CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
`
`
`
`Patients with myelodysplastic syndromes benefit from palliative therapy with
`amifostine, pentoxifylline, and oiprofloxacin 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)I
`(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-
`spond at all, 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 responded before.
`When examined by lineage, 19 of 22
`c 2000 by The American Society of Hematology
`showed improved ANCI 11 of 22 demon-
`(median age, 67 years)I 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-
`sponses were 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 ciprofloxacln
`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 of4 mg by mouth
`every morning for 4 weeks. Amifostine
`was administered intravenously 3 times a
`week at 3 dose levels (200 mg/M2, 300
`mg/Mz, and 400 mg/Mz) 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. 0f the 21 men and 8 women
`
`Introduction
`
`No single therapeutic approach appears to have made a significant
`impact on survival of patients with myelodysplastic syndromes
`(MDS)."2 Allogencic bone marrow (BM)
`transplantation}" a
`choice available to few patients given that the median age at
`diagnosis is approximately 70 years, is the only exception. Options
`range from supportive care to the use of stem cell transplantation.
`Based on the assumption that the cytopenias may reflect a primary
`bone marrow failure, colony-stimulating growth factors with
`overlapping activities designed to stimulate proliferation of hema-
`topoietic progenitors have been extensively investigated.5'7 The
`problem is
`that administered as
`single agents, granulocyte-
`macrophage colony-stimulating factor (GM-CSF) or G-CSF rarely
`improves the anemia and the thrombocytopenia so commonly the
`pathognomonic features ofMDS. Erythropoietin alone produces an
`improvement
`in the anemias of approximately 20% of patients,
`which increases to almost 50% when combined with G—CSFf“9
`However, only a proportion of patients respond, the response is
`usually temporary, and there is some concern related to an
`incidence of accelerated transformation. ”I
`Acute leukemia-like intensive induction therapies have been
`
`attempted in patients with high-risk MDS (those with excess blasts
`or chronic myelomonocytic leukemia), with as many as half the
`patients achieving complete remission.""3 Short duration ofremis-
`sion marked by a relentless return of MDS cells in most patients,
`treatment-related complications or mortality, frequent encounters
`with drug-resistant clones, and the morbidity caused by the
`appearance of unexpected and unusual opportunistic infections
`reflecting the enormously compromised state of the immune
`system in these patients make the intensive chemotherapy option
`less desirable.
`In summary, save for allogcneic transplantation,
`MDS is a universally fatal illness, and no single approach has either
`altered the natural history ofthe disease or improved survival.
`Given the biologic complexity and the unpredictable course of
`the disease ranging from chronic, insidious, and slowly progressive
`cytopenia to a rapidly evolving,
`lethal
`transformation to acute
`leukemia, it is not surprising that therapeutic options range widely
`between supportive care to intensive induction-type chemotherapy.
`Clearly, a better understanding ofthe basis for cytopenias in MDS
`is critical to design therapies tailored for individual needs. Recent
`biologic studies have demonstrated that cytokinc-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,lL
`Submitted June 16, 1999; accepted November 3, 1999.
`
`Supported by the National Cancer Institute (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, lL60612-3515: 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 accordance with 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 PAGE 1
`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 1
`
`

`

`BLOOD, 1 MARCH 2000 - VOLUME 95, NUMBER 5
`
`PALLlATlVE THERAPY FOR MDS
`
`1581
`
`intramedullary apoptosis of hernatopoietic cells may form this
`basis in most patients with MDS.'3‘”’ This insight offers a novel
`therapeutic window ofopportunity 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 or (TNF-or), transforming growth
`factor B (TGF-B), and interleukin 1b (IL-1b).”‘3" Because the
`pathologic course most likely results from the activity ofa cascade
`of cytokincs, suppression of any single cytokine by specific
`antibodies would not be the most desirable therapy. Rather, agents
`that
`interfere with the activity of several eytokines would be
`preferred. We chose to use pentoxifylline (PTX), a xanthine
`derivative known to interfere with the lipid-signaling pathway used
`by TNF-ot, TGF-B and IL-lb“ and thus reduces the activity of
`these cytokines.”24 Ciprofloxacin (Cipro) was concomitantly
`administered because it reduces the hepatic degradation of PTX,25
`and dexamethasone (Decadron) was added to down-regulate the
`translation of mRNA for TNF-ot?" This pentoxifylline—ciprofioxa—
`einAdexamethasone (PCD)
`therapy resulted in encouraging
`hematopoictie responses in
`18 of 43 patients with MDS,27
`and the mechanism of action was found to be cytokine related
`because responders showed the most sustained reductions in
`TNF-ot 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, ciprofioxacin, amifos-
`tine, and dexamethasone.
