Daratumumab, Ixazomib, Pomalidomide, and Dexamethasone as Salvage Therapy in Relapsed/Refractory Multiple Myeloma

The purpose of this study is to determine the overall response rate of patients with Multiple
Myeloma to the combination of Daratumumab, Ixazomib, Pomalidomide and Dexamethasone.

The drugs being used in this study are daratumumab ixazomib, pomalidomide, and dexamethasone.
Ixazomib may stop the growth of cancer by interfering with proteasomes (the protein breakdown
mechanism in the cells). Pomalidomide, and dexamethasone are standard drugs that can change
and regulate the immune system and may stop cancer cells from growing. Both Ixazomib and
Daratumumab are approved for use in Multiple Myeloma, but not in this combination.

Inclusion Criteria:

- All participants must be registered into the mandatory POMALYST 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

- Measurable disease

- Life expectancy of more than 3 months

- ECOG performance status of 0, 1, or 2

- No prior progression on pomalidomide

- All pts must have received prior lenalidomide therapy and been determined to be
relapsed and/or refractory.

- Adequate hepatic function

- Adequate renal function

- Additional Laboratory Requirements

1. ANC ≥1.0 x 10^9/L, Hgb ≥8 g/dL (transfusion permitted)

2. Platelet count ≥75 x 10^9/L (≥ 50x10^9/L if bone marrow plasma cells are ≥50% of
cellularity)

- 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 for through 120
days after the last dose of study medication.

- 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.

- All subjects must be counseled at a minimum of every 28 days about pregnancy
precautions and risks of fetal exposure.

- Females 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 (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 or ixazomib use

- Patients who are refractory to pomalidom

- Non-secretory or hyposecretory multiple myeloma defined as:

- Plasma cell leukemia (>2.0 x 10 9/L circulating plasma cells by standard differential)

- Waldenström's macroglobulinemia or IgM 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 HIV infection, known HIV seropositivity

- Active hepatitis infection

- Diagnosed or treated for another malignancy within 2 years before study enrollment or
previously diagnosed with another malignancy and have any evidence of residual
disease. Patients with nonmelanoma skin cancer or carcinoma in situ of any type are
not excluded if they have undergone complete resection.

- 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. 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

- Has known moderate or severe persistent asthma within the past 2 years per asthma
guidelines

- Known gastrointestinal disease or procedure that could interfere with the oral
absorption or tolerance of ixazomib or pomalidomide, including difficulty swallowing