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`A Phase I Trial of Recombinant Human Interleukin-11 (Neumega rhIL-11
`Growth Factor) in Women With Breast Cancer Receiving Chemotherapy
`By Michael S. Gordon, Worta J. McCaskill-Stevens, Linda A. Battiato, John Loewy, David Loesch, Elyse Breeden,
`Ron Hoffman, Kathleen J. Beach, Bernice Kuca, James Kaye, and George W. Sledge, Jr
`
`We performed a phase I trial of recombinant human in-
`terleukin-11 (rhlL-11) in women with breast cancer. Co-
`horts of three t o five women were accrued t o five dosage
`levels of rhlL-11 (10. 25, 50, 75, and 100 pglkgld). rhlL-11
`alone was administered by a daily subcutaneous injection
`for 14 days during a 28-day prechemotherapy "cycle 0."
`Patients (pts) subsequently received up t o four 28-day cy-
`cles of cyclophosphamide (1,500 mg/m*) and doxorubicin
`(60 mg/m2) chemotherapy followed by rhlL-11 at their as-
`signed dose (days 3 through 14). Sixteen pts (13 stage IV,
`3 stage 111B) were accrued t o this study. Median age was
`53 years and median Eastern Cooperative Oncology Group
`Performance Status was 0. A grade 3 neurologic event was
`seen in 1 pt at 100 pg/kg. Because of the degree of grade
`2 constitutional symptoms (myalgias/arthralgias and fa-
`tigue) at 75 pglkg, dose escalation was stopped and 75
`pg/kg was the maximally tolerated dose. No other grade
`3 or 4 adverse events related t o rhlL-11 were seen. The
`
`T problem for cancer patients receiving chemotherapy.
`
`HROMBOCYTOPENIA has become an increasing
`
`Because the use of the myeloid colony-stimulating factors
`(CSFs) has reduced the incidence of febrile neutropenia after
`standard-dose chemotherapy, the administration of more
`dose-intensive chemotherapy regimens has been pursued.'
`As a result, greater degrees of acute and prolonged thrombo-
`cytopenia are increasingly being observed. This has resulted
`in an increased utilization of platelet transfusions with the
`inherent increased risk of transfusion-related infectious com-
`plications. In addition, the quality of life of those patients
`requiring frequent blood counts and transfusions is impaired.
`Although the use of reinfused peripheral blood (PB) progeni-
`tor cells has reduced the degree of thrombocytopenia associ-
`ated with high-dose chemotherapy, this technology is cum-
`bersome and costly. No currently available hematopoietic
`growth factor routinely reduces the degree of thrombocyto-
`penia secondary to cytotoxic chemotherapy in a manner sim-
`ilar to that of the myeloid CSFs.
`Interleukin- 1 1 (IL- 1 1) is a pleiotropic hematopoietic
`growth factor initially detected in the conditioned medium
`derived from the immortalized primate bone marrow (BM)
`stromal cell line PU-34.' The activity of this agent was char-
`acterized by its stimulation of the proliferation of the IL-6-
`dependent plasmacytoma cell line, TI 165. This effect was
`not eliminated by the addition of anti-IL-6 antibodies, show-
`ing that this was a unique factor. The human homologue of
`the IL-11 gene was isolated from a lung fibroblast cell line
`and encoded a 19-kD protein comprised of 178 amino acids.
`This gene is located on chromosome 19.'
`In vitro, IL-11 synergizes with other hematopoietic growth
`factors (eg, IL-3 and c-kit ligand) promoting the proliferation
`of various classes of hematopoietic progenitor cells commit-
`ted to a variety of lineage^.^.^ As a single agent, IL-11 in-
`duces the maturation of early megakaryocytes by increasing
`megakaryocyte size and ploidy.6 In preclinical in vivo mod-
`els, IL- 1 1 stimulates platelet production in normal animals,
`including mice and nonhuman primates. This effect is dose-
`
`administration of rhlL-11 was not associated with fever.
`Reversible grade 2 fatigue and myalgiaslarthralgias were
`seen in all pts at 75 pglkg. Weight gain of 3% t o 590 associ-
`ated with edema was seen at doses >10 pg/kg but a capil-
`lary leak syndrome was not seen. rhlL-11 alone was associ-
`ated with a mean 7690, 93%. 108%. and 185% increase in
`platelet counts at doses of 10,25,50, and 75 pg/kg. respec-
`tively. No significant changes in leukocytes were seen. A
`mean 19% decrease in hematocrit was observed. Acute-
`phase proteins increased with treatment at all doses.
