THE FUTURE OF INTERFERON IN MYELOPROLIFERATIVE NEOPLASMS Jean-Jacques KILADJIAN Saint-Louis Hospital, University of Paris Paris, France

EVIDENCE FOR SUPERIOR EFFICACY AND DISEASE MODIFICATION AFTER THREE YEARS OF PROSPECTIVE

RANDOMIZED CONTROLLED TREATMENT OF POLYCYTHEMIA VERA PATIENTS WITH ROPEGINTERFERON ALFA-2B VS.

HYDROXYUREA/BEST AVAILABLE TREATMENT

HEINZ GISSLINGER, CHRISTOPH KLADE, PENCHO GEORGIEV, DOROTA KROCHMALCZYK, LIANA GERCHEVA-KYUCHUKOVA, MIKLOS EGYED, VIKTOR ROSSIEV, PETR DULICEK, ARPAD ILLES, HALYNA PYLYPENKO, LYLIA SIVCHEVA, JIRI MAYER, VERA YABLOKOVA,

KURT KREJCY, BARBARA GROHMANN-IZAY, HANS C. HASSELBALCH, ROBERT KRALOVICS, AND JEAN-JACQUES KILADJIAN

ASH 2018

Month 24 Efficacy Analysis

up to 3.6 years Safety Analysis Month 12 Month 0

Ropeginterferon alfa-2b phase III development in PV: PROUD-PV and CONTINUATION-PV Studies

Treatment-related adverse events in >10% of patients

Treatment-related AE Ropeg (n=95) n (%)

Control (n=76) n (%)

Thrombocytopenia 24 (25.3%) 25 (32.9%)

Leukopenia 21 (22.1%) 23 (30.3%)

Anaemia 10 (10.5%) 22 (28.9%)

Increased gamma-GT 11 (11.6%) 2 (2.6%)

Alanine aminotransferase increased 10 (10.5%) -

Platelet count decreased - 8 (10.5%)

Myalgia 10 (10.5%) 3 (3.9%)

% o

f res

pond

ers

0

10

20

30

40

50

60

70

80

90

100

M3-A M6-A M9-A

M12-A

(EOT in

PR)

M15-A

(CO-M

3)

M18-A

(CO-M

6)

M21-A

(CO-M

9)

M24-A

(CO-M

12)

M27-A

(CO-M

15)

M30-A

(CO-M

18)

M33-A

(CO-M

21)

M36-A

(CO-M

24)

AOP2014ControlAOP2014 (stat. significant RR)Control (stat. significant RR)

18

39

45

62 61 62

72 7167

73 7571

21

70 6975

6669

5249

52

59 58

51

RR:0.84 RR:0.56 RR:0.66 RR:0.85 RR:0.94 RR:0.90 RR:1.37 RR:1.42 RR:1.31 RR:1.29 RR:1.31 RR:1.38

Complete hematologic response (CHR)

Study Month Responder/N Responder % Responder/N Responder % P-value RR [95% CI]

(AOP2014/Control)

Ropeg (N=95) Control (N=76)

MONTH 12 (EOT in PR) 59/95 62.1 57/76 75.0 0.1201 0.85 [0.70-1.04]

MONTH 24 67/95 70.5 33/67 49.3 0.0111 1.42 [1.08-1.87]

MONTH 36 67/95 70.5 38/74 51.4 0.0122 1.38 [1.07-1.79]

Full A

nalys

is Se

t

CHR + improvement in disease burden

Study Month Responder/N Responder % Responder/N Responder % P-value RR [95% CI]

(AOP2014/Control)

Ropeg (N=95) Control (N=76)

MONTH 12 (EOT in PR) 44/95 46.3 39/76 51.3 0.5245 0.91 [0.67-1.23]

MONTH 24 47/95 49.5 27/71 38.0 0.1832 1.27 [0.89-1.81]

MONTH 36 50/95 52.6 28/74 37.8 0.0437 1.42 [1.01-2.00]

