| Eligibility |
Inclusion Criteria:
- Relapsed/refractory AML (>= 5% blasts in bone marrow or extramedullary leukemia);
adverse cytogenetics, e.g., as defined by the Medical Research Council (MRC)
Prognostic Groupings; secondary AML; organ dysfunction arising from significant
co-morbidities not directly linked to leukemia; Eastern Cooperative Oncology Group
[ECOG] = 2) or not willing to undergo intensive chemotherapy
- Patients must have measurable disease as defined the presence of >= 20% blasts in bone
marrow or extramedullary leukemia
- Eligible patient must show evidence of wild-type (WT) p53 as assessed by DNA
sequencing; note, that since patients with AML have a rapidly proliferating disease,
patient can be enrolled and begin treatment prior to obtaining the results of this
test; patients who are found to the TP53 mutated will be removed from study and can
continue on single agent decitabine; however patients will continue to be followed for
toxicity
- Age >= 18 years; because no dosing or adverse event data are currently available on
the use of KRT-232 (AMG-232) in patients < 18 years of age, children are excluded from
this study, but will be eligible for future pediatric trials
- ECOG performance status =< 2 (Karnofsky >= 60%)
- White blood count =< 25 x 10^9/L
- Total bilirubin < 1.5 x institutional upper limit of normal (ULN) (< 2.0 x ULN for
subjects with documented Gilbert's syndrome or < 3.0 x ULN for subjects for whom the
indirect bilirubin level suggests an extrahepatic source of elevation)
- Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase
[SGOT])/alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) =<
2.5 x ULN
- Alkaline phosphatase < 2.0 x ULN (if liver or bone metastases are present, < 3.0 x
ULN)
- Body surface area (BSA)-normalized creatinine clearance >= 30 mL/min/1.73 m^2 (using
Cockcroft-Gault creatinine clearance [CrCl])
- Prothrombin time (PT) or partial thromboplastin time (PTT) < 1.5 x upper limit of
normal (ULN), OR international normalized ratio (INR) < 1.5
- Patient must be willing to submit the blood sampling and bone marrow sampling for the
PK and PD analyses and exploratory biomarkers
- The effects of KRT-232 (AMG-232) on the developing human fetus are unknown; for this
reason and because decitabine is known to be teratogenic, women of child-bearing
potential must agree to use adequate contraception prior to study entry and for the
duration of study participation through 5 weeks (women) after receiving the last dose
of KRT-232 (AMG-232); should a woman become pregnant or suspect she is pregnant while
she or her partner is participating in this study, she should inform her treating
physician immediately; men treated or enrolled on this protocol must also agree to use
adequate contraception prior to the study, for the duration of study participation,
and 3 months after completion of KRT-232 (AMG-232) administration
- Adequate methods of effective birth control include sexual abstinence (men,
women); vasectomy; or a condom with spermicide (men) in combination with barrier
methods, hormonal birth control or intrauterine device (IUD) (women)
- Ability to understand and the willingness to sign a written informed consent document
- White blood cell (WBC) count =< 25,000/uL before administration of decitabine on cycle
1 day 1; Note: hydroxyurea may be used to control the level of circulating leukemic
blast cell counts to not lower than 10,000/uL during the study
Exclusion Criteria:
- Acute promyelocytic leukemia with t(15;17)(q22;q12) and/or PML-RARA molecular
rearrangement
- Patients with previously untreated AML with core binding factor (CBF) chromosomal
aberrations (inv[16]/t[16;16] or t[8;21]); Note that patients with relapsed or
refractory AML with CBF chromosomal aberrations will be eligible
- Unresolved toxicities from prior anti-tumor therapy, defined as not having resolved to
Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 grade 0 or 1, or to
levels dictated in the eligibility criteria with the exception of alopecia (grade 2 or
3 toxicities from prior antitumor therapy that are considered irreversible [defined as
having been present and stable for > 6 months], such as ifosfamide-related
proteinuria, may be allowed if they are not otherwise described in the exclusion
criteria AND there is agreement to allow by both the investigator and sponsor)
- Patients who are receiving any other investigational agents
- Major surgery within 28 days of study day 1
- Patients with known central nervous system involvement at the time of study entry will
be excluded from this clinical trial because of their poor prognosis and because they
often develop progressive neurologic dysfunction that would confound the evaluation of
neurologic and other adverse events
- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to KRT-232 (AMG-232) or decitabine
- All herbal medicines (e.g., St. John's wort), vitamins, and supplements consumed by
the subject within the 30 days prior to receiving the first dose of KRT-232 (AMG-232)
or venetoclax, and continuing use, if applicable, will be reviewed by the principal
investigator
- Avoid and seek alternatives to the use of KRT-232 with sensitive substrates of CYP3A.
