Increase In Hgb Research Articles

Pharmacodynamics of CNTO 530 and Darbepoetin-α in Human TNF-α Transgenic Mice, a Murine Model of Anemia of Chronic Disease

CNTO 530 and darbepoetin-a are long lived erythropoietin receptor agonists (ERAs). Clinically, anemia of chronic disease (ACD) is associated with increased expression of tumor necrosis factor-a (TNF-a) and mice transgenic for human TNF-a develop ACD. The purpose of this investigation was to compare the effects of these agents in a murine model of ACD. Human TNF-a expressing (Tg 197) mice were administered a single subcutaneous dose of CNTO 530 or darbepoetin-a and the pharmacodynamic response in bone marrow spleen and peripheral blood evaluated. RBC life span and reticulocyte age distribution were also evaluated. CNTO 530 induced a dose responsive increase in reticulocytes, RBCs and Hgb in both wild type and Tg197 mice. Although the reticulocyte response was similar to wild types, the RBC and Hgb response to CNTO 530 in Tg197 mice was blunted. There was no statistically significant difference in RBC life span with either compound. Darbepoetin-α caused a greater peak in % dead Pro/basophilic erythroblasts, greater peak EMH in the spleen and a greater increase in reticulocyte maturation time. In contrast, despite a similar peak increase, CNTO 530 caused a more sustained response of reticulocyte, EMH, RBC and Hgb, consistent with increased exposure. In conclusion, CNTO 530 and darbepoetin-a increased RBC and hemoglobin in a murine model of ACD. Compared to darbepoetin-a, CNTO 530 had a more sustained effect, consistent with increased exposure.

A Phase II Trial of Ofatumumab In Subjects with Waldenstrom's Macroglobulinemia.

A Phase II Trial of Ofatumumab In Subjects with Waldenstrom's Macroglobulinemia.

Erythropoiesis Equivalence, Pharmacokinetics and Immune Response following Repeat Hematide™ Administration in Cynomolgus Monkeys

Hematide is a synthetic PEGylated peptidic erythropoiesis stimulating agent (ESA) that is presently being developed for the correction of anemia in patients with chronic renal failure. Unlike currently marketed ESAs, Hematide does not possess any sequence homology to erythropoietin (EPO) and has not elicited moribund immune responses in animal safety studies thereby allowing the generation of a robust safety package. Animals administered marketed ESAs develop anti-EPO antibodies that null the effect of the administered ESA and neutralize endogenous EPO, resulting in severe anemia that precludes the interpretation of chronic safety studies. The primary objective of this study is to determine whether Hematide-specific antibodies are generated when male monkeys are exposed to high Hematide doses (10 mg/kg, intravenous [IV] and subcutaneous [SC]) administered at frequent dosing intervals (every two weeks) for a total of 9 doses; secondary objectives are to evaluate whether developed antibodies impact pharmacokinetics (PK) and pharmacology. In this study, no Hematide-specific antibodies were detected. Hematide exhibits a prolonged plasma half-life and slow clearance by either IV or SC administration. Hematide induced significant erythropoiesis with reticulocytosis and subsequent increases in red blood cells, hematocrit and hemoglobin (Hgb) levels. No erythropoietic differences were noted between the IV and the SC dosed groups with mean +/- SD Hgb levels of 20.9 +/- 2.5 and 20.3 +/- 2.1 g/dL, respectively, occurring on Day 48, corresponding to Hgb increases of 6.5 and 6.7 g/dL, respectively, over pre-dose levels. In conclusion, Hematide is a potent erythropoiesis stimulating agent that exhibits plasma persistence in monkeys. Similar erythropoietic responses were produced following IV and SC administration. The absence of antibody development suggests that Hematide, at the doses and regimen described, has a low immunogenic potential in cynomolgus monkeys.

Adding Hydroxyurea to Chronic Transfusion Therapy for Stroke in Sickle Cell Disease.

Abstract 4620 IntroductionTransfusions have clearly been shown to prevent stroke in patients with Sickle Cell Disease(SCD). The usual goal of transfusion therapy is to keep the percent sickle Hgb (%S) less than 30. %S greater than 30 has been associated with stroke reoccurance. Inability to transfuse adequately may result from poor vascular access or high hemolytic rate. Hydroxyurea, a drug which requires active erythropoeisis, is usually not given to patients who are chronically transfused. However, the presence of an elevated reticulocyte count in a transfused patient indicates ongoing sickle hematopoiesis. We added Hydroxyurea therapy to two patients who were unable to achieve %S levels less than 30 and who had elevated reticulocyte counts to assess whether this drug could improve their hematological parameters. ResultsWe treated two post stroke patients, one receiving pheresis therapy, and the other on straight transfusion therapy who were unable to achieve 30% Hgb S despite regular transfusions. Patient 1, a 33 y/o female with Hgb SS had been on transfusions since childhood for multiple CVA's and resulting moya-moya. Her last stroke had occurred while she was being chronically transfused and had a % S of 40. Due to venous access issues the patient was receiving straight transfusion only and was unable to adequately suppress her marrow. In 8/07 her %S was greater than 40 and her reticulocyte count was 11.3 %. Hydroxyurea was started at 1500 mg daily(22 mg/kg). Over the next 24 months her Bilirubin dropped from 8.7mg/dl to 1.9 mg/dl, her reticulocyte count dropped to 4%(figure below) and her MCV increased to 104.6 from 90. Her Hgb F rose to 30%.Her %S has not changed. She has remained clinically stable with no new neurological findings. The second patient, a 17 y/o male had been on chronic transfusions since childhood for a stroke which resulted in a dense left hemiparesis. He has been on a pheresis program for 13 years. Despite this his % S remained greater than 40% and had been as high as 60% prepheresis. Hydroxyurea was added in 5/08 at a dose of 25mg/kg. Within 6 months his pretransfusion %S had dropped to 22-27%. No increase in fetal Hgb was detected, possibly due to the exchange transfusion process. His bilirubin, which had been running between 12-16 mg/dl dropped to 7.6-8.9 mg/dl and his reticulocyte count went from an average of 19.6% to 11.2% in the same time frame. He has also remained stable. DiscussionThese two patients demonstrate that the addition of Hydroxyurea to patients on chronic transfusion can be useful in decreasing hemolytic rate and improving the efficacy of transfusions by decreasing sickle erythropoiesis and increasing fetal hemoglobin synthesis. Further studies of the combination of these two modalities may be warranted in those patients who cannot achieve adequate suppression of sickle erythropoeisis. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

