Ziftomenib and Olutasidenib for the Treatment of Relapsed or Refractory Acute Myeloid Leukemia that has Mutations in the IDH1 and NPM1 Genes

Inclusion Criteria

• Age >= 18 years
• Diagnosis of relapsed or refractory AML (including biphenotypic or bilineage leukemia) as defined by >= 5% marrow blasts; patients with isolated extramedullary AML without marrow involvement are not eligible
• AML disease must be characterized by IDH1 and NPM1 co-mutations as determined by local molecular testing (next generation sequencing, polymerase chain reaction [PCR]) * NPM1 mutations should be determined using a molecular assay such as next generation sequencing (NGS) by a Clinical Laboratory Improvement Act (CLIA)-certified local laboratory. Immunohistochemistry that can detect cytoplasmic localization of the NPM1 protein is not permitted. Eligible NPM1 mutations include Type A, B, and D mutations caused by a 4-nucleotide insertion in exon 12. Other NPM1 mutations in the same region that are known or likely to have the same effect on NPM1 function may be eligible based on principal investigator (PI) approval
• Eastern Cooperative Oncology Group (ECOG) performance status =< 2
• Adequate renal function with creatine clearance (CrCl) >= 60 ml/min to be calculated using Cockroft Gault formula
• Total bilirubin < 1.5 x upper limit of normal (ULN) unless increase is due to Gilbert’s disease or leukemic involvement, in which case total bilirubin < 5 x ULN will be considered eligible
• Aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) < 3 x ULN unless considered due to leukemic involvement, in which case AST and/or ALT < 5 x ULN will be considered eligible
• Baseline Fridericia’s formula-corrected QT interval (QTcF) =< 480 msec
• In the absence of rapidly proliferative disease, the interval from prior treatment to time of initiation of study therapy will be 14 days from last cytotoxic or non-cytotoxic (immunotherapy) agent(s), or an interval of 5 half-lives of the prior therapy whichever is shorter. Cytarabine (up to 2 gm/m^2), leukapheresis, and oral hydroxyurea are permitted in patients with rapidly proliferative disease before the start of study therapy for clinical benefit as needed. Hydroxyurea can also be administered during cycles 1-2 of study therapy for cytoreduction as deemed necessary by the treating physician and after discussion with the principal investigator (PI). Concurrent intrathecal therapy for central nervous system (CNS) prophylaxis or continuation of therapy for controlled CNS disease is permitted
• Female patients of childbearing potential must agree to use a highly effective method of contraception as well as a double-barrier method (e.g., condom with spermicide) and refrain from egg donation from screening visit until 180 days following the last dose of study intervention. Male patients capable of having intercourse with females of childbearing potential and who have not had vasectomies must agree to abstain from heterosexual intercourse or use a double-barrier method of contraception and have their partner use a highly effective method of contraception from the screening visit until 90 days following the last dose of study intervention. They must also refrain from sperm donation from the screening visit until 90 days following the last dose of study intervention
• Willing and able to provide informed consent

Exclusion Criteria

• Patients with t(15;17) karyotypic abnormality or acute promyelocytic leukemia (French American- British [FAB] class M3-AML)
• Patients with any concurrent uncontrolled clinically significant medical condition including life-threatening severe infection, or psychiatric illness, which could place the patient at unacceptable risk of study treatment or be unable to consent or comply with protocol therapy. Patients with controlled infections are allowed. Other prior or concurrent malignancies will be considered after discussion with the PI
• Patients with active, uncontrolled, leukemia involvement of the CNS
• Patients with grade II-IV active or extensive chronic graft-versus-host disease (cGHVD) status post stem cell transplant requiring topical therapy. Patients must have discontinued calcineurin inhibitors at least 2 weeks prior to the start of the study therapy
• Patients with any severe gastrointestinal or metabolic condition which could interfere with the absorption of oral study medications
• Known active hepatitis B (hepatitis B virus [HBV]) or hepatitis C (hepatitis C virus [HCV]) infection or known HIV infection
• Subject has a white blood cell count > 20 x 10^9/L. (Note: Hydroxyurea, leukapheresis, and cytarabine is permitted to meet this criterion- see above inclusion criteria)
• Prior treatment with ziftomenib or olutasidenib
• Nursing women, women of childbearing potential (WOCBP) with positive urine pregnancy test, or women of childbearing potential who are not willing to maintain adequate contraception. Appropriate highly effective method(s) of contraception include oral or injectable hormonal birth control, intrauterine device (IUD), and double barrier methods (for example, a condom in combination with a spermicide)
• Any condition which in the investigator’s opinion deems the participant an unsuitable candidate to receive study drugs including medical, psychological, familial, social or geographical consideration
• Receiving treatment with moderate or strong CYP3A inducer within 14 days or 5 half-lives (whichever is longer) prior to the first dose of study drug