Blood Adv in press

Enasidenib as Maintenance following Allogeneic Hematopoietic
Cell Transplantation for IDH2-Mutated Myeloid Malignancies.

Fathi AT, Kim HT, Soiffer RJ, Levis MJ, Li S, Kim AS, Mims AS, DeFilipp Z, El-Jawahri A, McAfee SL, Brunner AM, Narayan R, Knight LW, Kelley D, Bottoms AS, Perry LS, Wahl JL, Brock J, Breton E, Ho VT, Chen YB

IDH2 (isocitrate dehydrogenase 2) mutations occur in approximately 15% of patients with acute myeloid leukemia (AML). The IDH2 inhibitor enasidenib was recently approved for IDH2-mutated relapsed or refractory AML. We conducted a multi-center, phase I trial of maintenance enasidenib following allogeneic hematopoietic cell transplantation (HCT) in patients with IDH2-mutated myeloid malignancies. Two dose levels, 50mg and 100mg daily were studied in a 3x3 dose-escalation design, with 10 additional patients treated at the recommended phase 2 dose (RP2D). Enasidenib was initiated between days 30 and 90 following HCT and continued for twelve 28-day cycles. Twenty-three patients were enrolled, of whom 19 initiated post-HCT maintenance. Two had myelodysplastic syndrome, and 17 had AML. All but 3 were in first complete remission. No dose limiting toxicities were observed, and the RP2D was established at 100 mg daily. Grade ≥3 toxicities attributable to enasidenib were rare, with the most common being cytopenias. Eight patients stopped maintenance therapy before completing 12 cycles, due to adverse events (n=3), pursuing treatment for graft versus host disease (GVHD) (n=2), clinician choice (n=1), relapse (n=1), and COVID-19 infection (n=1). No cases of grade ≥3 acute GVHD were seen, and the 12-month cumulative incidence of moderate/severe chronic GVHD was 42% (20-63%). Cumulative incidence of relapse was 16% (95% CI: 3.7-36%); only one subject relapsed while receiving maintenance enasidenib. Two-year progression-free and overall survival were 69% (95% CI: 39-86%) and 74% (950% CI, 44-90%), respectively. Enasidenib is safe, well-tolerated, with preliminary activity as maintenance therapy following HCT, and merits additional study. The study was registered at ClinicalTrials.gov (NCT03515512).