`Compared with patients at the 10 pg/kg dose, patients
`receiving doses 225 pg/kg experienced less thrombocyto-
`penia in the first t w o cycles of chemotherapy. We conclude
`that rhlL-11 has thrombopoietic activity at all doses stud-
`ied, is well tolerated at doses of 10,25, and 50 pg/kg, and
`at doses 225 pg/kg has the potential t o reduce chemo-
`therapy-induced thrombocytopenia in this model.
`0 1996 by The American Society of Hematology.
`
`related and is characterized by increases in peripheral platelet
`counts, which peak approximately 14 to 21 days after initia-
`tion of administrati~n.'.~ Multilineage effects, including in-
`creases in reticulocytes and white blood cell (WBC) subsets,
`have been seen in several of these preclinical models.' After
`the administration of chemotherapy to mice, IL- 1 1 signifi-
`cantly accelerates the multilineage recovery of hematopoie-
`s ~ s . ~ When IL-11 is administered in a murine transplant
`model, it demonstrates similar multilineage effects, acceler-
`ating the recovery of platelets, neutrophils, and reticulo-
`cytes."
`Based on its in vitro and in vivo preclinical thrombopoietic
`activity, we hypothesized that IL-11, having potential throm-
`bopoietic activity and multilineage hematologic effects,
`would be an ideal hematopoietic growth factor to diminish
`the degree of chemotherapy-related thrombocytopenia. Our
`goal was to assess the safety and biologic properties of the
`recombinant protein (Neumega rhIL-11 growth factor; rhIL-
`1 1). In our study, rhIL- 11 was administered to women with
`breast cancer both before and after dose-intensive chemo-
`
`From Section of Hematology/Oncology, Indiana University
`School of Medicine, Indianapolis; Hematology/Oncology Section,
`University of Illinois College of Medicine, Chicago; Community
`Hospital of Indianapolis, Indianapolis, IN; and Genetics Institute,
`Cambridge, MA.
`Submitted October IO, 1995; accepted February 13, 1996.
`Supported by Genetics Institute and in part by Public Health
`Service Grant No. MOI RR750. M.S.G. is a recipient of an American
`Cancer Society Clinical Oncology Career Development Award.
`Address reprint requests to Michael S. Gordon, MD, UH-I 730,
`550 N University Blvd, Indianapolis, IN 46202-5265.
`The publication costs of this article were defrayed in part by page
`charge payment. This article must therefore be hereby marked
`"advertisement" in accordance with 18 U.S.C. section I734 solely to
`indicate this fact.
`0 1996 by The American Society of Hematology.
`0ooS-4971/96/8709-08$3.00/0
`
`Blood, Vol 87, No 9 (May 1). 1996: pp 3615-3624
`
`3615
`
`ALVOGEN, Exh. 1021, p. 0001
`
`

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`by guest For personal use only.on November 20, 2017.
`www.bloodjournal.org
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`From
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`3616
`
`therapy. We report that rhIL-11 is well tolerated at clinically
`relevant doses and has thrombopoietic activity in women
`with normal hematopoiesis. When administered after the ad-
`ministration of dose-intensive chemotherapy, rhIL- 1 1 at
`doses of 25 to 75 pgkg subcutaneously (SC) daily has the
`ability to attenuate the development of severe thrombocyto-
`penia.
`
`MATERIALS AND METHODS
`Parienr eligibility. Women with pathologically confirmed breast
`cancer that was either locally advanced (stage IIIB) or metastatic
`(stage 1V) were eligible for the study if they met the following
`criteria: age 18 years or older; practicing an approved method of
`birth control with a negative Beta Human Chorionic Gonadotropin
`(P-HCG) pregnancy test (if appropriate); an Eastern Cooperative
`Oncology Group (ECOG) performance status of 5 1; at least 4 weeks
`from prior adjuvant chemotherapy with complete recovery from all
`toxicity; adequate hepatic and renal function (total bilirubin level
`52.0 mg/dL, blood urea nitrogen (BUN) 5 3 0 mg/dL, serum creati-
`nine level 52.0 mg/dL); normal left ventricular ejection fraction
`(250% on radionuclide ejection fraction [RNEF]); no prior cbemo-
`therapy for metastatic disease; and no clinically significant cardiac
`or metabolic disease. Patients were required to be seronegative for
`human immunodeficiency virus and hepatitis B surface antigen.
`Patients with a history of thromboembolic phenomena, prior doxo-
`rubicin exposure of >250 mg/m2, those who were anticipated to
`require radiation therapy during the course of the study, had a contra-
`indication to delaying chemotherapy for 4 weeks, or were receiving
`treatment with corticosteroids, aspirin, nonsteroidal anti-inflamma-
`tory agents, or anticoagulant drugs were excluded. We also excluded
`patients with a documented history of brain metastases or seizures,
`or other cancer within 5 years of study entry (with the exception of
`carcinoma in situ of the uterine cervix or surgically cured nonmela-
`noma skin cancer). Patients were also ineligible if they had received
`radiation therapy or surgery within 2 weeks before study entry, had
`undergone prior pelvic irradiation at any time, or were treated with
`any investigational agent or cytokine within 4 weeks of study entry.
