1. Dan Douer, MD Attending Physician Leukemia Service Memorial Sloan-Kettering Cancer Center New York, New York Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Jointly sponsored by Postgraduate Institute for Medicine and Clinical Care Options, LLC This program is supported by an educational grant from Image: R.D.R./Copyright©2014 Custom Medical Stock Photo, Inc. All Rights Reserved

2. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia About These Slides  Users are encouraged to use these slides in their own noncommercial presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent  These slides may not be published or posted online without permission from Clinical Care Options (email permissions@clinicaloptions.com) Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.

3. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Faculty Dan Douer, MD Attending Physician Leukemia Service Memorial Sloan-Kettering Cancer Center New York, New York Dan Douer, MD, has disclosed that he has received consulting fees from Jazz Pharmaceuticals and Sigma Tau and funds for research support from Sigma Tau.

4. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Asparaginase: Properties  Enzyme used to deplete asparagine from ALL tumor cells by converting to aspartic acid  Active as single agent [1]  No known late effects  CNS antileukemia activity  Unique adverse effects –No myelosuppression –Hypersensitivity, pancreatitis, clotting of large veins –Liver toxicity, low fibrinogen (bleeding?), hyperglycemia, hypertriglyceridemia –Silent hypersensitivity (antibody formation) 1. Ertel IJ, et al. Cancer Res. 1979;39:3893-3896.

5. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Asparagine GlutamineGlutamic acid Asparagine synthetase Asparagine circulating in blood Aspartic acid Diet synthesis in liver Asparagine Depletion ALL tumor cell Asparaginase

6. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Asparaginase Formulations: Half-life 3. Asselin BL, et al. J Clin Oncol. 1993;11:1780-1786. *Maintenance dose. † Induction dose.

7. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Asparaginase in Newly Diagnosed ALL  Available and approved for patients with ALL  Children and adolescents: Incorporated (with other drugs) in all pediatric regimens  Adults: Clinician reluctance to use –Considered more toxic –No randomized trials –Historically, comparable outcomes with or without asparaginase

8. Asparaginase Treatment in ALL

9. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Asparaginase Treatment in ALL  Adequate asparagine depletion likely associated with better outcome [4-7]  In randomized pediatric trials, better outcome by prolonging asparaginase duration (asparagine depletion) alone [4,8-10]  In adults, short in postremission compared to children  “Pediatric inspired” regimens in adults with longer asparagine depletion appear to improve outcome (age < 45-55 yrs) [11] 4. Capizzi RL. Leuk Lymphoma. 1993;10(suppl):147-150. 5. Vrooman LM, et al. J Clin Oncol. 2013;31:1202-1210. 6. Sallan SE. Cancer Res. 1983;43:5601-5607. 7. Wetzler M, et al. Blood. 2007;109:4164-4167. 8. Silverman LB, et al. Blood. 2001;97:1211-1218. 9. Pession A, et al. J Clin Oncol. 2005;23:7161-7167. 10. Nachman JB, et al. N Engl J Med. 1998;338:1663-1671. 11. Ram R, et al. Am J Hematol. 2012;87:472-478.

10. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia “Treating Adults Like Children”: Pediatric Approaches in Adult ALL  Increase duration of asparagine depletion  More intense nonmyelosuppressive agents  Delayed reinduction  Early CNS prophylaxis (induction)  Allogeneic bone marrow transplant only for very high risk, eg, t(4;11), Philadelphia chromosome positive

11. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Asparaginase Intensification Pediatric and Pediatric-Inspired Regimens AsparaginaseUpper Age, YrsOS, % at F/U True pediatric DFCI protocol [12] E coli5073 at 2 yrs CALGB 10403 [13] Pegylated asparaginase 2500 IU/m 2 39 Study closed, results awaited Pediatric inspired PETHEMA [14] E coli3069 at 6 yrs GRAALL-2003 [15] E coli45/6066/41 at 3.5 yrs Modified BFM protocol [16] Pegylated asparaginase 2000 IU/m 2 5751 at 7 yrs Modified DFCI protocol [17] E coli (retrospective)35/6083/52 at 3 yrs Asparaginase intensification GMALL 7/03 [18] Pegylated asparaginase 500/1000  2000 IU/m 2 5567 at 3 yrs 12. DeAngelo DJ, et al. ASH 2007. Abstract 587. 13. CinicalTrials.gov. NCT00558519. 14. Ribera JM, et al. J Clin Oncol. 2008;26:1843-1849. 15. Huguet F, et al. J Clin Oncol. 2009;27:911-918. 16. Douer D, et al. J Clin Oncol. 2014;[Epub ahead of print]. 17. Storring JM, et al. Br J Haematol. 2009;146:76-85. 18. Goekbuget N, et al. ASH 2010. Abstract 494.

12. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Treatment With Asparaginase: Factors to Consider  Asparagine depletion –Formulation and dose of asparaginase –Duration of treatment; potential for sustained depletion? –Patient variability  Unique toxicity (increases with age > 55-60 yrs)  Resistance –Neutralizing antibody formation –Asparaginase synthetase  Synchronization with other chemotherapy drugs [19] 19. Douer D, et al. J Clin Oncol. 2014;[Epub ahead of print].

13. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia E Coli Asparaginase Suggested Dosing Recommendations Pegylated AsparaginaseLabel [22] Modified Adult Dosing [23-25] Dose2500 IU/m 2 2000 IU/m 2 Frequency Not less than every 14 days Not less than every 3-4 wks RouteIV or IMIV 20. Asparaginase [package insert]. July 2013. 21. Rytting ME. Blood and Lymphatic Cancer: Targets and Therapy. 2012;2012:2:117-124. 22. Pegaspargase [package insert]. November 2011. 23. Douer D, et al. J Clin Oncol. 2014;[Epub ahead of print]. 24. Goekbuget N, et al. ASH 2010. Abstract 494. 25. Weizler M, et al. Blood. 2007;109:4164-4167. Native E Coli Asparaginase*Label [20] Modified Adult Dosing [21] Dose6000 IU/m 2 No modification or 1 dose of 25,000 U/m 2 Frequency3 times per wk RouteIV or IM *Native E coli asparaginase not available in all countries.

14. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Pharmacokinetic Data After 1 Dose of Pegaspargase (2000 IU/m 2 IV)  Single IV dose of pegaspargase for frontline induction regimen in adults with newly diagnosed ALL (n = 25) T½ = 7.0 days (95% CI: 6.04-7.90) Time After Pegaspargase Dose Patients, n Patients With Asparagine Deamination, n (%) 2 hrs1414 (100) Day 71616 (100) Day 141212 (100) Day 20-21119 (82) Day 26-2894 (44) Time, Days 0714212335 Pegaspargase Serum Conc (IU/mL) 1 0.1 0.01 26. Douer D, et al. Blood. 2007;109:2744-2750.

15. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Grades 2-4 Pegylated Asparaginase– Related AEs in Adults Symptomatic AE, %Grades 2-4 (n = 92) Thrombosis13 Fatigue12 Clinical pancreatitis9 Nausea/vomiting8 Allergy5 Strokelike symptoms3 Neuropathy2 27. Rytting M, et al. ASH 2008. Abstract 1924. 28. Rytting M. Expert Opin Biol Ther 2010; 10:833-839. Laboratory AE, %Grades 2-4 (n = 92) Hyperbilirubinemia 24 Transaminasemia52 Hypertriglyceridemia20 Hyperglycemia33 Hypofibrinogenemia9  AEs from 3 protocols including pegylated asparaginase as part of therapy for adults with ALL

16. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Grades 3-5 Pegylated Asparaginase–Related AEs in Pediatric Regimens Select Grades 3-5 Laboratory AEs, % CALGB 10403 (58% 20-29 yrs; 28% 30-39 yrs) COG AALL0232 (60% 16-21 yrs) Hepatic abnormalities ALT50.048.7 AST30.222.2 Bilirubin22.924.7 Coagulation abnormalities Fibrinogen41.09.5 Prothrombin time1.00.6 PTT3.5 DIC0.71.3 Hyperglycemia32.335.4 29. Advani AS, et al. ASH 2013. Abstract 3903. Select Grades 3-5 Symptomatic AEs, % CALGB 10403 (58% 20-29 yrs; 28% 30-39 yrs) COG AALL0232 (60% 16-21 yrs) Febrile neutropenia*46.040.9 Allergic reaction9.419.0 Thrombosis7.63.8 Line-related0.7 Pancreatitis4.23.8 Osteonecrosis2.13.2 Liver failure1.01.9 CNS hemorrhage1.0 Neurologic CNS ischemia1.0 Confusion1.70.6 Encephalopathy0.75.1 Motor neuropathy5.915.8 Sensory neuropathy14.211.4 Seizure2.81.9 Speech impairment2.1 Somnolence0.70 Fracture0.30.6 *For cycles other than induction.

17. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Pegylated Asparaginase in Modified CCG- Augmented Pediatric BFM Protocol DNR VCR Peg-Asp Cyclo DEX Ara-C 6-TG IT-MTX Maintenance therapy continues for 2 yrs Induction 1 DNR VCR PRED Peg-Asp IT-MTX Cyclo VCR PRED Peg-Asp Ara-C 6MP IT-MTX HD-MTX VCR Peg-ASP PRED IT-MTX Pegylated asparaginase (2000 IU/m 2 IV x 6 doses) in adults with ALL x 2 Induction 2Consolidation 1Consolidation 2 Delayed Reinduction 1 ARA-C VM 26 x 2 30. Douer D, et al. J Clin Oncol. 2014;[Epub ahead of print].

18. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Pegylated Asparaginase–Related AEs in CCG-Augmented Pediatric BFM Protocol Asparaginase-Related Grade 3/4 AEs, % Patients, % (n = 51) Doses, % (n = 173) Pancreatitis145 Allergy63 Deep venous thrombus165 Transaminitis6335 Hyperbilirubinemia3113 Hyperglycemia3320 Hypertriglyceridemia1827 31. Douer D, et al. J Clin Oncol. 2014;[Epub ahead of print].

19. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Asparaginase Hypersensitivity  Incidence –Native E coli: 5% to 35% –Pegylated: 3% to 10%  Prevention –Steroid premedication –Anaphylactic kit –No test dose  Rechallenge –Grade 3/4: discontinue, switch to Erwinia asparaginase –Grade 1/2: potential antibody formation?

20. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Antibodies to Pegylated Asparaginase  Silent hypersensitivity/inactivation –Antiasparaginase antibody formation without clinical manifestations of allergy –May result in asparaginase resistance –Data suggested ~ 30% occurrence with native E coli asparaginase and < 5% with pegylated asparaginase [30]  Should analysis of antibody or enzymatic activity be done to detect silent antibodies (if no activity then stop/switch asparaginase)? –Relationship between antibodies and outcome unclear –Nadir serum asparaginase activity may be useful 32. Avramis VI, et al. Blood. 2002;99:1986-1994.

21. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Monitoring for Nadir Serum Asparaginase Activity (NSAA)  Debate remains on best dosing for asparaginase preparations to maximize efficacy while minimizing toxicity  Antibody monitoring used to detect silent inactivation [33]  NSAA used to monitor silent inactivation and individual patient variability for dosing [33] –Target activity: 100 U/L (0.1 U/mL)  Ongoing trials to assess real-time monitoring of NSAA to switch asparaginase preparations for silent inactivation –DFCI ALL Consortium Protocol 11-001 [34] –AIEOP-BFM ALL 2009 [35] 33. Schrey D, et al. Pediatr Blood Cancer. 2010;54:952-958. 34. ClinicalTrials.gov. NCT01574274. 35. ClinicalTrials.gov. NCT01117441.

22. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Individualized Dosing of Asparaginase  Weekly native E coli asparaginase using a 25,000 IU/m 2 FD or ID adjusted every 3 wks based on NSAA in pts aged 1-18 yrs with newly diagnosed ALL  All patients:  Pts with NSAA max < 0.1 IU/mL: –5-yr EFS: 73% with FD vs 91% with ID (P =.058) –5-yr EFS for pts who never changed preparations was similar (76% vs 78%) –5-yr EFS for pts with ID who switched to Erwinia or pegylated asparaginase due to silent inactivation: 95% (95% CI: 68-99) 36. Vrooman LM, et al. J Clin Oncol. 2013;31:1202-1210. 1.0 0.8 0.6 0.4 0.2 0 02468 Yrs Probability of EFS Fixed dose Individualized 95% CI 75-87 84-94 5 Yrs, % 82 90 P =.04

