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Domingos V, Nezvalova-Henriksen K, Dadkhah A, Moreno-Martinez ME, Ben Hassine K, Pires V, Kröger N, Bauters T, Hassan M, Duncan N, Kalwak K, Ansari M, Langebrake C, Admiraal R. A practical guide to therapeutic drug monitoring in busulfan: recommendations from the Pharmacist Committee of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2024:10.1038/s41409-024-02413-0. [PMID: 39271948 DOI: 10.1038/s41409-024-02413-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 08/01/2024] [Accepted: 09/04/2024] [Indexed: 09/15/2024]
Abstract
Busulfan (Bu) is an important component of many conditioning regimens for allogeneic hematopoietic cell transplantation. The therapeutic window of Bu is well characterized, with strong associations between Bu exposure and the clinical outcome in adults (strongest evidence in myelo-ablative setting) and children (all settings). We provide an overview of the literature on Bu as well as a step-by-step guide to the implementation of Bu therapeutic drug monitoring (TDM). The guide covers the clinical, pharmacological, laboratory and administrative aspects of the procedure. Through this document, we aim to support centers in implementing TDM for Bu to further enhance the success rates of HCT and improve patient outcomes. The Pharmacist Committee of the European Society for Blood and Marrow Transplantation (EBMT) encourages all centers to perform TDM for Bu in the aforementioned indications.
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Affiliation(s)
- Vera Domingos
- Department of Pharmacy, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | | | - Adrin Dadkhah
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria-Estela Moreno-Martinez
- Pharmacy Department, Hospital de la Santa Creu I Sant Pau, IIB Sant Pau, Barcelona, Spain
- School of Health Sciences Blanquerna, University Ramon Lull, Barcelona, Spain
| | - Khalil Ben Hassine
- Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
- Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Geneva, Switzerland
| | - Vera Pires
- Department of Pharmacy, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tiene Bauters
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Moustapha Hassan
- Experimental Cancer Medicine, Division of Biomolecular and Cellular Medicine (BCM), Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Clinical Research Center and Center of Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Nick Duncan
- Pharmacy department, Queen Elizabeth Hospital, Birmingham, UK
| | - Krzysztof Kalwak
- Department of Pediatric Hematology, Oncology and BMT, Wroclaw Medical University, Wroclaw, Poland
| | - Marc Ansari
- Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
- Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Geneva, Switzerland
| | - Claudia Langebrake
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rick Admiraal
- Department of Stem Cell Transplantation, Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands.
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Hughes JH, Long-Boyle J, Keizer RJ. Maximum a posteriori Bayesian methods out-perform non-compartmental analysis for busulfan precision dosing. J Pharmacokinet Pharmacodyn 2024; 51:279-288. [PMID: 38520573 PMCID: PMC11136738 DOI: 10.1007/s10928-024-09915-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
Dose personalization improves patient outcomes for many drugs with a narrow therapeutic index and high inter-individuality variability, including busulfan. Non-compartmental analysis (NCA) and model-based methods like maximum a posteriori Bayesian (MAP) approaches are two methods routinely used for dose optimization. These approaches vary in how they estimate patient-specific pharmacokinetic parameters to inform a dose and the impact of these differences is not well-understood. Using busulfan as an example application and area under the concentration-time curve (AUC) as a target exposure metric, these estimation methods were compared using retrospective patient data (N = 246) and simulated precision dosing treatment courses. NCA was performed with or without peak extension, and MAP Bayesian estimation was performed using either the one-compartment Shukla model or the two-compartment McCune model. All methods showed good agreement on real-world data (correlation coefficients of 0.945-0.998) as assessed by Bland-Altman plots, although agreement between NCA and MAP methods was higher during the first dosing interval (0.982-0.994) compared to subsequent dosing intervals (0.918-0.938). In dose adjustment simulations, both NCA and MAP estimated high target attainment (> 98%) although true simulated target attainment was lower for NCA (63-66%) versus MAP (91-93%). The largest differences in AUC estimation were due to different assumptions for the shape of the concentration curve during the infusion phase, followed by how the methods considered time-dependent clearance and concentration-time points collected in earlier intervals. In conclusion, although AUC estimates between the two methods showed good correlation, in a simulated study, MAP lead to higher target attainment. When changing from one method to another, or changing infusion duration and other factors, optimum estimated exposure targets may require adjusting to maintain a consistent exposure.
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Affiliation(s)
- Jasmine H Hughes
- InsightRX, 548 Market St. #88083, San Francisco, CA, 94104, USA.
| | - Janel Long-Boyle
- Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
- Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplantation, University of California, San Francisco, CA, USA
| | - Ron J Keizer
- InsightRX, 548 Market St. #88083, San Francisco, CA, 94104, USA
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Horikawa S, Kishimoto K, Uemura S, Hyodo S, Kozaki A, Saito A, Ishida T, Mori T, Hasegawa D, Kosaka Y. Impact of prophylactic echinocandin on the development of neurological complications in patients receiving busulfan-containing conditioning regimens for stem cell transplantation: A single-center retrospective study. Pediatr Transplant 2024; 28:e14728. [PMID: 38600717 DOI: 10.1111/petr.14728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/18/2023] [Accepted: 02/16/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Although neurotoxicity is a major adverse event associated with busulfan, little information is available regarding the association between drug interactions and neurological symptoms during busulfan-based regimens. This study evaluated the association between prophylactic echinocandins and neurological complications in patients receiving busulfan-containing conditioning regimens for stem cell transplantation. METHODS We retrospectively included consecutive patients who administered intravenous busulfan as a conditioning regimen at our facility between 2007 and 2022. Prophylactic echinocandin use was defined as the use of an echinocandin antifungal drug to prevent invasive fungal disease in SCT recipients. The primary outcome was the incidence of neurological complications within 7 days of busulfan initiation and was compared between the echinocandin group (patients received prophylactic echinocandin) and nonechinocandin group (patients received prophylactic antifungal drugs other than echinocandin and those without antifungal prophylaxis). RESULTS Among the 59 patients included in this study, the incidence of neurological complications in the echinocandin (n = 26) and nonechinocandin groups (n = 33) was 30.8% and 63.6%, respectively. We observed a negative association between prophylactic echinocandin use and the development of neurological complications after adjusting for the propensity score for receiving prophylactic echinocandins (adjusted odds ratio 0.294, 95% confidence interval 0.090 to 0.959). We observed a lower incidence of neurological complications in the echinocandin group than in the nonechinocandin group. CONCLUSION Our results suggested that the choice of antifungal prophylaxis is associated with busulfan neurotoxicity.
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Affiliation(s)
- Shogo Horikawa
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Kenji Kishimoto
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Suguru Uemura
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Sayaka Hyodo
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Aiko Kozaki
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Atsuro Saito
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Toshiaki Ishida
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Takeshi Mori
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Daiichiro Hasegawa
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
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Hagen P, Norton J, Tsai S, Campo L, Lee M, Gomez K, Stiff P. Busulfan, melphalan and carfilzomib high-dose chemotherapy and autologous haematopoietic stem cell transplantation in multiple myeloma. Br J Haematol 2024; 204:1422-1428. [PMID: 38176404 DOI: 10.1111/bjh.19281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
The standard of care for fit, newly diagnosed multiple myeloma patients includes induction therapy followed by consolidative high-dose chemotherapy with melphalan and autologous stem cell transplant (AHSCT). Intensified preparative regimens, such as busulfan and melphalan (BuMel), have shown promise to lengthen progression-free survival (PFS). We previously reported that the addition of bortezomib to BuMel improved PFS compared to melphalan alone in CIBMTR-matched controls. We now integrate the second-generation protease inhibitor, carfilzomib, before and after BuMel (BuMelCar) in a phase I/II trial with carfilzomib. Patients with NDMM, relapsed/refractory MM (RRMM) and those failing prior AHSCT were eligible. Primary end-points were safety and tolerability. Secondary end-points included minimal residual disease negativity rates, PFS and OS. The study enrolled 19 patients. 73% were high risk either due to R-ISS III status, adverse genetics or relapsed after prior AHSCT. The maximum tolerated dose (MTD) of carfilzomib was determined to be 36 mg/m2. Noted grade 3 toxicities were febrile neutropenia (79%), mucositis (21%) and diarrhoea (16%). The 2-year PFS for the whole cohort and MTD was 89% and 100% respectively. 80% of all patients and 82% of patients in the MTD cohort achieved MRD negativity. Further studies regarding this regimen are planned.
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Affiliation(s)
- Patrick Hagen
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Joseph Norton
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Stephanie Tsai
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Loredana Campo
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Mary Lee
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Kayeromi Gomez
- Clinical Research Office, Center for Translational Research and Education, Loyola University Chicago, Maywood, Illinois, USA
| | - Patrick Stiff
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
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Kim Y, Moon S, Rhee SJ. Optimal Once-Daily Busulfan Administration in Pediatric Patients: A Simulation-Based Investigation of Intravenous Infusion Times. Drug Des Devel Ther 2024; 18:871-879. [PMID: 38524879 PMCID: PMC10961087 DOI: 10.2147/dddt.s451970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose Pediatric patients receiving hematopoietic stem cell transplantation undergo regular administration of intravenous busulfan as a conditioning regimen. Once-daily regimen of busulfan has been proposed as a more convenient alternative to the traditional regimen, but it may increase the risk of toxicity such as veno-occlusive disease (VOD). The study aims to evaluate the pharmacokinetics (PKs) of once-daily regimens and investigate appropriate intravenous infusion times to reduce the risk of toxicity. Patients and methods Once-daily busulfan dosing regimens for pediatric patient were reviewed and selected including EMA- and FDA-based once-daily dosing regimens. We generated busulfan PK data of virtual pediatric patients using a previously developed population PK model. PK profiles and proportion of patients achieving the referenced maximum concentration (Cmax) and exposure to busulfan were used to evaluate the appropriateness of both infusion time and dosing regimens. Results Predicted PK profiles and exposure of busulfan showed relatively similar distributions for all once-daily dosing regimens. Most patients exceeded the referenced Cmax possibly associated with a high risk of VOD with all once-daily regimens when applied with 3 hours of infusion. Conclusion While intravenous infusion of once-daily busulfan is typically administered over 3 hours, our findings emphasize the necessity of considering sufficient infusion times to ensure safe drug utilization and prevent toxicity, which will aid in optimal busulfan use in pediatric oncology.
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Affiliation(s)
- Yun Kim
- College of Pharmacy, Daegu Catholic University, Gyeongsan, 38430, Republic of Korea
| | - Sungha Moon
- College of Pharmacy, Wonkwang University, Iksan, 54538, Republic of Korea
| | - Su-Jin Rhee
- College of Pharmacy, Wonkwang University, Iksan, 54538, Republic of Korea
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Allard J, Bucher S, Ferron PJ, Launay Y, Fromenty B. Busulfan induces steatosis in HepaRG cells but not in primary human hepatocytes: Possible explanations and implication for the prediction of drug-induced liver injury. Fundam Clin Pharmacol 2024; 38:152-167. [PMID: 37665028 DOI: 10.1111/fcp.12951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/27/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND The antineoplastic drug busulfan can induce different hepatic lesions including cholestasis and sinusoidal obstruction syndrome. However, hepatic steatosis has never been reported in patients. OBJECTIVES This study aimed to determine whether busulfan could induce steatosis in primary human hepatocytes (PHH) and differentiated HepaRG cells. METHODS Neutral lipids were determined in PHH and HepaRG cells. Mechanistic investigations were performed in HepaRG cells by measuring metabolic fluxes linked to lipid homeostasis, reduced glutathione (GSH) levels, and expression of genes involved in lipid metabolism and endoplasmic reticulum (ER) stress. Analysis of two previous transcriptomic datasets was carried out. RESULTS Busulfan induced lipid accumulation in HepaRG cells but not in six different batches of PHH. In HepaRG cells, busulfan impaired VLDL secretion, increased fatty acid uptake, and induced ER stress. Transcriptomic data analysis and decreased GSH levels suggested that busulfan-induced steatosis might be linked to the high expression of glutathione S-transferase (GST) isoenzyme A1, which is responsible for the formation of the hepatotoxic sulfonium cation conjugate. In keeping with this, the GST inhibitor ethacrynic acid and the chemical chaperone tauroursodeoxycholic acid alleviated busulfan-induced lipid accumulation in HepaRG cells supporting the role of the sulfonium cation conjugate and ER stress in steatosis. CONCLUSION While the HepaRG cell line is an invaluable tool for pharmacotoxicological studies, it might not be always an appropriate model to predict and mechanistically investigate drug-induced liver injury. Hence, we recommend carrying out toxicological investigations in both HepaRG cells and PHH to avoid drawing wrong conclusions on the potential hepatotoxicity of drugs and other xenobiotics.
