Supplementary Appendix

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1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Lokhorst HM, Plesner T, Laubach JP, et al. Targeting CD38 with daratumumab monotherapy in multiple myeloma. N Engl J Med 2015;373: DOI: /NEJMoa

2 SUPPLEMENTARY APPENDIX Targeting CD38 With Daratumumab Monotherapy in Multiple Myeloma Henk M. Lokhorst, M.D., Ph.D., Torben Plesner, M.D., Jacob P. Laubach, M.D., Hareth Nahi, M.D., Ph.D., Peter Gimsing, M.D., Ph.D., Markus Hansson, M.D., Ph.D., Monique C. Minnema, M.D., Ph.D., Ulrik Lassen, M.D., Ph.D., Jakub Krejcik, M.D., Antonio Palumbo, M.D., Niels W.C.J. van de Donk, M.D., Ph.D., Tahamtan Ahmadi, M.D., Ph.D., Imran Khan, M.D., Ph.D., Clarissa M. Uhlar, Ph.D., Jianping Wang, Ph.D., A. Kate Sasser, Ph.D., Nedjad Losic, M.Sc., Steen Lisby, M.D., Linda Basse, M.D., Nikolai Brun, M.D., Ph.D., and Paul G. Richardson, M.D. The authors affiliations are as follows: From the Department of Hematology, University Medical Center Utrecht, Utrecht (H.M.L., M.C.M., N.W.C.J.D.), and Department of Hematology, VU University Medical Center, Amsterdam (H.M.L., N.W.C.J.D.) both in the Netherlands; Vejle Hospital and University of Southern Denmark, Vejle (T.P., J.K.), and Rigshospitalet and University of Copenhagen (P.G., U.L.) and Genmab (N.L., S.L., L.B., N.B.), Copenhagen all in Denmark; Dana Farber Cancer Institute, Harvard Medical School, Boston ( J.P.L., P.G.R.); Karolinska Institute and the Department of Medicine, Division of Hematology, Karolinska University Hospital at Huddinge, Stockholm (H.N.), and Skåne University Hospital and Lund University, Lund (M.H.) all in Sweden; Myeloma Unit, Division of Hematology, University of Turin, Turin, Italy (A.P.); Janssen Research and Development, Spring House, PA (T.A., C.M.U., A.K.S.); and Janssen Research and Development, Raritan, NJ (I.K., J.W.). 1

3 Table of Contents Additional Methods... 3 Exposure to and Effect of Steroid Use... 6 Figure S1. Confirmation of CRs in Two Patients With VGPRs by IMWG Criteria Using Daratumumab Interference Reflex Assay Figure S2. Reduction in Bone Marrow Plasma Cells Following 16 mg/kg Daratumumab, Part 2, in Patients With Relapsed and Refractory MM Who Responded to Therapy Figure S3. Kaplan-Meier Curves of PFS Following Daratumumab Monotherapy in Patients With Relapsed and Refractory MM Table S1. International Myeloma Working Group Uniform Response Criteria for Multiple Myeloma Table S2. Demographics and Baseline Characteristics of Patients in Part Table S3. Treatment Discontinuation Due to AEs in Part Table S4. Serious AEs in Part Table S5. Infusion-related AEs in Part Table S6. Dosing and IRRs in Part Table S7. Responses in Part 1 in Patients Treated With 4 mg/kg Daratumumab or Higher Table S8. Summary of Responses in Part Table S9. Overall Response Rate Based on Prior Therapy in Patients Treated With 8 mg/kg Daratumumab in Part References

4 Additional Methods Pre- and post-infusion medications and infusion schedules Part 1 Initially, subjects received IV glucocorticoid equivalent to 100 mg prednisolone before the first 2 pre doses and before the first 2 full daratumumab infusions. In a protocol amendment (March 2009) the steroid premedication was restricted to 80 mg methylprednisolone to minimize the risk of using nonequivalent doses of other steroids. In a protocol amendment (April 2010) steroid premedication was added for all subsequent infusions after the second full infusion. Non-steroid premedications were 1 g paracetamol (acetaminophen, PO) 1 to 2 hours before treatment and antihistamine (clemastine 1 mg IV, cetirizine 10 mg PO, or equivalent) 1 to 2 hours before treatment. There was no post-infusion medication until a protocol amendment (May 2011) provided all subjects with 40 mg methylprednisolone PO (equivalent to 50 mg prednisolone) on the first and second days after all full infusions. Pre-dose infusions were administered over approximately 4 hours. Full daratumumab infusions were administered over 6 hours (500 ml) and later by protocol amendment (May 2011) over 8 hours (1000 ml). Part 2 In part 2, all subjects received premedication before each infusion, both predose and full dose. Subjects received 100 mg methylprednisolone or equivalent, which could 3

