Use of infliximab-daclizumab combination for the treatment of acute and chronic graft-versus-host disease of the liver and gut

Infliximab for steroid refractory or dependent gastrointestinal acute graft-versus-host disease in children after allogeneic hematopoietic stem cell transplantation

aGVHD of the GI tract is common after allogeneic HSCT. Corticosteroids are the mainstay of treatment. Recent data suggest infliximab might be beneficial for steroid refractory aGVHD. We reviewed our experience in 10 pediatric patients who developed severe steroid refractory aGVHD (stage 3, n = 6; stage 4, n = 4), after an allogeneic matched unrelated HSCT for various hematological diseases (leukemia, n = 7; thalassemia, n = 3). The median age was 9.5 yr (range, 0.8-18.5 yr). All patients received 10 mg/kg infliximab weekly for 3-4 doses. Eight patients had CR and two had partial response. None of the patients developed therapy-related adverse effects. All patients developed infections subsequently, which may or may not be related to infliximab. Five patients developed chronic GVHD (cGVHD) (four severe, one mild). Six patients died at 66-1451 days post-transplant, from infection (n = 3), aGVHD (n = 1), lung cGVHD (n = 1), or idiopathic pneumonia (n = 1). Four patients were alive at 238-924 days post-transplant, all of whom had an increase in BMI by six months post-transplant. In conclusion, infliximab is well tolerated and appears effective in children with steroid refractory or dependent GI aGVHD. Infection is common and mortality remains high.

Combination therapy of tacrolimus and infliximab reduces inflammatory response and dysmotility in experimental small bowel transplantation in rats

BACKGROUND

Intestinal transplantation initiates a functionally relevant inflammatory response by activation of resident macrophages within the muscularis associated with dysmotility. Infliximab is used successfully as a potent anti-inflammatory agent for the treatment of chronic inflammatory bowel diseases and as rescue therapy in acute steroid-resistant rejection in selected settings in clinical small bowel transplantation. We hypothesize that additional perioperative treatment with infliximab diminishes initiation of the inflammatory cascade and improves motility in small bowel grafts using a standard tacrolimus immunosuppressive protocol.

METHODS

Orthotopic intestinal transplantation was performed in rats. In two treatment groups (24/168 hr), infliximab was administered intravenously directly after reperfusion and tacrolimus was injected intramuscularly after transplantation and once a day. Two other treatment groups (24/168 hr) received standard immunosuppressive therapy with tacrolimus. Isogenic and allogenic transplanted vehicle-treated animals (24/168 hr) and native gut served as control.

RESULTS

Infliximab-treated grafts exhibited significantly less leukocyte infiltration at 24/168 hr after transplantation and at 168 hr significantly less apoptosis in the tunica muscularis compared with tacrolimus monotherapy. Additional infliximab treatment resulted in increased smooth muscle contractility (30%) after 24 hr compared with tacrolimus control.

CONCLUSIONS

Dysmotility of transplanted small bowel results from reperfusion injury and acute rejection. Additional perioperative treatment with infliximab reduces early unspecific inflammatory responses and complements immunosuppressive therapy with tacrolimus.

Pretransplant conditioning with Campath-1H (alemtuzumab) in pediatric matched unrelated hematopoietic stem cell transplants: an institutional experience

