Clinical trial NCT02176031
Conditions: Graft Versus Host Disease
Keywords: Graft Versus Host Disease
Sponsor: Dana-Farber Cancer Institute
Start date: 2015-01-01; Completion date: 2019-02-01
Enrollment: 21 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This research study is a Phase II clinical trial, which tests the safety and effectiveness of an investigational drug Natalizumab in treating Acute Graft-Versus-Host Disease (GVHD) in the Gastrointestinal (GI) Tract.

Detailed description:
Natalizumab is a drug that was initially discovered as a treatment for autoimmune conditions. Natalizumab has been approved for use in patients with Multiple Sclerosis and Crohn's disease. In these diseases, the drug works to inhibit dysfunctional immune cells that are responsible for the symptoms seen in these diseases. Acute graft versus host disease is caused by a similar dysfunction of immune cells; Natalizumab is thought to inhibit these immune cells, similarly to how it does in Multiple Sclerosis and Crohn's disease. In this research study,the investigators are looking to see whether Natalizumab provides additional benefit to patients receiving standard treatment for acute graft versus host disease of the gastrointestinal tract.

Participants who fulfill eligibility criteria will be entered into the trial to receive Natalizumab.

* Participant will receive a dose of the natalizumab through intravenous infusion. Participants may receive a second dose at Day 28 if they experience a partial response or very good partial response.
* Scheduled Physical Examination at screening, during the week of first dose and at 28 days, 56 days, 100 days, 180 days and one year.

Arms: arm 1: Natalizumab-

* (Day 0 and 28) Fixed dose Intravenous infusion over one hour. 2 hours observation completion of the infusion
* At 4 weeks, if there has been less than a complete response participants can be treated with a second dose of natalizumab.
* If participants have no response after one dose, they will be not be given a second dose.
* Participants who receive a second dose of natalizumab will be evaluated for response at day 56 after first treatment dose administered.
* Participants will be assessed for response to therapy with natalizumab at day +28, day +56, day +100, day + 180, and day +365.
* Commercial supplies of Methylprednisolone (or equivalent steroid) will be utilized. The formulation, preparation and route of administration will be as per package insert
Interventions: intervention 1: Natalizumab intervention 2: Methylprednisolone
Intervention descriptions: intervention 1: None intervention 2: None

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Protocol and Statistical Analysis Plan 
 
Title: Phase II Trial of Natalizumab (Tysabri®) plus Steroids for Initial Therapy of Acute 
Graft Versus Host Disease (aGVHD) of the Gastrointestinal Tract 
NCT number: 02176031 
Date: 27-FEB-2017 
 


 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
Protocol Version Date: Version 1.2, February 27th, 2017 
 
NCI Protocol #: N/A 
Local Protocol #: 14-140 
 
 
Title: Phase II Trial of Natalizumab (Tysabri®) plus Steroids for Initial Therapy of Acute 
Graft Versus Host Disease (aGVHD) of the Gastrointestinal Tract 
 
Funding: DFCI Medical Oncology Grant 
 
Principal Investigator: 
Corey Cutler, MD, MPH 
 
 
 
 
 
 
 
 
 
 
Dana Farber Cancer Institute  
 
 
 
 
 
 
 
 
 
450 Brookline Ave 
 
 
 
 
 
 
 
 
 
 
Boston, MA 02215 
 
 
 
 
 
 
 
 
 
 
 
617-632-3470 (Phone) 
 
 
 
 
 
 
 
 
 
 
617-632-5822 (Fax)  
 
 
 
 
 
 
 
 
 
 
Email: cscutler@partners.org  
 
 
 
 
 
 
 
  
 
Coordinating Center:  
Dana Farber Cancer Institute 
450 Brookline Ave 
Boston, MA 02215 
617-632-2525 (Phone) 
617-632-5175 (Fax) 
 
Co-Investigators: 
Natasha Kekre, MD 
Dana Farber Cancer Institute 
 
Joseph Antin, MD 
Dana Farber Cancer Institute 
 
John Koreth, MBBS, DPhil  
Dana Farber Cancer Institute 
 
Robert Soiffer, MD 
Dana Farber Cancer Institute 
 
Vincent Ho, MD 
Dana Farber Cancer Institute 
 
Philippe Armand, MD, PhD 
Dana Farber Cancer Institute 
 
Edwin Alyea, MD 
Dana Farber Cancer Institute 
 
Sarah Nikiforow, MD 
Dana Farber Cancer Institute 
 
Brett Glotzbecker, MD 
Dana Farber Cancer Institute 
 
Yi-Bin Chen, MD 
Massachusetts General Hospital 
 
Statistician: Haesook Kim, PhD, DFCI  
 
Agent(s): Natalizumab  


Tysabri for acute GVHD 
 
 
Version 1.2, February 27th, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
TABLE OF CONTENTS 
1. 
OBJECTIVES .................................................................................................................................................... 4 
1.1 
Study Design .................................................................................................................................................... 4 
1.2 
Primary Objectives .......................................................................................................................................... 4 
1.3 
Secondary Objectives ...................................................................................................................................... 4 
2. 
BACKGROUND ................................................................................................................................................ 4 
2.1 
Study Agent ...................................................................................................................................................... 4 
2.2 
Study Disease – Acute GVHD ......................................................................................................................... 6 
2.3 
α4β7 integrin and Acute GVHD ...................................................................................................................... 8 
2.4 
Rationale for α4ß7 Integrin Inhibition in Gastrointestinal Acute GVHD ....................................................... 8 
2.5 
Rationale for proposed starting doses and regimen chosen ............................................................................ 9 
3. 
PARTICIPANT SELECTION ........................................................................................................................ 10 
3.1 
Eligibility Criteria ......................................................................................................................................... 10 
3.2 
Exclusion Criteria ......................................................................................................................................... 11 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations ................................................. 11 
4. 
REGISTRATION PROCEDURES ................................................................................................................ 11 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ......................................................................... 11 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ..................................................................... 12 
4.3 
General Guidelines for Other Participating Institutions ........................................................................ 12 
4.4 
Registration Process for Other Participating Institutions ........................................................................... 12 
5. 
TREATMENT PLAN ...................................................................................................................................... 13 
5.1 
Pre-treatment Criteria ................................................................................................................................. 13 
5.2 Agent Administration ................................................................................................................................... 13 
5.3 
Definition of Dose-Limiting Toxicity .......................................................................................................... 14 
5.4 
General Concomitant Medication and Supportive Care Guidelines ............................................................. 14 
5.5 
Duration of Therapy ....................................................................................................................................... 14 
5.6 
Duration of Follow Up .................................................................................................................................. 14 
5.7 
Criteria for Removal from Study ................................................................................................................... 14 
6. 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS .................................... 15 
6.1 
Anticipated Toxicities .................................................................................................................................... 15 
6.2 
Dose Modifications/Delays ........................................................................................................................... 16 
7. 
DRUG FORMULATION AND ADMINISTRATION ................................................................................. 16 
7.1 
Natalizumab .................................................................................................................................................. 16 
7.2 
Steroids ......................................................................................................................................................... 18 


Tysabri for acute GVHD 
 
 
Version 1.2, February 27th, 2017  
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
8. 
CORRELATIVE/SPECIAL STUDIES .......................................................................................................... 19 
9. 
STUDY CALENDAR ...................................................................................................................................... 19 
10. 
MEASUREMENT OF EFFECT..................................................................................................................... 20 
10.1 Response Criteria for Overall aGVHD ......................................................................................................... 20 
10.2 Response Criteria for GI GVHD ................................................................................................................... 21 
11. 
ADVERSE EVENT REPORTING REQUIREMENTS ............................................................................... 22 
11.1 Definitions ..................................................................................................................................................... 22 
11.2 Procedures for AE and SAE Recording and Reporting ................................................................................. 24 
11.3 Reporting Requirements ................................................................................................................................ 25 
11.4 Reporting to the Study Sponsor ..................................................................................................................... 25 
11.5 Reporting to the Institutional Review Board (IRB) ....................................................................................... 26 
11.6 Reporting to the Food and Drug Administration (FDA) ............................................................................... 26 
11.7 Reporting to the NIH Office of Biotechnology Activities (OBA) ................................................................... 27 
11.8 Reporting to the Institutional Biosafety Committee (IBC) ............................................................................ 27 
11.9 Monitoring of Adverse Events and Period of Observation ............................................................................ 27 
12. 
DATA AND SAFETY MONITORING .......................................................................................................... 27 
12.1 Data Reporting .............................................................................................................................................. 27 
12.2 Safety Meetings ............................................................................................................................................. 28 
12.3 Monitoring ..................................................................................................................................................... 28 
13. 
REGULATORY CONSIDERATIONS .......................................................................................................... 29 
13.1 Protocol Review and Amendments ................................................................................................................ 29 
13.2 Informed Consent .......................................................................................................................................... 29 
13.3 Ethics and Good Clinical Practice (GCP) .................................................................................................... 29 
13.4 Study Documentation .................................................................................................................................... 30 
13.5 Records Retention ......................................................................................................................................... 30 
13.6 Multi-center Guidelines ................................................................................................................................. 30 
13.7 Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement (CTA) .............. 30 
14. 
STATISTICAL CONSIDERATIONS ............................................................................................................ 31 
14.1 Study Design/Endpoints ................................................................................................................................ 31 
14.2 Sample Size/Accrual Rate .............................................................................................................................. 32 
14.3 Stratification Factors .................................................................................................................................... 32 
14.4 Analysis of Secondary Endpoints .................................................................................................................. 32 
14.5 Reporting and Exclusions .............................................................................................................................. 32 
15. 
PUBLICATION PLAN .................................................................................................................................... 33 


Tysabri for acute GVHD 
 
 
Version 1.2, February 27th, 2017  
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
16. 
REFERENCES ................................................................................................................................................. 33 
17. 
APPENDICES .................................................................................................................................................. 37 
17.1 Appendix A: Performance Status Criteria ..................................................................................................... 37 
17.2 Appendix B: Acute GVHD Scoring ................................................................................................................ 38 


Tysabri for acute GVHD 
 
 
 Version 1.2, February 27th, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
4 
1. OBJECTIVES 
 
1.1 Study Design 
 
This is a phase II study of natalizumab in combination with standard of care steroids for the 
treatment of acute graft versus host disease (aGVHD) of the gastrointestinal (GI) tract.  
 
1.2 Primary Objectives 
 
• GVHD-free survival rate at day 56 after the first dose of Natalizumab is administered.  
 
1.3 Secondary Objectives 
 
• Proportions of complete response (CR), very good partial response (VGPR), partial 
response (PR), mixed response (MR), no response (NR) and progression of aGVHD 
at day 28 and day 56 after the first dose of natalizumab is administered. 
 
• Proportions of complete response (CR), very good partial response (VGPR), partial 
response (PR), mixed response (MR), no response (NR) and progression of GI 
aGVHD at day 28 and day 56 after the first dose of natalizumab is administered. 
 
• Incidence of aGVHD flares requiring therapy after initial CR or PR by day 28 after 
the first dose of natalizumab is administered. 
 
• Steroid dose at day 28, day 56, day 100, day 180 and one year after the first dose of 
Natalizumab is administered.  
 
• Incidence of systemic infections at day 56 and day 180 after the first dose of 
Natalizumab is administered. 
 
• Overall and GVHD free survival at 100 days, 180 days and one year after the first 
dose of Natalizumab is administered. 
 
