N-Acetylcysteine for Myeloproliferative Disorders

Recruiting in Palo Alto (17 mi)

+1 other location

Overseen by Angela Fleischman, MD, PhD

Age: 18+

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Phase 1 & 2

Recruiting

Sponsor: University of California, Irvine

Must not be taking: Interferon-alpha, JAK inhibitors

Disqualifiers: Pregnancy, Breastfeeding, Organ impairment, others

No Placebo Group

Approved in 4 Jurisdictions

Trial Summary

What is the purpose of this trial?

This trial is testing the best dose of N-acetylcysteine for patients with certain types of blood cancers. The medication helps reduce inflammation and protect cells, which might be beneficial for these patients. N-acetylcysteine (NAC) has been studied for its potential to prevent heart damage caused by certain cancer treatments and reduce flare-ups in chronic lung disease.

Will I have to stop taking my current medications?

You can continue taking your current medications for myeloproliferative disorders, like aspirin, hydroxyurea, or anagrelide, during the trial. However, you should not have taken interferon-alpha, a JAK inhibitor, or N-Acetylcysteine in the 28 days before joining the study.

What evidence supports the effectiveness of the drug N-Acetylcysteine for myeloproliferative disorders?

Research shows that N-Acetylcysteine (NAC) can reduce blood clots in a mouse model of myeloproliferative neoplasms, similar to the effects of aspirin. It also decreases harmful substances called reactive oxygen species, which are involved in the progression of these disorders. ^{1 2 3 4 5}

Is N-Acetylcysteine generally safe for humans?

N-Acetylcysteine (NAC) is generally considered safe for humans, even at higher doses up to 3000 mg/day, with common side effects like nausea, vomiting, and diarrhea being similar to those at standard doses. It has been used safely in various conditions, including chronic respiratory diseases and as an antidote for acetaminophen poisoning. ^{6 7 8 9 10}

How is the drug N-Acetylcysteine different from other drugs for myeloproliferative disorders?

N-Acetylcysteine (NAC) is unique because it is primarily known for its antioxidant properties and is commonly used to treat conditions like acetaminophen overdose and chronic respiratory diseases. Unlike traditional chemotherapy drugs for myeloproliferative disorders, NAC may offer a novel approach by potentially reducing oxidative stress, which is not a typical mechanism of action for existing treatments. ^{11 12 13 14 15}

Research Team

Angela Fleischman, MD, PhD

Principal Investigator

Chao Family Comprehensive Cancer Center

Eligibility Criteria

Adults diagnosed with essential thrombocythemia, polycythemia vera, or myelofibrosis can join this trial. They must be on stable MPN treatment and not have used interferon-alpha, JAK inhibitors, or N-Acetylcysteine recently. Participants need a certain symptom score and agree to use contraception. Those with severe allergies to N-AC, poor organ function, low blood counts, active infections or pregnancy are excluded.

Inclusion Criteria

I am willing to have my blood drawn and my symptoms checked regularly.

I have been diagnosed with ET, PV, or MF according to the latest criteria.

I have been diagnosed with ET, PV, or MF according to the latest criteria.

Exclusion Criteria

I am not currently taking interferon or a Jak inhibitor.

You have had an allergic reaction to N-AC in the past.

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive N-Acetylcysteine at varying doses to determine the optimal biological dose

8 weeks

Follow-up

Participants are monitored for safety and effectiveness after treatment

4 weeks

Treatment Details

Interventions

• N-Acetylcysteine (Antioxidant)

Trial Overview The study is testing the best dose of a drug called N-Acetylcysteine for patients with myeloproliferative neoplasms (MPNs). It's in early stages (phase I/II) to see how much should be given safely while participants continue their usual treatments for MPNs.

Participant Groups

Group I: Dose Level 3 (DL3) Experimental Treatment 1 Intervention

Patients take N-Acetylcysteince 1800 mg orally twice daily. If DL2 is well tolerated, the next cohort will progress to this dose level.

Group II: Dose Level 2 (DL2) Experimental Treatment 1 Intervention

Patients take N-Acetylcysteince 1200 mg orally twice daily. If DL1 is well tolerated, the next cohort will progress to this dose level.

