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Babakoohi S, Gu SL, Ehsan H, Markova A. Dermatologic complications in transplantation and cellular therapy for acute leukemia. Best Pract Res Clin Haematol 2023; 36:101464. [PMID: 37353285 PMCID: PMC10291442 DOI: 10.1016/j.beha.2023.101464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
Adoptive cellular immunotherapy, mainly hematopoietic stem cell transplant and CAR-T cell therapy have revolutionized treatment of patients with acute leukemia. Indications and inclusion criteria for these treatments have expanded in recent years. While these therapies are associated with significant improvements in disease response and overall survival, patients may experience adverse events from associated chemotherapy conditioning, engraftment, cytokine storm, supportive medications, and post-transplant maintenance targeted therapies. Supportive oncodermatology is a growing specialty to manage cutaneous toxicities resulting from the anti-cancer therapies. In this review, we summarize diagnosis and management of the common cutaneous adverse events including drug eruptions, graft-versus-host disease, neoplastic and paraneoplastic complications in patients undergoing cellular therapies.
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Affiliation(s)
- Shahab Babakoohi
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA.
| | - Stephanie L Gu
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Hamid Ehsan
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA
| | - Alina Markova
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
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2
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Lopez J, Devarkonda V, Thuzar M, Silva R, Akabane H. Acute Graft Versus Host Disease After Kidney-Pancreas Transplant. Cureus 2023; 15:e40415. [PMID: 37456451 PMCID: PMC10348074 DOI: 10.7759/cureus.40415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Acute graft vs. host disease (aGVHD) results from newly transplanted donor immune cells recognizing recipient tissues as foreign, leading to end-organ damage. Diagnosing aGVHD typically involves a combination of clinical evaluation, histological examination, laboratory tests, and imaging studies. Although typically associated with allogeneic stem cells transplant and less frequently with liver or small bowel transplants, solid organ transplant GVHD (SOT-GVHD) associated with kidney-pancreas transplants is exceedingly rare. Our patient presented with pancytopenia unexplained by typical causes. He developed classical aGVHD findings of fever, diarrhea, rash, and abnormal liver tests. Our case underscores the importance of keeping a broad differential when evaluating solid organ transplant patients.
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Affiliation(s)
- James Lopez
- Hematology and Medical Oncology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Vishal Devarkonda
- Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Moe Thuzar
- Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Roberto Silva
- Pathology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Hugo Akabane
- Hematology and Medical Oncology, Louisiana State University Health Sciences Center, Shreveport, USA
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3
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Chen J, Lu J, Hong X, Lu Q. Tocilizumab combined with ruxolitinib in the treatment of children with steroid resistant graft versus host disease after hematopoietic stem cell transplantation: report of 6 cases. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:470-473. [PMID: 37202101 PMCID: PMC10264977 DOI: 10.3724/zdxbyxb-2022-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/20/2022] [Indexed: 05/20/2023]
Abstract
Six children with steroid resistant graft versus host disease (GVHD) after hematopoietic stem cell transplantation admitted in the hospital, including 4 cases of acute GVHD and 2 cases of chronic GVHD. Among the 4 acute GVHD cases, the main manifestations were large area rash and fever in 2 cases, and abdominal pain and diarrhea in 2 cases. In 2 chronic GVHD cases, one presented lichenoid dermatosis, and the other showed repeated oral ulcers with difficult mouth opening. Patients received tocilizumab (8 mg/kg per dose every 3 weeks) and ruxolitinib (5-10 mg/d, 28 d), at least 2 courses were completed. All patients had complete responses (100%), and 5 patients responded after completion of two treatment courses, with the median time of remission was 26.7 d. The median follow-up period was 11 (7-25) months, and no severe treatment-related adverse reactions were observed.
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4
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Braun LM, Zeiser R. Kinase Inhibition as Treatment for Acute and Chronic Graft- Versus-Host Disease. Front Immunol 2021; 12:760199. [PMID: 34868001 PMCID: PMC8635802 DOI: 10.3389/fimmu.2021.760199] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/28/2021] [Indexed: 01/25/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is a potentially curative therapy for patients suffering from hematological malignancies via the donor immune system driven graft-versus-leukemia effect. However, the therapy is mainly limited by severe acute and chronic graft-versus-host disease (GvHD), both being life-threatening complications after allo-HCT. GvHD develops when donor T cells do not only recognize remaining tumor cells as foreign, but also the recipient’s tissue, leading to a severe inflammatory disease. Typical GvHD target organs include the skin, liver and intestinal tract. Currently all approved strategies for GvHD treatment are immunosuppressive therapies, with the first-line therapy being glucocorticoids. However, therapeutic options for glucocorticoid-refractory patients are still limited. Novel therapeutic approaches, which reduce GvHD severity while preserving GvL activity, are urgently needed. Targeting kinase activity with small molecule inhibitors has shown promising results in preclinical animal models and clinical trials. Well-studied kinase targets in GvHD include Rho-associated coiled-coil-containing kinase 2 (ROCK2), spleen tyrosine kinase (SYK), Bruton’s tyrosine kinase (BTK) and interleukin-2-inducible T-cell kinase (ITK) to control B- and T-cell activation in acute and chronic GvHD. Janus Kinase 1 (JAK1) and 2 (JAK2) are among the most intensively studied kinases in GvHD due to their importance in cytokine production and inflammatory cell activation and migration. Here, we discuss the role of kinase inhibition as novel treatment strategies for acute and chronic GvHD after allo-HCT.
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Affiliation(s)
- Lukas M Braun
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg, Freiburg, Germany.,Centre for Biological Signalling Studies (BIOSS) and Centre for Integrative Biological Signalling Studies (CIBSS), University of Freiburg, Freiburg, Germany
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5
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Mhandire K, Saggu K, Buxbaum NP. Immunometabolic Therapeutic Targets of Graft-versus-Host Disease (GvHD). Metabolites 2021; 11:736. [PMID: 34822394 PMCID: PMC8619522 DOI: 10.3390/metabo11110736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 01/17/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative option in the treatment of aggressive malignant and non-malignant blood disorders. However, the benefits of allo-HSCT can be compromised by graft-versus-host disease (GvHD), a prevalent and morbid complication of allo-HSCT. GvHD occurs when donor immune cells mount an alloreactive response against host antigens due to histocompatibility differences between the donor and host, which may result in extensive tissue injury. The reprogramming of cellular metabolism is a feature of GvHD that is associated with the differentiation of donor CD4+ cells into the pathogenic Th1 and Th17 subsets along with the dysfunction of the immune-suppressive protective T regulatory cells (Tregs). The activation of glycolysis and glutaminolysis with concomitant changes in fatty acid oxidation metabolism fuel the anabolic activities of the proliferative alloreactive microenvironment characteristic of GvHD. Thus, metabolic therapies such as glycolytic enzyme inhibitors and fatty acid metabolism modulators are a promising therapeutic strategy for GvHD. We comprehensively review the role of cellular metabolism in GvHD pathogenesis, identify candidate therapeutic targets, and describe potential strategies for augmenting immunometabolism to ameliorate GvHD.
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6
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Batgi H, Dal MS, Erkurt MA, Kuku I, Kurtoglu E, Hindilerden IY, Kaya E, Berber I, Ulas T, Altuntas F. Extracorporeal photopheresis in the treatment of acute graft-versus-host disease: A multicenter experience. Transfus Apher Sci 2021; 60:103242. [PMID: 34420882 DOI: 10.1016/j.transci.2021.103242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Extracorporeal photopheresis (ECP) is one of the second-line treatment strategies in steroid-refractory acute graft-versus-host disease (aGvHD). We aimed to share our multicenter experience using ECP in our steroid-refractory aGvHD patients. MATERIALS AND METHODS A retrospective observational series of 75 aGvHD patients from 4 transplant centers were analyzed. All ECP procedures were performed with the off-line system. All patients received ECP as second-line therapy. RESULTS 74.7 % of aGvHD patients were grade 3 or 4. The overall response rate was 42.7 % (32/75) in aGvHD including 17 complete responses (22.7 %). Median follow-up was 6 months (range, 1-68). Median overall survival (OS) was 5 months for non-responders and 68 months for responders (p < 0.001). Twenty-seven (36 %) patients are alive, and 48 (64 %) patients have died. CONCLUSIONS Early initiated ECP could be an effective treatment alternative in patients with steroid-refractory aGvHD.
