Original Article
`
`Acalabrutinib (ACP-196) in Relapsed
`Chronic Lymphocytic Leukemia
`John C. Byrd, M.D., Bonnie Harrington, D.V.M., Susan O’Brien, M.D.,
`Jeffrey A. Jones, M.D., M.P.H., Anna Schuh, M.D., Ph.D., Steve Devereux, M.D.,
`Jorge Chaves, M.D., William G. Wierda, M.D., Ph.D., Farrukh T. Awan, M.D.,
`Jennifer R. Brown, M.D., Ph.D., Peter Hillmen, M.B., Ch.B., Ph.D.,
`Deborah M. Stephens, D.O., Paolo Ghia, M.D., Jacqueline C. Barrientos, M.D.,
`John M. Pagel, M.D., Ph.D., Jennifer Woyach, M.D., Dave Johnson, B.S.,
`Jane Huang, M.D., Xiaolin Wang, Sc.D., Allard Kaptein, Ph.D., Brian J. Lannutti, Ph.D.,
`Todd Covey, B.A., Maria Fardis, Ph.D., Jesse McGreivy, M.D.,
`Ahmed Hamdy, M.B., B.Ch., Wayne Rothbaum, M.A., Raquel Izumi, Ph.D.,
`Thomas G. Diacovo, M.D., Amy J. Johnson, Ph.D., and Richard R. Furman, M.D.
`
`A BS TR AC T
`
`BACKGROUND
`Irreversible inhibition of Bruton’s tyrosine kinase (BTK) by ibrutinib represents an
`important therapeutic advance for the treatment of chronic lymphocytic leukemia
`(CLL). However, ibrutinib also irreversibly inhibits alternative kinase targets, which
`potentially compromises its therapeutic index. Acalabrutinib (ACP-196) is a more selec-
`tive, irreversible BTK inhibitor that is specifically designed to improve on the safety
`and efficacy of first-generation BTK inhibitors.
`METHODS
`In this uncontrolled, phase 1–2, multicenter study, we administered oral acalabrutinib
`to 61 patients who had relapsed CLL to assess the safety, efficacy, pharmacokinetics,
`and pharmacodynamics of acalabrutinib. Patients were treated with acalabrutinib at a
`dose of 100 to 400 mg once daily in the dose-escalation (phase 1) portion of the study
`and 100 mg twice daily in the expansion (phase 2) portion.
`RESULTS
`The median age of the patients was 62 years, and patients had received a median of
`three previous therapies for CLL; 31% had chromosome 17p13.1 deletion, and 75% had
`unmutated immunoglobulin heavy-chain variable genes. No dose-limiting toxic effects
`occurred during the dose-escalation portion of the study. The most common adverse
`events observed were headache (in 43% of the patients), diarrhea (in 39%), and in-
`creased weight (in 26%). Most adverse events were of grade 1 or 2. At a median follow-
`up of 14.3 months, the overall response rate was 95%, including 85% with a partial
`response and 10% with a partial response with lymphocytosis; the remaining 5% of
`patients had stable disease. Among patients with chromosome 17p13.1 deletion, the
`overall response rate was 100%. No cases of Richter’s transformation (CLL that has
`evolved into large-cell lymphoma) and only one case of CLL progression have occurred.
`CONCLUSIONS
`In this study, the selective BTK inhibitor acalabrutinib had promising safety and efficacy
`profiles in patients with relapsed CLL, including those with chromosome 17p13.1 dele-
`tion. (Funded by the Acerta Pharma and others; ClinicalTrials.gov number, NCT02029443.)
`
`The authors’ affiliations are listed in the
`Appendix. Address reprint requests to
`Dr. Byrd at B302 Starling Loving Hall, 320
`W. 10th Ave., Columbus, OH 43210, or at
` john . byrd@ osumc . edu.
`
`Drs. Byrd, Harrington, and O’Brien, and Dr.
`Hamdy, Mr. Rothbaum, Dr. Izumi, Dr.
`Diacovo, Dr. Johnson, and Dr. Furman
`contributed equally to this article.
`
`This article was published on December 7,
`2015, at NEJM.org.
`
`N Engl J Med 2016;374:323-32.
`DOI: 10.1056/NEJMoa1509981
`Copyright © 2015 Massachusetts Medical Society.
