A Phase | Study of 5-Azacytidine (NSC-102816)
`
`BRUCE I. SHNIDER, M.D., MAHMOODULLAHBAIG, M.D., and
`JACOB COLSKY, M.D. Washington, D.C., and Miami, Fla.
`
`5-Azacytidine was first synthesized by
`Piskala and Sorm!
`in 1964, and their
`studies demonstrated that the drug was
`readily incorporated into both DNA and
`RNA. Its antineoplastic activity is at-
`tributed to its ability to inhibit DNA,
`RNA, and protein synthesis. This in-
`hibitory action appears to be cell-cycle
`specific, and the greatest sensitivity is
`upon cells
`in the S-phase. Antitumor
`effect was demonstrated against L-1210
`mouse leukemia with intermittent or con-
`tinuous administration.
`Studies with radioactive-labeled drug®
`indicated that absorption from subcutane-
`ous injection sites was rapid, with peak
`plasma levels of
`radioactivity approxi-
`mately equal to that noted in patients re-
`ceiving the drug intravenously. The half-
`life after intravenous injection was 3.5
`hours and after subcutaneous administra-
`tion, 4.2 hours. Urinary excretion, how-
`
`
`From the Eastern Cooperative Oncology Group
`(ECOG) (Paul P. Carbone, Chairman) Supported
`in part by grants CA-02824 and CA-02822 from
`the National Cancer Institute, National Institutes
`of Health. 5-Azacytidine was supplied by Cancer
`Therapy Evaluation, DCT, NCI. 5-Azacytidine
`NSC 102816; CAS reg. no. 320-67-2; s-triazin-
`2(IH)-one-4-amino-19-p-ribofuranosyl.
`Des. SHNIDER and Baia: Division of Medical
`Oncology Department of Medicine, Georgetown
`University School of Medicine and the Oncology
`Service of
`the Georgetown Medical Division,
`District of Columbia General Hospital, Wash-
`ington, D.C.
`Dr. Cotsky: University of Miami School of
`Medicine, Jackson Memorial Hospital Program,
`Miami, Florida.
`
`April, 1976
`
`ever, was greater in patients receiving in-
`travenous injections. The highest uptake
`of 5-azacytidine in tumor
`tissue was
`achieved when the drug was given intra-
`venously. Small amounts of radioactivity
`were detected in the spinal fluid.
`Phase I studies by Weiss and associates?
`and by Karon‘ indicated that the toxicity
`associated with the administration of this
`drug to humans was primarily nausea,
`vomiting, and diarrhea. These studies
`further indicated that these troublesome
`side effects appeared to be related to the
`amount of drug given in each injection.
`Hematologic toxicity consisted of granu-
`locytopenia and thrombocytopenia usually
`occurring within three weeks after the
`start of chemotherapy. Transient eleva-
`tions of SGOT were seen in somepatients
`but there was no other evidence of hepatic
`toxicity.5
`Weiss noted clinical responses in 7 of
`11 patients with carcinoma of the breast,
`2 of 5 patients with melanoma, and 2 of
`6 patients with carcinoma of the colon.
`Subsequent studies with this drug in 29
`patients with advanced gastrointestinal
`carcinoma revealed the anticipated tox-
`icity with only one transient and partial
`objective response. Tan and associates”
`studied 21 patients, 9 of whom were chil-
`dren, using intravenous 5-azacytidine.
`Leukopenia and thrombocytopenia oc-
`curred in all patients; nausea and vomit-
`ing was often severe but diminished with
`divided doses of the drug. Occasional ab-
`
`205
`
`CELGENE 2112
`APOTEX v. CELGENE
`IPR2023-00512
`
`

