Daratumumab, Ixazomib, Pomalidomide, and Dexamethasone in Treating Patients with Multiple Myeloma That Has Come Back or Does Not Respond to Treatment

Inclusion Criteria

• Ability to understand and the willingness to sign a written informed consent
• All study participants must be registered into the mandatory pomalidomide (POMALYST) Risk Evaluation and Mitigation Strategy (REMS) program and be willing and able to comply with the requirements of the POMALYST REMS program
• Confirmed diagnosis of multiple myeloma having received >= 1 and =< 3 prior lines of treatment * Relapsed and/or refractory disease: includes primary refractory patients; refractory = progressive disease (PD) on treatment or within 60 days of last dose of therapy
• Measurable disease as defined by any of the following: * Serum M-protein level >= 0.5 g/dL by serum protein electrophoresis (SPEP), or * Urine M-protein >= 200 mg/24 hours by urine protein electrophoresis (UPEP), or * Involved serum free light chain >= 10 mg/dL (>= 100 mg/L) AND an abnormal free serum free light chain ratio in patients without measurable disease in the serum or urine
• Life expectancy of more than 3 months
• Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2
• No prior progression on pomalidomide
• All patients (pts) must have received prior lenalidomide therapy and been determined to be relapsed and/or refractory to lenalidomide
• Bilirubin =< 2 times the upper limit of normal (ULN)
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 3 times ULN
• Adequate renal function with creatinine clearance >= 30ml/min
• Absolute neutrophil count (ANC) >= 1.0 x 10^9/L
• Hemoglobin (Hgb) >= 8 g/dL (transfusion permitted)
• Platelet count >= 75 x 10^9/L (>= 50 x 10^9/L if bone marrow plasma cells are >= 50% of cellularity)
• Screening ANC should be independent of granulocyte-and granulocyte/macrophage colony stimulating factor (G-CSF and GM-CSF) support for at least 1 week and of pegylated G-CSF for at least 2 weeks
• Pts may receive red blood cell (RBC) or platelet transfusions, if clinically indicated, in accordance with institutional guidelines
• Screening platelet count should be independent of platelet transfusions for at least 2 weeks
• Women of child-bearing potential and men with partners of child-bearing potential must agree to use 2 methods of birth control or be surgically sterile or abstain from heterosexual activity from the time of signing the informed consent form through 120 days after the last dose of study medication. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately * A woman of child-bearing potential is any female (regardless of sexual orientation, having undergone a tubal ligation, or remaining celibate by choice) who meets the following criteria: ** Has not undergone a hysterectomy or bilateral oophorectomy; or ** Has not been naturally postmenopausal for at least 12 consecutive months (i.e., has had menses at any time in the preceding 12 consecutive months)
• Women of childbearing potential have negative pregnancy test within 72 hours of initiating study drug dosing
• Male subjects must agree to use a latex condom during sexual contact with females of childbearing potential even if they have had a successful vasectomy starting with the first dose of study therapy through 120 days after the last dose of study therapy. Females of Child bearing potential must agree to ongoing pregnancy testing. The patient must agree to inform his physician if he has had unprotected sexual contact with a female who can become pregnant or if he thinks for any reason that his sexual partner may be pregnant * Male pts cannot donate semen or sperm while taking pomalidomide and for 28 days after completing the study
• All subjects must be counseled at a minimum of every 28 days about pregnancy precautions and risks of fetal exposure
• Female of reproductive potential must adhere to the scheduled pregnancy testing as required in the POMALYST REMS program
• Subjects must agree to take enteric-coated aspirin 81 mg orally daily, or if history of prior thrombotic disease, must be fully anticoagulated with warfarin (international normalized ratio [INR] 2-3) or be treated with full-dose, low molecular weight heparin, as if to treat deep venous thrombosis (DVT)/pulmonary embolism (PE) at the investigator's discretion

Exclusion Criteria

• Current or anticipated use of other investigational agents
• Prior daratumumab and ixazomib use
• Patients who are refractory to pomalidomide
• Non-secretory or hyposecretory multiple myeloma
• POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Gammopathy, and Skin Changes) syndrome
• Plasma cell leukemia (> 2.0 x10^9/L circulating plasma cells by standard differential)
• Waldenstrom's macroglobulinemia or immunoglobulin (Ig)M myeloma
• Known central nervous system involvement by multiple myeloma
• Radiotherapy to multiple sites or immunotherapy within 2 weeks before enrollment (localized radiotherapy to a single site at least 1 week before start is permissible)
• Participation in an investigational therapeutic study within 3 weeks or within 5 drug half-lives (t1/2) prior to first dose, whichever time is greater. Non-interventional trials (i.e. observational trials) are permitted at any time point
• Female patients who are lactating or have a positive serum pregnancy test during the screening period
• Major surgery within 3 weeks prior to first dose
• Myocardial infarction within 6 months prior to enrollment, NYHA (New York Heart Association) class III or IV heart failure, uncontrolled angina, severe uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute ischemia or active conduction system abnormalities
• Acute active infection requiring systemic antibiotics, antivirals, or antifungals within two weeks prior to first dose
• Systemic treatment, within 14 days before the first dose of ixazomib, with strong CYP3A inducers (rifampin, rifapentine, rifabutin, carbamazepine, phenytoin, phenobarbital), or use of St. John’s wort
• Known or suspected human immunodeficiency virus (HIV) infection, known HIV seropositivity
• Active hepatitis infection * Seropositive for hepatitis B (defined by a positive test for hepatitis B surface antigen [HBsAg]). Subjects with resolved infection (ie, subjects who are HBsAg negative but positive for antibodies to hepatitis B core antigen [anti-HBc] and/or antibodies to hepatitis B surface antigen [anti-HBs]) must be screened using real-time polymerase chain reaction (PCR) measurement of hepatitis B virus (HBV) deoxyribonucleic acid (DNA) levels. Those who are PCR positive will be excluded. EXCEPTION: Subjects with serologic findings suggestive of HBV vaccination (anti-HBs positivity as the only serologic marker) AND a known history of prior HBV vaccination, do not need to be tested for HBV DNA by PCR * Seropositive for hepatitis C (except in the setting of a sustained virologic response [SVR], defined as aviremia at least 12 weeks after completion of antiviral therapy)
• Diagnosed or treated for another malignancy within 2 years before study enrollment or previously diagnosed with another malignancy and have any residual disease. Patients with nonmelanoma skin cancer or carcinoma in situ of any type are not excluded if they have undergone complete resection
• Any clinically significant medical disease or condition that, in the Investigator's opinion, may interfere with protocol adherence or a subject's ability to give informed consent
• Patient has >= grade 3 peripheral neuropathy, or grade 2 with pain on clinical examination during the screening period
• Contraindication to any of the required concomitant drugs
• Subjects with known or suspected light-chain amyloidosis of any organ
• Known allergies, hypersensitivity, or intolerance to monoclonal antibodies or human proteins, daratumumab, or its excipients (refer to investigator's brochure [IB]), or known sensitivity to mammalian-derived products
• Has known chronic obstructive pulmonary disease with a forced expiratory volume in 1 second (FEV1) < 50% of predicted normal (Note that FEV1 testing is required for subjects suspected of having chronic obstructive pulmonary disease and subjects must be excluded if FEV1 < 50% of predicted normal.)
• Has known moderate or severe persistent asthma within the past 2 years per asthma guidelines, or currently has uncontrolled asthma of any classification
• Known gastrointestinal disease or procedure that could interfere with the oral absorption or tolerance of ixazomib or pomalidomide, including difficulty swallowing