`
`n engl j med 374;4 nejm.org
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`Chronic lymphocytic leukemia (CLL)
`
`is the most prevalent leukemia among
`adults. Although chemoimmunotherapy
`prolongs the duration of remission and overall
`survival among most patients with CLL,1,2 re-
`lapse virtually always occurs. This has prompted
`aggressive discovery efforts for new therapies in
`CLL. Because B-cell receptor signaling is a driv-
`ing factor for CLL tumor-cell survival,3,4 proxi-
`mal kinases involved in this pathway have been
`therapeutic targets. Bruton’s tyrosine kinase
`(BTK) is immediately downstream of the B-cell
`receptor and is essential for the activation of
`several tumor-cell survival pathways relevant to
`CLL.5 In addition, BTK is involved in chemokine-
`mediated homing and adhesion of CLL cells to
`the microenvironment, which contribute to their
`maintenance and proliferation.6,7
`In mice and humans, loss of BTK function
`results in a B-cell–dysfunction phenotype with
`decreased serum immunoglobulin levels and an
`increased predisposition to infections. Few other
`adverse effects have been reported.8-10 The unique
`structure of BTK, which is characterized by a
`cysteine (C481) within the ATP-binding pocket,
`makes it an attractive therapeutic target. Ibruti-
`nib is a first-in-class, irreversible small-molecule
`inhibitor of BTK that has the ability to covalently
`bind to C481.11 Ibrutinib has shown substantial
`single-agent activity in patients with relapsed
`CLL and in previously untreated patients.12-14
`Progressive disease during ibrutinib treatment is
`uncommon in patients with previously untreated
`CLL and also in patients with low-risk genomic
`abnormalities.12-14
`Among those with high-risk genomic features,
`progression occurs more frequently, either shortly
`after the start of ibrutinib therapy, owing to
`Richter’s transformation (CLL that has evolved
`into large-cell lymphoma), or later with progres-
`sive CLL.15 Ibrutinib also irreversibly binds to
`other kinases (e.g., epidermal growth factor
`receptor [EGFR], tyrosine kinase expressed in
`hepatocellular carcinoma [TEC], interleukin-2–
`inducible T-cell kinase [ITK], and T-cell X chromo-
`some kinase [TXK]).11 These pharmacodynamic
`features may be responsible for ibrutinib-related
`adverse events that are not typically observed in
`BTK-deficient patients, such as rash, diarrhea,
`arthralgias or myalgias, atrial fibrillation, ecchy-
`mosis, and major hemorrhage.12-14
`
`Acalabrutinib (ACP-196) is a second-genera-
`tion, selective, irreversible inhibitor of BTK that
`has improved pharmacologic features, including
`favorable plasma exposure, rapid oral absorption,
`a short half-life, and the absence of irreversible
`targeting to alternative kinases, such as EGFR,
`TEC, and ITK. Given the success of ibrutinib in
`the treatment of relapsed CLL,12-14 we sought to
`determine whether selective targeting of BTK by
`acalabrutinib would be effective, as measured
`by response and safety profile; side effects repre-
`sent the most common reason that patients dis-
`continue ibrutinib treatment.15,16
`Furthermore, we hypothesized that it might
`be possible to administer acalabrutinib twice
`daily, thus achieving a complete and continuous
`level of drug binding to BTK (>95% over a period
`of 24 hours), without increased toxic effects
`from inhibition of alternative kinases. Full tar-
`get coverage may reduce drug resistance caused
`by mutations in the BTK enzyme and may also
`lower the rate of Richter’s transformation.
`
`Me thods
`
`Study Design
`Preclinical studies with CLL cells and normal
`immune cells were performed according to meth-
`ods outlined in the Supplementary Appendix
`(available with the full text of this article at
`NEJM.org) after written informed consent was
`obtained as part of an institutional review board–
`approved protocol at Ohio State University. The
`phase 1–2 multicenter study was designed to
`determine the recommended dose, safety, effi-
`cacy, pharmacokinetics, and pharmacodynamics
`of acalabrutinib in patients with relapsed CLL.
`All patients provided written informed consent.
`The institutional review board at each participat-
`ing site approved the study protocol (available at
`NEJM.org). The study was conducted according
`to the principles of the Declaration of Helsinki
`and the International Conference on Harmoni-
`sation Good Clinical Practice guidelines.
`
`Patients
`Eligibility criteria included the following: a diag-
`nosis of relapsed CLL or small lymphocytic
`lymphoma, as defined by the International
`Workshop on Chronic Lymphocytic Leukemia
`(IWCLL)17; a need for treatment, according to the
`
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`Downloaded from nejm.org by SHARISSE GEIGER on October 18, 2021. For personal use only. No other uses without permission.