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Affiliation(s)
- Hikmettullah Batgi
- University of Health Sciences, Ankara Oncology Training and Research Hospital, Department of Hematology & Apheresis Unit, Ankara, Turkey.
| | - Mehmet Sinan Dal
- University of Health Sciences, Ankara Oncology Training and Research Hospital, Department of Hematology & Apheresis Unit, Ankara, Turkey
| | | | - Irfan Kuku
- Inonu University, Department of Hematology, Malatya, Turkey
| | - Erdal Kurtoglu
- University of Health Sciences, Antalya Training and Research Hospital, Department of Hematology, Antalya, Turkey
| | - Ipek Yonal Hindilerden
- Istanbul University, Istanbul Medical Faculty, Department of Internal Medicine, Division of Hematology, Istanbul, Turkey
| | - Emin Kaya
- Inonu University, Department of Hematology, Malatya, Turkey
| | - Ilhami Berber
- Inonu University, Department of Hematology, Malatya, Turkey
| | - Turgay Ulas
- Near East University, School of Medicine, Department of Internal Medicine, Division of Hematology, Nicosia, Cyprus
| | - Fevzi Altuntas
- University of Health Sciences, Ankara Oncology Training and Research Hospital, Department of Hematology & Apheresis Unit, Ankara, Turkey; Ankara Yildirim Beyazit University, School of Medicine, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
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7
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Saad A, de Lima M, Anand S, Bhatt VR, Bookout R, Chen G, Couriel D, Di Stasi A, El-Jawahri A, Giralt S, Gutman J, Ho V, Horwitz M, Hsu J, Juckett M, Kharfan-Dabaja MA, Loren A, Meade J, Mielcarek M, Moreira J, Nakamura R, Nieto Y, Roddy J, Satyanarayana G, Schroeder M, Tan CR, Tzachanis D, Burn J, Pluchino L. Hematopoietic Cell Transplantation, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 18:599-634. [PMID: 32519831 DOI: 10.6004/jnccn.2020.0021] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hematopoietic cell transplantation (HCT) involves the infusion of hematopoietic progenitor cells into patients with hematologic disorders with the goal of re-establishing normal hematopoietic and immune function. HCT is classified as autologous or allogeneic based on the origin of hematopoietic cells. Autologous HCT uses the patient's own cells while allogeneic HCT uses hematopoietic cells from a human leukocyte antigen-compatible donor. Allogeneic HCT is a potentially curative treatment option for patients with certain types of hematologic malignancies, and autologous HCT is primarily used to support patients undergoing high-dose chemotherapy. Advances in HCT methods and supportive care in recent decades have led to improved survival after HCT; however, disease relapse and posttransplant complications still commonly occur in both autologous and allogeneic HCT recipients. Allogeneic HCT recipients may also develop acute and/or chronic graft-versus-host disease (GVHD), which results in immune-mediated cellular injury of several organs. The NCCN Guidelines for Hematopoietic Cell Transplantation focus on recommendations for pretransplant recipient evaluation and the management of GVHD in adult patients with malignant disease.
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Affiliation(s)
- Ayman Saad
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Marcos de Lima
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | | | | | | | | | - Vincent Ho
- Dana-Farber/Brigham and Women's Cancer Center
| | | | | | | | | | - Alison Loren
- Abramson Cancer Center at the University of Pennsylvania
| | - Javier Meade
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance
| | - Jonathan Moreira
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Yago Nieto
- The University of Texas MD Anderson Cancer Center
| | - Juliana Roddy
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Mark Schroeder
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
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8
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Abstract
Purpose of Review Graft-versus-host disease (GVHD) is an immune mediated disorder affecting 30 - 70% of patients after allogeneic hematopoietic stem cell transplantation (alloHSCT), and is a major cause of morbidity and non-relapse mortality (NRM) [1]. Dermatologists play a critical role in acute and chronic GVHD, as skin involvement is common and often the earliest involved site of disease [2]. Recent Findings GVHD shares clinical and histopathological features with a variety of other skin diseases, requiring thorough consideration of differential diagnoses in hematopoietic stem cell transplantation (HSCT) recipients with lesions suggestive of cutaneous GVHD. Treatment considerations for GVHD are influenced by factors such as disease classification, overall grading, organ involvement, associated symptoms, and immunological anti-tumor effect. Several treatments are available and may be indicated as monotherapy or adjuvant therapy to allow faster withdrawal or tapering of immunosuppression. While corticosteroids are often first line therapy, oral ruxolitinib has been recently approved for treatment of steroid-refractory aGHVD, and oral ibrutinib has been approved for steroid-refractory cGHVD. Summary This article provides current clinical, diagnostic, and therapeutic considerations relevant to the hospitalist for both acute and chronic mucocutaneous GVHD. Optimal inpatient management of these diseases requires an interdisciplinary team.
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9
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Abedin S, Hamadani M. Experimental Pharmaceuticals for Steroid-Refractory Acute Graft-versus-Host Disease. J Exp Pharmacol 2020; 12:549-557. [PMID: 33273867 PMCID: PMC7705269 DOI: 10.2147/jep.s259290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/16/2020] [Indexed: 01/19/2023] Open
Abstract
Acute GVHD (aGVHD) is a significant complication after allogeneic hematopoietic cell transplantation (HCT), occurring in up to 70% of HCT recipients. Steroid-refractory aGVHD represents a subset of patients failing initial therapy and is particularly morbid, with only 30% of patients surviving long term. Better therapies are urgently required for these patients. Here, we discuss recent advancements in the management of SR-aGVHD. We review the currently available therapies for SR-aGVHD including the results of the REACH1 and REACH2 trials, which provide the basis for the use of ruxolitinib for the treatment of SR-aGVHD. We additionally discuss newer agents under clinical investigation and will highlight the niche these agents may fill to further improve outcomes in aGVHD patient care.
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Affiliation(s)
- Sameem Abedin
- Blood & Marrow Transplantation and Cellular Therapy Program, Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mehdi Hamadani
- Blood & Marrow Transplantation and Cellular Therapy Program, Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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10
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Pasic I, Lipton JH, Kim DD, Viswabandya A, Kumar R, Lam W, Law AD, Mattsson J, Michelis FV. Post-transplant cyclophosphamide combined with anti-thymocyte globulin for graft-vs-host disease prophylaxis improves survival and lowers non-relapse mortality in older patients undergoing allogeneic hematopoietic cell transplantation. Ann Hematol 2020; 99:1377-1387. [DOI: 10.1007/s00277-020-04033-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/10/2020] [Indexed: 12/19/2022]
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11
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Mannina D, Kröger N. Janus Kinase Inhibition for Graft-Versus-Host Disease: Current Status and Future Prospects. Drugs 2020; 79:1499-1509. [PMID: 31359326 DOI: 10.1007/s40265-019-01174-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is a curative treatment for many hematological malignant and non-malignant diseases. A major complication of the procedure is the donor T-cell-mediated graft-versus-host disease (GvHD). GvHD accounts for about 10% of early mortality after transplantation. GVHD is also the major cause of morbidity and disability in the late follow-up phase of transplanted patients, mainly because of the low response to first-line steroids, and the lack of efficient second-line standard treatments. The increasing knowledge regarding GVHD pathogenesis provides new pharmacological targets, potentially exploitable in clinical practice, in order to prevent and treat this complication. This review provides a description of GVHD pathogenesis, with a focus on the central role of the Janus kinase-related mechanisms. The first inflammatory innate-immunity response is triggered by a JAK/STAT dependent pathway, and JAK inhibition impairs antigen-presenting cell differentiation and activation and downregulates the expression of signals for T-cell triggering. The chronic evolution of alloreactivity, characterized by the long-term maintenance of inflammation and fibrosis, is also dependent on JAK/STAT activation. Based on preclinical data, we reviewed the rationale behind the clinical use of JAK-inhibitors in GVHD, presenting available results of clinical trials and reports, and looked at future implementation of this new promising treatment approach.
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Affiliation(s)
- Daniele Mannina
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Hematology, Vita-Salute San Raffaele University Milano, Milan, Italy
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Escamilla Gómez V, García-Gutiérrez V, López Corral L, García Cadenas I, Pérez Martínez A, Márquez Malaver FJ, Caballero-Velázquez T, González Sierra PA, Viguria Alegría MC, Parra Salinas IM, Calderón Cabrera C, González Vicent M, Rodríguez Torres N, Parody Porras R, Ferra Coll C, Orti G, Valcárcel Ferreiras D, De la Cámara LLanzá R, Molés P, Velázquez-Kennedy K, João Mende M, Caballero Barrigón D, Pérez E, Martino Bofarull R, Saavedra Gerosa S, Sierra J, Poch M, Zudaire Ripa MT, Díaz Pérez MA, Molina Angulo B, Sánchez Ortega I, Sanz Caballer J, Montoro Gómez J, Espigado Tocino I, Pérez-Simón JA. Ruxolitinib in refractory acute and chronic graft-versus-host disease: a multicenter survey study. Bone Marrow Transplant 2019; 55:641-648. [PMID: 31700138 PMCID: PMC7051903 DOI: 10.1038/s41409-019-0731-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 10/13/2019] [Accepted: 10/17/2019] [Indexed: 01/22/2023]
Abstract
Graft-versus-host disease is the main cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. First-line treatment is based on the use of high doses of corticosteroids. Unfortunately, second-line treatment for both acute and chronic graft-versus-host disease, remains a challenge. Ruxolitinib has been shown as an effective and safe treatment option for these patients. Seventy-nine patients received ruxolitinib and were evaluated in this retrospective and multicenter study. Twenty-three patients received ruxolitinib for refractory acute graft-versus-host disease after a median of 3 (range 1–5) previous lines of therapy. Overall response rate was 69.5% (16/23) which was obtained after a median of 2 weeks of treatment, and 21.7% (5/23) reached complete remission. Fifty-six patients were evaluated for refractory chronic graft-versus-host disease. The median number of previous lines of therapy was 3 (range 1–10). Overall response rate was 57.1% (32/56) with 3.5% (2/56) obtaining complete remission after a median of 4 weeks. Tapering of corticosteroids was possible in both acute (17/23, 73%) and chronic graft-versus-host disease (32/56, 57.1%) groups. Overall survival was 47% (CI: 23–67%) at 6 months for patients with aGVHD (62 vs 28% in responders vs non-responders) and 81% (CI: 63–89%) at 1 year for patients with cGVHD (83 vs 76% in responders vs non-responders). Ruxolitinib in the real life setting is an effective and safe treatment option for GVHD, with an ORR of 69.5% and 57.1% for refractory acute and chronic graft-versus-host disease, respectively, in heavily pretreated patients.
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Affiliation(s)
- Virginia Escamilla Gómez
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | - Lucía López Corral
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | | | | | - Francisco J Márquez Malaver
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | - Teresa Caballero-Velázquez
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | | | | | - Cristina Calderón Cabrera
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | - Nancy Rodríguez Torres
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | | | | | | | | | | | | | - María João Mende
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Dolores Caballero Barrigón
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Estefanía Pérez
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | | | | | - Jorge Sierra
- Hospital Santa Creu I Sant Pau, Barcelona, Spain
| | - Marc Poch
- Clinic University Hospital of Valencia, Valencia, Spain
| | | | | | | | | | | | | | - Ildefonso Espigado Tocino
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | - José A Pérez-Simón
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain.
