Decitabine for High-Risk Sickle Cell Disease
Condition: Neutropenia; Sickle Cell Disease
MeSH terms: Anemia, Sickle Cell; Neutropenia
Intervention: Decitabine
Intervention description: 0.2mg/kg (range, 0.05-0.3 mg/kg) 1-2X/wk for a period of 48 weeks. Dose and frequency will be determined by hematologic toxicity and the achievement of an HbF level of greater the or equal to 20 percent.
Intervention MeSH terms: Decitabine
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 10.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: Neutropenia; Hemaglobin; Coagulation Disorders; Thrombocytosis; Red Blood Cells; Sickle Cell Disease

Summary:

      Background:

        -  In sickle cell disease (SCD), the proteins in the red blood cells that carry oxygen do
           not behave normally. In parts of the body where there are low levels of oxygen or where
           oxygen is used more, the sickle hemoglobin proteins may change shape and stick together.
           This causes the red cells to clump, which reduces blood flow. This leads to even lower
           oxygen levels and causes damage and/or pain.

        -  One way to stop the red blood cells from sticking together is to increase the levels of
           fetal (baby or good ) hemoglobin. The good hemoglobin then takes the place of the sickle
           hemoglobin.

        -  Hydroxyurea is the only approved drug for SCD. But hydroxyurea works in only about
           two-thirds of people with SCD. Even in those cases it sometimes stops working over time.

        -  Researchers are interested in testing decitabine. The drug may help to increase fetal
           hemoglobin levels. But it has not yet been approved to treat SCD.

      Objectives:

      - To test the safety and effectiveness of decitabine in increasing fetal hemoglobin levels
      and improving the symptoms of sickle cell disease.

      Eligibility:

      - People at least 18 years of age who have sickle cell disease that has not improved after at
      least 6 months of hydroxyurea therapy. Those who cannot take hydroxyurea because of side
      effects may also participate.

      Design:

        -  Participants will be screened with a physical exam and medical history. They will also
           have blood and urine tests, a lung function test, and other tests as required.

        -  Participants will receive decitabine injections up to twice a week for 1 year. Depending
           on the response to treatments, the dose will remain the same or be reduced to once a
           week.

        -  Participants will be monitored with frequent blood tests and other studies as directed
           by the study doctors.

        -  After the study is completed, participants will go back to their usual sickle cell care.
           If decitabine has improved a participant's SCD, treatment may be continued under regular
           health coverage insurance if this can be arranged.
    

Eligibility criteria:

        -  INCLUSION CRITERIA:

        Subjects who meet all of the following criteria are eligible for enrollment into the study:

          1. Age 18 years or older.

          2. Written, informed consent provided by the subject before study entry.

          3. Confirmed SCD (SS, S-beta (0)-thalassemia, or SC on hemoglobin electrophoresis),

          4. Symptomatic SCD while on 6 months of HU OR symptomatic SCD and intolerant of HU
             (unable or unwilling to tolerate HU due to hematological or other toxicities).
             Symptomatic SCD is defined as having one of following:

               -  HbF <5 percent, OR

               -  3 or more pain episodes per year requiring parenteral narcotics, OR

               -  1 or more acute chest syndrome episodes, OR

               -  Hemoglobin <9 degree g/dL and ARC less than or equal to 250,000/mm(3),

          5. Subject is in his/her steady state and not amidst any acute complication due to SCD.

          6. Willing to use 2 forms of contraception. Some acceptable combinations include male
             partner using condoms and female partner using oral contraceptives, male partner using
             condoms and female partner who had bilateral oophorectomy, male partner who had a
             vasectomy and female partner using injectable contraceptives (e.g. Depo Provera).

        EXCLUSION CRITERIA:

        Since the protocol targets an at risk population, and the tolerability and potential
        benefits of this approach have been suggested in off-label treatment of seriously ill SCD
        patients, the exclusion criteria are not overly stringent and are primarily directed at
        avoiding teratogenic risks.

        Subjects who meet any of the following criteria are disqualified from enrollment in the
        study:

          1. Inability to give informed consent.

          2. Experienced severe sepsis or septic shock within the previous 12 weeks.

          3. Last HU or erythropoietin dose obtained within the previous 4 weeks. Renal replacement
             doses of erythropoietin is allowed as decitabine would not be expected to exert a red
             cell and/or HbF response when there is no endogenous erythropoietin production.

          4. Participant is on chronic transfusion therapy (e.g., for history of TIA or stroke) and
             medically contraindicated to discontinue transfusions.

          5. Currently pregnant or breast-feeding.

          6. Sexually active female of childbearing potential (all females except those who are
             menopausal [appropriate age and no period for more than 12 months] or have had a
             hysterectomy and/or bilateral oophorectomy) who is unwilling to use at least 2
             acceptable methods of contraception as determined by the investigators. The use of a
             condom by a male partner would be considered one acceptable method of contraception.

          7. Sexually active male whose partner is of child-bearing potential and who is unwilling
             to use at least 2 acceptable methods of contraception as determined by the
             investigators during treatment and for 8 weeks after the last dose of decitabine.

          8. Moribund or any concurrent disease (e.g., hepatic, renal, cardiac, metabolic) of such
             severity that death within 24 weeks is likely.

          9. Other experimental or investigational drug therapy in the past 28 days.

         10. Inability to bring ANC above 2 x 10(9) cells/L or platelet count less than 1,000 x
             10(9) cells/L.

        For female participants: Not having heterosexual sexual contact starting 4 weeks before
        beginning to take decitabine and continuing until 4 weeks after the last dose of decitabine
        OR using TWO methods of birth control. One birth control method must be highly effective,
        such as an Intrauterine Device (IUD), birth control pills, Depo-Provera
        (medroxyprogesterone acetate) injections, or tying of the fallopian tubes. The other
        additional effective method of birth control can be use of a diaphragm or a condom by the
        male partner. Birth control should begin at the screening visit and continue until 4 weeks
        after the last dose of decitabine. These steps must be taken even if the patient has a
        history of infertility, unless the patient has had a hysterectomy or has not had periods
        for at least 24 months.

        For male participants: during decitabine treatment and 8 weeks after last dose of drug, a
        condom must be used when engaging in any sexual contact with a woman of child-bearing age,
        even in patients who have had a successful vasectomy.