A phase I trial of TRU-016, an anti-CD37 small modular immunopharmaceutical (SMIP) in relapsed and refractory CLL

3017 Background: CD37 is a tetraspan family member expressed predominantly on normal and transformed B-cells across a wide range of maturational stages. TRU-016 is a novel humanized anti-CD37 SMIP. Pre-clinical studies have demonstrated CD37 SMIP mediates significantly greater direct and NK-cell mediated killing of CLL cells as compared to other therapeutic antibodies used in CLL. A phase I study with TRU-016 was initiated based upon these data. Methods: Patients with relapsed/refractory CLL or SLL who had adequate organ function, platelets > 30,000/mm3 were eligible. Six doses and two different schedules (cohorts 1–8) have/or will be studied. The planned doses range from 0.03 mg/kg to 10 mg/kg IV once a week for 4 doses (cohort 1–6). The second schedule (cohort 7–8) will test 3.0 or 10.0 mg/kg on days 1, 3, and 5 the first week followed by 3 weekly doses. Dose escalation and de-escalation is based on CTC AE toxicity grades. Results: To date, 10 patients have been enrolled (cohort 1–5) and completed treatment; 1 patient (cohort 1–3: 0.03, 0.1, and 0.3 mg/kg); 3 patients at 1.0 mg/kg, and 4 patients at 3.0 mg/kg. Eight of the 10 have high risk genomic features [del(17p13.1), n=5 and del(11q22.3), n=3]. No dose limiting toxicities or serious adverse events have occurred. Mild (grade 1–2) infusion toxicity has been observed in 3 patients. Beginning with the 0.3 mg/kg dose, all eight patients demonstrated evidence of biological activity including patients with del(17p13.1). Two patients had partial clearing of leukemia cutis, and the other six had 27–94% reduction in peripheral lymphocyte count. One pt. had an increase in Hgb of 40% and a reduction in lymph nodes of 36%. Two patients had a significant increase in platelet count. Enrollment to cohort 6 is complete and further up-to-date data will be presented. Conclusions: To date, TRU-016 is a well tolerated treatment with minimal infusional toxicity and no observed dose limiting toxicity. Encouraging reduction in tumor lymphocyte blood counts, lymph node/spleen size and improvement in normal hematopoeitic function in patients with high risk genomic CLL have already been observed at low, non-saturating doses of CD37. Future single agent and combination studies of Tru16 in CLL are warranted. [Table: see text]

Effect of the response to first-line chemotherapy (chemo) in the chemotherapy-induced anemia control with the administration of Erithropoyetins (Epos) in metastatic non-small cell lung cancer (NSCLC) patients (pt)

e20647 Background: The aim of this retrospective study, is to measure the influence of the tumor control with chemo on the results of the chemo-induced anemia treatment with epos in pts with nsclc, that were non-anemic before chemo, and in whom the only recorded cause of anemia was chemotherapy treatment. cycle. Methods: We analyzed 57 stage IV nsclc pt (21 Squamous, 26 Adenocarcioma, 4 Lare cell, 6 non specified), 41 male, 16 female, 30 with tumor progression (progression) and 27 with partial response (responders). Average age was 60.3 years (CI 95%: 57.2; 63.4). Pt were treated between April 2004 and May 2008. Any patient with disease stabilization was included. 52 pt were treated with platin-gemcitabine, and 5 with cisplatin-paclitaxel. 17 pt received Erithropoyetin-α and 40 darbepoetin. Pt who received radiotherapy as part of their treatment, were excluded of the analysis. Pt began treatment of epos when hemoglobin (hgb) was <12gr/dl. Epos treatment was discontinued if the hgb level increased over 13gr/dl. No patient received epos with the first chemo cycle. Results: Pt with progression began the epos significantly before ( 100% before 4th chemo, 50% in the 2nd cycle) than responders ( 100% before 5th cycle, 7,4% at 2nd cycle) (p<0.001). Pt with progression, had a lower value of hgb at the beginning of the epos (median 9.82 in responders; 8.89 in progression; p=0.009). Recovery of the anemia was observed in 25.9% of the responders front to 3.3% of the pt with progression (p=0.014). No significant differences appeared in the requirements for red-cells transfusion (14.8% responders vs 30% progression; p=0.172). The mean hgb increase by each chemo cycle with epos was of 0.74gr/dl in responders and of 0.25gr/dl in pt with progression (p<0.001 CI 95%: 0.232–0.748 for the odds ratio). The mean absolute hgb increase in responders was singnificanly greater than in pt with progression (1.49 gr/dl vs 0.7 gr/dl p=0.008CI 95% 0.21–1.368 for the difference of the means). Conclusions: From the obtained data, we can conclude that the tumor response can have a direct impact on the efficacy of chemo-induced anemia treatment with epos; and that anemia control may reflect beneath disease control. No significant financial relationships to disclose.

