Overview

This research study is investigating the safety and effectiveness of using combination of isatuximab, lenalidomide and dexamethasone for the treatment of newly diagnosed multiple myeloma (MM). The study team will use lower doses than is currently standard for these drugs. Lower doses will be used to avoid or possibly reduce any unwanted side effects commonly associated with these drugs. Using lower doses of the combination isatuximab, lenalidomide and dexamethasone, has not been approved by the Food and Drug Administration (FDA) for the treatment of newly diagnosed MM.

Eligibility

Subject Eligibility In order to participate in this study a subject must meet all of the

eligibility criteria outlined below.

Inclusion Criteria

1. Written informed consent obtained to participate in the study and Health Insurance Portability and Accountability Act (HIPAA) authorization for release of personal health information (PHI). Consent must be obtained before performance of any study-related procedure not part of normal medical care, with the understanding that consent may be withdrawn by the subject at any time without prejudice to future medical care.
2. Willing and able to adhere to the study visit schedule and other protocol requirements based on the judgement of the investigator or protocol designee.
3. Predicted high risk for severe toxicity from intensive induction regimens, such as standard (full-dose) Bortezomib, cyclophosphamide, dexamethasone (VCD), lenalidomide, bortezomib, and dexamethasone (RVD), or lenalidomide and weekly dexamethasone (Rd) as each regimen was published. (Such regimens often use, for example, twice-weekly bortezomib or lenalidomide at 25 mg.) High-risk is defined as one of the following:
   1. Score ≥ 2 (indicating "frail") on the International Myeloma Working Group instrument (IMWG; Palumbo et al. [Blood 2015]),
   2. Karnofsky Performance Status (KPS) ≤ 70,
   3. Felt not to be candidate for full-intensity induction by treating clinician due to comorbidities, performance status, or other factors not otherwise captured by the Palumbo system or performance status. The reason for the subject's non-candidacy for full-intensity therapy should be described in the clinical documentation.

