CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
`
`
`
`Patients with myelodysplastic syndromesbenefit from palliative therapy with
`amifostine, pentoxifylline, and ciprofloxacin with or without dexamethasone
`Azra Raza, Huma Qawi, Laurie Lisak, Tanja Andric, Saleem Dar, Colleen Andrews, Paramesuaran Venugopal, Sefer Gezer,
`Stephanie Gregory, Jerome Loew, Erwin Robin, Shelby Rifkin, Wei-Tong Hsu, and Ray-Win Huang
`
`3 had RA with ringed
`anemia (RA),
`(RARS),
`5 had RA with
`sideroblasts
`excess blasts (RAEB), and 1 had chronic
`myelomonocytic leukemia (CMMoL). Five
`had secondary MDS.No differences were
`noted in response rates among the 3
`dose levels. Seven patients did not re-
`spondatall, and 22 showed an improve-
`ment in cytopenias (76%). Three had a
`triple lineage response, 10 had a double
`lineage response, and 9 had a single
`lineage response (8 of 9 in absolute
`neutrophil count [ANC] and 1 had more
`than a 50% reduction in packed red blood
`cell
`transfusions). Fifteen patients re-
`sponded only after the addition of dexa-
`methasone, whereas 7 respondedbefore.
`When examined by lineage, 19 of 22
`© 2000 by The Amerlcan Society of Hematology
`showed improved ANC,11 of 22 demon-
`(median age, 67 years), 20 had refractory
`
`
`strated more than 50% reduction in blood
`transfusions, improved Hb levels, or both,
`and 7 of 22 showed improvement
`in
`platelet counts.
`Interestingly,
`the re-
`sponseswere frequently slow to appear,
`and continued improvement
`in counts
`was seen up to 12 months of therapy and
`beyond. This study supports the feasibil-
`ity of treating patients with MDS with the
`unique approach of cytoprotection and
`anticytokine therapies as well as the
`principle that prolonged commitment to
`treatment is desirable when noncytotoxic
`agents are administered. (Blood. 2000;95:
`1580-1587)
`
`Thirty-five patients with myelodysplastic
`syndrome (MDS) were registered on pro-
`tocol MDS 96-02 and were receiving
`continuous therapy with pentoxifylline
`800 mg 3 times a day and ciprofloxacin
`500 mg twice a day by mouth; dexametha-
`sone was added to the regimen for the
`partial responders and the nonresponders
`after 12 weeks at a dose of 4 mg by mouth
`every morning for 4 weeks. Amifostine
`was administered intravenously 3 times a
`week at 3 dose levels (200 mg/M?, 300
`mg/M2, and 400 mg/M?) to cohorts of 10
`patients each. Therapy has been contin-
`ued for 1 year in responders. Twenty-nine
`have completed at
`least 12 weeks of
`therapy and are available for response
`evaluation. Of the 21 men and 8 women
`
`Introduction
`
`attempted in patients with high-risk MDS (those with excess blasts
`No single therapeutic approach appears to have madea significant
`or chronic myelomonocytic leukemia), with as many as halfthe
`impact on survival of patients with myelodysplastic syndromes
`patients achieving complete remission.!!.!? Short duration of remis-
`(MDS).!:2 Allogeneic bone marrow (BM)
`transplantation,>4 a
`sion marked byarelentless return of MDScells in mostpatients,
`choice available to few patients given that the median age at
`treatment-related complications or mortality, frequent encounters
`diagnosis is approximately 70 years, is the only exception. Options
`with drug-resistant clones, and the morbidity caused by the
`range from supportive care to the use of stem cell transplantation.
`appearance of unexpected and unusual opportunistic infections
`Based on the assumption that the cytopenias mayreflect a primary
`reflecting the enormously compromised state of the immune
`bone marrow failure, colony-stimulating growth factors with
`system in these patients make the intensive chemotherapy option
`overlapping activities designed to stimulate proliferation of hema-
`less desirable.
`In summary, save for allogeneic transplantation,
`topoictic progenitors have been extensively investigated? The
`MDS isa universally fatal illness, and no single approachhas either
`problem is
`that administered as
`single agents, granulocyte-
`altered the naturalhistory of the disease or improved survival.
`macrophage colony-stimulating factor (GM-CSF) or G-CSFrarely
`Given the biologic complexity and the unpredictable course of
`improves the anemia and the thrombocytopenia so commonly the
`the disease ranging from chronic,insidious, and slowly progressive
`pathognomonic features of MDS. Erythropoietin alone produces an
`cytopenia to a rapidly evolving,
`lethal
`transformation to acute
`improvement
`in the anemias of approximately 20% ofpatients,
`which increases to almost 50% when combined with G-CSF.#?
