Melphalan exists in different formulations and is marketed under several brand names.
Alkeran, manufactured by GlaxoSmithKline (GSK), is available as oral tablets or as an injection. Alkeran tablets are used as a palliative treatment. They are typically combined with prednisone and treatment also may include a proteasome inhibitor, such as Velcade (bortezomib) or an immunomodulatory agent such as Thalomid (thalidomide). Alkeran for injection is administered intravenously at a high dose prior to ASCT. It also can be used at a lower dose for the palliative treatment of patients with myeloma for whom oral therapy is not appropriate.
Evomela, marketed by Acrotech Biopharma, is an injectable formulation of melphalan without propylene glycol, a chemical compound with significant side effects. It is used as a conditioning treatment before ASCT and as palliative treatment in patients with myeloma for whom oral therapy is not sutiable.
Ygalo (melflufen), marketed by Oncopeptides, is an investigational melphalan formulation for the treatment of relapsed refractory multiple myeloma (RRMM). In Ygalo, melphalan is bound to flufenamide, increasing its effectiveness. Oncopeptides plans to submit a new drug application for Ygalo to the U. S. Food and Drug Administration (FDA) in the first quarter of 2020.
How does melphalan work?
Melphalan is an alkylating agent that attaches chemical molecules known as alkyl groups to DNA. The alkyl groups interfere with DNA replication, which is essential for cell division. Melphalan primarily affects rapidly dividing cells, such as myeloma cells.
As a palliative treatment, it helps control myeloma cell propagation. Melphalan also is used at higher doses as myeloablative chemotherapy prior to ASCT. At these doses, melphalan is more potent against myeloma cells, but also drastically reduces the number of healthy blood-forming cells in the bone marrow.
Melphalan in clinical trials
The effectiveness of melphalan together with other medications has been tested in many clinical trials.
A meta-analysis of six randomized controlled trials compared the effect of oral melphalan plus prednisone (MP) versus MP in combination with Thalomid (MPT) on overall survival (OS), progression-free survival (PFS), and one-year response rates in previously untreated elderly patients with multiple myeloma. The median OS for MPT was 39.3 months compared to 32.7 months for MP. The median PFS was 20.3 months for MPT, and 14.9 months for MP. The one-year response rates were 59% with MPT and 37% with MP.
A Phase 3 clinical trial (NCT00111319) called VISTA assessed whether the addition of Velcade to melphalan plus prednisone therapy decreases the time to disease progression in patients with previously untreated multiple myeloma. During the trial, 682 patients were assigned randomly to receive nine six-week cycles of melphalan (at a dose of 9 mg/m2) and prednisone (at a dose of 60 mg/m2) either alone or in combination with Velcade (at a dose of 1.3 mg/m2). The response rate was 71% in the group receiving melphalan, prednisone, and Velcade, compared to 35% in the group receiving melphalan and prednisone only. The median time to disease progression was 24 months in the group including Velcade, and 16.6 months in the group without Velcade.
Another clinical trial randomized 200 newly diagnosed multiple myeloma patients below age 65 to receive either high-dose intravenous melphalan to conventional-dose chemotherapy as conditioning therapy prior to ASCT. The conventional-dose group received a combination of chemotherapeutic agents known as VMCP and BVAP. The VMCP regimen included 1 mg intravenous vincristine, 5 mg/m2 oral melphalan, 110 mg/m2 oral cyclophosphamide, and 60 mg/m2 oral prednisone. The BVAP regimen included 1 mg intravenous vincristine, 30 mg/m2 intravenous carmustine, 30 mg/m2 intravenous doxorubicin, and 60 mg/m2 oral prednisone. VMCP and BVAP were administered at alternating cycles of three-week intervals for 12 months, for a total of 18 cycles.
The high-dose group first received four to six alternating cycles of VMCP and BVAP, before receiving 140 mg/m2 intravenous melphalan and undergoing total body irradiation prior to stem cell transplant. The response rate of patients receiving high-dose therapy was 81%, compared to 57% on standard-dose therapy. The probability of event-free survival for five years was 28% in the high-dose group and 10% in the conventional-dose group. The overall estimated five-year survival rate was 52% in the high-dose group and 12% in the conventional-dose group. Treatment-related mortality did not differ significantly between the two groups.
An open-label Phase 2b clinical trial (NCT01660633) assessed the safety and effectiveness of high-dose Evomela as a conditioning regimen prior to ASCT. During the trial, 61 patients received two doses of Evomela at 100 mg/m2 each, three days and two days before ASCT. The ORR was 100%, of which 21% was a complete response.
An ongoing Phase 1/2 trial (NCT01897714) is testing the effectiveness of escalating doses of melflufen in combination with dexamethasone to find the maximum tolerated dose of melflufen in patients with RRMM. This dose will then be used to assess the effectiveness and safety profile of melflufen in combination with dexamethasone in a larger group of patients.
Melphalan treatment leads to bone marrow suppression, which is characterized by a low count of white blood cells, platelets, and hemoglobin. This consequently increases the risk of infection, bleeding, and anemia. When used as a palliative treatment, blood counts have to be regularly monitored to find the optimal dosage of treatment and to avoid toxicity. High doses as part of a conditioning regimen for ASCT can be applied only when stem cells are available for rescue.
Common side effects of melphalan include nausea, vomiting, mucositis (inflammation and ulceration of mucous membranes), and diarrhea.
Last updated: Jan. 9, 2020
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