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Affiliation(s)
- Julien Allard
- Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Pierre-Jean Ferron
- INSERM, Univ Rennes, INRAE, Institut NUMECAN (Nutrition Metabolisms and Cancer) UMR_A 1341, UMR_S 1317, Rennes, France
| | - Youenn Launay
- INSERM, Univ Rennes, INRAE, Institut NUMECAN (Nutrition Metabolisms and Cancer) UMR_A 1341, UMR_S 1317, Rennes, France
| | - Bernard Fromenty
- INSERM, Univ Rennes, INRAE, Institut NUMECAN (Nutrition Metabolisms and Cancer) UMR_A 1341, UMR_S 1317, Rennes, France
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Combarel D, Tran J, Delahousse J, Vassal G, Paci A. Individualizing busulfan dose in specific populations and evaluating the risk of pharmacokinetic drug-drug interactions. Expert Opin Drug Metab Toxicol 2023; 19:75-90. [PMID: 36939456 DOI: 10.1080/17425255.2023.2192924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Busulfan is an alkylating agent widely used in the conditioning of hematopoietic stem cell transplantation possessing a complex metabolism and a large interindividual and intra-individual variability, especially in children. Combined with the strong rationale of busulfan PK/PD relationships, factors altering its clearance (e.g., weight, age, and GST-A genetic polymorphism mainly) can also affect clinical outcomes. AREAS COVERED This review aims to provide an overview of the current knowledge on busulfan pharmacokinetics, its pharmacokinetics variabilities in pediatric populations, drug-drug interactions (DDI), and their consequences regarding dose individualization. This review was based on medical literature up until October 2021. EXPERT OPINION To ensure effective busulfan exposure in pediatrics, different weight-based nomograms have been established to determine busulfan dosage and provided improved results (65 - 80% of patients correctly exposed). In addition to nomograms, therapeutic drug monitoring (TDM) of busulfan measuring plasmatic concentrations to estimate busulfan pharmacokinetic parameters can be used. TDM is now widely carried out in routine practices and aims to ensure the targeting of the reported therapeutic windows by individualizing busulfan dosing based on the clearance estimations from a previous dose.
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Affiliation(s)
- David Combarel
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France.,Université Paris-Saclay, Faculté de Pharmacie, Université Paris-Saclay, Chatenay-Malabry, France
| | - Julie Tran
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Julia Delahousse
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Gilles Vassal
- Gustave Roussy Comprehensive Cancer Center, & University Paris-Saclay, Villejuif, France
| | - Angelo Paci
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France.,Université Paris-Saclay, Faculté de Pharmacie, Université Paris-Saclay, Chatenay-Malabry, France
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Al-Enezi BF, Al-Hasawi N, Matar KM. Impact of valproic acid on busulfan pharmacokinetics: In vitro assessment of potential drug-drug interaction. PLoS One 2023; 18:e0280574. [PMID: 36696427 PMCID: PMC9876357 DOI: 10.1371/journal.pone.0280574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 01/03/2023] [Indexed: 01/26/2023] Open
Abstract
Busulfan (Bu) is an alkylating agent commonly used at high doses in the preparative regimens of hematopoietic stem cell transplantation (HSCT). It has been shown that such high doses of Bu are associated with generalized seizures which are usually managed by prophylactic antiepileptic drugs (AEDs) such as valproic acid (VPA). Being a strong enzyme inhibitor, VPA may inhibit Bu metabolism and thus increase its potential toxicity. Despite its clinical relevance, the potential interaction between Bu and VPA has not yet been evaluated. The aim of the present study was to assess and evaluate the potential drug-drug interaction (DDI) between Bu and VPA. This study was carried out by incubating Bu in laboratory-prepared rat liver-subcellular fractions including S9, microsomes, and cytosol, alone or in combination with VPA. The liver fractions were prepared by differential centrifugation of the liver homogenate. Analysis of Bu was employed using a fully validated LC-MS/MS method. The validation parameters were within the proposed limits of the international standards guidelines. Bu metabolic stability was assessed by incubating Bu at a concentration of 8 μg/ml in liver fractions at 37°C. There were significant reductions in Bu levels in S9 and cytosolic fractions, whereas these levels were not significantly (P ˃ 0.05) changed in microsomes. However, in presence of VPA, Bu levels in S9 fraction remained unchanged. These results indicated, for the first time, the potential metabolic interaction of Bu and VPA being in S9 only. This could be explained by inhibiting Bu cytosolic metabolism by the interaction with VPA either by sharing the same metabolic enzyme or the required co-factor. In conclusion, the present findings suggest, for the first time, a potential DDI between Bu and VPA in vitro using rat liver fractions. Further investigations are warranted in human-derived liver fractions to confirm such an interaction.
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Affiliation(s)
- Bashayer F. Al-Enezi
- Department of Pharmacology & Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Nada Al-Hasawi
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Kamal M. Matar
- Department of Pharmacology & Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
- * E-mail: ,
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Vegel A, Safa F, Safah H, Socola F, Ziglar N, Rink J, Entwisle S, Saba N. Outcomes of a Non-thiotepa Conditioning Regimen with BuCyE and ASCT for CNS Lymphoma: A Series of Three Patients. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2023. [DOI: 10.1016/j.cpccr.2023.100217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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10
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Smita P, Narayan PA, J K, Gaurav P. Therapeutic drug monitoring for cytotoxic anticancer drugs: Principles and evidence-based practices. Front Oncol 2022; 12:1015200. [PMID: 36568145 PMCID: PMC9773989 DOI: 10.3389/fonc.2022.1015200] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Cytotoxic drugs are highly efficacious and also have low therapeutic index. A great degree of caution needs to be exercised in their usage. To optimize the efficacy these drugs need to be given at maximum tolerated dose which leads to significant amount of toxicity to the patient. The fine balance between efficacy and safety is the key to the success of cytotoxic chemotherapeutics. However, it is possibly more rewarding to obtain that balance for this class drugs as the frequency of drug related toxicities are higher compared to the other therapeutic class and are potentially life threatening and may cause prolonged morbidity. Significant efforts have been invested in last three to four decades in therapeutic drug monitoring (TDM) research to understand the relationship between the drug concentration and the response achieved for therapeutic efficacy as well as drug toxicity for cytotoxic drugs. TDM evolved over this period and the evidence gathered favored its routine use for certain drugs. Since, TDM is an expensive endeavor both from economic and logistic point of view, to justify its use it is necessary to demonstrate that the implementation leads to perceivable improvement in the patient outcomes. It is indeed challenging to prove the utility of TDM in randomized controlled trials and at times may be nearly impossible to generate such data in view of the obvious findings and concern of compromising patient safety. Therefore, good quality data from well-designed observational study do add immense value to the scientific knowledge base, when they are examined in totality, despite the heterogeneity amongst them. This article compiles the summary of the evidence and the best practices for TDM for the three cytotoxic drug, busulfan, 5-FU and methotrexate. Traditional use of TDM or drug concentration data for dose modification has been witnessing a sea change and model informed precision dosing is the future of cytotoxic drug therapeutic management.
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Affiliation(s)
- Pattanaik Smita
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Patil Amol Narayan
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kumaravel J
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prakash Gaurav
- Department of Clinical Hematology and Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Gaffney KJ, Urban TA, Lucena M, Anwer F, Dean RM, Gerds AT, Hamilton BK, Jagadeesh D, Kalaycio ME, Khouri J, Pohlman B, Sobecks R, Winter A, Rybicki L, Majhail NS, Hill BT. Toxicity analysis of busulfan pharmacokinetic therapeutic dose monitoring. J Oncol Pharm Pract 2022:10781552221104422. [PMID: 35673764 DOI: 10.1177/10781552221104422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Busulfan-based conditioning regimens are associated with serious toxicities and literature reports increased risk of toxicities when daily area under the curve concentrations exceed 6000 µM-minute. We implemented real time pharmacokinetic-guided therapeutic drug monitoring of busulfan for myeloablative conditioning regimens. The objective was to compare toxicity of intravenous busulfan before and after therapeutic drug monitoring implementation. The primary endpoint was incidence of hepatotoxicity. Medical records were retrospectively reviewed with weight-based dose Busulfan/Cyclophosphamide (BuCy) conditioning from August 2017 through March 2018 (N = 14) and therapeutic drug monitoring from April 2018 through December 2018 (N = 22). Recipients of busulfan therapeutic drug monitoring were younger than those receiving weight-based dose (median: 45 vs. 58 years, p = 0.008). No other baseline differences were observed. There was no difference in hepatotoxicity between therapeutic drug monitoring and weight-based dose (median 1 vs. 0 days, p = 0.40). In the therapeutic drug monitoring group, 45% of patients had increases and 41% had decreases in busulfan dose after Bu1. Repeat pharmacokinetic after Bu2 were required in 32% of patients. A pharmacokinetic dose monitoring program for myeloablative conditioning intravenous busulfan regimens may be considered a safe practice in stem cell transplant recipients. The majority of patients receiving pharmacokinetic-guided therapeutic drug monitoring required dose changes and therapeutic drug monitoring patients had no significant difference in toxicity compared to those receiving weight-based dose.
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Affiliation(s)
- Kelly J Gaffney
- 2345Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Faiz Anwer
- 2569Cleveland Clinic, Cleveland, OH, USA
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Artul T, Henig I, Nassar L, Yehudai-Ofir D, Scherb I, Lurie Y, Efrati E, Zuckerman T, Kurnik D. Decreased Systemic Busulfan Exposure After Oral Dosing With Concomitant Levetiracetam Compared With Phenytoin. Ther Drug Monit 2022; 44:414-418. [PMID: 34739424 DOI: 10.1097/ftd.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Busulfan (Bu) conditioning used in hematopoietic stem cell transplantation may induce seizures, and prophylactic antiepileptic treatment is recommended. Following updated guidelines, in August 2019, the adult hematopoietic stem cell transplantation department of the Rambam Health Care Campus (Haifa, Israel) switched the antiepileptic prophylaxis protocol from phenytoin to oral levetiracetam during oral Bu conditioning. The aim of this study was to compare the pharmacokinetic parameters of Bu after oral dosing between patients receiving phenytoin and those receiving levetiracetam prophylaxis. METHODS This study was a retrospective cohort study in adults undergoing myoablative conditioning with oral Bu between August 2018 and August 2020. Bu pharmacokinetic parameters (AUC0-6, C0, Cmax, and Tmax) were compared in patients treated with phenytoin comedication (during the year before the change in policy) and levetiracetam comedication (during the year after the change). Potential confounders were accounted for including age, azole comedication, and body weight. RESULTS There were no significant differences in demographic and clinical parameters or weight-corrected Bu dose between the phenytoin group (n = 28) and the levetiracetam group (n = 25). There was no difference in the rate of voriconazole comedication, but fluconazole was more common in the phenytoin group (P = 0.026). The median AUC0-6 was significantly lower in the levetiracetam group (949 μM*min; IQR = 806 to 1101 μM*min) than in the phenytoin group (1208 μM*min; IQR = 1087 to 1389 μM*min; P < 0.001). This is a clinically significant difference of 258 μM*min (21%). Azole use was not associated with Bu exposure. CONCLUSIONS The findings suggest that, after treatment with oral Bu, oral levetiracetam comedication is associated with reduced systemic exposure compared with phenytoin comedication, possibly because of decreased bioavailability.
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Affiliation(s)
- Tareq Artul
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
| | - Israel Henig
- Adult Bone Marrow Transplantation Unit, Hematology Department, Rambam Health Care Campus, Haifa, Israel; and
| | - Laila Nassar
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Dana Yehudai-Ofir
- Adult Bone Marrow Transplantation Unit, Hematology Department, Rambam Health Care Campus, Haifa, Israel; and
| | - Inna Scherb
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
| | - Yael Lurie
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Edna Efrati
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
| | - Tsila Zuckerman
- Adult Bone Marrow Transplantation Unit, Hematology Department, Rambam Health Care Campus, Haifa, Israel; and
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Daniel Kurnik
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
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13
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Alatrash G, Saberian C, Bassett R, Thall PF, Ledesma C, Lu Y, Daher M, Valdez BC, Kawedia J, Popat U, Mehta R, Oran B, Nieto Y, Olson A, Anderlini P, Marin D, Hosing C, Alousi AM, Shpall EJ, Rondon G, Chen J, Qazilbash M, Champlin RE, Andersson BS, Kebriaei P. Vorinostat combined with Busulfan, Fludarabine, and Clofarabine Conditioning Regimen for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acute Leukemia: Long-term Study Outcomes. Transplant Cell Ther 2022; 28:501.e1-501.e7. [DOI: 10.1016/j.jtct.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/15/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
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14
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Kume T, Shimizu R, Akiyama K, Tsuchiya T, Shino M, Ikeda T, Iwai S. Hand-foot syndrome and risk factors for occurrence in hematopoietic stem cell transplantation recipients. Support Care Cancer 2021; 30:1539-1546. [PMID: 34536133 DOI: 10.1007/s00520-021-06573-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/13/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Hand-foot syndrome (HFS) is a typical skin disorder caused by the use of cytotoxic anticancer drugs and molecular targets. Similarly, various anticancer drugs have been used as a conditioning regimen for hematopoietic stem cell transplantation (HSCT), and skin disorders such as HFS have been reported. The aim of this study was to determine retrospectively the frequency of HFS in recipients who have received a first allogeneic HSCT and the risk factors for HFS occurrence. METHODS We retrospectively investigated the medical records of recipients who received their first allogeneic HSCT and neutrophil engraftment at Shizuoka Cancer Center from January 1, 2011, to December 31, 2019. RESULTS The occurrence of HFS was confirmed in 78 cases (48.1%), and no grade 3 HFS was confirmed. The median occurrence of HFS was 8 (- 3 to 19) days. In recipients with and without confirmed HFS, the median neutrophil engraftment day was 16.5 (10-33) and 15.0 (11-26) days, respectively (p = 0.013). Multivariate analysis indicated that the frequency of HFS was statistically significantly higher in women (p = 0.032), recipients administered busulfan (Bu) four times daily (p = 0.011), and recipients previously treated with anthracycline (p = 0.002). CONCLUSION Attention should be paid to HFS that occurs due to the conditioning regimen for HSCT in women, recipients who received 0.8 mg/kg of Bu four times a day, and recipients with a history of anthracycline administration, as HFS may affect the duration to neutrophil engraftment.
