Sirolimus Pre-conditioning on T Cell Activity and T-cell Engaging Bispecific Antibody Efficacy in Multiple Myeloma

Inclusion criteria

• To be eligible to participate in this study, an individual must meet all of the following criteria:
• Willingness and ability to provide signed and dated informed consent form.
• Stated willingness to comply with all study procedures and availability for the duration of the study.
• Aged 18 years of older.
• Diagnosis with multiple myeloma, per IMWG Consensus Criteria.20
• Planned for treatment with teclistamab, or talquetamab per standard of care, label indications.15
• Prior exposure to any of the following types of T-cell engaging therapies.
• Anti-BCMA x CD3 bispecific antibody (for example: teclistamab, elranatamab)
• Anti-GPRC5d x CD3 bispecific antibody (for example: talquetamab)
• Anti-GPRC5d x CD3 x CD38 trispecific antibody
• Anti-BCMA x CD3 x CD38 trispecific antibody
• Anti-BCMA x CD3 x GPRC5d trispecific antibody
• Anti-BCMA chimeric antigen T-cell (for example: idecabtagene vicleucel, ciltacabtagene autoleucel)
• Anti-FcRL5 x CD3 bispecific antibody
• Required clinical laboratory values during screening phase Hematologic Parameters Hemoglobin ≥7.0 g/dL; Platelets ≥25 x 109/L; Absolute Lymphocyte Count ≥0.2 x 109/L Chemistries AST/ALT \< 5 x the ULN; Total Bilirubin \< 3 x the ULN
• Ability to take oral medication and be willing to adhere to the sirolimus pre-conditioning regimen.
• ECOG performance status of 0, 1, or 2 (KPS of \>50).
• For males of reproductive potential: use of condoms or other methods to ensure effective contraception with partner per section5.3.
• Agreement to adhere to Lifestyle Considerations (see section 5.3) throughout study duration.

Exclusion criteria

• An individual who meets any of the following criteria will be excluded from participation in this study:
• Participants whose multiple myeloma is progressing at a rapid pace requiring immediate anti-myeloma therapy per assessment by the principal investigator or enrolling investigator are excluded.
• Excluded concomitant medication exposures:
• Exposure to corticosteroids within 1 week of treatment start
• Exposure to calcineurin inhibitor or mTOR inhibitors (tacrolimus, everolimus, temsirolimus, sirolimus)
• Immunomodulatory monoclonal antibodies targeting tumor necrosis factor alpha (e.g. infliximab), interleukin 6 (e.g. siltuximab),
• Janus kinase inhibitors (e.g. ruxolitinib)
• Any other investigational drug within 28 days
• History of allogeneic hematopoietic cell transplantation.
• Excluded concurrent medical conditions:
• Active uncontrolled infection within 7 days prior to treatment start
• Uncontrolled thrombotic event within 3 months of treatment start
• Acute myocardial infarction or acute coronary syndrome within 6 months of start of treatment
• Uncontrolled inflammatory bowel disease
• Active hepatitis B virus, hepatitis C virus, or Human Immunodeficiency Virus infection
• Uncontrolled rheumatologic conditions
• Use of ACE-inhibitor therapy within 1 week of treatment start
• Patients found to be taking ace-inhibitor therapy during screening can be included if the ace-inhibitor is substituted for an angiotensin receptor blocking agent. (https://drug-interactions.medicine.iu.edu/main-table)
• CYP3A4/p-gp inhibitors and inducers for 7 days prior to sirolimus doses and 7 days after sirolimus doses(see appendix A for list)
• Any other current active malignancy or history of metastatic malignancy that has the potential to interfere with the safety or efficacy assessment of the investigational intervention
• Pregnancy or lactation.
• Known allergic reactions to study agent (sirolimus).