`
`
`Patients and methods
`
`All patients were entered on the protocol MDS 96—02. The protocol was
`reviewed and approved by the Institutional Review Board (lRB) of the
`Rush—Presbytcrian—St. Luke’s Medical Center and by the lRBs of other
`participating institutions. All patients considered potential candidates for
`treatment on MDS 96-02 had the protocol explained to them by the
`Principal Investigator, and ifthey agreed to participate in the study, they
`signed an informed consent
`form before therapy began. All patients
`underwent a bone marrow examination before the start and after approxi-
`mately 12 weeks of therapy. Weekly complete blood counts with differen-
`tials were obtained on all the patients; only adults older than 18 years ofage
`were eligible for the study. All prethcrapy and postlhcrapy bone marrow
`examination results were reviewed at Rush University by a hemato-
`pathologist.
`
`Clinical studies
`
`Thirty-five patients with MDS were formally registered on the protocol
`MDS 96-02 after a bone marrow examination confirmed the diagnosis.
`Twenty—nine have completed at least 12 weeks ofther'apy and are available
`for a response evaluation. All patients began by taking pentoxifylline 400
`mg by mouth 3 times a week for l week. This was increased to 800 mg by
`mouth 3 times a week from the second week until the termination of the
`protocol. Ciprofioxacin (Cipro) was started at a dose ofSOO mg by mouth
`twice a week from the 3rd week. Amifostinc was administered 3 times per
`week (Monday. Wednesday. Friday) at 3 dose levels to cohorts of IO
`patients each. The first cohort received 200 mg/MZ,
`the second cohort
`received 300 mg/MZ. and the third eohon received 400 mg/M2 intrave—
`nously 3 tunes/week. After l2 weeks ofthcrapy with pentoxifylline. Cipro.
`
`and arnifostine. responses were evaluated according to the criteria described
`below. Partial responders. nonrcsponder's, or both were then given dexa-
`rncthasonc at 4 mg by mouth every morning in addition to the other drugs
`for a period of 4 weeks. After this 4-week course, dexamethasone was
`tapered and stopped, and then a maintenance dose of4 mg by mouth was
`given for 5 days every month after 6 weeks.
`The protocol was written to continrrc all drugs for a period ol'6 months
`and then to reduce the arnifostine frcqrrcney to twice a week and continue
`all drug administration for a total of | year. These drug durations and
`schedules were chosen for a variety of reasons. PTX and Cipro have been
`safely administered to patients with MDS for tip to 3 years in our previous
`study27 and therefore were continued for | year at frrll dose. Because the
`administration of dexamethasone at 4 mg by mouth every morning for I2
`weeks was associated with many of the expected side effects,27 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
`ofthricc weekly arnifostinc, the dose was reduced to twice weekly mainly
`for the convenience of the patients.