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Affiliation(s)
- Tetsuo Kume
- Department of Healthcare and Regulatory Sciences, Showa University School of Pharmacy, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan. .,Department of Pharmacy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Rika Shimizu
- Department of Nursing, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kana Akiyama
- Department of Pharmacy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Takayuki Tsuchiya
- Department of Pharmacy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Michihiro Shino
- Department of Pharmacy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Takashi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shinichi Iwai
- Department of Healthcare and Regulatory Sciences, Showa University School of Pharmacy, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
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15
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Remy A, Théorêt Y, Ansari M, Bittencourt H, Ducruet T, Nava T, Pastore Y, Rezgui MA, Krajinovic M, Kleiber N. Is Busulfan Clearance Different in Patients With Sickle Cell Disease? Let's Clear Up That Case With Some Controls. J Pediatr Hematol Oncol 2021; 43:e867-e872. [PMID: 33661168 DOI: 10.1097/mph.0000000000002106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 12/28/2020] [Indexed: 11/26/2022]
Abstract
In busulfan-based conditioning regimen for hematopoietic stem cell transplantation in children, accurate a priori determination of the first dose is important because of its narrow therapeutic window. Sickle cell disease (SCD) influences pharmacokinetics of the commonly used drugs by affecting organs responsible for drug metabolism and elimination. This pharmacokinetics study assesses the influence of SCD on the metabolic pathway of busulfan that is mainly metabolized in the liver. In this retrospective cross-sectional case-control study, 16 patients with SCD were matched to 50 patients without SCD on known busulfan clearance's covariates (glutathione-S-transferase alpha1 polymorphisms, age, weight). Clearance of the first dose of busulfan was not significantly different independently of genetic or anthropometric factors in patients with or without SCD.
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Affiliation(s)
- Amandine Remy
- Department of Pediatric Hematology, Univ. Lille, CHU Lille, Lille, France
- Unité de pharmacologie clinique
| | - Yves Théorêt
- Unité de pharmacologie clinique
- Departments of Pharmacology and Physiology
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Université de Montréal
| | - Marc Ansari
- CANSEARCH Research Laboratory, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva
- Department of Women-Children-Adolescents, Division of General Pediatrics, Pediatric Onco-Hematology Unit, Geneva University Hospital, Geneva, Switzerland
| | - Henrique Bittencourt
- Pediatrics
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Université de Montréal
| | - Thierry Ducruet
- Applied Clinical Research Unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - Tiago Nava
- CANSEARCH Research Laboratory, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva
- Department of Women-Children-Adolescents, Division of General Pediatrics, Pediatric Onco-Hematology Unit, Geneva University Hospital, Geneva, Switzerland
| | - Yves Pastore
- Pediatrics
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Université de Montréal
| | - Mohamed A Rezgui
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Université de Montréal
| | - Maja Krajinovic
- Departments of Pharmacology and Physiology
- Pediatrics
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Université de Montréal
| | - Niina Kleiber
- Departments of Pharmacology and Physiology
- Pediatrics
- Research Center, CHU Sainte-Justine
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16
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Park S, Shin DY, Hong J, Kim I, Koh Y, Byun JM, Yoon SS. Busulfan plus melphalan versus melphalan alone conditioning regimen after bortezomib based triplet induction chemotherapy for patients with newly diagnosed multiple myeloma. Ther Adv Hematol 2021; 12:20406207211012985. [PMID: 33995990 PMCID: PMC8111524 DOI: 10.1177/20406207211012985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background: High dose melphalan (HDMEL) is considered the standard conditioning regimen for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) patients. Recent studies showed superiority of busulfan plus melphalan (BUMEL) compared to HDMEL as a conditioning regimen. We compared the efficacy of HDMEL and BUMEL in newly diagnosed Asian MM patients, who are often underrepresented. Methods: This is a single-center, retrospective study including MM patients who underwent ASCT after bortezomib-thalidomide-dexamethasone (VTD) triplet induction chemotherapy between January 2015 and August 2019. Result: In the end, 79 patients in the HDMEL group were compared to 31 patients in the BUMEL group. There were no differences between the two groups with regards to sex, age at ASCT, risk group, and stage. The HDMEL group showed better response to pre-transplant VTD compared to BUMEL, but after ASCT the BUMEL group showed better overall response. In terms of progression-free survival (PFS), although BUMEL showed trends towards better PFS regardless of pre-transplant status and age, the difference did not reach statistical significance. The BUMEL group more often experienced mucositis related to chemotherapy, but there was no difference between the two groups with regards to hospitalization days, cell engraftment, and infection rates. Conclusion: BUMEL conditioning deserves attention as the alternative option to HDMEL for newly diagnosed MM patients, even in the era of triplet induction chemotherapy. Specifically, patients achieving very good partial response (VGPR) or better response with triplet induction chemotherapy might benefit the most from BUMEL conditioning. Tailored conditioning regimen, based on patient’s response to induction chemotherapy and co-morbidities, can lead to better treatment outcomes.
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Affiliation(s)
- Songyi Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongro-gu, Seoul 03080, Republic of Korea
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17
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Busulfan and melphalan conditioning is superior to melphalan alone in autologous stem cell transplantation for high-risk MM. Blood Adv 2020; 4:4834-4837. [PMID: 33027527 DOI: 10.1182/bloodadvances.2020002590] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/28/2020] [Indexed: 01/09/2023] Open
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18
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Esteves I, Santos FPS, Ribeiro AAF, Seber A, Sugawara EK, Sobrinho JJDN, Barros JC, Oliveira JSR, Fernandes JF, Hamerschlak N, Andersson BS, de Lima M, Kerbauy FR. Targeted-dose of busulfan: Higher risk of sinusoidal obstructive syndrome observed with systemic exposure dose above 5000 µMol⸱min. A historically controlled clinical trial. Hematol Oncol 2020; 38:773-781. [PMID: 32779746 DOI: 10.1002/hon.2789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 07/22/2020] [Accepted: 08/07/2020] [Indexed: 11/12/2022]
Abstract
Busulfan is given in the conditioning regimens preceding hematopoietic stem cell transplantation (HSCT), and plasma levels can be monitored. A targeted, individualized systemic exposure (SE) dose can be achieved by calculating the area under the plasma concentration versus time curve (AUC). The objective of this study was to determine a cutoff value for safety for the AUC for busulfan plasma levels in patients undergoing HSCT. A total of 149 consecutive HSCT patients were studied. After an oral test dose of busulfan, we set target doses of 4000, 5000, or 6000 µMol⸱min/day, and analyzed the AUC of oral or intravenous Bu. These patients were compared with 53 historical control subjects who had received myeloablative conditioning regimen without busulfan pharmacokinetic monitoring. Using a test dose and the administration route had no impact on the sinusoidal obstructive syndrome (SOS) incidence, transplant-related mortality or 1-year overall survival. However, patients receiving busulfan at doses set up at AUC > 5000 had an increased risk to develop SOS after HSCT (hazard ratio 3.39, p = 0.034, 95% CI 1.09-10.52). Adjusting the busulfan dose according to SE levels target dose during conditioning is associated with lower rates of oral severe mucositis and SOS. A cutoff of 5000 µMol⸱min is safe and does not impair survival.
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Affiliation(s)
- Iracema Esteves
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | | | | | | | | | - José Carlos Barros
- Transplantation, Hospital Dr. Euryclides de Jesus Zerbini, São Paulo, Brazil
| | | | - Juliana Folloni Fernandes
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,Bone Marrow Transplantation Unit, Itaci Hospital, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | | | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marcos de Lima
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio, USA
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19
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Solans BP, Chiesa R, Doncheva B, Prunty H, Veys P, Trocóniz IF, Standing JF. Modelling of neutrophil dynamics in children receiving busulfan or treosulfan for haematopoietic stem cell transplant conditioning. Br J Clin Pharmacol 2020; 86:1537-1549. [PMID: 32077123 DOI: 10.1111/bcp.14260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/16/2020] [Accepted: 02/01/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Busulfan and treosulfan are cytotoxic agents used in the conditioning regime prior to paediatric haematopoietic stem cell transplantation (HSCT). These agents cause suppression of myeloid cells leaving patients severely immunocompromised in the early post-HSCT period. The main objectives were: (i) to establish a mechanistic pharmacokinetic-pharmacodynamic (PKPD) model for the treatment and engraftment effects on neutrophil counts comparing busulfan and treosulfan-based conditioning, and (ii) to explore current dosing schedules with respect to time to HSCT. METHODS Data on 126 patients, 72 receiving busulfan (7 months-18 years, 5.1-47.0 kg) and 54 treosulfan (4 months-17 years, 3.8-35.8 kg), were collected. In total, 8935 neutrophil count observations were recorded during the study period in addition to drug concentrations to develop a mechanistic PKPD model. Absolute neutrophil count profiles were modelled semimechanistically, accounting for transplant effects and differing set points pre- and post-transplant. RESULTS PK were best described by 2-compartment models for both drugs. The Friberg semimechanistic neutropenia model was applied with a linear model for busulfan and a maximum efficacy model for treosulfan describing drug effects at various stages of neutrophil maturation. System parameters were consistent across both drugs. The HSCT was represented by an amount of progenitor cells enhancing the neutrophils' proliferation and maturation compartments. Alemtuzumab was found to enhance the proliferative rate under which the absolute neutrophil count begin to grow after HSCT. CONCLUSION A semimechanistic PKPD model linking exposure to either busulfan or treosulfan to the neutrophil reconstitution dynamics was successfully built. Alemtuzumab coadministration enhanced the neutrophil proliferative rate after HSCT. Treosulfan administration was suggested to be delayed with respect to time to HSCT, leaving less time between the end of the administration and stem cell infusion.
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Affiliation(s)
- Belén P Solans
- Pharmacometrics and Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Robert Chiesa
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, London, UK
| | - Bilyana Doncheva
- Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK
| | - Helen Prunty
- Department of Chemical Pathology, Great Ormond Street Hospital for Children, London, UK
| | - Paul Veys
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, London, UK
| | - Iñaki F Trocóniz
- Pharmacometrics and Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Joseph F Standing
- Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK.,Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,Paediatric Infectious Diseases Group, St George's, University of London, UK
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20
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Radhakrishnan SV, Boyer M, Sherwin CM, Zangari M, Tricot G. A Phase 1 Study of Intravenous Busulfan as a Conditioning Regimen for Multiple Myeloma. Cell Transplant 2019; 28:1624-1631. [PMID: 31619057 PMCID: PMC6923548 DOI: 10.1177/0963689719880541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The efficacy of melphalan (MEL) 140 mg/m2 pre-transplant conditioning versus
MEL 200 mg/m2 for the elderly is still debated. We hypothesized that
single-agent intravenous busulfan (BU) would show significant anti-myeloma efficacy and be
better tolerated by elderly patients. A prospective 3+3 dose escalation study enrolled
symptomatic multiple myeloma (MM) patients 65 years or older with SWOG performance 0–2 for
treatment with intravenous BU pre-transplant at different administration levels. The
primary objective was to determine the maximum tolerated dose (MTD) of BU that could be
safely given over the least number of days. All patients, except one, received maintenance
treatment post-transplant, mostly for 2 years. We enrolled 13 patients, mean age of 73
years (range 68–80). Pharmacokinetic analysis showed no greater than 2% accumulation in
the 13 patients, confirming a lack of accumulation in the multi-dose regimen. No deaths
occurred in the peri-transplant period. Grade 3/4 adverse effects were hematological, no
dose-limiting toxicity was observed and MTD was not reached. Three patients developed
grade 3 mucositis but none developed veno-occlusive disease. Ten (77%) patients achieved a
complete remission (CR) post-transplant with a remarkably long average time to best
response of 6.7 months (range: 6–14 m), and two attained a partial response. Median
overall survival was 84 months (95% CI, 21–104) and the median progression-free survival
was 60 months (95% CI, 9–93). Our results suggest that IV BU could be an alternative
conditioning regimen to MEL 140 in elderly patients with MM, and supports future
randomized trials.
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Affiliation(s)
- Sabarinath V Radhakrishnan
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Michael Boyer
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Department of Pediatrics, Dayton Children's Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Maurizio Zangari
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Guido Tricot
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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21
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Hill BT, Rybicki LA, Urban TA, Lucena M, Jagadeesh D, Gerds AT, Dean RM, Sobecks RM, Pohlman B, Bolwell B, Kalaycio ME, Hamilton BK, Copelan EA, Majhail NS. Therapeutic Dose Monitoring of Busulfan Is Associated with Reduced Risk of Relapse in Non-Hodgkin Lymphoma Patients Undergoing Autologous Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:262-271. [PMID: 31610237 DOI: 10.1016/j.bbmt.2019.09.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/10/2019] [Accepted: 09/28/2019] [Indexed: 11/28/2022]
Abstract
Optimal administration of busulfan (Bu) is hampered by variable and unpredictable drug metabolism in individual patients. At our institution, Bu was previously administered with fixed weight-based dosing (WBD) in combination with cyclophosphamide (Cy) and etoposide (E) for patients with non-Hodgkin lymphoma (NHL) undergoing autologous stem cell transplantation (ASCT). In 2014, we adopted real-time pharmacokinetic (PK)-guided therapeutic drug monitoring (TDM) of Bu for all NHL patients undergoing Bu-containing ASCT. Here we compare outcomes of NHL patients who underwent ASCT with Bu/Cy/E using WBD and those who did so using TDM of Bu. We studied 336 consecutive adult NHL patients who underwent ASCT with Bu/Cy/E using WBD from January 2007 to December 2013 (n = 258) or TDM from May 2014 to December 2017 (n = 78), excluding patients with mantle cell lymphoma. Clinical outcomes, including relapse, nonrelapse mortality (NRM), progression-free survival (PFS), and overall survival (OS), hepatotoxicity and pulmonary toxicity were compared in the 2 groups. To adjust for differences in baseline characteristics between the groups, propensity-matched cohorts of WBD and TDM patients were also studied. After the first dose of Bu, the dose was increased in 36% of the patients and decreased in 41%. Changes in pulmonary and liver function from baseline to transplantation were not different between the 2 groups, although these changes showed significantly less variability with TDM than with WBD. Relapse was significantly lower and PFS was improved with TDM; 2-year estimates were 19% for TDM and 38% for WBD for relapse (P = .004) and 69% and 55%, respectively, for PFS (P = .038). No significant between-group differences in NRM or OS were seen. In multivariable analysis, TDM remained prognostic for lower risk of relapse (hazard ratio [HR], .52; 95% confidence interval [CI], .30 to .89; P = .018), but did not remain prognostic for PFS (HR, .74; 95% CI, .48 to 1.16; P = .19). Propensity-matched cohorts displayed similar patterns of outcomes. In subset analysis based on disease status at ASCT, TDM was associated with less relapse and better PFS than WBD for patients who underwent transplantation in less than complete remission (CR) compared with those who underwent transplantation in CR. Compared with WBD, PK-directed TDM of Bu reduces the incidence of relapse when used in combination with Cy and E for patients with NHL undergoing ASCT, particularly for patients in less than CR. These data support the continued use of personalized PK-guided dosing for all NHL patients undergoing ASCT with Bu-containing preparative regimens.
