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Bug G, Labopin M, Kulagin A, Blaise D, Raiola AM, Vydra J, Sica S, Kwon M, López-Corral L, Bramanti S, von dem Borne P, Itälä-Remes M, Martino M, Koc Y, Brissot E, Giebel S, Nagler A, Ciceri F, Mohty M. Tacrolimus versus cyclosporine a combined with post-transplantation cyclophosphamide for AML In first complete remission: a study from the acute leukemia working party (EBMT). Bone Marrow Transplant 2024:10.1038/s41409-024-02331-1. [PMID: 38961258 DOI: 10.1038/s41409-024-02331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 06/09/2024] [Accepted: 06/11/2024] [Indexed: 07/05/2024]
Abstract
Choice of calcineurin inhibitor may impact the outcome of patients undergoing T-cell replete hematopoietic cell transplantation (HCT) with post-transplant cyclophosphamide (PT-Cy) and mycophenolate mofetil (MMF) for prophylaxis of graft-versus-host disease (GVHD). We retrospectively analyzed 2427 patients with acute myeloid leukemia (AML) in first remission transplanted from a haploidentical (n = 1844) or unrelated donor (UD, n = 583) using cyclosporine A (CSA, 63%) or tacrolimus (TAC, 37%) and PT-Cy/MMF. In univariate analysis, CSA and TAC groups did not differ in 2-year leukemia-free or overall survival, cumulative incidence (CI) of relapse or non-relapse mortality. CI of severe grade III-IV acute GVHD was lower with TAC (6.6% vs. 9.1%, p = 0.02), without difference in grade II-IV acute GVHD or grade III-IV acute GVHD/severe chronic GVHD, relapse-free survival (GRFS). In multivariate analysis, TAC was associated with a lower risk of severe grade III-IV acute GVHD solely with haploidentical donors (HR 0.64 [95% CI, 0.42-0.98], p = 0.04), but not UD (HR 0.49 [95% CI, 0.2-1.21], p = 0.12). There was no significant difference for chronic GVHD. In conclusion, PT-Cy/MMF-based GVHD prophylaxis resulted in favorable OS and GRFS, irrespective of the CNI added. In haploidentical HCT, TAC seemed to prevent severe acute GVHD more effectively than CSA without impact on other outcome parameters.
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Affiliation(s)
- Gesine Bug
- Goethe University Frankfurt, University Hospital, Dept of Medicine 2, Frankfurt am Main, Germany.
| | - Myriam Labopin
- Sorbonne University, Department of Hematology, Saint Antoine Hospital, INSERM UMR 938, Paris, France
| | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Didier Blaise
- Transplant and cellular immunotherapy program, Department of hematology, Institut Paoli Calmettes, Management Sport Cancer lab, Luminy, Aix Marseille University, Marseille, France
| | | | - Jan Vydra
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Univesidad Complutense de Madrid, Madrid, Spain
| | - Lucía López-Corral
- Hospital Universitario de Salamanca (Spain), IBSAL, Centro de Investigación del Cáncer-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Stefania Bramanti
- Department of Oncology/Hematology, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | | | | | - Massimo Martino
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Yener Koc
- Medicana International Hospital, Istanbul, Turkey
| | - Eolia Brissot
- Sorbonne University, Department of Hematology, Saint Antoine Hospital, INSERM UMR 938, Paris, France
| | - Sebastian Giebel
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Arnon Nagler
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Fabio Ciceri
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mohamad Mohty
- Sorbonne University, Department of Hematology, Saint Antoine Hospital, INSERM UMR 938, Paris, France
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McCune JS, Armenian SH, Nakamura R, Shan H, Kanakry CG, Mielcarek M, Gao W, Mager DE. Immunosuppressant adherence in adult outpatient hematopoietic cell transplant recipients. J Oncol Pharm Pract 2024; 30:322-331. [PMID: 37134196 PMCID: PMC10622331 DOI: 10.1177/10781552231171607] [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] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Medication nonadherence continues to be challenging for allogeneic hematopoietic cell transplant (HCT) recipients. The risk and severity of chronic graft-versus-host disease (GVHD) are associated with low immunosuppressant concentrations (which can be improved with model-informed precision dosing (MIPD)) and with immunosuppressant nonadherence (which can be improved with acceptable interventions). METHODS With the goals of improving adherence and achieving therapeutic concentrations of immunosuppressants to eliminate GVHD, we characterized the feasibility of using the Medication Event Monitoring (MEMS®) Cap in adult HCT recipients. RESULTS Of the 27 participants offered the MEMS® Cap at the time of hospital discharge, 7 (25.9%) used it, which is below our a priori threshold of 70%. These data suggest the MEMS® Cap is not feasible for HCT recipients. The MEMS® Cap data were available for a median of 35 days per participant per medication (range: 7-109 days). The average daily adherence per participant ranged from 0 to 100%; four participants had an average daily adherence of over 80%. CONCLUSIONS MIPD may be supported by MEMS® technology to provide the precise time of immunosuppressant self-administration. The MEMS® Cap was used by only a small percentage (25.9%) of HCT recipients in this pilot study. In accordance with larger studies using less accurate tools to evaluate adherence, immunosuppressant adherence varied from 0% to 100%. Future studies should establish the feasibility and clinical benefit of combining MIPD with newer technology, specifically the MEMS® Button, which can inform the oncology pharmacist of the time of immunosuppressant self-administration.