`
`Response criteria
`
`Responses were defined according to criteria previously r'epor‘tcd.3r"]0
`Restoration of normal hcmatopoicsis with normal peripheral blood counts
`was defined as complete remission. Partial
`remission was defined as
`improvement in l ofthe following parameters: (1) a decrease in monthly
`packed red blood cell (PRBC) transfusions by at least 50% was defined as a
`partial response; (2) an increase in hemoglobin by 2 g/dL over pretreatment
`value was considered a good response, whereas an increase by l g/dL was
`considered a partial response and anything less as no response;
`(3) an
`increase in platelet count by more than 30 GOO/pl. above pretreatment value
`if the pretreatment count was less than l50 000/pL was considered a good
`response, and an increase by lUOOO/trL was a partial response; (4) an
`increase in granulocyte count by 500/pL over pretreatment value or a 50%
`increase over pretreatment value; (5) disappearance of | or more cytogc-
`nctic abnormalities.
`
`Cytogenetic studies
`
`Standard karyotypie 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 used for 2 sample comparisons ofcontinuous
`variables. Contingency tables with x3 statistics or the Fisher exact test were
`used for analysis.
`
`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 minimum specified period of 12 weeks
`on the 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 oftoxic exposure
`(secondary MDS). Of the 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
`underwent autologous bone marrow transplantation for AML l0
`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
`for chronic lyrnphoeytic lerrkernia. 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
`
`RAZA el al
`
`BLOOD, 1 MARCH 2000 - VOLUME 95, NUMBER 5
`
`201wk
`2q2wk
`3q8wk
`2q1wk
`
`7
`8
`
`9
`
`10
`
`11
`
`12
`
`52
`73
`
`78
`
`61
`
`59
`
`71
`
`M
`M
`
`F
`
`F
`
`M
`
`M
`
`RA
`RAEB
`
`RARS
`
`RA
`
`RARS
`
`RAEB
`
`1.50
`9.20
`
`1 12
`
`0.36
`
`2.19
`
`1.45
`
`7.7
`9 2
`
`9.1
`
`6.8
`
`6.8
`
`7.2
`
`201wk
`202wk
`
`14
`89
`
`0 88
`6.96
`
`8.00
`8.00
`
`2q1wk
`1q2wk
`
`102wk
`
`434
`
`2.9
`
`10.40
`
`1q2wk
`
`1q3wk
`
`151
`
`0 42
`
`8.50
`
`1q8wk
`
`201wk
`
`242
`
`1.24
`
`9.90
`
`2q1wk
`
`2q2wk
`
`48
`
`0.65
`
`5.00
`
`2q4wk
`
`12
`136
`
`426
`
`150
`
`93
`
`27
`
`3.116
`
`7.60
`
`1.99
`0 30
`
`3.11
`6.28
`
`3.75
`
`10.60
`7.30
`
`10.50
`8.00
`
`9 30
`
`1q1wk
`2q4wk
`
`1q3wk (8wk
`gap)
`OFF STUDY
`
`5.02
`
`3 28
`
`9.60
`
`10 30
`
`206wk (after 24
`wkS)
`
`nil
`
`21
`
`123
`43
`
`28
`160
`
`447
`
`179
`
`65 _. e4
`
`M
`
`CMMOL
`
`2.39
`
`11.4
`
`—
`
`33
`
`NA
`
`8.50
`
`34
`
`4.08
`
`9.10
`
`—-
`
`45
`
`Table 1. Clinical and laboratory characteristics of MDS patients on protocol
`
`Baseline
`
` Week 12/Before Dexamethasone Week 24/Alter Dexamethasone
`
`RBC
`RBC
`RBC
`S. Age
`Hb
`Trans.
`Hb
`Trans.
`Hb
`Trans
`
`No
`(y)
`Sex
`FAB
`ANC (g/dL)
`(units)
`Plt
`ANC
`(g/dL)
`(units)
`Plt
`ANC
`(g/dL)
`(units)
`Plt
`Responses
`1
`72
`F
`RA
`0 43
`9.8
`—
`54
`NA
`8.90
`27
`1 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
`201wk
`44
`NA
`7 70
`35
`2q1wk
`ANC )- D
`4
`67
`M
`RA
`1.86
`B 8
`303wk
`115
`2.32
`6.50
`112
`OFF STUDY
`ANC
`5
`58
`M
`RA
`0 18
`9.6
`—
`54
`1.12
`9 00
`148
`1q6wk
`Trilineage
`6
`82
`M
`RARS
`0.26
`7.3
`2q1wk
`44
`0.19
`6 70
`49
`1q6wk
`pRBC
`:-50% + D
`Trilineage + D
`Bilineage
`(plts + trans.)