5 be reduced to 50 mg after visit 4. Non-steroid pre-infusion medications were as described in part 1. All subjects received 20 to 25 mg methylprednisolone PO, or equivalent, on the first and second days after all full-dose infusions. In schedules A and B, the first full infusion was preceded by a predose infusion the day before the infusion. The predose infusion was 10 mg in total dose. Predose infusions were administered over approximately 4 hours. 4

6 Safety Assessments In part 1, adverse events (AEs) that would lead to withdrawal of treatment were any of the following: an infusion reaction that prevented the infusion from being resumed regardless of the length of the reaction; study drug related serious adverse events (SAEs) with an onset after the start of infusion on an infusion day with NCI CTCAE grade 2 or higher, with the exception of nonhematologic reactions of grade 2 that responded to symptomatic therapy and resolved within 6 hours from the onset of the event; study drug related nonhematologic AEs of grade 3 or higher; hemolysis of grade 3 or higher; study drug related hematologic AEs of grade 4 or higher, with the exception of platelet counts of grade 4 or higher with a duration of less than 4 weeks; platelet counts of less than /L occurring 4 weeks after the latest infusion; platelet counts that decreased by 75% or greater since visit 2 during part 1, and remained higher than /L but increased less than /L above nadir 4 weeks after the latest infusion. In part 2, an AE that would lead to withdrawal of treatment was defined as a study drug related SAE with an onset within 48 hours after the start of infusion that corresponded to CTCAE grade 3 or higher, did not respond to symptomatic therapy, and did not resolve within 6 hours from onset of event. The investigator, sponsor, or IDMC could assess the event as study drug related. 5

7 Exposure to and Effect of Steroid Use Patients received pre-infusion, post-infusion steroid and concomitant steroids as indicated above. The majority of patients who were refractory to prior IMiD and PI regimens also received steroids as part of their therapy. Of the 57 patients refractory to their last line of therapy 54, (95%) also received steroids as part of their regimens and thus could be considered steroid refractory. Additionally, to exclude the possible contribution of pre-infusion, post-infusion and concomitant steroid use to the efficacy of daratumumab, median monthly dexamethasone equivalent doses were calculated. In the 16 mg/kg daratumumab group the maximum median dose was approximately 100 mg during Month 2 and declined to less than 40 mg by Month 3. Median monthly equivalent dexamethasone doses were identical between responders and nonresponders in the 16 mg/kg daratumumab group. 6

8 Figure S1. Confirmation of CRs in Two Patients With VGPRs by IMWG Criteria Using Daratumumab Interference Reflex Assay. Therapeutic levels of daratumumab were detected on serum protein electrophoresis gels and co-migrated with M-protein, thus causing interference with assessments of CR. Serum samples were preincubated with anti-idiotype antibodies prior to electrophoresis and immunofixation, causing shifts in daratumumab migration and allowing determination of M-protein levels (Axel 2014). Upper panel and lower panels represent one patient each. CR, complete response; VGPR, very good partial response; IMWG, International Myeloma Working Group; BL, baseline, TX, post-treatment; DARA, daratumumab; α-id, anti-idiotype; IgG, immunoglobulin G; κ, immunoglobulin kappa. 7

9 Figure S2. Reduction in Bone Marrow Plasma Cells Following 16 mg/kg Daratumumab, Part 2, in Patients With Relapsed and Refractory MM Who Responded to Therapy. Chart shows percentage of bone marrow plasma cells for the responders in the 16 mg/kg group at baseline and first post-baseline time point if baseline was >10%. Five patients remained stable at <5%. Seven subjects decreased to <5% from baseline values of 5 to 10% (3 subjects); >10 to 30% (3 subjects); and >30% (1 subject). One additional subject went from a baseline value of >30% to 10 to 30% at first post-baseline time point. MM, multiple myeloma. 8

10 Figure S3. Kaplan-Meier Curves of PFS Following Daratumumab Monotherapy in Patients With Relapsed and Refractory MM. PFS, progression-free survival; MM, multiple myeloma. 9

