Study of Imatinib Discontinuation in Chronic Myeloid Leukemia With Deep Molecular Response

Leukemia, Chronic Myeloid Clinical Trial

— EDI-PIO  

Official title:

Pilot Study of Imatinib Discontinuation in Patients With Chronic Myeloid Leukemia With Deep Molecular Response - Evaluation of Pioglitazone in Treatment-free Remission (EDI-PIO)

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT02852486
• Other study ID #: EDI-PIO-UNICAMP
• Status: Active, not recruiting
• Phase: Phase 2
• Start date: June 22, 2016
• Est. completion date: February 2024

Study information

• Verified date: November 2023
• Source: University of Campinas, Brazil
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The purpose of this study is to evaluate treatment-free remission after imatinib discontinuation in patients with chronic myeloid leukemia with deep molecular response. Before discontinuation, patients will receive pioglitazone associated with imatinib during 3 months.

Description:

Treatment of chronic myeloid leucemia (CML) with tyrosine kinase inhibitors (TKIs) changed dramatically the prognosis of CML, with high rates of cytogenetic and molecular remission and increase of overall and progression-free survival. However, the long-term treatment of CML has a high cost to the health system, due to the price of these drugs and the need for continued use. In addition, chronic adverse effects may compromise the quality of life of patients. Discontinuation trials of TKIs have been developed in order to identify groups of patients who may benefit from treatment discontinuation if they have obtained deeper molecular responses.The primary objective of this study is to evaluate treatment free remission (TFR) after imatinib discontinuation in patients treated for more than 3 years with imatinib and with deep molecular response stable for two years (defined in the present study as a molecular response of 4.5 log reduction in breakpoint cluster region (BCR)-Abelson murine leukemia viral oncogene homolog 1(ABL) transcripts levels according to the international scale (MR 4.5; BCR-ABL/ABL ratio < or = 0.0032%). Patients with these criteria will receive pioglitazone for 3 months concomitant with imatinib, prior to discontinuation. After imatinib discontinuation, patients will be evaluated by molecular assessment of BCR-ABL transcripts levels by quantitative real time polymerase chain reaction (RQ-PCR) monthly during the first year, every 2 months in the second year and then every 3 months. The criteria for restarting treatment will be the loss of major molecular response (MMR), documented by a single RQ-PCR test > 0.1%, or confirmed loss of 4 log reduction molecular response (MR4.0), by 2 consecutive RQ-PCR tests > 0.01%.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 31
• Est. completion date: February 2024
• Est. primary completion date: February 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• CML in chronic phase
• treatment with imatinib for 3 or more years
• MR4.5 (RQ-PCR< ou =0.0032%) confirmed by 4 RQ-PCR tests for BCR-ABL in the last 2 years (2 tests within the last 6 months)
• Eastern Cooperative Oncology Group Performance Status (ECOG) 0-2
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) = 2.5 reference level
• Bilirubins = 1.5 reference level
• Contraceptive precautions for women

Exclusion Criteria:

• Patients less than 18 years
• Severe organ disfunction (liver or kidney)
• Severe cardiovascular disease: grade I-IV from New York Heart Association (NYHA) or acute myocardial infarction in the last six months, symptomatic arrhythmias
• Fluid retention grade 3 or 4
• Osteoporosis in treatment
• Patients with previous CML in accelerated or blast phase or blast or Philadelphia positive (Ph+) acute lymphoid leukemia (ALL)
• BCR-ABL mutations related to resistance
• Previous allogeneic bone marrow transplantation

Related Conditions & MeSH terms

• Leukemia
• Leukemia, Chronic Myeloid
• Leukemia, Myelogenous, Chronic, BCR-ABL Positive

Intervention

Drug:
• Pioglitazone 30 Mg Oral Tablet
30 mg/day, orally, for 3 months, before imatinib discontinuation

Other:
• imatinib discontinuation
imatinib discontinuation after 3 months of pioglitazone

Locations

Country	Name	City	State
Brazil	Centro de Hematologia e Hemoterapia - Universidade Estadual de Campinas	Campinas	SP

Sponsors (1)

Lead Sponsor	Collaborator
University of Campinas, Brazil

Country where clinical trial is conducted

Brazil, 

References & Publications (15)

Branford S, Yeung DT, Ross DM, Prime JA, Field CR, Altamura HK, Yeoman AL, Georgievski J, Jamison BA, Phillis S, Sullivan B, Briggs NE, Hertzberg M, Seymour JF, Reynolds J, Hughes TP. Early molecular response and female sex strongly predict stable undetectable BCR-ABL1, the criteria for imatinib discontinuation in patients with CML. Blood. 2013 May 9;121(19):3818-24. doi: 10.1182/blood-2012-10-462291. Epub 2013 Mar 20. — View Citation