`All patients were required to give written informed consent, and the
`protocol was approved by the Institutional Review Board of the
`Indiana University School of Medicine.
`Study medication. Escherichia coli-derived, nonglycosylated
`rhIL-11 (Neumega rhIL-11 growth factor) was provided by Genetics
`Institute (Cambridge, MA). Vials containing 5 mg/mL of rhIL-ll
`in 1 mL of USP Sterile water for injection were used. Vials were
`used only once and then discarded. The specific activity of the rhIL-
`I 1 was determined by a bioassay on the basis of [3H]-thymidine
`incorporation in a responsive cell line and was >0.6 X IO6 U/mg.
`The study agent contained less than 1 ng of endotoxin by Limulus
`amoebocyte lysate assay Cyclophosphamide, doxorubicin, and Neu-
`pogen (Amgen Inc, Thousand Oaks, CA) (granulocyte colony-stimu-
`lating factor [G-CSF]) were obtained commercially.
`Study design.
`The study schema is shown in Fig 1. In this open-
`label, nonrandomized phase I trial, 16 patients were enrolled between
`December 1992 and December 1993. Cohorts of three to five patients
`were accrued to each of four planned dose levels of rhIL-11 including
`10, 25, 50, and 75 pg/kg/d. rbIL-11 was administered as a daily
`subcutaneous injection for 14 days followed by a 14-day washout
`period during a 28-day prechemotherapy safety period termed cycle
`0. Patients were observed for 6 hours in the General Clinical Re-
`search Center at Indiana University Medical Center after each of the
`first three doses of rhIL- 11 and continued to be treated as outpatients
`thereafter.
`After completion of cycle 0, patients received up to four monthly
`cycles of chemotherapy consisting of cyclophosphamide 1,500 mg/
`
`GORDON ET AL
`
`rhlL-11 -
`
`I
`
`1
`
`Day
`
`I
`
`14
`
`Cycle 0
`
`I
`
`28
`
`Day
`
`1 3
`
`I
`
`14
`
`Cycles 1-4
`
`28 I
`
`Fig 1. Study schema. Cohorts of at least three patients were ac-
`crued to each of the planned dose levels of rhlL-11. During the preche-
`motherapy phase termed cycle 0, rhlL-11 was administered by a daily
`SC injection for 14 consecutive days followed by 14 days of observa-
`tion. Subsequently, patients received up to four monthly cycles of
`chemotherapy. Cyclophosphamide (1,500 mg/mz) and doxorubicin
`(60 mg/m') were administered on day 1 of each cycle (dark arrow),
`followed by daily SC injections of rhlL-11 at their assigned dose for
`12 days (days 3 through 14).
`
`m2 and doxorubicin 60 mg/m2 on the first day of each 28-day cycle.
`All patients received rhIL-I1 at their assigned dose for 12 days (days
`3 through 14) following the administration of chemotherapy. Any
`patient who experienced severe neutropenia defined as a febrile neu-
`tropenic event or an absolute neutrophil count 5500 cells/pL for
`more than 5 days during cycles 1 or 2 were eligible to receive
`Neupogen at a dose of 5 pgkgld administered SC from day 3 through
`neutrophil recovery (absolute neutrophil count 22,000 cells/pL for
`3 days) in cycles 3 and 4. There was no intrapatient dose escalation
`allowed. If at any time the platelet count increased to greater than
`600,00O/pL during rhIL-l 1 administration, rhIL-11 was diston-
`tinued during that cycle of therapy.
`Dose escalation was based on adverse events seen in cycle 0
`only and was allowed if none of the three patients at a given dose
`experienced grade 3 or greater adverse events in the first 14 days
`of IL-I 1 therapy. If one of the three patients experienced a serious
`adverse event, an additional two patients were added to that cohort.
`Dose-limiting toxicity (DLT) was defined as the dose which resulted
`in two or more patients with grade 3 or greater toxicity. The maxi-
`mally tolerated dose (MTD) was defined as the dose level immedi-
`ately below that which resulted in DLT. An additional three patients
`were allowed to be accrued to either the MTD or, in the absence of
`establishing an MTD, to a safe, biologically active dose. These
`additional patients did not receive rhIL-11 during cycle 0, and were
`treated only in cycles 1 through 4 of the study. Patients experiencing
`grade 3 or greater toxicity were removed from the study. All toxici-
`ties were graded according to the World Health Organization (WHO)
`common toxicity criteria."
