Conditions: Graft Versus Host Disease
Keywords: Allogeneic stem cell grafts Allogeneic bone marrow graft Blood and Marrow Transplantation Stem cell graft Graft Versus Host Disease GVHD Extracorporeal Photopheresis ECP Photopheresis Methylprednisolone Medrol Depo-Medrol Solu-Medrol
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 81
Healthy volunteers: no

Brief summary:
The goal of this clinical research study is to find out whether adding extracorporeal photopheresis (ECP) to standard therapy for acute GVHD with corticosteroids improves response to treatment, length of treatment, and survival.

Detailed description:
ECP uses ultraviolet A radiation to treat lymphocytes. Although the exact reason why ECP may be beneficial is not completely understood, researchers believe that the lymphocytes treated this way are less likely to continue causing GVHD.

In this study, researchers want to evaluate whether adding another treatment to standard therapy with corticosteroids, in this case ECP, will improve the response to therapy, duration of therapy, and survival. After the diagnosis of acute GVHD, you will be randomly selected (at the toss of a coin) to be in one of 2 treatment groups. One group will receive treatment with corticosteroids (like methylprednisolone or prednisone) alone, and the other will receive ECP treatments in addition to the corticosteroids. ECP treatments are explained below.

In order to have ECP, you will need a special central venous catheter similar to the one you have now. A central venous catheter is a sterile flexible tube that will be placed into a large vein while you are under local anesthesia. Your physician will explain this procedure to you in more detail, and you will be required to sign a separate consent form for this procedure.

Blood is drawn by a machine called "photopheresis machine". This blood goes into a bowl inside the machine, where it is spun and separated into white cells (called buffy coat), red cells, and platelets. The red cells and platelets are promptly returned to you, while the white cells in the buffy coat undergo the process of ECP. The buffy coat will come out of the bowl and will be mixed with a substance called methoxsalen, that will make lymphocytes more sensitive to the effects of light. After mixing with methoxsalen, the buffy coat goes in to chamber where it is exposed to ultraviolet A radiation, and from there back to you. This process is done gradually, in cycles, and takes about 3 hours.

You will have up to 4 of these treatments weekly for the first 14 days of therapy, then 3 treatments weekly from Day 15-28, and after that 2 treatments weekly until Day 60, which is the end of the study. After Day 60, your doctor will decide whether ECP is worth continuing, and also the frequency of treatments. It is not necessary to be in the study to continue to receive ECP treatments. If you respond to the treatment, your corticosteroids will be reduced slowly to prevent the GVHD from coming back.

The length of corticosteroid therapy will depend on how GVHD responds to the treatment. You will follow a corticosteroid therapy tapering schedule according to the suggested guidelines. You will continue to receive tacrolimus or cyclosporine, whichever you have been using as GVHD prevention, throughout the study independent of what treatment group you are assigned.

While you are getting treatment in this study, every week you will have a physical exam and blood (about 1 tablespoon) will be drawn for routine tests. If your doctor thinks it is necessary, blood may be drawn more often.

You will be considered off-study after 6 months of treatment completion. You will be taken off study if you are unable to comply with study requirements, you refuse to continue participation in the study, or intolerable side effects occur.

This is an investigational study. ECP has been approved by the FDA for the treatment of a certain type of lymphomas of the skin and is commercially available. Its use in patients with GVHD is considered to be investigational. Up to 95 patients will take part in this study. All will be enrolled at MD Anderson.

Arms:
arm 1: Methylprednisolone at a dose of 2 mg/kg/day with a taper to no less than 1 mg/kg/day by day 14, and no less than 0.4 mg/kg/day by day 28. arm 2: Extracorporeal Photopheresis (ECP) 8-9 treatments weekly for days 1-14, 6 treatments weekly from days 15-28, and after that 2 treatments weekly until day 60 + Methylprednisolone at a dose of 2 mg/kg/day with a taper to no less than 1 mg/kg/day by day 14, and no less than 0.4 mg/kg/day by day 28.

Interventions: intervention 1: Photopheresis intervention 2: Methylprednisolone
Intervention descriptions: intervention 1: 8-9 photopheresis treatments weekly for days 1-14, 6 treatments weekly from days 15-28, and after that 2 treatments weekly until day 60. After day 60, your doctor will decide whether ECP is worth continuing, and the frequency of treatments. intervention 2: 2 mg/kg daily with a taper to no less than 1 mg/kg/day by day 14, followed by a tapering schedule according to the suggested guidelines.

Protocol document: