Ponatinib as first-line treatment for patients with chronic myeloid leukaemia in chronic phase: A phase 2 study

Preetesh Jain, Hagop Kantarjian, Elias Jabbour, Graciela Nogueras Gonzalez, Gautam Borthakur, Naveen Pemmaraju, Naval Daver, Evguenia Gachimova, Alessandra Ferrajoli, Steven Kornblau, Farhad Ravandi, Susan O'Brien, Jorge Cortes

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Ponatinib has shown efficacy in patients with refractory chronic myeloid leukaemia (CML) and in those with CML with a Thr315Ile mutation. We aimed to investigate the activity and safety of ponatinib as first-line treatment for patients with chronic-phase CML. METHODS: We did a single-arm, phase 2 trial at MD Anderson Cancer Center in Houston, TX, USA. Between May 3, 2012, and Sept 24, 2013, we enrolled patients with early (<6 months) chronic-phase CML and treated them with oral ponatinib once a day. Patients enrolled before July 25, 2013, were given a starting dose of 45 mg per day; we lowered this due to tolerability issues and patients enrolled after this date were given a starting dose of 30 mg per day. After a warning by the US Food and Drug Administration (FDA) in Oct 6, 2013, for vascular complications with ponatinib, we started all patients on aspirin 81 mg daily and reduced the dose of ponatinib to 30 mg or 15 mg per day for all patients. The primary endpoint was the proportion of patients who achieved complete cytogenetic response by 6 months in the per-protocol population. This trial is registered with ClinicalTrials.gov, number NCT01570868. FINDINGS: We enrolled 51 patients. Median follow-up was 20·9 months (IQR 14·9-25·2). 43 patients were started on 45 mg ponatinib every day; eight patients were started on 30 mg per day. 43 (94%) of 46 evaluable patients achieved complete cytogenetic response at 6 months. Most frequent toxicities included skin-related effects (n=35; 69%) and elevated lipase (n=32; 63%). Cardiovascular events (mainly hypertension) occurred in 25 (49%) patients. Grade 3-4 myelosuppression occurred in 15 (29%) patients. Five (10%) patients developed cerebrovascular or vaso-occlusive disease. 43 (85%) patients needed treatment interruptions at some time and 45 (88%) needed dose reductions. The study was terminated June 18, 2014, at the recommendation of the FDA due to concern about the increased risk of thromboembolism with ponatinib. INTERPRETATION: Patients with newly diagnosed CML in chronic phase respond well to treatment with ponatinib, with most achieving a complete cytogenetic response. Dose adjustment, extensive monitoring, and counselling of the patients for thromboembolic events is needed for patients on ponatinib therapy. However, due to the risk of vascular thrombotic events and the availability of alternative options for these patients, other drugs should be considered first in the frontline setting. FUNDING: MD Anderson Cancer Center, National Cancer Institute, ARIAD Pharmaceutical.

Original languageEnglish (US)
Pages (from-to)e376-e383
JournalThe Lancet Haematology
Volume2
Issue number9
DOIs
StatePublished - Jan 1 2015

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Leukemia, Myeloid, Chronic Phase
Therapeutics
Cytogenetics
ponatinib
United States Food and Drug Administration
Leukemia, Myelogenous, Chronic, BCR-ABL Positive
Blood Vessels
Social Adjustment

ASJC Scopus subject areas

  • Hematology

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Ponatinib as first-line treatment for patients with chronic myeloid leukaemia in chronic phase : A phase 2 study. / Jain, Preetesh; Kantarjian, Hagop; Jabbour, Elias; Gonzalez, Graciela Nogueras; Borthakur, Gautam; Pemmaraju, Naveen; Daver, Naval; Gachimova, Evguenia; Ferrajoli, Alessandra; Kornblau, Steven; Ravandi, Farhad; O'Brien, Susan; Cortes, Jorge.

In: The Lancet Haematology, Vol. 2, No. 9, 01.01.2015, p. e376-e383.