2. BACKGROUND 
 
 
2.1 Study Agent 
 
2.1.1 Natalizumab 
 
Natalizumab (Tysabri®, Biogen Inc.) is a recombinant humanized IgG4 monoclonal 
antibody.  The human region of this product functions as IgG4, considered to be the least 
immune activating of the IgG immunoglobulins as it does not have high affinity to most 
Fc gamma receptors and does not activate complement.  Natalizumab is engineered by 
incorporating murine complementarity-determining regions of the murine antibody that 
binds to the α4 chain of α4β7 integrin, onto human IgG4 (Rudick 2004).  Natalizumab is 


 
 
 
5
therefore a selective adhesion molecule inhibitor, acting directly against the α4 subunit of 
α4 integrins.  One integrin, α4β1, is found on activated lymphocytes and helps bind 
lymphocytes to ligands such as vascular cell adhesion molecule-1 (VCAM-1) in areas of 
inflammation.  Another integrin, α4β7, interacts with mucosal addressin-cell adhesion 
molecule and mediates homing of lymphocytes to the gastrointestinal (GI) tract.    
 
VCAM-1 is found in high concentrations in plaques found in multiple sclerosis (MS).  
Natalizumab as an inhibitor of the interaction between lymphocytes and VCAM-1 was 
quickly identified to be effective in MS.  There are 3 distinct mechanisms of action that 
are believed to occur in MS.  Firstly, natalizumab blocks the interaction between 
endothelial cells and extracellular matrix proteins.  Secondly, it blocks the interaction of 
monocytes and microglial cells to ligands of α4β1 integrin including osteopontin and 
VCAM-1.  Lastly, the blockade of the interaction of lymphocytes and extracellular matrix 
proteins is believed to induce apoptosis of these cells, further suppressing the immune 
activity at disease sites. (Rudick 2004)  
 
In the 1990s the idea that inhibition of α4β1 integrin could modulate inflammatory 
diseases was tested in animal models.  Anti-α4β1 integrin was found to prevent 
experimental autoimmune encephalomyelitis, an animal model that resembles MS 
(Yednock 1992).  Further animal models indicated that molecules directed against α4β1 
integrin decreased MRI lesions in experimental autoimmune encephalomyelitis (Kent 
1995 – 2 articles). 
 
In a phase I study of 28 patients with relapsing-remitting MS (RRMS) or secondary 
progressive MS, natalizumab was found to be safe and effective (Sheremata 1999).  A 
phase II trial was conducted comparing placebo, 3.0mg/kg and 6.0mg/kg of natalizumab 
in RRMS or secondary progressive MS (Miller 2003).  Marked reductions in both relapse 
rates and number of new or enlarging lesions were seen with both doses when compared 
to placebo at 6 months after treatment.  There was no significant difference in adverse 
events reported in the 3 treatment groups.   
 
Two pivotal phase III studies examining the impact of natalizumab on clinical outcomes 
in MS have led to the approval of this medication for the treatment of RRMS by the Food 
and Drug Administration.  In 2006, Rudick et al. reported the results of a large 
randomized study comparing interferon beta-1a with and without the addition of 
natalizumab (Rudick 2006).  Combination therapy proved to decrease the annual rate of 
relapse over a two-year period (0.34 vs. 0.75, P<0.001).  The second randomized trial 
was the AFFIRM study by Polman et al., which randomized patients to receive 
natalizumab versus placebo for RRMS (Polman 2006).  Again a significant reduction in 
rate of relapse at one year (by 83% with natalizumab) was observed as well as a 
significant decrease in the number of new or enlarging T2 hyperdense lesions on MRI.  
 
α4β7 is increased in disease sites of inflammatory bowel disease, providing another 
potential target for natalizumab.  Pilot studies have shown that a single dose of 
natalizumab could induce remission and significantly improve disease activity in Crohn’s 
disease and ulcerative colitis (Gordon 2001 and 2002).  Large randomized data from 


 
 
 
6
Europe have further shown a benefit to natalizumab at a dose of 3 mg/kg when compared 
to placebo (Ghosh 2003) in Crohn’s disease.  In this study, at 6 weeks, 71% of patients 
who received 2 infusions of 3mg/kg had response as compared to 38% who received 
placebo alone.  This significant benefit with natalizumab was sustained at 12 weeks after 
treatment.  Although the ENACT clinical trials demonstrated no significant early benefit 
to natalizumab in patients with Crohn’s disease, it did provide some benefit to 
maintaining response in patients treated with ongoing monthly infusions if they had an 
initial response (Sandborn 2005).   
 
2.1.2 Treatment-related Effects of Natalizumab 
 
Natalizumab is generally safe, causing only occasional hypersensitivity reactions. 
(Polman 2006)  The five level dose escalation study by Sheramata et al. showed very 
minimal adverse events, almost all of which were reported at the 3.0mg/kg dose.  Of the 
six patients receiving the 3.0mg/kg dose, one experienced headache, two experienced 
nausea and one had shakiness.  One patient receiving 1.0mg/kg reported urticaria.  Serum 
natalizumab concentrations rapidly decreased at doses of 0.1 mg/kg and 0.3mg/kg, but 
were detectable for one week when 0.3mg/kg was administered.  In contrast, patients 
receiving 1.0 and 3.0 mg/kg had detectable concentrations for 3 to 8 weeks.  Of note anti-
idiotypic antibodies were identified in 3 patients who received the 3.0mg/kg dose and 
persisted for 8 weeks after drug administration. 
 
The most concerning toxicity observed with natalizumab remains progressive multifocal 
leukoencephalopathy (PML), an opportunistic brain infection caused by JC virus.  After 
the incidence of 0.3% was reported by the SENTINEL trial (Rudick 2006), natalizumab 
was removed from the market voluntarily in 2005.  At that time, a large retrospective 
review of patients who had received natalizumab was embarked upon to determine the 
overall incidence of PML in a larger cohort of patients (Bloomgren 2012).  Two hundred 
and twelve cases of PML were identified amongst 99,571 patients treated with 
natalizumab (2.1 cases per 1000 patients).  The lowest dose of natalizumab that has been 
associated with PML is 8 doses, indicating that long-term administration is the major risk 
attributable to developing PML.  Other risk factors associated with the development of 
PML included positive anti-JC virus antibodies prior to treatment and the use of 
immunosuppressants prior to natalizumab administration. 
 
2.2 Study Disease – Acute GVHD 
 
Graft versus host disease (GVHD) is caused by allorecognition of host antigens by donor 
lymphocytes and is still a major cause of morbidity and mortality in patients receiving 
allogeneic stem cell transplantation (Ferrara 1991).  The condition occurs in 30 to 50% of 
patients receiving HLA matched transplants from a related donor and in 50 to 70% of those 
receiving transplants from an unrelated donor (Johnston 2008).  Classically, acute GVHD 
occurs during the first few months after transplant and usually involves the skin, liver, and 
intestinal tract, although other organs can also be involved (Deeg 2006).  The affected host 
organs are already compromised by intense conditioning regimens prior to transplant.  This 
injury which allows for the entry of microbial agents as well as the subsequent cytokine 


 
 
 
7
activation is thought to be the initial trigger for acute GVHD.  This consequently leads to the 
recruitment and activation of alloreactive naïve donor T cells in secondary lymphoid tissue 
(Goker 2001).  Target organ damage is subsequently mediated by the direct cytotoxic actions 
of activated donor effector T cells, which migrate to extralymphoid target sites, as well as the 
actions of local cytokines. 
 
Acute GVHD involving the gastrointestinal system usually manifests as anorexia, nausea, 
and voluminous diarrhea (>500ml/day) which can be hemorrhagic.  These symptoms are also 
seen in other post-transplant complications including toxicity from conditioning, medications 
and infections.  This can make the diagnosis of acute GVHD of the gut difficult for the 
clinician.  Although other organs can be affected by acute GVHD, the role of the 
gastrointestinal system is unique in that damage to this system appears to further propagate 
acute GVHD.  The loss of an intact gastrointestinal tract during transplant not only allows for 
local invasion of microbial agents, but also disrupts the normal gut flora.  This subsequently 
leads to the production of lipopolysaccharide, a potent stimulator of TNFα, IL-1 and IL-12 
(Hill 2000).  This therefore allows for the further activation of cytokines which leads to 
progression of acute GVHD.     
 
The mainstay of acute GVHD treatment remains corticosteroid therapy.  The starting dose is 
usually 1-2mg/kg daily of prednisone or the equivalent and is continued for 1-2 weeks prior 
to a steroid taper.  The response rate to single-agent steroid therapy when analyzed in large 
retrospective reviews is approximately 50% (MacMillan 2002, Martin 1990).  Unfortunately, 
even with an initial response to steroids, the durability of this response remains low at 24% 
and 40% for matched unrelated and related donor transplantation, respectively (Roy 1992, 
Weisdorf 1990).   
 
The suboptimal results observed historically with steroids alone as treatment of acute GVHD 
warrants the study of other compounds which may provide more benefit than steroids alone.  
Monoclonal antibody therapies directed against CD3, IL-2 and TNF-α have been used in 
conjunction with steroids to try to improve the response rates and length of response (Goker 
2001, Arai 2000, Bruner 2003, Tanaka 2000, Couriel 2009).  The main drawback to these 
treatments remains the same, the broad immunosuppression leads to both secondary 
infectious complications as well as disease progression.  The Blood and Marrow Transplant 
Clinical Trials Network completed a multi-center randomized, four-arm, phase II trial 
designed to identify the most promising agent for combination with steroids as initial therapy 
for the treatment of GVHD (Alousi 2009).  Day 28 complete response rates were 26% with 
etanercept, 60% with mycophenolate mofetil (MMF), 53% with denileukin diftitox, and 38% 
with pentostatin.  Overall survival at 9 months was also highest with MMF (64%).  
Unfortunately in phase III study of MMF versus placebo for the treatment of acute GVHD, 
there was no difference in GVHD free survival at 8 weeks, incidence of infection or overall 
survival at 6 months.  (Logan 2013)   
 
Multiple prospective and retrospective studies have been done adding agents like those 
described above to treat acute GVHD.  As reported by the consensus guidelines of the 
American Society of Bone Marrow Transplantation, none of these results have been robust 
enough to show that combination first line therapy is better than steroids alone (Martin 


 
 
 
8
2012).  For this reason, further investigation into new agents is needed to improve the 
response rates of acute GVHD to first line treatment.  Targeting α4β7 integrin for acute 
GVHD is a novel approach which may be effective and yield less overall immune 
suppression. 
 
 
2.3 α4β7 integrin and Acute GVHD 
 
GVHD is mediated by the activation of donor lymphocytes against host antigens.  This is 
mediated by interactions between donor T cells and antigen presenting cells (APCs).   
Multiple adhesion molecules, including intercellular molecule 1 (ICAM-1), lymphocyte 
function–associated antigen 1 (LFA-1) and vascular cell adhesion molecule 1 (VCAM-1), 
have been identified in the activation of T cells by APCs (Kobayashi 2000).  Once donor T 
lymphocytes interact with APCs, they differentiate into effector and memory T cells that 
target various organs implicated in acute GVHD.  It is now recognized that the development 
of these cytotoxic T lymphocytes occurs in secondary lymphoid tissue, most notably in gut-
associated secondary lymphoid tissue (GALT) which includes the Peyer’s patches of the 
small intestine (Murai 2003), mesenteric lymph nodes and the appendix.  This further 
explains why the gastrointestinal tract acts not only as a target site but a vital amplifier of 
GVHD.   
 