11 Table S1. International Myeloma Working Group Uniform Response Criteria for Multiple Myeloma. Response Stringent complete Response (scr) Complete response (CR) * Very good partial Response (VGPR) * Partial response (PR) Minimal response (MR) Stable disease (SD) Progressive disease (PD) Response Criteria CR as defined below, plus Normal FLC ratio, and Absence of clonal PCs by immunohistochemistry, immunofluorescence a or 2- to 4-color flow cytometry Negative immunofixation on the serum and urine, and Disappearance of any soft tissue plasmacytomas, and <5% PCs in bone marrow Serum and urine M-component detectable by immunofixation but not on electrophoresis, or 90% reduction in serum M-protein plus urine M-protein <100 mg/24 hours 50% reduction of serum M-protein and reduction in 24-hour urinary M- protein by 90% or to <200 mg/24 hours If the serum and urine M-protein are not measurable, a decrease of 50% in the difference between involved and uninvolved FLC levels is required in place of the M-protein criteria If serum and urine M-protein are not measurable, and serum free light assay is also not measurable, 50% reduction in bone marrow PCs is required in place of M-protein, provided baseline bone marrow plasma cell percentage was 30% In addition to the above criteria, if present at baseline, a 50% reduction in the size of soft tissue plasmacytomas is also required. In subjects with relapsed refractory myeloma adopted from the EBMT criteria (Blade 1998) Error! Reference source not found. : 25% but 49% reduction of serum M-protein and reduction in 24-hour urine M-protein by 50% to 89% In addition to the above criteria, if present at baseline, 25% to 49% reduction in the size of soft tissue plasmacytomas is also required No increase in size or number of lytic bone lesions (development of compression fracture does not exclude response) Not meeting criteria for CR, VGPR, PR, or progressive disease Increase of 25% from lowest response value in any one of the following: Serum M-component (absolute increase must be 0.5 g/dl), Urine M-component (absolute increase must be 200 mg/24 hours), Only in subjects without measurable serum and urine M-protein levels: the difference between involved and uninvolved FLC levels (absolute increase must be >10 mg/dl) Only in subjects without measurable serum and urine M-protein levels and without measurable disease by FLC levels, bone marrow PC percentage (absolute percentage must be 10%) Bone marrow plasma cell percentage: the absolute percentage must be >10% Definite development of new bone lesions or soft tissue plasmacytomas or definite increase in the size of existing bone lesions or soft tissue plasmacytomas. A definite increase is defined as a 50% (and at least 1 cm) increase as measured serially by the sum of the products of the cross-diameters of the measurable lesion. Development of hypercalcemia (corrected serum calcium >11.5 mg/dl) that can be attributed solely to the PC proliferative disorder EBMT = European Group for Blood and Marrow Transplantation; FLC = free light chain; PC = plasma cell 10

12 All response categories (CR, scr, VGPR, PR, and PD) require 2 consecutive assessments made at any time before the institution of any new therapy; CR, scr, VGPR, PR, and SD categories also require no known evidence of progressive or new bone lesions if radiographic studies were performed. VGPR and CR categories require serum and urine studies regardless of whether disease at baseline was measurable on serum, urine, both, or neither. Radiographic studies are not required to satisfy these response requirements. Bone marrow assessments need not be confirmed. For PD, serum M-component increases of more than or equal to 1 g/dl are sufficient to define relapse if starting M-component is 5 g/dl. *Clarifications to IMWG criteria for coding CR and VGPR in subjects in whom the only measurable disease is by serum FLC levels: CR in such subjects indicates a normal FLC ratio of 0.26 to 1.65 in addition to CR criteria listed above. VGPR in such subjects requires a >90% decrease in the difference between involved and uninvolved FLC levels. Clarifications to IMWG criteria for coding PD: Bone marrow criteria for PD are to be used only in subjects without measurable disease by M protein and by FLC levels; 25% increase refers to M protein, FLC, and bone marrow results, and does not refer to bone lesions, soft tissue plasmacytomas, or hypercalcemia and the lowest response value does not need to be a confirmed value. a Presence/absence of clonal cells is based upon the kappa/lambda ratio. An abnormal kappa/lambda ratio by immunohistochemistry or immunofluorescence requires a minimum of 100 plasma cells for analysis. An abnormal ratio reflecting presence of an abnormal clone is kappa/lambda of >4:1 or <1:2. Clinical Relapse Clinical relapse is defined using the definition of clinical relapse in the IMWG criteria (Durie 2007, Rajkumar 2011). In the IMWG criteria, clinical relapse is defined as requiring one or more of the following direct indicators of increasing disease or end-organ dysfunction that are considered related to the underlying plasma cell proliferative disorder: 1. Development of new soft tissue plasmacytomas or bone lesions on skeletal survey, magnetic resonance imaging, or other imaging 2. Definite increase in the size of existing plasmacytomas or bone lesions. A definite increase is defined as a 50% (and at least 1 cm) increase as measured serially by the sum of the products of the cross-diameters of the measurable lesion 3. Hypercalcemia (>11.5 mg/dl; >2.875mM/L) 4. Decrease in hemoglobin of more than 2 g/dl (1.25 mm) or to less than 10 g/dl 5. Rise in serum creatinine by more than or equal to 2 mg/dl ( 77 mm/l) 6. Hyperviscosity In some subjects, bone pain may be the initial symptom of relapse in the absence of any of the above features. However, bone pain without imaging confirmation is not adequate to meet these criteria in studies. 11