% o

f re

sp

on

de

rs

0

10

20

30

40

50

60

70

80

90

100

M3-A

M6-A

M9-A

M12-A

(EOT

in PR

)

M15-A

(CO-M

3)

M18-A

(CO-M

6)

M21-A

(CO-M

9)

M24-A

(CO-M

12)

M27-A

(CO-M

15)

M30-A

(CO-M

18)

M33-A

(CO-M

21)

M36-A

(CO-M

24)

AOP2014ControlAOP2014 (stat. significant RR)Control (stat. significant RR)

15

26

34

46 4946

5349

4552

5653

16

47 4551

4047 37 38

42

4639 38

RR:0.90 RR:0.55 RR:0.73 RR:0.91 RR:1.19 RR:0.97 RR:1.39 RR:1.27 RR:1.08 RR:1.16 RR:1.44 RR:1.42

Full A

nalys

is Se

t

% o

f res

pond

ers

0

10

20

30

40

50

60

70

80

90

100

M3-A M6-A M9-A

M12-A

(EOT in

PR)

M15-A

(CO-M

3)

M18-A

(CO-M

6)

M21-A

(CO-M

9)

M24-A

(CO-M

12)

M27-A

(CO-M

15)

M30-A

(CO-M

18)

M33-A

(CO-M

21)

M36-A

(CO-M

24)

AOP2014ControlAOP2014 (stat. significant RR)Control (stat. significant RR)

26

44

50

68 66 66

57

51

42

33 3127

RR:0.44 RR:0.84 RR:1.12 RR:1.94 RR:1.98 RR:2.31

JAK2 (V617F) - Molecular response

Study Month Responder/N Responder % Responder/N Responder % P-value RR [95% CI]

(AOP2014/Control)

Ropeg (N=95) Control (N=76)

MONTH 12 (EOT in PR) 41/94 43.6 38/75 50.7 0.5001 0.84 [0.62-1.15]

MONTH 24 (LOCF) 64/94 68.1 25/75 33.3 0.0001 1.99 [1.40-2.84]

MONTH 36 (LOCF) 62/94 66.0 20/74 27.0 <0.0001 2.31 [1.56-3.42]

Molec

ular

resp

onse

at

asse

ssm

ent v

isits

- LOC

F im

puta

tion -

FAS

Conclusions

• Results from three years of treatment in this large, prospective, controlled trial in PV confirm the previously reported efficacy and safety of ropeginterferon alfa-2b

• Ropeg showed high and durable hematologic responses and symptom control with good tolerability

• Ropeg reduced not only JAK2V617F but also additional mutations and cytogenetic aberrations confirming disease modification capability of IFNa

• Ropeginterferon alfa-2b will provide a valuable and safe new long-term treatment option with features clearly distinct from other treatment modalities including HU

COMPARISON OF LONG-TERM EFFICACY AND SAFETY OF ROPEGINTERFERON ALFA-2B VS. HU IN POLYCYTHEMIA VERA

PATIENTS AGED BELOW OR ABOVE 60 YEARS: TWO-YEAR ANALYSIS FROM THE PROUD/CONTINUATION PHASE III TRIALS

Heinz Gisslinger, Christoph Klade, Pencho Georgiev,

Dorota Krochmalczyk, Liana Gercheva-Kyuchukova, Miklos Egyed, Viktor Rossiev, Petr Dulicek, Arpad Illes, Halyna Pylypenko, Lylia Sivcheva, Jiri Mayer, Vera Yablokova, Barbara Grohmann-Izay, Gabriele Maurer, Hans Hasselbalch,

Robert Kralovics and Jean-Jacques Kiladjian

1) Gisslinger et al. EHA 2017 2) Gisslinger et al. ASH 2016

Off-label IFNα as first-line therapy is primarily used in patients of younger age, partly because of the misconception that the risk-benefit ratio is not so favorable in elderly patients. Aim: To analyze the efficacy and safety of Ropeginterferon alfa-2b and HU in two age cohorts (<60 years and ≥60 years).