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Affiliation(s)
- Brian T Hill
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina.
| | - Lisa A Rybicki
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | | | - Mariana Lucena
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Deepa Jagadeesh
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Aaron T Gerds
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Robert M Dean
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Ronald M Sobecks
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Brad Pohlman
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Brian Bolwell
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Matt E Kalaycio
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Betty K Hamilton
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Edward A Copelan
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio; Levine Cancer Institute, Charlotte, North Carolina
| | - Navneet S Majhail
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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22
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McCune JS, Wang T, Bo-Subait K, Aljurf M, Beitinjaneh A, Bubalo J, Cahn JY, Cerny J, Chhabra S, Cumpston A, Dupuis LL, Lazarus HM, Marks DI, Maziarz RT, Norkin M, Prestidge T, Mineishi S, Krem MM, Pasquini M, Martin PJ. Association of Antiepileptic Medications with Outcomes after Allogeneic Hematopoietic Cell Transplantation with Busulfan/Cyclophosphamide Conditioning. Biol Blood Marrow Transplant 2019; 25:1424-1431. [PMID: 30871976 PMCID: PMC6615968 DOI: 10.1016/j.bbmt.2019.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/03/2019] [Indexed: 01/07/2023]
Abstract
High-dose busulfan (BU) followed by high-dose cyclophosphamide (CY) before allogeneic hematopoietic cell transplantation (HCT) has long been used as treatment for hematologic malignancies. Administration of phenytoin or newer alternative antiepileptic medications (AEMs) prevents seizures caused by BU. Phenytoin induces enzymes that increase exposure to active CY metabolites in vivo, whereas alternative AEMs do not have this effect. Lower exposure to active CY metabolites with the use of alternative AEMs could decrease the risk of toxicity but might increase the risk of recurrent malignancy after HCT. Previous studies have not determined whether outcomes with alternative AEMs differ from those with phenytoin in patients treated with BU/CY before allogeneic HCT. We studied a cohort of 2155 patients, including 1460 treated with phenytoin and 695 treated with alternative AEMs, who received BU/CY before allogeneic HCT between 2004 and 2014. We found no differences suggesting decreased overall survival or relapse-free survival or increased risks of relapse, nonrelapse mortality, acute or chronic graft-versus-host disease, or regimen-related toxicity associated with the use of alternative AEMs compared with phenytoin. The risk of dialysis was lower in the alternative AEM group than in the phenytoin group. Alternative AEMs are safe for prevention of seizures after BU administration and can avoid the undesirable toxicities and drug interactions caused by phenytoin.
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Affiliation(s)
- Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA, USA; Department of Population Sciences, City of Hope, Duarte, CA, USA.
| | - Tao Wang
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Khalid Bo-Subait
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mahmoud Aljurf
- Adult HSCT Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Amer Beitinjaneh
- Department of Medicine, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Joseph Bubalo
- Department of Medicine, Oregon Health and Science University Hospital, Portland, OR, USA
| | - Jean-Yves Cahn
- Department of Medicine, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Jan Cerny
- Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Saurabh Chhabra
- Department of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Aaron Cumpston
- Division of Oncology, West Virginia University Hospitals, Morgantown, WV, USA
| | - L Lee Dupuis
- The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Hillard M Lazarus
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David I Marks
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Richard T Maziarz
- Department of Medicine, Oregon Health and Science University Hospital, Portland, OR, USA
| | - Maxim Norkin
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Child Health, Central Auckland, New Zealand
| | - Shin Mineishi
- Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Maxwell M Krem
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA, USA
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23
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Use of busulfan in conditioning for allogeneic hematopoietic stem cell transplantation in adults: a survey by the Transplant Complications Working Party of the EBMT. Bone Marrow Transplant 2019; 54:2013-2019. [PMID: 31160806 DOI: 10.1038/s41409-019-0579-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 11/08/2022]
Abstract
A survey was carried out among EBMT centers about the use of busulfan for conditioning in allogeneic stem cell transplantation. Of 109 responding centers, 106 used busulfan for conditioning, 102 in conventional myeloablative doses, and 93 in reduced doses (RIC). The route of administration was mostly intravenous, but ~10% of the centers gave the drug orally. The number of doses in i.v. administration varied and was in myeloablative conditioning mostly one (50 centers) or four (43 centers) doses a day. Seventeen of the 106 centers used pharmacokinetics for dose adjustment in myeloablative conditioning, nine in RIC. The details of pharmacokinetic monitoring varied markedly. Three quarters of the centers reported adjusting the dose based on obesity in myeloablative conditioning and about 60% in RIC. The most common method for dose calculation was ideal body weight + 0.25 × (actual body weight - ideal body weight). In conclusion, the present survey showed marked heterogeneity in the current practices of busulfan administration for conditioning. The impact of the heterogeneity is not well known. Due to this and the scarcity of support from controlled clinical studies, no clear guidelines can be presented, but some prevailing policies to be recommended were identified.
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24
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Pharmacokinetics analysis results are similar for oral compared to intravenous busulfan in patients undergoing hematopoietic stem cell transplantation, except for the earlier onset of mucositis. A controlled clinical study. Bone Marrow Transplant 2019; 54:1799-1804. [PMID: 31089278 DOI: 10.1038/s41409-019-0521-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/03/2019] [Accepted: 03/12/2019] [Indexed: 11/08/2022]
Abstract
Busulfan is used in myeloablative schemes for hematopoietic stem cell transplantation (HSCT), with monitoring of dosage through the area under the curve (AUC) of the drug plasma concentration (µMol min). In this study, we compared the complete pharmacokinetics of busulfan administered orally (Bu-Oral) and intravenously (Bu-IV). We evaluated 40 patients who underwent HSCT with different types of conditioning regimens. After one dose, in the Bu-Oral group (n = 21), the median AUC was 1174 µMol min (799-4000), reaching a median of 4440 µMol min (3428-7181.5) during conditioning in 24 h. In the Bu-IV group (n = 19), it was 1244.8 µMol min (1001.2-2021), reaching 5598.0 µMol min (3102-8818) during conditioning in 24 h. Measuring plasma concentration of Bu in patients undergoing HSCT is important, regardless of the formulation, and the inclusion of a pre-HSCT test can predict the optimal dose during conditioning. Pharmacokinetics of the oral administration of busulfan, as well as clearance, are extremely variable, and this can potentially compromise the clinical results of the treatment since it makes it difficult to predict clinical results.
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25
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Krishnamurti L, Neuberg DS, Sullivan KM, Kamani NR, Abraham A, Campigotto F, Zhang W, Dahdoul T, De Castro L, Parikh S, Bakshi N, Haight A, Hassell KL, Loving R, Rosenthal J, Smith SL, Smith W, Spearman M, Stevenson K, Wu CJ, Wiedl C, Waller EK, Walters MC. Bone marrow transplantation for adolescents and young adults with sickle cell disease: Results of a prospective multicenter pilot study. Am J Hematol 2019; 94:446-454. [PMID: 30637784 PMCID: PMC6542639 DOI: 10.1002/ajh.25401] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 12/21/2022]
Abstract
We conducted a multicenter pilot investigation of the safety and feasibility of bone marrow transplantation (BMT) in adults with severe sickle cell disease (SCD) (NCT 01565616) using a reduced toxicity preparative regimen of busulfan (13.2 mg/kg), fludarabine (175 mg/m2 ) and thymoglobulin (6 mg/kg) and cyclosporine or tacrolimus and methotrexate for graft-vs-host disease (GVHD) prophylaxis. Twenty-two patients (median age 22 years; range 17-36) were enrolled at eight centers. Seventeen patients received marrow from an HLA-identical sibling donor and five patients received marrow from an 8/8 HLA-allele matched unrelated donor. Before BMT, patients had stroke, acute chest syndrome, recurrent pain events, were receiving regular red blood cell transfusions, or had an elevated tricuspid regurgitant jet (TRJ) velocity, which fulfilled eligibility criteria. Four patients developed grades II-III acute GVHD (18%) and six developed chronic GVHD (27%) that was moderate in two and severe in one patient. One patient died of intracranial hemorrhage and one of GVHD. Nineteen patients had stable donor chimerism, 1-year post-transplant. One patient who developed secondary graft failure survives disease-free after a second BMT. The one-year overall survival and event-free survival (EFS) are 91% (95% CI 68%-98%) and 86% (95% CI, 63%-95%), respectively, and 3-year EFS is 82%. Statistically significant improvements in the pain interference and physical function domains of health-related quality of life were observed. The study satisfied the primary endpoint of 1-year EFS ≥70%. This regimen is being studied in a prospective clinical trial comparing HLA-matched donor BMT with standard of care in adults with severe SCD (NCT02766465).
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Affiliation(s)
- Lakshmanan Krishnamurti
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Donna S Neuberg
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Keith M Sullivan
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapies, Duke University Medical Center, Durham, North Carolina
| | - Naynesh R Kamani
- Center for Cancer and Blood Disorders, Children's National Health System, Washington, DC
| | - Allistair Abraham
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Federico Campigotto
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Wandi Zhang
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Thabat Dahdoul
- Division of Hematology/Oncology, Department of Medicine, University of Colorado, Denver, Colorado
| | - Laura De Castro
- Division of Hematology/Oncology, Department of Pediatrics, City of Hope Hospital, Duarte, California
| | - Suhag Parikh
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapies, Duke University Medical Center, Durham, North Carolina
| | - Nitya Bakshi
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Ann Haight
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Kathryn L Hassell
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Richmond of Virginia Commonwealth University, Richmond, Virginia
| | - Rebekah Loving
- Division of General Internal Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Joseph Rosenthal
- Division of Stem Cell Transplantation and Immunotherapy, Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia
| | - Shannon L Smith
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Wally Smith
- Division of Hematology/Oncology, Department of Pediatrics, UCSF Benioff Children's Hospital of Oakland, Oakland, California
| | | | - Kristen Stevenson
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Catherine J Wu
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Christina Wiedl
- Division of Hematology/Oncology, Department of Pediatrics, UCSF Benioff Children's Hospital of Oakland, Oakland, California
| | - Edmund K Waller
- Division of Stem Cell Transplantation and Immunotherapy, Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia
| | - Mark C Walters
- Division of Hematology/Oncology, Department of Pediatrics, UCSF Benioff Children's Hospital of Oakland, Oakland, California
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26
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Nakashima T, Tanaka T, Koido K, Nishibuchi Y, Hashimoto H, Ito A, Inamoto Y, Kurosawa S, Kim SW, Fukuda T, Terakado H. Comparison of valproate and levetiracetam for the prevention of busulfan-induced seizures in hematopoietic stem cell transplantation. Int J Hematol 2019; 109:694-699. [DOI: 10.1007/s12185-019-02637-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/15/2019] [Accepted: 03/17/2019] [Indexed: 12/13/2022]
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27
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Bashir Q, Thall PF, Milton DR, Fox PS, Kawedia JD, Kebriaei P, Shah N, Patel K, Andersson BS, Nieto YL, Valdez BC, Parmar S, Rondon G, Delgado R, Hosing C, Popat UR, Oran B, Ciurea SO, Lin P, Weber DM, Thomas SK, Lee HC, Manasanch EE, Orlowski RZ, Williams LA, Champlin RE, Qazilbash MH. Conditioning with busulfan plus melphalan versus melphalan alone before autologous haemopoietic cell transplantation for multiple myeloma: an open-label, randomised, phase 3 trial. LANCET HAEMATOLOGY 2019; 6:e266-e275. [PMID: 30910541 DOI: 10.1016/s2352-3026(19)30023-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Retrospective studies suggest that conditioning therapy with busulfan plus melphalan could result in longer progression-free survival compared with melphalan alone in patients with multiple myeloma undergoing autologous haemopoietic cell transplantation (auto-HCT). We aimed to test this hypothesis in a randomised trial. METHODS The primary objective of the study was to compare progression-free survival with conditioning of busulfan plus melphalan with melphalan alone in patients with multiple myeloma. Patients with newly diagnosed multiple myeloma who were eligible for cell transplantation, aged 70 years or younger, with at least stable disease, were randomly assigned (1:1) to treatment. Patients received either busulfan plus melphalan, with a test dose of busulfan 32 mg/m2 followed by pharmacokinetically adjusted doses on days -7, -6, -5, and -4 to achieve a target daily area under the curve (AUC) of 5000 mmol-minute and melphalan 70 mg/m2 per day on days -2 and -1 (total melphalan dose 140 mg/m2), or a melphalan dose of 200 mg/m2 on day -2. Randomisation was performed via a Clinical Trial Conduct Website at the University of Texas MD Anderson Cancer Center. The accrual is complete and final results are presented here. The study is registered with ClinicalTrials.gov, number NCT01413178. FINDINGS Between Oct 12, 2011, and March 22, 2017, 205 patients were assessed for eligibility and randomly assigned to treatment. The primary analysis of progression-free survival was measured in 202 patients who received treatment: 104 patients in the busulfan plus melphalan group and 98 patients in the melphalan alone group. 90 days after auto-HCT, 102 (98%) of 104 patients given busulfan plus melphalan and 95 (97%) of 98 patients given melphalan alone achieved partial response or better. The median follow-up in the busulfan plus melphalan group was 22·6 months (IQR 15·2-47·1) and 20·2 months (IQR 8·8-46·6) in the melphalan alone group. Median progression-free survival was 64·7 months (32·9-64·7) with busulfan plus melphalan versus 43·5 months (19·9-not estimated) with melphalan alone (hazard ratio 0·53 [95% CI 0·30-0·91]; p=0·022). There were no treatment-related deaths by day 100 in either group. Grade 2-3 mucositis was observed in 77 (74%) of 104 patients in the busulfan plus melphalan group versus 14 (14%) of 98 patients in the melphalan alone group. INTERPRETATION These findings, if confirmed in other ongoing studies, suggest that busulfan plus melphalan could replace melphalan alone as the conditioning regimen for auto-HCT in patients with newly diagnosed myeloma. FUNDING This study was funded in part by the National Institutes of Health (NIH) through MD Anderson's Cancer Center Support Grant (CA016672).