`leukemia, it is not surprising that therapeutic options range widely
`between supportivecare to intensive induction-type chemotherapy.
`However, only a proportion ofpatients respond, the response is
`Clearly, a better understanding ofthe basis for cytopenias in MDS
`usually temporary, and there is some concern related to an
`incidence ofaccelerated transformation. !"
`is critical to design therapiestailored for individual needs. Recent
`Acute leukemia-like intensive induction therapies have been
`biologic studies have demonstrated that cytokine-mediated excessive
`
`
`
`From the Rush Cancer Institute and the Departments of Pathology and
`Biostatistics, Rush-Presbyterian-St. Luke's Medical Center, Chicago; Ingall's
`Memorial Hospital, Harvey; and Northwest Community Hospital, Arlington
`Heights, !L
`Submitted June 16, 1999; accepted November3, 1999.
`
`Supported by the National CancerInstitute (grant PO1CA 75606), The Markey
`Charitable Trust, and the Dr Roy Ringo Grant for basic research in myelodys-
`plastic syndrome
`
`Reprints: Azra Raza, Pre-Leukemia and Leukemia Program, Rush Cancer
`Institute, Rush-Presbyterian-St. Luke’s Medical Center, 2242 West Harrison
`Street, Suite 108, Chicago, IL 60612-3515; e-mail: araza@rush.edu.
`
`The publication costs of this article were defrayed in part by page charge
`payment. Therefore, and solely to indicate this fact,
`this article is hereby
`marked “advertisement”in accordancewilh 18 U.S.C. section 1734.
`
`© 2000 by The American Society of Hematology
`
`1580
`
`BLOOD, 1 MARCH 2000 - VOLUME 95, NUMBER 5
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE1
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 1
`
`

`

`BLOOD, 1 MARCH 2000 - VOLUME95, NUMBER 5
`
`PALLIATIVE THERAPY FORMDS
`
`1581
`
`intramedullary apoptosis of hematopoietic cells may form this
`basis in most patients with MDS.'?"'6 This insight offers a novel
`therapeutic windowofopportunity because it naturally follows that
`suppression of the proapoptotic cytokines should lead to an
`improvement
`in cytopenias. The proinflammatory/proapoptotic
`cytokines that have so far been demonstrated to be candidates for
`this role are tumor necrosis factor « (TNF-a), transforming growth
`factor 8 (TGF-8), and interleukin 1b (IL-1b).'7?° Because the
`pathologic course mostlikely results from the activity of a cascade
`of cytokines, suppression of any single cytokine by specific
`antibodies would not be the most desirable therapy. Rather, agents
`that
`interfere with the activity of several cytokines would be
`preferred. We chose to use pentoxifylline (PTX), a xanthine
`derivative knownto interfere with the lipid-signaling pathway used
`by TNF-a, TGF-8 and IL-1b?! and thus reduces the activity of
`these cytokines.22*4 Ciprofloxacin (Cipro) was concomitantly
`administered because it reduces the hepatic degradation of PTX,
`and dexamethasone (Decadron) was added to down-regulate the
`translation of mRNA for TNF-a.2° This pentoxifylline-ciprofloxa-
`cin—dexamethasone (PCD)
`therapy resulted in encouraging
`hematopoietic responses in
`18 of 43 patients with MDS,??
`and the mechanism ofaction was found to be cytokine related
`because responders showed the most sustained reductions in
`TNF-a levels.
`the cytoprotective agent amifostine has been
`More recently,
`found to have substantial activity in improving cytopenias of
`patients with MDS.” In the current study, therefore, the anticyto-
`kine and cytoprotective approaches were combined to determine
`whether the gains in improving ineffective hematopoiesis of MDS
`could be further enhanced.This article reports on the first trial that
`combined all 4 agents namely, pentoxifylline, ciprofloxacin, amifos-
`tine, and dexamethasone.
`
`
`Patients and methods
`
`All patients were entered on the protocol MDS 96-02. The protoco! was
`reviewed and approved by the Institutional Review Board (IRB) of the
`Rush-Presbyterian-St. Luke’s Medical Center and by the IRBs of other
`participating institutions. All paticnts considered potential candidates for
`treatment on MDS 96-02 had the protocol explained to them by the
`Principal Investigator, and if they agreed to participate in the study, they
`signed an informed consent
`form before therapy began. All patients
`underwent a bone marrow examinationbefore the start and after approxi-
`mately 12 weeks of therapy, Weekly complete blood counts with differen-
`tials were obtained onall the patients; only adults older than 18 years of age
`were cligible for the study. Al] pretherapy and postthcrapy bone marrow
`examination results were revicwed at Rush University by a hemato-
`pathologist,
`
`Clinical studies
`
`Thirty-five patients with MDS were formally registered on the protocol
`MDS 96-02 aficr a bone marrow examination confirmed the diagnosis.