Group III: Dose Level 1 (DL1) Experimental Treatment 1 Intervention

Patients take N-Acetylcysteince 600 mg orally twice daily. This is the starting dose level for the study.

N-Acetylcysteine is already approved in Canada for the following indications:

Approved in Canada as N-Acetylcysteine for:

• Mucolytic agent
• Acetaminophen overdose

Who Is Running the Clinical Trial?

University of California, Irvine

Lead Sponsor

Trials

580

Recruited

4,943,000+

Chad T. Lefteris

University of California, Irvine

Chief Executive Officer since 2019

MBA from University of California, Irvine

Michael J. Stamos

University of California, Irvine

Chief Medical Officer since 2019

MD, PhD from University of California, Irvine

Findings from Research

The discovery of the JAK2V617F mutation has led to significant advancements in the treatment of myeloproliferative neoplasms (MPN), particularly with the development of JAK inhibitors like Ruxolitinib, which has shown effectiveness in reducing spleen size and improving quality of life in patients with myelofibrosis (MF).

In addition to JAK inhibitors, other innovative treatments such as immunomodulatory drugs (like pomalidomide), kinase inhibitors, and HDAC inhibitors are being explored in clinical trials, suggesting a promising future for combination therapies in MPN management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Novel therapeutic options in the treatment of BCR/ABL-negative myeloproliferative neoplasms]. Döhner, K., Stegelmann, F., Schlenk, RF., et al.[2021]

In a phase 2 clinical trial involving patients with high-risk myelofibrosis who had previously failed JAK inhibitor therapy, the SMAC mimetic LCL161 showed a 30% objective response rate, indicating potential efficacy in this difficult-to-treat population.

The treatment was generally well-tolerated, with the most common side effects being mild nausea and fatigue, and it provided clinical improvements in anemia for some patients, suggesting it could be a valuable option for those with limited treatment alternatives.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Final results of a phase 2 clinical trial of LCL161, an oral SMAC mimetic for patients with myelofibrosis. Pemmaraju, N., Carter, BZ., Bose, P., et al.[2021]

N-acetylcysteine (NAC) significantly extended the lifespan of JAK2V617F knockin mice, a model for polycythemia vera, without affecting blood counts or spleen size, suggesting its potential safety as a treatment.

NAC demonstrated antithrombotic effects by reducing thrombus formation and platelet activation, comparable to aspirin, indicating its promise as a therapeutic option to lower thrombotic risk in patients with myeloproliferative neoplasms.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

N-acetylcysteine inhibits thrombosis in a murine model of myeloproliferative neoplasm. Craver, BM., Ramanathan, G., Hoang, S., et al.[2021]

Reactive oxygen species (ROS) play a significant role in the progression of myeloproliferative neoplasms (MPNs) by promoting inflammation and genomic instability, suggesting that targeting ROS could be a promising therapeutic strategy.

N-acetyl-cysteine (NAC) has shown potent efficacy in reducing ROS levels and may benefit MPN patients, alongside other agents like interferon-alpha2, statins, and JAK inhibitors, potentially leading to improved treatment outcomes and reduced inflammation-related complications.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Role of Reactive Oxygen Species in Myelofibrosis and Related Neoplasms. Bjørn, ME., Hasselbalch, HC.[2018]

A review of 41 studies found that N-Acetylcysteine (NAC) can be safely used at doses higher than the standard 600 mg/day, with some studies administering up to 3000 mg/day for chronic respiratory diseases.

The safety profile of NAC at higher doses was comparable to standard doses, with gastrointestinal symptoms occurring at similar rates as in control groups, suggesting that increasing the dose may not significantly raise the risk of adverse effects.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Safety of N-Acetylcysteine at High Doses in Chronic Respiratory Diseases: A Review. Calverley, P., Rogliani, P., Papi, A.[2023]

N-Acetylcysteine is effective as a mucolytic agent for chronic bronchitis and as an antidote for paracetamol poisoning, with peak plasma concentrations achieved within 1 to 2 hours after oral doses of 200 to 400 mg.