Research output: Contribution to journalArticle

Jain, P, Kantarjian, H, Jabbour, E, Gonzalez, GN, Borthakur, G, Pemmaraju, N, Daver, N, Gachimova, E, Ferrajoli, A, Kornblau, S, Ravandi, F, O'Brien, S & Cortes, J 2015, 'Ponatinib as first-line treatment for patients with chronic myeloid leukaemia in chronic phase: A phase 2 study', The Lancet Haematology, vol. 2, no. 9, pp. e376-e383. https://doi.org/10.1016/S2352-3026(15)00127-1
Jain, Preetesh ; Kantarjian, Hagop ; Jabbour, Elias ; Gonzalez, Graciela Nogueras ; Borthakur, Gautam ; Pemmaraju, Naveen ; Daver, Naval ; Gachimova, Evguenia ; Ferrajoli, Alessandra ; Kornblau, Steven ; Ravandi, Farhad ; O'Brien, Susan ; Cortes, Jorge. / Ponatinib as first-line treatment for patients with chronic myeloid leukaemia in chronic phase : A phase 2 study. In: The Lancet Haematology. 2015 ; Vol. 2, No. 9. pp. e376-e383.
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AU - Jain, Preetesh

AU - Kantarjian, Hagop

AU - Jabbour, Elias

AU - Gonzalez, Graciela Nogueras

AU - Borthakur, Gautam

AU - Pemmaraju, Naveen

AU - Daver, Naval

AU - Gachimova, Evguenia

AU - Ferrajoli, Alessandra

AU - Kornblau, Steven

AU - Ravandi, Farhad

AU - O'Brien, Susan

AU - Cortes, Jorge

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N2 - BACKGROUND: Ponatinib has shown efficacy in patients with refractory chronic myeloid leukaemia (CML) and in those with CML with a Thr315Ile mutation. We aimed to investigate the activity and safety of ponatinib as first-line treatment for patients with chronic-phase CML. METHODS: We did a single-arm, phase 2 trial at MD Anderson Cancer Center in Houston, TX, USA. Between May 3, 2012, and Sept 24, 2013, we enrolled patients with early (<6 months) chronic-phase CML and treated them with oral ponatinib once a day. Patients enrolled before July 25, 2013, were given a starting dose of 45 mg per day; we lowered this due to tolerability issues and patients enrolled after this date were given a starting dose of 30 mg per day. After a warning by the US Food and Drug Administration (FDA) in Oct 6, 2013, for vascular complications with ponatinib, we started all patients on aspirin 81 mg daily and reduced the dose of ponatinib to 30 mg or 15 mg per day for all patients. The primary endpoint was the proportion of patients who achieved complete cytogenetic response by 6 months in the per-protocol population. This trial is registered with ClinicalTrials.gov, number NCT01570868. FINDINGS: We enrolled 51 patients. Median follow-up was 20·9 months (IQR 14·9-25·2). 43 patients were started on 45 mg ponatinib every day; eight patients were started on 30 mg per day. 43 (94%) of 46 evaluable patients achieved complete cytogenetic response at 6 months. Most frequent toxicities included skin-related effects (n=35; 69%) and elevated lipase (n=32; 63%). Cardiovascular events (mainly hypertension) occurred in 25 (49%) patients. Grade 3-4 myelosuppression occurred in 15 (29%) patients. Five (10%) patients developed cerebrovascular or vaso-occlusive disease. 43 (85%) patients needed treatment interruptions at some time and 45 (88%) needed dose reductions. The study was terminated June 18, 2014, at the recommendation of the FDA due to concern about the increased risk of thromboembolism with ponatinib. INTERPRETATION: Patients with newly diagnosed CML in chronic phase respond well to treatment with ponatinib, with most achieving a complete cytogenetic response. Dose adjustment, extensive monitoring, and counselling of the patients for thromboembolic events is needed for patients on ponatinib therapy. However, due to the risk of vascular thrombotic events and the availability of alternative options for these patients, other drugs should be considered first in the frontline setting. FUNDING: MD Anderson Cancer Center, National Cancer Institute, ARIAD Pharmaceutical.

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