Once activated in GALT, T cells recirculate in the bloodstream and home to specific organs 
based on specific adhesion molecules expressed on the T cell.  Molecules expressed on T 
cells that lead to lymphocyte trafficking back to the gastrointestinal tract include L-selectin 
(Dutt 2005), MAdCAM-1 (Ueha 2007) and LPAM (α4ß7 integrin) (Petrovic 2004).  T cells 
that home to the intestine have been shown in mouse models to induce crypt loss, loss of 
mucin-containing goblet cells within the crypts, increased apoptosis of epithelial cells at the 
crypt bases, and a severe infiltrate of inflammatory cells between the crypt walls and in the 
lamina propria. (Dutt 2005)  This results in loss of the normal architecture of the intestine, 
which leads to severe symptoms of gastrointestinal GVHD, including prolonged diarrhea and 
gut dysfunction.  These adhesion molecules represent a new target for both treatment and 
monitoring of acute GVHD.   
 
We have previously analyzed by flow cytometry the expression of α4ß7 integrin on 
lymphocytes from 59 hematopoietic stem cell transplant recipients and found α4β7 integrin 
to be significantly up-regulated on both naïve and memory T cell subsets in patients who 
subsequently developed intestinal aGVHD compared with those who developed primarily 
cutaneous aGVHD or did not develop aGVHD (Chen 2009 and 2013).  These preliminary 
studies demonstrate that α4ß7 integrin can act as a potential target to decrease GVHD of the 
gastrointestinal tract while maintaining the beneficial graft versus tumour effect. 
 
 
2.4 
Rationale for α4ß7 Integrin Inhibition in Gastrointestinal Acute GVHD 
 
Based on the preliminary data provided above that demonstrates the expression of α4β7 
integrin to be associated with gastrointestinal GVHD, it is reasonable to test natalizumab for 


 
 
 
9
the treatment of patients with gastrointestinal GVHD.  As indicated above, once T cells have 
migrated to the gut, they can cause severe damage to the crypt architecture, which can be 
difficult to regenerate once damage has occurred.  For this reason, most treatments have been 
unsuccessful at treating gut GVHD as the initiation of treatment is often after this damage 
has occurred.  In this study, the initiation of natalizumab at the onset of symptoms, in 
addition to steroids, will provide the best chance of preventing crypt necrosis by shutting 
down the homing of T cells to the gut as early as possible.  
 
It is hoped that given its specific targeting of α4β7 integrin, natalizumab can be successful in 
treating acute GVHD, yet be less globally immunosuppressive, the main concern with current 
available treatments of acute GVHD.  Retinoic acid, known to increase the expression of 
α4β7 integrin, has been shown to increase the homing of T cells to the gut, worsening acute 
GVHD of the gut. In this mouse model, retinoic acid did not demonstrate an upregulation of 
T cells to the spleen, liver, and lung.  This suggests that inhibiting the α4β7 integrin by 
natalizumab provides a specific targeted treatment of gut GVHD, without impacting other 
organ systems. (Chen 2013) 
 
Treatments for acute GVHD are not only immunoscuppressive, but also impair the graft 
versus tumor effect that is desired from donor T cells targeting malignant cells in the 
recipient.  Ceacam1, an adhesion molecule found on donor T cells, is thought to control the 
proliferation, activation and trafficking of T lymphocytes in the pathogenesis of GVHD, 
partially mediated through α4β7 integrin.  Absence of Ceacam1 leads to increased rates of 
gut GVHD while maintaining the desired graft versus tumor effect. (Lu 2011)  The absence 
of α4β7 integrin on hematologic malignancies provides natalizumab with the unique ability 
to abrogate gut GVHD without effecting the graft versus tumor effect.   
 
There have been studies as outlined above that have examined the maximal tolerated and 
efficacious doses of natalizumab in treating patients with autoimmune diseases including MS 
and Crohn’s disease.  In this phase II study, we plan to use much lower doses of natalizumab 
to determine if there is a possible treatment effect on acute gastrointestinal GVHD. 
 
2.5 
Rationale for proposed starting doses and regimen chosen 
The planned treatment for patients presenting with acute GVHD with GI involvement will be 
steroids with natalizumab.  In a phase I study of natalizumab, doses of 0.03 and 0.1mg/kg 
resulted in drug levels that were undetectable after completion of the infusion. (Sheramata 
1999)  The estimated half life of the 3.0mg/kg dose in this study was 4-5 days.  Approximately 
90% of patients will achieve over 80% saturation of α4 receptors after receiving a dose of 
3.0mg/kg or higher.  Receptor saturation is maintained for 3-4 weeks with the 3.0mg/kg 
dose.(Rudick 2004)   Standard monthly dosing of 300mg IV has been successfully used in 
patients with MS and Crohn’s disease.   
The treatment of acute GVHD, unlike MS or Crohn’s disease, is an acute process that should 
require short courses of treatment to demonstrate a response.  An initial standard dose of 
300mg IV will be used at confirmation of acute gut GVHD.  If at 4 weeks, there has been a 
response, but it is less than a complete response, patients can be treated with a second dose of 


 
 
 
10
300mg IV of natalizumab if he/she did not have a positive JC viral load or any toxicity to the 
first dose of natalizumab.  If patients have no response or progression after one dose, they will 
not be given a second dose.  Patients who receive a second dose of natalizumab will be 
evaluated for GVHD-free survival and response at day 56 after first treatment dose was 
administered.  
 
3. PARTICIPANT SELECTION 
 
3.1 
Eligibility Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study: 
 
3.1.1 Participants must have acute GVHD of the lower gastrointestinal tract as defined by 
the clinical impression of the treating physician, requiring systemic treatment.  
Minimum criteria for GI GVHD includes diarrhea of greater than 500 mL/day.  
Biopsy of the GI tract is required for study entry and must confirm the diagnosis of 
acute GVHD.  Stool samples to rule out infectious causes of diarrhea, including 
norovirus, Clostridium difficile and other clinically indicated infections must also 
be negative.  Eligibility includes: 
 
3.1.1.1 Acute GVHD developing after allogeneic hematopoietic stem cell 
transplantation (HSCT) using bone marrow, peripheral blood stem cells, 
or umbilical cord blood.  Recipients of non-myeloablative, reduced 
intensity and myeloablative transplants are eligible. 
3.1.1.2 Patients who develop acute GVHD after donor lymphocyte infusion (DLI) 
are eligible. 
3.1.1.3 There is no specified time window after day 0 of transplant as acute 
GVHD is only defined by clinical manifestations. 
3.1.1.4 Patients must have experienced neutrophil engraftment after HSCT as 
defined by absolute neutrophil counts ≥ 500 / µL × 3 consecutive 
measurements.  Absolute neutrophil count (ANC) should be calculated 
using the standard formula (Neut + Bands)(WBC × 101). 
3.1.1.5 Platelets ≥ 10,000 / μL (platelet transfusions are allowed on the same day) 
3.1.1.6 The presence of hepatic, upper GI and/or cutaneous acute GVHD is 
permitted. 
3.1.1.7 Steroids can be started up to 7 days prior to the administration of 
natalizumab. 
 


 
 
 
11
3.1.2 Age ≥ 18 
 
3.1.3 Ability to understand and the willingness to sign a written informed consent 
document. 
 
3.2 
Exclusion Criteria 
 
Participants who exhibit any of the following conditions at screening will not be 
eligible for admission into the study: 
 
3.2.1 Patients with the entity of Acute/Chronic GVHD overlap syndromes.   
 
3.2.2 Requiring mechanical ventilation 
 
3.2.3 Vasopressor requirement 
 
3.2.4 Concurrent hepatic veno-occlusive disease (VOD) based on clinical examination 
 
3.2.5 Karnofsky performance status < 30  
 
3.2.6 Participants may not be receiving any other study agents for at least 7 days prior to 
enrollment 
 
3.2.7 Prior use of natalizumab for any reason is not allowed 
 
3.2.8 Pregnant women are excluded from this study because of the potential teratogenic 
effects of natalizumab.  Because natalizumab enters breast milk, and the effect is 
unknown in infants, breastfeeding should be discontinued if the mother is treated 
with natalizumab.  
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations 
 
There is no evidence to suggest that the outcome will differ by gender or ethnicity.  
Given the small size of our study there is insufficient power to detect small effects in 
these groups.  There is no plan to exclude women, minorities, or underrepresented 
populations and they will be able to participate if eligibility criteria are met. 
 
4. REGISTRATION PROCEDURES 
   
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants with the DF/HCC Quality Assurance 
Office for Clinical Trials (QACT) central registration system. Registration must 
occur prior to the initiation of therapy. Any participant not registered to the protocol 
before treatment begins will be considered ineligible and registration will be denied.  
 


 
 
 
12
A member of the study team will confirm eligibility criteria and complete the 
protocol-specific eligibility checklist. 
  
Following registration, participants may begin protocol treatment. Issues that 
would cause treatment delays should be discussed with the Principal Investigator. If 
a participant does not receive protocol therapy following registration, the participant’s 
protocol status must be changed. Notify the QACT Registrar of participant status 
changes as soon as possible. 
 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions 
 
The QACT registration staff is accessible on Monday through Friday, from 8:00 AM to 
5:00 PM Eastern Standard Time. In emergency situations when a participant must begin 
treatment during off-hours or holidays, call the QACT registration line at 617-632-3761 
and follow the instructions for registering participants after hours. 
   
The registration procedures are as follows: 
 
1. 
Obtain written informed consent from the participant prior to the performance 
of any study related procedures or assessments. 
 
2. 
Complete the protocol-specific eligibility checklist using the eligibility 
assessment documented in the participant’s medical/research record. To be 
eligible for registration to the study, the participant must meet each 
inclusion and exclusion criteria listed on the eligibility checklist. 
  
Reminder: Confirm eligibility for ancillary studies at the same time as 
eligibility for the treatment study. Registration to both treatment and ancillary 
studies will not be completed if eligibility requirements are not met for all 
studies. 
  
3. 
Fax the eligibility checklist(s) and all pages of the consent form(s) to the 
QACT at 617-632-2295. 
  
4. 
The QACT Registrar will (a) validate eligibility, (b) register the participant on 
the study, and (c) randomize the participant when applicable. 
  
5. 
The QACT Registrar will send an email confirmation of the registration 
and/or randomization to the person initiating the registration immediately 
following the registration and/or randomization. 
  
4.3 General Guidelines for Other Participating Institutions 
N/A 
 
4.4 
Registration Process for Other Participating Institutions 
N/A  
 


 
 
 
13
 
 
5. TREATMENT PLAN  
 
 
Treatment will be administered on an inpatient and outpatient basis depending on the 
participant’s clinical condition. Expected toxicities and potential risks as well as dose 
modifications for natalizumab are described in Section 6 (Expected Toxicities and Dosing 
Delays/Dose Modification). No investigational or commercial agents or therapies other than 
those described below may be administered with the intent to treat the participant’s acute graft 
versus host disease (GVHD). 
 
5.1 
Pre-treatment Criteria 
 
5.1.1 For all cycles of natalizumab:  
• ANC ≥ 500 / µL (G-CSF support is allowed) 
• Platelets ≥ 10,000 / µL (platelet transfusions are allowed on the same day) 
 
5.2 Agent Administration  
 
5.2.1 Natalizumab 
 
• Administration - Natalizumab at a dose of 300 mg should be infused in 100 mL 
0.9% Sodium Chloride Injection, USP over approximately one hour.  After the 
infusion is complete, flush with 0.9% Sodium Chloride Injection, USP. 
• Dosing and Dosing schedule – Patients enrolled in the trial will receive 300mg of 
natalizumab as described above in administration of the drug.  For patients who 
have a less than complete response after the first dose of natalizumab, a second 
dose of 300mg will be administered in the same fashion as the first dose.  If 
however a patient has a complete response, no response, or progression of 
aGVHD, experiences a serious hypersensitivity reaction, or has a grade 3 or 
higher toxicity related to natalizumab, then a second dose of natalizumab will not 
be administered at 28 days after the first dose is given. 
• Drug, Tubing and Filtration – No special IV tubing or filtration is required. 
 