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`Acalabrutinib in Relapsed CLL
`
`IWCLL guidelines; receipt of at least one previ-
`ous therapy for CLL; an Eastern Cooperative
`Oncology Group performance status of 0, 1, or 2
`(on a scale from 0 to 5, with higher numbers
`indicating greater disability); adequate organ
`function, defined by creatinine and bilirubin
`levels of no more than 1.5 times the upper limit
`of the normal range and an alanine aminotrans-
`ferase level of no more than 2.5 times the upper
`limit of the normal range; and an absence of
`active infection. An absolute neutrophil count of
`at least 750 cells per cubic millimeter and a
`platelet count of at least 50,000 per cubic milli-
`meter were required if no bone marrow involve-
`ment was present, but no restrictions for cyto-
`penia were applied if bone marrow involvement
`was present. Exclusion criteria were any cancer
`that limited expected survival to less than 2 years,
`the need for warfarin therapy (other anticoagu-
`lation therapy was allowed), active gastrointes-
`tinal inflammation or malabsorption, and the
`use of medications associated with torsades
`des pointes, high-grade atrioventricular block,
`or a corrected QT interval of 480 msec or
`greater.
`
`Evaluation and Treatment
`All patients had a baseline assessment that in-
`cluded interphase cytogenetic analysis, muta-
`tional analysis of immunoglobulin heavy-chain
`variable (IGHV) genes, measurement of serum
`β2-microglobulin, and inquiry about B symp-
`toms (i.e., weight loss, night sweats, and fever).
`Patients were successively enrolled in cohorts
`that were to receive oral acalabrutinib at a dose
`of 100 mg, 175 mg, 250 mg, or 400 mg once
`daily as part of the dose-escalation (phase 1)
`portion of the study or 100 mg twice daily as
`part of the expansion (phase 2) portion. The
`definition of dose-limiting toxic effects included
`grade 3 or greater nonhematologic toxic effects
`(except for alopecia or nausea, vomiting, or diar-
`rhea that resolved with an intervention); grade 4
`neutropenia lasting more than 5 days; grade 4
`thrombocytopenia, or grade 3 thrombocytope-
`nia with bleeding; grade 3 or greater febrile
`neutropenia; or a dosing delay due to toxic ef-
`fects for more than 7 consecutive days. Escala-
`tion to the next cohort was allowed if fewer than
`two dose-limiting toxic effects were noted in six
`patients.
`
`Disease Evaluation
`Patients were evaluated at screening, weekly for
`the first month, every 2 weeks for the second
`month, monthly for 4 months, and every 3 months
`thereafter. Assessments included history taking,
`physical examination, and laboratory studies for
`signs of toxic effects. Numbers of T cells, natu-
`ral killer cells, and monocytes were measured at
`baseline and before cycles 3, 10, and 16 (each
`cycle lasted 28 days). Serum immunoglobulin
`levels were measured on the same schedule. Ad-
`verse events were graded according to the Na-
`tional Cancer Institute Common Toxicity Crite-
`ria, version 4.03. Hematologic toxic effects were
`graded according to IWCLL criteria.17
`Study end points for phase 1 included safety
`(maximum tolerated dose), pharmacodynamics,
`and pharmacokinetics; end points for phase 2
`included the overall response rate, progression-
`free survival, and long-term side-effect profile.
`Response assessments, including radiologic ex-
`amination, were performed at the end of cycles
`2, 4, 6, 9, 12, 15, 18, and 21 for most patients.
`Bone marrow biopsy was performed in all pa-
`tients at 12 months or when all other criteria for
`a complete response were met. Response was
`evaluated on the basis of the IWCLL criteria,17
`but isolated lymphocytosis was not considered
`to indicate a relapse (a summary of the response
`criteria is available in Table S6 in the Supple-
`mentary Appendix). A partial response in the
`context of lymphocytosis was considered to be a
`partial response with lymphocytosis. Patients
`could be evaluated for efficacy if they had re-
`ceived at least one dose of acalabrutinib and had
`undergone at least one tumor-response assess-
`ment during treatment.
`
`Pharmacokinetic and Pharmacodynamic
`Analyses
`Detailed pharmacokinetic analyses were per-
`formed with the use of a validated assay during
`cycle 1 of therapy. BTK occupancy (the level of
`drug binding to BTK) by acalabrutinib was mea-
`sured in peripheral-blood mononuclear cells with
`the aid of a biotin-tagged analogue probe at
`baseline, 4 hours after administration of acala-
`brutinib on days 1, 8, and 28, and before admin-
`istration of acalabrutinib on days 2, 8, and 28.