While it has significant therapeutic benefits, common side effects include nausea, vomiting, and diarrhea, and it may interact with other drugs, particularly paracetamol and certain anticancer agents.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Clinical pharmacokinetics of N-acetylcysteine. Holdiness, MR.[2022]

A systematic review of 3 randomized controlled trials and 5 observational studies involving a total of 21,141 patients evaluated the effects of N-acetylcysteine (NAC) on COVID-19 pneumonia, but the evidence for its efficacy was very low due to serious imprecision and indirectness.

While NAC showed no significant impact on in-hospital mortality or the need for ICU admission in RCTs, some observational studies suggested potential benefits, indicating that further research is needed to confirm its safety and effectiveness in treating COVID-19 pneumonia.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

N-acetylcysteine efficacy in patients hospitalized with COVID-19 pneumonia: a systematic review and meta-analysis. Paraskevas, T., Kantanis, A., Karalis, I., et al.[2023]

In a study involving 12 hemodialysis patients, intravenous administration of 2 g of N-acetylcysteine (NAC) over 3 hours was found to be safe, with no observed side effects during the six dialysis sessions.

NAC reached a steady state concentration after the fourth infusion, indicating effective pharmacokinetics in dialysis patients, with a significant dialytic clearance of 5.52 l/h.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pharmacokinetics of N-acetylcysteine following repeated intravenous infusion in haemodialysed patients. Soldini, D., Zwahlen, H., Gabutti, L., et al.[2018]

N-acetylcysteine (NAC) can significantly reduce the production of inflammatory markers like TNF-alpha and TGF-beta1 in alveolar macrophages from patients with idiopathic pulmonary fibrosis (IPF), suggesting its potential as an anti-inflammatory treatment.

In a study involving 16 IPF patients, NAC demonstrated a dose-dependent effect, with the highest concentration (10 mM) leading to substantial suppression of both spontaneous and LPS-stimulated inflammatory responses, indicating its possible role in slowing disease progression.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

N-acetylcysteine inhibits TNF-alpha, sTNFR, and TGF-beta1 release by alveolar macrophages in idiopathic pulmonary fibrosis in vitro. Cu, A., Ye, Q., Sarria, R., et al.[2016]

N4-Palmitoyl-1-beta-D-arabinofuranosylcytosine (PLAC) showed some efficacy in treating acute leukemia and myelodysplastic syndromes, with 2 out of 20 patients with acute myelogenous leukemia achieving complete remission and 1 patient with acute lymphoblastic leukemia achieving partial remission after 25-66 days of treatment.

Despite some gastrointestinal side effects and myelosuppression, PLAC's oral administration offers a less intensive treatment option for patients with MDSs and MPDs, making it suitable for older patients who may not tolerate aggressive chemotherapy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Treatment of leukemia and myelodysplastic syndromes with orally administered N4-palmitoyl-1-beta-D-arabinofuranosylcytosine. Ohno, R., Hirano, M., Yamagata, K., et al.[2019]

A patient with myelofibrosis that progressed to acute non-lymphocytic leukaemia (ANLL) achieved complete remission twice using low doses of cytosine arabinoside (ARA-C).

The treatment with low-dose ARA-C was effective and did not result in serious toxicity, suggesting it could be a safe therapeutic option for patients with myeloproliferative disorders transitioning to ANLL.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Low-dose cytosine arabinoside therapy in a patient with myelofibrosis during transformation to acute non-lymphocytic leukemia. Jensen, MK., Johansen, P., Ahlbom, G.[2019]

N4-Palmitoyl-1-beta-D-arabinofuranosylcytosine (PL-AC) showed efficacy in treating various forms of leukemia and myelodysplastic syndromes, with 11 out of 76 patients with acute myeloid leukemia achieving complete remission after a median of 26 days on doses ranging from 100-900 mg/day.

Despite some major side effects like gastrointestinal toxicities and myelosuppression, PL-AC may be a valuable treatment option for older patients with acute leukemia and myelodysplastic syndromes, as it can be administered orally and does not always require hospitalization.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[A phase II study of N4-palmitoyl-1-beta-D-arabinofuranosylcytosine (PL-AC) in patients with acute leukemia and myelodysplastic syndromes. Cooperative Study Group for PL-AC]. Kimura, K.[2013]

Acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) accounts for 25-34% of AML cases and is associated with poor outcomes, including low remission rates and a median overall survival of only 9-12 months, highlighting the urgent need for more effective treatments.

