This phase I/II trial studies the best dose and side effects of venetoclax and how well it works in combination with ixazomib and dexamethasone in treating patients with t(11;14) negative multiple myeloma that has come back or does not respond to treatment. Ixazomib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Drugs used in chemotherapy, such as venetoclax and dexamethasone work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. It is not yet known how well venetoclax works with ixazomib and dexamethasone in treating patients with multiple myeloma.
PRIMARY OBJECTIVES: I. To evaluate the safety profile and tolerability of oral combination therapy with ixazomib citrate (ixazomib) (I), venetoclax (V), dexamethasone (D) in non-t(11;14) relapsed/refractory multiple myeloma (RRMM) with dose-escalating design to determine the maximum tolerated dose (MTD) and recommended phase II dose (RP2D). (Phase I) II. To compare overall response rate (ORR; measured as best response) of IVD and ID in a proteasome inhibitor (PI)-non-refractory cohort. (Phase II, Cohort 1) III. To evaluate ORR of IVD in PI-refractory cohort. (Phase II, Cohort 2) SECONDARY OBJECTIVES: I. To observe and record anti-tumor activity. II. To determine the rate of very good partial response (VGPR) or better. III. To determine time to progression (TTP). IV. To determine duration of response (DOR). V. To determine progression-free survival (PFS). VI. To determine overall survival (OS). EXPLORATORY OBJECTIVES: I. To correlate and predict responses with the following tests, using bone marrow aspirate samples at (a) baseline and (b) during treatment on day 8 (or day 9 to allow for scheduling flexibility): BCL2, NOXA, and MCL1 by flow cytometry; polymerase chain reaction (PCR) for BCL2, BCL2L1 (=BCL-XL), and MCL-1 messenger ribonucleic acid (mRNA) expression, and BCL2:BCL2L1 and BCL2:MCL1 ratios; and Ex vivo Mathematical Myeloma Advisor (EMMA). II. To evaluate the drug exposure and to correlate with toxicities using venetoclax peripheral blood pharmacokinetic (PK) analysis. OUTLINE: This is a phase I, dose-escalation study of venetoclax followed by a phase II study. PI non-refractory patients are randomized to 1 of 2 arms. ARM I: Patients receive ixazomib citrate orally (PO) on days 1, 8, and 15, venetoclax PO once daily (QD) on days 1-28 and dexamethasone PO on days 1, 8, 15, and 22. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. ARM II: Patients receive ixazomib citrate PO on days 1, 8, and 15, and dexamethasone PO on days 1, 8, 15, and 22. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. ARM III: PI-refractory patients receive ixazomib citrate, venetoclax and dexamethasone as Arm I. After completion of study treatment, patients are followed for 30 days.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Maximum tolerated dose/recommended phase II dose (MTD/RP2D) of venetoclax (Phase I)
The MTD is defined as the highest dose level in which 1 or fewer of 6 patients experience a dose limiting toxicity. That dose level is considered the MTD/RP2D.
Time frame: Up to 28 days
Overall response rate (ORR) (Phase II)
For cohort 1, the difference in ORR between the two arms will be tested by using the Cochran-Mantel-Haenszel (CMH) test.
Time frame: Up to 2.5 years
Overall response rate (ORR) (Phase II)
For cohort 2, the ORR will be estimated, and the lower limit of the one-sided 90% confidence interval (CI) will be computed using the Atkinson and Brown method (Atkinson and Brown 1985), which accounts for the nature of a two-stage design.
Time frame: Up to 2.5 years
Very good partial response (VGPR) or better response rate
VGPR or better response rate is defined as the proportion of subjects with documented VGPR or better based on the International Myeloma Working Group criteria. The binomial distribution will be used to calculate the point estimate of the VGPR or better response rate and 95% CI for each study arm. The difference in VGPR or better response rate between two arms in cohort 1 will be assessed by the CMH test.
Time frame: Up to 2.5 years
Time to progression (TTP)
Kaplan-Meier plots will be presented for TTP.
Time frame: From the date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of first documented progressive disease (PD) or death due to multiple myeloma, whichever occurs first, assessed up to 2.5 years
Time to progression (TTP)
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Given PO
The difference between ixazomib, venetoclax, dexamethasone (IVD) and ixazomib, dexamethasone (ID) in cohort 1 will be assessed by the stratified log-rank test.
Time frame: From the date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of first documented PD or death due to multiple myeloma, whichever occurs first, assessed up to 2.5 years
Time to progression (TTP)
The hazard ratio of time-to-event endpoints for IVD versus ID in cohort 1 will be estimated by the stratified Cox proportional hazard regression model.
Time frame: From the date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of first documented PD or death due to multiple myeloma, whichever occurs first, assessed up to 2.5 years
Progression-free survival (PFS)
Kaplan-Meier plots will be presented for PFS.
Time frame: From the date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of first documented PD or death due to any cause, whichever occurs first, assessed up to 2.5 years
Progression-free survival (PFS)
The difference between IVD and ID in cohort 1 will be assessed by the stratified log-rank test.
Time frame: From the date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of first documented PD or death due to any cause, whichever occurs first, assessed up to 2.5 years
Progression-free survival (PFS)
The hazard ratio of time-to-event endpoints for IVD versus ID in cohort 1 will be estimated by the stratified Cox proportional hazard regression model.
Time frame: From the date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of first documented PD or death due to any cause, whichever occurs first, assessed up to 2.5 years
Duration of response (DOR)
Kaplan-Meier plots will be presented for DOR.
Time frame: From the subject's date of first documented response (partial response [PR] or better) to the date of first documented PD or death due to multiple myeloma (MM), whichever occurs first, assessed up to 2.5 years
Duration of response (DOR)
The difference between IVD and ID in cohort 1 will be assessed by the stratified log-rank test.
Time frame: From the subject's date of first documented response (PR or better) to the date of first documented PD or death due to MM, whichever occurs first, assessed up to 2.5 years
Duration of response (DOR)
The hazard ratio of time-to-event endpoints for IVD versus ID in cohort 1 will be estimated by the stratified Cox proportional hazard regression model.
Time frame: From the subject's date of first documented response (PR or better) to the date of first documented PD or death due to MM, whichever occurs first, assessed up to 2.5 years
Overall survival (OS)
Kaplan-Meier plots will be presented for OS.
Time frame: From the subject's date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of death due to any cause, assessed up to 2.5 years
Overall survival (OS)
The difference between IVD and ID in cohort 1 will be assessed by the stratified log-rank test.
Time frame: From the subject's date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of death due to any cause, assessed up to 2.5 years
Overall survival (OS)
The hazard ratio of time-to-event endpoints for IVD versus ID in cohort 1 will be estimated by the stratified Cox proportional hazard regression model.
Time frame: From the subject's date of the first dose of study drug (cohort 2) or date of randomization (cohort 1) to the date of death due to any cause, assessed up to 2.5 years