`Twenty-nine have completed at east 12 weeks of therapy and are available
`for a response evaluation. All patients began by taking pentoxifylline 400
`mg by mouth 3 times a week for | week. This wasincreased to 800 mg by
`mouth 3 times a week from the second week until the termination ofthe
`protocol. Ciprofloxacin (Cipro) wasstarted at a dose of 500 mg by mouth
`lwiee a week fromthe 3rd week. Amifostine was administered 3 times per
`week (Monday. Wednesday, Friday) at 3 dose levels to cohorts of 10
`patients each. The first cohort reccived 200 mg/M?,
`the second cohort
`received 300 mg/M2, and the third cohort reecived 400 mg/M? intrave-
`nously 3 limesAveck. After 12 weeks of therapy with pentoxifylline, Cipro,
`
`and amifostine, responses were evaluatedaccording tothe criteria described
`below, Partial responders, nonresponders, or both were then given dexa-
`methasone at 4 mg by mouth every morning in addition to the other drugs
`for a period of 4 weeks. After this 4-wecek course, dexamethasone was
`tapered and stopped, and then a maintenance dose of 4 mg by mouth was
`given for 5 days every monthafler 6 weeks.
`The protocol was written to continue all drugs fora period of 6 months
`and then to reduce the amifostine frequency to twice a week and continue
`all drug administration for a total of | ycar. These drug durations and
`schedules were chosen fora varicty of reasons, PTX and Cipro have been
`safely administered to paticnts with MDSfor up to 3 years in our previous
`study?’ and therefore were continued for | year at full dose, Because the
`administration of dexamethasone at 4 mg by mouth every morning for 12
`wecks was associated with many of the expected side effects,?? in the
`current protocol]
`this was changed to a 5-day per month intermittent
`schedule after continuous daily administration for 4 weeks. After 6 months
`of thrice weekly amifostinc, the dose was reduced to twice weekly mainly
`for the convenienceofthe patients.
`
`Response criteria
`
`Responses were defined according to criteria previously reported.2?
`Restoration of normal hematopoicsis with normal peripheral blood counts
`was defined as complete remission. Partial
`remission was defined as
`improvement in 1 of the following parameters: (1) a decrease in monthly
`packed red bloodcell (PRBC) transfusions by at least 50% was defined as a
`partial response; (2) an increase in hemoglobin by 2 g/dL overpretreatment
`value was considered a good response, whereus anincrease by | g/dL was
`considered a partial response and anything Icss as no response;
`(3) an
`increase in platelet count by more than 30 000/uL above pretreatment value
`if the pretreatment count was Iess than 150 000/uL was considered a good
`response, and an increase by !0000/pL was a partial response; (4) an
`increase in granulocyte count by 500/pL overpretreatment value or a 50%
`increase overpretreatment value; (5) disappearance of | or more cytoge-
`netic abnormalities.
`
`Cytogenetic studies
`
`Standard karyotypic analysis using GTG banding was performed on every
`case before therapy was started and each time a marrow was performed
`thereafter.
`
`Statistical analysis
`
`Mann-Whitney U tests were usedfor 2 sample comparisons of continuous
`variables. Contingency tables with x?statistics or the Fisher exact test were
`used foranalysis.
`
`Results
`
`Thirty-five patients with a confirmed diagnosis of MDS were
`registered on protocol! 96-02, and 29 patients could be evaluated
`because they completed the minimumspecified period of 12 weeks
`onthe study. Of the 29 patients who are the subject of this report,
`there were 21 men and 8 women, 27 were white,
`1 was His-
`panic, and 1 was African American. The median age was 67 years