23. Managing Adverse Events Associated With Asparaginase

24. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Hypersensitivity or Silent Inactivation: Switching to Erwinia Asparaginase  Switching may allow continuation of treatment in patients who develop hypersensitivity [38]  Potential role in switching preparations for silent inactivation [39]  Although not intended for nonallergic toxicities, may be less toxic due to short half-life Erwinia AsparaginaseRecommended Dosing [37] Dose25,000 IU/m 2 Frequency 3 times/wk for 2 wks to replace each remaining dose of pegylated asparaginase RouteIV or IM 37. Salzer WL, et al. Blood. 2013;122:507-514. 38. NCCN. Clinical practice guidelines in oncology: acute lymphoblastic leukemia. v.2.2013. 39. Vrooman LM, et al. J Clin Oncol. 2013;31:1202-1210.

25. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Pegylated Asparaginase in Adults: High- Grade Hyperbilirubinemia  Common AE with pegylated asparaginase treatment (31%)  Resolves spontaneously without clinical liver disease  Often long in duration –Peaks after 2-3 wks and resolves by 3-4 wks –Does not necessarily recur on subsequent doses –May delay subsequent cycle  High-grade transaminitis more common (65%) 40. Burke PW, et al. ASH 2013. Abstract 2671.

26. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Serum Thrombin Activity (%) Antithrombin III Deficiency Following Pegylated Asparaginase IV Dose in Adults 41. Douer D, et al. Blood. 2007;109:2744-2750. 20 40 60 80 100 120 140 160 051015202530 Days After Pegylated Asparaginase Treatment

27. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Reduction of Asparaginase Toxicity: Tips for Administration in Adults  Guidelines for Prevention and Management of Asparaginase-Associated Toxicities in Adults and Older Adolescents [1]  Discontinue asparaginase treatment for clinical pancreatitis or major clot [1] 43. Stock W, et al. Leuk Lymphoma. 2011;52:2237-2253. ToxicityManagement [1] Hypersensitivity  Prophylactic steroids, antihistamines, epinephrine as clinically indicated  Switch to Erwinia asparaginase Pancreatitis  Early diagnosis/treatment  Hold tx if amylase/lipase > 3 x ULN until stabilized or declining  Discontinue tx for symptomatic disease Hypertriglyceridemia  Initiate gemfibrozil Major clot  Minimize cryoprecipitate, initiate low-molecular-weight heparin, consider antithrombin-III in brain thrombosis  With clinical correlate, hold tx until acute toxicity and clinical signs resolve and anticoagulant therapy stable or completed

28. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Summary: Asparaginase Administration in Patients With ALL  Native: 6000 IU/m 2 3 x per wk  Pegylated: 2000-2500 IU/m 2 not less than every 14 days (pediatric) or 2000 IU/m 2 not less than every 4 wks (adult)  Asparaginase formulations should be used as part of a multiagent chemotherapy regimen  Serum enzymatic activity varies between patients; potential to measure and adjust dose?  Potential to monitor for silent antibody formation?  Dose: replace each pegylated asparaginase dose with 6 doses 25,000 IU/m 2 IM 3 x per wk E coli AsparaginaseErwinia Asparaginase

29. clinicaloptions.com/oncology Optimizing Use of Asparaginase in Acute Lymphocytic Leukemia Conclusions  Asparaginase is an active drug in ALL and should continue to be studied in patients with ALL using optimal and safe dosing –Pegylated asparaginase preferred as first-line agent; can achieve up to 4 wks of asparagine depletion with possible minimal antibody formation –Native E coli asparaginase also available for first-line therapy in some countries –Erwinia asparaginase can be effectively used if hypersensitivity or silent inactivation occurs  Toxicities could be prevented or ameliorated by following newly developed management guidelines

30. Go Online for More CCO Coverage of ALL! Capsule Summaries of all the key data from ASH Additional CME-certified programs on ALL with expert faculty commentary on best treatment approaches and gaps in care clinicaloptions.com/oncology