`Billneage
`(ANC vl- trans )
`Bilineage
`(ANC + trans.)
`Bilineage (trans
`(Hb) + ANC i- D)
`Trilineage
`(transfusion
`without D;
`ANC + oil
`were with D)
`ANC + D; blasts
`30% to (5%
`Bilineage (trans.
`Hb + ANC)
`Bilineage
`ANC + plt + D
`Bilineage pRBC
`>50% + plt + D
`NR
`Bilineage .l. D
`(ANC + trans )
`ANC + D
`ANC + D
`Bilineage
`ANC + pIt + D
`NR
`65
`nil
`8.50
`1.36
`84
`nil
`9.8
`1.43
`NR
`17
`3q2wk
`7.60
`2.32
`16
`302wk
`9
`0.67
`NR
`38
`NA
`11.00
`NA
`42
`NA
`13.2
`1.97
`NR
`1q2wk
`89
`1q2wk
`8.20
`0.75
`201
`1q1wk
`9
`1 31
`ANC + D
`202wk
`47
`2q2wk
`7.50
`2.05
`66
`202wk
`7.4
`2.17
`ANC + D
`2q3wk
`280
`2q3wk
`6.40
`2.16
`358
`2q3wk
`7 1
`2312
`NR
`3q3wk
`51
`3q3wk
`8.60
`2.55
`172
`2q1wk
`8.5
`1 91
`Bilineage
`OFF STUDY
`47
`1q3wk - none
`8.70
`0 46
`16
`2q2wk
`9.3
`0 42
`trans + pll
`
`13 40
`
`—
`
`8.70
`
`202wk
`
`133
`
`242
`
`10.10
`
`303wk
`
`115 7- 242
`
`9 50 2quk
`8 00
`2q2wk
`
`nil
`304wk
`2q4wk
`
`nil
`302wk
`
`9.30
`7 00
`6.80
`
`10.20
`8.10
`
`9 10
`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
`
`22
`23
`24
`25
`26
`27
`28
`29
`
`74
`
`81
`
`52
`
`73
`
`56
`69
`
`47
`69
`68
`
`75
`52
`66
`66
`67
`78
`66
`66
`
`M
`
`F
`
`M
`
`M
`M
`
`M
`M
`M
`
`M
`F
`M
`F
`M
`F
`M
`F
`
`RA
`
`RA
`
`RAEB
`
`RA
`RAEB
`
`RA
`RA
`RA
`
`RA
`RA
`RAEB
`RA
`RA
`RA
`RA
`RA
`
`2.41
`
`1.60
`
`0.29
`
`0.55
`0.91
`
`3.48
`1.04
`0.31
`
`7.3
`
`201wk
`
`110
`
`2.01
`
`10.00
`
`2q1wk
`
`6.9
`
`6.7
`
`7.9
`7 6
`
`9 4
`9.3
`9.2
`
`202wk
`
`229
`
`1 94
`
`7 90
`
`2q2wk
`
`3q1wk
`
`21
`
`0 16
`
`8.50
`
`3q1wk
`
`1q4wk
`2q1wk
`
`nil
`304wk
`NA
`
`159
`6
`
`0.32
`0.93
`
`27
`41
`63
`
`1.98
`0.68
`0.176
`
`7.60
`7.70
`
`8.10
`7.30
`6.40
`
`202wk
`2q1wk
`
`nil
`3q4wk
`2q4wk
`
`138
`
`161
`
`21
`
`81
`20
`
`19
`28
`66
`
`2.54
`
`5.58
`
`NA
`
`O 64
`1 56
`
`5.77
`4.2
`1 18
`
`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 with excess blasts; ANC. absolute
`neutrophil count/mL; Hb, hemoglobin in g/dL: RBC Trans, number of units of packed red blood cells transfused: q, every; wk, weeks; Pll. platelels in thousands per microliter;
`NA. not available for that date; +D. with dexamethasone; Responses: ANC, response in neutrophils: Plt, response in plalelet counts; Hb. response in hemoglobin levels:
`pRBC > 50%, decrease in 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 shown in Table 1.