Pharmacodynamics of CNTO 530 in a Murine Model of B-Thalassemia

CNTO 530 is an erythropoietin (EPO) receptor agonist that links two EMP-1 peptides to a MIMETIBODYä scaffold. Here, we characterize the in vivo efficacy of CNTO 530 in a murine model of b-Thalassemia. Hematological analysis confirmed dysregulated erythropoiesis in these mice with decreased red blood cells (RBC), hemoglobin (Hgb), and hematocrit (Hct) indices compared to age matched C57BL/6 littermates. An increase in reticulocytes was also observed concurrent with decreased mean cell volume (MCV) and increased red cell distribution width (RDW) suggesting compensatory erythropoiesis. In addition, splenomegaly was observed consistent with increased hematopoiesis. To test the effectiveness of CNTO 530 in this model, a timecourse study was done comparing treatment with CNTO 530 to darbepoetin-a. A single subcutaneous (s.c.) dose of CNTO 530 at 10,000 U/kg dose stimulated a long-lived, approximately 4 g/dL increase in hemoglobin compared to the less than 1 g/dL, short lived increase in Hgb observed in response to darbepoetin-a at 10,000 U/kg. Mice dosed with CNTO 530 also showed an increase in RBC, Hct, and MCV where darbepoetin-a had no significant effect. Non-thalassemic littermates were also given a single s.c. dose of 10,000 U/kg of CNTO 530 or darbepoetin-a which showed these drugs indeed are efficacious in normal background animals. These results demonstrate that CNTO 530 caused a potent, reproducible and longer-lived response in Hgb than darbepoietin in a model of b-thalassemia.

A Phase I, Single and Fractionated, Ascending‐Dose Study Evaluating the Safety, Pharmacokinetics, Pharmacodynamics, and Immunogenicity of an Erythropoietin Mimetic Antibody Fusion Protein (CNTO 528) in Healthy Male Subjects

The erythropoietin mimetic antibody fusion protein CNTO 528 was developed as a novel antibody fusion protein by constructing an active hematopoietic peptide onto an IgG1-based scaffold. This resulted in a molecule with a long circulating half-life and a prolonged effect of stimulating reticulocyte production and hemoglobin (Hgb) synthesis. To assess the safety, pharmacokinetics, and pharmacodynamics of CNTO 528, the authors gave 44 adult healthy male subjects single or fractionated doses of intravenous CNTO 528 or placebo. CNTO 528 was generally well tolerated. The maximum observed concentration (Cmax) and the area under the concentration versus time curve (AUC) increased in an approximately dose-dependent manner between the 0.09-mg/kg and 0.9-mg/kg doses. The maximum effect on the reticulocyte response occurred approximately 8 to 9 days after administration. A median increase in Hgb (> or =1 g/dL above baseline) was achieved 9 to 10 days after administration, with a maximum effect between 19 and 26 days. Two subjects in the 0.9-mg/kg dose group had elevated Hgb concentrations requiring phlebotomy. In this first-in-human study, CNTO 528 was well tolerated and effective in elevating and maintaining Hgb by at least 1 g/dL following a single intravenous administration, which suggests that an erythropoietin mimetic molecule, such as CNTO 528, may be an effective therapy for patients with anemia.

Bevacizumab-associated erythrocytosis in metastatic renal cell carcinoma (mRCC)

16096 Background: Bevacizumab (Bev), a monoclonal vascular endothelial growth factor (VEGF) antibody, has activity in mRCC. A surrogate biomarker that would accurately predict therapeutic VEGF inhibition and anti-tumor response to Bev would be useful. Preclinical work at our institution revealed that extremely stringent VEGF inhibition in mice and non-human primates resulted in increases in hemoglobin (Hgb) and erythropoietin (Epo). This Epo production originates in the liver, not the kidney, implicating endogenous VEGF as a previously unsuspected repressor of hepatic Epo synthesis and suggests that Hgb and Epo may be non-invasive markers for VEGF inhibition in vivo. We retrospectively reviewed whether erythrocytosis was evident in patients who received Bev as monotherapy or in combination for mRCC. Methods: Ten patients were eligible. Demographic data, history of anemia, baseline Hgb, treatment Hgb levels, response, and confounding factors such as recent chemotherapy, blood transfusions, iron, or growth factor use were assessed. Percent change in baseline Hgb to peak level was calculated. Correlation between the degree of change and progression-free survival (PFS) in responders was evaluated. Results: Patient characteristics: 90% male, median age 61, 60% first-line treatment, 60% bone metastases, 70% baseline anemia. Five patients were on concurrent treatment with sunitinib, sorafenib, or erlotinib. Hgb rose on Bev in 9 patients. The median change in Hgb was 1.4 g/dL (0–2.7). The median percent rise was 12.3% (6.8–22.2%); 10.9% in the monotherapy cohort and 18.6% in the combination group. The median time to initial increase in Hgb was 42 days and 84 days to peak. Best response was disease stabilization in 7 patients. Degree of peak increase correlated with longer PFS: a 5–15% increase yielded a 3.7 month median PFS and a greater than 15% increase corresponded to a 6.5 month median PFS. Conclusions: The majority (90%) experienced erythrocytosis on Bev suggesting a correlative effect. This is the first human study to identify erythrocytosis as a possible consequence of Bev treatment. The correlation between degree of increase in Hgb and longer PFS suggests that Hgb may be useful as a surrogate marker of stringent VEGF inhibition. This relationship warrants validation in a larger patient sample. No significant financial relationships to disclose.