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13
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A monocentric study of steroid-refractory acute graft-versus-host disease treatment with tacrolimus and mTOR inhibitor. Bone Marrow Transplant 2019; 55:86-92. [DOI: 10.1038/s41409-019-0633-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/02/2019] [Accepted: 06/22/2019] [Indexed: 12/12/2022]
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14
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Abstract
Graft-versus-host disease (GVHD) is an adverse immunologic phenomenon following allogenic hematopoietic stem cell transplant. Cutaneous manifestations are the earliest and most common presentation of the disease. This article describes the pathophysiology, clinical presentation, diagnosis, and treatment options available for acute and chronic GVHD. Acute and chronic GVHD result from an initial insult triggering an exaggerated inflammatory cascade. Clinical presentation for cutaneous acute GVHD is limited to maculopapular rash and oral mucosal lesions, whereas chronic GVHD can also include nail, scalp, and genitalia changes. Diagnosis is often made clinically and supported by biopsy, laboratory and radiology findings.
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Affiliation(s)
| | - Sree S Kolli
- Department of Dermatology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA.
| | - Lindsay C Strowd
- Department of Dermatology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA
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15
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Axt L, Naumann A, Toennies J, Haen SP, Vogel W, Schneidawind D, Wirths S, Moehle R, Faul C, Kanz L, Axt S, Bethge WA. Retrospective single center analysis of outcome, risk factors and therapy in steroid refractory graft-versus-host disease after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2019; 54:1805-1814. [PMID: 31089279 DOI: 10.1038/s41409-019-0544-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 01/09/2023]
Abstract
Acute and chronic graft-vs.-host disease (aGvHD and cGvHD) are major complications after allogeneic hematopoietic cell transplantation (HCT) leading to substantial morbidity and mortality. This retrospective single-center study analyzes incidence, therapy, and outcome of GvHD in n = 721 patients ≥18 years having received allogeneic HCT 2004-2013 with a special focus on steroid refractory GvHD. Acute (n = 355/49.2%) and chronic (n = 269/37.3%) GvHD were mainly treated by steroids in first-line therapy. The proportion of steroid refractory aGvHD and cGvHD was 35.7% and 31.4%, respectively. As there is no standard therapy for steroid refractory GvHD, a range of different agents was used. In aGvHD, the overall response rate (ORR) of steroid refractory GvHD to second-line treatment was 27.4%. Mycophenolate mofetil (MMF) and mTOR inhibitors led to superior response rates (ORR 50.0% and 53.3%, respectively). In steroid refractory cGvHD therapy, ORR was 44.4%. Use of calcineurin inhibitors (CNI; n = 11/45.5%), MMF (n = 18/50.0%), mTOR inhibitors (n = 10/60.0%), and extracorporeal photophoresis (ECP; n = 16/56.3%) showed ORR above average. Targeted therapies lead to responses in 7.7% (n = 13). This data may help to improve the design of future prospective clinical studies in GvHD.
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Affiliation(s)
- L Axt
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - A Naumann
- Institute for Clinical Epidemiology and Applied Biometry, Eberhard-Karl University Tuebingen, Tuebingen, Germany
| | - J Toennies
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - S P Haen
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - W Vogel
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - D Schneidawind
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - S Wirths
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - R Moehle
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - C Faul
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - L Kanz
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany
| | - S Axt
- Department for Visceral, General and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - W A Bethge
- Department of Hematology and Oncology, Medical Center University Hospital Tuebingen, Tuebingen, Germany.
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Jones K, Bryant S, Luo J, Kiesler P, Koontz S, Warren J, Malech H, Kang E, Dveksler G. Recombinant Pregnancy-Specific Glycoprotein 1 Has a Protective Role in a Murine Model of Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2018; 25:193-203. [PMID: 30253241 DOI: 10.1016/j.bbmt.2018.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/13/2018] [Indexed: 12/23/2022]
Abstract
Acute graft-versus-host disease (aGVHD) is an immune-mediated reaction that can occur after hematopoietic stem cell transplantation in which donor T cells recognize the host antigens as foreign, destroying host tissues. Establishment of a tolerogenic immune environment while preserving the immune response to infectious agents is required for successful bone marrow transplantation. Pregnancy-specific glycoprotein 1 (PSG1), which is secreted by the human placenta into the maternal circulation throughout pregnancy, likely plays a role in maintaining immunotolerance to prevent rejection of the fetus by the maternal immune system. We have previously shown that PSG1 activates the latent form of transforming growth factor β1 (TGF-β), a cytokine essential for the differentiation of tolerance-inducing CD4+FoxP3+ regulatory T cells (Tregs). Consistent with this observation, treatment of naïve murine T cells with PSG1 resulted in a significant increase in FoxP3+ cells that was blocked by a TGF-β receptor I inhibitor. We also show here that PSG1 can increase the availability of active TGF-β in vivo. As the role of CD4+FoxP3+ cells in the prevention of aGVHD is well established, we tested whether PSG1 has beneficial effects in a murine aGHVD transplantation model. PSG1-treated mice had reduced numbers of tissue-infiltrating inflammatory CD3+ T cells and had increased expression of FoxP3 in T cells compared with vehicle-treated mice. In addition, administration of PSG1 significantly inhibited aGVHD-associated weight loss and mortality. On the other hand, administration of PSG1 was less effective in managing aGVHD in the presence of an alloimmune reaction against a malignancy in a graft-versus-leukemia experimental model. Combined, this data strongly suggests that PSG1 could be a promising treatment option for patients with aGVHD following bone marrow transplantation for a nonmalignant condition, such as an autoimmune disorder or a genetic immunodeficiency.
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Affiliation(s)
- Karlie Jones
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Sarah Bryant
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jian Luo
- Palo Alto Veterans Institute for Research, VA Palo Alto Health Care System, Palo Alto, California
| | - Patricia Kiesler
- Mucosal Immunity Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Sherry Koontz
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - James Warren
- Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Harry Malech
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Elizabeth Kang
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Gabriela Dveksler
- Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
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17
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Kim TK, DeVeaux M, Stahl M, Perreault S, Isufi I, Cooper D, Foss F, Shlomchik W, Zelterman D, Zeidan AM, Seropian S. Long-term follow-up of a single institution pilot study of sirolimus, tacrolimus, and short course methotrexate for graft versus host disease prophylaxis in mismatched unrelated donor allogeneic stem cell transplantation. Ann Hematol 2018; 98:237-240. [PMID: 30027436 DOI: 10.1007/s00277-018-3427-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/30/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Tae Kon Kim
- Section of Hematology/Department of Internal Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, USA
| | | | - Maximilian Stahl
- Section of Hematology/Department of Internal Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, USA
| | | | - Iris Isufi
- Section of Hematology/Department of Internal Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, USA
| | - Dennis Cooper
- Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Francine Foss
- Section of Hematology/Department of Internal Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, USA
| | - Warren Shlomchik
- University of Pittsburgh School of Medicine, Division of Hematology and Oncology, Department of Medicine, UPMC Hillman Cancer Center, Pittsburgh, USA
| | | | - Amer M Zeidan
- Section of Hematology/Department of Internal Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, USA
| | - Stuart Seropian
- Section of Hematology/Department of Internal Medicine and Yale Cancer Center, Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, USA.
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18
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Hill L, Alousi A, Kebriaei P, Mehta R, Rezvani K, Shpall E. New and emerging therapies for acute and chronic graft versus host disease. Ther Adv Hematol 2018; 9:21-46. [PMID: 29317998 PMCID: PMC5753923 DOI: 10.1177/2040620717741860] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/10/2017] [Indexed: 12/14/2022] Open
Abstract
Graft versus host disease (GVHD) remains a major cause of morbidity and mortality following allogeneic hematopoietic stem-cell transplantation (HSCT). Despite the use of prophylactic GVHD regimens, a significant proportion of transplant recipients will develop acute or chronic GVHD following HSCT. Corticosteroids are standard first-line therapy, but are only effective in roughly half of all cases with ~50% of patients going on to develop steroid-refractory disease, which increases the risk of nonrelapse mortality. While progress has been made with improvements in survival outcomes over time, corticosteroids are associated with significant toxicities, and many currently available salvage therapies are associated with increased immunosuppression, infectious complications, and potential loss of the graft versus leukemia (GVL) effect. Thus, there is an unmet need for development of newer treatment strategies for both acute and chronic GVHD to improve long-term post-transplant outcomes and quality of life for HSCT recipients. Here, we provide a concise review of major emerging therapies currently being studied in the treatment of acute and chronic GVHD.
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Affiliation(s)
- LaQuisa Hill
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Rohtesh Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 0423, Houston, TX 77030-4000, USA
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19
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Ragon BK, Mehta RS, Gulbis AM, Saliba RM, Chen J, Rondon G, Popat UR, Nieto Y, Oran B, Olson AL, Patel K, Hosing CM, Qazilbash MH, Shah N, Kebriaei P, Shpall EJ, Champlin RE, Alousi AM. Pentostatin therapy for steroid-refractory acute graft versus host disease: identifying those who may benefit. Bone Marrow Transplant 2017; 53:315-325. [PMID: 29269797 DOI: 10.1038/s41409-017-0034-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/20/2017] [Accepted: 10/12/2017] [Indexed: 11/09/2022]
Abstract
We report outcomes of 60 patients with steroid-refractory (SR)-aGVHD treated with pentostatin. Almost half (47%) of patients had grade 4 GVHD-22% had stage 3-4 liver GVHD and 51% had stage 3-4 lower gastrointestinal tract (LGI) GVHD. Patients received a median of 3 courses (range, 1-9) of pentostatin. Day 28 overall response rate (ORR) was 33% (n = 20) (complete response 18% (n = 11), partial response 15% (n = 9)). Non-relapse mortality was 72% (95% confidence interval (CI) 61-84%) and overall survival (OS) was 21% (95% CI 12-32%) at 18 months. On univariate analysis, age >60 years (HR 1.9, 95% CI 1.01-3.7, p = 0.045) and presence of liver GVHD (HR 1.9, 95% CI 1.9, 95% CI 1.5-3.3, p = 0.03) were significant predictors of poor OS while patients with LGI GVHD had superior OS than those without (HR 0.4, 95% CI 0.2-0.8, p = 0.01). On stratified analysis, patients <60 years with isolated LGI GVHD had the best outcomes with an ORR of 48% and OS of 42% at 18 months. Among older patients, OS was 14% in those with isolated LGI aGVHD and 0% in others. Pentostatin remains a viable treatment option for SR-aGVHD, especially in patients 60 years or younger with isolated LGI involvement.