`(range, 46-81 years), and 5 patients had a history of toxic exposure
`(secondary MDS). Ofthe 5 patients with secondary MDS, patient 2
`had a history of myelofibrosis but did not
`receive any cyto-
`toxic therapy (Table 1), patient 17 underwent autologous stem
`cell
`transplantation for non-Hodgkin’s
`lymphoma, patient
`19
`undenvent autologous bone marrow transplantation for AML 10
`years before the diagnosis of MDS, patient 23 had breast cancer
`and underwent 6 cycles of chemotherapy 1 year before the
`diagnosis, and patient 29 underwent multiple cytotoxic therapies
`tor chronic lymphocytic Ieukemia. Twenty patients had refractory
`anemia (RA) according to the French-American-British (FAB)
`classification, 3 had RA with ringed sideroblasts (RARS), 5 had RA
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 2
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 2
`
`

`

`1582
`
`RAZAelal
`
`BLOOD, 1 MARCH 2000 » VOLUME 95, NUMBER 5
`
` 2q1wk
`2q2wk
`3q8wk
`2qiwk
`
`7
`8
`
`9
`
`10
`
`52 MRA
`73
`M_
`RAEB
`
`78
`
`61
`
`F
`
`F
`
` RARS
`
`RA
`
`1,50
`9.20
`
`1.12
`
`0.36
`
`7.7
`9.2
`
`9.1
`
`6.8
`
`2qiwk
`2q2wk
`
`14
`89
`
`0,88
`6,96
`
`8.00
`8.00
`
`2qiwk
`1q2wk
`
`3.11
`12
`1366.28
`
`1q2wk
`
`434
`
`2.9
`
`10.40
`
`1q2wk
`
`1q3wk
`
`161
`
`0.42
`
`8.50
`
`1q8wk
`
`426
`
`150
`
`3,75
`
`9.30
`
`3.116
`
`7.60
`
`1.99
`0.30
`
`10.60
`7.30
`
`10,50
`8.00
`
`21
`
`123
`43
`
`28
`160
`
`447
`
`1q1wk
`2q4wk
`
` 1q3wk (8wk
`gap)
`OFF STUDY
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`41. RARS©2.1959 M- 6.8 2qiwk 242 1.24 9.90 2q1iwk 93 5,02 9.60 2q6wk(after 24 179 Bilineage (trans
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`1271 3,28=10.30M RAEB 145 7.2 2q2wk 48 0.65 8.00 2q4wk 27° nil 65— 84 Trilineage
`
`
`
`«74
`
`M
`
`CMMoL
`
`2.39
`
`11.4
`
`—
`
`33°
`
`°=NA
`
`8.50
`
`—
`
`344,08
`
`9.10
`
`—
`
`45
`
`Table 1. Clinical and laboratory characteristics of MDS patients on protocol
`
`Baseline
`Week 12/Before Dexamethasone
`Week 24/After Dexamethasone
`
`RBC
`RBC
`RBC
`S$. Age
`Hb
`Trans,
`Hb
`Trans.
`Hb
`Trans.
`
`No
`(y)
`Sex
`FAB
`ANC (g/dL)
`(units)
`Pit
`ANC
`(g/dL)
`(units)
`Plt
`ANC
`(g/dL)
`(units)
`Plt
`Responses
`1
`72
`FRA
`0.43
`9.8
`_
`54
`NA
`8.90
`271,33
`7.20
`-
`21
`ANC + D
`2
`63
`M_
`RA
`0.26
`10
`_
`99
`0.36
`9.00
`106
`OFF STUDY
`NR
`3.
`«(49
`M
`RA
`1.50
`7.5
`2qiwk
`44
`NA
`7.70
`35
`2q1wk
`ANC +D
`4
`67
`M
`RA
`1.86
`8.8
`3q3wk
`115
`2.32
`6.50
`112
`OFF STUDY
`ANC
`5
`58
`M
`RA
`0.18
`9.6
`_
`54
`1.12
`9.00
`148
`i1q6wk
`Trilineage
`6
`82
`M
` RARS
`0.26
`7.3
`2qiwk
`44
`0.19
`6.70
`49
`1q6wk
`pRBC
`>50% + D
`Trilineage + D
`Bilineage
`(pts + trans.)
`Bilineage
`{ANC +trans.)
`Bilineage
`{ANC +trans.)
`
`
`
`wks)
`(Hb) + ANC + D)
`
`
`{transfusion
`without D;
`ANC + pit
`were with D)
`ANG + D;blasts
`30% to <5%
`Bilineage(trans.
`Hb + ANC)
`Bilineage
`ANC +pit -+ D
`Bilineage pRBC
`>50% + pit + D
`NR
`Bilineage + D
`{ANC + trans.}
`ANC +0
`ANC + D
`Bilineage
`ANC +plt -+ D
`NR
`65
`nil
`8.50
`1.36
`84
`nil
`9.8
`1.43
`NR
`17
`3q2wk
`7.60
`2.32
`16
`3q2wk
`9
`0,67
`NR
`38
`NA
`11,00
`NA
`42
`NA
`13.2
`1.97
`NR
`1q2wk
`89
`1q2wk
`8,20
`0,75
`201
`tqiwk
`9
`1,31
`ANC +D
`2q2wk
`47
`2q2wk
`7.50
`2.05
`66
`2q2wk
`74
`2.17
`ANC +D
`2q3wk
`280
`2q3wk
`6.40
`2.16
`358
`2q3wk
`7.1
`2.32
`NR
`3q3wk
`51
`3q3wk
`8.60
`2.55
`172
`2qiwk
`85
`1.91
`Bilineage
`OFF STUDY
`47
`1q3wk-~none
`8.70
`0.48
`16
` 2q2wk
`93
`0.42
`trans. + pll
`
`13,40
`
`—
`
`8.70
`
`2q2wk
`
`133
`
`242
`
`10.10
`
`3q3wk
`
`115 — 242
`
`2q2wk
`2q2wk
`
`nil
`3q4wk
`2q4wk
`
`nil
`3q2wk
`
`9.50
`8.00
`
`9.30
`7.00
`880
`
`10.20
`8.10
`
`910
`8.20
`6.60
`8.20
`
`49
`18
`
`26
`36
`105
`
`57
`18
`
`45
`80
`297
`29
`
`13.