`All patients underwent a thorough physical exami-
`Evaluations.
`nation including vital signs and ECOG performance status before
`enrollment on the study. This evaluation was repeated at intervals
`throughout the study. An RNEF (MUGA scan) was performed before
`
`ALVOGEN, Exh. 1021, p. 0002
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`

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`by guest For personal use only.on November 20, 2017.
`www.bloodjournal.org
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`PHASE I TRIAL OF rhlL-11
`
`Table 1. Characteristics of Patients
`
`No. of patients
`Median age (range)
`Median ECOG PS (range)
`Stage
`Ill6
`IV
`Menopausal status
`Premenopausal
`Postmenopausal
`
`16
`53 (26-67)
`0 (0-1)
`
`3
`13
`
`4
`12
`
`enrollment and repeated after the second and fourth cycles of chemo-
`therapy. A chest radiograph and electrocardiogram were obtained at
`baseline, after the completion of rhIL-11 administration in cycle 0
`(day 15, cycle 0) and at the end of cycle 0 (day 28). Complete blood
`counts including a manual differential count, absolute reticulocyte
`count, and an automated quantitation of platelet size were obtained
`at baseline and three times per week during cycles 0 through 4.
`Patients who developed platelet counts ~600,000/pL during cycle
`0 underwent daily complete blood counts until the platelet count
`decreased to below this level. Urinalysis, coagulation profiles, serum
`chemistries, and serum levels of acute phase proteins (C-reactive
`protein, fibrinogen, and haptoglobin) were performed at baseline and
`at varying intervals during cycles 0 through 4.
`BM aspirates and trephine biopsies for morphology, progenitor
`cell numbers, immunophenotyping, and megakaryocyte ploidy anal-
`ysis were performed at baseline and after completion of rhIL- 11
`administration in cycle 0 (day 15, cycle 0).
`Serum samples were evaluated
`Serum anti-ll-ll antibodies.
`for the development of anti-IL-11 antibodies by an enzyme-linked
`immunoabsorbent assay (ELISA). Serum samples were obtained at
`baseline, on day 15 of cycle 0, and before the start of each cycle of
`chemotherapy (cycles 1 through 4) and at the follow-up visit 4 weeks
`after the end of the last chemotherapy cycle.
`Clinical response criteria.
`Tumor measurements were obtained
`at baseline, after completion of cycle 0, and after the second and
`fourth cycles of chemotherapy. Clinical response was evaluated by
`comparing tumor measurements obtained from radiographic or phys-
`ical examination findings. Standard Eastern Cooperative Oncology
`Group breast cancer response criteria were used. Any patient who
`was found to have progressive disease at any time was removed
`from the study.
`Statistical analysis.
`Dose-limiting criteria were defined by stan-
`dard criteria based on the dose-escalation schema outlined above.
`Analysis of changes in serum chemistries and acute-phase proteins
`was performed using a two-sided Student’s paired t-test. Results of
`hematologic parameters were reported as mean or median values.
`When appropriate, 95% confidence intervals were calculated and
`presented.
`
`RESULTS
`Patient characteristics. Sixteen patients with pathologi-
`cally confirmed breast cancer (3 stage IIIB, 13 stage IV)
`were accrued to this phase I trial. Pretreatment characteristics
`and extent of diseaselprior therapy are shown in Tables 1
`and 2. All 16 were eligible for assessment of safety. Thirteen
`patients received rhIL-11 during cycle 0: 12 patients were
`enrolled in cohorts of 3 at the 10, 25, 50, and 75 pgkg dose
`levels and 1 patient was enrolled at the 100 pgkg dose level.
`After the completion of dose escalation, an additional three
`patients were accrued to the 50 pgkg dose cohort to gain
`
`3617
`
`additional information about the effects of rhIL-11 at this
`dose after chemotherapy. The median age for patients treated
`on this study was 53 years (range, 26 to 67 years). Median
`ECOG performance status was 0 (range, 0 to 1). Nine pa-
`tients had received prior adjuvant chemotherapy, including
`4 who received prior radiation therapy (including patient
`number 008 at the 50 pgkg dose who had previously re-
`ceived lumbar radiotherapy) and 5 who received prior hor-
`monal therapy. Among the remaining patients, 2 had re-
`ceived prior radiotherapy and hormonal therapy, 2 had
`received prior hormonal therapy only, and 3 had received
`no prior therapy (all with stage IIIB disease).
`Treatment with rhIL-11 was generally well
`ZL-11 safety.