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Affiliation(s)
| | - Rohtesh S Mehta
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Alison M Gulbis
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rima M Saliba
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Julianne Chen
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriela Rondon
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yago Nieto
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Betul Oran
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amanda L Olson
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Krina Patel
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chitra M Hosing
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Nina Shah
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Partow Kebriaei
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Amin M Alousi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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21
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Chao YH, Chang YC, Wu HP, Peng CT, Weng TF, Wu KH. Everolimus for pediatric patients with acute graft-versus-host disease after hematopoietic stem cell transplantation: A pilot study. Medicine (Baltimore) 2017; 96:e8464. [PMID: 29095297 PMCID: PMC5682816 DOI: 10.1097/md.0000000000008464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute graft-versus-host disease (aGVHD) is a significant cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Due to the poor prognosis for patients not responding to first-line steroids treatment, improvements in aGVHD therapy are needed. Everolimus is a promising candidate that combines immunosuppressive properties with anti-neoplastic effects. Here, we retrospectively reviewed the efficacy of everolimus with steroids as primary treatment in 13 patients with grade II to grade IV aGVHD after HSCT. Among them, 12 (92.3%) had complete response to everolimus with steroids without additional immunosuppressive agents. The median duration of therapy was 76 days (range 20-110). Asymptomatic hypertriglyceridemia was the most common therapy complication (69.2%), but treatment interruption was not needed. Thrombotic microangiopathy was rare (7.7%), but can be quickly solved by stopping everolimus and cyclosporine treatment. Other toxicities were manageable. Two patients developed chronic GVHD (15.4%), limited in one and extensive in the other. The overall survival was 76.9% with a median follow-up of 3.4 years after HSCT (range 0.7-5.7). Accordingly, everolimus with steroids were feasible for patients with aGVHD after HSCT as primary treatment. Further large-scale studies are required.
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Affiliation(s)
- Yu-Hua Chao
- Department of Pediatrics, Chung Shan Medical University Hospital
- School of Medicine, Chung Shan Medical University
| | - Yin-Chen Chang
- Department of Nursing, College of Medicine and Nursing, Hungkuang University
| | - Han-Ping Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University, Taoyuan
| | - Ching-Tien Peng
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University
- Department of Biotechnology and Bioinformatics, Asia University
| | - Te-Fu Weng
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University
| | - Kang-Hsi Wu
- Division of Pediatric Hematology-Oncology, Children's Hospital, China Medical University
- School of Post-Baccalaureate Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
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22
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Xu LP, Huang XJ. [How I treat acute graft versus host disease]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:649-655. [PMID: 28954341 PMCID: PMC7348246 DOI: 10.3760/cma.j.issn.0253-2727.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 11/23/2022]
Affiliation(s)
- L P Xu
- Peking Universi-ty, People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
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23
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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24
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Kim SS. Treatment Options in Steroid-Refractory Acute Graft-Versus-Host Disease Following Hematopoietic Stem Cell Transplantation. Ann Pharmacother 2016; 41:1436-44. [PMID: 17684033 DOI: 10.1345/aph.1k179] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: To evaluate the treatment options in steroid-refractory acute graft-versus-host disease (GVHD) following hematopoietic stem cell transplantation. Data Sources: Literature was obtained by searching MEDLINE (1966–May 2007) and EMBASE (1980–May 2007). Study Selection and Data Extraction: All pertinent clinical trials, retrospective studies, case reports, and compassionate use studies were identified and evaluated for safety and efficacy of the pharmacologic agents. Data Synthesis: Steroid-refractory acute GVHD is associated with high rates of morbidity and mortality. Although various pharmacologic agents have been studied in the treatment of steroid-refractory acute GVHD, no treatments have been established as a salvage therapy. Preliminary data on different pharmacologic agents have been identified and evaluated for their efficacy and tolerability in the treatment of steroid-refractory acute GVHD. The effects of the pharmacologic agents varied significantly among patients: severity of the disease, involvement of different organs, and the patient's age seem to be the major factors that affect an individual's response to drug therapy. In addition, the treatments are further challenged by the high incidence of potentially fatal opportunistic infections that occur during the therapy. Conclusions: Selection of pharmacologic agents for the treatment of steroid-refractory acute GVHD should be based on the target organs, adverse drug reactions, and economic factors. Further studies with larger sample sizes are warranted to better understand the roles of these agents in the treatment of steroid-refractory acute GVHD.
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Affiliation(s)
- Sara S Kim
- Department of Pharmacy, The Mount Sinai Medical Center, New York, NY, USA.
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25
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Lutz M, Mielke S. New perspectives on the use of mTOR inhibitors in allogeneic haematopoietic stem cell transplantation and graft-versus-host disease. Br J Clin Pharmacol 2016; 82:1171-1179. [PMID: 27245261 PMCID: PMC5061796 DOI: 10.1111/bcp.13022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 12/17/2022] Open
Abstract
Inhibition of the mechanistic target of rapamycin (mTOR) has been exploited largely both in solid tumour oncology and solid organ transplantation. More recently mTOR inhibitors such as sirolimus and everolimus have been introduced to the field of allogeneic haematopoietic stem cell transplantation where their unique combination of immunosuppressive purposes offering reduced nephrotoxicity and potential antimalignant effects reflect a unique drug profile that has led to their widespread use in both prophylaxis and therapy of graft-versus-host disease (GVHD). On the other hand haematological insufficiency, infectious complications as well as vasculopathies, have been frequently reported as limiting toxicities. Here, we review both the retrospective and prospective experience available to date and stress the need for prospective registration trials to reduce off label use and improve patient safety by optimizing dosing and enhancing pharmacovigilance. Furthermore, we speculate on the future role of mTOR inhibitors in allogeneic haematopoietic stem cell transplantation.
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Affiliation(s)
- Mathias Lutz
- Department of Medicine A, Münster University Medical Center, Münster, Germany
| | - Stephan Mielke
- Department of Internal Medicine II, Würzburg University Medical Center, Würzburg, Germany.
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26
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Wasko JA, Westholder JS, Jacobson PA. Rifampin-sirolimus-voriconazole interaction in a hematopoietic cell transplant recipient. J Oncol Pharm Pract 2016; 23:75-79. [PMID: 26763003 DOI: 10.1177/1078155215624263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Patients undergoing hematopoietic cell transplantation are treated with multiple medications, potentially complicated by drug-drug interactions. Drug interactions with sirolimus, voriconazole, and rifampin are particularly difficult because of the complex and simultaneous enzyme inhibition and induction mechanisms. We report a hematopoietic cell transplantation patient receiving sirolimus and voriconazole who was given rifampin while being treated for presumed methicillin-resistant Staphylococcus aureus meningitis. Summary A 31 year-old female received a nonmyeloablative allogeneic umbilical cord hematopoietic cell transplantation for myelodysplastic syndrome transformed to acute myeloid leukemia (AML). Her graft versus host disease and antifungal prophylaxis included sirolimus and voriconazole, respectively. Therapeutic drug monitoring prior to admission revealed a stable outpatient sirolimus regimen of 0.4 mg orally daily (trough goal 3-12 mcg/L). She was admitted to the inpatient hematopoietic cell transplantation service and diagnosed with methicillin-resistant Staphylococcus aureus bacteremia and presumed bacterial meningitis 217 days after transplant. Intravenous rifampin and vancomycin were initiated and voriconazole was changed to micafungin. Sirolimus trough concentrations were undetectable two days after starting rifampin. Therapeutic sirolimus concentrations were achieved four days later, at a sirolimus dose of 16-18 mg orally daily. Rifampin was discontinued after nine days and the sirolimus dose was adjusted accordingly, maintaining therapeutic levels throughout follow-up. The patient suffered a flare of chronic skin graft versus host disease requiring etanercept, high-dose systemic steroids, and topical steroids. Conclusion To the best of our knowledge, this is the first report describing the management of sirolimus during the transition from voriconazole inhibition to rifampin induction. Clinicians should be aware of potential drug-drug interactions.
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Affiliation(s)
- Justin A Wasko
- 1 Department of Pharmacy, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - James S Westholder
- 1 Department of Pharmacy, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Pamala A Jacobson
- 2 Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
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27
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Renteria AS, Levine JE, Ferrara JLM. Therapeutic targets and emerging treatment options in gastrointestinal acute graft-versus-host disease. Expert Opin Orphan Drugs 2016; 4:469-484. [PMID: 30057862 DOI: 10.1517/21678707.2016.1166949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction Graft-versus-host disease (GVHD) continues to be the major lethal complication of allogeneic hematopoietic stem cell transplantation (HCT) but the standard of care, high dose steroids, has not changed in 40 years. Approximately 50% of GVHD patients will develop steroid refractory disease, typically involving the gastrointestinal (GI) tract, which has a very poor prognosis. Newly developed GVHD biomarker-based risk scores provide the first opportunity to treat patients at the onset of symptoms according to risk of steroid failure. Furthermore, improvements in our understanding of the pathobiology of GVHD, its different signaling pathways, involved cytokines, and the role of post-translational and epigenetic modifications, has identified new therapeutic targets for clinical trials. Areas covered This manuscript summarizes the pathophysiology, diagnosis, staging, current and new targeted therapies for GVHD, with an emphasis on GI GVHD. A literature search on PubMed was undertaken and the most relevant references included. Expert Opinion The standard treatment for GVHD, high dose steroids, offers less than optimal outcomes as well as significant toxicities. Better treatments, especially for GI GVHD, are needed to reduce non-relapse mortality after allogeneic HCT. The identification of high risk patients through a biomarker-defined scoring system offers a personalized approach to a disease that still requires significant research attention.
