Oral vitamin C supplementation in patients with clonal cytopenia of undetermined significance or lower‐risk myeloid malignancies: Results from EVITA, a phase 2 randomized, placebo‐controlled trial
Stine Ulrik Mikkelsen, Ali Al‐Mousawi, Amalie Bach Puglisi, Anders Pommer Vallentin, Astrid Østergaard Mortensen, Zachary Madaj, Toshinori Hinoue, Heidi Naomi Ottesen, Jakob Schmidt Jespersen, Linn Gillberg, Morten Tulstrup, Niels Richard Hansen, Jakob Werner Hansen, Mette Klarskov Andersen, Stacey Lyn Thomas, Christine Isaguirre, Ryan Sheldon, Marie Adams, Ryan Burgos, Stephen Baylin, Bo Kok Mortensen, Casey Lee O’Connell, Marianne Tang Severinsen, Peter William Laird, Jens Lykkesfeldt, Peter Jones, Kirsten GrønbækAbstract
Background
Vitamin C (VitC) is a cofactor for TET enzymes involved in DNA demethylation and epigenetic regulation. Mutations in TET2 are common drivers of leukemia. Preclinical studies suggest that VitC may delay leukemia progression. This study aimed to evaluate the biological activity, safety, and clinical impact of oral VitC in patients with clonal cytopenia of undetermined significance (CCUS) or lower risk myeloid malignancies.
Methods
EVITA (Epigenetics, Vitamin C, and Abnormal Hematopoiesis) was a double‐blind, randomized, placebo‐controlled, phase 2 trial conducted in Denmark and the United States. Adults with CCUS or lower risk myeloid malignancies not receiving anticancer therapy were randomly assigned (1:1) to receive oral VitC (1000 mg/day) or placebo for 12 months, followed by long‐term follow‐up. The primary end point was the median clonal growth rate from baseline to end of treatment. EVITA was registered at
Results
Between November 1, 2017, and September 28, 2022, 109 patients were enrolled (VitC, n = 55; placebo, n = 54). Although the primary end point, median clonal growth rate, did not differ between groups (−0.016; 95% CI, −0.096 to 0.064; p = .70), secondary outcomes included differences in inflammatory cytokine trajectories and fewer serious adverse events in the VitC group versus placebo (18 of 55 [33%] vs. 30 of 53 [57%]). In exploratory analyses, overall survival was significantly longer with VitC (hazard ratio, 0.35; 95% CI, 0.17 to 0.71; p = .0025).
Conclusions
These findings suggest oral VitC as a safe, biologically active intervention in patients with early‐stage myeloid malignancies and precursor conditions. A phase 3 trial is warranted.