`tolerated. All side effects were reported regardless of their
`presumed relationship to rhIL-11 (Table 3). When the rhIL-
`11 alone cycle (cycle 0) is analyzed, the most common side
`effect is a therapy-related anemia that occurred in 11 of 11
`patients who completed this phase of the trial. This anemia
`(-20% decrease in hematocrit) generally developed within
`2 to 3 days of the initiation of IL-11 dosing and resolved
`over a 1- to 2-week period after completion of IL-11 therapy.
`Plasma volume studies performed in three patients showed
`increased plasma volumes (20%, 18%, and 21%) from days
`2 to 15. No patient experienced significant blood loss or had
`any laboratory evidence of hemolysis. These increases in
`plasma volume are consistent with the development of the
`anemia.
`The other most frequently reported side effects during
`cycle 0 included constitutional symptoms including arthral-
`gias and myalgias, fatigue, nausea, and headache. Edema of
`the extremities was seen in all except one patient treated at
`doses 2 2 5 pgkg and was primarily dependent in nature.
`The edema typically developed in the second week of rhIL-
`11 therapy and resolved after completion of the 14 days of
`treatment. No clinically significant fevers nor capillary leak
`syndromes were seen in patients receiving rhIL- 1 1 during
`cycle 0. Although the majority of the side effects seen were
`mild-moderate (grade 1-2), the constitutional symptoms and
`edema were believed to be dose-related and were more in-
`tense at doses 250 pgkgld. When cycles of IL-11 adminis-
`tered after chemotherapy were evaluated, a similar toxicity
`profile was observed. No other unexpected adverse events
`were identified.
`Five patients were removed from study for adverse events
`believed to be possibly or probably related to the study drug
`(Table 4). Only one patient was removed from study during
`cycle 0 for a severe adverse event (grade 3 or higher). This
`patient, the first treated at the 100-pgkg dose level, experi-
`enced the onset of an expressive aphasia after three doses
`of rhIL-11. Computed tomographic (CT) scan of the head
`showed a 1- to 2-cm left Brocha’s infarct and rhIL-11 ther-
`apy was discontinued. Her platelet count at the time of ad-
`mission for the event was 220,0001pL and her fibrinogen
`level was 670 mg/dL. The patient underwent noninvasive
`doppler evaluation of her carotid arteries which demon-
`strated no clinically significant vaso-occlusive disease. With
`continued observation, the patient recovered to her baseline
`neurologic status. A second patient, with a history of hyper-
`tension, treated at the 50 pgkg dose, was removed after
`
`ALVOGEN, Exh. 1021, p. 0003
`
`

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`From
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`3618
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`Table 2. Extent of Prior Therapy and Sites of Disaase for Enrolled Patients
`
`GORDON ET AL
`
`Pt. No.
`1
`2
`3
`4
`5
`6
`7
`8
`9
`10
`11
`12
`13
`14
`15
`16
`
`Age
`56
`67
`59
`54
`44
`36
`52
`60
`66
`37
`54
`64
`67
`26
`48
`52
`
`Prior Adj Chemo
`Prior RT
`Radiated Sitek)
`Interval
`CMF
`Y
`Chest Wall
`17 m o
`CMF
`29 m o
`N
`NIA
`CAFICMF
`19 m o
`N
`NIA
`CMF
`12 m o
`N
`NIA
`None
`NIA
`N
`NIA
`None
`NIA
`N
`NIA
`CAF
`100 m o
`Y
`Breast
`None
`N/A
`Y
`Lumbar spine
`None
`NIA
`N
`NIA
`CMF
`Y
`Breast
`12 m o
`CMF
`Y
`Breast
`34 m o
`None
`NIA
`N
`NIA
`None
`NfA
`Y
`Breast
`NIA
`N
`NIA
`None
`CMF
`7 m o
`N
`NIA
`CMF
`19 m o
`N
`NIA
`Abbreviations: CMF. cyclophosphamidelmethotrexateIfluorouraciI; CAF, cyclophosphamide/doxorubicin/fluorouraciI; Pt. No, patient number;
`Adi Chemo, adjuvant chemotherapy; RT, radiotherapy; NED, no evidence of disease; LN, lymph node; Y, yes; N, no; NIA, not applicable.