`

`SHNIDER, BAIG, AND COLSKY
`
`dominal pain, diarrhea, and fever were
`also noted. No regressions were seen in the
`patients with solid tumors of lymphomas
`in this series. One of 7 acute lymphatic
`leukemias had a poor remission. Karon
`et al.t studying 34 children with advanced
`acute leukemia receiving doses of 5-
`azacytidine ranging from 2 to 300 mg/m?
`daily X 5 noted responses in 6 of 12
`myelocytic leukemias and 4 of 22 lymph-
`ocytic leukemia. Cunninghametal.,® using
`the agent in the treatment of carcinoma
`of the breast and comparingit with CCNU,
`noted a low response rate for both agents
`(two of 19 patients treated with CCNU
`and 2 of 21 patients treated with 5-
`azacytidine). Vogler et al.,5 reporting on
`the phase I studies of the Southeastern
`Cancer Study Group, noted that
`5-
`azacytidine given twice weekly at doses of
`150-200 mg/m? would produce granu-
`locytopenia after several weeks associated
`with nausea, vomiting, and diarrhea. No
`renal or hepatic toxicity was noted. Bellet
`et al.,° using the subcutaneous route of ad-
`ministration, noted only mild gastrointes-
`tinal toxicity at doses producing signifi-
`cant bone marrow depression. Hepatic
`toxicity occurred in five patients, possibly
`related to extensive hepatic involvement
`with metastatic tumor.
`This report concerns the preliminary
`phase I study done by the Eastern Co-
`operative Oncology Group with this agent
`in patients with solid tumors.
`Our study was undertaken as an at-
`tempt to determine the tolerated dose for
`the daily and once-weekly schedules of ad-
`ministration in the event that more de-
`finitive therapeutic studies were to be
`undertaken by the group.
`
`Methods and Materials
`
`Patients were selected for study who
`had progressive disease and who were
`not considered candidates for other group
`studies with a higher priority and for
`whomno other therapy was available. All
`206
`
`had to be in reasonably good status and to
`have a life expectancy of at least three
`months. They were to have no evidence of
`bone marrow suppression and were to
`have been off all prior myelosuppressive
`or hormonal therapy and x-ray therapy
`for at least six weeks prior to entering the
`study. Cases were entered in a sequential
`pattern with only one patient at each of
`the
`cooperating
`institutions
`entering
`study per week for each schedule of drug
`administration. Four patients were to be
`entered at each level for each dose sched-
`ule during the initial phase of the study
`before proceeding to the next dose in the
`escalation pattern.
`Participants could be withdrawn from
`the study at any time either upon request
`of the patient or the investigator if it was
`deemed in the best interest of the patient.
`No patient was to reenter the study after
`completing an initial drug trial unless
`eight weeks had elapsed from the time of
`the last drug dose.
`Participants in the study were ran-
`domly assigned to either of
`the two
`groups. The
`first group received 5-
`azacytidine once weekly intravenously for
`a period of four weeks, and the second
`group received 5-azacytidine daily for five
`days followed by a nine-day observation
`period. A second course of five days was
`given after the observation period. At the
`end of four weeks, both treatment groups
`were observed for an additional four-week
`period for delayed toxicity or to allow
`toxicity to regress before being removed
`from the study.
`The initial starting dose for the weekly
`schedule was 200 mg/m?, and the starting
`dose for the five-day daily injection sched-
`ule was 50 mg/m?. Incremental increases
`of both drugs were taken in a stepwise
`fashion as follows: step (1), increase by
`100 per cent of starting dose; step (2), in-
`crease by 6624 per cent of starting dose;
`step (3), increase by 50 per cent of start-
`ing dose; step (4), increase by 3314 per
`
`The Journal of Clinical Pharmacology
`
`