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Affiliation(s)
- Qaiser Bashir
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA.
| | - Peter F Thall
- Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Denái R Milton
- Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Patricia S Fox
- Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Jitesh D Kawedia
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Nina Shah
- Department of Hematology and Blood and Marrow Transplant, University of California San Francisco, San Francisco, CA, USA
| | - Krina Patel
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Borje S Andersson
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Yago L Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Ben C Valdez
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Simrit Parmar
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Gabriela Rondon
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Ruby Delgado
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Chitra Hosing
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Uday R Popat
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Betul Oran
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Stefan O Ciurea
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Pei Lin
- Department of Hematopathology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Donna M Weber
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Sheeba K Thomas
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Hans C Lee
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Elisabet E Manasanch
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Loretta A Williams
- Department of Symptom Research, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Richard E Champlin
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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28
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Evaluation of a Test Dose Strategy for Pharmacokinetically-Guided Busulfan Dosing for Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:391-397. [DOI: 10.1016/j.bbmt.2018.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 09/10/2018] [Indexed: 11/17/2022]
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29
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Jain T, Kunze KL, Khetarpal BK, McCallen MR, Betcher JA, Ofori HT, Khera N, Slack JL, Leis JF, Sproat LZ, Noel P, Palmer J. Early fluctuations in busulfan levels with therapeutic dose monitoring during allogeneic stem cell transplantation: do they matter? Leuk Lymphoma 2019; 60:2034-2041. [PMID: 30626239 DOI: 10.1080/10428194.2018.1562183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Therapeutic dose monitoring is widely adopted for determination of busulfan (Bu) dose for use as a conditioning regimen. However, while dose adjustments are being incorporated, transient fluctuations of Bu levels may occur. We aim to understand if these fluctuations affect clinical outcomes of these patients. We compared outcomes in patients in whom the absolute dose changes and fluctuation of AUC were ≥ median% versus < median%. Rates of sinusoidal obstructive syndrome, grades 2-4/grades 3-4 acute and chronic graft versus host disease were not different between the two cohorts. The Kaplan-Meier curves for overall survival showed no significant differences. Six patients required >50% dose adjustment and four had a fluctuation in AUC of >50%. One of these patients died of sinusoidal obstruction syndrome and two died of infections. In our study, the transient fluctuations in Bu levels did not affect clinical outcomes; hence obviating the need for test dose strategy.
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Affiliation(s)
- Tania Jain
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Katie L Kunze
- b Division of Biostatistics , Mayo Clinic , Phoenix , AZ , USA
| | | | | | | | - Henry T Ofori
- d Division of Pharmacy , Mayo Clinic , Phoenix , AZ , USA
| | - Nandita Khera
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - James L Slack
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Jose F Leis
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Lisa Z Sproat
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Pierre Noel
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Jeanne Palmer
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
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30
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Huang J, Li Z, Liang W, Chen B, Hu J, Yang W. Accurate Prediction of Initial Busulfan Exposure Using a Test Dose With 2- and 6-Hour Blood Sampling in Adult Patients Receiving a Twice-Daily Intravenous Busulfan-Based Conditioning Regimen. J Clin Pharmacol 2018; 59:638-645. [PMID: 30512187 DOI: 10.1002/jcph.1354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/12/2018] [Indexed: 11/05/2022]
Abstract
This study aimed to predict the area under the curve (AUC) of the initial busulfan dose using a test dose with the sparse sampling scheme in adult patients who underwent hematopoietic cell transplant. A test dose of 0.8 mg/kg busulfan was used 2 days before twice-daily intravenous busulfan-based conditioning regimens were administered. The AUC and the clearance (CL) were calculated for both the test dose and the first dose (AUCT , CLT , AUC1, and CL1 ) by noncompartmental analysis. The sparse sampling schemes of the test dose were developed by Bayesian method based on the population pharmacokinetic model. The optimal sparse sampling schemes were determined by evaluating the mean prediction error, the root mean square error, the absolute mean prediction error, and Bland-Altman plot. The mean AUC1 was 7.20 ± 1.48 mg • h/L, which ranged from 4.70 to 9.46 mg • h/L. The AUC1 was below the therapeutic concentration of 7.38 mg • h/L in 45% (9 of 20) of the patients. The CLT of 3.05 ± 0.56 mL/min/kg was not significantly different with the CL1 of 3.03 ± 0.69 mL/min/kg (P = .901). A sampling scheme at 2 and 6 hours after the test dose was developed to predict the AUCT (mean prediction error of 1.64%, root mean square error of 6.17%, and absolute mean prediction error of 4.94%). Additionally, the Bland-Altman plot showed that the 2-sampling scheme provided an acceptably accurate prediction of the AUC1 . A test dose with a 2-sampling scheme was sufficient to personalize the initial busulfan dosing in hematopoietic cell transplant recipients.
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Affiliation(s)
- Jingjing Huang
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ziwei Li
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wu Liang
- NeoTrident Co. Ltd., Beijing, China
| | - Bing Chen
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiong Hu
- Department of Blood Marrow Transplantation, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wanhua Yang
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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31
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Safety and Efficacy of Once-Daily Intravenous Busulfan in Allogeneic Transplantation: A Matched-Pair Analysis. Biol Blood Marrow Transplant 2018; 24:2139-2144. [PMID: 29680515 DOI: 10.1016/j.bbmt.2018.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/11/2018] [Indexed: 12/26/2022]
Abstract
Compared with 4-times-daily infusion of intravenous busulfan (ivBU4), the safety and efficacy of once-daily infusion of ivBU (ivBU1) has not been fully clarified. We have been routinely using ivBU1 in a conditioning regimen in adult patients with myeloid malignancy who undergo allogeneic hematopoietic stem cell transplantation. In this study, a total of 91 patients who received ivBU1 for 2 days (n = 18) or 4 days (n = 73) in our institutions were compared with 273 control patients who received ivBU4, who were matched for age, sex, performance status, disease risk, conditioning regimen, and donor type, selected from the database of the Japanese Society for Hematopoietic Cell Transplantation using optimal matching algorithms. One-year overall survival (56.8% versus 57.1%, P = .94), disease-free survival (51.6% versus 50.8%, P = .73), relapse rate (28.5% versus 26.2%, P = .94), nonrelapse mortality (19.9% versus 23.0%, P = .71), and the incidence of graft-versus-host disease were not significantly different between the ivBU1 and ivBU4 groups. In patients who received ivBU1, neutrophil recovery was slower (median days: 22 versus 17, P = .001), and the incidence of veno-occlusive disease was lower (2.6% versus 17.4%, P = .04). In conclusion, ivBU1 can be safely administered with clinical outcomes similar to those with ivBU4.
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Kawazoe A, Funaki T, Kim S. Population Pharmacokinetic Analysis of Busulfan in Japanese Pediatric and Adult HCT Patients. J Clin Pharmacol 2018; 58:1196-1204. [DOI: 10.1002/jcph.1120] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/14/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Atsuko Kawazoe
- Otsuka Pharmaceutical Co., Ltd.; 3-2-27 Otedori, Chuo-ku Osaka Japan
| | - Tomoo Funaki
- Otsuka Pharmaceutical Co., Ltd.; 3-2-27 Otedori, Chuo-ku Osaka Japan
| | - Seongryul Kim
- Otsuka Pharmaceutical Co., Ltd.; 3-2-27 Otedori, Chuo-ku Osaka Japan
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Myers AL, Kawedia JD, Champlin RE, Kramer MA, Nieto Y, Ghose R, Andersson BS. Clarifying busulfan metabolism and drug interactions to support new therapeutic drug monitoring strategies: a comprehensive review. Expert Opin Drug Metab Toxicol 2017; 13:901-923. [PMID: 28766962 DOI: 10.1080/17425255.2017.1360277] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Busulfan (Bu) is an alkylating agent with a limited therapeutic margin and exhibits inter-patient variability in pharmacokinetics (PK). Despite decades of use, mechanisms of Bu PK-based drug-drug interactions (DDIs), as well as the negative downstream effects of these DDIs, have not been fully characterized. Areas covered: This article provides an overview of Bu PK, with a primary focus on how known and potentially unknown drug metabolism pathways influence Bu-associated DDIs. In addition, pharmacogenomics of Bu chemotherapy and Bu-related DDIs observed in the stem cell transplant clinic (SCT) are summarized. Finally the increasing importance of Bu therapeutic drug monitoring is highlighted. Expert opinion: Mechanistic studies of Bu metabolism have shown that in addition to GST isoenzymes, other oxidative enzymes (CYP, FMO) and ABC/MDR drug transporters likely contribute to the overall clearance of Bu. Despite many insights, results from clinical studies, especially in polypharmacy settings and between pediatric and adult patients, remain conflicting. Further basic science and clinical investigative efforts are required to fully understand the key factors determining Bu PK characteristics and its effects on complications after SCT. Improved TDM strategies are promising components to further investigate, for instance DDI mechanisms and patient outcomes, in the highly complex SCT treatment setting.
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Affiliation(s)
- Alan L Myers
- a Department of Pharmacy Research, Division of Pharmacy , The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
| | - Jitesh D Kawedia
- a Department of Pharmacy Research, Division of Pharmacy , The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
| | - Richard E Champlin
- b Department of Stem Cell Transplantation , The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
| | - Mark A Kramer
- a Department of Pharmacy Research, Division of Pharmacy , The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
| | - Yago Nieto
- b Department of Stem Cell Transplantation , The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
| | - Romi Ghose
- c Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy , The University of Houston , Houston , TX , USA
| | - Borje S Andersson
- b Department of Stem Cell Transplantation , The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
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Rhee SJ, Lee JW, Yu KS, Hong KT, Choi JY, Hong CR, Park KD, Shin HY, Song SH, Kang HJ, Lee H. Pediatric patients undergoing hematopoietic stem cell transplantation can greatly benefit from a novel once-daily intravenous busulfan dosing nomogram. Am J Hematol 2017; 92:607-613. [PMID: 28370238 DOI: 10.1002/ajh.24734] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/12/2017] [Accepted: 03/20/2017] [Indexed: 11/07/2022]
Abstract
Busulfan, a bifunctional alkylating agent, has been used as a conditioning regimen prior to allogeneic hematopoietic stem cell transplantation (HSCT). The aim of this study was to derive a novel once-daily intravenous (IV) busulfan dosing nomogram for pediatric patients undergoing HSCT using a population pharmacokinetic (PK) model. A population PK analysis was performed using 2183 busulfan concentrations in 137 pediatric patients (age: 0.6-22.2 years), who received IV busulfan once-daily for 4 days before undergoing HSCT. Based on the final population PK model, an optimal once-daily IV busulfan dosing nomogram was derived. The percentage of simulated patients achieving the daily target area under the concentration-time curve (AUC) by the new nomogram was compared with that by other busulfan dosing regimens including the FDA regimen, the EMA regimen, and the empirical once-daily regimen without therapeutic drug monitoring (TDM). A one-compartment open linear PK model incorporating patient's body surface area, age, dosing day, and aspartate aminotransferase as a significant covariate adequately described the concentration-time profiles of busulfan. An optimal dosing nomogram based on the PK model performed significantly better than the other dosing regimens, resulting in >60% of patients achieving the target AUC while the percentage of patients exceeding the toxic AUC level was kept <25% during the entire treatment period. A novel once-daily busulfan dosing nomogram for pediatric patients undergoing HSCT is useful for clinicians, particularly in a setting where TDM service is not readily available or to optimize the dose on day 1.
