FDA Approves Enasidenib (Idhifa), a First-of-Its-Kind Drug, for Advanced Blood Cancer

By Matthew Tontonoz,

Acute myeloid leukemia cells under a microscope
Summary

Acute myeloid leukemia is a rare but hard-to-treat blood cancer that primarily affects older adults. The FDA has approved a new medicine for the disease that works in a manner different from standard chemotherapies.

The US Food and Drug Administration has approved the drug enasidenib (Idhifa®) for the treatment of acute myeloid leukemia (AML) that has stopped responding to other therapies.

The FDA based its decision on the results of a phase I/II trial led by Memorial Sloan Kettering hematologist-oncologist Eytan Stein. People receiving the drug had higher response rates and lived significantly longer than is typical with existing treatments for the disease. Dr. Stein presented the study’s data in June at the annual meeting of the American Society of Clinical Oncology. A paper detailing the findings was simultaneously published in the journal Blood.

Enasidenib is the first drug of its kind to be approved for any cancer. Rather than kill cancer cells, enasidenib rehabilitates them. It allows them to develop as normally functioning blood cells, reversing a stalled developmental state that causes the cells to behave as wayward miscreants. This makes the treatment much less toxic.

“Most of our drugs for AML are toxic to cells. Patients have this prolonged period of bone marrow suppression, which can lead to dangerous infections,” Dr. Stein notes. “This is a drug where you don’t see that. Instead, you see the differentiation of cells into normal, healthy adult cells.”

Enasidenib is an oral medication that people can take at home, with a low risk of side effects.

Birth of a New Drug

Enasidenib (previously known as AG-221) belongs to an emerging class of epigenetic drugs. These medications work to correct patterns of misdirected gene activity stemming from the way DNA is packaged in cells. Epigenetics has captured the attention of cancer biologists because, in principle, this altered DNA packaging is more easily fixed than changes in the DNA sequence itself. MSK’s Center for Epigenetics Research is a leader in this field.

Center for Epigenetics Research
The center fosters inquiry in the rapidly growing fields of cancer epigenetics and epigenomics by bringing together Memorial Sloan Kettering scientists and clinicians with different areas of expertise.
Learn more

The scientific rationale for enasidenib in particular goes back to genetic evidence unearthed about seven years ago. By sequencing the genome of cancer cells in people with AML, scientists discovered that about 12% have a mutation in a gene called IDH2. The mutation causes the protein made by this gene to go haywire. Instead of doing its normal job, the protein produces a molecular byproduct called 2-HG. The troublesome offshoot interferes with a cell’s ability to remove methyl groups from its DNA. With too much methyl around, a cell’s transcriptional machinery can’t get to the DNA. The inability to access DNA prevents cellular differentiation, because the cells can’t turn on the genes they need to grow up.

“That’s sort of the definition of leukemia,” Dr. Stein points out. “It’s the accumulation of immature white blood cells.”

These discoveries led to the idea that if you could block the mutant protein, you could lower levels of 2-HG. That would restore a cell’s ability to remove superfluous methyl groups, and its ability to differentiate.

By sequencing the genome of cancer cells in people with AML, scientists discovered that about 12% have a mutation in a gene called IDH2.

MSK’s President and CEO Craig Thompson did much of the preclinical work deciphering the relationship between the IDH2 mutation and the block to differentiation, including work done while he was a professor at the University of Pennsylvania. MSK physician-scientists Ross Levine and Omar Abdel-Wahab were key collaborators in this research.

Scientists at Agios Pharmaceuticals, the maker of enasidenib, undertook the development of a molecule that could specifically block the action of the mutated enzyme. “They did all the structural modeling and chemical research that developed the drug that fits into the binding site of the mutant enzyme,” Dr. Stein says.

On the clinical side, MSK played a lead role in testing the drug’s safety and efficacy. “We’ve accrued the most patients onto the trial,” Dr. Stein says. “We’ve been driving a lot of the clinical development and also the correlative science to understand what’s happening in patients.” Overseeing this clinical effort is Martin Tallman, Chief of the Leukemia Service.

Back to top Arrow (up) icon.Icon pointing upwards. Usually means that the containing element can be opened and closed.

Safe and Effective

The clinical trial of enasidenib, conducted between 2013 and 2016, enrolled a total of 239 people with myeloid malignancies that had an IDH2 mutation. Included were 176 people who had relapsed or refractory AML. Most of these individuals had received two or more prior therapies. The trial showed that the drug was safe and generally well tolerated. The most common side effects were jaundice (38%) and nausea (23%).

It's really a transformation. Patients will go from being riddled with infections to having a normally functioning body.
Eytan M. Stein
Eytan M. Stein hematologic oncologist

The overall response rate for those with AML was 40%, with a median overall survival time of 9.3 months and an estimated one-year survival rate of 39%. For the 34 people (19.3%) who attained a complete response, the median survival time was 19.7 months. This study did not directly compare enasidenib with standard-of-care chemotherapy, but historically people with relapsed or refractory AML have an average survival time of about three months. These extensions in survival time are therefore significant.