             Subjects qualifying for enrollment by criterion C should be discussed with the Medical
             Monitor before enrollment, to ensure uniform application of this criterion across
             participating sites.
          4. Measurable MM diagnosed according to the following standard criteria. Criteria A and B
             must be met, in addition to C and/or D:
               1. Monoclonal plasma cells in bone marrow ≥ 10% and/or presence of biopsy-proven
                  plasmacytoma
               2. Monoclonal protein (M-protein) present in serum and/or urine, defined as serum
                  M-protein of ≥ 1 g/dL (0.5 g/dL for Immunoglobulin A (IgA) MM) OR urine M-protein
                  of ≥ 200 mg/24 hours. Subjects lacking an M-protein meeting those criteria must
                  have a serum free light chain assay with an involved light chain ≥ 10 mg/dL (100
                  mg/L) and an abnormal serum free light chain ratio.
               3. One or more MM-related organ dysfunction findings such as hypercalcemia, renal
                  insufficiency, anemia, and bone lesions (CRAB) criteria listed below:
                    -  Calcium elevation in blood (serum calcium 1 mg/dL ≥ upper limit of normal or
                       > 11 mg/dL)
                    -  Renal insufficiency (creatinine clearance < 40 ml/min or serum creatinine >
                       2 mg/dL)
                    -  Anemia (hemoglobin < 10 g/dL or ≥ 2 g/dL below normal)
                    -  Bone lesions (lytic bone lesions) on x-rays, computerized tomography (CT),
                       Magnetic resonance imaging (MRI) or Positron emission tomography (PET)
               4. Myeloma-related biomarker of malignancy (1 or more should be fulfilled):
                    -  ≥ 60% bone marrow plasmacytosis
                    -  Serum involved / uninvolved free light chain ratio of ≥ 100, provided
                       absolute level of involved light chain is at least 100 mg/L (10 mg/dL)
                    -  More than one focal lesion on MRI ≥ 5 mm in size
          5. No prior systemic anti-myeloma therapy lasting more than 28 days (generally one
             cycle). Any prior therapy must be completed a minimum of 14 days before starting study
             drugs.
          6. Subjects who require radiotherapy (which must be localized in its field size) may be
             treated during screening but initiating study therapy should be deferred until the
             radiotherapy is completed and 14 days have elapsed since the last date of
             radiotherapy.
          7. Demonstrate adequate organ function and laboratory values as defined in below.
             Hematological
               -  Hemoglobin (Hgb) ≥ 8 g/dL Transfusion of packed red blood cells or use of
                  erythropoietin or analogs is permitted, if clinically appropriate, to achieve
                  this threshold.
               -  Absolute Neutrophil Count (ANC) ≥ 1.0 x 109/L Use of growth factors is permitted
                  to fulfill this criterion, particularly if low ANC is felt to be due to MM by
                  treating clinician. If low ANC is felt to be due to non-MM causes, such as
                  myelodysplasia or other bone marrow disorders unrelated to MM, then subject
                  should not be enrolled on the study.
               -  Platelets ≥ 50 × 109/L if < 50% of bone marrow nucleated cells are plasma cells,
                  and
               -  ≥ 30 × 109/L if ≥ 50% of BM (Bone Marrow) nucleated cells are plasma cells.
               -  Platelet transfusions are permitted to reach entry criteria. If low platelets are
                  felt to be due to non-MM causes, such as myelodysplasia or other bone marrow
                  disorders unrelated to MM, then subject should not be enrolled on the study.
             Renal
             • Calculated or measured glomerular filtration rate (GFR):Any GFR as long as not
             currently dialysis-dependent
          8. Females of childbearing potential (FCBP)* must have a negative serum or urine
             pregnancy test with a sensitivity of at least 25 mIU/mL within 10 - 14 days prior to
             and again within 24 hours of starting lenalidomide and must either commit to continued
             abstinence from heterosexual intercourse or begin two acceptable methods of birth
             control, one highly effective method and one additional effective method at the same
             time, at least 28 days before she starts taking lenalidomide through 30 days after the
             last dose of lenalidomide and 5 months after the last dose of isatuximab. FCBP must
             also agree to ongoing pregnancy testing during the entire duration of treatment and
             monthly for 5 months after the last dose of isatuximab. Men must agree to use a latex
             or synthetic condom during sexual contact with a FCBP even if they have had a
             vasectomy from the time of signing the informed consent form through 30 days after the
             last dose of lenalidomide and 5 months after the last dose of isatuximab. These same
             subjects must not donate sperm. All subjects must be counseled at a minimum of every
             28 days about pregnancy precautions and risks of fetal exposure. All subjects enrolled
             into this trial, must be registered in and must comply with all requirements of the
             REVLIMID Risk Evaluation and Mitigation Strategy (REMS) program.
               -  A female of childbearing potential (FCBP) is a sexually mature female who: 1) has
                  not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been
                  naturally postmenopausal for at least 24 consecutive months (i.e., has had menses
                  at any time in the preceding 24 consecutive months).
        Exclusion Criteria
          1. Active infection requiring systemic antibiotics or other serious infection within 14
             days prior to study treatment.
          2. Subjects felt to not be candidates by treating physician for any systemic therapy due
             to excessive comorbidities, frailty, impaired performance status, or other severe
             limitations. Such limitations can be conceptualized generally as making subjects
             exceedingly high-risk for any systemic treatment for their MM. These limitations often
             stem from medical comorbidities unrelated to MM and they are hence unlikely to improve
             with MM therapy. The reasons for exclusion will be documented.
          3. Any clinically significant, uncontrolled medical conditions that, in the
             Investigator's opinion, would expose excessive risk to the subject or may interfere
             with compliance or interpretation of the study results.
          4. Light-chain (AL) amyloidosis. Subjects with secondary amyloidosis due to MM are
             eligible, if the amyloidosis is not felt to be a clinically significant issue (e.g.,
             amyloid found incidentally on bone marrow core biopsy without evidence of
             amyloid-mediated organ compromise).
          5. Myocardial infarction within 3 months prior to study treatment or has New York Heart
             Association (NYHA) Class III or IV heart failure, uncontrolled angina, severe
             uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute
             ischemia or active conduction system abnormalities.
          6. Known allergy to any of the study medications, their analogues, or excipients in the
             various formulations of any agent.
          7. Hypersensitivity or history of intolerance to steroids, mannitol, pregelatinized
             starch, sodium stearyl fumarate, histidine (as base and hydrochloride salt), arginine
             hydrochloride, poloxamer 188, sucrose or any of the other components of study therapy
             that are not amenable to premedication with steroids and H2 blockers or would prohibit
             further treatment with these agents.
          8. Known gastrointestinal (GI) disease that could interfere with the oral absorption or
             tolerance of dexamethasone or lenalidomide including difficulty swallowing.
          9. Serious medical or psychiatric illness likely to interfere with participation in this
             clinical study.
         10. Patients with a history of prior or concurrent second primary malignancy whose natural
             history or treatment does not have the potential to interfere with the safety or
             efficacy assessment of the investigational treatment should generally be eligible.
         11. Receiving other investigational agents less than 14 days or 5 half-lives of first dose
             of therapy on this protocol, whichever is longer.
         12. Concurrent use of other anti-cancer agents or treatments with possible exception of
             agents with low likelihood of affecting outcome of this study, such as adjuvant
             hormonal therapy for remote history of breast cancer.
         13. Known to be HIV+ or have active infection with hepatitis A, B, or C; or tuberculosis.
         14. Chronic daily corticosteroids for other, non-MM-related medical conditions exceeding
             low-dose (e.g., prednisone ≥ 10 mg daily or equivalent).
         15. Subject is receiving prohibited medications or treatments as listed in the protocol
             that cannot be discontinued/replaced by an alternative therapy.