`Phosphorylation of BTK was measured by means
`of intracellular flow cytometry. Immunoblot
`
`n engl j med 374;4 nejm.org
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`T h e ne w e ngl a nd jou r na l o f m e dic i ne
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`analysis was performed with the use of methods
`described previously.18 The murine thrombosis
`model has been described previously.19 Addi-
`tional details for laboratory studies are provided
`in the Supplementary Appendix.
`
`Study Oversight
`This study was designed by the first, third, and
`last authors together with the sponsor (Acerta
`Pharma). The clinical investigators and their re-
`search teams collected and evaluated all the data
`and assessed all the patients. The sponsor was
`responsible for analyzing the data. Investigators
`had open access to all data and analyses under
`standard confidentiality agreements. The first
`author wrote the initial draft of the manuscript.
`No professional medical-writing services were
`used. All the authors reviewed the manuscript,
`made the decision to submit the manuscript for
`publication, and vouch for the accuracy and
`completeness of the data and analyses reported
`and the fidelity of the study to the protocol.
`
`Statistical Analysis
`Results are presented through October 1, 2015.
`All the safety and efficacy analyses included
`patients who received acalabrutinib. One patient
`who discontinued treatment after 8 days was
`excluded from the analysis of the overall re-
`sponse rate, according to the protocol, because
`computed tomography had not been performed
`during treatment. However, laboratory assess-
`ments and physical examination showed that the
`patient had had a response and that the disease
`was not progressing when treatment was discon-
`tinued. Descriptive statistics were used to sum-
`marize the findings. The Wilcoxon signed-rank
`test was used to assess the change from baseline
`in immune-cell counts, cytokine levels, and im-
`munoglobulin levels. Only patients with data at
`baseline and for each subsequent follow-up visit
`were included, and no adjustment for multiplic-
`ity was made. Because many exploratory tests
`were performed, P values of less than 0.05
`should not be regarded as definitive, but rather
`as hypothesis-generating. Progression-free sur-
`vival was defined as the time from the first dose
`of acalabrutinib to documented disease progres-
`sion or death and was estimated with the use of
`the Kaplan–Meier method.20 Data on progres-
`sion-free survival for patients who discontinued
`treatment without documented disease progres-
`
`sion were censored at the time of the last clinical
`assessment. Noncompartmental pharmacokinetic
`analyses were performed with the use of vali-
`dated WinNonlin software (Certara USA).
`
`R esults
`
`Mechanism of Action
`The chemical structures of acalabrutinib and
`ibrutinib are shown in Figure S1 in the Supple-
`mentary Appendix. Acalabrutinib showed dose-
`dependent inhibition of B-cell receptor signaling
`in primary CLL cells (Fig. S2A in the Supplemen-
`tary Appendix). In kinase-inhibition assays, aca-
`labrutinib was a more selective BTK inhibitor
`than ibrutinib (Table S1 in the Supplementary
`Appendix). These biochemical findings are physi-
`ologically relevant, because acalabrutinib did not
`inhibit EGFR, TEC, or ITK signaling (Fig. S2B
`through S2D in the Supplementary Appendix).
`The findings provide structural, biochemical,
`and in vitro differentiation of acalabrutinib from
`ibrutinib. These data, combined with objective
`clinical responses in a study of naturally occur-
`ring canine B-cell lymphomas, provided justifi-
`cation for the clinical development of acalabru-
`tinib for the treatment of CLL.21
`
`Patient Demographics
`A total of 61 patients were sequentially enrolled
`at six sites in the United States and the United
`Kingdom and received at least one dose of acala-
`brutinib. The baseline characteristics of the pa-
`tients are listed in Table 1. At a median follow-
`up of 14.3 months (range, 0.5 to 20), 53 patients
`are still receiving treatment. The primary rea-
`sons for treatment discontinuation in 8 patients
`were the investigator’s or patient’s decision in
`the case of 2 patients; active autoimmune hemo-
`lytic anemia that required additional therapy in
`1 patient; fatal pneumonia in 1 patient; adverse
`events of diarrhea, gastritis, and dyspnea in 1 pa-
`tient each; and CLL progression in 1 patient.