A phase III randomized controlled study comparing iron sucrose intravenously (IV) to no iron treatment of anemia in cancer patients undergoing chemotherapy and erythropoietin stimulating agent (ESA) therapy

9109 Background: The effect of using IV iron sucrose in managing cancer chemotherapy-related anemia has not been previously reported. To investigate this issue, we conducted a randomized study of IV iron sucrose in patients (pts) with cancer chemotherapy-related anemia who completed 8 prior wks of ESA therapy. Methods: This prospective, multicenter, randomized, open label, Phase III clinical trial enrolled 375 pts with chemotherapy induced anemia (Hgb levels = 10.0 g/dL) and was conducted in 2 stages. During Stage I (8-wk duration), pts received treatment with fixed ESA doses (100-mcg of darbepoetin or 40,000 units epoetin wkly or 200 mcg of darbepoetin every other wk). Pts were classified as either ESA responders (= 1 g/dL increase in Hgb) or ESA non-responders with each group randomized (Stage 2) separately to receive either 12 wks of fixed doses of ESA plus up to 1,500 mg of iron sucrose (given in 3 divided doses of up to 500mg) or 12 wks of fixed doses of ESA alone. Laboratories (including iron indices and acute phase reactants), quality of life and adverse events were assessed at baseline and throughout. Results: Iron sucrose plus ESA compared to ESA alone resulted in greater mean maximum Hgb levels and greater number of pts who achieved Hgb increases = 2.0 and ≥ 3.0 g/dl in both prior ESA responders and non-responders. There was also a statistically significant improvement in fatigue and iron stores in the iron sucrose treated pts. Baseline iron status did not predict responsiveness to iron sucrose therapy. Three serious but non-life threatening iron sucrose related adverse events were observed including one case of significant, transient hypotension in a female weighing 50 kg. Conclusions: IV iron sucrose increased Hgb levels and iron stores significantly and is well tolerated in doses up to 500 mg increments in ESA treated patients with cancer chemotherapy- related anemia. IV iron sucrose should be considered in combination with erythropoietic therapy in anemic cancer patients receiving chemotherapy. [Table: see text]

A Randomized Controlled Trial of Oral versus Intravenous Iron in Chronic Kidney Disease

Background: It is unknown whether intravenous iron or oral iron repletion alone can correct anemia associated with chronic kidney disease (CKD). We conducted a randomized multicenter controlled trial in adult anemic, iron-deficient non-dialysis CKD (ND-CKD) patients (≧stage 3) not receiving erythropoiesis-stimulating agents (ESAs). Methods: The participants were randomized to receive either a sodium ferric gluconate complex (intravenous iron) 250 mg i.v. weekly × 4 or ferrous sulfate (oral iron) 325 mg t.i.d. × 42 days. Hemoglobin (Hgb), ferritin and transferrin saturation (TSAT) were measured serially, and the Kidney Disease Quality of Life (KDQoL) questionnaire was administered on days 1 and 43. The primary outcome variable was change from baseline (CFB) to endpoint in Hgb values. Results: Seventy-five patients were analyzed (intravenous iron n = 36, oral iron n = 39). CFB in Hgb was similar in the two groups (intravenous iron 0.4 g/dl vs. oral iron 0.2 g/dl, p = n.s.). However, the increase in Hgb was only significant with intravenous iron (p < 0.01). In comparison to oral iron, intravenous iron achieved greater improvements in ferritin (232.0 ± 160.8 vs. 55.9 ± 236.2 ng/ml, p < 0.001) and TSAT (8.3 ± 7.5 vs. 2.9 ± 8.8%, p = 0.007). Intravenous iron caused greater improvements in KDQoL scores than oral iron (p < 0.05). The most common side effect reported with intravenous iron was hypotension, while constipation was more common with oral iron. Conclusions: Oral and intravenous iron similarly increase Hgb in anemic iron-depleted ND-CKD patients not receiving ESAs. Although in comparison to oral iron, intravenous iron may result in a more rapid repletion of iron stores and greater improvement in quality of life, it exposes the patients to a greater risk of adverse effects and increases inconvenience and cost.

HematideTM, a Synthetic Peptide-Based Erythropoiesis Stimulating Agent (ESA), Assessed for Correction of Anemia in Oncology Patients Receiving Chemotherapy.

Introduction: Hematide™, a novel synthetic PEGylated peptidic compound, binds to and activates the erythropoietin receptor. It is being developed for the treatment of anemia associated with chronic kidney disease and cancer.Objective: To assess the subcutaneous (SC) Hematide™ dose required to increase hemoglobin (Hgb) by ≥1 g/dL in anemic cancer patients on chemotherapy. Safety, PD and PK assessment of Hematide™ are also planned.Method: In an ongoing phase 2, openlabel, multicenter, dosefinding study, Hematide™ is being given SC in 15 patient cohorts every 3 wks for 4 doses. The initial dose is 0.10 mg/kg. Entry criteria include confirmed solid tumor malignancy or lymphoma, ≥9 weeks of chemotherapy, baseline (BL) Hgb ≥8 and <11 g/dL, and adequate iron, folate, and B12 stores.Results: Preliminary results are presented for the 1st cohort. Mean body weight for the 8 female and 7 male patients was 67.8Kg. Nine out of 15 patients completed 12 weeks follow-up. Six patients terminated early for non-study drug related SAEs (2), remission of cancer (1), or transfusions (3, Hgb values posttransfusion excluded from this report) . Week 7: 10 patients completed Week (Wk) 7 with data available. Their mean ± SD Hgb increased from BL by 1.6 ± 1.8 g/dL. Seven had a ≥1.0 g/dL Hgb increase (range 1.7–3.7 g/dL) at Wk 7. Of the remaining 3 patients, 2 had a Hgb increase of 1.65 and 1.1 g/dL, respectively at Wk 9; the 3rd had a Hgb increase of 1.7 g/dL at Wk 12. One patient with missing Wk 7 data had Hgb increases of 1.8 and 3.4 g/dL at Wk 6 and 9 respectively. Week 9: 11 patients had Wk 9 data that show a mean ±SD Hgb increase from baseline of 2.2 ±1.79 g/dL. Of these, 10 had Hgb increases of ≥1.0 g/dL (range 1.1–5.2 g/dL). The one patient who did not have ≥1.0 g/dL Hgb increase at Wk 9 had a Hgb increase of 1.7 g/dL at Wk 12. Four SAEs (none related to study drug) were reported in 3 patients.Conclusion: Preliminary data from the 1st cohort indicate that Hematide™ given every 3 wks appears to be well tolerated and results in an increase in Hgb of ≥ 1g/dL by Wk 7 in the majority of this study population. Additional data will be presented as it becomes available.