`

`PHASE I STUDY OF &5-AZACYTIDINE
`
`cent of the starting dose; and step (5), in-
`crease by 25 per cent of the starting dose.
`Weekly evaluations were made of drug
`toxicity and progress of
`the study by
`telephone conference calls among the par-
`ticipating investigators. No incremental
`increase or assignment of new patients to
`a new dose level was made without prior
`evaluation of the status of all patients ac-
`tively participating in the drug study.
`Serial laboratory tests were performed ac-
`cording to the protocol design, and x-rays
`and measurements of lesions were made
`at two-week intervals where appropriate.
`The study was to be terminated when a
`tolerated dose without prohibitive toxic
`side effects was established for both the
`daily and weekly schedules of drug ad-
`ministration.
`7
`5-Azacytidine was reconstituted with
`5 to 10 ml sterile water and administered
`by rapid intravenous push. After the first.
`patients developed severe nausea and
`vomiting, chlorperazine (Compazine) was
`given parentally 15 minutes prior to the
`intravenous administration of 5-azacyti-
`dine. Chlorperazine by suppository was re-
`peated during the next 24-48 hours as re-
`quired.
`nr
`
`Results
`
`Twelve patients received 21 courses of
`5-azacytidine by the daily schedule and
`15 patients received 50 weekly courses of
`drug by the weekly schedule (Table I).
`Table II showsthe toxicity encountered at
`each of the dose levels for the daily sched-
`ule. Nausea and vomiting were the most
`prominent toxic side effects and occurred
`in every patient. Phenothiazines were only
`partially successful
`in relieving these -
`symptoms. The vomiting usually had its
`onset 30 minutes to 214 hours after the in-
`jection of 5-azacytidine and in some in-
`stances persisted for as long as 12-16
`hours. In some patients,
`this was asso-
`ciated with diarrhea. As the severity of
`the nausea and vomiting increased, so did
`
`April, 1976
`
`TABLE I
`
`Patient Distribution of Dose and
`Schelule of 5-Azacytidine
`
`Dose (mg/m2)
`
`No. of
`patients
`
`No. of
`courses
`
`50
`100
`133
`158
`
`Daily Schedule
`4
`3
`3
`2
`
`Total
`
`12
`
`200
`400
`533
`633
`Total
`
`Weekly Schedule
`4
`4
`5
`2
`15
`
`7
`6
`5
`3
`
`21
`
`14
`15
`15
`5
`50
`
`the degree of weight loss, and some pa-
`tients refused to continue in the study
`after having severe nausea and vomiting
`during the first course of therapy.
`Aside from the gastrointestinal toxicity
`(Tables II and III), we encountered no
`stomatitis and only one episode of skin
`rash. This was a transient mild maculo-
`papular eruption which occurred during
`the fourth week of the weekly schedule of
`drug administration at a dose of 200
`mg/m?. One patient on the daily schedule
`and one patient on the weekly schedule
`showed a rise in blood urea nitrogen
`which returned to normal when the drug
`was discontinued. Two patients on the
`daily schedule also had a rise in uric acid
`from normal values prior to therapy to
`9.6 and 10 mg/100 ml after completion of
`a five-day course of drug. (One of these
`patients also had both an increase in blood
`urea nitrogen and uric acid.) One possible
`instance of hepatotoxicity occurred in a
`patient
`receiving drug weekly as evi-
`denced by a rise in SGOT from 30 units to
`
`207
`
`

`

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`The Journal of Clinical Pharmacology
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`

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`PHASE I STUDY OF 5-AZACYTIDINE
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`310
`
`The Journal of Clinical Pharmacology
`
`

`

`PHASE I STUDY OF 5-AZACYTIDINE
`
`receiving
`72 units. This patient was
`compazine for control of his emesis.
`Hematologic toxicity became more evi-
`dent with increasing dose levels at both
`the daily and weekly schedules. On the
`weekly schedule, a cumulative effect was
`suggested by a later nadir of leukocyte de-
`pression and a longer period before a re-
`turn to normal occurred. Only one in-
`stance of thrombocytopenia occurred at
`the the doses studied (Table IV).
`
`Discussion
`
`5-Azacytidine has been studied by a
`number of investigators to delineate its
`clinical pharmacology and therapeutic ac-
`tivity. It is apparent from the animal
`studies that the total dose required to pro-
`duce toxicity is less when the drug is
`given intermittently over a long period of
`time rather than in a short course of
`therapy. In our studies in humans,
`the
`toxic side effects (gastrointestinal), which
`were the dose-limiting factors, were seen in
`patients receiving both the five-day course
`and the once-weekly schedule without
`much difference in severity. Patients re-
`ceiving the once-weekly schedule, how-
`ever, were morelikely to be willing to con-
`tinue therapy because the gastrointestinal
`side effects were of shorter duration and
`there was a period during which they
`were free of these toxic side effects before
`the next scheduled dose.
`Since the primary problem with drug
`administration, as far as the patient is
`concerned,
`is vomiting, nausea, and at
`times, diarrhea, it may be worthwhile to
`give the drug on a weekly schedule divid-
`ing the dose into two injections, 12 hours
`apart. Some of our preliminary studies
`suggest
`that
`the gastrointestinal
`side
`effects may be diminished when drug is
`given in this manner or when the total
`dose is given in two divided doses three
`to four days apart.
`The tolerated daily dose for this study
`was in the range of 150 mg/m? given for
`
`April, 1976
`
`five days every two weeks. The dose-limit-
`ing factors were severe nausea and vomit-
`ing with associated weight loss. For the
`single weekly dose, 500 mg/m? appeared
`to be the tolerated dose without the severe
`nausea, vomiting, and diarrhea of
`the
`daily schedule. This dose divided into two
`injections given 12 hours apart could be
`utilized in the phase I trials or for com-
`bination chemotherapy studies. No at-
`tempt was made to study the therapeutic
`efficacy of the drug in this short-range
`phase I evaluation.
`In other clinical studies, this drug has
`been administered to patients with both
`solid tumors and hematologic malignan-
`cies. The successful treatment of patients
`with acute leukemias refractory to other
`formsof therapy has been reported by two
`investigators.*!° Bellet et al.® reported ob-
`jective tumor regressions in two patients
`given
`subcutaneous
`5-azacytidine,
`one
`adenocarcinoma of the breast and one
`adenocarcinoma of the ovary. Much less
`success has been seen in patients with
`solid tumors.?8
`Clinical studies to date have indicated
`that
`5-azacytidine has
`some
`activity
`against myelocytie and lymphocytic leu-
`kemia in children, has only very limited
`activity in adenocarcinoma of the breast
`and adenocarcinoma of the ovary and
`malignant melanoma, and noactivity in
`advanced
`gastrointestinal
`carcinoma.
`Whether this drug has any value in com-
`bination chemotherapyis yet to be estab-
`lished.
`
`Summary
`5-Azacytidine was administered daily
`to 12 patients in a five-day schedule and
`to 15 patients in a weekly schedule as part
`of a phase I trial. The daily dose ranged
`from 50 mg/m? to 158 mg/m? and the
`weekly dose,
`from 200 mg/m? to 633
`mg/m?. The maximum total dose was 2000
`mg in the daily schedule and 3775 mgin
`the weekly schedule. The major toxicity
`
`211
`
`