13 Table S2. Demographics and Baseline Characteristics of Patients in Part 1. Total (N = 32) Median (range) age, y 61.5 (42-76) Median (range) weight, kg 80.5 (60-117) Gender, n (%) Male 23 (72) Female 9 (28) Race, n (%) White 32 (100) Median (range) time since diagnosis, mo 72.6 ( ) ECOG score, n (%) 0 14 (44) 1 17 (53) 2 1 (3) ECOG, Eastern Cooperative Oncology Group. 12

14 Table S3. Treatment Discontinuation Due to AEs in Part 1. Total Analysis set: all treated 32 Total no. subjects with AEs leading to 5 (16%) treatment discontinuation Preferred term Bronchospasm 2 (6%) Cytokine release syndrome 1 (3%) Flushing 1 (3%) Hepatic function abnormal 1 (3%) Hypersensitivity 1 (3%) AE, adverse event. 13

15 Table S4. Serious AEs in Part 1. Total Analysis set: all treated 32 Total no. subjects with serious AEs 12 (37%) MedDRA system organ class/preferred term General disorders and administration site conditions 3 (9%) Pyrexia 3 (9%) Infections and infestations 3 (9%) Metapneumovirus infection 1 (3%) Pneumonia 1 (3%) Urinary tract infection 1 (3%) Respiratory, thoracic, and mediastinal disorders 2 (6%) Bronchospasm 2 (6%) Blood and lymphatic system disorders 1 (3%) Anemia 1 (3%) Thrombocytopenia 1 (3%) Cardiac disorders 1 (3%) Atrial fibrillation 1 (3%) Gastrointestinal disorders 1 (3%) Abdominal pain 1 (3%) Hepatobiliary disorders 1 (3%) 14

16 Total Hepatic function abnormal 1 (3%) Immune system disorders 1 (3%) Cytokine release syndrome 1 (3%) Injury, poisoning, and procedural complications 1 (3%) Spinal compression fracture 1 (3%) Investigations 1 (3%) Free hemoglobin present 1 (3%) Psychiatric disorders 1 (3%) Confusional state 1 (3%) AE, adverse event. 15

17 Table S5. Infusion-related AEs in Part 1. Total Any Grade Grade 3 or 4 Analysis set: all treated Total no. subjects with infusion related reactions 20 (63%) 2 (6%) MedDRA system organ class/preferred term General disorders and administration site conditions 11 (34%) 0 Pyrexia 7 (22%) 0 Influenza-like illness 4 (13%) 0 Fatigue 2 (6%) 0 Chest discomfort 1 (3%) 0 Respiratory, thoracic, and mediastinal disorders 6 (19%) 1 (3%) Bronchospasm 2 (6%) 1 (3%) Cough 1 (3%) 0 Dysphonia 1 (3%) 0 Dyspnoea 1 (3%) 0 Nasal congestion 1 (3%) 0 Rhinitis allergic 1 (3%) 0 Gastrointestinal disorders 5 (16%) 0 Nausea 3 (9%) 0 Dry mouth 1 (3%) 0 Lip edema 1 (3%) 0 Vomiting 1 (3%) 0 Vascular disorders 5 (16%) 0 Flushing 2 (6%) 0 Hypertension 2 (6%) 0 Hypotension 2 (6%) 0 16

