Metformin and Nelfinavir in Treating Patients With Relapsed and/or Refractory Multiple Myeloma

PRIMARY OBJECTIVES:

I. To assess the maximum tolerated dose (MTD) of administering metformin hydrochloride
(metformin) in combination with nelfinavir mesylate (nelfinavir) in patients with
relapsed/refractory multiple myeloma.

SECONDARY OBJECTIVES:

I. To describe the safety and tolerability of metformin in combination with nelfinavir in
patients with relapsed/refractory multiple myeloma.

II. To assess the best hematological response of the combination of metformin and nelfinavir
within 6 cycles of initiating therapy.

EXPLORATORY OBJECTIVES:

I. To describe the safety and tolerability of adding bortezomib to the combination of
metformin and nelfinavir.

II. To describe any depth of hematological response obtained after adding bortezomib to the
combination of metformin and nelfinavir.

III. Assess clinical biomarkers predictive of response to the combination of metformin and
nelfinavir with or without the addition of bortezomib such as bioenergetic profiles of the
myeloma cells, GLUT4 expression on myeloma cells, PI3K/AKT/mTOR and MAPK signaling pathways
and metabolomics-based profiling.

OUTLINE: This is a dose-escalation study.

Patients receive metformin hydrochloride orally (PO) on days 1-21 of cycle 1 and days 1-14 of
cycles 2-6. Patients also receive nelfinavir mesylate PO on days 1-14. Treatment repeats
every 21 days for up to 6 cycles in the absence of disease progression or unacceptable
toxicity. Patients with progressive disease (PD) at any time within 5 cycles or no minimal
response (unconfirmed [u]MR or MR) after 2 cycles or no partial response (uPR or PR) after 4
cycles also receive bortezomib subcutaneously (SC) once weekly every 21 days in the absence
of disease progression or unacceptable toxicity.

Inclusion Criteria:

- Actively relapsing multiple myeloma

- Measurable disease of multiple myeloma as defined by at least ONE of the following:

- Serum monoclonal protein >= 0.5 g/dL

- If immunoglobulin A (IgA) isotype, then IgA quantification > upper limit of
normal.

- >= 200 mg of monoclonal protein in the urine on 24-hour electrophoresis

- Serum immunoglobulin free light chain >= 10 mg/dL AND abnormal serum
immunoglobulin kappa to lambda free light chain ratio

- Monoclonal bone marrow plasmacytosis >= 10% (evaluable disease)

- Patients must have received at least 2 prior regimens and patients should have been
exposed to a proteasome inhibitor (PI), an immunomodulatory drugs (IMiD) and an
anti-CD38 antibody. NOTE: Induction therapy followed by an autologous stem cell
transplant (ASCT) and maintenance therapy without any relapse counts as 1 regimen

- Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1 or 2

- Hemoglobin >= 8.0 g/dL (obtained =< 14 days prior to registration)

- Absolute neutrophil count (ANC) >= 1000/mm^3 (obtained =< 14 days prior to
registration)

- Platelet count >= 50,000/mm^3 or >= 30,000/mm^3 if bone marrow plasma cells percentage
>= 50% by morphology (obtained =< 14 days prior to registration)

- Total bilirubin =< 1.5 x upper limit of normal (ULN) (obtained =< 14 days prior to
registration)

- Alanine aminotransferase (ALT) and aspartate transaminase (AST) =< 3 x ULN (=< 5 x ULN
for patients with liver involvement) (obtained =< 14 days prior to registration)

- Calculated creatinine clearance >= 45 ml/min using the Cockcroft-Gault formula
(obtained =< 14 days prior to registration)

- Negative pregnancy test done =< 7 days prior to registration, for persons of
childbearing potential only. NOTE: If the urine test is positive or cannot be
confirmed as negative, a serum pregnancy test will be required

- Provide written informed consent

- Able to swallow metformin and nelfinavir tablets

- Willingness to provide mandatory blood sample and bone marrow aspirate for research
purposes

- Willingness to return to Mayo Clinic for follow-up (during the active monitoring phase
of the study)

Exclusion Criteria:

- The following populations should be excluded from study:

- Pregnant persons

- Nursing persons

- Persons of childbearing potential who are unwilling to employ adequate
contraception

- Major surgery =< 14 days before study registration

- Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment
of the investigator, would make the patient inappropriate for entry into this study or
interfere significantly with the proper assessment of safety and toxicity of the
prescribed regimens

- Immunocompromised patients and patients known to be human immunodeficiency virus (HIV)
positive and currently receiving antiretroviral therapy

- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
study requirements

- Receiving any other investigational agent which would be considered as a treatment for
the primary neoplasm

- Another active malignancy requiring therapy such as radiation, chemotherapy, or
immunotherapy. NOTE: Patients on hormonal therapy for treated breast or prostate
cancer are permitted if they meet other eligibility criteria

- History of myocardial infarction =< 6 months prior to registration, or congestive
heart failure requiring use of ongoing maintenance therapy for life-threatening
ventricular arrhythmias

- Known allergy to any of the study medications, their analogues or excipients in the
various formulations

- Subjects must not have conditions associated with increased risk of metformin
associated lactic acidosis, including New York Heart Association class III or IV
congestive heart failure, history of acidosis of any type, alcoholic liver disease, or
habitual intake of 3 or more alcoholic beverages per day

- Clinical history of type I or type II diabetes

- Currently on either metformin or a HIV-PI or both

- Elevated baseline lactate level > ULN (2.3 mmol/L)

- Any of the following recent prior anti-myeloma therapy:

- Alkylators (e.g. melphalan, cyclophosphamide) and anthracyclines =< 14 days prior
to registration

- High dose corticosteroids (equivalent to > 10 mg of prednisone/day) and
immunomodulatory drugs (thalidomide or lenalidomide) =< 7 days prior to
registration

- Monoclonal antibodies =< 14 days prior to registration

- Currently receiving any of the medications that cannot be discontinued 7 days prior to
starting study and throughout study therapy