A Combination of Rituxan, Cyclophosphamide and Dexamethasone (RCD) Results in Long-Lasting Responses in Autoimmune Anemia and Thrombocytopenia in CLL Patients: A Single Institution Study.

Coombs positive hemolytic anemia (AIHA) and idiopathic thrombocytopenic purpura (ITP) are well-known complications of chronic lymphocytic leukemia(CLL). Both are autoimmune phenomena thought to be byproducts of the immune system dysregulation manifested in patients with CLL. Rituxan, cyclophosphamide and dexamethasone(RCD) are known to effectively target lymphocytes and inhibit autoimmune processes. We present our data analyzing 18 CLL patients with one or both of these autoimmune processes treated with the RCD regimen between 1998 and 3/2006. These patients consisted of 15 with AIHA alone, 2 with both AIHA and ITP and one with ITP alone. The RCD cycle consisted of rituximab 375mg/m2 iv infusion given on day 1, cyclophosphamide 750–1000mg/m2 iv (depending on CLL tumor burden) on day 2, and dexamethasone 12 mg iv on days 1 and 2, and orally days 3 through 7. These cycles were repeated at intervals of 3–4 weeks, depending upon recovery of blood counts. All 18 patients responded to treatment in terms of hgb, platelets or both. For the first episodes of AIHA (n=17) mean starting hgb was 8.1g/dL (range 4.0–12.1) and mean post-treatment hgb was 13.2 g/dL(range 10.0–15.4)(Table 1). The three patients with ITP had a platelet increase from nadirs of 1,000, 1,000 and 14,000 to 408,000, 161,000 and 135,000, respectively. Mean duration of initial response was 22 months (range 6–41). Nine patients relapsed and were retreated with RCD. Again, all 9 responded, and had a mean increase in hgb of 5.1g/dL (range 1.4–7.7) with a mean duration of second response of 16 months(range 3–33). Overall, median survival from initiation of RCD was 70 months (95% CI; 46 to an upper limit not-yet determinable, with follow-up to 8/2006).Of 8 patients with post-treatment Coombs data available for the first episode of AIHA, 4 (50%) converted to Coombs negativity (Table2) and had a mean duration of response of 23.0 months (range 12–41) vs 8.8 months for those who did not convert(range 6–11). In all AIHA episodes (including repeat episodes) with post-treatment Coombs data available (n=18), 6 of 18 (33%) converted to Coombs negativity. The mean duration of response was 19.8 months (range 6–41) for all episodes with conversion to Coombs negativity, vs 7.0 months for those without(range 3–12). This finding that Coombs conversion portends a longer duration of response suggests treatment goals for AIHA should be a conversion to Coombs negative, and not stopped with recovery of hgb.Table 1Hemoglobin response to RCDNMeanStd DeviationMin HgbMaxHgb at start episode 1178.1 g/dL2.14.0 g/dL12.1 g/dLHgb at end episode 11713.2 g/dL1.410.0 g/dL15.4 g/dLHgb delta episode 1175.1 g/dL2.31.7 g/dL10.2 g/dLHgb at start episode 298.4 g/dL2.35.3 g/dL12.2 g/dLHgb at end episode 2913.5 g/dL1.412.3 g/dL16.6 g/dLHgb delta episode 295.1 g/dL2.11.4 g/dL7.7 g/dLTable 2Post-treatment Coombs status and response durationNMean duration of response (in months)Post-treatment Coombs negativity in episode 1422.2 (range 12-41)Post-treatment Coombs positivity in episode 148.8 (range 6-11)Post-treatment Coombs negativity in all episodes619.8 (range 6-41)Post-treatment Coombs positivity in all episodes127.1 (range 3-12)

Long-Term Clinical Benefit of Lenalidomide (Revlimid) Treatment in Patients with Myelodysplastic Syndrome and Chromosome Deletion 5q.

Background: Myelodysplastic syndromes (MDS) are hematological disorders characterized by chronic anemia, and are often refractory to cytokine therapy. Two phase 2 studies evaluating lenalidomide in MDS (MDS-001 and MDS-003), demonstrated a high frequency of erythroid response in patients with a chromosome 5q31 deletion (List AF et al., N Eng J Med 2005; 352:549–557 and List AF et al., in press). Herein we report on the durability of response with long term follow-up approaching 4 years.Methods: All enrolled subjects were evaluated for frequency and duration of red blood cell transfusion independence (RBC-TI), change in hemoglobin (Hgb), pathologic and cytogenetic response, and safety.Results: Ten 5q31- patients achieved a cytogenetic and/or major erythroid response in MDS-001. Four of these patients have maintained a major response for at least 2 years (range 2.2 to 3.7 years). In MDS-003, 99 (67%) of 148 enrolled patients achieved RBC-TI. Of the 99 responders 83 were Low/Int-1, 3 were Int-2/High and 13 were not classified. Median increase in Hgb from baseline to maximum achieved during RBC-TI was 5.4 g/dL (range 1.1, 11.4). The estimated median duration of response was 115.9 weeks, and 52 (53%) of 99 responders remain on study with ongoing RBC-TI response as of 30 June 2006. Duration of response was at least 52 weeks for 63 (64%), 78 weeks for 52 (53%), and 104 weeks for 36 (36%) of 99 responding patients. Variables (or co-variates) associated with longer duration of TI in multivariate analysis included low baseline transfusion requirement (<4 units per 8 wks, p=0.002), 5q- syndrome (p=0.01) and low IPSS (p=0.02) classifications. Among 85 evaluable patients, major cytogenetic responses were achieved in 37 (44%) and minor responses in 24 (28%). Cytogenetic responses occurred in patients with complex karyotypes as well as those with an isolated 5q31 deletion. The frequencies of major and minor cytogenetic responses were similar among patients with and without 5q- syndrome. The most common drug-related adverse events (AE) were Grade 3/4 neutropenia and thrombocytopenia, reported in 87 (59%) and 74 (50%) of 148 patients, respectively although hematologic AEs led to study discontinuation in only 13 (9%) of patients. Pneumonia was the only serious adverse event that occurred in >10% of patients (15/148; 10%). Adverse events were manageable through supportive treatment and dose reduction.Conclusion: Lenalidomide is an effective treatment in MDS patients with an associated chromosome 5q31 deletion, with RBC-TI and major erythroid response maintained for median duration > 2 years.