`
`14
`
`15
`
`16
`
`17
`18
`
`19
`20
`21
`
`81
`
`52
`
`«73
`
`M
`
`RA
`
`FRA
`
`M
`
` RAEB
`
`56 MRA
`69
`M
` RAEB
`
`RA
`M_
`47
`69 MRA
`68 MRA
`
`2.41
`
`1.60
`
`0.29
`
`0.55
`0.91
`
`3.48
`1.04
`0.31
`
`7.3
`
`2qiwk
`
`110
`
`2.01
`
`10.00
`
`2q1wk
`
`6.9
`
`6.7
`
`7.9
`7.6
`
`9.4
`93
`92
`
`2q2wk
`
`229
`
`1.94
`
`7.90
`
`2q2wk
`
`3qiwk
`
`21
`
`0.16
`
`8.50
`
`3qiwk
`
`1q4wk
` 2q1wk
`
`nil
`3q4wk
`NA
`
`159
`6
`
`0.32
`0.93
`
`27
`41
`63
`
`1,98
`0.68
`0.176
`
`7.60
`7.70
`
`8.10
`7,80
`6.40
`
`2q2wk
`2q1wk
`
`nil
`3q4wk
`2q4wk
`
`RA
`%M
`75
`22
`FRA
`62
`23
`#%™M_
`RAEB
`66
`24
`FRA
`«66
`25
`67 MRA
`26
`2778
`FRA
`28
`«66
`M
`RA
`29°
`«66
`F
`RA
`
`138
`
`161
`
`21
`
`81
`20
`
`19
`28
`66
`
`2.54
`
`5.58
`
`NA
`
`0.64
`1,56
`
`5.77
`4.2
`118
`
`1.3
`3,02
`
`4,27
`10.1
`4.04
`0.86
`
`M, male; F, female; FAB, French-American-Brilish classification; RA, refractory anemia; RARS, RAwith ringed sideroblasts; RAEB, RA wilh excess blasts; ANC, absolute
`neutrophil count/mL; Hb, hemoglobin in g/dL; RBC Trans, numberof units of packed red bloodcells transfused; q, every; wk, weeks; Pil, plalelels in thousandspermicroliter;
`NA, not available for that date; +D, with dexamethasone; Responses: ANC, response in neutrophils; Plt, responsein pialelet counts; Hb, response in hemoglobin levels;
`pRBC > 50%, decreasein packed red blood cell transfusion requirements by 50%; NR, no response.
`
`with excess blasts (RAEB), and 1 had chronic myelomonocytic
`leukemia (CMMoL). These data are shownin Table 1.
`
`Protocol compliance and toxicity
`
`Ofthe 35 patients registered on MDS 96-02, 3 died before 12
`weeks of therapy could be completed,
`1 discontinued therapy
`because of intolerable nausea,
`| had a myocardial
`infarction and
`discontinued therapy within 4 weeks, and 1 was registered but
`neverstarted treatment. Of the 29 patients who could be evaluated
`for response because they completed at least 12 weeks oftherapy, 9
`were treated on the 200 mg/M? dose ofamifostine, 8 on the 300
`mg/M? dose, and 12 on the 400 mg/M?. Twelve patients received
`
`the highest dose of amitostine because 3 patients in the lower dose
`groups could not be evaluated. No differences were noted in
`response rates among these groups. Responses were seen in 22 of
`29 (76%) patients, 7 of 9 (78%) received the lowest dose of
`amifostine, 6 of 8 (75%) reccived the intermediate dose, and 9 of12
`(76%) received the highest dose of amifostine (P = .98). Although
`29 paticnts completed 12 weeks of therapy, only 8 patients
`completed 6 months, 5 completed 9 months, and 3 completed the
`full year of treatment specified in the protocol. Sixtcen patients
`stopped treatment because there was no further improvement in
`their cytopenias, 5 stopped because ofintolerable side effects, 5
`showed progression ofdisease, and 3 completed the full year of
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 3
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 3
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`

`

`BLOOD, 1 MARCH 2000 * VOLUME 95, NUMBER 5
`
`PALLIATIVE THERAPY FORMDS
`
`1583
`
`Vomiting
`
`Decreased appetite
`
`Hypotension
`
`
`Table 2. Adverse effects of amifostine by dose groups
`Grade (% Patients)
` Symptom Group Grade 1 Grade 2
`
`
`
`Nausea
`1
`3.6
`0
`2
`14
`3.6
`3
`i]
`3.6
`1
`3.6
`0
`2
`7
`7
`3
`3.6
`7
`4
`0
`0
`2
`0
`3.6
`3
`3.6
`0
`1
`0
`0
`2
`0
`7
`3
`0
`7
`4
`0
`0
`2
`3.6
`3.6
`3
`0
`3.6
`1
`0
`0
`2
`0
`74
`3
`0
`0
`4
`0
`0
`2
`0
`0
`3
`0
`0
`1
`0
`0
`2
`0
`0
`
`03 36
`
`
`Rash
`
`Fever
`
`Depression
`
`Anxiely
`
`Group 1, amifostine 200 mg/M? intravenously 3 times a week; group2, amifosline
`300 mg/M? intravenously 3 times a week; group 3, amifostine 400 mg/M2 intrave-
`nously 3 limes a week.
