomib (SC) at 1.3 mg/m2 on days 1, 4, 8, and 11 of every 4-week cycle. Dexamethasone 40 mg (PO) D 1-4, 9-12 (Q4W). ASCT. The conditioning regimen is melphalan 200 mg/m2. CONSOLIDATION: two cycles (Q4W) of Isatuximab, Iberdomide, Bortezomib and Dexamethasone, as in induction, starting approximately 2 months after hospital discharge or 3 months after transplantation. Isatuximab will be infused monthly since the start of continuous therapy (after the second cycle of consolidation). CONTINUOUS TREATMENT: Iberdomide and monthly Isatuximab until progression, unacceptable toxicity, patient withdrawal, loss to follow up or death. During continuous treatment, dexamethasone 40 mg is used as a standardized premedication for Isatuximab.