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Affiliation(s)
- Anne S Renteria
- Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John E Levine
- Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James L M Ferrara
- Hematologic Malignancies Translational Research Center, Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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28
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Armand P, Kim HT, Sainvil MM, Lange PB, Giardino AA, Bachanova V, Devine SM, Waller EK, Jagirdar N, Herrera AF, Cutler C, Ho VT, Koreth J, Alyea EP, McAfee SL, Soiffer RJ, Chen YB, Antin JH. The addition of sirolimus to the graft-versus-host disease prophylaxis regimen in reduced intensity allogeneic stem cell transplantation for lymphoma: a multicentre randomized trial. Br J Haematol 2016; 173:96-104. [PMID: 26729448 DOI: 10.1111/bjh.13931] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/18/2015] [Indexed: 11/28/2022]
Abstract
Inhibition of the mechanistic target of rapamycin (mTOR) pathway has clinical activity in lymphoma. The mTOR inhibitor sirolimus has been used in the prevention and treatment of graft-versus-host disease (GVHD) after allogeneic haematopoietic stem cell transplantation (HSCT). A retrospective study suggested that patients with lymphoma undergoing reduced intensity conditioning (RIC) HSCT who received sirolimus as part of their GVHD prophylaxis regimen had a lower rate of relapse. We therefore performed a multicentre randomized trial comparing tacrolimus, sirolimus and methotrexate to standard regimens in adult patients undergoing RIC HSCT for lymphoma in order to assess the possible benefit of sirolimus on HSCT outcome. 139 patients were randomized. There was no difference overall in 2-year overall survival, progression-free survival, relapse, non-relapse mortality or chronic GVHD. However, the sirolimus-containing arm had a significantly lower incidence of grade II-IV acute GVHD (9% vs. 25%, P = 0·015), which was more marked for unrelated donor grafts. In conclusion, the addition of sirolimus for GVHD prophylaxis in RIC HSCT is associated with no increased overall toxicity and a lower risk of acute GVHD, although it does not improve survival; this regimen is an acceptable option for GVHD prevention in RIC HSCT. This trial is registered at clinicaltrials.gov (NCT00928018).
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Affiliation(s)
- Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haesook T Kim
- Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Paulina B Lange
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Angela A Giardino
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Veronika Bachanova
- Department of Medical Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Steven M Devine
- Department of Medicine, The Ohio State University Comprehensive Cancer Center Ohio State University, Columbus, OH, USA
| | - Edmund K Waller
- Department of Hematology/Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Neera Jagirdar
- Department of Hematology/Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John Koreth
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Edwin P Alyea
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Steven L McAfee
- Bone Marrow Transplant Unit, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yi-Bin Chen
- Bone Marrow Transplant Unit, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Sirolimus-related anal ulceration in a female patient after allogeneic stem cell transplantation. Bone Marrow Transplant 2015; 51:132-3. [PMID: 26367228 DOI: 10.1038/bmt.2015.198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chen X, Wang C, Yin J, Xu J, Wei J, Zhang Y. Efficacy of Mesenchymal Stem Cell Therapy for Steroid-Refractory Acute Graft-Versus-Host Disease following Allogeneic Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0136991. [PMID: 26323092 PMCID: PMC4554731 DOI: 10.1371/journal.pone.0136991] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/11/2015] [Indexed: 12/13/2022] Open
Abstract
Background Mesenchymal stem cells (MSCs) have been broadly used experimentally in various clinical contexts. The addition of MSCs to initial steroid therapy for acute graft-versus-host disease (aGVHD) may improve patient outcomes. However, investigations regarding prognostic factors affecting the efficacy of MSC therapy for steroid-refractory aGVHD remain controversial. We thus conducted a systematic review and meta-analysis of published clinical trials to determine possible prognostic factors affecting the efficacy of MSCs in treating steroid-refractory aGVHD. Methods and Findings Clinical trials using MSC therapy for steroid-refractory aGVHD were identified by searching PubMed and EMBASE databases. A total of 6,963 citations were reviewed, and 13 studies met the inclusion criteria. A total of 301 patients from thirteen studies were included. Of these, 136 patients showed a complete response (CR), and 69 patients displayed a partial (PR) or mixed response (MR). In total, 205 patients exhibited overall response (ORR). Patients with skin steroid-refractory aGVHD showed a better clinical response than gastrointestinal (CR: odds ratio [OR] = 1.93, 95% confidence interval [95%CI]: 1.05–3.57, p < 0.05) and liver (CR: OR = 2.30, 95%CI: 1.12–4.69, p < 0.05, and ORR: OR = 2.93, 95%CI: 1.06–8.08, p < 0.05) steroid-refractory aGVHD. Those with grade II steroid-refractory aGVHD exhibited a better clinical response following MSC therapy than recipients with grade III–IV (CR: OR = 3.22, 95%CI: 1.24–8.34, p < 0.05). Completion therapy may improve the CR but reduce ORR compared with induction therapy (CR: OR = 0.20, 95%CI: 0.09–0.44, p < 0.05; ORR: OR = 2.18, 95%CI: 1.17–4.05, p = 0.01). There was also a trend towards a better clinical response in children compared with adults (CR: OR = 2.41, 95%CI: 1.01–5.73, p = 0.05). Conclusions Age, skin involvement, lower aGVHD grade, and the number of infusions are the main prognostic factors affecting the efficacy of MSC therapy for steroid-refractory aGVHD.
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Affiliation(s)
- Xiaomei Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunyan Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jin Yin
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhuan Xu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: (YZ); (JW)
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: (YZ); (JW)
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Khaled SK, Palmer JM, Herzog J, Stiller T, Tsai NC, Senitzer D, Liu X, Thomas SH, Shayani S, Weitzel J, Forman SJ, Nakamura R. Influence of Absorption, Distribution, Metabolism, and Excretion Genomic Variants on Tacrolimus/Sirolimus Blood Levels and Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 22:268-276. [PMID: 26325438 DOI: 10.1016/j.bbmt.2015.08.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/19/2015] [Indexed: 01/23/2023]
Abstract
Allelic variants of genes implicated in drug absorption, distribution, metabolism, and excretion (ADME) determine the pharmacokinetic variability of many medications and are increasingly recognized as important factors determining the success or failure of medical treatments. Both tacrolimus and sirolimus have narrow therapeutic ranges maintained by therapeutic drug monitoring (TDM). Using an ADME panel that covers >99% of the PharmaADME working group core list (188 single nucleotide polymorphism [SNP] and 12 copy number variant [CNV] assays in 36 pharmacogenetically relevant genes), we studied 177 patients who underwent allogeneic hematopoietic cell transplantation (HCT) using tacrolimus/sirolimus-based graft-versus-host disease (GVHD) prophylaxis. We tested for possible associations between ADME variants and tacrolimus/sirolimus drug levels, concentration/dose (C/D) ratio, and clinical endpoints, including acute GVHD. A total of 62 SNP and 6 CNV assays were evaluable after removing the variants, which were homozygous in (nearly) all samples. For sirolimus, rs2032582 (ABCB1) T-carriers versus non-T-carriers were associated with higher blood levels (P = .01), with similar results for C/D ratio. Generalized estimating equation analysis supported these findings. For tacrolimus, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were associated with higher blood levels than CYP3A5*1/*1 (P = .002). By multivariable analysis, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were independently associated with decreased acute GVHD compared with CYP3A5*1/*1, after adjustment for conditioning, donor type, race/ethnicity, and age. We demonstrated association of specific ADME genetic polymorphisms with blood levels of tacrolimus/sirolimus, and incidence of acute GVHD after HCT, in spite of TDM and dose adjustment. A larger ongoing study will determine whether these associations have clinical utility beyond TDM.