`
`Pharmacokinetic Measurements
`Acalabrutinib was rapidly absorbed and elimi-
`nated after oral administration (Fig. 1A). Pharma-
`cokinetic results showed that exposure to acala-
`brutinib increased in a dose-proportional manner,
`with no drug accumulation. Mean peak plasma
`values occurred between 0.6 and 1.1 hours. The
`mean half-life was approximately 1 hour across
`
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`Acalabrutinib in Relapsed CLL
`
`all cohorts. Additional pharmacokinetic mea-
`surements are summarized in Table S2 in the
`Supplementary Appendix.
`
`Pharmacodynamic Measurements
`The binding of acalabrutinib to the C481 residue
`was assessed in all treatment cohorts, with data
`summarized in Figure 1B. Starting with the
`dose of 100 mg once daily, BTK occupancy was
`complete (99 to 100%) 4 hours after dosing and
`ranged from 87 to 95% before dose administra-
`tion with once-daily dosing. Because acalabruti-
`nib has no plasma accumulation, we explored
`the feasibility and safety of a dosing regimen of
`100 mg twice daily. Figure 1C shows improved
`BTK occupancy of 99% 4 hours after dose ad-
`ministration and 97% before dose administra-
`tion on days 8 and 28. The interruption of B-cell
`receptor signaling was also assessed by mea-
`surement of phosphorylated BTK, as shown in
`Figure 1D. After treatment with acalabrutinib,
`complete loss of phosphorylated BTK was ob-
`served at the respective time points across all
`cohorts. Assessment of the in vivo function of
`platelets isolated from the blood of patients re-
`ceiving acalabrutinib or ibrutinib (as a positive
`control) revealed a reduction in platelet–vessel
`wall interactions in the latter but not the former
`in a humanized mouse model of thrombosis
`(Fig. S4 in the Supplementary Appendix). Direct
`natural-killer-cell–mediated cytotoxicity was eval-
`uated with the use of peripheral blood from the
`patients. Non–antibody-dependent cytotoxicity
`was not impaired with acalabrutinib treatment
`as compared with the pretreatment control (Fig.
`S3 in the Supplementary Appendix). Proinflam-
`matory cytokines decreased significantly from
`baseline to day 28 of treatment (Fig. S5 in the
`Supplementary Appendix).
`
`Safety
`Long-term therapy with acalabrutinib has not
`been associated with any high-grade cumulative
`toxic effects. Most of the events that were ob-
`served were grade 1 or 2 and resolved over time
`(Table 2). The most common adverse events were
`headache (with overall events occurring in 43%
`of the patients and grade 3 or 4 events in 0%),
`diarrhea (overall in 39% and grade 3 or 4 in 2%),
`increased weight (overall in 26% and grade 3
`or 4 in 2%), pyrexia (overall in 23% and grade 3
`or 4 in 3%), and upper respiratory tract infection
`
`Table 1. Baseline Demographic and Clinical Characteristics of the Patients.
`
`Characteristic
`
`Age
`
`Median — yr
`
`Range — yr
`
`≥65 yr — no. (%)
`
`≥70 yr — no. (%)
`
`Diagnosis of chronic lymphocytic leukemia — no. (%)
`
`ECOG performance status — no. (%)*
`
`0
`
`1
`
`2
`
`Bulky lymph nodes — no. (%)
`
`≥5 cm in diameter
`
`≥10 cm in diameter
`
`Rai risk classification — no. (%)†
`
`Low
`
`Intermediate
`
`High
`
`No. of previous therapies
`
`Median
`
`Range
`
`Cytopenia at baseline — no. (%)
`
`Absolute neutrophil count ≤1500 μl
`
`Hemoglobin ≤11.0 g/dl
`
`Platelet count ≤100,000/μl
`
`Prognostic factors — no./total no. (%)
`
`Unmutated immunoglobulin variable-region heavy-
`chain gene
`
`Chromosome 17p13.1 deletion‡
`
`Chromosome 11q22.3 deletion‡
`β2-microglobulin >3.5 mg/liter
`
`Value
`(N = 61)
`
`62
`
`44–84
`
`27 (44)
`
`15 (25)
`
`61 (100)
`
`22 (36)
`
`36 (59)
`
`3 (5)
`
`28 (46)
`
`3 (5)
`
`1 (2)
`
`19 (31)
`
`41 (67)
`
`3
`
`1–13
`
`15 (25)
`
`21 (34)
`
`32 (52)
`
`38/51 (75)
`
`18/59 (31)
`
`17/59 (29)
`
`47/58 (81)
`
`* Values for Eastern Cooperative Oncology Group (ECOG) performance status
`range from 0 to 5, with higher numbers indicating greater disability.
