Carfilzomib, Clarithromycin (Biaxin®), Lenalidomide (Revlimid®), and Dexamethasone (Decadron®) [Car-BiRD] Therapy for Subjects With Multiple Myeloma

While new anti-myeloma therapies such as bortezomib and immunomodulatory drugs have been
developed, multiple myeloma remains an incurable malignancy. Given that obtaining a complete
remission (CR) with therapy will allow patients with newly diagnosed multiple myeloma to
enjoy a higher quality of life and longer duration of freedom from disease symptoms, finding
an optimally effective and well-tolerated regimen is imperative.

The robust overall response rate of 91% with the BiRD regimen for patients with newly
diagnosed multiple myeloma is encouraging and we believe that by adding carfilzomib the
overall response rate and CR rate can be improved. As carfilzomib has proven efficacy in
myeloma and in patient's who have relapsed on bortezomib, we anticipate that it will
synergize with the previous BiRD regimen to induce greater reduction of tumor burden overall.

The primary endpoints include best response rate, toxicities, progression free survival,
event free survival, and overall survival. In those patients who are eligible for autologous
stem cell transplantation, we will also study the effect of carfilzomib on CD 34+ stem cell
yield following mobilization.

Inclusion Criteria:

- Subject must voluntarily sign and understand written informed consent.

- Subject is ≥ 18 years at the time of signing the consent form.

- Subject has histologically confirmed multiple myeloma that has never before been
treated.

- Subject had no anti-myeloma therapy within 14 days prior to initiation of study
treatment except for corticosteroids with a maximum allowed dosage equivalent to three
pulses of dexamethasone (40mg daily for 4 days equals one pulse). Patients may have
received prior adjuvant antiresorptive therapy (i.e., pamidronate or zoledronic acid)
as routine care, or radiation therapy as palliation for pain and/or spinal cord
compression.

- Subject has measurable disease as defined by > 0.5 g/dL serum monoclonal protein, > 10
mg/dL involved serum free light chain (either kappa or lambda) provided that the serum
free light chain ratio is abnormal, > 0.2 g/24 hrs urinary M-protein excretion, and/or
measurable plasmacytoma(s) of at least 1cm in greatest dimension as measured by either
CT scanning or MRI.

- Subject has a Karnofsky performance status ≥ 60% (> 50% if due to bony involvement of
myeloma (see Appendix VI).

- Subject is able to take prophylactic anticoagulation as detailed in section 9.1
(patients intolerant to aspirin may use warfarin or low molecular weight heparin).

- Subject is registered into the mandatory RevAssist® program, and is willing and able
to comply with the requirements of RevAssist® program.

- If subject is a female of childbearing potential (FCBP),† she must have a negative
serum or urine pregnancy test with a sensitivity of at least 25 mIU/mL within 10 - 14
days prior to and again within 24 hours of prescribing lenalidomide (prescriptions
must be filled within 7 days) and must either commit to continued abstinence from
heterosexual intercourse or begin TWO acceptable methods of birth control, one highly
effective method and one additional effective method AT THE SAME TIME, at least 28
days before she starts taking lenalidomide. FCBP must also agree to ongoing pregnancy
testing. Men must agree to use a latex condom during sexual contact with females of
child bearing potential even if they have had a successful vasectomy.

- Subjects must meet the following laboratory parameters:

- Absolute neutrophil count (ANC) ≥750 cells/mm3 (1.0 x 109/L)

- Hemoglobin ≥ 7 g/dL

- Platelet count ≥ 30,000/mm3 (75 x 109/L)

- Serum SGOT/AST < 3.0 x upper limits of normal (ULN)

- Serum SGPT/ALT < 3.0 x upper limits of normal (ULN)

- Serum creatinine < 2.5 mg/dL (221 µmol/L)

- Serum total bilirubin < 2.0 mg/dL (34 µmol/L)

Exclusion Criteria:

- Subject has immeasurable MM (no measurable monoclonal protein, free light chains in
blood or urine, or measureable plasmacytoma on radiologic scanning).

- Subject has a prior history of other malignancies unless disease free for ≥ 5 years,
except for basal cell or squamous cell carcinoma of the skin, carcinoma in situ of the
cervix or breast, or localized prostate cancer with Gleason score < 7 with stable
prostate specific antigen (PSA) levels.

- Subject has had myocardial infarction within 6 months prior to enrollment , or
NYHA(New York Hospital Association) Class III or IV heart failure, Ejection Fraction <
35%, uncontrolled angina, severe uncontrolled ventricular arrhythmias,
electrocardiographic evidence of acute ischemia or active conduction system
abnormalities.

- Female subject who is pregnant or lactating.

- Subject has known HIV infection

- Subject has known active hepatitis B or hepatitis C infection.

- Subject has active viral or bacterial infections or any coexisting medical problem
that would significantly increase the risks of this treatment program.

- Subject has known hypersensitivity to dexamethasone, clarithromycin, lenalidomide,
thalidomide, allopurinol, or carfilzomib.

- Subject has a history of thromboembolic event within the past 4 weeks prior to
enrollment.

- Subject has any clinically significant medical or psychiatric disease or condition
that, in the Investigator's opinion, may interfere with protocol adherence or a
subject's ability to give informed consent.