18 Total Any Grade Grade 3 or 4 Immune system disorders 4 (13%) 1 (3%) Cytokine release syndrome 2 (6%) 0 Hypersensitivity 2 (6%) 1 (3%) Cardiac disorders 3 (9%) 0 Tachycardia 2 (6%) 0 Palpitations 1 (3%) 0 Nervous system disorders 3 (9%) 0 Dizziness 2 (6%) 0 Headache 1 (3%) 0 Skin and subcutaneous tissue disorders 3 (9%) 0 Pruritus 2 (6%) 0 Rash 2 (6%) 0 Infections and infestations 1 (3%) 0 Nasopharyngitis 1 (3%) 0 AE, adverse event. 17

19 Table S6. Dosing and IRRs in Part 2. Cohort A Cohort B Cohort C Cohort D Cohort E (n = 16) (n = 8) (n = 6) (n = 20) (n = 22) Dose, mg/kg Washout No No No Yes Yes Predose: Yes Yes No No No 10% of full dose, max 10 mg First full infusion volume, ml Second full infusion volume, ml Subsequent full infusion volume, ml IRRs 81% 75% 17% 70% 77% Intensity of IRRs * (grade) IRR, infusion-related reaction. *One patient experienced a grade 3 IRR. 18

20 Table S7. Responses in Part 1 in Patients Treated With 4 mg/kg Daratumumab or Higher. 4 mg/kg 8 mg/kg 16 mg/kg 24 mg/kg Response, n (%) (n = 3) (n = 3) (n = 3) (n = 3) ORR 1 (33) 0 1 (33) 2 (67) CR Stringent CR VGPR PR 1 (33) 0 1 (33) 2 (67) MR 2 (67) 1 (33) 0 0 Stable disease 0 1 (33) 1 (33) 1 (33) Progressive disease (33) 0 Not evaluable 0 1 (33) 0 0 No responses were observed in patients treated with 2 mg/kg daratumumab or less. ORR, overall response rate; CR, complete response; VGPR, very good partial response; PR, partial response; MR, minimal response. 19

21 Table S8. Summary of Responses in Part 2. 8 mg/kg (n = 30) 16 mg/kg (n = 42) Response n (%) 95% CI (%) n (%) 95% CI (%) CR* 0 2 (5) 0.6, 16 VGPR 0 2 (5) 0.6, 16 VGPR or better 0 4 (10) 3, 23 PR 3 (10) 2, (26) 14, 42 ORR 3 (10) 2, (36) 22, 52 MR 6 (20) 8, 39 4 (10) 3, 23 Stable disease 14 (47) 28, (52) 36, 68 Progressive disease 6 (20) 8, 39 0 Not evaluable 1 (3) 0.1, 17 1 (2) 0.1, 13 ORR, overall response rate; CI, confidence interval; CR, complete response; VGPR, very good partial response; PR, partial response; MR, minimal response; IMWG, International Myeloma Working Group. Note: Response was assessed by a computerized algorithm, based on International Uniform Response Criteria Consensus Recommendations. *CRs were originally classified as VGPRs per IMWG criteria due to daratumumab interference. CR was confirmed by daratumumab interference reflex assay. 3 scr + CR + VGPR. scr + CR + VGPR + PR. 20

22 Table S9. Overall Response Rate Based on Prior Therapy in Patients Treated With 8 mg/kg Daratumumab in Part 2. Number of Number of patients responders, n (%) 3 lines of prior therapy 5 1 (20) >3 lines of prior therapy 25 2 (8) Double refractory to PI and IMiD 18 2 (11) Refractory to last line of prior therapy 24 2 (8) Refractory to pomalidomide 2 0 Refractory to lenalidomide 26 2 (8) Refractory to bortezomib 20 2 (10) Refractory to bortezomib + lenalidomide 18 2 (11) PI, proteasome inhibitor; IMiD, immunomodulatory agent. 21

23 References Axel AE, McCudden CR, Xie H, Hall BM, Sasser AK. Development of clinical assay to mitigate daratumumab, an IgG1k monoclonal antibody, interference with serum immunofixation (IFE) and clinical assessment of M-protein response in multiple myeloma. Presented at: the Annual Meeting of the American Association for Cancer Research; April 5-9, 2014; San Diego, CA Abstract Blade J, Samson D, Reece D, et al. Criteria for evaluating disease response and progression in patients with multiple myeloma treated by high-dose therapy and haemopoietic stem cell transplantation. Myeloma Subcommittee of the EBMT. European Group for Blood and Marrow Transplant. Br J Haematol 1998;102: Durie BGM, Harousseau JL, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia 2006;20: Rajkumar SV, Harousseau JL, Durie B, et al. Consensus recommendations for the uniform reporting of clinical trials: report of the International Myeloma Workshop Consensus Panel 1. Blood 2011;117: