Menin-Inhibitor Targeted Maintenance in AML

Phase 2Not Yet RecruitingNCT07563010

Center for International Blood and Marrow Transplant Research144 enrolled

Overview

Revumenib is a first in class oral menin inhibitor that targets a central oncogenic dependency shared across KMT2Ar, NPM1m, and NUP98r AML. In addition to suppressing leukemogenic transcriptional programs and promoting leukemic differentiation, menin inhibition has been shown to modulate epigenetic states linked to antigen presentation and immune recognition. These properties provide a strong biological rationale for evaluating revumenib as maintenance therapy following alloHCT, with the goal of suppressing residual leukemic clones while preserving or enhancing GVL activity during immune reconstitution.

Menin is a critical cofactor for oncogenic transcriptional programs in AML subsets driven by KMT2A rearrangements, NPM1 mutations, and NUP98 rearrangements. The interaction between menin and KMT2A promotes aberrant expression of HOX and MEIS genes, maintaining leukemic self-renewal and blocking differentiation. Revumenib is a potent, selective, oral small-molecule inhibitor of the menin-KMT2A interaction that has demonstrated clinical activity in relapsed or refractory AML. Beyond its direct anti-leukemic effects, emerging preclinical data indicate that menin inhibition may favorably modulate leukemia-immune interactions in the post-transplant environment. Menin inhibition has been shown to induce myeloid differentiation and increase expression of antigen presentation machinery, including MHC class II, in KMT2Ar and NPM1m AML. This effect is mediated through activation of interferon-related signaling pathways and results in enhanced recognition of leukemia cells by donor T cells. In parallel, menin inhibition has been shown to augment donor T-cell effector function and reduce T-cell exhaustion, collectively strengthening the GVL response without directly increasing alloreactivity against normal tissues. Findings suggest that revumenib may function as a dual-mechanism maintenance therapy following allo-HCT which includes 1) suppressing residual leukemic clones by disrupting menin-dependent transcriptional programs, and 2) enhancing immune-mediated leukemia control by improving leukemia immunogenicity and donor T-cell function. Importantly, revumenib is orally administered and has a manageable and well-characterized safety profile, making it suitable for prolonged administration in the post-transplant setting with appropriate monitoring.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Aged ≥18 years at the time of signing informed consent 2. Able to provide written informed consent personally or via a legally authorized representative in accordance with applicable regulatory and institutional requirements 3. Willing and able to comply with all study procedures and available for the duration of the study 4. Diagnosis of acute myeloid leukemia (AML) in complete morphologic remission with one of the following molecular abnormalities: 1. KMT2A-rearranged (KMT2Ar) AML 2. Excluding KMT2A partial tandem duplication (KMT2A-PTD) 3. NPM1-mutated (NPM1m) AML 4. Including FLT3-ITD or TKD co-mutation 5. NUP98-rearranged (NUP98r) AML 5. Planned first allogeneic hematopoietic cell transplantation (allo-HCT) for AML. 6. Transplant Characteristics 1. Planned allo-HCT using bone marrow or peripheral blood stem cell graft source. 2. Planned reduced-intensity/non-myeloablative conditioning (RIC/NMA) or myeloablative conditioning (MAC), using a conditioning regimen permitted- by the protocol and consistent with standard clinical practice, meeting CIBMTR criteria for conditioning intensity 7. Planned donor: 1. HLA-matched related donor (5/6 or 6/6) 2. Matched unrelated donor (8/8) 3. Mismatched unrelated donor (7/8) 4. Haploidentical donor meeting institutional requirements 8. Performance Status: 1. Karnofsky Performance Status ≥70%. 2. Left ventricular ejection fraction (LVEF) by transthoracic echocardiogram (TTE) or multigated acquisition (MUGA) with no clinical evidence of heart failure: * RIC/NMA: ≥50% * MAC: ≥5 9. Pulmonary function meeting the following criteria, without supplemental oxygen other than CPAP: 1. RIC/NMA: DLCO (corrected for hemoglobin) and FEV1 ≥40% predicted 2. MAC: DLCO and FEV1 ≥50% predicted 10. Estimated creatinine clearance (CrCl) ≥45mL/min calculated using the Cockcroft-Gault formula or 24-hour urine collection, consistent with standard eligibility criteria for allogeneic HCT recipients. 11. Liver function acceptable per local institutional guidelines for allo-HCT eligibility. 12. Reproductive Status: Willingness to use contraception in accordance with local regulations from first study intervention through the required contraceptive period Willingness to use contraception in accordance with local regulations from first study intervention through the required contraceptive period Exclusion Criteria: 1. Disease Status a. Evidence of active AML prior to HCT, assessed within 42 days before transplant, defined as any of the following: * ≥5% bone marrow blasts * Circulating blasts within 14 days before conditioning * CNS or other extramedullary disease 2. Other active malignancy that, in the investigator's judgment, could interfere with safety or efficacy assessment 3. Treatment with non-protocol antileukemic therapy (donor lymphocyte infusion for relapse prophylaxis or treatment will be considered an EFS event) 4. Cardiac / QT Risk 1. Requirement for concomitant medications known to prolong QT/QTc interval, except low-risk agents used as standard supportive care 2. Diagnosis or suspicion of Long QT syndrome, or a family history of Long QT syndrome 3. QTcF \>450 msec. 4. History within 6 months of study entry of: * Myocardial infarction * Unstable angina * Congestive heart failure (NYHA Class ≥ II) * Life-threatening or uncontrolled arrhythmia * Cerebrovascular accident or transient ischemic attack 5. Chronic respiratory disease requiring continuous supplemental oxygen, or other significant organ dysfunction that would adversely affect study participation. 6. Active, uncontrolled infection, including any of the following: 1. Active, uncontrolled systemic fungal, bacterial, or viral infection within 14 days prior to the start of conditioning 2. Any other documented active, uncontrolled infection at the start of conditioning 3. Chronic viral infections with evidence of active disease, including: * HIV: detectable viral load within 6 months prior to screening * Hepatitis B Hepatitis C: positive HCV antibody with detectable HCV RNA 7. Planned HCT using cord blood, ex vivo T cell depletion, engineered grafts, or experimental graft sources 8. Malabsorption syndrome or GI condition that precludes oral administration, including: 1. Inability to swallow oral medications 2. Prior gastric bypass or severe gastroparesis d. Cirrhosis with Child-Pugh Class B or C 9. Pregnant or breastfeeding 10. Prior intolerance to menin inhibitor therapy resulting in ≥ Grade 3 treatment-related adverse events 11. Any condition, therapy, laboratory abnormality, or allergy to excipients that, in the investigator's judgment, could confound study results, interfere with the participant's ability to comply with study procedures or complete the study, or make participation not in the participant's best interest.