`
`Protocol compliance and toxicity
`
`Of the 35 patients registered on MDS 96-02, 3 died before 12
`weeks of therapy could be completed,
`1 discontinued therapy
`because of intolerable nausea,
`1 had a myocardial
`infarction and
`discontinued therapy within 4 weeks, and 1 was registered but
`never started treatment. Ofthe 29 patients who could be evaluated
`for response because they completed at least 12 weeks oftherapy, 9
`were treated on the 200 mg/M2 dose ofamifostine, 8 on the 300
`nig/MI dose, and 12 on the 400 mg/MZ. Twelve patients received
`
`the highest dose ofamifostinc 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 ofti (7500) received the intermediate dose, and 9 01"12
`(76%) received the highest dose ofamifostine (P = .98). Although
`29 patients completed 12 weeks of therapy, only 8 patients
`completed 6 months, 5 completed 9 months. and 3 completed the
`full year 01. treatment specified in the protocol. Sixteen patients
`stopped treatment because there was no further improvement in
`their cytopenias. 5 stopped because of intolerable side effects, 5
`showed progression ot‘diseasc. 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
`
`

`

`BLOOD,1 MARCH 2000 . VOLUME 95, NUMBER 5
`
`PALLIATIVE THERAPY FOR MDS
`
`1583
`
`
`Table 2. Adverse effects of amifostine by dose groups
`Grade (“lo Patients)
`
`Symptom
`Group
`Grade 1
`Grade 2
`Nausea
`1
`3.6
`0
`2
`14
`3.6
`
`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
`
`Vomiting
`
`Decreased appetite
`
`Hypolension
`
`RaSh
`
`Fever
`
`Depression
`
`Of the 29 evaluable patients. 7 had no response after at least 12
`3'6
`123.6
`:1!
`weeks of therapy whereas 22 of29 (76%) showed partial response
`7
`7
`2
`in that there was improvement in their eytopenias. There were no
`7
`3.6
`3
`complete responders. Seven patients showed some improvement
`0
`0
`1
`before the addition ofdexamethasonc, and 15 only responded after
`3.6
`0
`2
`PCD + amifostinc. The median time to response varied depending
`0
`3.6
`3
`on the lineage and on whether the patient received dexamethasonc.
`0
`0
`1
`Nineteen patients showed an improvement in ANC, 11 in hemoglo-
`7
`0
`2
`bin or transfusion requirements, and 7 in platelet count. Overall,
`7
`0
`3
`.
`.
`.
`.
`3.6
`3.6
`2
`there were 3 triple lineage responders, 10 double lineage respond-
`0
`0
`1
`crs, and 9 smgle lineage responders (8 019 in ANC only; 1 showed
`3.6
`0
`3
`more than 50% reduction in PRBC transfusions). The details of
`0
`0
`1
`these responses and the precise blood counts are shown in Table 1.
`H
`0
`2
`In summary, two-thirds of the responding patients had improved
`0
`0
`3
`ANC, half showed improvement
`in the erythroid lineage, and
`o
`0
`1
`one—third showed improvement in their platelet counts. Improve-
`0
`0
`2
`ments in these eytopenias were noted more rapidly after the
`0
`0
`3
`addition of dexamethasone, whereas a more gradual
`improve-
`0
`0
`1
`Amely
`
`
`
`: ment occurred in the patients who did not receive the additional g :6
`steroid therapy.