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Affiliation(s)
- Jeannine S. McCune
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, USA
| | - Saro H. Armenian
- Department of Population Sciences, City of Hope, and Department of Pediatrics, City of Hope Medical Center, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, USA
| | - Hayoue Shan
- Department of Biostatistics, City of Hope, Duarte, CA, USA
| | - Christopher G. Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Center and Department of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Wei Gao
- Andrew and Peggy Cherng Department of Medical Engineering, Division of Engineering and Applied Science, California Institute of Technology, Pasadena, CA, USA
| | - Donald E. Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
- Enhanced Pharmacodynamics, LLC, Buffalo, NY, USA
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McCune JS, Navarro SL, Risler LJ, Phillips BR, Ren S, Schoch HG, Baker KS. The presence of busulfan metabolites and pharmacometabolomics in plasma drawn immediately before allograft infusion in hematopoietic cell transplant recipients. Clin Transl Sci 2023; 16:2577-2590. [PMID: 37749994 PMCID: PMC10719475 DOI: 10.1111/cts.13651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/27/2023] Open
Abstract
Busulfan is hepatically metabolized through glutathione (GSH) conjugation; in vitro, this process depletes hepatocyte GSH stores and generates the cytotoxic metabolite γ-glutamyldehydroalanylglycine, which is too unstable to be quantitated in vivo. We sought to evaluate if pre-graft (i.e., immediately before allograft infusion) concentrations of busulfan metabolites' and of endogenous metabolomic compounds (EMCs) representing the glutathione pathway were associated with clinical outcomes in hematopoietic cell transplant (HCT) recipients receiving busulfan. The clinical outcomes evaluated were relapse, acute graft versus host disease (GVHD), chronic GVHD, non-relapse mortality, and neutrophil nadir. In pre-graft samples obtained from patients immediately before allograft infusion, our objectives were to evaluate for: (1) the presence of busulfan and its metabolites tetrahydrothiophenium ion (THT+), tetrahydrothiophene 1-oxide, sulfolane, and 3-hydroxysulfolane (N = 124); (2) EMCs using a global metabolomics assay (N = 77); and (3) the association of the busulfan metabolites and the EMCs with clinical outcomes. In the pre-graft samples, busulfan and THT+ could not be detected. THT 1-oxide, sulfolane, and 3-hydroxysulfolane were quantitated in 9.6%, 26%, and 58% of pre-graft samples; their concentrations were not associated with clinical outcomes. Four pre-graft EMCs were statistically significantly associated with the neutrophil nadir. The pre-graft EMCs were not associated with the other clinical outcomes. In conclusion, busulfan's metabolites are present in patients' plasma immediately before allograft infusion; the neutrophil nadir is associated with pre-graft EMCs. Future research should investigate the association of clinical outcomes with the concentrations of busulfan's metabolites and EMCs in the pre-graft plasma from allogeneic HCT recipients.