Outcomes

Primary Outcomes

Relapse Free Survival (RFS) in KMT2Ar, NPM1m, and NUP98r acute leukemias in the Intent-to-Treat (ITT) population with a minimum of 1 year of follow-up post-randomization

RFS is defined as the time from randomization to the date of relapse or the date of death from any cause, whichever comes first. RFS is defined as the time from randomization to the date of relapse or the date of death from any cause, whichever comes first.

Time frame: From date of randomization until relapse, assessed up to 13 months

Secondary Outcomes

RFS in the modified ITT (mITT) population

relapse free survival in modified intent to treat population

Time frame: From date of randomization until relapse, assessed up to 13 months

Overall survival (OS) in the ITT population

Overall survival rate in the intent to treat population

Time frame: From date of randomization until death, assessed up to 13months

Relapse incidence in the ITT population

Incidences of relapses in intent to treat patient population

Time frame: From date of randomization to the first incident of relapse, assessed up to 13 months

Event free survival (EFS) in the ITT population

Time from the date randomization to the date of a event such as relapse/progression, death from any cause, graft failure, use of donor lymphocyte infusion

Time frame: From date of randomization to first event of relapse or disease progression, assessed up to 13 months

Non-relapse mortality (NRM) in the ITT population

Death in patients in the absence of disease progression or relapse

Time frame: From date of randomization to death unrelated to relapse, assessed up to 13 months

Frequency, duration, and severity of Treatment-Emergent Adverse Events (TEAEs), Treatment-Related Adverse Events (TRAEs), Adverse Events of Special Interest (AESIs), and Serious Adverse Events (SAEs) in the Safety Analysis population

Documentation of number of treatment related of adverse events; their frequencies, duration, and severity

Time frame: From date of randomization to end of treatment, assessed up to 13 months

Incidence of clinically significant clinical laboratory abnormalities and shifts from baseline to the worst post-baseline grade in the Safety Analysis population

Documentation of clinically significant clinical laboratory abnormalities occurred from baseline.