CALQUENCE reduced the risk of disease progression or death by 71% vs. standard of care combinations at three years in the ASCEND Phase III trial
AstraZeneca presented updated results from the ASCEND Phase III trial at the ASH Annual Meeting, highlighting CALQUENCE's significant efficacy for relapsed chronic lymphocytic leukemia. After three years, CALQUENCE demonstrated a 71% lower risk of disease progression or death compared to investigator's choice therapies. Moreover, safety data from the ELEVATE-RR trial revealed CALQUENCE had fewer adverse events than ibrutinib, particularly in terms of atrial fibrillation incidence. CALQUENCE is approved for CLL and small lymphocytic lymphoma, with ongoing studies for its use in various hematologic malignancies.
- CALQUENCE showed a 71% reduction in disease progression or death in CLL patients at three years.
- Fewer adverse events observed with CALQUENCE compared to ibrutinib, enhancing its safety profile.
- Ongoing clinical trials are evaluating CALQUENCE for multiple B-cell blood cancers.
- CALQUENCE treatment led to a 19% incidence of serious infections in previous trials.
- Patients experienced significant cytopenias, with up to 23% developing grade 3 or 4 neutropenia.
ELEVATE-RR head-to-head trial data also presented at ASH showed patients on ibrutinib experienced a
These data, presented at the 63rd
Additional safety analyses from the ELEVATE-RR Phase III trial were also presented at ASH to further characterize adverse events (AEs) related to treatment with Bruton’s tyrosine kinase (BTK) inhibitors CALQUENCE and ibrutinib. Overall, patients on ibrutinib experienced a
For any grade atrial fibrillation/flutter, a key secondary endpoint in the ELEVATE-RR Phase III trial, median time to onset was longer for CALQUENCE versus ibrutinib (28.8 versus 16.0 months), and cumulative incidence was lower at all timepoints from six months through two years.3
Additionally, the ELEVATE-RR Phase III trial showed incidence of all-grade atrial fibrillation/flutter was lower for CALQUENCE across subgroups of age, prior line of therapy and among patients without prior history of heart complications.3 Atrial fibrillation is an irregular heart rate that can increase the risk of stroke, heart failure and other heart-related complications.4
INDICATION AND USAGE
CALQUENCE is a Bruton tyrosine kinase (BTK) inhibitor indicated for the treatment of adult patients with mantle cell lymphoma (MCL) who have received at least one prior therapy.
This indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.
CALQUENCE is also indicated for the treatment of adult patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL).
IMPORTANT SAFETY INFORMATION ABOUT CALQUENCE® (acalabrutinib) capsules
Serious and Opportunistic Infections
Fatal and serious infections, including opportunistic infections, have occurred in patients with hematologic malignancies treated with CALQUENCE.
Serious or Grade 3 or higher infections (bacterial, viral, or fungal) occurred in
Hemorrhage
Fatal and serious hemorrhagic events have occurred in patients with hematologic malignancies treated with CALQUENCE. Major hemorrhage (serious or Grade 3 or higher bleeding or any central nervous system bleeding) occurred in
Use of antithrombotic agents concomitantly with CALQUENCE may further increase the risk of hemorrhage. In clinical trials, major hemorrhage occurred in
Consider the benefit-risk of withholding CALQUENCE for 3-7 days pre- and post-surgery depending upon the type of surgery and the risk of bleeding.
Cytopenias
Grade 3 or 4 cytopenias, including neutropenia (
Second Primary Malignancies
Second primary malignancies, including skin cancers and other solid tumors, occurred in
Atrial Fibrillation and Flutter
Grade 3 atrial fibrillation or flutter occurred in
ADVERSE REACTIONS
The most common adverse reactions (≥
*Treatment-emergent decreases (all grades) of hemoglobin (
Dose reductions or discontinuations due to any adverse reaction were reported in
The most common adverse reactions (≥
*Treatment-emergent decreases (all grades) of hemoglobin, platelets, and neutrophils were based on laboratory measurements and adverse reactions.
In patients with previously untreated CLL exposed to CALQUENCE, fatal adverse reactions that occurred in the absence of disease progression and with onset within 30 days of the last study treatment were reported in
Adverse reactions led to CALQUENCE dose reduction in
In patients with relapsed/refractory CLL exposed to CALQUENCE, serious adverse reactions occurred in
Adverse reactions led to CALQUENCE dose reduction in
DRUG INTERACTIONS
Strong CYP3A Inhibitors: Avoid co-administration with a strong CYP3A inhibitor. If a strong CYP3A inhibitor will be used short-term, interrupt CALQUENCE.
Moderate CYP3A Inhibitors: When CALQUENCE is co-administered with a moderate CYP3A inhibitor, reduce CALQUENCE dose to 100 mg once daily.