`
`these side effects were experienced primarily in the 2
`again, all
`higher dose groups rather than the lowest dose amifostine group
`(Table 2).
`
`Hematologic responses
`
`Ofthe 29 evaluable patients, 7 had no response after at least 12
`wecks oftherapy whereas 22 of 29 (76%) showedpartial response
`in that there was improvementin thcir cytopenias. There were no
`complete responders. Seven paticnts showed some improvement
`before the addition of dexamethasone, and 15 only responded after
`PCD + amifostine. The median time to response varied depending
`onthe lineage and on whether the patient received dexamethasone.
`Nineteenpatients showed an improvement in ANC, 11 in hemoglo-
`bin or transfusion requirements, and 7 tn platelet count. Overall,
`there were 3 triple lineage responders, 10 double lineage respond-
`ers, and 9 single lineage responders (8 of 9 in ANC only; 1 showed
`more than 50% reduction in PRBC transfusions). The details of
`these responses and the precise blood counts are shown in Table 1.
`In summary, two-thirds of the responding paticnts had improved
`ANC, half showed improvement
`in the erythroid lineage, and
`one-third showed improvementin their platelet counts. Improve-
`ments in these cytopenias were noted more rapidly after the
`addition of dexamethasone, whereas a more gradual
`improve-
`ment occurred in the patients who did not receive the additional
`steroid therapy.
`Significant statistical improvement was seen in ANC after 16
`weeks (P = .01) and 24 weeks (P = .02) of therapy. The erythroid
`and platelet count
`responses were not statistically significant
`(P = .52 and P = .72, respectively, at 24 weeks). Figure 1 graphi-
`cally depicts the serial ANC counts in all 29 patients. Figure 2
`graphically demonstrates the hematologic responses in 4 respond-
`ing patients. These 4 patients were chosen for more detailed
`description because they represent a variety of responses after
`therapy with PCD + amifostine:
`
`Patient 14
`
`therapy. Approximately half the treated patients experienced some
`side effects
`from the drugs (Table 2). Briefly, 57% patients
`experienced nausea and 10% vomiting. Among the patients who
`experienced nausea, vomiting, or both there was a difference in
`those who received the higher doses of amifostine compared with
`those whoreceived the lowest dose. For example, in the 200 mg/M?
`amifostine dose group, the incidence for nausea was 11% compared
`with 25% and 26% at the higher doses. Similarly, though 7% of
`patients at the lowest dose of amifostine experienced vomiting,
`14% had vomiting at both the higher doses. From 17% to 20% of
`patients experienced decreased appetite, hypotension, rash, and
`fever, whereas depression (13%) and anxiety (3%) were rarer. Once
`
`b.0u 4
`
`Figure 1. Graphic presentation of absolute neutrophil
`countsin patients with MDS during therapy.
`
`9.99
`
`This 8l-year-old white man was diagnosed with RA on 11/1/96
`(Table 1, Figure 2a). He had a hypercellular BM and normal
`cytogenetics, At the time of diagnosis, his white blood cell count
`was 4200/pL, Hb level was 5.7 g/dL, and platelet count was
`
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`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE4
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 4
`
`

`

`
`
`1584=RAZAetal BLOOD, 1 MARCH 2000 « VOLUME 95, NUMBER 5
`
`RL
`
`Figure 2. Graphic presentation of peripheral
`blood indices in 4 (A-D) patients treated with
`PCD and amifostine. '2 U PRBCtransfusion.
`
`
`
`
`
`
`
`
`
`A
`B
`'
`=
`~
`|r —=
`.