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Affiliation(s)
- Su-jin Rhee
- Department of Clinical Pharmacology and Therapeutics; Seoul National University College of Medicine and Hospital; Seoul Republic of Korea
| | - Ji Won Lee
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics; Seoul National University College of Medicine and Hospital; Seoul Republic of Korea
| | - Kyung Taek Hong
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Jung Yoon Choi
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Che Ry Hong
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Kyung Duk Park
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Hee Young Shin
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Sang Hoon Song
- Department of Laboratory Medicine; Seoul National University College of Medicine; Seoul Republic of Korea
| | - Hyoung Jin Kang
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Howard Lee
- Department of Clinical Pharmacology and Therapeutics; Seoul National University College of Medicine and Hospital; Seoul Republic of Korea
- Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology; Seoul National University; Seoul Republic of Korea
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Nieto Y, Valdez BC, Pingali SR, Bassett R, Delgado R, Nguyen J, Shah N, Popat U, Jones RB, Andersson BS, Gulbis A, Ahmed S, Bashir Q, Parmar S, Patel K, Myers A, Rondon G, Orlowski RZ, Champlin R, Qazilbash M. High-dose gemcitabine, busulfan, and melphalan for autologous stem-cell transplant in patients with relapsed or refractory myeloma: a phase 2 trial and matched-pair comparison with melphalan. LANCET HAEMATOLOGY 2017; 4:e283-e292. [PMID: 28522110 PMCID: PMC5844223 DOI: 10.1016/s2352-3026(17)30080-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/13/2017] [Accepted: 03/20/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND High-dose melphalan is of limited benefit as autologous stem-cell transplantation (ASCT) regimen for relapsed/refractory myeloma. Its poor results in this setting prompted us to study a new high-dose combination of infusional gemcitabine/busulfan/melphalan (Gem/Bu/Mel). METHODS We conducted a phase 2 trial of Gem/Bu/Mel in patients with primary refractory or relapsed disease after bortezomib and/or an immunomodulatory drug (IMiD), or receiving a salvage ASCT. Gemcitabine (1,875 mg/m2 over 3 hours × 2 days) was followed by busulfan (target AUC 4,000/day × 4 days) and melphalan (60 mg/m2/day × 2 days). The primary endpoint of this trial was to determine the stringent complete remission (sCR) rate of Gem/Bu/Mel in this population. We then retrospectively compared the study patients with all other concurrent patients eligible for this trial who, instead, received melphalan at 200 mg/m2 IV at our center. For survival outcomes, we used a statistical algorithm to select a subset from the control cohort that matched with the Gem/Bu/Mel patients by gender, age, disease status, double refractoriness to proteasome inhibitors/IMIDs, duration from diagnosis to transplant and cytogenetic risk, in a 1–2:1 ratio. All analyses are per protocol. This is the final analysis of the clinical trial. Trial registered at NCI.gov (NCT01237951). FINDINGS We enrolled 74 patients on the Gem/Bu/Mel trial, median age 58 (interquartile range [IQR], 11), median 2 prior therapy lines (IQR, 3), 38 high-risk cytogenetics, 17 unresponsive to all prior treatments, and 33 receiving a salvage ASCT. Toxicities of Gem/Bu/Mel included grade 3 mucositis (N=12), grade 3 dermatitis (N=5), grade 3 transaminase elevation (N=7), grade 3 diarrhea (N=2), grade 5 sudden death (N=1) and grade 5 sepsis (N=2). The study patients and the 184 concurrent controls received similar post-ASCT maintenance. Gem/Bu/Mel resulted in more sCR (24.6% v 12.6%, P=0.040), similar overall responses (73.8% v 74.1%, P=0.77) and similar transplant-related mortality (4.0% v 3.8%, P=0.90). The median follow-up times for the Gem/Bu/Mel patients and the matched subset (N=111) were 36 months (IQR, 15.2) and 34 months (IQR, 27), respectively. Gem/Bu/Mel resulted in improved progression-free survival (median 15.1 v 9.3 months, P=0.0030; hazard ratio=0.60; P=0.021) and overall survival (median 37.5 v 23 months, P=0.0092; hazard ratio=0.65, P=0.0087). INTERPRETATION Gem/Bu/Mel is a safe and active ASCT regimen for refractory/relapsed myeloma, with better outcomes than a concurrent matched cohort receiving melphalan. Funding Supported by a grant from Otsuka Pharmaceutical Development & Commercialization Inc. and NCI Grant P30 CA016672.
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Affiliation(s)
- Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Benigno C Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sai R Pingali
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roland Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ruby Delgado
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John Nguyen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roy B Jones
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alison Gulbis
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sairah Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Simrit Parmar
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Krina Patel
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alan Myers
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert Z Orlowski
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Carmustine replacement in intensive chemotherapy preceding reinjection of autologous HSCs in Hodgkin and non-Hodgkin lymphoma: a review. Bone Marrow Transplant 2017; 52:941-949. [DOI: 10.1038/bmt.2016.340] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 11/08/2016] [Accepted: 11/16/2016] [Indexed: 11/08/2022]
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Andersson BS, Thall PF, Valdez BC, Milton DR, Al-Atrash G, Chen J, Gulbis A, Chu D, Martinez C, Parmar S, Popat U, Nieto Y, Kebriaei P, Alousi A, de Lima M, Rondon G, Meng QH, Myers A, Kawedia J, Worth LL, Fernandez-Vina M, Madden T, Shpall EJ, Jones RB, Champlin RE. Fludarabine with pharmacokinetically guided IV busulfan is superior to fixed-dose delivery in pretransplant conditioning of AML/MDS patients. Bone Marrow Transplant 2016; 52:580-587. [PMID: 27991894 PMCID: PMC5382042 DOI: 10.1038/bmt.2016.322] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 11/25/2022]
Abstract
We hypothesized that IV Busulfan (Bu) dosing could be safely intensified through pharmacokinetic (PK-) dose guidance to minimize the inter-patient variability in systemic exposure (SE) associated with body-sized dosing, and this should improve outcome of AML/MDS patients undergoing allogeneic stem cell transplantation (allo-HSCT). To test this hypothesis, we treated 218 patients (median age 50.7 years, male/female 50/50%) with fludarabine (Flu) 40 mg/m2 once daily ×4, each dose followed by IV Bu, randomized to 130 mg/m2 (N=107) or PK-guided to average daily SE, AUC of 6,000 µM-min (N=111), stratified for remission-status, and allo-grafting from HLA-matched donors. Toxicity and graft vs. host disease (GvHD) rates in the groups were similar; the risk of relapse or treatment-related mortality remained higher in the fixed-dose group throughout the 80-month observation period. Further, PK-guidance yielded safer disease-control, leading to improved overall and progression-free survival, most prominently in MDS-patients and in AML-patients not in remission at allo-HSCT. We conclude that AML/MDS patients receiving pretransplant conditioning treatment with our 4-day regimen may benefit significantly from PK-guided Bu-dosing. This could be considered an alternative to fixed dose delivery since it provides the benefit of precise dose delivery to a predetermined SE without increasing risk(s) of serious toxicity and/or GvHD.
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Affiliation(s)
- B S Andersson
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - B C Valdez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Al-Atrash
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Chen
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Gulbis
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D Chu
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Martinez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Parmar
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - U Popat
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P Kebriaei
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Alousi
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M de Lima
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Rondon
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Q H Meng
- Division of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Myers
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Kawedia
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L L Worth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - T Madden
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - E J Shpall
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R B Jones
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Kebriaei P, Bassett R, Lyons G, Valdez B, Ledesma C, Rondon G, Oran B, Ciurea S, Alousi A, Popat U, Patel K, Ahmed S, Olson A, Bashir Q, Shah N, Jones R, Marin D, Rezvani K, Nieto Y, Khouri I, Qazilbash M, Hosing C, Shpall E, Champlin RE, Andersson BS. Clofarabine Plus Busulfan is an Effective Conditioning Regimen for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acute Lymphoblastic Leukemia: Long-Term Study Results. Biol Blood Marrow Transplant 2016; 23:285-292. [PMID: 27816651 DOI: 10.1016/j.bbmt.2016.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/01/2016] [Indexed: 11/25/2022]
Abstract
We investigated the long-term safety and disease control data obtained with i.v. busulfan (Bu) combined with clofarabine (Clo) in patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic hematopoietic stem cell transplantation (HSCT). A total of 107 patients, median age 38 years (range, 19 to 64 years) received a matched sibling donor (n = 52) or matched unrelated donor (n = 55) transplant for ALL in first complete remission (n = 62), second complete remission (n = 28), or more advanced disease (n = 17). Nearly one-half of the patients had a high-risk cytogenetic profile as defined by the presence of t(9;22) (n = 34), t(4;11) (n = 4), or complex cytogenetics (n = 7). Clo 40 mg/m2 was given once daily, with each dose followed by pharmacokinetically dosed Bu infused over 3 hours daily for 4 days, followed by hematopoietic cell infusion after 2 days of rest. The Bu dose was based on the drug clearance as determined by a test Bu dose of 32 mg/m2. The target daily area under the curve was 5500 µmol/min for patients aged <60 years and 4000 µmol/min for patients aged >59 years. With a median follow-up of 3.3 years among surviving patients (range, 1 to 5.8 years), the 2-year progression-free survival (PFS) for patients undergoing HSCT in first complete remission (CR1), second complete remission (CR2), or more advanced disease was 62%, 34%, and 35%, respectively. The regimen was well tolerated, with nonrelapse mortality (NRM) of 10% at 100 days and 31% at 2 years post-HSCT. The incidence of grade II-IV and III-IV acute graft-versus-host disease (GVHD) was 35% and 10%, respectively; 18% patients developed extensive chronic GVHD. The 2-year overall survival (OS) for patients undergoing HSCT in CR1, CR2, or more advanced disease was 70%, 57%, and 35%, respectively. Among 11 patients aged >59 years treated with reduced-dose Bu in CR1 (n = 7) or CR2 (n = 4), 4 remain alive and disease-free, with a median follow-up of 2.6 years (range, 2 to 4.7 years). Only the presence of minimal residual disease at the time of transplantation was associated with significantly worse PFS and OS in multivariate analysis. Our data indicate that the Clo-Bu combination provides effective disease control while maintaining a favorable safety profile. OS and NRM rates compare favorably with those for traditional myeloablative total body irradiation-based conditioning regimens.
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Affiliation(s)
- Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
| | - Roland Bassett
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Genevieve Lyons
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Ben Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Celina Ledesma
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Stefan Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Krina Patel
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Sairah Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Roy Jones
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - David Marin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
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Association of busulfan exposure with survival and toxicity after haemopoietic cell transplantation in children and young adults: a multicentre, retrospective cohort analysis. LANCET HAEMATOLOGY 2016; 3:e526-e536. [PMID: 27746112 DOI: 10.1016/s2352-3026(16)30114-4] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 08/03/2016] [Accepted: 08/10/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intravenous busulfan combined with therapeutic drug monitoring to guide dosing improves outcomes after allogeneic haemopoietic cell transplantation (HCT). The best method to estimate busulfan exposure and optimum exposure in children or young adults remains unclear. We therefore assessed three approaches to estimate intravenous busulfan exposure (expressed as cumulative area under the curve [AUC]) and associated busulfan AUC with clinical outcomes in children or young adults undergoing allogeneic HCT. METHODS In this retrospective analysis, patients from 15 centres in the Netherlands, USA, Canada, Switzerland, UK, Italy, Germany, and Australia who received a busulfan-based conditioning regimen between March 18, 2001, and Feb 12, 2015, were included. Cumulative AUC was calculated by numerical integration using non-linear mixed effect modelling (AUCNONMEM), non-compartmental analysis (AUC from 0 to infinity [AUC0-∞] and to the next dose [AUC0-τ]), and by individual centres using various approaches (AUCcentre). The main outcome of interest was event-free survival. Other outcomes of interest were graft failure or relapse, or both; transplantation-related mortality; acute toxicity (veno-occlusive disease or acute graft versus-host disease [GvHD]); chronic GvHD; overall survival; and chronic-GvHD-free event-free survival. We used propensity-score-adjusted Cox proportional hazard models, Weibull models, and Fine-Gray competing risk regressions for statistical analyses. FINDINGS 790 patients were enrolled, 674 of whom were included: 274 (41%) with malignant and 400 (59%) with non-malignant disease. Median age was 4·5 years (IQR 1·4-10·7). The median busulfan AUCNONMEM was 74·4 mg × h/L (95% CI 31·1-104·6), which correlated with the standardised method AUC0-∞ (r2=0·74), but the latter correlated poorly with AUCcentre (r2=0·35). Estimated 2-year event-free survival was 69·7% (95% CI 66·2-73·0). Event-free survival at 2 years was 77·0% (95% CI 72·1-82·9) in the 257 patients with an optimum intravenous busulfan AUC of 78-101 mg × h/L compared with 66·1% (60·9-71·4) in the 235 patients at the low historical target of 58-86 mg × h/L and 49·5% (29·2-66·0) in the 44 patients with a high (>101 mg × h/L) busulfan AUC (p=0·011). Compared with the low AUC group, graft failure or relapse occurred less frequently in the optimum AUC group (hazard ratio [HR] 0·57, 95% CI 0·39-0·84; p=0·0041). Acute toxicity (HR 1·69, 1·12-2·57; p=0·013) and transplantation-related mortality (2·99, 1·82-4·92; p<0·0001) were significantly higher in the high AUC group (>101 mg × h/L) than in the low AUC group (<78 mg × h/L), independent of indication; no difference was noted between AUC groups for chronic GvHD (<78 mg × h/L vs ≥78 mg × h/L, HR 1·30, 95% CI 0·73-2·33; p=0·37). INTERPRETATION Improved clinical outcomes are likely to be achieved by targeting the busulfan AUC to 78-101 mg × h/L using a new validated pharmacokinetic model for all indications. FUNDING Research Allocation Program and the UCSF Helen Friller Family Comprehensive Cancer Center and the Mt Zion Health Fund of the University of California, San Francisco.
