A randomised phase II trial of Cyclophosphamide and Dexamethasone in combination with Ixazomib, in relapsed or refractory multiple myeloma (RRMM) patients who have relapsed after treatment with thalidomide, lenalidomide and bortezomib
1.Able to give informed consent and willing to follow study protocol assessments
2. Aged 18 years or over
3. Participants with confirmed MM based on IMWG criteria, 2009
4. Measurable disease with at least one of the following:
- Paraprotein >5g/L or 0.5 g/l for IgD subtype
- Serum free light chains >100mg/L with abnormal radio for light chain only myeloma
- Bence Jones protein >200mg/L
5. Participants with relapsed or relapsed refractory myeloma and now require further treatment following exposure to thalidomide, lenalidomide and bortezomib regardless of response to these.
6. ECOG Performance Status ≤ 2
7. Required laboratory values within 14 days prior to start of treatment:
- Platelet count ≥50x109/L. Platelet count of 30-50 is acceptable if bone marrow aspirate shows tumour replacement of >50%. Platelet support is permitted within 14 days prior to randomisation although platelet transfusions to help patients meet eligibility criteria are not allowed within 72 hours prior to the blood sample to confirm protocol eligibility.
- Absolute neutrophil count ≥1.0 x 109/L. Growth factor support is not permitted within 14 days prior to randomisation
- Haemoglobin > 9 g/dL. Blood support is permitted
- ALT and / or AST ≤3 x upper limit of normal
- Creatinine clearance ≥ 30 ml/min (using Cockcroft Gault formula)
- Bilirubin ≤1.5 x upper limit of normal
8. Female participants should avoid becoming pregnant and male participants should avoid impregnating a female partner. Both non-sterilised and sterilised females and males of reproductive age should use effective methods of contraception during the entire trial treatment (including treatment breaks) and up to 90 days after the last dose of trial treatment.
9.Post allograft patients may be included if >12 months from transplant.
1. Participants meeting any of the following exclusion criteria are not eligible to register for this trial.
2. The following participantss will be excluded:
- Those with non-measurable disease
- Those with a solitary bone or solitary extramedullary plasmacytoma
- Plasma cell leukaemia
3. Prior malignancy other than those treated with curative surgery.
4. Participants with a known or underlying uncontrolled concurrent illness that, in the investigators opinion, would make the administration of the study drug hazardous or circumstances that could limit compliance with the study, including, but not limited to the following: acute or chronic graft versus host disease, uncontrolled hypertension, symptomatic congestive heart failure, unstable angina pectoris, myocardial infarction within past 6 months, uncontrolled cardiac arrhythmia, renal failure, psychiatric or social conditions that may interfere with participant compliance, or any other condition (including laboratory abnormalities) that in the opinion of the Investigator places the participant at unacceptable risk for adverse outcome if he/she were to participate in the study.
5. Participants who have previously received MLN9708 / Ixazomib in a trial. Previous experimental agents or approved anti-tumour treatment within 30 days before the date of randomisation.
6. A maximum of 160mg of dexamethasone (in 40mg blocks) may be given between screening and the beginning of treatment if medically required but should be stopped before trial treatment starts. Bisphosphonates for bone disease are also permitted.
7. Participants with a history of a refractory nausea, diarrhoea, vomiting, malabsorption, gastrointestinal surgery or other procedures that might, in the opinion of the Investigator, interfere with the absorption or swallowing of the study drug(s)
8. Peripheral neuropathy of ≥ grade 2 (or grade 1 with pain) severity (as per NCICTCAEv4.0)
9. Gastrointestinal disorders that may interfere with absorption of the study drug
10. Active symptomatic fungal, bacterial, and/or viral infection including known active HIV or known viral (A, B or C) hepatitis
11. Female participants who are lactating or have a positive pregnancy test at screening
12. Known allergy to any of the study medications, their analogues, or excipients in the various formulations of any agent
13. Systemic treatment, within 14 days prior to the first dose of ixazomib, with strong inhibitors of CYP1A2 (fluvoxamine, enoxacin, ciprofloxacin), strong inhibitors of CYP3A (clarithromycin, telithromycin, itraconazole, voriconazole, ketoconazole, nefazodone, posaconazole) or strong CYP3A inducers (rifampin, rifapentine, rifabutin, carbamazepine, phenytoin, phenobarbital), or use of Ginkgo biloba or St. John’s wort
14. Major surgery within 14 days prior to the date of randomisation
15. Radiotherapy within 7 days prior to randomisation for palliative pain control or therapeutic radiotherapy within 14 days prior to randomisation
16. Myeloma involving the Central Nervous System.
Other trials currently active for Multiple Myeloma
Myeloma XI is intended to be a unifying trial addressing issues in patients of all ages and providing a strategy within which to introduce new treatments as they become available.
There are two distinct treatment pathways.
Intensive pathway: for younger/fitter patients where intensive HDT with stem cell support is considered appropriate. Comparing a thalidomide-containing regimen with a lenalidomide-containing regimen, as induction treatment prior to HDT.
Non-intensive pathway: for older/less fit patients where standard-dose chemotherapy is considered appropriate. To compare an attenuated thalidomide-containing regimen with an attenuated lenalidomide-containing regimen.
A phase II randomised trial of carfilzomib, cyclophosphamide and dexamethasone (CCD) vs cyclophosphamide, velcade and dexamethasone (CVD) for first relapse and primary refractory multiple myeloma