`
`"
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`i
`
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`Gute
`
`
`
`
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`
`149 000/uL. He received 5 U PRBC,which brought his Hb level to
`10 g/dL. Patient started treatment approximately 6 weeks after
`diagnosis (12/16/96) and continued to require 2 to 3 U PRBC each
`week until March 1997. Of note, however, wasthe gradual increase
`in his hemoglobin values between transfusions. Once the transfu-
`sion requirements stopped, the hemoglobin continued to increase
`until the end of therapy at | year, as shownin the graph. The patient
`has been off therapy since 01/06/98, and his latest values on
`9/10/98 were Hb, 14.9 g/dL; WBC, 8 400/yL; and platelet count,
`134 000/uL. He feels well.
`Patient 12
`
`This 58-year-old white man was diagnosed with RA in June 1997
`when he sought treatment for profound pancytopenia and severe
`fatigue (Table 1, Figure 2b). He had a hypercellular BM and
`cytogenetic abnormality 46, XY, del20(qlI .2ql3.3/46 X Y). After
`several PRBC transfusions, his Hb level
`increased to 9.6 g/dL,
`WBC was 1500/uL, and platelet count 54 000/uL when he started
`on the protocol. As seen in Figure 2B, he did require PRBCs twice
`in the next 3 months, but then his Hb fevel continued to improve,
`reaching a maximumof 13.9 g/dL. His WBC andplatclet counts
`
`respectively). After
`also improved (8200 uL and 180000 uL,
`approximately 1] months oftreatment, the patient expcrienced a
`severe hypotensive episode after a routine amifostine injection. All
`study drugs were stopped at this point (6/12/98), and the patient
`began to experience a slowdecline in all his counts within 6 wecks
`of halting therapy. By October, he was placed on PCD therapy
`because his Hb fell to 8.5 g/dL and his platelet count decreased to
`the 70 000/uL range. He has been showing responseto this therapy.
`Patient 6
`
`This 82-year-old white man was diagnosed with RARS on 9/9/96
`(Table 1, Figure 2C). He was started on MDS 96-02 on 3/31/97, at
`which time his WBC count was 1100/pL, Hb level was 7.3 g/dL,
`andplatelet count was 44 000/dL. He had normal cytogenetics and
`hypercellular BM with 3% blasts. He required 2 U PRBC almost
`every 7 to 10 days andplatelets every 2 to 3 weeks. After treatment
`with amifostine + PC, the patient continued to require the same
`level oftransfusions until dexamethasone was added. At that point,
`he showed a dramatic response by becoming transfusion indepen-
`dent for S months. After approximately 8 months of therapy, the
`patient was takenoff all medications because no further improvement
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 5
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 5
`
`

`

`PALLIATIVE THERAPY FOR MDS=1585
`BLOOD, 1 MARCH 2000 » VOLUME 95, NUMBER 5
`
`was noted in the cytopenias. He began to require transfusions
`within 8 wecks of halting therapy and was started on another
`protocol. His condition eventually transformed to AML 6 months
`later, and he died on 8/13/98.
`
`Patient 7
`
`Amifostine, or ethyol, is an organic thiophosphate that exists as
`a pro-drug.** Alkaline phosphatase in the cell dephosphorylatesit
`into an active form. Because normal cells rather than tumorcells
`
`This 52-year-old white man was diagnosed with RA in 1992 and
`underwent multiple therapies for MDS before he started on this
`protocol (Table |, Figure 2D). He began treatment on 1/13/97 when
`his Hb was 8.9 g/dL (after PRBC transfusion), WBC count was
`3000/pL, and platelet count was 18 000/uL. He wasreceiving 2 U
`PRBC every 7 to 10 days and platelet transfusions every 1
`to 3
`weeks. His BM washypocellular (10% cellularity), and cytogenet-
`ics showed an abnormal karyotype with 46XY, de(7) t(1;7) (q10;
`p10)/46, XYde(14) t(1;14) (q10; p10)(2)/46XY(14). He continued
`to require both blood and platelet transfusions until the dexametha-
`sone was added on 5/21/97. After approximately 2 months of
`therapy with APC + D, this patient became completely transfusion
`independent. Eventually, amifostine + PC was stopped (7/9/97),
`and the patient has been maintained on a 5 day per month cycle of
`dexamethasone at 4 mg by mouth 4 times a day. He has only
`required blood andplatelet transfusions twice in the last year, both
`times because he was undergoing elective hip replacement surgery.
`Atpresent, he continues to be transfusion independent.