Long Term Clinical Benefit of Lenalidomide (Revlimid) Treatment in Patients with Myelodysplastic Syndrome without Del 5q Cytogenetic Abnormalities.

Background: MDSs are clonal hematopoietic stem cell malignancies characterized by cytopenias resulting from ineffective hematopoiesis. A phase 2 study of lenalidomide (MDS-002) demonstrated hematological improvement in patients with MDS without an associated deletion 5q cytogenetic abnormality (List AF, et al. Haematologica 2006; 91[suppl1]:379[abst 1032]). We now report multicenter results after 〉2 yrs follow-up.Methods: A total of 214 pts with transfusion-dependent anemia were categorized into the following IPSS MDS risk groups after central review of bone marrow morphology, karyotype, and peripheral blood findings: Low/Int-1 (168 [78%]); Int-2/High (8 [4%]); and unclassified (38 [18%]). Patients were unclassified for missing or inadequate marrow studies for central review (morphology [29] or cytogenetic [7]) or other diagnoses (AML [1], atypical CML [1]). Patients were evaluated for frequency and duration of red blood cell transfusion independence (RBC-TI) (IWG criteria), hemoglobin (Hgb) response, and safety. The starting dose of lenalidomide was 10 mg (daily or daily × 3 wks q28d cycle).Results: Overall, 56 (26%) of 214 enrolled patients achieved RBC-TI. Median time to RBC-TI was 5 wks, median duration of RBC-TI response was 41.0 wks (range, 8.0–136.4), and median Hgb increase achieved during RBC-TI was 3.2 g/dL (range, 1.0–9.8). An additional 36 patients experienced a ≥ 50% reduction in RBC transfusions (overall hematological improvement in 92 [43%] patients). Overall, 47 (22%) patients had an abnormal karyotype at baseline and 9 (19%) patients achieved a cytogenetic response (4 complete). The most common drug-related grade 3/4 adverse events (AEs) were neutropenia and thrombocytopenia (25% and 20%, respectively). Deep vein thrombosis occurred in only 2 (1%) patients. The duration of RBC-TI was ≥ 52 weeks in 21 (38%) patients. Among these 21 patients, 14 (67%) did not require a lenalidomide dose reduction during the first 52 weeks of treatment. Analyses of response variables will be presented. Dose-limiting neutropenia/thrombocytopenia was not reported after 52 weeks. The most commonly reported AEs after 52 weeks were mild-moderate diarrhea and fatigue (38% and 29%, respectively).Conclusion: Lenalidomide is an active, well-tolerated treatment in MDS patients with transfusion-dependent anemia that is not associated with a deletion 5q abnormality. The rate of erythroid hematologic improvement and duration of RBC-TI is encouraging and offers a possible alternative to cytokine therapy.

Chronic Preclinical Safety Evaluation of Hematide™, a PEGylated Peptidic Erythropoiesis Stimulating Agent, in Monkeys.

Hematide, a synthetic PEGylated peptidic compound specifically binds and activates the erythropoietin receptor thereby stimulating erythropoiesis. To support chronic clinical dosing requirements, a comprehensive safety program was undertaken including a 9-month IV Cynomolgus monkey toxicology study. Four groups, composed of 16 male and 16 females in the vehicle-control and high dose groups and 8 male and 8 females in the low and mid-dose groups, received 0, 0.2, 2, and 20 mg/kg Hematide IV Q3W for up to 9 months followed by a 14-week recovery. An interim sacrifice was conducted on days 90 and 195. Clinical observations including ophthalmologic examinations, body weight, and food consumption were recorded. Clinical pathologic evaluations, organ weight, histopathologic, and ECG examinations were performed. Toxicokinetics and anti-Hematide antibodies were also assessed. Unscheduled deaths included 3 high-dose animals on Days 79, 104 and 207. Chronic administration was associated with polycythemia that was time and dose-dependent. There were no gender-related differences. At Day 90, the average Hgb levels for males were 13.9, 17.0, 21.7, and 23.3 g/dL for 0, 0.2, 2.0, and 20 mg/kg, respectively, corresponding to Hgb increases, over controls, of 3.1, 7.8, and 9.4 g/dL. Thereafter, Hgb values maintained peak levels. At Day 279, for the males, the average Hgb levels were 13.7, 15.5, 21.9, and 23.0 g/dL for 0, 0.2, 2.0, and 20 mg Hematide/kg, respectively, corresponding to Hgb increases, over controls, of 1.8, 8.2, and 9.3 g/dL. During the recovery period, hematology values steadily decreased to values more similar to controls. By Day 372, approximately fourteen weeks after the final dose of Hematide, for males, the average Hgb levels were 12.7, and 11.7 g/dL for 0 and 20 mg/kg, respectively. The findings in the three high dose animals that died prior to sacrifice indicated that the cause of death was secondary to hemodynamic changes that were attributed to exaggerated polycythemia induced by very high and repeated Hematide doses. Effects on the micro-vasculature of several organ sections (brain, kidney, liver, lung, spleen, and gastro-intestinal tract) were observed for monkeys dosed at ≥ 2.0 mg/kg. The return to normalcy from suspected test article related lesions was generally complete in monkeys euthanized after a 14-week recovery period for the 20.0 mg/kg group except for effects on choroid plexus and kidneys which were still detectable. Hematide displayed a sustained plasma level following intravenous administration in monkeys. At all dose levels and dosing intervals, increases in AUC values were greater than dose proportional, indicating a deviation from linear kinetics over the dose range studied. Apparent half-life (t1/2) at steady state (Day 106) ranged from ~30 h at the low dose to ~90 h at the high dose. Three of 32 monkeys in the 20 mg/kg group were deemed likely positive for anti-Hematide antibodies but the antibodies were not cross-reactive with erythropoietin. No antibodies were detected in the low and medium dose groups. No difference in pharmacology and toxicology profiles were observed in the 3 antibody-positive monkeys compared to antibody-negative monkeys. In conclusion, Hematide is a potent ESA with prolonged half-life and this study supports chronic clinical administration for the correction of anemia associated with chronic kidney disease and cancer.

