- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04943302
Isatuximab and Bendamustine in Systemic Light Chain Amyloidosis
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Systemic light-chain amyloidosis is a disorder in which clonal plasma cells produce misfolded immunoglobulin light chains that deposit in tissues resulting in organ dysfunction and ultimately death. The incidence in the United States is estimated to be 9.7 to 14.0 cases per million person-years with median survival from diagnosis between 6 months and 3 years.
The standard of care for those who are eligible is high dose chemotherapy with ASCT. However, only 20-25% of patients are eligible for ASCT with another one-third of patients becoming eligible after bortezomib-based induction. Transplant ineligible patients and patients with relapsed disease after transplant are treated with evolving combinations of anti-plasma cell agents adapted from multiple myeloma including melphalan, cyclophosphamide, proteasome inhibitors, immunomodulatory agents with no therapies approved specifically for this disease.
Bendamustine is an alkylating agent that has established anti plasma cell efficacy in both first-line and refractory multiple myeloma. Known for its efficacy and tolerability in a wide array of hematologic malignancies, toxicity profile consists of cytopenias, gastrointestinal side effects, and allergic reactions. In patients with indolent non-Hodgkin's lymphoma, bendamustine with rituximab showed superior 5 year event free survival compared to R-CHOP or R-CVP with a more tolerable toxicity profile.
The tolerability of bendamustine made it an attractive agent for AL amyloidosis given the older patient population and co-existence of organ impairment. Efficacy of bendamustine in AL amyloidosis was recently demonstrated in a multicenter phase II study of 31 patients with relapsed/refractory AL amyloidosis who were given bendamustine 100mg/m2 on days 1 and 2 and dexamethasone 40mg weekly of 28 day cycle (2-12 cycles, median 4 cycles). Hematologic response of very good partial response (VGPR) or greater was achieved in 29% of patients (11% complete response) at median of 2.8 months and 29% achieved organ response. The median overall survival (OS) was 18.2 months, but the median OS was not reached among patients who achieved a hematologic partial response (PR) or better after 2 cycles at a median follow up of 14.9 months. Overall, treatment was well tolerated; the most common grade 3/4 toxicities were leukopenia, fatigue, renal dysfunction, rash, and mood symptoms.
Plasma cells are known to express CD38, including the monoclonal plasma cells that result in AL amyloidosis. Monoclonal antibodies targeting CD38 have become standard of care in multiple myeloma and more recently have demonstrated safety and superior efficacy when combined with cyclophosphamide, bortezomib, and dexamethasone (CyBorD) compared to CyBorD alone in patients with newly diagnosed AL amyloidosis.
Isatuximab is a monoclonal antibody that binds CD38 expressed on plasma cells and results in toxicity and lysis of the cell. Efficacy has been demonstrated in relapsed/refractory multiple myeloma based on a randomized, multicenter, phase 3 clinical trial comparing isatuximab, pomalidomide, and dexamethasone to pomalidomide and dexamethasone which resulted in a significant improvement in PFS (11.5 months vs. 6.5 months; HR 0.596; p=0.001). An ongoing trial, S1702, is investigating isatuximab in patients with relapsed or refractory AL amyloidosis (NCT03499808).
This study proposes the combination of isatuximab and bendamustine as a neurotoxic-sparing and steroid-minimizing regimen for newly diagnosed or relapsed/refractory AL amyloidosis.
Study Type
Phase
- Phase 2
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Age ≥ 18
- Histopathologically confirmed AL amyloidosis based on detection by polarizing microscopy of green birefringent material in Congo Red stained tissue specimens or characteristic electron microscopy appearance or immunohistohemical stain with anti-light chain anti-sera. Diagnosis cannot be based solely on congo red stain on bone marrow biopsy.