Strong CYP3A Inducers: Avoid co-administration with a strong CYP3A inducer. If a strong CYP3A inducer cannot be avoided, increase the CALQUENCE dose to 200 mg approximately every 12 hours.
Gastric Acid Reducing Agents: If treatment with a gastric acid reducing agent is required, consider using an H2-receptor antagonist or an antacid. Take CALQUENCE 2 hours before taking an H2-receptor antagonist. Separate dosing with an antacid by at least 2 hours.
Avoid co-administration with proton pump inhibitors. Due to the long-lasting effect of proton pump inhibitors, separation of doses may not eliminate the interaction with CALQUENCE.
SPECIFIC POPULATIONS
Based on findings in animals, CALQUENCE may cause fetal harm and dystocia when administered to a pregnant woman. There are no available data in pregnant women to inform the drug-associated risk. Advise pregnant women of the potential risk to a fetus.
Pregnancy testing is recommended for females of reproductive potential prior to initiating CALQUENCE therapy. Advise female patients of reproductive potential to use effective contraception during treatment with CALQUENCE and for at least 1 week following the last dose of CALQUENCE.
It is not known if CALQUENCE is present in human milk. Advise lactating women not to breastfeed while taking CALQUENCE and for at least 2 weeks after the final dose.
Avoid administration of CALQUENCE in patients with severe hepatic impairment. Dose modifications are not required for patients with mild or moderate hepatic impairment.
Please see full Prescribing Information, including Patient Information.
Notes
ASCEND: Three-year follow-up data for CALQUENCE in relapsed or refractory CLL (abstract #393)
ASCEND is a global, randomized, multicenter, open-label, Phase III trial that evaluated the efficacy and safety of CALQUENCE (100mg twice-daily until disease progression or unacceptable toxicity) versus investigator’s choice of IdR or BR in patients with relapsed or refractory CLL.1,5 ASCEND is the first randomized trial to directly compare a BTK inhibitor as monotherapy with standard chemoimmunotherapy or idelalisib and rituximab combinations.
Summary of ASCEND results1
Efficacy
|
CALQUENCE
Median follow-up
|
IdR/BR
|
Individual assessments
|
|
(N=155) |
(N=155) |
IdR (N=119) |
BR (N=36) |
|
PFS* |
||||
HR ( |
0.29 (0.21, 0.41) |
0.31
|
0.25
|
|
p-value |
p<0.0001 |
p<0.0001 |
p<0.0001 |
|
Median PFS,
|
NR |
16.8 |
16.2 |
18.6 |
Estimated PFS
|
63 |
21 |
- |
- |
OS |
||||
HR ( |
0.69 (0.43, 1.10) |
- |
- |
|
p-value |
p=0.1184 |
- |
- |
|
Median OS,
|
NR |
NR |
- |
- |
Estimated OS
|
80 |
73 |
- |
- |
ORR* |
||||
ORR, % |
83 |
85 |
- |
- |
INV-assessed
|
92 |
88 |
- |
- |
CI, confidence interval; NR, not reached; OS, overall survival; ORR, overall response rate; PR, partial response
*Investigator-assessed
AEs led to treatment discontinuation in
ELEVATE-RR: Additional safety analyses of CALQUENCE versus ibrutinib in relapsed or refractory CLL (abstract #3721)
Results from the ELEVATE-RR Phase III trial were first presented on
Additional safety data were used to characterize BTK inhibitor-related AEs, using measures of frequency, duration and drug exposure (versus incidence alone) to measure AE burden. Median treatment exposures were 38.3 months in the CALQUENCE arm and 35.5 months in the ibrutinib arm.3
For any-grade hypertension, median time to onset was similar for CALQUENCE and ibrutinib (8.1 months versus 7.0), but cumulative incidence was lower for CALQUENCE at 6 months (
Among cardiovascular AEs of clinical interest, incidences of any-grade atrial fibrillation/flutter, hypertension and bleeding were statistically higher with ibrutinib versus CALQUENCE, with higher exposure-adjusted incidence (2.0-, 2.8-, and 1.6-fold, respectively) and exposure-adjusted time with event (2.8-, 3.7-, and 1.8-fold).3
CLL
CLL is the most common type of leukemia in adults, with an estimated 114,000 new cases globally in 2017, and the number of people living with CLL is expected to grow with improved treatment as patients live longer with the disease.2,6-8
In CLL, too many blood stem cells in the bone marrow become abnormal lymphocytes and these abnormal cells have difficulty fighting infections. As the number of abnormal cells grows, there is less room for healthy white blood cells, red blood cells and platelets. This could result in anemia, infection and bleeding.6 B-cell receptor signaling through BTK is one of the essential growth pathways for CLL.