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Scordo M, Bhatt V, Hsu M, Omuro AM, Matasar MJ, DeAngelis LM, Dahi PB, Moskowitz CH, Giralt SA, Sauter CS. A Comprehensive Assessment of Toxicities in Patients with Central Nervous System Lymphoma Undergoing Autologous Stem Cell Transplantation Using Thiotepa, Busulfan, and Cyclophosphamide Conditioning. Biol Blood Marrow Transplant 2016; 23:38-43. [PMID: 27713090 DOI: 10.1016/j.bbmt.2016.09.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/30/2016] [Indexed: 11/17/2022]
Abstract
High-dose therapy and autologous stem cell transplantation (ASCT) with thiotepa, busulfan, and cyclophosphamide (TBC) conditioning has emerged as an effective postinduction treatment strategy for patients with primary central nervous system lymphoma (PCNSL) or secondary central nervous system lymphoma (SCNSL), but it is associated with considerable toxicity and transplantation-related mortality (TRM) in the modern era. Forty-three adult patients with chemosensitive PCNSL or SCNSL underwent TBC-conditioned ASCT between 2006 and 2015. Twenty-eight of these patients received pharmacokinetically (PK)-targeted busulfan dosing. The median number of clinically relevant individual grade ≥3 nonhematologic toxicities per patient was 5. We found no association between pretransplantation patient characteristics and the presence of more than 5 grade ≥3 nonhematologic toxicities. Patients with elevated first-dose busulfan area under the curve values did not experience more toxicity. Paradoxically, patients treated with more than 2 regimens before undergoing ASCT had lower first-dose busulfan AUC values. With a median follow-up among survivors of 20 months, 1-year progression-free survival (PFS) and overall survival (OS) from the time of ASCT were 83% and 87%, respectively. Although this study reaffirms the favorable PFS and OS associated with TBC-conditioned ASCT for PCNSL or SCNSL, this treatment strategy carries a large toxicity burden.
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Affiliation(s)
- Michael Scordo
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Valkal Bhatt
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meier Hsu
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Antonio M Omuro
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Matthew J Matasar
- Department of Medicine, Lymphoma Service, Adult BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Parastoo B Dahi
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Craig H Moskowitz
- Department of Medicine, Lymphoma Service, Adult BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Craig S Sauter
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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Palmer J, McCune JS, Perales MA, Marks D, Bubalo J, Mohty M, Wingard JR, Paci A, Hassan M, Bredeson C, Pidala J, Shah N, Shaughnessy P, Majhail N, Schriber J, Savani BN, Carpenter PA. Personalizing Busulfan-Based Conditioning: Considerations from the American Society for Blood and Marrow Transplantation Practice Guidelines Committee. Biol Blood Marrow Transplant 2016; 22:1915-1925. [PMID: 27481448 DOI: 10.1016/j.bbmt.2016.07.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/21/2016] [Indexed: 12/12/2022]
Abstract
The Practice Guidelines Committee of the American Society of Blood or Marrow Transplantation (ASBMT) sought to develop an evidence-based review about personalizing busulfan-based conditioning. The Committee sought to grade the relevant published studies (June 1, 2008 through March 31, 2016) according to criteria set forth by the Steering Committee for Evidence Based Reviews from ASBMT. Unfortunately, the published literature was too heterogeneous and lacked adequately powered and sufficiently controlled studies for this to be feasible. Despite this observation, the continued interest in this topic led the Practice Guidelines Committee to develop a list of most frequently asked questions (FAQs) regarding personalized busulfan dosing. This "Considerations" document is a list of these FAQs and their responses, addressing topics of practical relevance to hematopoietic cell transplantation clinicians.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Jeannine S McCune
- Department of Pharmacology University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Miguel-Angel Perales
- Division of Hematology/Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Joseph Bubalo
- Department of Pharmacy Practice, Oregon Health Sciences University, Portland, Oregon
| | - Mohamad Mohty
- Department of Hematology, Hospital Saint-Antoine, University UPMC, Paris, France
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
| | - Angelo Paci
- Pharmacology and Drug Analysis Department, Institut de Cancerologie Gustav Roussy, Villejuif, France
| | - Moustapha Hassan
- Department of Clinical Research Centre, Karolinska Institutet, Stockholm, Sweden
| | - Christopher Bredeson
- Hematology, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Paul Shaughnessy
- Adult Blood and Marrow Transplant, Texas Transplant Physician's Group, San Antonio, Texas
| | - Navneet Majhail
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jeff Schriber
- Cancer Transplant Institute, Honor Health, Scottsdale, Arizona
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbuilt-Ingram Cancer Center, Nashville, Tennessee
| | - Paul A Carpenter
- Department of Pediatrics, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
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Alatrash G, Thall PF, Valdez BC, Fox PS, Ning J, Garber HR, Janbey S, Worth LL, Popat U, Hosing C, Alousi AM, Kebriaei P, Shpall EJ, Jones RB, de Lima M, Rondon G, Chen J, Champlin RE, Andersson BS. Long-Term Outcomes after Treatment with Clofarabine ± Fludarabine with Once-Daily Intravenous Busulfan as Pretransplant Conditioning Therapy for Advanced Myeloid Leukemia and Myelodysplastic Syndrome. Biol Blood Marrow Transplant 2016; 22:1792-1800. [PMID: 27377901 DOI: 10.1016/j.bbmt.2016.06.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/22/2016] [Indexed: 12/12/2022]
Abstract
Pretransplant conditioning regimens critically determine outcomes in the setting of allogeneic stem cell transplantation (allo-SCT). The use of nucleoside analogs such as fludarabine (Flu) in combination with i.v. busulfan (Bu) has been shown to be highly effective as a pretransplant conditioning regimen in acute myeloid leukemia (AML), chronic myeloid leukemia (CML), and myelodysplastic syndrome (MDS). Because leukemia relapse remains the leading cause of death after allo-SCT, we studied whether clofarabine (Clo), a nucleoside analog with potent antileukemia activity, can be used to complement Flu. In a preliminary report, we previously showed the safety and efficacy of Clo ± Flu with i.v. Bu in 51 patients with high-risk AML, CML, and MDS. The study has now been completed, and we present long-term follow-up data on the entire 70-patient population, which included 49 (70%), 8 (11%), and 13 (19%) patients with AML, MDS, and CML, respectively. Thirteen patients (19%) were in complete remission, and 41 patients (59%) received matched unrelated donor grafts. Engraftment was achieved in all patients. Sixty-three patients (90%) achieved complete remission. There were no deaths reported at day +30, and the 100-day nonrelapse mortality rate was 4% (n = 3). Thirty-one percent of patients (n = 22) developed grades II to IV acute graft-versus-host disease, and the median overall survival and progression-free survival times were 2.4 years and .9 years, respectively. Our results confirm the safety and overall and progression-free survival advantage of the arms with higher Clo doses and lower Flu doses, which was most prominent in the AML/MDS group.
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Affiliation(s)
- Gheath Alatrash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benigno C Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia S Fox
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Haven R Garber
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Selma Janbey
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura L Worth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy B Jones
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marcos de Lima
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Hematologic Malignancies and Stem Cell Transplant, Case Western Reserve University, Cleveland, Ohio
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Flowers CR, Costa LJ, Pasquini MC, Le-Rademacher J, Lill M, Shore TB, Vaughan W, Craig M, Freytes CO, Shea TC, Horwitz ME, Fay JW, Mineishi S, Rondelli D, Mason J, Braunschweig I, Ai W, Yeh RF, Rodriguez TE, Flinn I, Comeau T, Yeager AM, Pulsipher MA, Bence-Bruckler I, Laneuville P, Bierman P, Chen AI, Kato K, Wang Y, Xu C, Smith AJ, Waller EK. Efficacy of Pharmacokinetics-Directed Busulfan, Cyclophosphamide, and Etoposide Conditioning and Autologous Stem Cell Transplantation for Lymphoma: Comparison of a Multicenter Phase II Study and CIBMTR Outcomes. Biol Blood Marrow Transplant 2016; 22:1197-1205. [PMID: 27040394 PMCID: PMC4914052 DOI: 10.1016/j.bbmt.2016.03.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/15/2016] [Indexed: 11/17/2022]
Abstract
Busulfan, cyclophosphamide, and etoposide (BuCyE) is a commonly used conditioning regimen for autologous stem cell transplantation (ASCT). This multicenter, phase II study examined the safety and efficacy of BuCyE with individually adjusted busulfan based on preconditioning pharmacokinetics. The study initially enrolled Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) patients ages 18 to 80 years but was amended due to high early treatment-related mortality (TRM) in patients > 65 years. BuCyE outcomes were compared with contemporaneous recipients of carmustine, etoposide, cytarabine, and melphalan (BEAM) from the Center for International Blood and Marrow Transplant Research. Two hundred seven subjects with HL (n = 66) or NHL (n = 141) were enrolled from 32 centers in North America, and 203 underwent ASCT. Day 100 TRM for all subjects (n = 203), patients > 65 years (n = 17), and patients ≤ 65 years (n = 186) were 4.5%, 23.5%, and 2.7%, respectively. The estimated rates of 2-year progression-free survival (PFS) were 33% for HL and 58%, 77%, and 43% for diffuse large B cell lymphoma (DLBCL; n = 63), mantle cell lymphoma (MCL; n = 29), and follicular lymphoma (FL; n = 23), respectively. The estimated rates of 2-year overall survival (OS) were 76% for HL and 65%, 89%, and 89% for DLBCL, MCL, and FL, respectively. In the matched analysis rates of 2-year TRM were 3.3% for BuCyE and 3.9% for BEAM, and there were no differences in outcomes for NHL. Patients with HL had lower rates of 2-year PFS with BuCyE, 33% (95% CI, 21% to 46%), than with BEAM, 59% (95% CI, 52% to 66%), with no differences in TRM or OS. BuCyE provided adequate disease control and safety in B cell NHL patients ≤ 65 years but produced worse PFS in HL patients when compared with BEAM.
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Affiliation(s)
- Christopher R Flowers
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Division of BMT, Emory University, Atlanta, Georgia
| | - Luciano J Costa
- Medical University of South Carolina, Charleston, South Carolina
| | - Marcelo C Pasquini
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Le-Rademacher
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Lill
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Tsiporah B Shore
- Weill Cornell Medical Center Hematology/Oncology, The New York Hospital, New York, New York
| | - William Vaughan
- Bone Marrow Transplantation Program, University of Alabaman at Birmingham, Birmingham, Alabama
| | - Michael Craig
- West Virginia University, Health Science Center, Morgantown, West Virginia
| | - Cesar O Freytes
- South Texas Veterans Health Care System, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Thomas C Shea
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Mitchell E Horwitz
- Adult Stem Cell Transplant Program, Division of Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | - Shin Mineishi
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Damiano Rondelli
- Department of Medicine, Section of Hematology-Oncology, University of Illinois at Chicago, Chicago, Illinois
| | | | - Ira Braunschweig
- Department of Oncology, Montefiore Medical Center, Bronx, New York
| | - Weiyun Ai
- Medicine, University of California, San Francisco, San Francisco, California
| | - Rosa F Yeh
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Tulio E Rodriguez
- Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Ian Flinn
- Sarah Cannon Research Institute, Nashville, Tennessee
| | - Terrance Comeau
- New Brunswick Stem Cell Transplant Program, St. John, New Brunswick, Canada
| | - Andrew M Yeager
- Blood and Marrow Transplantation Program, The University of Arizona Cancer Center, Tucson, Arizona
| | - Michael A Pulsipher
- Division of Hematology, Oncology, and Blood and Marrow Transplant, Children's Hospital Los Angeles, Keck School of Medicine and University of Southern California, Los Angeles, California
| | | | - Pierre Laneuville
- Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Philip Bierman
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Andy I Chen
- Center for Hematologic Malignancies, Oregon Health & Science University, Portland, Oregon
| | - Kazunobu Kato
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, New Jersey
| | - Yanlin Wang
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, New Jersey
| | - Cong Xu
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, New Jersey
| | - Angela J Smith
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, New Jersey
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Division of BMT, Emory University, Atlanta, Georgia.
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Daily Weight-Based Busulfan with Cyclophosphamide and Etoposide Produces Comparable Outcomes to Four-Times-Daily Busulfan Dosing for Lymphoma Patients Undergoing Autologous Stem Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1588-1595. [PMID: 27343718 DOI: 10.1016/j.bbmt.2016.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/13/2016] [Indexed: 11/20/2022]
Abstract
High-dose busulfan (Bu) is an integral component of commonly used preparative regimens for both allogeneic and autologous transplantation. There is significant interest in comparing the efficacy and toxicity of administering Bu every 6 (Bu6) or every 24 hours (daily Bu). To facilitate a therapeutic dose-monitoring protocol, we transitioned from Bu6 to daily Bu dosing for patients with Hodgkin and non-Hodgkin lymphoma undergoing autologous stem cell transplantation (ASCT). Here, we retrospectively review outcomes of 400 consecutive eligible lymphoma patients who underwent ASCT from 2007 to 2013 with high-dose busulfan (Bu), cyclophosphamide (Cy), and etoposide (E). Bu was given at a fixed dose of either .8 mg/kg every 6 hours for 14 doses for 307 patients or a fixed dose of 2.8 mg/kg every 24 hours for 4 doses (days -9 through -6) for 93 patients who underwent transplantation after the transition from Bu6 to daily Bu was made. Toxicity was assessed using pulmonary and liver function tests (LFT) at specified time points before and after ASCT. Baseline patient and disease characteristics of patients dosed with Bu6 and daily Bu were similar. There was no significant difference in forced expiratory volume in 1 second or diffusing capacity of the lungs for carbon monoxide before and after transplantation in the Bu6 versus daily Bu cohorts. Changes in LFTs with daily Bu were not significantly different than those with Bu6. There were no differences in relapse, nonrelapse mortality, progression-free survival, or overall survival between Bu6 and Bu 24 administration schedules in univariable or multivariable analysis (P ≥ .34). For a subset of 23 patients who had first-dose Bu levels measured, we observed significant variation in an median estimated cumulative area under the curve (AUC) of 17,568 µM-minute (range, 12,104 µM-23,084 µM-minute). In conclusion, daily Bu with Cy/E is more convenient than Bu6, has equivalent outcomes, and results in no increase in either hepatic or pulmonary toxicity. Consistent with previous reports, there is a significant range of Bu AUC levels, with a standard deviation of 13%. These data provide rationale for our prospective clinical trial of real-time therapeutic dose monitoring of Bu.