`
`Stage
`IV
`IV
`IV
`IV
`IllB
`IV
`IV
`IV
`IllB
`IV
`IV
`IV
`IV
`IllB
`IV
`IV
`
`Site(s) of Disease
`Bone
`Liver
`Liver
`NED
`Breast
`NED
`LN
`BonefChest Wall
`Breast
`LNIBreast
`Pulmonary
`Pulmonary
`Pulmonary
`Breast
`Chest Wall
`NED
`
`identification of a 1- to 2-cm intracerebral bleed at the time
`of the nadir of her blood counts following chemotherapy
`during cycle 1. This patient was admitted to the hospital
`with an episode of neutropenic fever and staphylococcal
`sepsis. Mental status changes were investigated with a CT
`scan of the head, which showed a small intracerebral bleed
`in the setting of chronic hypertensive cerebrovascular dis-
`ease. The patient was removed from study and recovered
`completely with no significant sequelae from this event. The
`third patient, enrolled on the 75-ygkg dose level, withdrew
`from the study after completion of cycle 1 because of what
`she perceived as unacceptable constitutional symptoms char-
`acterized by fatigue, arthralgias and myalgias, and edema.
`A final two patients were removed because of indwelling
`catheter-related complications of infection and thrombosis.
`Reasons for the removal of additional patients who failed to
`complete the entire four cycles of chemotherapy included:
`progression of disease (two patients), change in therapy to
`
`Table 3. Adverse Clinical Effects of rhlL-11 During Cycle 0
`(All Grade 1 and 21
`
`rhlL-11 (pglkgid)
`
`10
`
`3
`
`1
`
`2
`
`0
`3
`3 0
`3
`0
`3
`0
`2
`0
`1
`0
`2
`0
`0
`3
`0
`0
`
`25
`
`3
`
`50
`
`3
`
`1
`
`1
`1
`1
`2
`1
`3
`0
`2
`0
`
`2
`
`2
`0
`1
`0
`0
`0
`0
`1
`0
`
`1
`
`1
`2
`1
`2
`1
`1
`1
`0
`2
`
`2
`
`2
`0
`2
`0
`0
`1
`1
`0
`0
`
`75
`
`3
`
`1
`
`2
`
`2
`0
`1
`1
`3
`0
`0
`1
`1
`1
`1
`2
`1
`1
`1 1
`2
`0
`
`100
`
`1
`
`1
`
`0
`0
`0
`0
`0
`1
`0
`1
`0
`
`2
`
`0
`0
`0
`0
`0
`0
`0
`0
`0
`
`
`
`
`
`
`
`
`
`
`
`
`
`No. Assessable Pts
`
`WHO Grade
`
`Anemia
`Arthralgia/myalgia
`Fatigue
`Rhinorrhea
`Nausea
`Edema
`Headache
`Injection site rxn
`Tachycardia
`
`Abbreviation: rxn, reaction.
`
`BM transplant (one patient), and neutropenic sepsis (one
`patient).
`Anti-rhIL- 1 1 antibody
`Serum anti-rhlL-11 antibodies,
`formation was assessed in all 16 patients. Two subjects were
`observed to demonstrate an anti-rhIL-11 response that was
`consistent with antibody formation as a result of product
`exposure. Of these two, one subject showed a positive re-
`sponse at the follow-up visit only, but had insufficient sample
`to confirm the authenticity of this titer. The other subject
`had a relatively low titer 14 days after product exposure,
`and although this subject did not have a detectable titer at
`the follow-up visit (26 days postexposure), there was a faint
`reactivity with the rhIL-11 band when this sample was ana-
`lyzed by Western immunoblot analysis.
`Hematologic effects of IL-1 I during cycle 0.
`In the first
`course of therapy IL-11 was administered alone, 4 weeks
`before chemotherapy, to allow the evaluation of the safety
`as well as the hematologic and hematopoietic effects of IL-
`1 1 . Treatment with IL- 11 alone was associated with a dose-
`related increase in platelet counts. Increases of 76%, 93%,
`108%, and 185% over baseline values were seen at the
`IO-, 2 5 , 50-, and 75-pgkg/d dose levels, respectively (Fig
`2A through D). This thrombocytosis was characterized by
`an initial slight transient decrease in platelets within the
`first 2 days of IL-I 1 therapy. Subsequently, platelet counts
`gradually increased to their peak levels over the 2 weeks of
`treatment. Maximal platelet counts occurred at a median of
`18, 19, 16, and 14 days from the initiation of therapy for
`
`Table 4. Reasons for Discontinuation of rhlL-11 Therapy
`
`Pt. No. Dose (pglkg)
`
`Reason
`
`009
`010
`012
`013
`016
`
`50
`75
`75
`100
`50
`
`Intracerebral bleed during nadir
`Intolerable grade 2 constitutional and edema
`Central catheter thrombosis
`Right parietal cerebrovascular accident
`Central catheter thrombosis
`
`ALVOGEN, Exh. 1021, p. 0004
`
`

`

`From
`
`by guest For personal use only.on November 20, 2017.
`www.bloodjournal.org
`
`
`
`
`
`
`e
`
`'Oo0
`
`3. -
`= 800
`700
`r 5 600
`2 500
`0
`
`l
`
`-t 002
`
`3619
`
`
`
`900 - -
`
`t 800
`0 0
`," 700
`
`X
`I
`
`600
`
`C
`500
`u
`400
`0 -
`2 300
`-
`n
`200
`
`u
`
`400
`
`c ; 300 : 200
`
`c
`
`100
`
`0
`
`j
`
`loo0 900
`
`700
`0 r
`
`8 400
`,0°1
`300
`
`200
`
`100
`
`0 4 8 12 1 6 20 24 28
`
`loo 0
`
`0
`
`4
`
`8 12 16 20 24 2 8
`
`-
`
`Oo7
`
`-t-
`
`l
`
`A
`
`i
`
`D
`
`
`
`1000 1
`j -0- 010
`900 -
`3 800 .
`0 8 700
`r
`X
`600
`c 5 500
`u
`400
`
`-
`100 1
`
`I
`0
`5 300
`m
`
`200
`
`PHASE I TRIAL OF rhlL-11
`
`Fig 2. Thrombopoirtic &e&
`of rhll-11 during cy-
`cle 0. Before the administration of chemotherapy,
`rhlL-11 was administered for 14 consecutive days
`(days 1 through 14) followed by 14 days of observa-
`tion (days 15 through 28). Platelet counts for ell pa-
`tients treated at the lo-, 25-, 50-, and 75-pglkgld
`dose levels are shown in (A) through ID), respec-
`tively.
`
`0 4 8 12 16 20 24 28
`
`day of treatment
`
`
`
`-
`
`0
`
`0 4 8 12 16 20 24 28
`day of treatment
`
`the four dose levels, respectively. After completion of rhIL-
`11 therapy, platelet counts gradually decreased, and all re-
`turned to baseline pretreatment values by the initiation of
`cycle 1. There were no significant changes in the mean plate-
`let volume after IL-11 therapy at any doses studied and
`platelet aggregometry performed pretreatment and on day
`15 demonstrated no consistent evidence of an IL- 11 -related
`effect on platelet function.
`IL-11 was associated with a decrease in hematocrit which,
`at the doses studied in this trial, was not dose-related. This
`phenomenon is graphically displayed in Fig 3A and B. An
`initial decrease in hemoglobin levels was identified within
`48 hours of the initiation of therapy and continued through
`the course of treatment. A mean 20% decrease in hematocrits
`was identified for all patients at all doses. This effect was
`associated with a modest reticulocytosis (data not shown).
`IL-11 had no detectable effects on the numbers of WBCs or
`subsets of WBCs.
`Hematologic effects of IL-11 afer chemotherapy.
`Of the
`16 patients enrolled on the study, 12 received rhIL-11 at
`their assigned dose after at least two cycles of chemotherapy.
`
`The median platelet counts for the first cycle of chemother-
`apy are shown in Fig 4. Although no patient developed se-
`vere thrombocytopenia in the first cycle of chemotherapy
`(defined as a platelet count <20,OOO/pL), the median nadir
`platelet counts for patients receiving rhIL-11 at doses 2 2 5
`mgkg/d appear to be higher compared with those patients
`treated at the 10-pg/kg/d dose. Table 5 reports the nadir
`platelet counts for each patient across the first two cycles of
`planned chemotherapy. Mean nadir platelet counts of 67,
`159, 152, and 161,OOO/pL were seen during the first cycle
`in the lo-, 25-,50-, and 75-pgkgld dose levels, respectively.
`This apparent attenuation of thrombocytopenia at doses of
`25, 50, and 75 pgkg was also evident during the second
`cycle of therapy where mean nadir platelet counts of 44,OOO,
`140,000, 126,000, and 102,000/yL were seen for the four
`doses, respectively. Unfortunately, patient drop-out (only 9
`patients completed cycle 3 and 7 completed cycle 4) makes
`the evaluation of IL-11's effects on thrombocytopenia in the
`latter two cycles difficult. However, there does appear to be
`a trend toward a continued attenuation of severe thrombocy-
`topenia at doses 2 2 5 pg/kg/d. Platelet transfusions were
`
`ALVOGEN, Exh. 1021, p. 0005
`
`

`

`From
`
`3620
`
`I*
`
`by guest For personal use only.on November 20, 2017.
`www.bloodjournal.org
`
`
`
`
`
`
`I 001 -
`002 -
`003 -
`004 -
`
`005
`I 006
`
`'-
`
`rnnn .
`
`GORDON ET AL
`
`I
`0 700
`0 0
`
`600
`
`500
`
`- -
`.
