Daratumumab-Based Therapy for the Treatment of Newly Diagnosed Multiple Myeloma With Kidney Failure
Daratumumab-Based Therapy for the Treatment of Newly Diagnosed Multiple Myeloma With Kidney Failure
This phase II trial studies how well daratumumab-based therapy works in treating patients
 with newly diagnosed multiple myeloma with kidney failure. Daratumumab-based therapy includes
 daratumumab, bortezomib, dexamethasone, and thalidomide or lenalidomide. Daratumumab is a
 monoclonal antibody that may interfere with the ability of cancer cells to grow and spread.
 Bortezomib is a drug that prevents myeloma cells from getting rid of their waste products,
 leading to being targeted for death. Dexamethasone is a steroid that is commonly used, either
 alone or in combination with other drugs, to treat multiple myeloma. Lenalidomide and
 thalidomide may stop the growth of multiple myeloma by blocking the growth of new blood
 vessels necessary for tumor growth. Giving daratumumab, bortezomib, dexamethasone, and
 thalidomide or lenalidomide may be a good way to treat patients with newly diagnosed multiple
 myeloma with kidney failure.
PRIMARY OBJECTIVE:

 I. To determine the proportion of patients with newly diagnosed myeloma and acute kidney
 injury (AKI) who have renal function recovery following 2 cycles (6 weeks) of treatment with
 a daratumumab-based induction regimen.

 SECONDARY OBJECTIVES:

 I. Overall response rate at the end of 2 and 4 cycles of therapy. II. Adverse event profile
 of the combination in patients with AKI. III. Pharmacokinetic parameters of maximum
 concentration (Cmax), area under the curve (AUC), time to maximum concentration (tmax),
 clearance, and half life (t1/2) of daratumumab in combination treatment in the AKI
 population.

 IV. Global assessment of renal function at cycle initiation including creatinine clearance
 (CrCl).

 V. Timeline of changes in pharmacodynamic markers of light chains, urine paraprotein, and
 serum paraprotein measures.

 OUTLINE:

 Patients receive daratumumab intravenously (IV) weekly of cycles 1-3 and on day 1 only of
 cycle 4, bortezomib subcutaneously (SC) on days 1, 4, 8, and 11, and dexamethasone IV or
 orally (PO) on days 1-4 of cycle 1 and on day 1 of cycles 2-4 and PO on days 8 and 15 of all
 cycles. Beginning cycle 2, patients may also receive lenalidomide PO daily on days 1-14 or
 thalidomide PO once daily (QD) on days 1-21. Treatment repeats every 21 days for 4 cycles in
 the absence of disease progression or unacceptable toxicity.

 After completion of study treatment, patients are followed up for 30 days.
Inclusion Criteria:

 -  Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0-2

 -  Creatinine clearance < 30 mL/min by Cockcroft-Gault (C-G), 24 hour urine collection or
 the Modification of Diet in Renal Disease (MDRD) methods. The same method used for
 inclusion will be used for renal response assessment

 -  Documented multiple myeloma as defined by the International Myeloma Working Group
 (IMWG) 2014 criteria including: Clonal bone marrow plasma cells >= 10%. In addition,
 the patient must meet one of the criteria in day (d)1 or d2:

 -  Evidence of end organ damage that can be attributed to the underlying plasma cell
 proliferative disorder, specifically (one or more of the following):

 -  Hypercalcemia: serum calcium > 0.25 mmol/L (> 1 mg/dL) higher than the upper
 limit of normal (ULN) or > 2.75 mmol/L (>11 mg/dL)

 -  Renal insufficiency: creatinine clearance (CrCl) < 30 mL/min

 -  Anemia: hemoglobin value of > 2 g/dL below the lower limit of normal, or a
 hemoglobin value < 10 g/L

 -  Bone lesions: 1 or more osteolytic lesions on skeletal radiography, computed
 tomography (CT), or magnetic resonance imaging (MRI)

 -  Measurable disease as defined by any of the following:

 -  Serum M-protein level >= 1.0 g/dL or urine M-protein level >= 200 mg/24 hours.

