Treatment for Acute Graft-Versus-Host Disease (BMT CTN 0302)

Study Overview
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Brief Summary
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The study is a randomized Phase II, four arm treatment trial. The primary purpose of the study is to define new agents with promising activity against acute graft-versus-host disease (GVHD) suitable for testing against corticosteroids alone in a subsequent Phase III trial.

Detailed Description
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BACKGROUND: Acute graft-versus-host disease (GVHD) is the major complication of allogeneic hematopoietic stem cell (HSC) transplantation. Acute GVHD produces significant morbidity and complicates patient management resulting in organ toxicity, frequent infections, malnutrition, and substantial delay in recovery from transplantation. Corticosteroids have been the primary therapy for acute GVHD for over three decades. Various additional immunosuppressive strategies have been tested as GVHD therapy but neither anti-thymocyte globulin (ATG), CD5-immunotoxins, IL-1 antagonists nor other agents have been demonstrably helpful in either control of GVHD symptoms or improvement in survival. Published response rates of complete response (CR) to acute GVHD therapy with corticosteroids range from 25-41%. These rates will be used as benchmarks for assessing efficacy of promising new agents. New immunosuppressive agents and strategies are required to improve the management of GVHD and decrease the toxicities of the immunosuppressive regimens. DESIGN NARRATIVE: In this trial, patients with newly diagnosed acute GVHD will be randomly assigned to receive corticosteroids plus one of four new agents (etanercept, MMF, denileukin diftitox [Ontak], and pentostatin). A control arm of only corticosteroids will not be employed. Each agent will be assessed for safety and efficacy (at least 35% complete remission [CR] rate at Day 28 of therapy can be expected from previously untreated patients).

Official Title
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Initial Systemic Treatment of Acute GVHD: A Phase II Randomized Trial Evaluating Etanercept, Mycophenolate Mofetil (MMF), Denileukin Diftitox (ONTAK), and Pentostatin in Combination With Corticosteroids (BMT CTN #0302)

Conditions
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Graft vs Host Disease, Immune System Disorders

Intervention / Treatment
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* Drug: Etanercept
* Drug: Mycophenolate Mofetil
* Drug: Denileukin Diftitox
* Drug: Pentostatin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Prior allogeneic hematopoietic stem cell transplant using either bone marrow, peripheral blood stem cells, or cord blood De novo acute GVHD diagnosed within 48 hours prior to enrollment; biopsy confirmation of GVHD is strongly recommended but not required; enrollment should not be delayed awaiting biopsy or pathology results; the patient must have had no previous systemic immune suppressive therapy given for treatment of acute GVHD except for a maximum 48 hours of prior corticosteroid therapy (at least 1 mg/kg/day methylprednisolone) Patients that have undergone a scheduled donor lymphocyte infusion (DLI) as part of their original transplant therapy plan Absolute neutrophil count (ANC) greater than 500/µL Clinical status at enrollment to allow tapering of steroids to not less than 1 mg/kg/day methylprednisolone (1.4 mg/kg/day prednisone) at Day 28 of therapy (e.g., persisting malignant disease suggesting the need for accelerated taper of immunosuppression) Estimated creatinine clearance greater than 30 mL/minute Assent and educational materials provided to, and reviewed with, patients under the age of 18 Exclusion Criteria: ONTAK, pentostatin, or etanercept given within 7 days of enrollment Active uncontrolled infection Patients that have undergone an unscheduled DLI, or DLI that was not part of their original transplant therapy plan If any prior steroid therapy (for indication other than GVHD), treatment at doses of at least 0.5 mg/kg/day methylprednisolone within 7 days prior to onset of GVHD Patients unlikely to be available at the transplant center on Day 28 and 56 of therapy A clinical syndrome resembling de novo chronic GVHD developing at any time after allotransplantation (see Chapter 2 of the BMT CTN Manual of Procedures for details of de novo chronic GVHD) Other investigational therapeutics for GVHD within 30 days, including agents used for GVHD prophylaxis Patients who are pregnant, breast feeding, or if sexually active, unwilling to use effective birth control for the duration of the study Adults unable to provide informed consent Patients with a history of intolerance to any of the study drugs

Ages Eligible for Study
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Minimum Age: 2 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Etanercept<br>Enroll within 48 hours of new onset acute GVHD and randomize to Etanercept | Drug: Etanercept<br>* Etanercept [25 mg subcutaneously twice weekly for up to 4 weeks; discontinue if in complete response by 4 weeks].<br>* Other names: ENBREL®;|
| Experimental: Mycophenolate Mofetil<br>Enroll within 48 hours of new onset acute GVHD and randomize to Mycophenolate Mofetil | Drug: Mycophenolate Mofetil<br>* Mycophenolate mofetil (MMF) [20 mg/kg (maximum 1 gm) orally or intravenously twice daily; continue through prednisone taper, then taper MMF over 4 weeks].<br>* Other names: CellCept®;|
| Experimental: Denileukin Diftitox<br>Enroll within 48 hours of new onset acute GVHD and randomize to Denileukin Diftitox | Drug: Denileukin Diftitox<br>* Denileukin Diftitox (ONTAK®) [9 mcg/kg intravenously Days 1, 3, 5, 15, 17, 19].<br>* Other names: ONTAK®;|
| Experimental: Pentostatin<br>Enroll within 48 hours of new onset acute GVHD and randomize to Pentostatin | Drug: Pentostatin<br>* Pentostatin [1.5 mg/m2 daily for 3 days; Days 1-3 and repeat Days 15-17<br>* Other names: Nipent®;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Complete Response (CR) at Day 28 of Therapy | Complete response at day 28 after randomization. CR was defined as resolution of all signs and symptoms of Graft-Versus-Host Disease (GVHD) in all evaluable organs in comparison to Day 1 scoring. | Measured at Day 28 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Partial Response (PR), Mixed Response (MR), and Progression | Partial response, mixed response, and progression at Day 28 after randomization. Partial response was defined as improvement in one or more organs involved with Graft-Versus-Host Disease (GVHD) symptoms without progression in others. Mixed response was defined as 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. Progression was defined as deterioration in at least one organ without any improvement in others. | Measured at Day 28 | 
| Proportion of Treatment Failure |  | Measured at Day 56 | 
| Number of Patients With Acute Graft-versus-host Disease (GVHD) Flares at Day 90 | Flares were defined as any increase in symptoms of or therapy for acute GVHD after an initial response (i.e., progression from an earlier CR or PR). | Measured at Day 90 | 
| Number of Patients Discontinuing Immune Suppression Without Flare | Immunosuppression discontinuation was defined as the discontinuation of corticosteroids and all additional immunosuppressives, except cyclosporine or tacrolimus, for treatment of acute GVHD without subsequent flare by Day 90 post-initiation of therapy and later by discontinuation of all immunosuppressive medications, including cyclosporine or tacrolimus. | Measured at Days 90, 180, and 270 post-treatment | 
| Number of Patients With Chronic Graft-versus-host Disease (GVHD) | Number of patients with limited and extensive chronic GVHD at 9 months | Measured at 9 months | 
| Number of Patients Surviving at 6 and 9 Months Post Randomization |  | Measured at 6 and 9 months | 
| Cumulative Incidence of Systemic Infections |  | Measured at Day 270 | 
| Incidence of Epstein-Barr Virus (EBV)-Associated Lymphoma |  | Measured at 9 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Acute Graft vs Host Disease, GVHD