`-
`E
`0 -
`" 400
`J
`< 300
`L m -
`
`200
`
`100
`
`0
`
`1
`
`3
`
`5
`
`8
`
`1 0 1 2 15 1 7 1 9 2 2 2 4 2 6
`
`Days of Cycle 1
`
`Fig 4. Median platelet counts during cycle 1 of chemotherapy.
`The median platalet counts for patients treated at doses of 10 to 75
`pglkgld of rhlL-11 in cycle 1 of chemotherapy are shown. Nadir plate-
`let counts for all doses occurred on or around day 12 of the cycle.
`
`20 !
`
`0
`
`.
`
`I
`4
`
`.
`
`I
`8
`
`.
`
`.
`
`,
`1 2
`
`I
`1 6
`
`.
`
`I
`
`20
`
`.
`
`I
`24
`
`.
`
`28 508
`- -
`-
`011 -
`c - 40b
`
`Q
`
`.-
`
`010
`
`012
`
`I
`
`cycle appeared to be constant during each of the cycles of
`therapy. Eight patients were transfused with packed red
`blood cells a total of 1 1 times, with three of these eight
`patients having two transfusions each.
`IL-11 did not ameliorate the leukopenia or neutropenia
`associated with our moderately dose-intensive chemother-
`
`e
`
`0
`
`1 2
`
`1 6
`
`2 0
`
`2'4
`
`day of treatment
`
`2'8
`
`~
`
`~
`
`Dose
`(pg/kgl
`
`10
`
`Fig 3. Effects of rhlL-11 on hematocrit in cycle 0. During cycle 0,
`e transient rhlL-11 -related anemia was identified. Hematocrit values
`for patients treated at the 10- and 25-pglkg (AI as well as 50- and
`75-pglkg IB) dose levels are shown. The anemia was rapid in onset
`and maximal on or about day 14 of the cycle. Gradual recovary to
`pretreatment levels were seen after completion of rhlL-11 therapy.
`No patient required transfusion for this rhlL-11 -related anemia.
`
`required once each during cycles 3 and 4 in only one patient
`in the 10 pg/kg cohort (patient 001).
`IL-11 administration did not appear to increase the degree
`of chemotherapy-induced anemia. A mean 20% decrease in
`hematocrits was seen across all cycles of therapy similar to
`that seen in cycle 0. Similar to the anemia seen in cycle 0,
`the IL-11 -related anemia in the chemotherapy cycles was
`generally reversible after completion of IL- 1 1 therapy. Al-
`though there did appear to be a component of cumulative
`myelosuppression in those patients receiving three to four
`cycles of chemotherapy, the impact of the IL- 11 in any given
`
`25
`
`50
`
`75
`
`Table 5. Effect of rhlL-11 on Platrlet Counts
`After Chemotherapy (Cycles 1 and 2)
`
`Pt.
`No.
`
`001
`002
`003
`Mean
`
`004
`005
`006
`Mean
`
`007
`008
`009
`014
`015
`016
`Mean
`
`01 0
`01 1
`012
`Mean
`
`~~
`
`~~~
`
`Cycle 1 (xl.OOO/pLl
`
`~
`
`Cycle 2 ~x1,OOO/~Ll
`
`Pretreatment
`
`Nadir
`
`Pretreatment
`
`Nadir
`
`276
`233
`202
`237
`
`313
`368
`320
`334
`
`252
`161
`436
`291
`309
`197
`274
`
`274
`199
`467
`313
`
`45
`73
`83
`67
`
`124
`209
`145
`159
`
`159
`89
`160
`142
`172
`189
`152
`
`143
`93
`246
`161
`
`266
`340
`-*
`303
`
`45 1
`239
`303
`331
`
`283
`193
`-*
`261
`297
`283
`263
`-*
`373
`405
`389
`
`37
`51
`-*
`44
`
`123
`195
`102
`140
`
`172
`61
`-*
`126
`118
`151
`126
`-*
`86
`118
`102
`
`Data not available because patient discontinued particiption in
`study.
`
`ALVOGEN, Exh. 1021, p. 0006
`
`

`

`From
`
`by guest For personal use only.on November 20, 2017.
`www.bloodjournal.org
`
`
`
`
`
`
`PHASE I TRIAL OF rhlL-11
`
`apy. Based on this observation, patients experiencing severe
`neutropenia (defined as an absolute neutrophil count 4 0 0
`cells/pL for >5 days) or an episode of neutropenic fever in
`cycles 1 or 2 were allowed to receive standard regimens of
`G-CSF (5 ygkg SC once daily) in cycles 3 and 4. A total
`of 33 cycles of chemotherapy were administered without G-
`CSF, whereas seven patients were treated with G-CSF during
`a total of nine cycles of chemotherapy. During cycles in
`which G-CS