Prospective evaluation of epoetin-alfa (EA) vs epoetin-beta (EB) vs darbepoetin (DE) in anemic cancer patients (pts) receiving chemotherapy (CT): Early results of an independent observational survey by the Italian ReVERTO network

18548 Background: Direct comparison of EA vs EB vs DE has never been performed. In order to define the efficacy, impact on quality of life (QL) and pt’s preference, a prospective observational comparison of erythropoietic agents has been carried out. Methods: Anemic pts (hgb &lt;11 gr/dL) scheduled to receive at least 3 cycles of CT were stratified according to 5 factors (platinum-based CT vs non-platinum; hgb ≤9,5 vs &gt;9,5; PS ≤0–1 vs &gt;1; previous CT vs upfront CT; and previous antianemic therapy vs not) and were autonomously assigned by 15 investigators to EA (3 times a week) or EB (3 times a week and only in pts receiving platinum-based CT) or DE (once a week) therapy. Efficacy by hgb level changes and transfusion needing was evaluated after each cycle of CT, QL by Fact-An questionnaire after 1 and 3 cycles of CT, and pt’s preference for standard vs weekly schedule at least once thereafter. Results: From 09/04 to 12/05 177 pts were recruited: 41%, 39% and 20% were assigned to DE, EA and EB, respectively. Severe anemia at baseline (≤9,5) was reported in 29% of pts, whereas 47% received platinum-based CT. Stratifying categories were well balanced among the treatment groups. Baseline mean hgb values were 9.7, 9.9, and 10 for DE, EA and EB, respectively. As of the general population, DE produced higher subsequent mean hgb increase in respect to EA and EB (Mean increase [gr/dL] for DE: 0.84, 1.58, 2.03; EA: 0.34, 0.84, 1.68; EB: 0.76, 1.54, 1.17). No difference was observed neither among pts receiving platinum-based CT, (mean increase: DE: 0.34, 1.76, 2.8; EA: 0.7, 1.27, 2.14; EB: 0.76, 1.54, 1.71) nor among pts with severe anemia at baseline (DE: 0.98, 2, 2.6; EA: 1.24, 1.94, 3.13; EB: 1.25, 2.25, 2.75). Transfusion needing ranged from 7% for DE to 3% for EB without any significant difference. To date 67% of pts completed at least one subsequent QL valuation, whereas 62% gave their preference for treatment schedule. Conclusions: Early results of our prospective analysis show that antianemic therapy with D is at least as effective as standard schedule of EA or EB. Efficacy of DE seems confirmed in pts with bad prognostic categories for anemia. Major data on QL and pt’s preference will be presented. No significant financial relationships to disclose.

Hematide™, a Synthetic Peptide-Based Erythropoiesis Stimulating Agent (ESA), Demonstrates Erythropoietic Activity in a Phase 2 Single Dose, Dose Escalating Study in Patients with Chronic Kidney Disease (CKD).

Hematide is a PEGylated synthetic peptidic ESA that binds to and activates the erythropoietin (EPO) receptor. It has demonstrated potent and sustained dose dependent erythropoietic activity in healthy volunteers (HV).Methods: A randomized double-blind placebo controlled dose escalation study is being conducted to assess safety, pharmacokinetics (PK) and pharmacodynamics (PD) of Hematide administered as a single intravenous (IV) injection in EPO-naïve patients with Chronic Kidney Disease (CKD) pre-dialysis. Cohorts of 9 patients each (7 on Hematide and 2 on placebo) are planned with escalating doses. The results of this study are compared with those of a recently completed Phase 1 dose escalating study of Hematide in 4 cohorts of HV in which the pharmacologically active dose (PAD; i.e., the dose resulting in a statistically and clinically significant increase in hemoglobin) of Hematide was defined.Results: 28 day follow up of the 9 patients in Cohort 1 is complete. As of this date, the study remains blinded and we assume that increases in reticulocytes and hemoglobin (Hgb) are due to Hematide. Injections were well tolerated with no adverse events reported as related to study drug injection. In 7 patients whose reticulocytes increased, counts peaked at 7–10 days with a mean change from baseline of 151.4 ± 18.4 x 109/L before returning within baseline at 21 days post-injection. A Hgb increase was also observed in these 7 patients with a mean difference in change from baseline Hgb between these 7 responding and the 2 non-responding subjects of 0.80 g/dL at Day 10 (p = 0.028) and 1.16 g/dL (p = 0.08) at Day 28 post-injection. The PD profile of these 7 responding patients is comparable to that of the 10 HV receiving a PAD of Hematide. For example, the average maximum Hgb increase from baseline was 1.22 g/dL (SD: 0.37) in patients versus 1.36 g/dL (SD: 0.39) in HV. However, the PAD for CKD patients was half the Hematide dose that was required to obtain a similar Hgb effect in HV. Unblinded results from the complete study, including dose responses, follow-up after 28 days, PK data, additional PD data, EPO levels and iron status assessment will be presented and compared to the results in HV.Conclusion: A single IV injection of Hematide administered to patients with CKD was well tolerated and demonstrated potent and sustained erythropoietic activity of the same magnitude as that observed in HV. The PAD in patients with CKD was half of that observed in HV. These preliminary data suggest that patients with CKD may be more sensitive to Hematide and/or might have a different PK profile compared to HV. The sustained increases in Hgb levels for at least one month following a single dose of Hematide are compatible with anticipated monthly dosing of Hematide to maintain Hgb in target range. This is a reduced frequency of administration compared to that of currently available ESAs. These results serve as a basis to plan studies of repeat doses of Hematide in patients with anemia related to cancer or CKD and this plan will be outlined.