If use of a sensitive CYP3A substrate with KRT-232 cannot be avoided, monitor subjects
closely for toxicity. There is no identified drug-drug interaction potential for
KRT-232 with other CYP enzymes
- Patient must not have received known moderate or strong CYP3A inducers within 7 days
of enrollment; antifungal drugs, including those that are CYP3A inhibitors, are
permitted; as part of the enrollment/informed consent procedures, the patient will be
counseled on the risk of interactions with other agents, and what to do if new
medications need to be prescribed or if the patient is considering a new
over-the-counter medicine or herbal product
- Treatment with medications known to cause corrected QT (QTc) interval prolongation
within 7 days of study day 1 is not permitted unless approved by the principal
investigator; use of ondansetron is permitted for treatment of nausea and vomiting
- Current use of warfarin, factor Xa inhibitors and direct thrombin inhibitors
- Note: Low molecular weight heparin and prophylactic low dose warfarin are
permitted; PT/PTT must meet the inclusion criteria; subjects taking warfarin must
have their INR followed closely
- Uncontrolled intercurrent illness including, but not limited to, active infection,
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or
psychiatric illness/social situations that would limit compliance with study
requirements; patients receiving an anti-microbial agent may be eligible if the
patient remains afebrile and hemodynamically stable for 72 hours; patients with
myocardial infarction within 6 months of study day 1, symptomatic congestive heart
failure (New York Heart Association [NYHA] class III and higher), unstable angina, or
cardiac arrhythmia requiring medication are excluded
- Patients with gastrointestinal (GI) tract disease causing the inability to take oral
medication, malabsorption syndrome, requirement for intravenous alimentation, prior
surgical procedures affecting absorption, uncontrolled inflammatory GI disease (e.g.,
Crohn's disease, ulcerative colitis)
- Patients with history of bleeding diathesis
- Positive hepatitis B surface antigen (HepBsAg) (indicative of chronic hepatitis B),
positive hepatitis total core antibody with negative HBsAG (suggestive of occult
hepatitis B), or detectable hepatitis C virus ribonucleic acid (RNA) by a
polymerase-chain reaction (PCR) assay (indicative of active hepatitis C - screening is
generally done by hepatitis C antibody [HepCAb], followed by hepatitis C virus RNA by
PCR if HepCAb is positive)
- Human immunodeficiency virus (HIV)-patients positive for human immunodeficiency virus
(HIV) are NOT excluded from this study, but HIV-positive patients must have:
- A stable regimen of highly active anti-retroviral therapy (HAART)
- No requirement for concurrent antibiotics or antifungal agents for the prevention
of opportunistic infections
- A CD4 count above 250 cells/mcL and an undetectable HIV viral load on standard
PCR-based test
- Men and women of reproductive potential who are unwilling to practice acceptable
methods of effective birth control while on study through 5 weeks (women) or 3 months
and 1 week (men) after receiving the last dose of KRT-232 (AMG-232); acceptable
methods of effective birth control include sexual abstinence (men, women); vasectomy;
or a condom with spermicide (men) in combination with barrier methods, hormonal birth
control or IUD (women)
- Pregnant women are excluded from this study because KRT-232 (AMG-232) is an agent with
the potential for teratogenic or abortifacient effects; because there is an unknown
but potential risk for adverse events in nursing infants secondary to treatment of the
mother with KRT-232 (AMG-232), breastfeeding should be discontinued if the mother is
treated with KRT-232 (AMG-232); these potential risks may also apply to other agents
used in this study
- Patients with a baseline QTc > 500 msec and patients with a family history of
prolonged QT syndrome
- Patients with known TP53 mutations or chromosome 17 or 17p deletions
- Patients previously treated with azacytidine, decitabine, or venetoclax
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