Measurable disease (one of the following):
- Serum monoclonal protein ≥ 0.5g/dL
- Urine monoclonal protein >200mg/dL in 24 hour urine collection
- Clonal population of plasma cells in the bone marrow
- dFLC > 40mg/L
- Mayo Cardiac Amyloid Stage I-IIIA based on the Mayo 2004/European Addition criteria
- ECOG 0-2
- ANC ≥ 1.0 x10^9/L
- Hemoglobin ≥ 8g/dL
- Platelet count ≥ 75 x10^9/L
- Calculated creatinine clearance ≥ 30mL/min based on the Cockcroft-Gault formula
- AST and ALT ≤ 2.5x ULN
- Serum bilirubin < 1.5x ULN
- Willingness to provide consent and participate in study activities
- Male participants must agree to use contraception during the intervention period and for at least 5 months after the last dose of isatuximab treatment and refrain from donating sperm during this period.
Female participants may not be pregnant, not be breastfeeding, and at least one of the following conditions apply:
- Not a female of childbearing potential
- A female of childbearing potential who has 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 prior to starting study medication and before each cycle of study treatment and must either commit to continue abstinence from heterosexual intercourse or apply a highly effective method of birth control during the intervention period and for at least 5 months after the last dose of isatuximab treatment
Exclusion Criteria:
- Resistant to prior anti CD38 antibody therapy as defined as either non-responsive or progression while on or within 60 days of discontinuation of treatment
- Received anti CD38 antibody in the previous 6 months
- Active symptomatic multiple myeloma as defined by IMWG. Smoldering multiple myeloma is permissible.
- Myocardial infarction within 6 months prior to enrollment.
- NYHA class IIIB or IV heart failure
- Mayo Cardiac Amyloid Stage IIIB based on the Mayo 2004/European Addition criteria (See Appendix A)
- Uncontrolled angina
- Severe uncontrolled ventricular arrhythmias
- Active conduction system abnormalities not including 1st degree AV-block, Wenckebach type 2nd degree heart block, or left bundle branch block.
- Use of other investigational drug within 14 days or 5 half-lives of the investigational drug prior to initiation of study intervention, whichever is longer.
- Any clinically significant, uncontrolled medical condition that, in the investigator's opinion, would expose the patient to excessive risk or may interfere with compliance or interpretation of the study results.
- Active systemic infection and severe infections requiring treatment with parenteral administration of antibiotics.
Known to be HIV+ or to have hepatitis A, B, or C active infection
Uncontrolled or active HBV infection: Patients with positive HBsAg and/or HBV DNA
- Patients can be eligible if anti-HBc IgG positive (with or without positive antiHBs) but HBsAg and HBV DNA are negative.
- If anti-HBV therapy in relation with prior infection was started before initiation of IMP, the anti-HBV therapy and monitoring should continue throughout the study treatment period.
- Patients with negative HBsAg and positive HBV DNA observed during screening period will be evaluated by a specialist for start of anti-viral treatment: study treatment could be proposed if HBV DNA becomes negative and all the other study criteria are still met.
Active HCV infection: positive HCV RNA and negative anti HCV
- Patients with antiviral therapy for HCV started before initiation of IMP and positive HCV antibodies are eligible. The antiviral therapy for HCV should continue throughout the treatment period until seroconversion.
- Patients with positive anti-HCV and undetectable HCV RNA without antiviral therapy for HCV are eligible.
- Pregnancy or breastfeeding
- Treatment or diagnosis of another malignancy within 3 years of enrollment except complete resection of basal cell carcinoma or squamous cell carcinoma of the skin, an in situ malignancy, low risk prostate cancer.
- Hypersensitivity to bendamustine
- 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 intervention that are not amenable to premedication with steroids and H2 blockers or would prohibit further treatment with these agents.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: N/A
- Interventional Model: Sequential Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Isatuximab + bendamustine
Bendamustine will be administered by IV at a dose of 70mg/m2 on cycle days 1 and 8 for up to 6 cycles.