Background

Efficacy Results 24 Months – by age group

Ropeginterferon alfa-2b induced higher CHR rates compared to control, irrespective of age.

CHR CHR & improvement in disease burden

Maintenance of CHR Maintenance of CHR & improvement in

disease burden

*RR Ropeg/control [95% CI]: 2.82 [1.37-5.79]

Ropeginterferon alfa-2b induced higher maintenance rates of CHR compared to control, irrespective of age.

*P<0.001

Efficacy Results 24 Months – by age group

Molecular response (LOCF)

*RR Ropeg/control [95% CI]: 2.17 [1.38 to 3.42]

Ropeginterferon alfa-2b induced a higher molecular response compared to control, irrespective of age

*P<0.001

Efficacy Results 24 Months – by age group

Long-term Safety: up to 3.6 years of treatment; mean 2.7 years

• Comparable numbers of AEs and serious AEs in the treatment arms, irrespective of age. • Number of ADRs was comparable in the patients <60 years but a trend towards a lower number of ADRs

(serious and non-serious) was evident for Ropeginterferon alfa-2b vs. control in patients ≥60 ys

Ropeg Control <60 years

N=49 ≥60 years

N=46 <60 years

N=39 ≥60 years

N=37

Patients with AE 44 (89.8%) 43 (93.5%) 36 (92.3%) 34 (91.9%)

Patients with serious AE 3 (6.1%) 10 (21.7%) 4 (10.3%) 9 (24.3%)

Patients with adverse drug reaction (ADR) 38 (77.6%) 29 (63.0%) 29 (74.4%) 33 (89.2%)

Patients with serious ADR 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (10.8%)*

Patients with ≥ Grade 3 AE 10 (20.4%) 16 (34.8%) 10 (25.6%) 14 (37.8%)

*Acute Leukemia, Anemia, Leukopenia, Granulocytopenia

• A high CHR, symptom improvement and molecular response (JAK2V617F) as well as maintenance of response achieved by long-term treatment with Ropeginterferon alfa-2b was shown, with an advantage over HU independent of age

• Ropeginterferon alfa-2b was well tolerated in all age groups. The safety

analysis in patients ≥60 years showed a positive trend regarding less ADRs and less serious ADRs for Ropeginterferon alfa-2b vs. HU

• Ropeginterferon alfa-2b provides a valuable, efficacious and safe new

treatment option for PV patients of all ages, including those older than 60

Summary - Conclusion

IFN TREATMENT DISCONTINUATION

PVN1 study – peg-IFNα-2a discontinuation • Causes of peg-IFNα-2a discontinuation

• 38% for hematol. CR

• 27% for toxicity

Fatigue (n= 2) Depression (n= 1) Auto-antibodies (n=2) Thyroiditis (n= 1) Arthralgia (n= 1) Neutropenia (n= 1) Neuropathy gr. 2 (n= 1) LFTs elevation gr. 2 (n=1)

OUTCOME OF PATIENTS AFTER DISCONTINUATION?

Objectives • Single center study of outcome of MPN patients treated with

IFN after discontinuation (whichever the cause)

• Endpoints (competing risk) : • hematological relapse

• thrombosis

• hematological transformation

• EFS (thrombosis, transformation, death)

• Predictive factors

Results • Since 2000 in St-Louis hospital, 333 MPN patients

received IFNa

• 149 stops • 78 PV, 61 ET, 10 MF

• Reasons for stopping:

• Toxicity : 79 (53%)

• Prolonged CHR: 52 (35%)

• Median time on IFN : 28.3 months

• Last follow-up:

• 109 (73%) patients were in CHR for a median time after IFN discontinuation of 42 months [23-58]

• including 46 (42%) without cytoreductive therapy after 33 months [19-53]

