Steroid-free combination of 5-azacytidine and venetoclax for the treatment of multiple myeloma

Haematologica. 2024 Sep 1;109(9):2930-2943. doi: 10.3324/haematol.2023.283771.

Abstract

Multiple myeloma (MM) is an incurable plasma cell malignancy that, despite an unprecedented increase in overall survival, lacks truly risk-adapted or targeted treatments. A proportion of patients with MM depend on BCL-2 for survival, and, recently, the BCL-2 antagonist venetoclax has shown clinical efficacy and safety in t(11;14) and BCL-2 overexpressing MM. However, only a small proportion of MM patients rely on BCL-2 (approx. 20%), and there is a need to broaden the patient population outside of t(11;14) that can be treated with venetoclax. Therefore, we took an unbiased screening approach and screened epigenetic modifiers to enhance venetoclax sensitivity in 2 non-BCL-2 dependent MM cell lines. The demethylase inhibitor 5-azacytidine was one of the lead hits from the screen, and the enhanced cell killing of the combination was confirmed in additional MM cell lines. Using dynamic BH3 profiling and immunoprecipitations, we identified the potential mechanism of synergy is due to increased NOXA expression, through the integrated stress response. Knockdown of PMAIP1 or PKR partially rescues cell death of the venetoclax and 5-azacytidine combination treatment. The addition of a steroid to the combination treatment did not enhance the cell death, and, interestingly, we found enhanced death of the immune cells with steroid addition, suggesting that a steroid-sparing regimen may be more beneficial in MM. Lastly, we show for the first time in primary MM patient samples that 5-azacytidine enhances the response to venetoclax ex vivo across diverse anti-apoptotic dependencies (BCL-2 or MCL-1) and diverse cytogenetic backgrounds. Overall, our data identify 5-azacytidine and venetoclax as an effective treatment combination, which could be a tolerable steroid-sparing regimen, particularly for elderly MM patients.

MeSH terms

  • Antineoplastic Combined Chemotherapy Protocols* / pharmacology
  • Antineoplastic Combined Chemotherapy Protocols* / therapeutic use
  • Azacitidine* / pharmacology
  • Azacitidine* / therapeutic use
  • Bridged Bicyclo Compounds, Heterocyclic* / pharmacology
  • Bridged Bicyclo Compounds, Heterocyclic* / therapeutic use
  • Cell Line, Tumor
  • Drug Synergism
  • Humans
  • Multiple Myeloma* / drug therapy
  • Multiple Myeloma* / genetics
  • Multiple Myeloma* / metabolism
  • Multiple Myeloma* / mortality
  • Multiple Myeloma* / pathology
  • Proto-Oncogene Proteins c-bcl-2 / antagonists & inhibitors
  • Proto-Oncogene Proteins c-bcl-2 / genetics
  • Proto-Oncogene Proteins c-bcl-2 / metabolism
  • Sulfonamides* / administration & dosage
  • Sulfonamides* / pharmacology
  • Sulfonamides* / therapeutic use

Substances

  • venetoclax
  • Bridged Bicyclo Compounds, Heterocyclic
  • Azacitidine
  • Sulfonamides
  • Proto-Oncogene Proteins c-bcl-2

Grants and funding

Funding: The authors would like to thank the following funding agencies for their support: the Leukemia Research Foundation (LRF-RCSI-2020) and Science Foundation Ireland (19/FFP/6461) (to TNC) and Irish Research Council (IRCLA/2022/2822) Breakthrough Cancer Research (BCR-RCSI-2020) (to LF).