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Floeter AE, McCune JS. Levetiracetam for the prevention of busulfan-induced seizures in pediatric hematopoietic cell transplantation recipients. J Oncol Pharm Pract 2016; 23:344-349. [PMID: 27208016 DOI: 10.1177/1078155216651128] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective The objective of this study was to compare clinical outcomes in children undergoing hematopoietic cell transplantation who received levetiracetam versus those who received phenytoin for the prevention of busulfan-induced seizures. Methods This study was an IRB-approved, single-center, retrospective analysis of pediatric patients receiving intravenous busulfan for hematopoietic cell transplantation conditioning from January 2009 to July 2014. The primary study endpoint was the incidence of seizure during busulfan administration (day -8 to 0). Key transplant related-outcomes were also collected, including the incidence of graft rejection, sinusoidal obstruction syndrome, relapse, and death. Results A total of 20 patients met criteria for inclusion in the study. The population was heterogeneous with regard to the indication for hematopoietic cell transplantation, donor type, stem cell source, and conditioning regimen. Nine patients (45%) received levetiracetam and 11 (55%) received phenytoin for seizure prophylaxis. No seizures or graft rejections were observed in the study population. One relapse, one case of sinusoidal obstruction syndrome, and two deaths occurred in the levetiracetam group, while no relapses, two cases of sinusoidal obstruction syndrome, and one death occurred in the phenytoin group. Conclusion These data suggest similar safety and effectiveness between levetiracetam and phenytoin for the prevention of busulfan-induced seizures in a small, heterogeneous pediatric hematopoietic cell transplantation population.
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Affiliation(s)
- Abby E Floeter
- 1 Department of Pharmacy Services, Oregon Health & Science University, Portland, USA
| | - Jeannine S McCune
- 2 Department of Pharmacy and Department of Pharmaceutics, University of Washington, Seattle, USA.,3 Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, USA
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Damlaj M, Alkhateeb HB, Hefazi M, Partain DK, Hashmi S, Gastineau DA, Al-Kali A, Wolf RC, Gangat N, Litzow MR, Hogan WJ, Patnaik MM. Fludarabine-Busulfan Reduced-Intensity Conditioning in Comparison with Fludarabine-Melphalan Is Associated with Increased Relapse Risk In Spite of Pharmacokinetic Dosing. Biol Blood Marrow Transplant 2016; 22:1431-1439. [PMID: 27164061 DOI: 10.1016/j.bbmt.2016.04.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/30/2016] [Indexed: 11/16/2022]
Abstract
Fludarabine with busulfan (FB) and fludarabine with melphalan (FM) are commonly used reduced-intensity conditioning (RIC) regimens. Pharmacokinetic dosing of busulfan (Bu) is frequently done for myeloablative conditioning, but evidence for its use is limited in RIC transplants. We compared transplant outcomes of FB versus FM using i.v. Bu targeted to the area under the curve (AUC). A total of 134 RIC transplants (47 FB and 87 FM) for acute myelogenous leukemia and myelodysplastic syndrome were identified, and median follow-up of the cohort was 40 months (range, 0 to 63.3). A significantly higher 2-year cumulative incidence of relapse (CIR) was associated with FB versus FM at 35.6% versus 17.3%, respectively (P = .0058). Furthermore, 2-year progression-free survival rates were higher for FM versus FB at 60.5% versus 48.7%, respectively (P = .04). However, 2-year rates of nonrelapse mortality (NRM) and overall survival (OS) were similar. The need for dose adjustment based on AUC did not alter relapse risk or NRM. Patients with Karnofsky performance status ≥ 90 who received FM had a 2-year OS rate of 74.8% versus 48.3% for FB (P = .03). FB use remained prognostic for relapse in multivariable analysis (hazard ratio, 2.75; 95% confidence interval, 1.28 to 5.89; P = .0097). In summary, in spite of AUC-directed dosing, FB compared with FM was associated with a significantly higher CIR.
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Affiliation(s)
- Moussab Damlaj
- Division of Hematology & HSCT, Department of Oncology, King AbdulAziz Medical City, Riyadh, Saudi Arabia; Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Hassan B Alkhateeb
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mehrdad Hefazi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Daniel K Partain
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shahrukh Hashmi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Gastineau
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aref Al-Kali
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert C Wolf
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - William J Hogan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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47
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Pasquini MC, Le-Rademacher J, Zhu X, Artz A, DiPersio J, Fernandez HF, Mineishi S, Kamishohara M, Mehta J, Nakamura Y, Ratanatharathorn V, Sobecks R, Burkart J, Bredeson C. Intravenous Busulfan-Based Myeloablative Conditioning Regimens Prior to Hematopoietic Cell Transplantation for Hematologic Malignancies. Biol Blood Marrow Transplant 2016; 22:1424-1430. [PMID: 27154848 DOI: 10.1016/j.bbmt.2016.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/14/2016] [Indexed: 11/19/2022]
Abstract
Busulfan (Bu)-containing regimens are commonly used in myeloablative conditioning regimens before allogeneic hematopoietic cell transplantation (HCT). Yet, there is considerable variability on how Bu is administered related to frequency (4 times a day [Q6] or daily [Q24]) and combinations with other chemotherapeutic agents (cyclophosphamide [Cy] or fludarabine [Flu]). We performed a prospective cohort study of recipients of Bu-based conditioning according to contemporary practices to compare different approaches (BuCy Q6, n = 495; BuFlu Q24, n = 331; BuCy Q24, n = 96; BuFlu Q6, n = 91) in patients with myeloid malignancies between 2009 and 2011. BuFlu Q24 recipients were more likely to be older and tended to have worse performance status and a higher comorbid burden. The cumulative incidences of hepatic veno-occlusive disease (P = .40), idiopathic pneumonia (P = .50), and seizures (P = .50) did not differ across groups. One-year HCT-related mortality ranged from 12% to 16% (P = .80), 3-year relapse incidence ranged from 32% to 36% (P = .80), and 3-year overall survival ranged from 51% to 58% (P = .20) across groups. This study demonstrates that HCT conditioning regimens using i.v. Bu Q6 or Q24 alone or in combination with Cy or Flu have similar outcomes in the myeloablative setting for treatment of myeloid malignancies.
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Affiliation(s)
- Marcelo C Pasquini
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Jennifer Le-Rademacher
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaochun Zhu
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew Artz
- Section of Hematology/Oncology, University of Chicago School of Medicine, Chicago, Illinois
| | - John DiPersio
- Department of Hematology/Oncology, Barnes Jewish Hospital, St. Louis, Missouri
| | - Hugo F Fernandez
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Shin Mineishi
- Bone Marrow Transplant Program, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Jayesh Mehta
- Department of Hematology/ Oncology, Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Voravit Ratanatharathorn
- Department of Clinical Arrangements, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan; J.P. McCarthy Cord Stem Cell Bank, Detroit, Michigan
| | - Ronald Sobecks
- Department of Hematopoietic Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jeanne Burkart
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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48
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De La Serna J, Sanz J, Bermúdez A, Cabrero M, Serrano D, Vallejo C, Gómez V, Moraleda JM, Perez SG, Caballero MD, Conde E, Lahuerta JJ, Sanz G. Toxicity and efficacy of busulfan and fludarabine myeloablative conditioning for HLA-identical sibling allogeneic hematopoietic cell transplantation in AML and MDS. Bone Marrow Transplant 2016; 51:961-6. [PMID: 26950372 DOI: 10.1038/bmt.2016.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/17/2015] [Accepted: 11/19/2015] [Indexed: 12/26/2022]
Abstract
The safety and efficacy of a 4-day myeloablative conditioning (MAC) regimen consisting of Bu 3.2 mg/kg and fludarabine 40 mg/m(2)/day for HLA-identical sibling allogeneic hematopoietic cell transplantation (HCT) in myeloid malignancies was investigated in 133 patients (median age, 47 years; range 19-74 years) with de novo AML (60%), secondary AML (20%) or myelodysplastic syndrome (20%). All patients engrafted. Hepatic veno-occlusive disease occurred in five patients (4%), and severe toxicities, mostly mucositis, occurred in twenty-three (17%) patients. The non-relapse mortality (NRM) at 100 days was 1.5%. The incidences of acute GVHD grade 2-4 and grade 3-4 were 32 and 13%, respectively. At a median follow-up of 38 months, the cumulative incidence of chronic GVHD was 67%. The relapse incidence was 30% (27 and 31%, respectively, in patients with early- and late-stage disease), and the overall NRM was 15%. The actuarial 4-year disease-free survival (DFS) and overall survival (OS) were 54 and 62%, respectively. Patients aged <50 years had better outcomes compared with older patients (DFS 64 vs 42%, P=0.006; OS 73 vs 47%, P<0.001, respectively).
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Affiliation(s)
- J De La Serna
- Hematology Department, Servicio de Hematología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - J Sanz
- Hematology Department, Hospital Universitario La Fe, Valencia, Spain
| | - A Bermúdez
- Hematology Department, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - M Cabrero
- Hematology Department, Hospital Universitario Clínico de Salamanca, Salamanca, Spain
| | - D Serrano
- Hematology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - C Vallejo
- Hematology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - V Gómez
- Hematology Department, Hospital Universitario de la Princesa, Madrid, Spain
| | - J M Moraleda
- Hematology Department, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - S G Perez
- Hematology Department, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - M D Caballero
- Hematology Department, Hospital Universitario Clínico de Salamanca, Salamanca, Spain
| | - E Conde
- Hematology Department, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - J J Lahuerta
- Hematology Department, Servicio de Hematología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - G Sanz
- Hematology Department, Hospital Universitario La Fe, Valencia, Spain
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49
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Cuellar-Rodriguez J, Freeman AF, Grossman J, Su H, Parta M, Murdock H, Shah N, Bollard C, Kong HH, Moutsopoulos N, Stone K, Gea-Banacloche J, Holland SM, Hickstein DD. Matched related and unrelated donor hematopoietic stem cell transplantation for DOCK8 deficiency. Biol Blood Marrow Transplant 2015; 21:1037-45. [PMID: 25636378 PMCID: PMC4426076 DOI: 10.1016/j.bbmt.2015.01.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/21/2015] [Indexed: 10/24/2022]
Abstract
We performed allogeneic hematopoietic stem cell transplantation in 6 patients with mutations in the dedicator-of-cytokinesis-8 (DOCK8) gene using a myeloablative conditioning regimen consisting of busulfan 3.2 mg/kg/day i.v. for 4 days and fludarabine 40 mg/m(2)/day for 4 days. Three patients received allografts from matched related donors and 3 patients from matched unrelated donors. Two patients received peripheral blood stem cells and 4 patients bone marrow hematopoietic stem cells. Tacrolimus and short-course methotrexate on days 1, 3, 6, and 11 were used for graft-versus-host-disease (GVHD) prophylaxis. All 6 patients are alive at a median follow-up of 22.5 months (range, 14 to 35). All patients achieved rapid and high levels of donor engraftment and complete reversal of the clinical and immunologic phenotype. Adverse events consisted of acute skin GVHD in 2 patients and post-transplant pulmonary infiltrates in a patient with extensive bronchiectasis pretransplant. Thus, a uniform myeloablative conditioning regimen followed by allogeneic hematopoietic stem cell transplantation in DOCK8 deficiency results in reconstitution of immunologic function and reversal of the clinical phenotype with a low incidence of regimen-related toxicity.
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Affiliation(s)
- Jennifer Cuellar-Rodriguez
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Alexandra F Freeman
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jennifer Grossman
- Division of Hematology and Hematologic Malignancies, Alberta Health Services, Calgary, Alberta, Canada
| | - Helen Su
- Laboratory of Host Defense, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Mark Parta
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc. (formerly SAIC-Frederick, Inc.), Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Heardley Murdock
- Laboratory of Host Defense, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Nirali Shah
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Catherine Bollard
- Center for Cancer and Immunology Research at the Children's Research Institute, Children's National Medical Center, Washington, DC
| | - Heidi H Kong
- Dermatology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Niki Moutsopoulos
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Kelly Stone
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Juan Gea-Banacloche
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Dennis D Hickstein
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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50
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Sakellari I, Mallouri D, Batsis I, Apostolou C, Konstantinou V, Abela EM, Douka V, Marvaki A, Karypidis K, Iskas M, Baliakas P, Kaloyannidis P, Yannaki E, Sotiropoulos D, Kouvatseas G, Smias C, Anagnostopoulos A. Carmustine, etoposide, cytarabine and melphalan versus a newly designed intravenous busulfan-based Busulfex, etoposide and melphalan conditioning regimen for autologous hematopoietic cell transplant: a retrospective matched-pair analysis in advanced Hodgkin and non-Hodgkin lymphomas. Leuk Lymphoma 2015; 56:3071-81. [DOI: 10.3109/10428194.2015.1028054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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