Results

Impact of molecular response on clinical outcomes Influence of JAK2V617 allele burden on the predicted probability of

persistent complete hematological response without cytoreductive therapy

JAK2 End IFN (%)

Proba

bility

of CH

R

0 20 40 60 80 100

00.2

0.40.6

0.81.0

Kiladjian et al., ASH 2016

COMBINATION THERAPY WITH IFN

RUXOPEG, a Multi-Center Bayesian Phase 1/2 Adaptive Randomized Trial of the Combination of

Ruxolitinib and Pegylated Interferon Alpha 2a in Patients with MPN-Associated Myelofibrosis

ClinicalTrials.gov Identifier: NCT02742324

Phase 1: a Bayesian dose finding study to assess the safety of the combination of different doses of ruxolitinib and peg-IFN alpha-2a Phase 2: a secondary randomized evaluation of the 2 optimal doses found in the first part of the study

Primary tolerance criterion: occurrence of dose limiting toxicity within 45 days

18 patients enrolled from Sept 2017 to Nov 2018

Analysis on the first 16 patients allowing for DLT assessment

RUXOPEG study design - phase 1

Ruxolitinib (started D1)

10 mg BID 15 mg BID 20 mg BID

Peg-IFN 45 mcg/w (started D15)

n= 3 n= 3 n= 3

Peg-IFN 90 mcg/w n= 3

Peg-IFN 135 mcg/w n= 3 n= 3

Phase 1 - Conclusion

No DLT was observed among the 18 enrolled patients

Starting Phase 2: a secondary randomized evaluation of the 2 optimal doses found in the first part of the study Ruxolitinib 15 mg BID + Peg-IFN 135 mcg/w Ruxolitinib 20 mg BID + Peg-IFN 135 mcg/w

Primary efficacy criterion: > 50% reduction in spleen length within 6 months

Will include up to a total of 42 patients (24 additional patients)

Mean: 9.7 5.0 4.7 4.0 5.0

0

5

10

15

20

M0 M3 M6 M9 M12Time

value

M0 M3 M6 M9 M12

05

1015

20

• Efficacy of the combination for reducing the spleen size

RUXOPEG study - phase 1 preliminary efficacy results Sp

leen

size

BCM

by

palp

atio

n (c

m)

Sple

en si

ze B

CM b

y pa

lpat

ion

(cm

) M0 M3 M6 M9 M12

M0 M3 M6 M9 M12

RUXOPEG study - phase 1 preliminary efficacy results

Mean: 74% 64% 46%

JAKV

617F

alle

le b

urde

n

JAKV

617F

alle

le b

urde

n

0%

20%

40%

60%

80%

100%

M0 M6 M12

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

M0 M6 M12

• Efficacy of the combination for reducing the MPN clone

Patient #110-002 5 mutations at baseline Dose level 1: Rux 10 mg BID Peg 45 mcg/w

80%

41% 38%

6% 2%

51%

19%

30%

0%

11%

JAK2V617F ASXL1 DNMT3A EZH2 TET2

M0 M12

• Efficacy of the combination for reducing the MPN clones

RUXOPEG study - phase 1 preliminary efficacy results

0.01

0.1

1

10

100

IL-8/CXCL8

0.01

0.1

1

10

CXCL1/GRO alpha

0.1

1

10

CCL2/MPC-1

Multiplex assay of 45 cytokines at different time points

Different Cytokine Profiles : screening/end of treatment (n=8 first patients )

• Efficacy of the combination for reducing cytokine levels

RUXOPEG study - phase 1 preliminary efficacy results

M0 M12 M0 M12 M0 M12

Marie-Hélène Schlageter

CD56Bright

CD56Dim

NK

Phenotype evolution during treatment

In CD3+ CD4+

In CD3+

Th1

Th17

Th2

Cytokine expression in T lymphocytes

Treg CD25high CD127-/low

Population of Treg

TCM Naïve

TEM TEMRA

Population of naïve and memory T lymphocytes

PD1+ CD4+

PD1+ CD4-

Checkpoint expression in T lymphocytes

pSTAT1Tyr pSTAT3Tyr pSTAT5Tyr

control STAT1tyr STAT1tyr IFN-a STAT1tyr IFN-y

STAT3tyr STAT3tyr IL-6

STAT5tyr STAT5tyr GM-CSF

control control

Activation of immune cells during treatment

• At baseline • After Rux alone • After Rux + Peg IFN • At 12 months

Ancillary study of immune cells

Claude Capron

• Efficacy of the combination for improving bone marrow histology RUXOPEG study - phase 1 preliminary efficacy results