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Affiliation(s)
- Jeannine S. McCune
- Department of Hematologic Malignancies Translational SciencesCity of HopeDuarteCaliforniaUSA
| | - Sandi L. Navarro
- Division of Public Health SciencesFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Linda J. Risler
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Brian R. Phillips
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Suping Ren
- Department of Hematologic Malignancies Translational SciencesCity of HopeDuarteCaliforniaUSA
| | - H. Gary Schoch
- Clinical Research DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - K. Scott Baker
- Clinical Research DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
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Wada F, Kondo T, Yamamoto R, Yamagiwa T, Arai Y, Mizumoto C, Kanda J, Kitawaki T, Yamashita K, Takaori-Kondo A. Addition and drug monitoring of mycophenolate mofetil for GVHD prophylaxis in unrelated bone marrow transplantation. Bone Marrow Transplant 2022; 57:1198-1200. [PMID: 35501566 DOI: 10.1038/s41409-022-01692-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Ryusuke Yamamoto
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takero Yamagiwa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Chisato Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Reduced Enterohepatic Recirculation of Mycophenolate and Lower Blood Concentrations are Associated with the Stool Bacterial Microbiome After Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:372.e1-372.e9. [PMID: 35489611 DOI: 10.1016/j.jtct.2022.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is an important immunosuppressant used after allogeneic hematopoietic cell transplant (HCT). MMF has a narrow therapeutic index and blood concentrations of mycophenolic acid (MPA), the active component of MMF, are highly variable. Low MPA concentrations are associated with risk of graft vs host disease (GvHD) while high concentrations are associated with toxicity. Reasons for variability are not well known and may be due, at least in part, to the presence of β-glucuronidase producing bacteria in the gastrointestinal tract which enhance MPA enterohepatic recirculation (EHR) by transforming MPA metabolites formed in the liver back to MPA. OBJECTIVE To determine if individuals with high MPA EHR have a greater abundance of β-glucuronidase producing bacteria in their stool and higher MPA concentrations relative to those with low EHR. STUDY DESIGN We conducted a pharmacomicrobiomics study in 20 adult HCT recipients receiving a myeloablative or reduced intensity preparative regimen. Participants received MMF 1g IV every 8 hours with tacrolimus. Intensive pharmacokinetic sampling of mycophenolate was conducted before hospital discharge. Total MPA, MPA glucuronide (MPAG) and acylMPAG were measured. EHR was defined as a ratio of MPA area under the concentration-versus-time curve (AUC)4-8 to MPA AUC0-8. Differences in stool microbiome diversity and composition, determined by shotgun metagenomic sequencing, were compared above and below the median EHR (22%, range 5-44%). RESULTS Median EHR was 12% and 29% in the low and high EHR groups, respectively. MPA troughs, MPA AUC4-8 and acylMPAG AUC4-8/AUC0-8, were greater in the high EHR group vs low EHR group [1.53 vs 0.28 mcg/mL, p = 0.0001], [7.33 vs 1.79 hr*mcg/mL, p = 0.0003] and [0.33 vs 0.24 hr*mcg/mL, p = 0.0007], respectively. MPA AUC0-8 was greater in the high EHR than the low EHR group and trended towards significance [22.8 vs. 15.3 hr*mcg/mL, p=0.06]. Bacteroides vulgatus, stercoris and thetaiotaomicron were 1.2-2.4 times more abundant (p=0.039, 0.024, 0.046, respectively) in the high EHR group. MPA EHR was positively correlated with B. vulgatus (⍴=0.58, p≤0.01) and B. thetaiotaomicron (⍴=0.46, p<0.05) and negatively correlated with Blautia hydrogenotrophica (⍴=-0.53, p<0.05). Therapeutic MPA troughs were achieved in 80% of patients in the high EHR group and 0% in the low EHR. There was a trend towards differences in MPA AUC0-8 and MPA Css mcg/mL in high vs. low EHR groups (p=0.06). CONCLUSION MPA EHR was variable. Patients with high MPA EHR had greater abundance of Bacteroides species in stool and higher MPA exposure than patients with low MPA EHR. Bacteroides may therefore be protective from poor outcomes such as graft vs host disease but in others it may increase the risk of MPA adverse effects. These data need to be confirmed and studied after oral MMF.