• Hydrations – No hydration is required. 
 
• Special Equipment – Standard IV infusion pump is required. 
 
• Observation – Participants will be observed for 2 hours following completion of 
the infusion of natalizumab for the first infusion.  Patients will be monitored for 
development of hypersensitivity symptoms, including urticaria, dizziness, fever, 
rash, rigors, pruritus, nausea, flushing, hypotension, dyspnea, and chest pain.  If 


 
 
 
14
there are no reactions to the first infusion, observation for one hour is required for 
the second infusion. 
 
• Vital signs – Vital signs (temperature, heart rate, blood pressure, and respiratory 
rate) should be monitored approximately every 10 minutes during the infusion of 
natalizumab. 
 
• Infusion reactions – participants will be monitored closely for possible infusion-
related reactions from the administration of natalizumab.  Symptoms include 
lightheadedness, fever, rash, sweats, sensation of throat closing, shortness of 
breath, throat/lip swelling, headache, and pruritis.  If an infusion-related reaction 
is suspected, the infusion should be immediately stopped and treatment with 
supportive measures such as intravenous fluids, corticosteroids, and 
diphenhydramine should be given at the discretion of the investigator.    Patients 
who experience a serious hypersensitivity reaction should not be re-treated with 
natalizumab. 
 
5.3 
Definition of Dose-Limiting Toxicity 
N/A 
 
5.4 
General Concomitant Medication and Supportive Care Guidelines 
 
There are no recommended anti-emetics or other pre-medications or IV hydration 
recommended with administration of natalizumab.  Routine use of growth factor (G-
CSF) support in the absence of documented neutropenia is not recommended.  
Transfusional support will be given per institutional practice.  Anti-infective 
prophylaxis directed towards: CMV, gram positive (encapsulated bacteria), 
pneumocystis jirovicii, and fungal infections will be given per standard institutional 
practice.   
 
5.5 
Duration of Therapy 
 
Duration of therapy will depend on individual response, evidence of disease 
progression and tolerance. Patients will receive a maximum of two doses of 
natalizumab (see section 5.2.1 on dosing and dosing schedule for eligibility 
requirements for a second dose of natalizumab).   
 
5.6 
Duration of Follow Up  
 
Participants will be followed for 12 months after completion of scheduled treatment 
even after removal from study or until death, whichever occurs first. Participants 
removed from study for unacceptable adverse events will be followed until resolution 
or stabilization of the adverse event. 
 
5.7 
Criteria for Removal from Study  
 


 
 
 
15
Participants will be removed from study when the participant completes the follow 
up phase, or if lost to follow-up, death or participant withdrawal occurs (whichever 
comes first).  The reason for study removal and the date the participant was 
removed must be documented in the study specific case report form (CRF).   
 
In the event of unusual or life-threatening complications, participating investigators 
must immediately notify the Principal Investigator (Dr. Corey Cutler telephone # 
617-632-3470). 
 
6. EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS  
 
Dose delays and modifications will be made using the following recommendations. Toxicity 
assessments will be done using the CTEP Active Version of the NCI Common Terminology 
Criteria for Adverse Events (CTCAE) which is identified and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
In the case of toxicity, appropriate medical treatment should be used (including anti-emetics, 
anti-diarrheals, etc.). 
 
All adverse events experienced by participants will be collected from the time of the first dose 
of study treatment, through the study and until the final study visit. Participants continuing to 
experience toxicity at the off study visit may be contacted for additional assessments until the 
toxicity has resolved or is deemed irreversible. 
  
6.1 
Anticipated Toxicities 
  
A list of the adverse events and potential risks associated with the agents administered in 
this study appear below and will determine whether dose delays and modifications will 
be made or whether the event requires expedited reporting in addition to routine 
reporting. 
  
6.1.1 Adverse Event Lists for Natalizumab 
Hypersensitivity Reactions 
Hypersensitivity reactions are not expected to occur in this setting, but they have been 
observed in patients receiving natalizumab, including serious systemic reactions (ex. 
anaphylaxis) which occurred at an incidence of <1%.  These reactions usually occur 
within two hours of the start of the infusion. Symptoms associated with these reactions 
can include urticaria, dizziness, fever, rash, rigors, pruritus, nausea, flushing, 
hypotension, dyspnea, and chest pain. Generally, these reactions are associated with 
antibodies to natalizumab.  If a hypersensitivity reaction occurs, discontinue 
administration of natalizumab and initiate appropriate therapy. Patients who experience 
a serious hypersensitivity reaction should not be re-treated with natalizumab.  
 
Immunosuppression / Infection 


 
 
 
16
The immune system effects of natalizumab may increase the risk for infections. In studies 
of natalizumab for the treatment of MS, certain types of infections, including pneumonias 
and urinary tract infections (including serious cases), gastroenteritis, vaginal infections, 
tooth infections, tonsillitis, and herpes infections, occurred more often in natalizumab 
treated patients than in placebo-treated patients.  One opportunistic infection, 
cryptosporidial gastroenteritis with a prolonged course, was observed in a patient who 
received natalizumab. In Crohn’s disease studies, opportunistic infections (pneumocystis 
carinii pneumonia, pulmonary mycobacterium avium intracellulare, bronchopulmonary 
aspergillosis, and burkholderia cepacia) have been observed in <1% of natalizumab 
treated patients; some of these patients were receiving concurrent immunosuppressants.  
Patients being treated in study will receive infection prophylaxis as per standard 
institutional guidelines.   
 
Hepatotoxicity 
Clinically significant liver injury has been reported in patients treated with natalizumab in 
the postmarketing setting. Signs of liver injury, including markedly elevated serum 
hepatic enzymes and elevated total bilirubin, occurred as early as six days after the first 
dose; signs of liver injury have also been reported for the first time after multiple doses. 
In some patients, liver injury recurred upon rechallenge, providing evidence that 
natalizumab caused the injury. If significant liver injury is observed after the first dose of 
natalizumab, a second dose will not be administered. 
 
Progressive Multifocal Leukoencephalopathy (PML) 
As previously outlined, the most concerning toxicity observed with natalizumab remains 
PML, an opportunistic brain infection caused by JC virus.  In a large retrospective 
analysis, 212 cases of PML were identified amongst 99,571 patients treated with 
natalizumab (2.1 cases per 1000 patients) (Bloomgren 2012).  The lowest dose of 
natalizumab that has been associated with PML is 8 doses, indicating that long-term 
administration is the major risk attributable to developing PML.  Although PML is not 
expected to occur in this study, if a case is reported, the study will be immediately halted. 
 
6.2 
Dose Modifications/Delays 
  
As most patients in this study will receive a single dose of natalizumab, dose reduction or 
delay are not applicable.  If a patient experiences any grade 3 or higher toxicity to the first 
dose of natalizumab or has a positive JC viral load, he/she will not be considered eligible 
for a second dose.   
7. DRUG FORMULATION AND ADMINISTRATION  
 
7.1 
Natalizumab 
 
7.1.1 Description 
 
Natalizumab is a recombinant humanized IgG4k monoclonal antibody produced in 
murine myeloma cells.  Natalizumab contains human framework regions and the 


 
 
 
17
complementarity-determining regions of a murine antibody that binds to a4-
integrin.  The molecular weight of natalizumab is 149 kilodaltons.   
 
In patients with MS, following the repeat intravenous administration of a 300 mg 
dose of natalizumab, the mean ± SD maximum observed serum concentration 
was 110 ± 52 mcg/mL.  Mean average steady-state trough concentrations ranged 
from 23 mcg/mL to 29 mcg/mL. The observed time to steady-state was 
approximately 24 weeks after every four weeks of dosing. The mean ± SD half-
life, volume of distribution, and clearance of natalizumab were 11 ± 4 days,  
5.7 ± 1.9 L, and 16 ± 5 mL/hour, respectively. 
  
The effects of total body weight, age, gender, race, selected hematology and 
serum chemistry measures, co-administered medications (infliximab, 
immunosuppressants, or steroids), and the presence of anti-natalizumab 
antibodies were investigated in a population pharmacokinetic analysis (n=1156). 
The presence of anti-natalizumab antibodies was observed to increase 
natalizumab clearance.  Pharmacokinetics of natalizumab in patients with renal 
or hepatic insufficiency have not been studied. 
 
7.1.2 Form 
 
Natalizumab is supplied as a sterile, colorless, and clear to slightly opalescent 
concentrate for intravenous (IV) infusion.  Each 15 mL dose contains 300 mg 
natalizumab; 123 mg sodium chloride, USP; 17.0 mg sodium phosphate, 
monobasic, monohydrate, USP; 7.24 mg sodium phosphate, dibasic, heptahydrate, 
USP; 3.0 mg polysorbate 80, USP/NF, in water for injection, USP at pH 6.1. 
 
7.1.3 Storage and Stability 
 
Natalizumab single-use vials must be refrigerated between 2-8°C (36°-46°F) or 
stored according to instructions in the Package Inset.  Do not use beyond the 
expiration date stamped on the carton and vial label.  DO NOT SHAKE OR 
FREEZE.  Protect from light.  If not used immediately, store the Natalizumab 
solution for infusion at 2-8°C (36°-46°F).  Natalizumab solution for infusion must 
be administered within 8 hours of preparation. 
  
7.1.4 Compatibility 
 
Other medications should not be injected into infusion set side ports or mixed 
with natalizumab.  Natalizumab concentrate is supplied as 300 mg natalizumab in 
a sterile, single-use vial free of preservatives.  Each package contains a single-use 
vial. 
7.1.5 Handling 
 


 
 
 
18
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and 
safe disposal of the study agent in a self-contained and protective environment. 
 
Use of filtration devices during administration has not been evaluated.  Other 
medications should not be injected into infusion set side ports or mixed with 
natalizumab.   
 
7.1.6 Availability 
 
Natalizumab will be commercially supplied free-of-charge from Biogen.   
 
7.1.7 Preparation 
 
Natalizumab concentrate is supplied as 300 mg natalizumab in a sterile, single-use 
vial free of preservatives.  Each package contains a single-use vial. 
 
7.1.8 Administration 
 
Natalizumab at a dose of 300 mg should be infused in 100 mL 0.9% Sodium 
Chloride Injection, USP over approximately one hour.  After the infusion is 
complete, flush with 0.9% Sodium Chloride Injection, USP. 
 
7.1.9 Ordering 
 
Natalizumab will be supplied by Biogen Idec Inc. and should be obtained by the 
site research pharmacy using the study-specific drug order form.  Natalizumab 
will be supplied free of charge and will be ordered from Biogen Idec Inc. 
 
7.1.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, must 
maintain a careful record of the inventory and disposition of the agent 
(investigational or free of charge) using the NCI Drug Accountability Record or 
another comparable drug accountability form. (See the CTEP website at 
http://ctep.cancer.gov/protocolDevelopment  for the “Policy and Guidelines for  
Accountability and Storage of Investigational Agents” or to obtain a copy of the 
drug accountability form.) 
 
7.1.11 Destruction and Return 
 
At the end of the study, unused supplies of natalizumab should be destroyed 
according to institutional policies. Destruction will be documented in the Drug 
Accountability Record Form. 
 
7.2 
Steroids 


 
 
 
19
 
Commercial supplies of Methylprednisolone (or equivalent steroid) will be utilized. The 
formulation, preparation and route of administration will be as per package insert. 
 