Graft versus host disease (GVHD) remains a major cause of mortality and morbidity after matched unrelated hematopoietic stem cell transplantation (HSCT). Campath-1 H (alemtuzumab), a humanized monoclonal antibody to CD52 antigen, is thought to reduce GVHD incidence through in vivo T-cell depletion. Through the same mechanism it can potentially increase the risk of relapse by reducing the graft versus leukemia effect and possibly increase the risk of infection due to delayed immune recovery. A retrospective case analysis of 17 pediatric matched unrelated HSCTs done in our institution between January 2003 and June 2009 with Campath-1H as part of the pretransplant conditioning regimen was conducted. Grade I-II acute GVHD was noted in 29.4% of the HSCTs. No patient developed chronic GVHD. All but one patient with severe aplastic anemia engrafted. A relapse of primary disease was noted in 35.3% of the transplants. Three patient deaths were due to relapse and 1 due to disseminated varicella infection. Overall survival was 100% and 94% at 100 days and 1 year, respectively. Our experience suggests Campath-1H used as part of pretransplant conditioning regimen in pediatric unrelated HSCTs effectively reduces the risk of serious GVHD with no apparent increase in life-threatening infections or relapse compared with that reported with conventional regimens. Larger studies, with longer duration of follow-up, are required to further assess its role with regards to graft versus leukemia effect and to establish if the decreased incidence of GVHD and infectious complications is sustained in larger cohorts.

Treatment of graft-versus-host disease with monoclonal antibodies and related fusion proteins

Allogeneic hematopoietic stem cell transplantation has evolved from an experimental treatment approach to a widely used, curative therapy to treat malignant and nonmalignant diseases of the hematopoietic system. Despite advances in donor selection, conditioning regimens and supportive care, acute and chronic graft-versus-host disease (GvHD) remain a major cause of morbidity and mortality. Steroids are the standard first-line treatment and are able to control GvHD in approximately 50% of patients. Those who fail on steroids have a poor long-term prognosis. Therefore, a large number of drugs and procedures have been evaluated as second-line therapy. Monoclonal antibodies have increasingly been used to treat malignancy and autoimmune disease during the last 20 years. Their unique ability to target specific antigens theoretically enables them to directly interfere with cellular mechanisms that are involved in GvHD pathology. For this reason, monoclonal antibodies have been studied extensively as a second-line treatment for acute and chronic GvHD. The purpose of this article is to collect published data on clinical trials from the current literature and to give an overview on efficacy and toxicity of monoclonal antibody treatment for GvHD.

Perioperative infliximab application ameliorates acute rejection associated inflammation after intestinal transplantation

As we have shown in the past, acute rejection-related TNF-α upregulation in resident macrophages in the tunica muscularis after small bowel transplantation (SBTx) results in local amplification of inflammation, decisively contributing to graft dysmotility. Therefore, the aim of this study is to investigate the effectiveness of the chimeric-monoclonal-anti-TNF-α antibody infliximab as perioperative single shot treatment addressing inflammatory processes during acute rejection early after transplantation. Orthotopic, isogenic and allogenic SBTx was performed in rats (BN-Lewis/BN-BN) with infliximab treatment. Vehicle and IV-immunoglobulin-treated animals served as controls. Animals were sacrificed after 24 and 168 h. Leukocyte infiltration was investigated in muscularis whole mounts by immunohistochemistry, mediator mRNA expression by Real-Time-RT-PCR, apoptosis by TUNEL and smooth muscle contractility in a standard organ bath. Both, infliximab and Sandoglobulin® revealed antiinflammatory effects. Infliximab resulted in significantly less leukocyte infiltration compared to allogenic controls and IV-immunoglobulin, which was accompanied by lower gene expression of MCP-1 (24 h), IFN-γ (168 h) and infiltration of CD8-positive cells. Smooth muscle contractility improved significantly after 24 h compared to all controls in infliximab treated animals accompanied by lower iNOS expression. Perioperative treatment with infliximab is a possible pharmaceutical approach to overcome graft dysmotility early after SBTx.

Consensus Conference on Clinical Practice in Chronic GVHD: Second-Line Treatment of Chronic Graft-versus-Host Disease