 -  Note: All attempts should be made to determine eligibility of the subject
 based on the central laboratory results of screening blood and urine
 M-protein measurements. In exceptional circumstances, the local laboratory
 results for blood and urine M-protein measurements may be used to determine
 eligibility, but only if the results are clearly (e.g., 25% or more) above
 the thresholds for measurability; or

 -  IgA, IgD, IgE, or IgM multiple myeloma: serum M-protein level >= 0.5 g/dL or
 urine M-protein level >= 200 mg/24 hours; or

 -  Light chain multiple myeloma without measurable disease in the urine: serum Ig
 free light chain (FLC) >= 10 mg/dL and abnormal serum Ig kappa/lambda FLC ratio

 -  Prior treatment to stabilize the patient with steroids up to 160 mg IV equivalents of
 dexamethasone is allowed

 -  Prior treatment to stabilize the patient with bortezomib up to 2 doses of 1.3 mg/m^2
 each dosing equivalent is allowed

 -  Subject agrees to refrain from blood donations during therapy on study and for 8 weeks
 after therapy is completed

 -  Female patients who:

 -  Are postmenopausal for at least 1 year before the screening visit, OR

 -  Are surgically sterile, OR

 -  If they are of childbearing potential, agree to practice 2 effective methods of
 contraception, at the same time, from the time of signing the informed consent
 form through 90 days after the last dose of study drug, OR

 -  Agree to practice true abstinence when this is in line with the preferred and
 usual lifestyle of the subject. (Periodic abstinence [e.g., calendar, ovulation,
 symptothermal, post-ovulation methods] and withdrawal are not acceptable methods
 of contraception.)

 -  Are planning to donate eggs during the period of study and up to 3 months after
 the last dose of study drug

 -  Females of childbearing potential (FCBP) must have a negative serum or urine
 pregnancy test with a sensitivity of at least 50 mIU/mL within 10 - 14 days prior
 to and again within 24 hours of starting study drugs

 -  Male patients, even if surgically sterilized (i.e., status post-vasectomy), must agree
 to one of the following:

 -  Agree to practice effective barrier contraception during the entire study
 treatment period and through 90 days after the last dose of study drug, OR

 -  Agree to practice true abstinence when this is in line with the preferred and
 usual lifestyle of the subject. (Periodic abstinence (e.g., calendar, ovulation,
 symptothermal, post-ovulation methods] and withdrawal are not acceptable methods
 of contraception.)

 -  Agree to no sperm donation during the period of study and up to 3 months after
 the last dose of study drug

 Exclusion Criteria:

 -  Diagnosed with smoldering multiple myeloma (MM), monoclonal gammopathy of undetermined
 significance, Waldenstrom's macroglobulinemia, polyneuropathy, organomegaly,
 endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome, amyloidosis
 or primary or secondary plasma cell leukemia

 -  Participant has >= grade 3 peripheral neuropathy, or grade 2 with pain on clinical
 examination within 21 days before initiation of protocol therapy

 -  Plasmapheresis within 28 days

 -  Platelet count =< 75,000 cells/mm^3 at time of screening evaluation. Platelet
 transfusions to help patients meet eligibility criteria are not allowed within 3 days
 before study enrollment

 -  Participants with an absolute neutrophil count (ANC) =< 1000 cells/mm^3 at time of
 screening evaluation. Growth factors may not be used to meet ANC eligibility criteria
 within 14 days of obtaining screening evaluation

 -  Participants with hemoglobin level < 7.0 g/dL, at time of screening. Transfusion may
 be used to meet eligibility criteria within 7 days of obtaining screening evaluation

 -  Participants with hepatic impairment, defined as bilirubin >= 1.5 x institutional
 upper limit of normal (ULN) or aspartate aminotransferase (AST) (serum
 glutamic-oxaloacetic transaminase [SGOT]), alanine aminotransferase (ALT) (serum
 glutamate pyruvate transaminase [SGPT]), or alkaline phosphatase >= 3 x institutional
 ULN, within 21 days of initiation of protocol therapy

 -  Patients may be receiving concomitant therapy with bisphosphonates and low dose
 corticosteroids (e.g., prednisone up to but no more than 10 mg p.o. once daily [q.d.]
 or its equivalent) for symptom management and comorbid conditions. Doses of
 corticosteroid should be stable for at least 7 days prior to study treatment.)