Clinical evaluation and comparison of erythropoietic growth factors for chemotherapy-induced anemia (CIA)

Background CIA is a significant problem in> 50% of cancer pts, impacting quality of life. Our objective was to evaluate & compare the use of epoetin (E) & darbepoetin (D) for CIA at our institution. Methods In this observational study, demographics, doses, hemoglobin (Hgb), transfusions, & chemotherapy use were followed× 12 wks in 108 adults (54 D, 54 E). By an intent to treat analysis, successful clinical response was defined as a Hgb (g/dL) increase≥ 2 or Hgb ≥12 at wk 12. Practice patterns were compared to clinical guidelines. Results The usual starting dose was 200 mcg QOW for D & 40K units Q7D for E. Demographics were similar between groups: mean (SD) age 52(1.4) yr, 57.8% female, 65.6% had solid tumors. Mean (SD) baseline Hgb was 10.2 (1.4) for D, & 10.0 (1.3) for E (p=0.3). At 12 wks, mean (SD) Hgb increase was: D, 1.1 (1.9); E, 0.8 (1.7), p=0.7. In all pts, the mean (SD) 12 wk Hgb was 11.0 (1.5); D, 11.4 (1.6); E, 10.7 (1.4) (p=0.04). The overall clinical response rate at the end of therapy was 38.9% (42.6% D, 35.2% E, p= 0.4). No dose changes occurred with D; 8 E pts were dose escalated. Therapy was rarely discontinued in non-responders. Conclusions The effectiveness of erythropoietic growth factors in clinical practice was lower than reported in clinical trials, due in part to underutilization of clinical guidelines & dose escalations. Both D & E provided equivalent responses in our population. Due to high cost of therapy, future plans are to implement a prospective monitoring program for use of these agents in our institution. Clinical Pharmacology & Therapeutics (2005) 77, P17–P17; doi: 10.1016/j.clpt.2004.11.068

Phase III Prospective Randomized Trial of EPO with or without G-CSF Versus Supportive Therapy Alone in the Treatment of Myelodysplastic Syndromes (MDS): Results of the ECOG- CLSG Trial(E1996).

MDS are a heterogeneous group of clonal disorders characterized by the development of one or more symptomatic cytopenias. We evaluated the role of erythropoietin (EPO) with or without granulocyte colony stimulating factor (G-CSF) for the treatment of anemic patients with MDS. Patients with refractory anemia (RA n=40), RA with ringed sideroblasts( RARS n=36), and RA with excess blasts (RAEB n= 29) were initially randomized to either supportive therapy (ST) or EPO, 150 u/kg/d. Patients on the ST arm could cross over to the EPO arm if after at least a 4 month period of observation they had a ≥ 50% increase in their transfusion requirement. In patients who did not respond to or did not maintain their response to EPO( 150 u/kg) , G-CSF, 1mcg/kg/d was administered in addition to the EPO. Patients who did not respond after 4 months received an increased dose of EPO at 300u/kg/d + G-CSF. Bone marrow studies and iron stores were evaluated before each change in treatment. Response criteria were CR (complete response), GR (good erythroid response), which required a sustained increase of the pre-transfused Hgb value of > 2 g/dl or loss of the transfusion requirement or PR (partial response), defined as a decrease in the transfusion requirement by ≥ 50% or an increase in the Hgb by > 1 g/dl above the pretreatment level. A GR or PR must be sustained for at least 4 months. Transformation to acute leukemia was defined as ≥ 30% blasts in the bone marrow. 118 patients were enrolled , 109( 53 EPO, 56 ST) were eligible and 105 were evaluable for response. The median age was 73 (range 37–88 years). The response rate (CR+GR+PR) in the EPO arm was 35% vs. 9% in the ST arm (p=. 002). Of the 23 patients who crossed over from the ST arm, 30% responded to EPO (GR+PR). Six of 27 patients (22%) who received EPO 150u/kg + G-CSF responded (CR+GR+PR). Ten patients received EPO 300 u/kg + G-CSF and 6(60%) responded (CR+GR+PR). Transformation to acute leukemia occurred in 3.6% and 0% in the supportive therapy and EPO arm respectively( P=.50). A complete response (CR) was documented in 2 patients, 1 each on EPO and EPO+G-CSF. There was a survival difference for patients who had an erythroid response: median survival 53 months for responders vs 26 months for non-responders (p=.009). Neither EPO nor the addition of G-CSF was associated with an increase rate of transformation to acute leukemia. Toxicities were comparable in all the treatment arms. The pretreatment serum EPO level correlated with the response to treatment (P=.004): median EPO of 48 vs. 140 mu/ml for responders versus non-responders. Responses were observed in all subtypes. Responses were greater in RA>RARS>RAEB. In conclusion, EPO administration was associated with a significant increase in Hgb and a decrease in the transfusion requirement in anemic patients with MDS. Low doses of G-CSF + EPO were effective in EPO nonresponsive or refractory patients. In MDS patients EPO + low dose G-CSF was not associated with progression or transformation to acute leukemia.