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Multiple myeloma remains an incurable disease despite recent advances in treatment, and so patients may undergo multiple rounds of remission and relapse. Each relapse results in poorer outcomes; therefore, there is a considerable unmet medical need for patients who are refractory to proteasome inhibitors, immunomodulatory drugs, and/or anti-CD38 monoclonal antibodies. Agents with new modes of action, including B-cell maturation antigen (BCMA)-targeting immunotherapies, offer promising treatment options for patients with relapsed and refractory multiple myeloma (RRMM).
Teclistamab is a bispecific antibody with a CD3 arm that binds to T cells and a BCMA arm that binds to myeloma cells. The redirected T cells then subsequently kill the myeloma cells by releasing perforins and granzymes. Teclistamab is currently being tested in the phase I MajesTEC-1 trial (NCT03145181) for patients with RRMM. The results of this trial led the U.S. Food and Drug Administration (FDA) to grant teclistamab Priority Medicine (PRIME) designation earlier in the year and breakthrough therapy designation on June 1, 2021.1 The results of this trial were recently presented at the 2021 American Society of Oncology (ASCO) Annual Meeting by Amrita Krishnan2 and the European Hematology Association (EHA)2021 Virtual Congress by Neils van de Donk3. The results were also recently published in The Lancet by Saad Usmani,4 and are summarized below.
Figure 1. Study design*
QW, once weekly; RP2D, recommended phase II dose; SC, subcutaneous.
*Adapted from Krishnan, et al.2
†Arrows represent SC administration of teclistamab.
Table 1. Baseline characteristics*
Characteristic |
Total SC |
RP2D |
---|---|---|
Median age (range), years |
64.0 (39–84) |
62.5 (39–84) |
Male (%) |
59 |
65 |
Median time since diagnosis, year (range) |
5.9 (0.8–23.5) |
5.7 (0.8–17.4) |
Extramedullary soft tissue plasmacytomas ≥1, (%) |
15 |
20 |
Bone marrow plasma cells ≥60% (%) |
18 |
8 |
High-risk cytogenetics (%) |
30 |
37 |
ISS stage (%) |
|
|
I |
50 |
62 |
II |
35 |
28 |
II |
15 |
10 |
Median prior line of therapy (range) |
5 (2–14) |
5 (2–11) |
Prior transplantation (%) |
86 |
85 |
Refractory status (%) |
|
|
PI |
89 |
88 |
Carfilzomib |
67 |
68 |
IMiD |
96 |
95 |
Pomalidomide |
75 |
70 |
Anti-CD38 mAb |
93 |
98 |
Triple class |
79 |
83 |
Penta drug |
38 |
38 |
Refractory to last line of therapy |
88 |
83 |
IMiD, immunomodulatory drug; ISS, International Staging System; mAb, monoclonal antibody; PI, proteosome inhibitor; RP2D, recommended phase II dose; SC, subcutaneous. |
Table 2. AEs occurring in ≥20% of patients in the SC cohort*
|
Total SC |
RP2D |
||
---|---|---|---|---|
AE* |
Any Grade |
Grade 3/4 |
Any Grade |
Grade 3/4 |
Hematologic (%) |
|
|
|
|
Neutropenia |
63 |
44 |
65 |
40 |
Anemia |
51 |
26 |
50 |
28 |
Thrombocytopenia |
41 |
21 |
45 |
20 |
Leukopenia |
26 |
12 |
33 |
18 |
Nonhematologic (%) |
|
|
|
|
CRS |
60 |
0 |
70 |
0 |
Nausea |
32 |
0 |
33 |
0 |
Fatigue |
29 |
1 |
38 |
3 |
Injection site erythema |
27 |
0 |
33 |
0 |
Headache |
25 |
0 |
20 |
0 |
Diarrhea |
23 |
3 |
23 |
5 |
Cough |
21 |
1 |
10 |
0 |
Pyrexia |
21 |
0 |
13 |
0 |
AE, adverse event; CRS, cytokine release syndrome; RP2D, recommended phase II dose; SC, subcutaneous. |
Figure 2. Overall response rate*
CR, complete response; ORR, overall response rate; PR, partial response; RP2D, recommended phase II dose; SC, subcutaneous; sCR, stringent complete response; VGPR, very good partial response.
*Adapted from Krishnan, et al.2
Teclistamab showed encouraging efficacy and safety in patients with triple-class RRMM, including high-risk patients with extramedullary disease. These results support the RP2D (1,500 µg/kg SC once weekly) of teclistamab and demonstrate it to be well tolerated, with no new safety signals identified. CRS events with the step-up dosing plan were low-grade and manageable. The response rate to teclistamab was high, with durable responses that deepened over time. With the SC dosing, drug levels exceeded target exposure, and T cell induction was observed. The open-label phase II expansion study (NCT04557098) of teclistamab at the RP2D is currently underway. Future studies will evaluate teclistamab in earlier lines of therapy as well as in combination with other agents, such as immunomodulatory drugs and anti-CD38 antibodies.
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