Cross NC, White HE, Muller MC, Saglio G, Hochhaus A. Standardized definitions of molecular response in chronic myeloid leukemia. Leukemia. 2012 Oct;26(10):2172-5. doi: 10.1038/leu.2012.104. Epub 2012 Apr 16. — View Citation

Experts in Chronic Myeloid Leukemia. The price of drugs for chronic myeloid leukemia (CML) is a reflection of the unsustainable prices of cancer drugs: from the perspective of a large group of CML experts. Blood. 2013 May 30;121(22):4439-42. doi: 10.1182/blood-2013-03-490003. Epub 2013 Apr 25. — View Citation

Falchi L, Kantarjian HM, Wang X, Verma D, Quintas-Cardama A, O'Brien S, Jabbour EJ, Ravandi-Kashani F, Borthakur G, Garcia-Manero G, Verstovsek S, Burger JA, Luthra R, Cortes JE. Significance of deeper molecular responses in patients with chronic myeloid leukemia in early chronic phase treated with tyrosine kinase inhibitors. Am J Hematol. 2013 Dec;88(12):1024-9. doi: 10.1002/ajh.23560. Epub 2013 Sep 12. — View Citation

Gambacorti-Passerini C, Antolini L, Mahon FX, Guilhot F, Deininger M, Fava C, Nagler A, Della Casa CM, Morra E, Abruzzese E, D'Emilio A, Stagno F, le Coutre P, Hurtado-Monroy R, Santini V, Martino B, Pane F, Piccin A, Giraldo P, Assouline S, Durosinmi MA, Leeksma O, Pogliani EM, Puttini M, Jang E, Reiffers J, Piazza R, Valsecchi MG, Kim DW. Multicenter independent assessment of outcomes in chronic myeloid leukemia patients treated with imatinib. J Natl Cancer Inst. 2011 Apr 6;103(7):553-61. doi: 10.1093/jnci/djr060. Epub 2011 Mar 21. Erratum In: J Natl Cancer Inst. 2016 Sep;108(9). pii: djw211. doi: 10.1093/jnci/djw211. Piazza, Rocco [added]. — View Citation

Mahon FX, Rea D, Guilhot J, Guilhot F, Huguet F, Nicolini F, Legros L, Charbonnier A, Guerci A, Varet B, Etienne G, Reiffers J, Rousselot P; Intergroupe Francais des Leucemies Myeloides Chroniques. Discontinuation of imatinib in patients with chronic myeloid leukaemia who have maintained complete molecular remission for at least 2 years: the prospective, multicentre Stop Imatinib (STIM) trial. Lancet Oncol. 2010 Nov;11(11):1029-35. doi: 10.1016/S1470-2045(10)70233-3. Epub 2010 Oct 19. — View Citation

Prost S, Relouzat F, Spentchian M, Ouzegdouh Y, Saliba J, Massonnet G, Beressi JP, Verhoeyen E, Raggueneau V, Maneglier B, Castaigne S, Chomienne C, Chretien S, Rousselot P, Leboulch P. Erosion of the chronic myeloid leukaemia stem cell pool by PPARgamma agonists. Nature. 2015 Sep 17;525(7569):380-3. doi: 10.1038/nature15248. Epub 2015 Sep 2. — View Citation

Rea D, Rousselot P, Guilhot J, Guilhot F, Mahon FX. Curing chronic myeloid leukemia. Curr Hematol Malig Rep. 2012 Jun;7(2):103-8. doi: 10.1007/s11899-012-0117-2. — View Citation

Ross DM, Branford S, Seymour JF, Schwarer AP, Arthur C, Bartley PA, Slader C, Field C, Dang P, Filshie RJ, Mills AK, Grigg AP, Melo JV, Hughes TP. Patients with chronic myeloid leukemia who maintain a complete molecular response after stopping imatinib treatment have evidence of persistent leukemia by DNA PCR. Leukemia. 2010 Oct;24(10):1719-24. doi: 10.1038/leu.2010.185. Epub 2010 Sep 2. — View Citation

Ross DM, Branford S, Seymour JF, Schwarer AP, Arthur C, Yeung DT, Dang P, Goyne JM, Slader C, Filshie RJ, Mills AK, Melo JV, White DL, Grigg AP, Hughes TP. Safety and efficacy of imatinib cessation for CML patients with stable undetectable minimal residual disease: results from the TWISTER study. Blood. 2013 Jul 25;122(4):515-22. doi: 10.1182/blood-2013-02-483750. Epub 2013 May 23. — View Citation