Steroid refractory chronic graft-versus-host disease (cGVHD) is associated with a significant morbidity and mortality. Although first-line treatment of cGVHD is based on controlled trials, second-line treatment is almost solely based on phase II trials or retrospective analyses. The consensus conference on clinical practice in cGVHD held in Regensburg aimed to achieve a consensus on the current evidence of treatment options as well as to provide guidelines for daily clinical practice. Treatment modalities are the use of steroids and calcineurin inhibitors as well as immunomodulating modalities (photopheresis, mTOR-inhibitors, thalidomide, hydroxychloroquine, vitamin A analogs, clofazimine), and cytostatic agents (mycophenolate mofetil, methotrexate, cyclophosphamide, pentostatin). Recent reports showed some efficacy of rituximab, alemtuzumab, and etanercept in selected patients. Moreover, tyrosine kinase inihibitors such as imatinib came into the field because of their ability to interfere with the platelet-derived growth factor (PDGF-R) pathway involved in fibrosis. An other treatment option is low-dose thoracoabdominal irradiation. Although different treatment options are available, the "trial-and-error system" remains the only way to identify the drug effective in the individual patient, and valid biomarkers are eagerly needed to identify the likelihood of response to a drug in advance. Moreover, the sparse evidence for most treatment entities indicates the urgent need for systematic evaluation of second-line treatment options in cGVHD.

Inflammatory cytokine inhibition with combination daclizumab and infliximab for steroid-refractory acute GVHD

Treatment options for steroid-refractory GVHD (SR-GVHD) are unsatisfactory and prognosis is poor. Inflammatory cytokines IL-2 and TNF-α are important mediators of GVHD and may be critical targets for therapy. We retrospectively reviewed our experience using combination anti-cytokine therapy of daclizumab and infliximab. Seventeen evaluable patients had a median age of 47 years (range 35-63). The conditioning regimen was myeloablative in 13 and non-myeloablative in 4 cases. GVHD occurred at a median of 49 days after transplant in 12 patients (range 21-231 days) and at a median of 46 days (range 25-119 days) after donor lymphocyte infusion in 5 patients. All patients had persistent or progressive GVHD despite 1-2 mg/kg/day of corticosteroids for a median of 7 days (range 2-26 days). They received a combination of daclizumab and infliximab for acute GVHD IBMTR severity index B (3), C (10) or D (4). Of the 17 patients analyzed, 47% responded to treatment, 24% had complete resolution of symptoms and 24% had partial responses. Survival was limited and all the patients died a median of 6.7 months (range 1.6-26) from transplant and 35 days from initiation of daclizumab/infliximab. This retrospective analysis suggests that combination anti-cytokine therapy with daclizumab/infliximab has significant activity in SR-GVHD, but outcomes remain poor. New methods to prevent and treat GVHD are urgently needed.

Daclizumab therapy for children with corticosteroid-resistant acute graft-vs.-host disease

MAbs such as daclizumab have shown promising results in the treatment of corticosteroid-resistant aGVHD. Data describing the efficacy of MAbs in children are limited. We describe the efficacy of daclizumab in children with corticosteroid-resistant aGVHD. Seventeen children (0.4-16.2 yr) received daclizumab for aGVHD. Safety was evaluated in all 17. Response was evaluated in the 15 children who received a full course of daclizumab. A PR was defined as improvement of aGVHD symptoms in at least one organ without worsening in other organs. We observed an overall response rate (CR plus PR) of 40% (6/15). Four children had a CR and two had a PR. aGVHD involving the gut had the highest response rate (five of 10; 50%). Adverse effects attributed to daclizumab were limited to an episode of reactive arthritis. Mortality was high (47%; eight of 17) though five of the six responders to daclizumab survived. The mean length of follow-up in the surviving nine patients was 32 months (range seven to 48). We conclude that daclizumab is effective in the treatment of children with corticosteroid-resistant aGVHD, especially in patients with gut involvement.

Advances in hematopoietic stem cell transplantation for primary immunodeficiency

The molecular bases of most primary immunodeficiencies (PID) have been discovered. Long-term follow-up of patient cohorts treated with antimicrobial prophylaxis has demonstrated good short-term prognosis but with increasing morbidity and mortality over time. The results of hematopoietic stem cell transplantation (HSCT) for PID have improved incrementally over time, with survival and cure of 90% for some defined diseases. This article examines the advances in HSCT for PID and argues that HSCT should be considered earlier for most patients.