Liposomal daunorubicin-cytarabine (CPX-351) is the only therapy specifically approved for AML-MRC, showing promise for newly diagnosed patients, while hypomethylating agents like azacitidine are commonly used for those who cannot tolerate CPX-351, indicating a need for further research on combination therapies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

AML with Myelodysplasia-Related Changes: Development, Challenges, and Treatment Advances. Koenig, KL., Sahasrabudhe, KD., Sigmund, AM., et al.[2021]

Inhibition of histone deacetylases (HDACs) shows potential as a therapeutic strategy for acute myelogenous leukaemia (AML), with some patients achieving complete haematological remission, although this is rare (< 5%).

Common side effects from HDAC inhibitors like butyrate derivatives, valproic acid, and depsipeptide include neurological toxicity and gastrointestinal issues, indicating that while there may be some antileukaemic effects, the overall clinical benefit is limited and further research on combination therapies is needed.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Protein lysine acetylation in normal and leukaemic haematopoiesis: HDACs as possible therapeutic targets in adult AML. Bruserud, Ø., Stapnes, C., Tronstad, KJ., et al.[2019]

References

1. Germany pubmed.ncbi.nlm.nih.gov

[Novel therapeutic options in the treatment of BCR/ABL-negative myeloproliferative neoplasms]. [2021]

2. United States pubmed.ncbi.nlm.nih.gov

Final results of a phase 2 clinical trial of LCL161, an oral SMAC mimetic for patients with myelofibrosis. [2021]

3. United States pubmed.ncbi.nlm.nih.gov

N-acetylcysteine inhibits thrombosis in a murine model of myeloproliferative neoplasm. [2021]

4. United States pubmed.ncbi.nlm.nih.gov

The Role of Reactive Oxygen Species in Myelofibrosis and Related Neoplasms. [2018]

5. United States pubmed.ncbi.nlm.nih.gov

Deactylase inhibition in myeloproliferative neoplasms. [2023]

6. New Zealand pubmed.ncbi.nlm.nih.gov

Safety of N-Acetylcysteine at High Doses in Chronic Respiratory Diseases: A Review. [2023]

7. Switzerland pubmed.ncbi.nlm.nih.gov

Clinical pharmacokinetics of N-acetylcysteine. [2022]

8. Germany pubmed.ncbi.nlm.nih.gov

N-acetylcysteine efficacy in patients hospitalized with COVID-19 pneumonia: a systematic review and meta-analysis. [2023]

9. Germany pubmed.ncbi.nlm.nih.gov

Pharmacokinetics of N-acetylcysteine following repeated intravenous infusion in haemodialysed patients. [2018]

10. Italy pubmed.ncbi.nlm.nih.gov

N-acetylcysteine inhibits TNF-alpha, sTNFR, and TGF-beta1 release by alveolar macrophages in idiopathic pulmonary fibrosis in vitro. [2016]

11. Germany pubmed.ncbi.nlm.nih.gov

Treatment of leukemia and myelodysplastic syndromes with orally administered N4-palmitoyl-1-beta-D-arabinofuranosylcytosine. [2019]

12. Sweden pubmed.ncbi.nlm.nih.gov

Low-dose cytosine arabinoside therapy in a patient with myelofibrosis during transformation to acute non-lymphocytic leukemia. [2019]

13. Japan pubmed.ncbi.nlm.nih.gov

[A phase II study of N4-palmitoyl-1-beta-D-arabinofuranosylcytosine (PL-AC) in patients with acute leukemia and myelodysplastic syndromes. Cooperative Study Group for PL-AC]. [2013]

14. Switzerland pubmed.ncbi.nlm.nih.gov

AML with Myelodysplasia-Related Changes: Development, Challenges, and Treatment Advances. [2021]

15. England pubmed.ncbi.nlm.nih.gov

Protein lysine acetylation in normal and leukaemic haematopoiesis: HDACs as possible therapeutic targets in adult AML. [2019]