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Affiliation(s)
- Samer K Khaled
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research of the Hematologic Malignancies and Stem Cell Transplantation Institute of the City of Hope, Duarte, CA.
| | | | - Josef Herzog
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Tracey Stiller
- Division of Biostatistics, City of Hope, Duarte, California
| | - Ni-Chun Tsai
- Division of Biostatistics, City of Hope, Duarte, California
| | - David Senitzer
- Division of Histocompatibility (HLA Laboratory), City of Hope, Duarte, California
| | - Xueli Liu
- Division of Biostatistics, City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | | | - Jeffrey Weitzel
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
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Zeiser R, Burchert A, Lengerke C, Verbeek M, Maas-Bauer K, Metzelder SK, Spoerl S, Ditschkowski M, Ecsedi M, Sockel K, Ayuk F, Ajib S, de Fontbrune FS, Na IK, Penter L, Holtick U, Wolf D, Schuler E, Meyer E, Apostolova P, Bertz H, Marks R, Lübbert M, Wäsch R, Scheid C, Stölzel F, Ordemann R, Bug G, Kobbe G, Negrin R, Brune M, Spyridonidis A, Schmitt-Gräff A, van der Velden W, Huls G, Mielke S, Grigoleit GU, Kuball J, Flynn R, Ihorst G, Du J, Blazar BR, Arnold R, Kröger N, Passweg J, Halter J, Socié G, Beelen D, Peschel C, Neubauer A, Finke J, Duyster J, von Bubnoff N. Ruxolitinib in corticosteroid-refractory graft-versus-host disease after allogeneic stem cell transplantation: a multicenter survey. Leukemia 2015; 29:2062-8. [PMID: 26228813 DOI: 10.1038/leu.2015.212] [Citation(s) in RCA: 389] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 07/23/2015] [Accepted: 07/24/2015] [Indexed: 12/15/2022]
Abstract
Despite major improvements in allogeneic hematopoietic cell transplantation over the past decades, corticosteroid-refractory (SR) acute (a) and chronic (c) graft-versus-host disease (GVHD) cause high mortality. Preclinical evidence indicates the potent anti-inflammatory properties of the JAK1/2 inhibitor ruxolitinib. In this retrospective survey, 19 stem cell transplant centers in Europe and the United States reported outcome data from 95 patients who had received ruxolitinib as salvage therapy for SR-GVHD. Patients were classified as having SR-aGVHD (n=54, all grades III or IV) or SR-cGVHD (n=41, all moderate or severe). The median number of previous GVHD-therapies was 3 for both SR-aGVHD (1-7) and SR-cGVHD (1-10). The overall response rate was 81.5% (44/54) in SR-aGVHD including 25 complete responses (46.3%), while for SR-cGVHD the ORR was 85.4% (35/41). Of those patients responding to ruxolitinib, the rate of GVHD-relapse was 6.8% (3/44) and 5.7% (2/35) for SR-aGVHD and SR-cGVHD, respectively. The 6-month-survival was 79% (67.3-90.7%, 95% confidence interval (CI)) and 97.4% (92.3-100%, 95% CI) for SR-aGVHD and SR-cGVHD, respectively. Cytopenia and cytomegalovirus-reactivation were observed during ruxolitinib treatment in both SR-aGVHD (30/54, 55.6% and 18/54, 33.3%) and SR-cGVHD (7/41, 17.1% and 6/41, 14.6%) patients. Ruxolitinib may constitute a promising new treatment option for SR-aGVHD and SR-cGVHD that should be validated in a prospective trial.
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Affiliation(s)
- R Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - A Burchert
- Department of Hematology, Oncology and Immunology, Philipps University Marburg, and University Medical Center Giessen and Marburg, Marburg, Germany
| | - C Lengerke
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - M Verbeek
- III Department of Internal Medicine, Technical University of Munich, Munich, Germany
| | - K Maas-Bauer
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - S K Metzelder
- Department of Hematology, Oncology and Immunology, Philipps University Marburg, and University Medical Center Giessen and Marburg, Marburg, Germany
| | - S Spoerl
- III Department of Internal Medicine, Technical University of Munich, Munich, Germany
| | - M Ditschkowski
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - M Ecsedi
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - K Sockel
- Department of Hematology and Oncology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - F Ayuk
- Department of Stem Cell Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - S Ajib
- Department of Internal Medicine II, University Hospital, Frankfurt/Main, Germany
| | - F S de Fontbrune
- Hematology Stem cell transplant Unit, Saint Louis Hospital, APHP, Paris, France
| | - I-K Na
- Department of Stem Cell Transplantation, Charité University Medicine Berlin, Berlin, Germany
| | - L Penter
- Department of Stem Cell Transplantation, Charité University Medicine Berlin, Berlin, Germany
| | - U Holtick
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - D Wolf
- Medical Clinic III, Oncology, Hematology and Rheumatology, University Hospital Bonn (UKB), Bonn, Germany
| | - E Schuler
- Department of Hematology, Oncology and Clinical Immunology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - E Meyer
- Department of Bone Marrow Transplantation, Stanford University Medical School, Stanford, CA, USA
| | - P Apostolova
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - H Bertz
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - R Marks
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - M Lübbert
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - R Wäsch
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - C Scheid
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - F Stölzel
- Department of Hematology and Oncology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - R Ordemann
- Department of Hematology and Oncology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - G Bug
- Department of Internal Medicine II, University Hospital, Frankfurt/Main, Germany
| | - G Kobbe
- Department of Hematology, Oncology and Clinical Immunology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - R Negrin
- Department of Bone Marrow Transplantation, Stanford University Medical School, Stanford, CA, USA
| | - M Brune
- Department of Internal Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - A Spyridonidis
- Department of Bone Marrow Transplantation, Patras University Medical School, Patras, Greece
| | - A Schmitt-Gräff
- Department of Pathology, Freiburg University Medical Center, Freiburg, Germany
| | | | - G Huls
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S Mielke
- Department of Hematology and Oncology, University Medical Centre Würzburg, Würzburg, Germany
| | - G U Grigoleit
- Department of Hematology and Oncology, University Medical Centre Würzburg, Würzburg, Germany
| | - J Kuball
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Flynn
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - G Ihorst
- Clinical Trials Unit, Department of Hematology, Freiburg University Medical Center, Freiburg, Germany
| | - J Du
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - B R Blazar
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - R Arnold
- Department of Stem Cell Transplantation, Charité University Medicine Berlin, Berlin, Germany
| | - N Kröger
- Department of Stem Cell Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - J Passweg
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - J Halter
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - G Socié
- Hematology Stem cell transplant Unit, Saint Louis Hospital, APHP, Paris, France
| | - D Beelen
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - C Peschel
- III Department of Internal Medicine, Technical University of Munich, Munich, Germany
| | - A Neubauer
- Department of Hematology, Oncology and Immunology, Philipps University Marburg, and University Medical Center Giessen and Marburg, Marburg, Germany
| | - J Finke
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - J Duyster
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
| | - N von Bubnoff
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Freiburg, Germany
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García-Martín P, Alarcón-Payer C, López-Fernández E, Moratalla L, Romero A, Sainz J, Ríos R, Jurado M. Transplantation-Associated Thrombotic Microangiopathy in Patients Treated With Sirolimus and Cyclosporine as Salvage Therapy for Graft-Versus-Host Disease. Ann Pharmacother 2015; 49:986-94. [DOI: 10.1177/1060028015593369] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Transplantation-associated thrombotic microangiopathy (TA-TMA) is a rare complication of hematopoietic stem cell transplantation. Because sirolimus (SIR) and calcineurin inhibitor—either cyclosporine (CsA) or tacrolimus—have become more common as graft-versus-host disease (GVHD) prophylaxis, we are witnessing a higher frequency of this complication. Objective: To analyze the incidence, timing, and management of TA-TMA in patients who received the combination of CsA and SIR as therapy for uncontrolled GVHD in one single center. Methods: This was a retrospective analysis from February 2002 to June 2014 of the combination of SIR and CsA as salvage therapy in 61 patients with treatment-refractory or relapsed acute GVHD (n = 24) or chronic GVHD (n = 37) in a tertiary hospital. Results: A total of 61 patients received CsA and SIR as salvage therapy for acute (n = 16), late acute (n = 8), overlap syndrome (n = 22), or classic chronic (n = 15) GVHD. We identified 13 patients with TA-TMA (21.3%), and the status of GVHD was active in 11 of 13 patients. Only 1 patient showed high CsA levels, and 6 of 13 patients had very high concentrations of SIR in blood. We used an enzyme inducer in 6 patients, which proved effective in 3. Overall survival for TA-TMA patients was inferior compared to that for non TA-TMA patients at 12 months (42.9% vs 51.9%) and 24 months (34.3% vs 49.1%), although this difference was not significant. Conclusion: Prompt identification and good management of TA-TMA, with better control of GVHD, may contribute to a decrease in patient mortality that would result from this complication.
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Affiliation(s)
- Paloma García-Martín
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Elisa López-Fernández
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Lucía Moratalla
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Antonio Romero
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Juan Sainz
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Rafael Ríos
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Manuel Jurado
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
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34
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State-of-the-art acute and chronic GVHD treatment. Int J Hematol 2015; 101:452-66. [DOI: 10.1007/s12185-015-1785-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 03/23/2015] [Indexed: 01/09/2023]
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35
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Garnett C, Apperley JF, Pavlů J. Treatment and management of graft-versus-host disease: improving response and survival. Ther Adv Hematol 2014; 4:366-78. [PMID: 24319572 DOI: 10.1177/2040620713489842] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Graft-versus-host disease (GVHD) is a significant cause of morbidity and mortality following allogenic haematopoietic stem-cell transplantation and thus the focus of much ongoing research. Despite considerable advances in our understanding of the pathophysiology, diagnosis and predisposing factors for both acute and chronic forms of the disease, a standardised therapeutic strategy is still lacking. There is good evidence for initial treatment of both acute and chronic forms of the disease with corticosteroid therapy. However, the most effective approach to steroid-refractory disease remains controversial, with current practice based mainly on smaller studies and varying considerably between local institutions. Timely diagnosis, multidisciplinary working and good supportive care, including infection prophylaxis, are clearly important in optimizing response and survival in such patients. It is hoped that in the future systematic research strategies and the identification of novel therapeutic targets may improve outcome further. The following review aims to outline some of the existing options for the treatment and management of acute and chronic GVHD.
