A Study of Zoledronic Acid, Pravastatin, and Lonafarnib for Patients With Progeria

• To describe any acute and chronic toxicities associated with treating progeria patients with the combination of zoledronic acid, pravastatin and lonafarnib [ Time Frame: 4 weeks ] [ Designated as safety issue: Yes ]
• To investigate which clinical and laboratory studies are needed to monitor or alter therapy to prevent unacceptable toxicity [ Time Frame: 4 weeks ] [ Designated as safety issue: Yes ]
• To assess the pharmacokinetics of lonafarnib in patients with progeria. [ Time Frame: 4 weeks ] [ Designated as safety issue: No ]
• To assay for the inhibition of HDJ-2 farnesylation in Peripheral Blood Leukocytes (PBL) [ Time Frame: 4 weeks ] [ Designated as safety issue: No ]
• To obtain baseline clinical and laboratory data so that longer-term measures of efficacy will be achievable if treatment continues beyond the 4-week feasibility study period. [ Time Frame: 4 weeks ] [ Designated as safety issue: No ]

Progerias are rare "premature aging" diseases in which children die of severe atherosclerosis leading to strokes and heart attacks. It is a multisystem disease with objective clinical markers for disease progression. These include abnormalities in growth and body composition, bone mineral density, join function, endocrine function, alopecia, and vascular disease. There is currently no therapy proven effective for any of the progressive and deleterious aspects of this disorder.

Progeria is caused by a gene defect in the gene LMNA, coding for the nuclear protein lamin A. Lamin A is normally expressed by most differentiated cells, and requires posttranslational farnesylation to incorporate into the nuclear membrane. This trial proposes to use three agents (zoledronic acid, pravastatin, and lonafarnib) to inhibit farnesylation of abnormal lamin, the disease causing protein in Progeria. The primary objective of this study is to evaluate the feasibility of administering intravenous zoledronic acid, oral pravastatin and oral lonafarnib, to patients wtih Progeria for a minimum of 4 weeks.

This is an open label single arm feasibility trial. A combination of two oral agents (pravastatin and lonafarnib) and one intravenous (IV) agent (zoledronic acid) will be administered at doses and schedule currently applied in pediatrics. These agents all target farnesylation pathways at different points. Our goal is to inhibit farnesylation of abnormal lamin, the disease-causing protein in Hutchinson-Gilford Progeria Syndrome and progeroid laminopathies (henceforth "progeria"). The drugs will include the intravenous bisphosphonate zoledronic acid, oral HMG co-reductase inhibitor pravastatin and the oral farnesyltransferase inhibitor (FTI) lonafarnib (SCH 66336). Patients with genetically confirmed progeria will be eligible for this protocol. Treatment will be initiated for 4 weeks duration and may be extended depending on tolerability. This study will assess the feasibility of this treatment regimen in the first 4 weeks. If tolerated for 4 weeks, patients can be treated with this regimen for up to 6 months.

• Drug: Lonafarnib
  Lonafarnib capsules are to be orally administered twice per day approximately every 12 hours. Lonafarnib dosing will begin at 150 mg/m2 by mouth twice daily. Dose levels are 150, 115, 90 and 70 mg/m2. Patients experiencing significant drug related grade 3 or 4 toxicity and not responding to therapy interruption or supportive care measures will be dose reduced by one dose level.
• Drug: Zoledronic Acid
  Zoledronic acid will be administered intravenously at week one of this treatment trial. Week one administration will consist of one infusion over a 30 minute period, 0.0125 mg/kg body weight.
  Other Name: Zometa, Reclast
• Drug: Pravastatin
  Pravastatin will begin at 5 mg by mouth once daily for children weighing less than 10 kg, and 10 mg by mouth once daily for children weighing 10 kg or greater.

Inclusion Criteria:

• Genetic Diagnosis: All patients must have confirmatory mutational analysis showing mutation in the lamin A gene.
• Patients must display clinical signs of progeria as per the clinical trial team.
• Patients must be willing and able to come to Boston for appropriate studies and examinations at initiation of study and at week 4 of study.
• Patient must have adequate organ and marrow function as defined by study parameters

Exclusion Criteria:

• Other than the drugs used in this protocol, other drugs targeted to treat Progeria are excluded. Drugs to treat symptoms of Progeria are permitted.
• Patients must not be taking medications that significantly affect the metabolism of lonafarnib at the time they start lonafarnib.
• Patient must have no uncontrolled infection.
• Subjects who have known or suspected hypersensitivity to any of the excipients included in the formulation should not be treated.
• Patients must not be pregnancy of breast-feeding. Female patients of childbearing potential must have negative serum or urine pregnancy test. Male and female patients of reproductive potential must agree to use a medically accepted form of birth control while on study and up to 10 weeks after treatment. It is permissible for female patients to take oral contraceptives or other hormonal methods while receiving treatment with lonafarnib.

• Dana-Farber Cancer Institute
• Brigham and Women's Hospital
• Schering-Plough