Rousselot P, Charbonnier A, Cony-Makhoul P, Agape P, Nicolini FE, Varet B, Gardembas M, Etienne G, Rea D, Roy L, Escoffre-Barbe M, Guerci-Bresler A, Tulliez M, Prost S, Spentchian M, Cayuela JM, Reiffers J, Chomel JC, Turhan A, Guilhot J, Guilhot F, Mahon FX. Loss of major molecular response as a trigger for restarting tyrosine kinase inhibitor therapy in patients with chronic-phase chronic myelogenous leukemia who have stopped imatinib after durable undetectable disease. J Clin Oncol. 2014 Feb 10;32(5):424-30. doi: 10.1200/JCO.2012.48.5797. Epub 2013 Dec 9. — View Citation

Rousselot P, Huguet F, Rea D, Legros L, Cayuela JM, Maarek O, Blanchet O, Marit G, Gluckman E, Reiffers J, Gardembas M, Mahon FX. Imatinib mesylate discontinuation in patients with chronic myelogenous leukemia in complete molecular remission for more than 2 years. Blood. 2007 Jan 1;109(1):58-60. doi: 10.1182/blood-2006-03-011239. Epub 2006 Sep 14. — View Citation

Takahashi N, Kyo T, Maeda Y, Sugihara T, Usuki K, Kawaguchi T, Usui N, Okamoto S, Ohe Y, Ohtake S, Kitamura K, Yamamoto M, Teshima H, Motoji T, Tamaki T, Sawada K, Ohyashiki K. Discontinuation of imatinib in Japanese patients with chronic myeloid leukemia. Haematologica. 2012 Jun;97(6):903-6. doi: 10.3324/haematol.2011.056853. Epub 2011 Dec 16. — View Citation

Wang T, Xu J, Yu X, Yang R, Han ZC. Peroxisome proliferator-activated receptor gamma in malignant diseases. Crit Rev Oncol Hematol. 2006 Apr;58(1):1-14. doi: 10.1016/j.critrevonc.2005.08.011. Epub 2006 Jan 18. — View Citation

Yhim HY, Lee NR, Song EK, Yim CY, Jeon SY, Shin S, Kim JA, Kim HS, Cho EH, Kwak JY. Imatinib mesylate discontinuation in patients with chronic myeloid leukemia who have received front-line imatinib mesylate therapy and achieved complete molecular response. Leuk Res. 2012 Jun;36(6):689-93. doi: 10.1016/j.leukres.2012.02.011. Epub 2012 Mar 5. — View Citation

* Note: There are 15 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Treatment-free remission after imatinib discontinuation	Treatment-free remission time after imatinib discontinuation in patients with CML treated with pioglitazone for 3 months before imatinib discontinuation. Calculated from the date of imatinib discontinuation until imatinib reintroduction	Through study completion (five years)
Primary	Number of participants with treatment-related adverse events as assessed by CTCAE v4.0	assessment of number of participants with treatment-related adverse events as assessed by CTCAE v4.0 during the 3 months of treatment with imatinib and pioglitazone	3 months
Secondary	proportion of patients with MMR, MR4.0, MR4.5	Proportion of patients with MMR, MR4.0 and MR4.5 at 3, 6 and 12 months after imatinib discontinuation	3, 6 and 12 months
Secondary	Time from imatinib discontinuation until loss of MMR	Time measured from the date of imatinib discontinuation until the date of loss of MMR, in days	Through study completion (five years)
Secondary	Rate of loss of complete cytogenetic response	% of patients who lost complete cytogenetic response	Through study completion (five years)
Secondary	Time to reach MMR after restarting imatinib	Time measured from the date of the reestart of imatinib until the achievement of MMR, days	Through study completion (five years)
Secondary	Overall survival after imatinib discontinuation	Overall survival is calculated from the date of imatinib discontinuation until the date of death by any cause	Through study completion (five years)
Secondary	Progression-free survival after imatinib discontinuation	PFS is calculated from the date of imatinib discontinuatio until the date of progression of the disease	Through study completion (five years)
Secondary	Event-free survival after imatinib discontinuation	Event-free is calculated from the date of imatinib discontinuation until the date of loss of complete hematologic response, disease progression or death	Through study completion (five years)
Secondary	Molecular relapse free survival	Calculated from the date of imatinib discontinuation until de loss of major molecular response	Through study completion (five years)