`Group 1,amifostine 200 mg/M2 intravenously 3 times a week; group 2. amifosline
`Significant statistical improvement was seen in ANC after 16
`300 mg/M2 intravenously 3 times a week; group 3, amitostine 400 mg/M2 intrave-
`weeks (P = .01) and 24 weeks (P = .02) of therapy. The erythroid
`nously 3 limes a week.
`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 + amifostinc:
`
`therapy. Approximately halfthe 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 who received the lowest dose. For example, in the 200 mg/M2
`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
`
`Patient 14
`
`This 81-year—old white man was diagnosed with RA on 11/1/96
`(Table 1, Figure 2a). He had a hypcrcellular 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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`Figure 1. Graphic presentation ofabsolute neutrophil
`counts in patients with MDS during therapy.
`
`2.00
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`
`DR. REDDY’S LABS., INC. EX. 1020 PAGE 4
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`

`

`1584
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`Figure 2. Graphic presentation of peripheral
`blood indices in 4 (A—D) patients treated with
`PCB and amifostine. '2 U PRBC transfusion.
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`338315
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`149 OOO/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, was the gradual increase
`in his hemoglobin values between transfusions. Once the transfu-
`sion requirements stopped, the hemoglobin continued to increase
`until the end ofthcrapy at 1 year, as shown in 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/uL; and platelet count,
`134 OOO/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
`cytogenetie abnormality 46, XY, de120(qll .2ql3.3)/46 X Y). After
`several PRBC transfusions, his 1-1b 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 28, he did require PRBCs twice
`in the next 3 months, but then his Hb level continued to improve,
`reaching a maximum of 13.9 g/dL. His WBC and platelet counts
`
`respectively). After
`also improved (8200 uL and 180 000 uL,
`approximately 11 months of treatment, the patient experienced 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 slow decline in all his counts within 6 weeks
`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 OOO/uL range. He has been showing response to 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 llOO/uL, Hb level was 7.3 g/dL,
`and platelet count was 44 000/dL. He had normal cytogenetics and
`hypereellular BM with 3% blasts. He required 2 U PRBC almost
`every 7 to 10 days and platelets every 2 to 3 weeks. After treatment
`with amifostine + PC, the patient continued to require the same
`level oftransfiisions until dexamethasone was added. At that point,
`he showed a dramatic response by becoming transfusion indepen-
`dent t‘or 5 months. After approximately 8 months of therapy, the
`patient was taken off all medications because no further improvement
`
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`

`

`BLOOD. 1 MARCH 2000 - VOLUME 95. NUMBER 5
`
`PALLIATIVE THERAPY FOR MDS
`
`1585
`
`was noted in the cytopenias. He began to require transfusions
`within 8 weeks of halting therapy and was started on another
`protocol. His condition eventually transformed to AMI. 6 months
`later, and he died on 8/13/98.
`
`Patient 7
`
`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 I, Figure 2D). He began treatment on I/13/97 when
`his l-Ib was 8.9 g/dL (after PRBC transfusion), WBC count was
`3000/pL, and platelet count was 18 OOO/uL. He was receiving 2 U
`PRBC every 7 to 10 days and platelet transfusions every I
`to 3
`weeks. His BM was hypocellular (10% cellularity), and cytogenet-
`ics showed an abnormal karyotype with 46XY, de(7) t(l;7) (q10;
`p10)/46, XYde(I4) t(I;I4) (q10; p10)(2)/46XY(I4). 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 and platelet transfusions twice in the last year, both
`times because he was undergoing elective hip replacement surgery.
`At present, he continues to be transfusion independent.
`
`Cytogenetlc studles
`
`Detailed karyotypes were performed in every patient. Fourteen
`patients had normal karyotypes when therapy was begun, and 15
`patients showed abnormal chromosomes. The most frequent abnor-
`malities affected chromosome 5 or 7 (8 patients), 2 had del20
`abnormality,
`1 had an isochromosome 17 (qu), 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 in this group of29 patients.