ASCEND
ASCEND (ACE-CL-309) is a global, randomized, multicenter, open-label Phase III trial evaluating the efficacy of CALQUENCE in patients with relapsed or refractory CLL.5,9
In the trial, 310 patients were randomized (1:1) into two treatment arms. Patients in the first arm received CALQUENCE monotherapy (100mg twice-daily until disease progression or unacceptable toxicity). Patients in the second arm received physician’s choice of either rituximab, a CD20 monoclonal antibody, in combination with idelalisib, a PI3-kinase inhibitor, or rituximab in combination with bendamustine, a chemotherapy.9
The primary endpoint at the interim analysis was PFS assessed by an Independent Review Committee (IRC), and key secondary endpoints included investigator-assessed PFS, IRC- and investigator-assessed overall response rate and duration of response, as well as overall survival, patient-reported outcomes and time to next treatment.
ASCEND is the first randomized Phase III trial to directly compare a BTK inhibitor as monotherapy to these combinations in relapsed or refractory CLL.5,9
ELEVATE-RR
ELEVATE-RR (ACE-CL-006) is a randomized, multicenter, open-label Phase III non-inferiority trial of CALQUENCE versus ibrutinib in patients with relapsed or refractory CLL after at least one prior therapy, and at least one of the following prognostic factors: presence of 17p deletion, or presence of 11q deletion.10,11
In the trial, 533 patients were randomized (1:1) into two arms. Patients in the first arm received CALQUENCE (100mg orally twice-daily until disease progression or unacceptable toxicity). Patients in the second arm received ibrutinib (420mg orally once-daily until disease progression or unacceptable toxicity).11
The primary endpoint for the trial was IRC-assessed PFS (non-inferiority; tested after 250 events, upper margin of
ELEVATE-RR is the first randomized Phase III trial to directly compare two BTK inhibitors as monotherapy in relapsed or refractory CLL.
CALQUENCE
CALQUENCE (acalabrutinib) is a next-generation, selective inhibitor of BTK. CALQUENCE binds covalently to BTK, thereby inhibiting its activity.13,14 In B cells, BTK signaling results in activation of pathways necessary for B-cell proliferation, trafficking, chemotaxis and adhesion.13
CALQUENCE is approved for the treatment of CLL and small lymphocytic lymphoma (SLL) in the US, approved for CLL in the EU and several other countries worldwide and approved in
In the US and several other countries, CALQUENCE is also approved for the treatment of adult patients with mantle cell lymphoma (MCL) who have received at least one prior therapy. The US MCL indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. CALQUENCE is not currently approved for the treatment of MCL in
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References
1. Jurczak W, Pluta A, Wach M, et al. Three-Year Follow-Up of the ASCEND Trial: Acalabrutinib vs Rituximab Plus Idelalisib or Bendamustine in Relapsed/Refractory Chronic Lymphocytic Leukemia [abstract]. Presented at:
2.
3. Seymour JF, Byrd J, Hillmen P, et al. Characterization of Bruton Tyrosine Kinase Inhibitor (BTKi)-Related Adverse Events in a Head-to-Head Trial of Acalabrutinib Versus Ibrutinib in Previously Treated Chronic Lymphocytic Leukemia (CLL) [abstract and poster]. Presented at: ASH Annual Meeting and Exposition;
4.
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6.
7. Global Burden of Disease Cancer Collaboration. Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived with Disability, and Disability-Adjusted Life-Years for 29 Cancer Groups, 1990 to 2017. JAMA Oncol. 2019;5(12):1749-1768.
8. Jain N, Chen T, Ayer T, et al. Prevalence and Economic Burden of Chronic Lymphocytic Leukemia (CLL) in the Era of Oral Targeted Therapies. Blood. 2015; 126:871.
9. Ghia P, Pluta A, Wach M, et al. ASCEND: Phase III, Randomized Trial of Acalabrutinib Versus Idelalisib Plus Rituximab or Bendamustine Plus Rituximab in Relapsed or Refractory Chronic Lymphocytic Leukemia [published online ahead of print, 2020 May 27]. J Clin Oncol. 2020;38(25):2849-2861.
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11. Byrd JC, Hillmen P, Ghia P, et al. Acalabrutinib Versus Ibrutinib in Previously Treated Chronic Lymphocytic Leukemia: Results of the First Randomized Phase III Trial. J Clin Oncol. 2021;39(31):3441-3452.
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13. CALQUENCE® (acalabrutinib) [prescribing information].
14. Wu J, Zhang M, Liu D. Acalabrutinib (ACP-196): a selective second-generation BTK inhibitor. J Hematol Oncol. 2016;9(21).
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