7.2.1 Administration 
 
The suggested initial choice and dosing of steroid is methylprednisolone at 2 
mg/kg daily.  If methylprednisolone is not used, any steroid, in oral or parenteral 
formulation, can be administered in equivalent dosing to methylprednisolone.  For 
oral doses of steroids, the dose can be rounded to the nearest available tablet 
strength. Dosing and dose reductions when response is achieved will be at the 
discretion of the investigator.  A suggested taper is 10-25% every 1-2 weeks. 
 
8. CORRELATIVE/SPECIAL STUDIES  
Patients who are treated on this trial will have baseline and serial post-treatment peripheral 
blood samples collected and banked.  Peripheral blood samples will be collected on the day 
of natalizumab infusion, but prior to starting the infusion (day of infusion will be day 0).  
Further peripheral blood samples will be collected at day 7, day 14, day 21, day 28, day 56, 
day 100, day 180 and one year after administration of natalizumab.  The day 0 peripheral 
blood sample should be collected within 24 hours prior to the start of the Natalizumab 
infusion.  The correlative data that will be analyzed in these samples will be α4 receptor 
saturation and pharmacokinetic studies at one week intervals after treatment.  Levels of α4 
receptor saturation will be correlated with aGVHD and clinical treatment responses.  
Aliquots of such samples will also be banked for future correlative studies. 
All peripheral blood samples collected for correlative studies will be collected in EDTA 
tubes, with a blood volume of approximately 10mL.  At the time of collection, cells will be 
cryopreserved in FBS + 10% DMSO at –180°C and will be stored in the Pasquarello tissue 
bank.  Mononuclear cells will be isolated by density gradient centrifugation. Peripheral blood 
mononuclear cells will be washed before analysis by flow cytometry.  Flow cytometry will 
include a panel of T cell markers and α4β7 integrin.  Pharmacokinetic studies will be 
performed using ELISA with an anti-idiotypic monoclonal antibody specific for natalizumab 
as the capture antibody. 
9. STUDY CALENDAR 
Baseline evaluations are to be conducted within 1-week prior to start of protocol therapy.  
In the event that the participant's condition is deteriorating, laboratory evaluations should 
be repeated within 48 hours prior to initiation of the next cycle of therapy.  All assessments 
must be performed prior to administration of any study medication. All study assessments 
and medications should be administered within + 3 days of the protocol-specified date, unless 
otherwise noted.  Steroids can be administered up to 7 days before administration of 
natalizumab.  Day 0 is the day of infusion of the first dose of natalizumab. 


 
 
 
20
Subjects who develop a positive serum viral load for JC virus will NOT receive a second 
infusion of natalizumab.  For patients who have a less than complete response after the first 
dose of natalizumab, a second dose of 300mg will be administered in the same fashion as the 
first dose.  If however a patient has a complete response, no response, or progression of 
aGVHD, experiences a serious hypersensitivity reaction, or has a grade 3 or higher toxicity, 
then a second dose of natalizumab will not be administered. 
  
 
Pre- 
Study 
Day 
0 
Day 
7 
Day 
14 
Day 
21 
Day 
28 
Day 
35 
Day 
42 
Day 
49 
Day
56 
Day 
100 
Day 
180 
Day 
365 
Natalizumab 
 
 X 
 
 
 
(X) 
 
 
 
 
 
 
 
Steroid dose 
   X 
X 
X-----------------------------------------------------------------------------------------X 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
History 
X 
 
 
 
 
X 
 
 
 
X 
X 
X 
X 
Concurrent meds 
X 
 
   X------------------------------------------------------------------------------------------X 
Physical exam (Ht, Wt, 
BSA, VS) 
X 
X 
 
 
 
X 
 
 
 
X 
X 
X 
X 
Performance Status 
X 
X 
 
 
 
X 
 
 
 
X 
X 
X 
X 
CBC w/diff, plts 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Serum chemistrya 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Chimerismb 
 
 
X 
 
 
X 
 
 
 
X 
X 
X 
X 
JC viral loadc 
X 
 
 
 
 
(X) 
 
 
 
X 
 
 
 
Correlative Studies 
 
X 
X 
X 
X 
X 
 
 
 
X 
X 
X 
X 
Adverse event evaluation 
 
 
    X------------------------------------------------------------------------------------------X 
a: Albumin, alkaline phosphatase, total bilirubin, BUN, calcium, chloride, glucose, LDH, phosphorus, potassium, 
total  protein, SGOT   [AST], SGPT [ALT], sodium. 
b: includes total and T cell chimerism studies  
c: JC viral load will be checked again at day 28 if a second dose of Natalizumab is to be given 
 
10. MEASUREMENT OF EFFECT  
 
Participants will be assessed for response to therapy with natalizumab at day +28, day 
+56, day +100, day +180 and day +365 after administration of the first dose of 
Natalizumab.  Staging of each organ system involved in aGVHD will be done by 
standard NIH criteria (see 17.2 – Appendix B). 
 
10.1 Response Criteria for Overall aGVHD 


 
 
 
21
10.1.1 GVHD-free survival – days alive with complete resolution of all signs and 
symptoms of acute GVHD 
10.1.2 Complete Response (CR) – resolution of all signs and symptoms of acute GVHD 
10.1.3 Very Good Partial Response (VGPR) 
• Skin – no rash or residual erythematous rash involving < 25% of the body 
surface, without bullae (residual faint erythema and hyperpigmentation do 
not count) AND 
• Liver – total serum bilirubin concentration < 2 mg/dL or <25% of baseline 
at enrollment AND 
• Gut – tolerating food or enteral feeding, predominantly formed stools, no 
overt gastrointestinal bleeding or abdominal cramping, no more than 
occasional nausea/vomiting  
10.1.4 Overall Response Rate = (CR + VGPR) 
10.1.5 Partial Response (PR) - an improvement of one stage in one or more organs 
without progression in any other organ  
10.1.6 Mixed Response (MR) – improvement in one or more organs with deterioration in 
another organ manifesting symptoms of GVHD or development of symptoms of 
GVHD in a new organ 
10.1.7 Non-response (NR) to Therapy - no reduction in any GVHD organ staging on day 
+15 after the first dose of Natalizumab is administered. 
10.1.8 Progression of Acute GVHD on Therapy 
• New organ involvement (skin, liver, or intestine) on day +8 after the first 
dose of Natalizumab is administered or thereafter 
• Increased organ specific symptoms sufficient to increase the organ stage by 
one or more on day +8 after the first dose of Natalizumab is administered or 
thereafter 
• Flare of GVHD while tapering steroids +/- other agents will be defined as 
the need to increase systemic corticosteroid dose >50% of the starting dose 
on day +1 after the first dose of Natalizumab is administered or thereafter,  
OR the need to add another systemic agent to treat acute GVHD 
10.2 Response Criteria for GI GVHD 


 
 
 
22
10.2.1 Complete Response (CR) – resolution of all signs and symptoms of acute GI 
GVHD 
10.2.2 Very Good Partial Response (VGPR) - tolerating food or enteral feeding, 
predominantly formed stools, no overt gastrointestinal bleeding or abdominal 
cramping, no more than occasional nausea/vomiting 
10.2.3 Overall Response Rate = (CR + VGPR) 
10.2.4 Partial Response (PR) - an improvement by one or more stages of GI GVHD, not 
meeting criteria for VGPR or CR  
10.2.5 Non-response (NR) to Therapy - no reduction in GI GVHD staging on day +15 
after the first dose of Natalizumab is administered 
10.2.6 Progression:  
• Increased GI specific symptoms sufficient to increase the organ stage by 
one or more on day +8 after the first dose of Natalizumab is administered or 
thereafter 
• Flare of GI GVHD while tapering steroids +/- other agents will be defined 
as the need to increase systemic corticosteroid dose >50% of the starting 
dose on day +1 after the first dose of Natalizumab is administered or 
thereafter,  OR the need to add another systemic agent to treat acute GVHD 
 
11. ADVERSE EVENT REPORTING REQUIREMENTS 
11.1 Definitions 
11.1.1 Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition or 
experience that develops or worsens in severity after starting the first dose of 
natalizumab. All grade 2 related and unexpected and all grade 3 and higher 
adverse events experienced by participants will be collected from the time of the 
first dose of study treatment, through the study and until the final study visit. 
Grade 4 skin rash, diarrhea and increased bilirubin are expected adverse events as 
a result of aGVHD and do not require reporting. All positive JC viral loads need 
to be reported regardless of grade. 
 
Abnormal laboratory values or diagnostic test results constitute adverse events 
only if they induce clinical signs or symptoms or require treatment or further 
diagnostic tests.  
11.1.2 Serious adverse event (SAE) 


 
 
 
23
 
A serious adverse event (SAE) is any adverse event, occurring at any dose and 
regardless of causality that:  
• Results in death 
• Is life-threatening. Life-threatening means that the person was at 
immediate risk of death from the reaction as it occurred, i.e., it does not 
include a reaction which hypothetically might have caused death had it 
occurred in a more severe form. 
• Requires or prolongs inpatient hospitalization (i.e., the event required at 
least a 24-hour hospitalization or prolonged a hospitalization beyond the 
expected length of stay). Hospitalization admissions and/or surgical 
operations scheduled to occur during the study period, but planned prior to 
study entry are not considered SAEs if the illness or disease existed before 
the person was enrolled in the trial, provided that it did not deteriorate in 
an unexpected manner during the trial (e.g., surgery performed earlier than 
planned). 
• Results in persistent or significant disability/incapacity. Disability is 
defined as a substantial disruption of a person’s ability to conduct normal 
life functions. 
• Is a congenital anomaly or birth defect; or 
• Is an important medical event when, based upon appropriate medical 
judgment, it may jeopardize the participant and require medical or surgical 
intervention to prevent one of the outcomes listed above. Examples of 
such medical events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home; blood dyscrasias or 
convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse. 
 
Events not considered to be serious adverse events are hospitalizations for: 
• Routine treatment or monitoring of the studied indication, not associated 
with any deterioration in condition, or for elective procedures 
• Elective or pre-planned treatment for a pre-existing condition that did not 
worsen 
• Emergency outpatient treatment for an event not fulfilling the serious 
criteria outlined above and not resulting in inpatient admission 
• Respite care 
11.1.3 Expectedness 
 
Adverse events can be 'Expected' or 'Unexpected.'  
11.1.3.1 
Expected adverse event 
 
Expected adverse events are those that have been previously identified as 
resulting from administration of the agent. For the purposes of this study, 
an adverse event is considered expected when it appears in the current 


 
 
 
24
adverse event list, the Investigator’s Brochure, the package insert or is 
included in the informed consent document as a potential risk.   
 
Refer to Section 6.1 for a listing of expected adverse events associated 
with the study agent(s). 
11.1.3.2 
Unexpected adverse event 
 
 
For the purposes of this study, an adverse event is considered unexpected 
when it varies in nature, intensity or frequency from information 
provided in the current adverse event list, the Investigator’s Brochure, 
the package insert or when it is not included in the informed consent 
document as a potential risk.  Although not explicitly stated as adverse 
events from the study agent, grade 4 rash, diarrhea, and increased 
bilirubin are clinical manifestations of acute GVHD and will not be 
considered unexpected adverse events in this study. 
11.1.4 Attribution 
 
Attribution is the relationship between an adverse event or serious adverse event 
and the study treatment. Attribution will be assigned as follows: 
 
• Definite – The AE is clearly related to the study treatment. 
• Probable – The AE is likely related to the study treatment. 
• Possible – The AE may be related to the study treatment.  
• Unlikely - The AE is doubtfully related to the study treatment. 
• Unrelated - The AE is clearly NOT related to the study treatment. 
11.2 Procedures for AE and SAE Recording and Reporting 
 
Participating investigators will assess the occurrence of AEs and SAEs at all participant 
evaluation time points during the study.  
 