`
`
`Discussion
`
`Myelodysplastic syndromes are universally fatal disorders. Be-
`cause erythroid, myeloid, and megakaryocytic cells, and occasion-
`ally B lymphocytes, have been found to be clonal in nature, it is
`likely that the transfomting event(s) has occurred at a pluripotential
`stem cell stage.“ One approach to treating this illness with a
`curative intent would be to target the abnormal clone directly by
`using intensive chemotherapy, stem cell transplantation, or both.
`The associated prohibitive morbidity and mortality, however,
`especially in an elderly group of patients, render these procedures
`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 ofcytopenias
`in these patients. We have observed the presence of extensive
`apoptosis in the bone marrows of as many as 75% of patients with
`MDS.l4 The parallel high levels of TNF-ot18 and IL-lbI7 in these
`marrows suggested that cytokine-mediated apoptosis played a
`significant role in the genesis of cytopenias.32 Accordingly, we
`treated patients with pentoxifylline and ciprofioxacin with or
`without dexamethasone, demonstrating that the administration of
`these therapies resulted in a reduction in the level ofTNF-u in the
`bone marrows of patients with MDSZ" and improvement in the
`cytopenias ofapproximately 40% patients.”
`
`Antifostine. or ethyol, is an organic thiophosphate that exists as
`a pro-drug.33 Alkaline phosphatase in the cell dephosphorylates it
`into an active form. Because normal cells rather than tumor cells
`
`have higher alkaline phosphatase levels, more active drug is
`available to them.33 In the presence ofchemotherapeutic agents, the
`free thiol
`in amifostine provides an alternative target for reactive
`molecules of alkylating or platinum agents and can act as a potent
`scavenger of oxygen-free radicals. These protective effects are
`more pronounced in normal cells because more active drug is
`available to them.33'34 In addition, amifostine has been found to
`stimulate hematopoiesis in humans.35 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 MDS progenitors in vitro.”
`In vivo, amifostine has been useful in stimulating hematopoiesis in
`patients with MDS as well.” In a group ofacute myeloid leukemia
`patients who have poor prognoses, amifostine was found to
`suppress apoptosis, TNF-a, IL-6 production, and telomerase expres-
`sion.36 Because these are desirable therapeutic effects to be
`achieved in patients with MDS, the current study was designed to
`test whether a combination of anti-cytokine (PCD) and cytoprotec-
`tive (amifostine) strategies would be more useful
`than either
`strategy alone. The results
`indicate that although this novel
`approach may not prove to be curative in the long run, it provides
`substantial palliative support for at least some ofthe patients.
`The salient findings ofthis trial can be summarized as follows.
`Of the 29 evaluable patients, none achieved complete remission;
`however, 22 showed partial response. Two thirds ofthe patients had
`improved ANC, half showed an erythroid response, and one third
`had improved platelet counts. The median time to response was
`long, I I to 12 weeks for erythroid and platelet responses even in the
`group administered dexamethasone. Two thirds of the responses
`occurred after the addition of dexamethasone, and one third
`occurred only in response to amifostine, pentoxifylline, and
`ciprofioxacin. 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
`duration, and only 16 patients completed 6 months oftherapy. The
`main reason to discontinue therapy was a lack of continued
`effective response (16 patients). Others included intolerable side
`effects (5 patients) and disease progression (5 patients). For 12 to
`16 weeks therapy was fairly well tolerated, and no differences were
`noted in the response rates among the 3 dose schedules. Toxicity,
`especially nausea, was higher in the highest dose group. There was
`a response seen in every FAB category,
`including 1 patient
`with CMMoL.
`
`Amifostinc + PCD therapy appears to be a positive addition to
`treatment options for patients with MDS. The results of this
`combination are better than those seen with PCD alone27 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”37
`because of