M0 M12 UPN #110-009

Specific and Synergistic Targeting of JAK2V617F Cells by Interferon Alpha (IFN) and Arsenic (As2O3)

in Myeloproliferative Neoplasms (MPNs)

Nabih Maslah, Tracy Dagher, Valérie Edmond, Bruno Cassinat, Valérie Lallemand-Breitenbach, Emmanuelle Verger, Isabelle Plo,

Jean-Jacques Kiladjian, Jean-Luc Villeval, and Hugues de Thé

ASH 2018

KI JAK2VF / Ubi GFP donor

WT donor

recipient WT

9,5 Gy

BMT 5 weeks

IFN

As2O3 9,5 Gy

Relapse after treatment discontinuation

2ry BMT

Disease in transplanted mice ?

KI JAK2V617F loxP TG Ubi GFP

Preclinical model: Chimeric KI JAK2V617F / JAK2WT grafted model

Hematological response Molecular response

Arsenic increases the hematological response induced by IFN in blood and tissues

0

100

200

300

400

500

600

NT IFN IFN+ARS

Sple

en w

eigh

t (m

g)

4 independent experiments n-25-28 animals

ANOVA Dunnet test

*** ***

***

* 4 independent experiments N-14-19 animals

***

***

**

***

***

ns

***

*** ns

IFN+As2O3 in vivo treatment in chimeric KI JAK2V617F / JAK2WT mice: Improvement of Hematological response

0

25

50

75

100

Lin- LSK SLAM

Perc

ent o

f BM

GFP

+ ce

lls

4 independent experiments n-25-28 animals

ANOVA Dunnet test 1 out of 2 experiments n=3 animals

*** ***

*** ***

*** ***

***

***

**

***

***

***

ns

***

***

Addition of Arsenic to Interferon eradicates JAK2V617F leukemic stem cells?

IFN+As2O3 in vivo treatment in chimeric KI JAK2V617F / JAK2WT mice: Improvement of Molecular response

*** ***

Chimeric recipient

JAK2V617F / WT

9.5 Gy

5 weeks

IFNα

As2O3

9.5 Gy

2ry BMT Disease in transplanted mice

?

Arsenic greatly increases the suppression of disease-initiating cells induced by IFN

* from hematocrit and allele burden. 4 independent experiments

n-12-15 animals ANOVA Dunnet test

0

20

40

60

80

100

NT IFN IFN+A2O3

Perc

ent o

f dis

ease

free

* se

cond

ary

mic

e (%

)

IFN+As2O3 in vivo treatment in chimeric KI JAK2V617F / JAK2WT mice: Eradication of disease-initiating cells in secondary transplants

Chimeric recipient

JAK2V617F / WT

9.5 Gy

5 weeks

IFN

As2O3

Disease relapse

9 weeks after treatment

discontinuation

Arsenic decreases the percentage of disease relapse observed after discontinuation of the IFN treatment

**

* from hematocrit and allele burden. 4 independent experiments

n-12-15 animals ANOVA Dunnet test

0

20

40

60

80

100

NT IFN IFN+A2O3

Rela

pse*

aft

er tr

eatm

ent

disc

ont!

nuat

ion

(%)

IFN+As2O3 in vivo treatment in chimeric KI JAK2V617F / JAK2WT mice: Lower risk of disease recurrence after treatment discontinuation

9 weeks

Conclusion