Isatuximab will be administered by IV at a dose of 10mg/kg on cycle 1 days 1, 8, 15, and 22; cycle 2-6 days 1,8; and cycle 7-12 day 1.
|
To be given by IV at 70mg/m2 on cycle days 1 and 8 for up to 6 cycles
To be given by IV at10mg/kg IV on cycle 1 days 1,8,15, and 22; cycle 2-6 days 1,8; and cycle 7-12 days 1
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Estimated Hematologic Response
Time Frame: 36 Months
|
Hematologic complete response + very good partial response (CR+VGPR) with definitions as follows:
|
36 Months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Organ Response Rate
Time Frame: 36 Months
|
Organ response rate as defined by:
|
36 Months
|
Progression-Free Survival (PFS)
Time Frame: 36 Months
|
PFS per the IMWG definition of progression of disease:
|
36 Months
|
Rates if Bone Marrow MRD
Time Frame: 36 Months
|
Bone marrow MRD negativity by NGS at a sensitivity of 1x10-6 at the time of complete response, end of treatment visit, and end of study visit.
|
36 Months
|
Time to Next Treatment
Time Frame: 36 Months
|
Time to next treatment
|
36 Months
|
Toxicity of the Regimen
Time Frame: 36 Months
|
Toxicity assessment with CTCAE v5.0
|
36 Months
|
Peripheral Blood BCMA Levels (exploratory)
Time Frame: 36 Months
|
Peripheral blood BCMA levels as assayed by the Comenzo Laboratory at Tufts Medical Center.
|
36 Months
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Cindy Varga, MD, Tufts Medical Center
Publications and helpful links
General Publications
- Munshi NC, Avet-Loiseau H, Rawstron AC, Owen RG, Child JA, Thakurta A, Sherrington P, Samur MK, Georgieva A, Anderson KC, Gregory WM. Association of Minimal Residual Disease With Superior Survival Outcomes in Patients With Multiple Myeloma: A Meta-analysis. JAMA Oncol. 2017 Jan 1;3(1):28-35. doi: 10.1001/jamaoncol.2016.3160.
- Simon R. Optimal two-stage designs for phase II clinical trials. Control Clin Trials. 1989 Mar;10(1):1-10. doi: 10.1016/0197-2456(89)90015-9.
- Friedberg JW, Cohen P, Chen L, Robinson KS, Forero-Torres A, La Casce AS, Fayad LE, Bessudo A, Camacho ES, Williams ME, van der Jagt RH, Oliver JW, Cheson BD. Bendamustine in patients with rituximab-refractory indolent and transformed non-Hodgkin's lymphoma: results from a phase II multicenter, single-agent study. J Clin Oncol. 2008 Jan 10;26(2):204-10. doi: 10.1200/JCO.2007.12.5070. Erratum In: J Clin Oncol. 2008 Apr 10;26(11) 1911.
- Palladini G, Dispenzieri A, Gertz MA, Kumar S, Wechalekar A, Hawkins PN, Schonland S, Hegenbart U, Comenzo R, Kastritis E, Dimopoulos MA, Jaccard A, Klersy C, Merlini G. New criteria for response to treatment in immunoglobulin light chain amyloidosis based on free light chain measurement and cardiac biomarkers: impact on survival outcomes. J Clin Oncol. 2012 Dec 20;30(36):4541-9. doi: 10.1200/JCO.2011.37.7614. Epub 2012 Oct 22.
- Dispenzieri A, Gertz MA, Kyle RA, Lacy MQ, Burritt MF, Therneau TM, Greipp PR, Witzig TE, Lust JA, Rajkumar SV, Fonseca R, Zeldenrust SR, McGregor CG, Jaffe AS. Serum cardiac troponins and N-terminal pro-brain natriuretic peptide: a staging system for primary systemic amyloidosis. J Clin Oncol. 2004 Sep 15;22(18):3751-7. doi: 10.1200/JCO.2004.03.029.
- Attal M, Richardson PG, Rajkumar SV, San-Miguel J, Beksac M, Spicka I, Leleu X, Schjesvold F, Moreau P, Dimopoulos MA, Huang JS, Minarik J, Cavo M, Prince HM, Mace S, Corzo KP, Campana F, Le-Guennec S, Dubin F, Anderson KC; ICARIA-MM study group. Isatuximab plus pomalidomide and low-dose dexamethasone versus pomalidomide and low-dose dexamethasone in patients with relapsed and refractory multiple myeloma (ICARIA-MM): a randomised, multicentre, open-label, phase 3 study. Lancet. 2019 Dec 7;394(10214):2096-2107. doi: 10.1016/S0140-6736(19)32556-5. Epub 2019 Nov 14. Erratum In: Lancet. 2019 Dec 7;394(10214):2072.
- Palladini G, Hegenbart U, Milani P, Kimmich C, Foli A, Ho AD, Vidus Rosin M, Albertini R, Moratti R, Merlini G, Schonland S. A staging system for renal outcome and early markers of renal response to chemotherapy in AL amyloidosis. Blood. 2014 Oct 9;124(15):2325-32. doi: 10.1182/blood-2014-04-570010. Epub 2014 Aug 12.
- Novak AJ, Darce JR, Arendt BK, Harder B, Henderson K, Kindsvogel W, Gross JA, Greipp PR, Jelinek DF. Expression of BCMA, TACI, and BAFF-R in multiple myeloma: a mechanism for growth and survival. Blood. 2004 Jan 15;103(2):689-94. doi: 10.1182/blood-2003-06-2043. Epub 2003 Sep 25.
- Gertz MA. Immunoglobulin light chain amyloidosis: 2020 update on diagnosis, prognosis, and treatment. Am J Hematol. 2020 Jul;95(7):848-860. doi: 10.1002/ajh.25819. Epub 2020 Apr 28.
- Quock TP, Yan T, Chang E, Guthrie S, Broder MS. Epidemiology of AL amyloidosis: a real-world study using US claims data. Blood Adv. 2018 May 22;2(10):1046-1053. doi: 10.1182/bloodadvances.2018016402.
- Cornell RF, Zhong X, Arce-Lara C, Atallah E, Blust L, Drobyski WR, Fenske TS, Pasquini MC, Rizzo JD, Saber W, Hari PN. Bortezomib-based induction for transplant ineligible AL amyloidosis and feasibility of later transplantation. Bone Marrow Transplant. 2015 Jul;50(7):914-7. doi: 10.1038/bmt.2015.73. Epub 2015 Apr 27.
- Gentile M, Vigna E, Recchia AG, Morabito L, Mendicino F, Giagnuolo G, Morabito F. Bendamustine in multiple myeloma. Eur J Haematol. 2015 Nov;95(5):377-88. doi: 10.1111/ejh.12609. Epub 2015 Jul 14.
- Cheson BD, Rummel MJ. Bendamustine: rebirth of an old drug. J Clin Oncol. 2009 Mar 20;27(9):1492-501. doi: 10.1200/JCO.2008.18.7252. Epub 2009 Feb 17. Erratum In: J Clin Oncol. 2009 Jun 10;27(17):2892.
- Flinn IW, van der Jagt R, Kahl BS, Wood P, Hawkins TE, Macdonald D, Hertzberg M, Kwan YL, Simpson D, Craig M, Kolibaba K, Issa S, Clementi R, Hallman DM, Munteanu M, Chen L, Burke JM. Randomized trial of bendamustine-rituximab or R-CHOP/R-CVP in first-line treatment of indolent NHL or MCL: the BRIGHT study. Blood. 2014 May 8;123(19):2944-52. doi: 10.1182/blood-2013-11-531327. Epub 2014 Mar 3.
- Flinn IW, van der Jagt R, Kahl B, Wood P, Hawkins T, MacDonald D, Simpson D, Kolibaba K, Issa S, Chang J, Trotman J, Hallman D, Chen L, Burke JM. First-Line Treatment of Patients With Indolent Non-Hodgkin Lymphoma or Mantle-Cell Lymphoma With Bendamustine Plus Rituximab Versus R-CHOP or R-CVP: Results of the BRIGHT 5-Year Follow-Up Study. J Clin Oncol. 2019 Apr 20;37(12):984-991. doi: 10.1200/JCO.18.00605. Epub 2019 Feb 27.
- Lentzsch S, Lagos GG, Comenzo RL, Zonder JA, Osman K, Pan S, Bhutani D, Pregja S, Sanchorawala V, Landau H. Bendamustine With Dexamethasone in Relapsed/Refractory Systemic Light-Chain Amyloidosis: Results of a Phase II Study. J Clin Oncol. 2020 May 1;38(13):1455-1462. doi: 10.1200/JCO.19.01721. Epub 2020 Feb 21.