`

`SHNIDER, BAIG, AND COLSKY
`
`was gastrointestinal, with nausea and
`vomiting occurring in all patients in this
`study. Myelosuppression was
`less
`fre-
`quently encountered and appeared to be
`related to the increase in 5-azacytidine
`dose. Patients receiving 5-azacytidine in
`a weekly schedule of administration ap-
`peared to tolerate the drug better and to
`be more willing to continue their therapy.
`
`References
`
`1, Piskala, A. and Sorm, F.: Nucleic acid
`components and their analogues. L1 syn-
`thesis of 1-glycosyl derivatives of 5-azaura-
`cil and 5-azacytosine. Coll. Czech. Commun.
`29:2060 (1964).
`2. Weiss, A. J., Stambough, J. E., Mastrangelo,
`M. J., Laucius, J. F., and Bellet R. E.:
`Phase I study of 5-azacytidine
`(NSC-
`102816). Cancer Chemother. Rep. 56:413
`(1972).
`3. Troetel, W. M., Weiss, A. J., Stambough,
`J. E., Laucius, J. F., and Mantei, R. W.:
`Absorption, distribution and excretion of
`5-azacytidine (NSC-102816) in man. Can-
`cer Chemother. Rep. 56:405 (1972).
`4. Karon, M., Sieger, L., Leinbrock, 8., Nesbit,
`M., and Finklestein, J.:
`5-Azacytidine
`
`effective treatment for acute leukemia in
`children. Proc. Amer. Assoc. Cancer Res.
`14:94 (1973).
`Vogler, W. R., and Sureyya, N. A.: Phase
`I
`study of 5-azacytidine. Proc. Amer.
`Assoc. Cancer Res. 14:59 (1973).
`Moertel, C. G., Shutt, A. J.,- Reitmemeer,
`R. J., and Hahn, R. G.: Phase II study of
`5-azacytidine (NSC-102816) in the treat-
`ment of advanced gastrointestinal cancer.
`Cancer Chemother. Rep. 56:649 (1972).
`Tan, C., Burchenal, J., Feinstein, M., Garcia,
`E., Sidhu, J., and Krakoff, I. H.: Clinical
`trial of 5-azacytidine. Proc. Amer. Assoc.
`Cancer Res. 14:97 (1973).
`Cunningham, T. J., Rosner, D., Alsou, K. B.,
`Nemoto, T., Dao, T., and Horton, J.: A
`comparison of 5-azacytidine with CCNU
`in breast cancer. Proc. Amer. Assoc. Can-
`cer Res. 14:89 (1973).
`Bellet, R. E., Mastrangelo, M. J., Engstrom,
`P. F., Strawitz, J. G., Weiss, A. J., and
`Yarbro, J. W.: Clinical
`trial with sub-
`cutaneously
`administered
`5-azacytidine
`(NSC-102816). Cancer Chemother. Rep.
`58:217 (1974).
`McCredie, K. B., Bodey, G. P., Burgess,
`M. A., Gutterman, J. V., Rodriguez, V.,
`Sullivan, M. P., and Freireich, E. J.:
`Treatment of
`acute leukemia with 5-
`azacytidine (NSC-102816). Cancer Chemo-
`ther. Rep. 57:319 (1973).
`
`10.
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`212
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`The Journal of Clinical Pharmacology,
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`