Moreover, people taking the drug start to feel better almost immediately because the level of their infection-fighting white blood cells rapidly returns to normal.

“It’s really a transformation,” Dr. Stein says. “Patients will go from being riddled with infections to having a normally functioning body. It’s pretty amazing.” (The dramatic experience of people taking enasidenib was the subject of a New Yorker article by Jerome Groopman in 2014 aptly called “The Transformation.”)

Unfortunately, most of the people who received enasidenib did eventually relapse. This points to the need to develop more-effective combinations of drugs. Clinical trials of several such combinations are ongoing. A few people in the study had very deep and long-lasting responses and are still alive and cancer free today.

Enasidenib is approved for people with relapsed or refractory AML that tests positive for an IDH2 mutation, as determined by an FDA-approved test. 

Back to top Arrow (up) icon.Icon pointing upwards. Usually means that the containing element can be opened and closed.

Craig Thompson is a co-founder of Agios Pharmaceuticals, which has a financial relationship with Celgene Corporation. Eytan Stein has received grants and personal fees from Celgene Corporation and from Agios Pharmaceuticals. Ross Levine has received research support from Celgene Corporation.

Comments

These phenomenal people are doing a great job helping people live longer, healthier lives and they are curing people in many cases, thereby saving lives. The Doctors mentioned in this article are great people, as is the entire staff at MSKCC. They are all pioneer's in finding a way to cure all Cancers. I just want to say that all the employees who work at MSKCC, from each and every department are committed, very kind, hard working and caring. It's an honor to work with them all. They are all doing their very best. There is no place like this on earth.

What would be the cost of this drug and what is the dosage.

I am a patient of Dr. Popoudoupolis and had a stem cell transplant March 2015 at MSK for AML.
I am curious to know if this new therapy might have any relevance to me?
Thank you

Dear Sal, this drug is approved for relapsed or refractory disease. If you want to learn more you can discuss this with your healthcare team at your next appointment. Thank you for your comment, and best wishes to you.

I am wondering if there is any new treatment for CLL.

Dear Walter, MSK has a number of clinical trials investigating new treatments for CLL. If you are interested in a consultation to learn more, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you.

This is brilliant would love to be involved, completed Master's Degree in Molecular Biology at Adelphi University

Would this help mds patients? Ty

Dear Carolyn, the drug is currently approved only for relapsed or refractory AML that carries the IDH2 mutation, but in clinical trials it has shown promise in treating MDS with the IDH2 mutation as well. If you are interested in making an appointment to discuss this with one of our MDS experts, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment.

I had 3 month trail of AG-221 starting Apr. 2014 for my MDS-RAEB 2. It took my blasts from 15% to 2%. Doctors advised any drug brings temporary relapse and advised a transplant which happened July 2014. Since I am writing this you can assume it was a success. Complete relapse for 3 years. But I am still fighting GVHD.

Dear Ray, thank you for sharing your story. Best wishes to you.

Will this drug help high level mds that is progressing into aml. Ty

I was recently diagnosed with AML with the IDH2 mutstion. I am being seen at Hackensack university. I believe this is something they are going to try with me. I am 33 years old and from what I read I feel I am a perfect candidate. Ultimately I assume a stem cell transplant would still be recommended?

Dear Adam, we're sorry to hear about your diagnosis. Unfortunately we are not able to answer medical questions on our blog. If you would like to arrange for a consultation with experts at MSK, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information. Thank you for your comment, and best wishes to you.

Are there any outcomes relating to AG 221 in non-relapsed or non-refractory AML patients ?

Dear Randolph, we sent your question to Dr. Stein, who responded that his team presented at the American Society of Hematology Meeting in December 2017 from an arm of the phase 1-2 study that enrolled patients with untreated AML with an IDH2 mutation. The overall response rate was 37.8% and the drug was very well tolerated. In addition there was data presented on the combination of Enasidenib with 5-aza for newly diagnosed AML patients with an IDH2 mutation.

The current open and accruing trials for this patient population are:

BEAT-AML – Single agent enasidenib for newly diagnosed AML patients
Protocol 16-1550 – randomized study of 5-aza vs. 5-aza/enasidenib in newly diagnosed AML pts unfit for induction chemotherapy
Protocol 16-012 – phase 1 study of enasidenib in combination with induction chemotherapy

If you are interested in making an appointment to learn more about participating in one of these trials, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information. Thank you for your comment, and best wishes to you.

Thank you, M.S.K. !

You mentioned you have other meds that could combine with Idhifa if it stops working? If I read this correctly could you explain further. I've been on this protocol since March 2018 and CR in May. Thank you from a humble and grateful patient.

Add new comment

We welcome your questions and comments. While we share many of them with our world-class doctors and researchers, we regret that in order to protect your privacy, we are not able to make personal medical recommendations on this forum, nor do we publish comments that contain your personal information. If you would like to consult with an MSK doctor, we encourage you to make an appointment at 800-525-2225 or request an appointment online.

Your email address is kept private and will not be shown publicly.