All AEs and SAEs whether reported by the participant, discovered during questioning, 
directly observed, or detected by physical examination, laboratory test or other means, 
will be recorded in the participant’s medical record and on the appropriate study-
specific case report forms.  
 
The descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE reporting. All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.0. 
A copy of the CTCAE version 4.0 can be downloaded from the CTEP website at: 
 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 


 
 
 
25
11.3 Reporting Requirements 
 
For multi-site trials where a DF/HCC investigator is serving as the principal 
investigator, each participating investigator is required to abide by the reporting 
requirements set by the DF/HCC. The study must be conducted in compliance with 
FDA regulations, local safety reporting requirements, and reporting requirements of the 
principal investigator.  
 
Each investigative site will be responsible to report SAEs that occur at that institution 
to their respective IRB. It is the responsibility of each participating investigator to 
report serious adverse events to the study sponsor and/or others as described below.  
 
 
11.4 Reporting to the Study Sponsor 
11.4.1 Serious Adverse Event Reporting 
 
All serious adverse events that occur after the initial dose of study treatment, 
during treatment, or within 30 days of the last dose of treatment must be reported 
to the DF/HCC Overall Principal Investigator on the local institutional SAE form. 
This includes events meeting the criteria outlined in Section 11.1.2, as well as the 
following: 
 
• Grade 2 (moderate) and Grade 3 (severe) Events – Only events that are 
unexpected and possibly, probably or definitely related/associated with the 
intervention. 
Note: Grade 2 or Grade 3 lab abnormalities that are considered by the 
investigator to be clinically insignificant and do not require therapy, or 
adjustment in prior therapy, do not need to be reported. 
 
• All Grade 4 (life-threatening or disabling) Events – Unless expected AND 
specifically listed in the protocol as not requiring reporting.  Grade 4 
evens previously mentioned that do not require reporting include rash, 
diarrhea and increase bilirubin. 
 
• All Grade 5 (fatal) Events – When the participant is enrolled and actively 
participating in the trial OR when the event occurs within 30 days of the 
last study intervention.  
 
• All positive JC viral loads need to be reported regardless of PCR level 
reported. 
 
Note: If the participant is in long term follow up, report the death at the time 
of continuing review.  
 


 
 
 
26
Participating investigators must report each serious adverse event to the DF/HCC 
Overall Principal Investigator within 24 hours of learning of the occurrence. In 
the event that the participating investigator does not become aware of the serious 
adverse event immediately (e.g., participant sought treatment elsewhere), the 
participating investigator is to report the event within 24 hours after learning of it 
and document the time of his or her first awareness of the adverse event. Report 
serious adverse events by telephone, email or facsimile to: 
 
 
 
Corey Cutler, MD, MPH 
617-632-3470 (Phone) 
617-632-5168 (Fax) 
Email: cscutler@partners.org  
 
Within the following 24-48 hours, the participating investigator must provide 
follow-up information on the serious adverse event. Follow-up information should 
describe whether the event has resolved or continues, if and how the event was 
treated, and whether the participant will continue or discontinue study 
participation. 
11.4.2 Non-Serious Adverse Event Reporting  
 
Non-serious adverse events will be reported to the DF/HCC Overall Principal 
Investigator on the toxicity Case Report Forms.   
11.5 Reporting to the Institutional Review Board (IRB) 
 
Investigative sites within DF/HCC will report all serious adverse events directly to the 
DFCI Office for Human Research Studies (OHRS). 
11.6 Reporting to the Food and Drug Administration (FDA) 
 
 The DF/HCC Overall Principal Investigator, as holder of the IND, will be responsible 
for all communication with the FDA. Dr. Corey Cutler, the principal investigator, 
currently holds the IND for natalizumab (#121195).  The DF/HCC Overall Principal 
Investigator will report to the FDA, regardless of the site of occurrence, any adverse 
event that is serious, unexpected and reasonably related (i.e., possible, probable, 
definite) to the study treatment. 
 
Unexpected fatal or life-threatening experiences associated with the use of the study 
treatment will be reported to FDA as soon as possible but in no event later than 7 
calendar days after initial receipt of the information. 
 
All other serious unexpected experiences associated with the use of the study treatment 
will be reported to FDA as soon as possible but in no event later than 15 calendar days 
after initial receipt of the information. 
 
 
 


 
 
 
27
Events will be reported to the FDA by telephone (1-800-FDA-1088) or by fax (1-800-
FDA-0178) using Form FDA 3500A (Mandatory Reporting Form for investigational 
agents). A formal written submission will be sent in as well.  Forms are available at 
http://www.fda.gov/medwatch/getforms.htm.  
11.7 Reporting to the NIH Office of Biotechnology Activities (OBA) 
 
Not applicable  
11.8 Reporting to the Institutional Biosafety Committee (IBC) 
 
Not applicable  
11.9 Monitoring of Adverse Events and Period of Observation 
 
All adverse events, both serious and non-serious, and deaths that are encountered from 
initiation of study intervention, throughout the study, and within 30 days of the last 
study intervention should be followed to their resolution, or until the participating 
investigator assesses them as stable, or the participating investigator determines the 
event to be irreversible, or the participant is lost to follow-up. The presence and 
resolution of AEs and SAEs (with dates) should be documented on the appropriate case 
report form and recorded in the participant’s medical record to facilitate source data 
verification.  
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, and/or 
monitoring visit to obtain additional case details deemed necessary to appropriately 
evaluate the SAE report (e.g., hospital discharge summary, consultant report, or 
autopsy report).  
 
Participants should be instructed to report any serious post-study event(s) that might 
reasonably be related to participation in this study. Participating investigators should 
notify the DF/HCC Overall Principal Investigator and their respective IRB of any 
unanticipated death or adverse event occurring after a participant has discontinued or 
terminated study participation that may reasonably be related to the study.   
 
12. DATA AND SAFETY MONITORING 
12.1 Data Reporting 
12.1.1 Method  
Dana Farber Cancer Institute will collect, manage, and monitor data for this 
study.  
12.1.2 Data Submission  


 
 
 
28
The schedule for completion and submission of case report forms (paper or 
electronic) to Coordinating Center is as follows: 
 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration with QACT 
On Study Form 
Within 14 days of registration 
Baseline Assessment Form 
Within 14 days of registration 
Treatment Form 
Within 10 days of the last day of the cycle 
Adverse Event Report Form 
Within 10 days of the last day of the cycle 
Response Assessment Form 
Within 10 days of the completion of the cycle 
required for response evaluation 
Off Treatment/Off Study Form Within 14 days of completing treatment or 
being taken off study for any reason 
Follow up/Survival Form 
Within 14 days of the protocol defined follow 
up visit date or call 
 
12.2 Safety Meetings 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor 
toxicity and accrual data from this trial. The committee is composed of clinical 
specialists with experience in oncology and who have no direct relationship with the 
study. Information that raises any questions about participant safety will be addressed 
with the Principal Investigator and study team. 
 
The DSMC will meet quarterly and/or more often if required to review toxicity and 
accrual data.  Information to be provided to the committee may include:  up-to-date 
participant accrual; all grade 2 or higher unexpected adverse events that have been 
reported; summary of all deaths occurring within 30 days for Phase I or II protocols; for 
gene transfer protocols, summary of all deaths while being treated and during active 
follow-up; any response information; audit results, and a summary provided by the 
study team. Other information (e.g. scans, laboratory values) will be provided upon 
request.  
12.3 Monitoring  
 
Involvement in this study as a participating investigator implies acceptance of 
potential audits or inspections, including source data verification, by representatives 


 
 
 
29
designated by the DF/HCC Overall Principal Investigator (or Protocol Chair) or 
DF/HCC. The purpose of these audits or inspections is to examine study-related 
activities and documents to determine whether these activities were conducted and 
data were recorded, analyzed, and accurately reported in accordance with the protocol, 
institutional policy, Good Clinical Practice (GCP), and any applicable regulatory 
requirements.  
 
All data will be monitored for timeliness of submission, completeness, and adherence 
to protocol requirements. Monitoring will begin at the time of participant registration 
and will continue during protocol performance and completion.  
13. REGULATORY CONSIDERATIONS 
13.1 Protocol Review and Amendments 
This protocol, the proposed informed consent and all forms of participant 
information related to the study (e.g., advertisements used to recruit participants) and 
any other necessary documents must be submitted, reviewed and approved by a 
properly constituted IRB governing each study location.  
Any changes made to the protocol must be submitted as amendments and must be 
approved by the IRB prior to implementation. Any changes in study conduct must be 
reported to the IRB. The DF/HCC Overall Principal Investigator (or Protocol Chair) 
will disseminate protocol amendment information to all participating investigators.  
All decisions of the IRB concerning the conduct of the study must be made in 
writing. 
13.2 Informed Consent 
 
All participants must be provided a consent form describing this study and providing 
sufficient information for participants to make an informed decision about their 
participation in this study. The formal consent of a participant, using the IRB approved 
consent form, must be obtained before the participant is involved in any study-related 
procedure. The consent form must be signed and dated by the participant or the 
participant’s legally authorized representative, and by the person obtaining the consent. 
The participant must be given a copy of the signed and dated consent document. The 
original signed copy of the consent document must be retained in the medical record or 
research file.  
13.3 Ethics and Good Clinical Practice (GCP) 
This study is to be conducted according to the following considerations, which 
represent good and sound research practice: 
• 
US Code of Federal Regulations (CFR) governing clinical study conduct and 
ethical principles that have their origin in the Declaration of Helsinki 


 
 
 
30
o Title 21 Part 50 – Protection of Human Subjects 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr50_02.html  
o Title 21 Part 54 – Financial Disclosure by Clinical Investigators 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr54_02.html  
o Title 21 Part 56 – Institutional Review Boards 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr56_02.html  
o Title 21 Part 312 – Investigational New Drug Application 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr312_02.html  
• 
State laws 
• 
DF/HCC research policies and procedures        
http://www.dfhcc.harvard.edu/clinical-research-support/clinical-research-unit-
cru/policies-and-procedures/  
It is understood that deviations from the protocol should be avoided, except when 
necessary to eliminate an immediate hazard to a research participant. In such case, 
the deviation must be reported to the IRB according to the local reporting policy.  
13.4 Study Documentation 
 
The investigator must prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each 
research participant. This information enables the study to be fully documented and the 
study data to be subsequently verified. 
 
Original source documents supporting entries in the case report forms include but are 
not limited to hospital records, clinical charts, laboratory and pharmacy records, 
recorded data from automated instruments, microfiches, photographic negatives, 
microfilm or magnetic media, and/or x-rays.  
13.5 Records Retention 
 
All study-related documents must be retained for the maximum period required by 
applicable federal regulations and guidelines or institutional policies.  
13.6 Multi-center Guidelines 
 
Not applicable 
13.7 Cooperative Research and Development Agreement (CRADA)/Clinical Trials 
Agreement (CTA)  
 
Not applicable 


 
 
 
31
14. STATISTICAL CONSIDERATIONS  
14.1 Study Design/Endpoints 
This is a phase II trial to determine the GVHD free survival rate at day 56 after the first dose 
of Natalizumab (Tysabri®) is administered plus steroids for initial therapy of GI acute 
GVHD. The initial treatment will be one dose of 300mg IV.  Patients can be treated with a 
second dose of natalizumab at 28 days if they are deemed eligible (see section 5.2.1 for 
eligibility requirements for a second dose of natalizumab).  The primary endpoint is GVHD 
free survival rate at day 56 after the first dose of Natalizumab is administered. GVHD free 
survival is defined as achieving complete response without death or relapse or requiring 
secondary immunosuppressive therapy.  GVHD response criteria are defined in section 10.1 
and 10.2.  Patients who receive a second dose of Natalizumab will be evaluated at day 56 
after the administration of the first treatment dose.   Secondary endpoints are outlined in 
section 1.3 (under secondary objectives).   
 