`
`have higher alkaline phosphatase levels, more active drug is
`available to them.*? In the presence of chemotherapeutic agents, the
`free thiol
`in amifostine provides an alternative target for reactive
`molecules of alkylating or platinum agents and canact as a potent
`scavenger of oxygen-free radicals. These protective effects arc
`more pronounced in normal cells because more active drug is
`available to them.*344 In addition, amifostine has been found to
`stimulate hematopoiesis in humans.*> The precise mechanism of
`this hematopoietic promoting activity is unclear; however, preincu-
`bation exposure to amifostine was associated with profound
`stimulation and enhanced survival of MDSprogenitors in vitro.°°
`In vivo, amifostine has been useful in stimulating hematopoiesis in
`patients with MDS aswell.?? In a group of acute myeloid leukemia
`patients who have poor prognoses, amifostine was found to
`suppress apoptosis, TNF-a, IL-6 production, and telomerase expres-
`sion.** Because these are desirable therapeutic effects to be
`achicved in patients with MDS, the current study was designed to
`test whether a combination ofanti-cytokine (PCD) and cytoprotec-
`tive (amifostine) strategics would be more useful
`than either
`strategy alone. The results
`indicate that although this novel
`approach maynot prove to be curative in the long run, it provides
`substantial palliative support for at least someofthe patients.
`The salientfindingsof this trial can be summarized as follows.
`Of the 29 evaluable patients, none achieved complete remission;
`however, 22 showedpartial response. Twothirds of the patients had
`improved ANC, half showed an erythroid response, and one third
`had improved platelet counts. The median time to response was
`long, 11 to 12 weeks for erythroid and platelet responses even in the
`group administered dexamethasone. Twothirds of the responses
`occurred after the addition of dexamethasone, and one third
`occurred only in response to amifostine, pentoxifylline, and
`ciprofloxacin. Although the responders often required blood and
`platelet transfusions for 2 to 3 months while undergoing therapy, a
`gradual
`improvement
`in their cytopenias was noted that often
`continued for several months. No complete responses or cytoge-
`netic responses were seen. Although the protocol was designed to
`provide continued therapy for 1 year, only 3 patients completed that
`Myelodysplastic syndromes are universally fatal disorders. Be-
`duration, and only 16 patients completed 6 months of therapy. The
`cause erythroid, myeloid, and megakaryocytic cells, and occasion-
`main reason to discontinue therapy was a lack of continued
`ally B lymphocytes, have been found to be clonal in nature, it is
`effective response (16 patients). Others included intolerable side
`likely that the transforming event(s) has occurred atapluripotential
`effects (5 patients) and disease progression (5 patients). For 12 to
`stem cell stage.7! One approach to treating this illness with a
`16 weeks therapy wasfairly well tolerated, and no differences were
`curative intent would be to target the abnormal clone directly by
`noted in the response rates among the 3 dose schedules. Toxicity,
`using intensive chemotherapy, stem cell transplantation, or both.
`especially nausea, was higher in the highest dose group. There was
`The associated prohibitive morbidity and mortality, however,
`a response seen in every FAB category,
`including 1 patient
`especially in an elderly group of patients, render these procedures
`with CMMOoL.
`applicable only to a select subgroup of MDS patients. An alterna-
`tive approach, which may not be curative but could provide
`substantial palliation, would be to suppress the cause of cytopenias
`in these patients. We have observed the presence ofextensive
`apoptosis in the bone marrows of as many as 75% of patients with
`MDS."4 The parallel high levels of TNF-a!* and IL-1b!’ in these
`marrows suggested that cytokine-mediated apoptosis played a
`significant role in the genesis of cytopenias.** Accordingly, we
`treated patients with pentoxifylline and ciprofloxacin with or
`without dexamethasone, demonstrating that the administration of
`these therapies resulted in a reduction in the level of TNF-a in the
`bone marrows of patients with MDS”* and improvement in the
`cytopenias of approximately 40% patients.??
`
`Cytogenetic studies
`
`Detailed karyotypes were performed in every patient. Fourteen
`patients had normal karyotypes when therapy was begun, and 15
`patients showed abnormal chromosomes. The most trequent abnor-
`malities affected chromosome 5 or 7 (8 patients), 2 had del20
`abnormality,
`1 had an isochromosome 17 (ql0), and 4 had other
`cytogenetic anomalies. Serial studies were performed when pos-
`sible and showed clonal evolution with the appearance of new
`abnormalities in 4 patients. No cytogenetic responses were ob-
`served inthis group of 29 patients.
`
`
`Discussion
`
`Amifostine + PCD therapy appears to be a positive additionto
`treatment options for patients with MDS. The results of this
`combination are better than those seen with PCD alone?’ or
`amifostine alone,” though the long-term outcome ofthe patients is
`unknown. It is difficult to compare the current study with the other
`published reports of patients with MDS treated with amifostine??”
`because of the differences in the duration of treatment and the
`
`combination of amifostine with PCD in our study. We based our
`study duration on previous experience with using PTX + Cipro by
`another group,?> which we thought was short, our own encouraging
`experience using PCD for a longer d