Preventing CAR-T cell toxicities with emapalumab

A Phase 2 Trial of Emapalumab for the Prevention of CAR-T Cell Associated Toxicities

This study is testing if a drug called emapalumab can help prevent side effects in people with large B-cell non-Hodgkin's lymphoma who are receiving another treatment called axicabtagene ciloleucel.

Quick facts

• Phase: PHASE2
• Study type: Interventional
• Enrollment: 28 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: Massachusetts General Hospital (other)
• Drugs / interventions: ipilimumab, nivolumab, pembrolizumab, atezolizumab, canakinumab, tocilizumab, emapalumab, CAR-T, Chemotherapy, cyclophosphamide, Fludarabine
• Locations: 2 sites (Boston, Massachusetts and 1 other locations)
• Trial ID: NCT06550141 on ClinicalTrials.gov

What this trial studies

This phase 2 multi-center, open label study evaluates the safety and efficacy of emapalumab in preventing toxicities associated with axicabtagene ciloleucel in patients with second- or third-line large B-cell non-Hodgkin's lymphoma. Participants will undergo screening for eligibility, receive lymphodepleting chemotherapy, and be treated with both emapalumab and axicabtagene ciloleucel. The study aims to follow participants for up to 24 months to assess the impact of emapalumab on cytokine release syndrome. The FDA has approved axicabtagene ciloleucel for this condition, while emapalumab is being investigated for this specific use.

Who should consider this trial

Good fit: Ideal candidates are adult patients with relapsed or refractory large B-cell lymphoma who have received prior systemic therapy.

Not a fit: Patients with large B-cell lymphoma who are not refractory to first-line chemoimmunotherapy or who have not relapsed within 12 months may not benefit from this study.

Why it matters

Potential benefit: If successful, this study could significantly reduce the incidence of CAR-T cell associated toxicities in patients with large B-cell lymphoma.

How similar studies have performed: Other studies have shown promise in using similar approaches to manage CAR-T cell associated toxicities, but this specific application of emapalumab is novel.

Eligibility criteria

Inclusion Criteria:

* Adult patients with large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy. Or adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma.
* At least 1 measurable lesion per Lugano at time of screening.
* At least 2 weeks or 5 half-lives, whichever is shorter, must have elapsed since any prior systemic therapy at the time the subject is planned for leukapheresis, except for systemic inhibitory/stimulatory immune checkpoint therapy however steroids only require a 7-day washout.
* At least 3 half-lives must have elapsed from any prior systemic inhibitory/stimulatory immune checkpoint molecule therapy at the time the subject is planned for leukapheresis (e.g. ipilimumab, nivolumab, pembrolizumab, atezolizumab, OX40 agonists, 4-1BB agonists, etc).
* Age 18 or older
* Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2.
* Adequate renal, hepatic, pulmonary and cardiac function defined as:

  * ANC ≥1000/uL
  * Platelet count ≥50,000/uL
  * Absolute lymphocyte count ≥100/uL
  * Creatinine clearance (as estimated by Cockcroft Gault or CKD-EPI) ≥ 30 mL/min
  * Serum ALT/AST ≤2.5 per institutional ULN
  * Total bilirubin ≤1.5 mg/dl, except in subjects with Gilbert's syndrome.
  * Cardiac ejection fraction ≥ 40%, no clinically significant pericardial effusion, and no clinically significant ECG findings
  * Baseline oxygen saturation \>92% on room air.
* Females of childbearing potential must have a negative serum or urine pregnancy test (females who have undergone surgical sterilization or who have been postmenopausal for at least 2 years are not considered to be of childbearing potential).
* Ability to understand and the willingness to sign a written informed consent document.

Exclusion Criteria:

* History of malignancy other than nonmelanoma skin cancer or carcinoma in situ (e.g. cervix, bladder, breast) or follicular lymphoma unless disease free for at least 3 years.
* History of Richter's transformation of CLL.
* Autologous stem cell transplant within 6 weeks of planned axicabtagene ciloleucel infusion.
* History of allogeneic stem cell transplantation.
* Presence of uncontrolled fungal, bacterial, viral, or other infection at time of screening.
* Known history of acute or chronic active hepatitis B or C infection. Subjects with history of hepatitis infection must have cleared their infection as determined by standard serological and genetic testing per current Infectious Diseases Society of America (IDSA) guidelines.

  * Patients should also be negative for latent Tb, CMV (NAT), EBV (NAT) and adenovirus (NAT) by PCR testing.
* No evidence of active CNS disease regardless of prior CNS history.
* History or presence of CNS disorder such as seizure disorder, cerebrovascular ischemia/hemorrhage within 6 months of enrollment.
* History of myocardial infarction, cardiac angioplasty or stenting, unstable angina, or other clinically significant cardiac disease within 12 months of enrollment.
* History of symptomatic pulmonary embolism within 3 months of enrollment; ongoing anticoagulation is allowed if beyond 3 months.
* Any medical condition likely to interfere with assessment of safety or efficacy of study treatment.
* History of allergic reactions or severe immediate hypersensitivity reaction to any of the agents used in this study or compounds of similar chemical or biologic composition.
* Females who are pregnant or breastfeeding or female or male participants who are not willing to practice birth control from the time of consent through 6 months after the completion of axicabtagene ciloleucel
* In the investigators judgment, the subject is unlikely to complete all protocol-required study visits or procedures, including follow-up visits, or comply with the study requirements for participation.
* History of autoimmune disease requiring ongoing systemic immunosuppression. Steroids are allowed up to 5mg predinosine-equivalent for adrenal insufficiency.
* Patients anticipated to require canakinumab, JAK inhibitors, TNF inhibitors, and tocilizumab for non-CAR-T management of baseline autoimmune/inflammatory disease at the time of emapalumab initiation.
* Receipt of a BCG vaccine within 12 weeks prior to Screening.
* Receipt of a live or attenuated live (other than BCG) vaccine within 4 weeks prior to screeing.
* Participants who are receiving any other investigational agents for this condition.

Where this trial is running

Boston, Massachusetts and 1 other locations

• Massachusetts General Hospital — Boston, Massachusetts, United States (RECRUITING)
• Dana-Farber Cancer Institute — Boston, Massachusetts, United States (NOT_YET_RECRUITING)

Study contacts

• Principal investigator: Matthew Frigault, MD — Massachusetts General Hospital
• Study coordinator: Matthew Frigault, MD

Conditions: Large B-cell Lymphoma, Relapsed Non-Hodgkin Lymphoma, Refractory Non-Hodgkin Lymphoma, Diffuse Large B Cell Lymphoma, Primary Mediastinal Large B-cell Lymphoma, High-grade B-cell Lymphoma, Follicular Lymphoma, Second Line Large B-cell Non-Hodgkin's Lymphoma