 -  Steroids more than 160 mg IV equivalents of dexamethasone or bortezomib > 2 doses of
 1.3 mg/m^2 each dosing equivalents

 -  Known significant cardiac abnormalities including:

 -  Congestive heart failure, New York Heart Association (NYHA) class III or IV

 -  Uncontrolled angina, arrhythmia or hypertension

 -  Myocardial infarction within the past six months

 -  Any other uncontrolled or severe cardiovascular condition

 -  Prior cerebrovascular event with residual neurologic deficit

 -  Known history of chronic obstructive pulmonary disease with a forced expiratory volume
 in 1 second (FEV1) < 50% of predicted normal

 -  Has known history of moderate or severe persistent asthma within the past 2 years, or
 currently has uncontrolled asthma of any classification

 -  Serious, intercurrent illness including, but not limited to, clinically relevant
 active infection, uncontrolled diabetes mellitus, or serious co-morbid medical
 conditions such as chronic restrictive pulmonary disease, and cirrhosis

 -  Seropositive for human immunodeficiency virus (HIV)

 -  Seropositive for hepatitis B (defined by a positive test for hepatitis B surface
 antigen [HBsAg]). Subjects with resolved infection (i.e., subjects who are HBsAg
 negative but positive for antibodies to hepatitis B core antigen [anti-HBc] and/or
 antibodies to hepatitis B surface antigen [anti-HBs]) must be screened using real-time
 polymerase chain reaction (PCR) measurement of hepatitis B virus (HBV)
 deoxyribonucleic acid (DNA) levels. Those who are PCR positive will be excluded.
 EXCEPTION: Subjects with serologic findings suggestive of HBV vaccination (anti-HBs
 positivity as the only serologic marker) AND a known history of prior HBV vaccination,
 do not need to be tested for HBV DNA by PCR

 -  Seropositive for hepatitis C (except in the setting of a sustained virologic response
 [SVR], defined as a viremia at least 12 weeks after completion of antiviral therapy)

 -  Any condition, including laboratory abnormalities, that in the opinion of the
 investigator places the subject at unacceptable risk if he/she were to participate in
 the study

 -  Diagnosed or treated for another malignancy within 2 years before study enrollment or
 previously diagnosed with another malignancy and have any evidence of residual
 disease. Patients with nonmelanoma skin cancer or carcinoma in situ of any type are
 not excluded if they have undergone complete resection

 -  Known hypersensitivity to acyclovir or similar anti-viral drug

 -  Known severe intolerance to steroid therapy

 -  Participants with known central nervous system (CNS) involvement

 -  Poor tolerability or known allergy to any of the study drugs or compounds of similar
 chemical or biologic composition to dexamethasone, boron or mannitol

 -  Female participants pregnant or breast-feeding

 -  Participants who have undergone major surgery =< 4 weeks prior to starting study drug
 or who have not recovered from side effects of the surgery

 -  Participants with any significant history of non-compliance to medical regimens or
 unwilling or unable to comply with the instructions given to him/her by the study
 staff

 -  Prior exposure to anti-CD38 therapy

 -  Radiotherapy within 14 days before enrollment. If the involved field is small, 7 days
 will be considered a sufficient interval between treatment and administration of study
 medications

 -  Any serious medical or psychiatric illness that could, in the investigator's opinion,
 potentially interfere with the completion of treatment according to this protocol

 -  Participation in other clinical trials, including those with other investigational
 agents not included in this trial, within 30 days of the start of this trial and
 throughout the duration of this trial