For the assessment of the primary endpoint, we employ a two-stage design with early 
stopping for futility after first stage of accrual. The mainstay of acute GVHD treatment 
remains corticosteroid therapy. The response rate to single-agent steroid therapy when 
analyzed in large retrospective reviews was approximately 50% (MacMillan 2002, Martin 
1990). The response rate to GI aGVHD was similar to the overall response rate. 
Unfortunately, even with an initial response to steroids, the durability of this response 
remains low at 24% and 40% for matched unrelated and related donor transplantation, 
respectively (Roy 1992, Weisdorf 1990).   Based on this information and extrapolating our 
internal data, we consider Natalizumab efficacious if the GVHD free survival rate at day 56 
after the first dose of Natalizumab is administered is 50% or higher and inefficacious if the 
rate is 30% or lower. 
 
The target accrual goal is 30 evaluable patients. In the first stage, 15 patients will be accrued. 
If there are 4 or fewer patients with GVHD free survival at day 56 after the first dose of 
Natalizumab is administered, then this agent will be regarded as futile and the study will be 
terminated early. If there are 5 or more patients with GVHD free survival in the first 15 
patients, additional 15 patients will be accrued in the second stage.  After the second stage, if 
the total number of patients with GVHD free survival at day 56 after the first dose of 
Natalizumab is administered is 13 or more, then this agent will be regarded as efficacious for 
the treatment of GI acute GVHD. Conversely, if the total number of GVHD free survival is 
12 or fewer, then this agent will be regarded as futile.  
 
With this design, if the true but unknown GVHD free survival rate is 30%, the probability of 
stopping early for futility is 0.52, but 0.06 if the true but unknown rate is 50%. The overall 
power is 0.80 with a type I error rate 0.08. Table 1 below presents the operating 
characteristics of this design. 
Table 1. Operating Characteristics 
  
True but unknown GVHD-free rate at day 56 of 
treatment 
  
0.3 
0.35 
0.4 
0.45 
0.5 
Futility after Stage 1 
0.52 
0.35 
0.22 
0.12 
0.06 


 
 
 
32
Overall Power 
0.08 
0.21 
0.41 
0.62 
0.80 
Expected sample size 
22.3 
24.7 
26.7 
28.2 
29.1 
14.2 Sample Size/Accrual Rate 
 
Based on our data in the past 3 years, approximately 6% of patients developed grade 
2-4 gastrointestinal acute GVHD after allogeneic stem cell transplantation. 
Considering about 250 patients are transplanted per year at this institute and assuming 
about 50% capture rate, we project that the accrual rate will be approximately 7.5 
patients per year and thus it will take approximately 4 years to complete the target 
accrual goal of 30 patients if the study is not terminated after the first stage of accrual. 
If non-DFCI centers enroll patients, the accrual will complete sooner.      
14.3 Stratification Factors 
None 
14.4 Analysis of Secondary Endpoints 
 
Secondary endpoints are outlined in section 1.3 (under secondary objectives).  
Proportions will be reported descriptively. Overall survival (OS) and GVHD-free 
survival will be assessed using the Kaplan-Meier method. Relapse and non-relapse 
mortality will be assessed in the competing risks framework. If there is enough 
number of events, we will also explore regression models for OS and GVHD-free 
survival and relapse although the number of covariates included in the model will be 
limited.  As to the analysis of correlative studies, peripheral blood samples will be 
collected at day 0, day 7, day 14, day 21, day 28, day 56, day 100, day 180 and one year 
after the first dose of Natalizumab is administered. Descriptive statistics and graphical 
assessment will first be employed to characterize pre to post treatment difference in 
levels of α4 receptor saturation and pre-to-post treatment difference will be tested 
using either paired t test or Wilcoxon-signed-rank test. If appropriate, change over 
time will be examined in repeated measures analysis. Due to the exploratory nature, 
multiple comparisons will not be considered. In particular, we will confirm whether 
the expression of α4ß7 integrin is up-regulated in patients with GI aGVHD prior to the 
development of GI aGVHDand assess whether natalizumab reduces the expression 
level of α4ß7 integrin and whether the level is associated with GVHD-free survival.  
14.5 Reporting and Exclusions 
 
Adverse events will be monitored closely. The monitoring guidelines will serve as a 
trigger for consultation with the Dana-Farber/Harvard Cancer Center Data and Safety 
Monitoring Committee (DF/HCC DSMC) for additional review, and are not regarded 
as formal stopping rules that would mandate automatic closure of study enrollment. In 
the previous studies reported in the literature, natalizumab is generally safe and 
causing only minimal adverse events (see Section 2.1.2). Based on this information, 
natalizumab-related grade 4 or higher toxicities is projected to be <10%. If in the first 
10 patients, we observe 2 or more patients with non-hematologic CTCAE grade 4 or 


 
 
 
33
higher that are possibly/probably/definitely attributable to natalizumab, further accrual 
and administration of natalizumab will be halted pending review by the DSMC. 
Depending on the findings of its review, the DSMC may recommend the permanent 
closure of enrollment of that arm or continuation of enrollment.  In addition, if a case 
of PML is reported, the study (both accrual and drug administration) will be 
immediately halted.  Patients who developed a positive JC viral load or who have any 
toxicity to the first dose of natalizumab will not be eligible for a second dose of 
natalizumab. 
 
With this design, the probability of halting enrollment is 0.09 if the true but unknown 
rate of grade 4 or higher non-hematologic toxicity that are attributable to natalizumab 
is 5%, 0.26 if the rate is 10%, and 0.85 if the true rate is 30%.   
15. PUBLICATION PLAN 
The results of this trial will be made public within 24 months of the end of data collection. 
The initial release of data will be an abstract that meets the requirements of the International 
Committee of Medical Journal Editors. A full report of the outcomes, to be published in a 
peer-reviewed journal, will be made public no later than three (3) years after the end of data 
collection.  
 
 
16. REFERENCES  
 
1. Rudick RA, Sandrock A. Natalizumab: alpha 4-integrin antagonist selective adhesion 
molecule inhibitors for MS. Expert Rev Neurother. 2004 Jul;4(4):571-80. 
2. Yednock TA, Cannon C, Fritz LC, Sanchez-Madrid F, Steinman L, Karin N. Prevention 
of experimental autoimmune encephalomyelitis by antibodies against alpha 4 beta 1 
integrin. Nature. 1992 Mar 5;356(6364):63-6 
3. Kent SJ, Karlik SJ, Rice GP, Horner HC. A monoclonal antibody to alpha 4-integrin 
reverses the MR-detectable signs of experimental allergic encephalomyelitis in the guinea 
pig. J Magn Reson Imaging. 1995 Sep-Oct;5(5):535-40.  
4. Kent SJ, Karlik SJ, Cannon C, Hines DK, Yednock TA, Fritz LC, Horner HC. A 
monoclonal antibody to alpha 4 integrin suppresses and reverses active experimental 
allergic encephalomyelitis. J Neuroimmunol. 1995 Apr;58(1):1-10. 
5. Sheremata WA, Vollmer TL, Stone LA, Willmer-Hulme AJ, Koller M. A safety and 
pharmacokinetic study of intravenous natalizumab in patients with MS. Neurology. 1999 
Mar 23;52(5):1072-4. 
6. Miller DH, Khan OA, Sheremata WA, Blumhardt LD, Rice GP, Libonati MA, Willmer-
Hulme AJ, Dalton CM, Miszkiel KA, O'Connor PW; International Natalizumab Multiple 
Sclerosis Trial Group. A controlled trial of natalizumab for relapsing multiple sclerosis. 
N Engl J Med. 2003 Jan 2;348(1):15-23. 
7. Rudick RA, Stuart WH, Calabresi PA, Confavreux C, Galetta SL, Radue EW, Lublin FD, 
Weinstock-Guttman B, Wynn DR, Lynn F, Panzara MA, Sandrock AW; SENTINEL 
Investigators. Natalizumab plus interferon beta-1a for relapsing multiple sclerosis. N 
Engl J Med. 2006 Mar 2;354(9):911-23. 


 
 
 
34
8. Polman CH, O'Connor PW, Havrdova E, Hutchinson M, Kappos L, Miller DH, Phillips 
JT, Lublin FD, Giovannoni G, Wajgt A, Toal M, Lynn F, Panzara MA, Sandrock AW; 
AFFIRM Investigators. A randomized, placebo-controlled trial of natalizumab for 
relapsing multiple sclerosis. N Engl J Med. 2006 Mar 2;354(9):899-910. 
9. Gordon FH, Lai CW, Hamilton MI, Allison MC, Srivastava ED, Fouweather MG, 
Donoghue S, Greenlees C, Subhani J, Amlot PL, Pounder RE. A randomized placebo-
controlled trial of a humanized monoclonal antibody to alpha4 integrin in active Crohn's 
disease. Gastroenterology. 2001 Aug;121(2):268-74.  
10. Gordon FH, Hamilton MI, Donoghue S, Greenlees C, Palmer T, Rowley-Jones D, 
Dhillon AP, Amlot PL, Pounder RE. A pilot study of treatment of active ulcerative colitis 
with natalizumab, a humanized monoclonal antibody to alpha-4 integrin. Aliment 
Pharmacol Ther. 2002 Apr;16(4):699-705. 
11. Ghosh S, Goldin E, Gordon FH, Malchow HA, Rask-Madsen J, Rutgeerts P, Vyhnálek P, 
Zádorová Z, Palmer T, Donoghue S; Natalizumab Pan-European Study Group. 
Natalizumab for active Crohn's disease. N Engl J Med. 2003 Jan 2;348(1):24-32. 
12. Sandborn WJ, Colombel JF, Enns R, Feagan BG, Hanauer SB, Lawrance IC, Panaccione 
R, Sanders M, Schreiber S, Targan S, van Deventer S, Goldblum R, Despain D, Hogge 
GS, Rutgeerts P; International Efficacy of Natalizumab as Active Crohn's Therapy 
(ENACT-1) Trial Group; Evaluation of Natalizumab as Continuous Therapy (ENACT-2) 
Trial Group. Natalizumab induction and maintenance therapy for Crohn's disease. N Engl 
J Med. 2005 Nov 3;353(18):1912-25. 
13. Bloomgren G, Richman S, Hotermans C, Subramanyam M, Goelz S, Natarajan A, Lee S, 
Plavina T, Scanlon JV, Sandrock A, Bozic C. Risk of natalizumab-associated progressive 
multifocal leukoencephalopathy. N Engl J Med. 2012 May 17;366(20):1870-80. 
14. Rudick RA, Sandrock A. Natalizumab: alpha 4-integrin antagonist selective adhesion 
molecule inhibitors for MS. Expert Rev Neurother. 2004 Jul;4(4):571-80. 
15. Ferrara JL, Deeg HJ. Graft-versus-host disease. N Engl J Med. 1991 Mar 7;324(10):667-
74. 
16. Johnston L. Acute graft-versus-host disease: differing risk with differing graft sources 
and conditioning intensity. Best Pract Res Clin Haematol. 2008 Jun;21(2):177-92. 
17. Deeg HJ, Antin JH. The clinical spectrum of acute graft-versus-host disease. Semin 
Hematol. 2006 Jan;43(1):24-31. 
18. Goker H, Haznedaroglu IC, Chao NJ. Acute graft-vs-host disease: pathobiology and 
management. Exp Hematol. 2001 Mar;29(3):259-77. 
19. Hill GR, Ferrara JL. The primacy of the gastrointestinal tract as a target organ of acute 
graft-versus-host disease: rationale for the use of cytokine shields in allogeneic bone 
marrow transplantation. Blood. 2000 May 1;95(9):2754-9. 
20. MacMillan ML, Weisdorf DJ, Wagner JE, DeFor TE, Burns LJ, Ramsay NK, Davies SM, 
Blazar BR. Response of 443 patients to steroids as primary therapy for acute graft-versus-
host disease: comparison of grading systems. Biol Blood Marrow Transplant. 
2002;8(7):387-94. 
21. Martin PJ, Schoch G, Fisher L, Byers V, Anasetti C, Appelbaum FR, Beatty PG, Doney 
K, McDonald GB, Sanders JE, et al. A retrospective analysis of therapy for acute graft-
versus-host disease: initial treatment. Blood. 1990 Oct 15;76(8):1464-72. 
22. Roy J, McGlave PB, Filipovich AH, Miller WJ, Blazar BR, Ramsay NK, Kersey JH, 
Weisdorf DJ. Acute graft-versus-host disease following unrelated donor marrow 


