Addition of Etanercept and Extracorporeal Photopheresis (ECP) to Standard Graft-Versus-Host Disease (GVHD) Prophylaxis in Stem Cell Transplant
| Status: | Active, not recruiting |
|---|---|
| Conditions: | Orthopedic, Hematology |
| Therapuetic Areas: | Hematology, Orthopedics / Podiatry |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 4/21/2016 |
| Start Date: | March 2009 |
| End Date: | May 2016 |
Addition of Etanercept and Extracorporeal Photopheresis to Standard GVHD Prophylaxis in Patients Undergoing Reduced Intensity Unrelated Donor Hematopoietic Stem Cell Transplant
This research study investigates the benefits and possible risks of adding both etanercept
(Enbrel) and ECP (extracorporeal photopheresis) to the conventional preventative (or
prophylactic) treatments for graft-versus-host disease (GVHD). GVHD is a common, serious,
and too often fatal, complication after matched unrelated donor stem cell transplantation,
regardless of the pre-transplant conditioning regimen used (full or reduced intensity).
Reduced intensity transplants which employ lower doses of chemotherapy during the
conditioning phase of the transplant, are less toxic than full intensity transplants.
Reduced intensity transplants may extend the unrelated donor transplant option to older
patients or to patients with existing medical conditions or illness, where a full intensity
transplant is not possible. To be successful, reduced intensity transplants need to offset
any lower effectiveness in killing cancer cells during the conditioning phase, with the
establishment of a donor cell, graft-versus-leukemia effect (GVL). The GVL effect and GVHD
are associated with each other and therefore, the goal of GVHD prophylaxis for this study is
not so much to prevent all GVHD, but rather to prevent serious and fatal acute GVHD.
Most GVHD-related deaths are either the direct consequence of severe GVHD or from infections
associated with intense immunosuppression, a consequence of the standard treatments for
acute GVHD, which almost always include high-dose steroids. A more effective prophylaxis
therapy that allows for the GVL effect to develop, while limiting the exposure to high-dose
steroids may reduce transplant mortality and morbidity. We also will study how key chemical
and cellular factors relate to clinical outcome.
(Enbrel) and ECP (extracorporeal photopheresis) to the conventional preventative (or
prophylactic) treatments for graft-versus-host disease (GVHD). GVHD is a common, serious,
and too often fatal, complication after matched unrelated donor stem cell transplantation,
regardless of the pre-transplant conditioning regimen used (full or reduced intensity).
Reduced intensity transplants which employ lower doses of chemotherapy during the
conditioning phase of the transplant, are less toxic than full intensity transplants.
Reduced intensity transplants may extend the unrelated donor transplant option to older
patients or to patients with existing medical conditions or illness, where a full intensity
transplant is not possible. To be successful, reduced intensity transplants need to offset
any lower effectiveness in killing cancer cells during the conditioning phase, with the
establishment of a donor cell, graft-versus-leukemia effect (GVL). The GVL effect and GVHD
are associated with each other and therefore, the goal of GVHD prophylaxis for this study is
not so much to prevent all GVHD, but rather to prevent serious and fatal acute GVHD.
Most GVHD-related deaths are either the direct consequence of severe GVHD or from infections
associated with intense immunosuppression, a consequence of the standard treatments for
acute GVHD, which almost always include high-dose steroids. A more effective prophylaxis
therapy that allows for the GVL effect to develop, while limiting the exposure to high-dose
steroids may reduce transplant mortality and morbidity. We also will study how key chemical
and cellular factors relate to clinical outcome.
Inclusion Criteria:
- Candidate for unrelated donor (allogeneic) HSCT for hematologic conditions, either
malignant or non-malignant.
- Donor can be unrelated marrow, blood or cord blood.
- Any disease for which unrelated donor transplant is appropriate is eligible except:
- Progressive or poorly controlled malignancies for which the likelihood of
durable disease control [i.e., patients expected to have at least 6 months PFS
from date of transplant] is <25%.
- This determination of likelihood of durable disease control must take into
account the patient's disease status and consideration of the agents and doses
used in the reduced intensity conditioning regimen.
- The determination of adequate disease control will be certified by the PI or
designee on the eligibility checklist.
- Patients may be consented to this trial based on disease control at the time of
consent, but later removed from the trial prior to initiation of transplant
conditioning regimen if disease status confirmation between consenting and
transplant changes. In the event this occurs these patients will be replaced.
- Must be receiving a recognized reduced intensity transplant as determined by the
University of Michigan Blood and Marrow Transplantation Program.
- Patients age 50 or older are eligible based on age.
- Patients may be <50 years old if they are eligible for a reduced intensity
conditioning regimen based on disease type (eg, indolent lymphoma) or if
comorbidities preclude a full-intensity transplant.
- Patients must have adequate venous access by either peripheral vein or central line
so that ECP can be performed.
- Patients must be expected to tolerate the fluid shifts associated with ECP. The
primary reason for expected intolerance of ECP is small size (ie, <30kg weight), but
other factors may also be considered in this determination.
Exclusion Criteria:
- Not a candidate for a reduced intensity transplant conditioning regimen (based on the
current U-M BMT program clinical guidelines).
- Patient has a suitable related donor available for transplant.
- Karnofsky or Lansky performance status of < 50% at the time of admission for HSCT
- Patients with evidence of HIV infection or other opportunistic infection including
but not limited to Tuberculosis and Histoplasmosis.
- Patients with active bacterial, fungal or viral infection not responding to
treatment.
- Any medical or psychological conditions that would keep the patient from complying
with the protocol and/or would markedly increase the morbidity and mortality from the
procedure.
- Pregnancy.
- T-cell depleted allograft
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