- Matsuda M, Gono T, Shimojima Y, Hoshii Y, Ikeda S. Phenotypic analysis of plasma cells in bone marrow using flow cytometry in AL amyloidosis. Amyloid. 2003 Jun;10(2):110-6. doi: 10.3109/13506120309041732.
- Palladini G, Kastritis E, Maurer MS, Zonder J, Minnema MC, Wechalekar AD, Jaccard A, Lee HC, Bumma N, Kaufman JL, Medvedova E, Kovacsovics T, Rosenzweig M, Sanchorawala V, Qin X, Vasey SY, Weiss BM, Vermeulen J, Merlini G, Comenzo RL. Daratumumab plus CyBorD for patients with newly diagnosed AL amyloidosis: safety run-in results of ANDROMEDA. Blood. 2020 Jul 2;136(1):71-80. doi: 10.1182/blood.2019004460.
- Jiang H, Acharya C, An G, Zhong M, Feng X, Wang L, Dasilva N, Song Z, Yang G, Adrian F, Qiu L, Richardson P, Munshi NC, Tai YT, Anderson KC. SAR650984 directly induces multiple myeloma cell death via lysosomal-associated and apoptotic pathways, which is further enhanced by pomalidomide. Leukemia. 2016 Feb;30(2):399-408. doi: 10.1038/leu.2015.240. Epub 2015 Sep 4.
- Comenzo RL, Reece D, Palladini G, Seldin D, Sanchorawala V, Landau H, Falk R, Wells K, Solomon A, Wechalekar A, Zonder J, Dispenzieri A, Gertz M, Streicher H, Skinner M, Kyle RA, Merlini G. Consensus guidelines for the conduct and reporting of clinical trials in systemic light-chain amyloidosis. Leukemia. 2012 Nov;26(11):2317-25. doi: 10.1038/leu.2012.100. Epub 2012 Apr 5.
- Staron A, Burks EJ, Lee JC, Sarosiek S, Sloan JM, Sanchorawala V. Assessment of minimal residual disease using multiparametric flow cytometry in patients with AL amyloidosis. Blood Adv. 2020 Mar 10;4(5):880-884. doi: 10.1182/bloodadvances.2019001331.
- Kahl BS, Bartlett NL, Leonard JP, Chen L, Ganjoo K, Williams ME, Czuczman MS, Robinson KS, Joyce R, van der Jagt RH, Cheson BD. Bendamustine is effective therapy in patients with rituximab-refractory, indolent B-cell non-Hodgkin lymphoma: results from a Multicenter Study. Cancer. 2010 Jan 1;116(1):106-14. doi: 10.1002/cncr.24714.
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- Martin T, Strickland S, Glenn M, Charpentier E, Guillemin H, Hsu K, Mikhael J. Phase I trial of isatuximab monotherapy in the treatment of refractory multiple myeloma. Blood Cancer J. 2019 Mar 29;9(4):41. doi: 10.1038/s41408-019-0198-4.
- Laabi Y, Gras MP, Carbonnel F, Brouet JC, Berger R, Larsen CJ, Tsapis A. A new gene, BCM, on chromosome 16 is fused to the interleukin 2 gene by a t(4;16)(q26;p13) translocation in a malignant T cell lymphoma. EMBO J. 1992 Nov;11(11):3897-904. doi: 10.1002/j.1460-2075.1992.tb05482.x.
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- Xu S, Lam KP. B-cell maturation protein, which binds the tumor necrosis factor family members BAFF and APRIL, is dispensable for humoral immune responses. Mol Cell Biol. 2001 Jun;21(12):4067-74. doi: 10.1128/MCB.21.12.4067-4074.2001.
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- Godara A, Zhou P, Kugelmass A, Ma X, Rosenthal B, Toskic D, Fogaren T, Varga C, Comenzo RL. Presence of soluble and cell-surface B-cell maturation antigen in systemic light-chain amyloidosis and its modulation by gamma-secretase inhibition. Am J Hematol. 2020 May;95(5):E110-E113. doi: 10.1002/ajh.25734. Epub 2020 Jan 29. No abstract available.
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Study record dates
Study Major Dates
Study Start (Anticipated)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- 00001665
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
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