 
 
 
35
transplantation: failure of conventional therapy. Bone Marrow Transplant. 1992 
Jul;10(1):77-82. 
23. Weisdorf D, Haake R, Blazar B, Miller W, McGlave P, Ramsay N, Kersey J, Filipovich 
A. Treatment of moderate/severe acute graft-versus-host disease after allogeneic bone 
marrow transplantation: an analysis of clinical risk features and outcome. Blood. 1990 
Feb 15;75(4):1024-30. 
24. Arai S, Vogelsang GB. Management of graft-versus-host disease. Blood Rev. 2000 
Dec;14(4):190-204. 
25. Bruner RJ, Farag SS. Monoclonal antibodies for the prevention and treatment of graft-
versus-host disease. Semin Oncol. 2003 Aug;30(4):509-19. 
26. Tanaka J, Asaka M, Imamura M. T-cell co-signalling molecules in graft-versus-host 
disease. Ann Hematol. 2000 Jun;79(6):283-90. 
27. Couriel DR, Saliba R, de Lima M, Giralt S, Andersson B, Khouri I, Hosing C, Ippoliti C, 
Shpall EJ, Champlin R, Alousi A. A phase III study of infliximab and corticosteroids for 
the initial treatment of acute graft-versus-host disease. Biol Blood Marrow Transplant. 
2009 Dec;15(12):1555-62. 
28. Alousi AM, Weisdorf DJ, Logan BR, Bolaños-Meade J, Carter S, Difronzo N, Pasquini 
M, Goldstein SC, Ho VT, Hayes-Lattin B, Wingard JR, Horowitz MM, Levine JE; Blood 
and Marrow Transplant Clinical Trials Network. Etanercept, mycophenolate, denileukin, 
or pentostatin plus corticosteroids for acute graft-versus-host disease: a randomized phase 
2 trial from the Blood and Marrow Transplant Clinical Trials Network. Blood. 2009 Jul 
16;114(3):511-7. 
29. Logan,BR.,Alousi, AM, Antin JH et al.  A Multi-Center, Randomized, Double Blind, 
Phase III Clinical Trial Comparing Steroids/Placebo Vs. Steroids/Mycophenolate Mofetil 
As Initial Therapy for Acute Graft-Versus-Host Disease. Blood and Marrow Transplant 
Clinical Trials Network Study 0802.  ASBMT 2013; Abstract 50. 
30. Martin PJ, Rizzo JD, Wingard JR, Ballen K, Curtin PT, Cutler C, Litzow MR, Nieto Y, 
Savani BN, Schriber JR, Shaughnessy PJ, Wall DA, Carpenter PA. First- and second-line 
systemic treatment of acute graft-versus-host disease: recommendations of the American 
Society of Blood and Marrow Transplantation. Biol Blood Marrow Transplant. 2012 
Aug;18(8):1150-63. 
31. Kobayashi S, Hashino S, Tanaka J, Mori A, Kobayashi M, Asaka M, Imamura M. 
Increased adhesion molecule expression during graft-versus-host disease. Transplant 
Proc. 2000 Nov;32(7):2452-3. 
32. Murai M, Yoneyama H, Ezaki T, Suematsu M, Terashima Y, Harada A, Hamada H, 
Asakura H, Ishikawa H, Matsushima K. Peyer's patch is the essential site in initiating 
murine acute and lethal graft-versus-host reaction. Nat Immunol. 2003 Feb;4(2):154-60. 
33. Dutt S, Ermann J, Tseng D, Liu YP, George TI, Fathman CG, Strober S. L-selectin and 
beta7 integrin on donor CD4 T cells are required for the early migration to host 
mesenteric lymph nodes and acute colitis of graft-versus-host disease. Blood. 2005 Dec 
1;106(12):4009-15. 
34. Ueha S, Murai M, Yoneyama H, Kitabatake M, Imai T, Shimaoka T, Yonehara S, 
Ishikawa S, Matsushima K. Intervention of MAdCAM-1 or fractalkine alleviates graft-
versus-host reaction associated intestinal injury while preserving graft-versus-tumor 
effects. J Leukoc Biol. 2007 Jan;81(1):176-85. 


 
 
 
36
35. Petrovic A, Alpdogan O, Willis LM, Eng JM, Greenberg AS, Kappel BJ, Liu C, Murphy 
GJ, Heller G, van den Brink MR. LPAM (alpha 4 beta 7 integrin) is an important homing 
integrin on alloreactive T cells in the development of intestinal graft-versus-host disease. 
Blood. 2004 Feb 15;103(4):1542-7. 
36. Chen YB, Kim HT, McDonough S, Odze RD, Yao X, Lazo-Kallanian S, Spitzer TR, 
Soiffer R, Antin JH, Ritz J. Up-Regulation of alpha4beta7 integrin on peripheral T cell 
subsets correlates with the development of acute intestinal graft-versus-host disease 
following allogeneic stem cell transplantation. Biol Blood Marrow Transplant. 2009 
Sep;15(9):1066-76. 
37. Chen YB, McDonough S, Chen H, Kennedy J, Illiano C, Attar EC, Ballen KK, Dey BR, 
McAfee SL, Jagasia M, Soiffer R, Spitzer TR, Ritz J. Expression of α4β7 integrin on 
memory CD8(+) T cells at the presentation of acute intestinal GVHD. Bone Marrow 
Transplant. 2013 Apr;48(4):598-603. 
38. Lu SX, Kappel LW, Charbonneau-Allard AM, Atallah R, Holland AM, Turbide C, 
Hubbard VM, Rotolo JA, Smith M, Suh D, King C, Rao UK, Yim N, Bautista JL, Jenq 
RR, Penack O, Na IK, Liu C, Murphy G, Alpdogan O, Blumberg RS, Macian F, Holmes 
KV, Beauchemin N, van den Brink MR. Ceacam1 separates graft-versus-host-disease 
from graft-versus-tumor activity after experimental allogeneic bone marrow 
transplantation. PLoS One. 2011;6(7):e21611. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
37
 
 
 
 
 
 
 
 
17. APPENDICES  
17.1 Appendix A: Performance Status Criteria 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Description 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no 
evidence of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of 
disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able to 
carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; 
some signs or symptoms of 
disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 
work. 
2 
In bed < 50% of the time. 
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities. Up and about more 
than 50% of waking hours. 
60 
Requires occasional assistance, 
but is able to care for most of 
his/her needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care 
and assistance. 
30 
Severely disabled, 
hospitalization indicated. Death 
not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization 
indicated. Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly.  
5 
Dead. 
0 
Dead. 


 
 
 
38
 
 
 
 
 
 
 
17.2 Appendix B: Acute GVHD Scoring (adapted from Glucksberg, H et al. 
Transplantation 1974;18:295) 
 
 
 


Protocol #14-140 D: 3.31.2014mrh/F:7/10/2014SS 
 
DANA-FARBER CANCER INSTITUTE 
Nursing Protocol Education Sheet 
Protocol Number: 
14-140 
Protocol Name: 
Phase II Trial of Natalizumab (Tysarbri®) plus Prednisone for Initial Therapy of 
Acute Graft versus Host Disease (aGVHD) of the Gastrointestinal Tract 
DFCI Site PI: 
Corey Cutler, MD, MPH 
DFCI Research Nurse: 
Susan Stephenson,  RN 
Page the DFCI research nurse or DFCI site PI if there are any questions/concerns about the protocol.   
Please also refer to ONC 15: Oncology Nursing Protocol Education Policy 
*** Remember to check the ALERT PAGE*** 
              SPECIAL NURSING CONSIDERATIONS UNIQUE TO THIS PROTOCOL 
Study Design 
 
 Natalizumab (Tysabri) is a recombinant humanized IgG4 monoclonal antibody. In this study, the initiation of 
Natalizumab at the onset of symptoms, in addition to steroids, will provide the best chance of preventing 
crypt necrosis by shutting down the homing of T cells to the gut as early as possible.  The absent of α4β7 
integrin on hematologic malignancies provides Natalizumab with the unique ability to abrogate gut GVHD 
without effecting the graft versus tumor effect. Thus, it is hoped that given its specific targeting of  integrin, 
Natalizumab can be successful in treating acute GVHD, yet be less globally immunosuppressive, the main 
concern with current available treatments of acute GVHD. α4β7 is increased in disease sites of inflammatory 
bowel disease, providing another potential target for Natalizumab.  
 
Dose 
Calc
ul-
• Natalizumab: dosed as a flat mg IV, Sections   7.1.8. 
Study Drug  
Administration 
Treatment Plan administration Guidelines are found in Sections 5 and 7. 
• Treatment of acute GVHD is an acute process that requires short courses of treatment. 
• Initial standard dose IV will be used at confirmation of acute gut GVHD.  
• If at 4 weeks there has been less than a complete response, participants can be treated with a second dose of 
Natalizumab.  
• Pre-treatment criteria: ANC ≥ 500/μL (G-CSF) support is allowed); Platelets:  ≥ 10,000/μL (platelet 
transfusions are allowed on the same day). 
• Observations: will be observed for 2 hours following completion of infusion of Natalizumab for the first 
infusion (monitor for possible infusion related reactions).  See Section 5.2.1. for details. 
• Vital Signs: (temp, Heart rate, blood pressure and respiratory rate) should be monitored approximately 
every 10 minutes during the infusion of Natalizumab. 
Dose 
Modifi
cation
Expected Toxicities and Dosing Delays / Dose Modifications are outlined in Section 6. 
 
Concom
itant 
Meds 
General Concomitant Medication and Supportive Care Guidelines are in Section 5.4. 
• 
Routine use of growth factor (G-CSF) support in the absence of documented neutropenia is not 
recommended.  
• 
Prednisone requirements: See Section 7.2 to 7.2.1 
Req
uire
d 
Study Calendar data is outlined in Section 9. 
• 
Correlative/Special Studies- refer to Section 8. 
Charting Tips 
All study drugs require documentation of exact administration time. 
Please be sure to DOCUMENT study medication actual UP/DOWN times in medical record (e.g. LMR, 
eMAR, nursing notes). Edit eMAR as needed to match the exact time given. 
• If there is a discrepancy in the infusion time, delay in administration, or the infusion takes longer than is 
permitted by the guidelines of the protocol, please document the reason for the discrepancy in the 
medical record. 
Please be sure to also DOCUMENT any required observation periods, any additional vital signs, routes of 
administration, or injection sites