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36
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Nakamura R, Forman SJ. Reduced intensity conditioning for allogeneic hematopoietic cell transplantation: considerations for evidence-based GVHD prophylaxis. Expert Rev Hematol 2014; 7:407-21. [DOI: 10.1586/17474086.2014.898561] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Alam N, Atenafu EG, Tse G, Viswabandya A, Gupta V, Kim D, Lipton JH, Messner HA, Kuruvilla J. Limited benefit of pentostatin salvage therapy for steroid-refractory grade III-IV acute graft-versus-host disease. Clin Transplant 2013; 27:930-7. [PMID: 24304375 DOI: 10.1111/ctr.12268] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 11/28/2022]
Abstract
Corticosteroid-refractory (SR) acute graft-versus-host disease (aGVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation. Multiple agents have been evaluated in this setting, but the benefit of pentostatin has not been described well. We report a single-center experience of pentostatin salvage therapy for SR aGVHD. Fifteen patients received pentostatin for SR aGVHD from March 2005 till March 2010 after failure to respond to methylprednisolone ≥ 2 mg/kg/d for at least seven d. All patients had grade III-IV aGVHD prior to pentostatin therapy. Thirteen (87%), 10 (67%), and six (40%) patients had gastrointestinal (GI), skin, and liver involvement of aGVHD, respectively. Pentostatin was given at a median of 33 d after steroid therapy initiation. The dose of pentostatin was 1.4 mg/m(2) daily for three d, repeated every two wk. Eight (53%) patients also received additional therapies. Complete responses were noted in two patients (both in skin). However, one patient relapsed and did not respond to additional salvage treatment. Partial responses were seen in three patients. Fourteen died of GVHD-related causes. This study suggested that pentostatin is of limited benefit in the treatment for SR grade III-IV aGVHD.
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Affiliation(s)
- Naheed Alam
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
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Affiliation(s)
- Inken Hilgendorf
- University Medicine of Rostock, Department of Hematology, Oncology and Palliative Care, Ernst-Heydemann-Strasse 6, Rostock, D-18055, Germany
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Lim JY, Park MJ, Im KI, Kim N, Jeon EJ, Kim EJ, Cho ML, Cho SG. Combination cell therapy using mesenchymal stem cells and regulatory T-cells provides a synergistic immunomodulatory effect associated with reciprocal regulation of TH1/TH2 and th17/treg cells in a murine acute graft-versus-host disease model. Cell Transplant 2013; 23:703-14. [PMID: 23452894 DOI: 10.3727/096368913x664577] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Mesenchymal stem cells (MSCs) have been considered to be an ideal cellular source for graft-versus-host disease (GVHD) treatment due to their unique properties, including tissue repair and major histocompatibility complex (MHC)-unmatched immunosuppression. However, preclinical and clinical data have suggested that the immunomodulatory activity of MSCs is not as effective as previously expected. This study was performed to investigate whether the immunomodulatory capacity of MSCs could be enhanced by combination infusion of regulatory T (Treg) cells to prevent acute GVHD (aGVHD) following MHC-mismatched bone marrow transplantation (BMT). For GVHD induction, lethally irradiated BALB/c (H-2(d)) mice were transplanted with bone marrow cells (BMCs) and spleen cells of C57BL/6 (H-2(b)) mice. Recipients were injected with cultured recipient-derived MSCs, Treg cells, or MSCs plus Treg cells (BMT + day 0, 4). Systemic infusion of MSCs plus Treg cells improved clinicopathological manifestations and survival in the aGVHD model. Culture of MSCs plus Treg cells increased the population of Foxp3(+) Treg cells and suppressed alloreactive T-cell proliferation in vitro. These therapeutic effects were associated with more rapid expansion of donor-type CD4(+)CD25(+)Foxp3(+) Treg cells and CD4(+)IL-4(+) type 2 T-helper (Th2) cells in the early posttransplant period. Furthermore, MSCs plus Treg cells regulated CD4(+)IL-17(+) Th17 cells, as well as CD4(+)IFN-γ(+) Th1 cells. These data suggest that the combination therapy with MSCs plus Treg cells may have cooperative effects in enhancing the immunomodulatory activity of MSCs and Treg cells in aGVHD. This may lead to development of new therapeutic approaches to clinical allogeneic hematopoietic cell transplantation.
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Affiliation(s)
- Jung-Yeon Lim
- Laboratory of Immune Regulation, Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Current practice in diagnosis and treatment of acute graft-versus-host disease: results from a survey among German-Austrian-Swiss hematopoietic stem cell transplant centers. Biol Blood Marrow Transplant 2013; 19:767-76. [PMID: 23376495 DOI: 10.1016/j.bbmt.2013.01.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/23/2013] [Indexed: 12/19/2022]
Abstract
To assess current clinical practice in diagnosis and treatment of acute graft-versus-host disease (aGVHD), we performed a survey among German, Austrian, and Swiss allogeneic hematopoietic stem cell transplantation (allo-HSCT) centers. Thirty-four of 72 contacted centers (47%) completed both the diagnostic and therapeutic sections of the survey, representing 65% of allo-HSCT activity within the participating countries in 2011. Three pediatric centers answered as requested only the diagnostic part of the survey. In the presence of diarrhea and decreased oral intake after engraftment, only 4 centers (12%) do not perform any endoscopy before the start of immunosuppressive treatment. In case of a skin rash with the differential diagnosis of drug reaction, only 12 centers (35%) perform a skin biopsy up front, whereas 19 do so after failure of systemic steroids. In the presence of rapidly increasing cholestasis occurring without any other signs of aGVHD, 11 centers (32%) perform a liver biopsy up front and 14 only after failure of steroid treatment, whereas 9 centers do not perform a liver biopsy at all. Twenty centers (59%) use a percutaneous approach, 12 a transvenous approach, and 1 mini-laparoscopy for liver biopsies. First-line treatment of cutaneous aGVHD stage 1 consists of topical treatment alone in 17 of 31 responding centers (61%), whereas isolated cutaneous aGVHD stage III is treated with systemic steroids (prednisolone below 0.5 mg/kg/day n = 2, 0.5 to 1.0 mg/kg/day n = 10, above 1.0 to 2.5 mg/kg/day n = 19) without or with topical agents (steroids n = 10; calcineurin inhibitors n = 3). In gastrointestinal manifestations of aGVHD, 9 centers (29%) add topical to systemic steroids, and 3 consider topical steroids as the only treatment for mild gastrointestinal and cutaneous aGVHD. The choice of agent for second-line treatment as well as the sequence of administration are extremely heterogeneous, most likely due to a lack of convincing data published. Most frequently used are mycophenolate mofetil (n = 14) and extracorporeal photopheresis (n = 10). Our survey also demonstrates that clinicians chose salvage therapies for steroid-refractory aGVHD based on their centers' own clinical experience.
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Goyal RK, Han K, Wall DA, Pulsipher MA, Bunin N, Grupp SA, Mada SR, Venkataramanan R. Sirolimus pharmacokinetics in early postmyeloablative pediatric blood and marrow transplantation. Biol Blood Marrow Transplant 2012; 19:569-75. [PMID: 23266742 DOI: 10.1016/j.bbmt.2012.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022]
Abstract
This study examined the pharmacokinetics of sirolimus in pediatric allogeneic blood and marrow transplantation (BMT) recipients in the presence and absence of concomitant fluconazole. Forty pediatric BMT recipients received a daily oral dose of sirolimus and a continuous i.v. infusion of tacrolimus for graft-versus-host disease prophylaxis. Fluconazole was administered i.v. to 19 patients and orally to 6 patients. Full pharmacokinetic profiles of sirolimus within a single dosing interval were collected. Whole-blood sirolimus concentrations were measured by HPLC/mass spectrometry. Noncompartmental analysis was performed using WinNonlin. Nonlinear mixed-effects pharmacokinetic models were developed using NONMEM following standard procedures. The mean ± SD sirolimus trough level before the dose (C0) was 8.0 ± 4.6 ng/mL (range, 1.8-21.6 ng/mL). The peak concentration was 19.9 ± 11.8 ng/mL (range, 3.9-46.1 ng/mL), and the trough level 24 hours later (C24) was 9.1 ± 5.3 ng/mL (range, 1.0-19.1 ng/mL). The terminal disposition half-life (T1/2) was 24.5 ± 11.2 hours (range, 5.8-53.2 hours), and the area under the concentration-versus-time curve (AUC0-24) was 401.1 ± 316.3 ng·h/mL (range, 20.7-1332.3 ng·h/mL). In patients at steady state, C0 and C24 were closely correlated (R(2) = 0.77) with a slope of 0.99, indicating the achievement of steady state. C24 was 1.7-fold greater (P = .036) and AUC0-24 was 2-fold greater (P = .012) in Caucasian patients (n = 22) compared with Hispanic patients (n = 9). The average apparent oral clearance was 3-fold greater (P = .001) and the apparent oral volume of distribution was 2-fold greater (P = .018) in patients age ≤12 years compared with those age >12 years. C24 was significantly lower in patients (n = 10) who developed grade III-IV aGVHD (n = 10) than in those with grade 0-II aGVHD (n = 22) (6.1 ± 2.9 ng/mL versus 9.4 ± 5.5 ng/mL; P = .044). Dose-normalized sirolimus trough concentrations were significantly higher in patients receiving concomitant fluconazole therapy compared with those not receiving fluconazole (C0: 3.9 ± 2.5 versus 2.4 ± 1.5 ng/mL/mg, P = .030; C24: 4.8 ± 3.3 versus 2.5 ± 1.7 ng/mL/mg, P = .018). This pharmacokinetic study of sirolimus in pediatric patients documents a large interindividual variability in the exposure of sirolimus. Steady-state trough blood concentrations were correlated with drug exposure. Trough concentrations were higher with a concomitant use of fluconazole and were higher in Caucasian patients than in Hispanic patients. Oral clearance was greater in children age ≤12 years than in older children and adolescents. With therapeutic drug monitoring, the majority (79%) of sirolimus trough levels could be maintained within the target range (3-12 ng/mL). This study provides a rationale and support for dose adjustments of sirolimus based on steady-state blood concentrations aimed at achieving a target concentration to minimize toxicity and maximize therapeutic benefits in pediatric BMT recipients.
