Ruxolitinib and Tyrosine Kinase Inhibitors for the Treatment of Recurrent Chronic Phase-Chronic Myeloid Leukemia

Inclusion Criteria

• Age >= 18 years
• Willing and able to give informed consent
• Diagnosed with CML in chronic phase and have either the b3a2 (e14a2) or b2a2 (e13a2) variants that give rise to the p210 BCR-ABL protein. Subtype classification whether b3a2 (e14a2) or b2a2 (e13a2) is not required for study eligibility
• Must have a documented history of attempting only one prior TKI discontinuation under the guidance of a treating physician
• Must have met ALL the following criteria prior to first attempt to discontinue their TKI: * Stable molecular response (MR4; =< 0.01% international reporting scale [IS]) for >= 2 years (allowance for a 2-week variance) , as documented on at least four tests, performed at least 3 months apart (e.g. If a patient has had > 4 polymerase chain reaction [PCR] tests performed during the two years leading up to their initial TKI discontinuation, any value between 0.01 and 0.05% IS is considered a stable result, however, at least 4 tests must be < 0.01% IS. If any results are >0.05% IS, tests must have been repeated within 1 month and be less than 0.01% IS and stable.) * Treatment with one of the following Food and Drug Administration (FDA) approved TKIs; imatinib, dasatinib, nilotinib or bosutinib, at any dose for a minimum of approximately 3 years (allowance of a 4-week variance) prior to discontinuing TKIs * Has been on any number of TKIs, but has not been resistant to any TKI (changes made for intolerance are allowed)
• Must have relapsed (defined as loss of major molecular response [MMR]), real-time quantitative (RQ)-polymerase chain reaction (PCR) for BCR-ABL > 0.1% IS after first attempted discontinuation of TKI
• After first failed TFR attempt, must have a minimum duration of 1 year on a TKI, and must plan to remain on this same TKI for a minimum of 12 months during the combination treatment phase
• Current TKI must be the same as the TKI being taken prior to the initial TFR attempt (e.g. if patient is on imatinib prior to first TFR attempt, they should be on imatinib at time of enrollment on this study)
• Eastern Cooperative Oncology Group (ECOG) performance status 0-3
• Must have a RQ-PCR for BCR-ABL =< 0.0032% IS (MR4.5) reported by the trial designated central lab at the time of study enrollment
• Female patients must meet one of the following: * Postmenopausal for at least one year before the screening visit * Surgically sterile * If they are of childbearing potential, agree to practice two effective methods of contraception from the time of signing of the informed consent form through 90 days after the last dose of study drug * Must also adhere to the guidelines of any treatment-specific pregnancy prevention program, if applicable * Agree to practice true abstinence when this is in line with the preferred and usual lifestyle of the subject. (Periodic abstinence [e.g., calendar, ovulation, symptothermal, postovulation methods] and withdrawal are not acceptable contraception methods.)
• Male patients, even if surgically sterilized (i.e., status post vasectomy), must agree to one of the following: * Practice effective barrier contraception during the entire study treatment period and through 90 days after the last study drug dose * Must also adhere to the guidelines of any treatment-specific pregnancy prevention program, if applicable * Agree to practice true abstinence when this is in line with the preferred and usual lifestyle of the subject. (Periodic abstinence [e.g., calendar, ovulation, symptothermal, postovulation methods] and withdrawal are not acceptable methods of contraception.)
• TFR PHASE:
• Stable molecular response (MR4.5; =< 0.0032% IS) documented on at least three tests, performed at least 3 months apart while on combination therapy
• TFR phase screening PCR RQ-PCR for BCR-ABL =< 0.0032% IS (MR4.5)
• ECOG 0-3
• Completion of 12 cycles on the combination therapy phase

Exclusion Criteria

• History of accelerated or blast phase CML
• History of TKI resistance
• A second malignancy requiring active treatment
• Subjects who have previously received treatment with a JAK inhibitor
• Subjects with platelet (PLT) count < 100 x 10^9/L
• Subjects with an absolute neutrophil count (ANC) of < 1 x 10^9/L
• Subjects with hemoglobin < 8 g/dL
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) >= 3 times the institutional upper limit of normal
• Creatinine >= 2 times the institutional upper limit of normal
• Total bilirubin >= 1.5 times the institutional upper limit of normal or > 3.0 x the institutional upper limit of normal with Gilbert syndrome (unless direct bilirubin is within normal limits)
• Pregnant or lactating
• Unable to comply with lab appointments schedule and patient-reported outcome (PRO) assessments
• Another investigational drug within 4 weeks of enrollment
• Any serious medical or psychiatric illness that could, in the investigator’s opinion, interfere with the completion of treatment according to this protocol
• Patient has undergone a prior allogeneic transplant
• Screening 12-lead electrocardiogram (ECG) showing a baseline corrected QT interval > 500msec (patients with a pacemaker will still be eligible with corrected QT (QTc) > 500 msec)