`† The Rai stage (which ranges from 0 [low risk] to I or II [intermediate risk] to III
`or IV [high risk]) was derived at the time of screening for this trial.
`‡ Deletion of chromosome 17p13.1 or chromosome 11q22.3 was determined at
`a local laboratory or by a review of the patient’s medical history.
`
`(overall in 23% and grade 3 or 4 in 0%). Severe
`diarrhea, rash, arthralgia or myalgia, bruising,
`and bleeding events each occurred in no more
`than 2% of patients. No major hemorrhage or
`atrial fibrillation was noted. Serious adverse
`events are listed in Table S3 in the Supplemen-
`tary Appendix. Only one death (due to pneumo-
`
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`A PlasmaConcentrationofAcalabrutiniboverTime
`104
`
`B BTKOccupancy,AllCohorts
`100
`
`87%
`
`Before
`
`99% 92%
`After
`175 mg QD
`(N=8)
`
`Before
`
`100%
`After
`250 mg QD
`(N=7)
`Cohort
`
`95%
`
`Before
`
`100%
`After
`400 mg QD
`(N=6)
`
`97%
`
`Before
`
`99%
`After
`100 mg BID
`(N=27)
`
`Median
`89%
`99%
`After
`100 mg QD
`(N=8)
`
`Before
`
`90
`
`80
`
`70
`
`60
`10
`
`0
`
`BTKOccupancy(%)
`
`100 mg QD
`175 mg QD
`250 mg QD
`400 mg QD
`100 mg BID
`
`1
`
`2
`3
`4
`HourafterAdministration
`
`5
`
`6
`
`103
`
`102
`
`101
`
`1
`
`0
`
`(ng/ml)
`
`MeanConcentration
`
`C BTKOccupancy,100-mg,Twice-DailyCohort
`100
`
`D ChangeinPhosphorylatedBTKwithAcalabrutinibvs.Control
`4
`
`P<0.001
`
`3
`
`2
`
`1
`
`FactorChange
`
`0
`
`Day 8, 4 hr
`Day 1, before
`Day 28, before
`
`Day 2, before Day 8, before
`Day 1, 4 hr
`Day 28, 4 hr
` dosing
`dosing
`dosing
`dosing
`after dosing
`after dosing
`after dosing
`
`N=28
`
`N=26
`
`N=27
`
`N=27
`
`N=28
`
`N=19
`
`Median
`97%
`
`95%
`
`97%
`
`99%
`
`97%
`
`99%
`
`90
`
`80
`50
`
`BTKOccupancy(%)
`
`0
`
`Day 8, 4 hr
`Day 28, before
`Day 2, before
`Day 8, before
`Day 1, 4 hr
`Day 28, 4 hr
`dosing
`dosing
`dosing
`after dosing
`after dosing
`after dosing
`
`TimeofAssessment
`
`TimeofAssessment
`
`Figure 1. Acalabrutinib Pharmacokinetics and Pharmacodynamics.
`Panel A shows the mean plasma concentration of acalabrutinib over time in the once-daily (QD) and twice-daily (BID) cohorts. Panel B
`shows Bruton’s tyrosine kinase (BTK) occupancy (the level of drug binding to BTK) in each cohort before and 4 hours after dosing on
`day 8 (steady-state). For the BID cohort, BTK occupancy was evaluated for the morning dose only. Panel C shows BTK occupancy over
`time in the 100-mg BID cohort. In the box plots in Panels B and C, the horizontal line in the center of the box shows the median, the upper
`and lower edges of the box the 25th and 75th percentiles, respectively, and the I bars 1.5 times the interquartile range according to the
`Tukey method. Panel D shows the change in phosphorylated BTK levels over time for all patients. The horizontal lines indicate the means,
`and the I bars standard deviations. The control was each patient’s baseline sample exogenously treated with a saturating concentration
`of acalabrutinib; for details, see the Supplementary Appendix.
`
`nia) has occurred during the study. Serum IgG,
`IgA, and IgM levels were measured over time,
`and the results did not show a clinically signifi-
`cant change over time, except among patients
`receiving intravenous immune globulin (Fig. S6
`in the Supplementary Appendix). Numbers of
`T cells (CD4+ and CD8+), natural killer cells,
`
`and monocytes also showed no clinically sig-
`nificant change over time (Fig. S7 in the Supple-
`mentary Appendix).
`
`Clinical Response
`The clinical activity of acalabrutinib was robust,
`with 98% of the patients having a reduction in
`
`328
`
`n engl j med 374;4 nejm.org
`
`January 28, 2016
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org by SHARISSE GEIGER on October 18, 2021. For personal use only. No other uses without permission.
`
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`

`

`Acalabrutinib in Relapsed CLL
`
`Table 2. Adverse Events.*
`
`Adverse Event
`
`Headache
`
`Diarrhea
`
`Increased weight
`
`Pyrexia
`
`Upper respiratory tract infection
`
`Fatigue
`
`Peripheral edema
`
`Hypertension
`
`Nausea
`
`Contusion
`
`Arthralgia
`
`Petechiae
`
`Decreased weight
`
`All Grades†
`
`Grades 1–2
`
`Grades 3–4
`
`number of patients (percent)
`
`26 (43)
`
`24 (39)
`
`16 (26)
`
`14 (23)
`
`14 (23)
`
`13 (21)
`
`13 (21)
`
`12 (20)
`
`12 (20)
`
`11 (18)
`
`10 (16)
`
`10 (16)
`
`10 (16)
`
`26 (43)
`
`23 (38)
`
`15 (25)
`
`12 (20)
`
`14 (23)
`
`11 (18)
`
`13 (21)
`
`8 (13)
`
`12 (20)
`
`11 (18)
`
`9 (15)
`
`10 (16)
`
`10 (16)
`
`0
`
`1 (2)
`
`1 (2)
`
`2 (3)
`
`0
`
`2 (3)
`
`0
`
`4 (7)
`
`0
`
`0
`
`1 (2)
`
`0
`
`0
`
`* Listed are adverse events that were reported in at least 15% of the 61 patients, on or before the data cutoff date of
`October 1, 2015, regardless of the cause.
`† One grade 5 event of pneumonia was reported.
`
`lymphadenopathy and 61% having concomitant
`treatment-related lymphocytosis (defined as an
`absolute lymphocyte count >5000 cells per micro-
`liter and an increase of ≥50% from baseline)
`(Fig. 2A and 2B). The absolute lymphocyte count
`increased by a median of only 40% from base-
`line, despite substantial reductions in lymphade-
`nopathy (Fig. 2A and 2B). Among patients who
`had cytopenia at baseline, improvements in
`platelet count, hemoglobin levels, and absolute
`neutrophil count were noted in 62%, 76%, and
`80% of the patients, respectively (Table S4 in the
`Supplementary Appendix). Among the 16 patients
`who had B symptoms at baseline, resolution of
`symptoms occurred in 88% of the patients by
`the end of cycle 3 and in 100% of patients by the
`end of cycle 9 (Table S5 in the Supplementary
`Appendix).
`At a median follow-up of 14.3 months, the
`overall response rate among the 60 patients who
`could be evaluated was 95% (partial response in
`85% and partial response with lymphocytosis in
`10%), and the rate of stable disease was 5%.
`Responses were observed across all cohorts (Fig.
`2C), and the response rate increased over time
`(Fig. 2D). Among the 18 patients with chromo-
`some 17p13.1 deletion, the response rate was
`100% (partial response in 89% and partial re-
`
`sponse with lymphocytosis in 11%). Among the
`4 patients who had received previous idelalisib
`therapy, the response rate was 100% (partial
`response in 75% and partial response with lym-
`phocytosis in 25%). At the time of the analysis,
`only 1 patient with chromosome 17p13.1 dele-
`tion had disease progression during therapy. At
`progression, this patient had a C481S (major
`clone) mutation in BTK and an L845F (minor
`clone) mutation in PLCγ2, as has been reported
`in some patients who had disease progression
`during ibrutinib therapy.22 No cases of Richter’s
`transformation have been reported. A Kaplan–
`Meier plot of progression-free survival is shown
`in Figure 3. Only two events of progression or
`death have been noted thus far: one death from
`pneumonia (at 13 months) and a single case of
`CLL progression (at 16 months).
`
`Discussion
`
`The introduction of irreversible BTK inhibitors
`such as ibrutinib for the treatment of CLL and
`other related B-cell lymphoproliferative disor-
`ders represented a major therapeutic advance.12-14
`Concurrent with ibrutinib clinical development,
`another irreversible BTK inhibitor, CC-292, was
`studied in CLL. CC-292 had an acceptable side-
`
`n engl j med 374;4 nejm.org
`
`January 28, 2016
`
`329
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org by SHARISSE GEIGER on October 18, 2021. For personal use only. No other uses without permission.