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Affiliation(s)
- Rakesh K Goyal
- Division of Blood and Marrow Transplantation and Cellular Therapies, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
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Kubiak DW, Koo S, Hammond SP, Armand P, Baden LR, Antin JH, Marty FM. Safety of Posaconazole and Sirolimus Coadministration in Allogeneic Hematopoietic Stem Cell Transplants. Biol Blood Marrow Transplant 2012; 18:1462-5. [DOI: 10.1016/j.bbmt.2012.04.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 04/30/2012] [Indexed: 11/28/2022]
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Abouelnasr A, Roy J, Cohen S, Kiss T, Lachance S. Defining the role of sirolimus in the management of graft-versus-host disease: from prophylaxis to treatment. Biol Blood Marrow Transplant 2012; 19:12-21. [PMID: 22771839 DOI: 10.1016/j.bbmt.2012.06.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 06/28/2012] [Indexed: 11/16/2022]
Abstract
Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Measures developed that have significantly reduced GVHD were also frequently associated with an increased risk of relapse. GVHD and graft-versus-tumor (GVT) effects are tightly linked, and balance between both reactions is difficult to achieve. To have an impact on the outcome and quality of life after HSCT, improvements in current strategies to prevent and treat GVHD while preserving the GVT effect are clearly needed. Sirolimus (rapamycin) is a lipophilic macrocytic lactone with immunosuppressive, antitumor, and antiviral properties. Because of its multiple modes of activities, it is being increasingly used in the management of GVHD. This review aims to summarize its mechanisms of action and potential advantages over other immunosuppressors and to analyze the most relevant studies investigating its role in both prevention and treatment of GVHD.
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Affiliation(s)
- Ahmed Abouelnasr
- Division of Haematology-Oncology, Stem Cell Transplant Program Hôpital Maisonneuve-Rosemont, Université de Montréal, Québec, Canada
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Dignan FL, Clark A, Amrolia P, Cornish J, Jackson G, Mahendra P, Scarisbrick JJ, Taylor PC, Hadzic N, Shaw BE, Potter MN. Diagnosis and management of acute graft-versus-host disease. Br J Haematol 2012; 158:30-45. [DOI: 10.1111/j.1365-2141.2012.09129.x] [Citation(s) in RCA: 248] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
| | - Andrew Clark
- Bone Marrow Transplant Unit; Beatson Oncology Centre; Gartnavel Hospital; Glasgow; UK
| | - Persis Amrolia
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital; London; UK
| | - Jacqueline Cornish
- Department of Haematology; Bristol Royal Hospital for Children; Bristol; UK
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle; UK
| | - Prem Mahendra
- Department of Haematology; University Hospital Birmingham; Birmingham; UK
| | | | - Peter C. Taylor
- Department of Haematology; Rotherham General Hospital; Rotherham; UK
| | - Nedim Hadzic
- Paediatric Liver Service and Institute of Liver Studies; King's College Hospital; London; UK
| | | | - Michael N. Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London; UK
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Martin PJ, Inamoto Y, Flowers MED, Carpenter PA. Secondary treatment of acute graft-versus-host disease: a critical review. Biol Blood Marrow Transplant 2012; 18:982-8. [PMID: 22510383 DOI: 10.1016/j.bbmt.2012.04.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
Abstract
Management of steroid-resistant or steroid-refractory acute graft-versus-host disease (aGVHD) poses one of the most vexing and difficult problems faced by transplantation physicians. In the current study, we used 10 criteria to evaluate 67 reports describing secondary treatment of patients with aGVHD. The goal of this exercise was not only to provide a critical summary of the literature but also to offer suggestions that could improve future studies. Areas especially in need of improvement include the use of a consistent treatment regimen, the assessment of response at a consistent prespecified time point, consideration of concomitant treatment in assessing response, documentation that selection bias was minimized, and the use of methods that test a formal statistical hypothesis based on a contemporaneous or historical benchmark. Our results suggest that previous published reports collectively offer little guidance in discerning the most effective treatments for patients with steroid-resistant or steroid-refractory aGVHD. Adherence to the proposed criteria in future reports would enable meaningful comparisons across studies and thereby accelerate progress in evaluating new treatments for patients with aGVHD.
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Affiliation(s)
- Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA.
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Yoshimi A, Kurokawa M. Evi1 forms a bridge between the epigenetic machinery and signaling pathways. Oncotarget 2012; 2:575-86. [PMID: 21795762 PMCID: PMC3248179 DOI: 10.18632/oncotarget.304] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Recent studies have demonstrated the significance of the leukemia oncogene Evi1 as the regulator of hematopoietic stem cells and marker of poor clinical outcomes in myeloid malignancies. Evi1-mediated leukemogenic activities include a wide array of functions such as the induction of epigenetic modifications, transcriptional control, and regulation of signaling pathways. We have recently succeeded in comprehensively elucidating the oncogenic function of Evi1 in a model of the polycomb-Evi1-PTEN/AKT/mTOR axis. These results may provide us with novel therapeutic approaches to conquer the poor prognosis associated with Evi1-activated leukemia or other solid tumors with high Evi1 expression. Here, we review the current understanding of the role of Evi1 in controlling the development of leukemia and highlight potential modalities for targeting factors involved in Evi1-regulated signaling.
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Affiliation(s)
- Akihide Yoshimi
- Department of Hematology and Oncology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Martínez C, Urbano-Ispízua A. Graft-versus-host disease therapy: something else beyond glucocorticoids? Haematologica 2012; 96:1249-51. [PMID: 21880641 DOI: 10.3324/haematol.2011.050534] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Drobyski WR, Pasquini M, Kovatovic K, Palmer J, Douglas Rizzo J, Saad A, Saber W, Hari P. Tocilizumab for the treatment of steroid refractory graft-versus-host disease. Biol Blood Marrow Transplant 2011; 17:1862-8. [PMID: 21745454 PMCID: PMC3716013 DOI: 10.1016/j.bbmt.2011.07.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/05/2011] [Indexed: 11/24/2022]
Abstract
Corticosteroid refractory graft-versus-host disease (GVHD) is one of the major challenges in the management of allogeneic stem cell transplant recipients. Although numerous agents have been employed to treat this patient population, no standardized second-line therapy exists. In this study, we report our experience with the administration of tocilizumab, an anti-interleukin 6 receptor antibody, in the treatment of steroid refractory GVHD. Tocilizumab was administered to 8 patients with refractory acute (n = 6) or chronic GVHD (cGVHD) (n = 2) once every 3 to 4 weeks. The majority of patients with acute GVHD (aGVHD) had grade IV organ involvement of the skin or gastrointestinal tract, whereas both patients with cGVHD had long-standing severe skin sclerosis at the time of treatment. There were no allergic or infusion-related adverse events. Treatment was discontinued in one patient over concerns that tocilizumab may have worsened preexisting hyperbilirubinemia. Several patients also had transient elevations in serum transaminase values. Infections were the primary adverse events associated with tocilizumab administration. Four patients (67%) with aGVHD had either partial or complete responses apparent within the first 56 days of therapy. One patient with cGVHD had a significant response to therapy, whereas the second had stabilization of disease that allowed for a modest reduction in immune suppressive medications. These results indicate that tocilizumab has activity in the treatment of steroid refractory GVHD and warrants further investigation as a therapeutic option for this disorder.
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Affiliation(s)
- William R Drobyski
- Bone Marrow Transplant Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Abstract
Mammalian target of rapamycyin (mTOR) is a downstream serine/threonine kinase of the PI3K/AKT pathway that integrates signals from the microenvironment such as cytokines, growth factors, and nutriments to regulate multiple cellular processes, including mRNA translation, autophagy, metabolism, growth and survival. mTOR operates in two distinct multi-protein complexes: mTORC1 and mTORC2; sharing mTOR kinase as a common catalytic subunit, mTORC1 controls cell growth and mTORC2 modulates cell survival and drug resistance. mTOR signalling pathway has been found to be deregulated in many haematological malignancies, and has been designed as an attractive anti-tumor target. Thereby, mTOR inhibition with rapamycin (sirolimus) or its derivates (rapalogs) represents promising treatments, either alone or in combination with strategies to target other pathways that may overcome resistance. At present time, numerous clinical trials with mTOR inhibitors are ongoing for treatment of haematological diseases with modest or promising results. The aim of this review is to present the rationale for using mTOR inhibitors in haematology, first via biological explanations and secondly, by focusing on each haematological malignancies with new perspective of treatment.
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Sofroniadou S, Goldsmith D. Mammalian target of rapamycin (mTOR) inhibitors: potential uses and a review of haematological adverse effects. Drug Saf 2011; 34:97-115. [PMID: 21247219 DOI: 10.2165/11585040-000000000-00000] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors (mTORis) constitute a relatively new category of immunosuppressive and antineoplastic drugs. These share a unique mechanism of action that is focused on the inhibition of the mTOR. Their clinical applications have recently expanded significantly to cover a wide spectrum of immune and non-immune-mediated disorders, including, apart from solid organ transplantation, various solid organ and haematological malignancies, rheumatological and auto-immune diseases such as rheumatoid arthritis, systemic lupus erythematosus, fibrotic conditions, e.g. pulmonary and hepatic fibrosis, and even metabolic problems such as diabetes mellitus and obesity. The most challenging and frequent adverse effects of the mTORis are the haematological ones, especially anaemia, leukopenia and thrombocytopenia. A unique characteristic of mTORi-induced anaemia is concurrent marked microcytosis. Recently, mechanisms have been proposed to explain the microcytic appearance of this anaemia; these include globin production defect, erythropoietin resistance, chronic inflammation, dysregulation of cellular iron metabolism and hepcidin-mediated iron homeostasis interference. As the differential diagnosis of microcytic anaemia includes pure iron deficiency, functional iron deficiency and haemoglobinopathies, characterization of the anaemia requires significant investigation, time and costs. Therefore, understanding of the likely interaction between mTORis and patients is valuable in clinical practice. Moreover, this could expand the drugs' therapeutic applications to other disorders, and suggest novel targets for further research.
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Affiliation(s)
- Sofia Sofroniadou
- Department of Renal Medicine and Transplantation, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre (AHSC), London, UK
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