`
` Copyright © 2016 Massachusetts Medical Society. All rights reserved.
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1010, p. 7 of 10
`
`

`

`T h e ne w e ngl a nd jou r na l o f m e dic i ne
`
`Stable
`disease
`
`Partial
`response
`
`Partial response
`with lymphocytosis
`
`Patient
`
`Partial response
`93
`
`87
`
`81
`
`77
`
`100
`
`25
`
`0
`
`−25
`
`−50
`
`−75
`
`B
`
`MaximumChangeinSPD(%)
`
`MedianChangefromBaselineinSPD(%)
`
`0
`
`−10
`
`−20
`
`−30
`
`−40
`
`−50
`
`−60
`
`−70
`
`−80
`
`−90
`
`−100
`
`−100
`
`SPD (N=56)
`
`700
`
`600
`
`500
`
`400
`
`300
`
`200
`
`100
`
`0
`
`ALC (N=61)
`
`−100
`
`0
`
`21
`
`3 4 5 6 7 8 9 101112131415161718192021
`Cycle
`
`D
`
`Partial response
`with lymphocytosis
`
`Partial
`response
`
`Stable
`disease
`
`100
`
`25
`
`100
`
`100
`
`10
`85
`
`75
`
`13
`
`77
`
`A
`
`MedianChangefromBaselineinALC(%)
`
`C
`
`50
`41
`
`52
`
`28
`
`20
`
`9
`Stable disease
`
`0
`
`2
`
`4
`
`59
`
`36
`
`5
`
`6
`
`Partial response with
`lymphocytosis
`18
`
`5
`
`8
`
`13
`6
`
`10
`12
`Cycle
`
`10
`3
`
`14
`
`16
`
`7
`
`0
`18
`
`0
`
`20
`
`22
`
`60
`
`58
`
`58
`
`57
`
`48
`
`31
`
`14
`
`3
`
`100
`90
`80
`70
`60
`50
`40
`30
`20
`10
`0
`
`BestResponseoverTime(%)
`
`No.of
`Patients
`
`100
`90
`80
`70
`60
`50
`40
`30
`20
`10
`0
`
`BestResponse(%)
`
`5
`
`0
`
`0
`
`0
`
`0
`
`10
`
`All Cohorts
`
`250 m g Q D 400 m g Q D
`
`100 m g Q D 175 m g Q D
`100 m g BID
`(N =8)
`(N =60)
`(N =8)
`(N =7)
`(N =6)
`(N =31)
`
`MedianFollow-up(mo)
`
`14.3
`
`19.2
`
`17.8
`
`16.4
`
`14.6
`
`11.8
`
`Cohort
`
`Figure 2. Response to Acalabrutinib.
`Panel A shows the median percent change from baseline in the absolute lymphocyte count (ALC) and the sum of the products of lymph-
`node diameters (SPD) in all patients. I bars represent 95% confidence intervals. Panel B shows the greatest change from baseline in
`lymphadenopathy among patients who had lymphadenopathy at baseline and at least one measurement during treatment (N = 56). Four
`patients had no measurable lymphadenopathy at baseline or during treatment, and 1 patient did not undergo computed tomographic
`scanning during treatment before study discontinuation. All measurements were based on radiologic assessments. Panel C shows the
`investigator-assessed best response to therapy among all patients who could be evaluated for efficacy (N = 60) and according to treat-
`ment cohort. Panel D shows the best response over time among all patients who could be evaluated at the respective time point.
`
`effect profile, but the clinical results were infe-
`rior to those observed in previous phase 1 stud-
`ies of ibrutinib.23,24 At the time, it was suggested
`that CC-292 may be a more selective inhibitor of
`BTK than ibrutinib. This introduced the ques-
`tion of whether irreversible BTK inhibitors need
`to inhibit alternative targets, as ibrutinib does,
`to ensure efficacy. In the current study, we
`
`showed that acalabrutinib has structural, bio-
`chemical, in vitro, pharmacokinetic, and pharma-
`codynamic properties that are different from
`those of ibrutinib. These preclinical findings
`prompted initiation of this study involving pa-
`tients with relapsed CLL; in this ongoing study,
`acalabrutinib therapy has be