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6
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Uchiyama K, Saito Y, Takekuma Y, Sugita J, Teshima T, Sugawara M. Pharmacokinetics of mycophenolic acid after haplo-hematopoietic stem cell transplantation in Japanese recipients. J Oncol Pharm Pract 2020; 28:31-38. [PMID: 33349149 DOI: 10.1177/1078155220980815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Mycophenolate mofetil (MMF), a mycophenolic acid (MPA) prodrug, is used to prevent graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation (HSCT). Although previous studies have reported that enterohepatic circulation (EHC) of MPA, which is usually observed in MMF-treated patients, does not occur in HSCT patients, it is unclear what happens in haploidentical-HSCT (haplo-HSCT) patients, who are using post-transplant cyclophosphamide. This study was conducted to investigate MPA pharmacokinetics in haplo-HSCT patients. METHODS Seventeen haplo-HSCT patients, who received MMF for GVHD prophylaxis, were enrolled in this study. We collected blood samples on days 14 and 28, and plasma MPA concentrations were measured by high-performance liquid chromatography; pharmacokinetic parameters such as area under the curve (AUC), mean residence time (MRT), and apparent oral clearance (CL/F) were measured with moment analysis. We also evaluated EHC as AUC6-12h/AUC0-12h. RESULTS There was no significant difference in MPA pharmacokinetic parameters between days 14 and 28. There was also no difference between the pharmacokinetic parameter changes and diarrhea. Additionally, varying plasma MPA concentrations suggested that MPA EHC did not occur. CONCLUSION In this study, we revealed the pharmacokinetics of MMF in Japanese haplo-HSCT recipients. Additionally, our study demonstrated that MPA EHC might not occur in Japanese haplo-HSCT recipients.
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Affiliation(s)
- Kazuki Uchiyama
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshitaka Saito
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Junichi Sugita
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Mitsuru Sugawara
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan.,Laboratory of Pharmacokinetics, Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Japan
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Ueda Oshima M, Storer BE, Qiu H, Chauncey T, Asch J, Boyer MW, Giaccone L, Flowers M, Mielcarek M, Storb R, Maloney DG, Sandmaier BM. Long-term Outcomes with Nonmyeloablative HLA-Identical Related Hematopoietic Cell Transplantation Using Tacrolimus and Mycophenolate Mofetil for Graft-versus-Host Disease Prophylaxis. Transplant Cell Ther 2020; 27:163.e1-163.e7. [PMID: 33830025 DOI: 10.1016/j.jtct.2020.10.016] [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: 09/02/2020] [Revised: 09/29/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
Nonmyeloablative allogeneic hematopoietic cell transplantation (HCT) from HLA-identical related donors using cyclosporine (CSP) and mycophenolate mofetil (MMF) for postgrafting immunosuppression is effective therapy for hematologic cancers. However, graft-versus-host-disease (GVHD) remains a major cause of morbidity and mortality. Pilot data suggested lower acute GVHD incidence with tacrolimus/MMF compared to historical experience using CSP/MMF after nonmyeloablative HCT. In a phase II multicenter trial, we evaluated the effect of tacrolimus/MMF for GVHD prophylaxis after HLA-identical related donor peripheral blood HCT in patients with hematologic malignancies (n = 150) using conditioning with 2 Gy total body irradiation (TBI) for patients with a preceding (within 6 months) planned autologous HCT (n = 50) or combined with 90 mg/m2 fludarabine for those without recent autologous HCT (n = 100). Oral tacrolimus was given from days -3 to 56 (tapered by day +180 if no GVHD). Oral MMF was given from days 0 to 27. Patient median age was 57 (range, 20 to 74) years. The cumulative incidences (CI) of day 100 grade II to IV and III to IV acute GVHD were 27% and 4%, respectively. With median follow-up of 10.3 (range, 3.1 to 14.5) years, the 5-year CI of chronic extensive GVHD was 48%. One-year and 5-year estimates of nonrelapse mortality, relapse/progression, survival, and progression-free survival were 9% and 13%, 35% and 50%, 73% and 53%, and 56% and 37%, respectively. GVHD prophylaxis with tacrolimus/MMF resulted in a low risk of acute GVHD and compared favorably with results from a concurrent trial using CSP/MMF. A randomized phase III trial to investigate tacrolimus/MMF versus CSP/MMF in nonmyeloablative HCT is warranted.
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Affiliation(s)
- Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington.
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Huiying Qiu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Thomas Chauncey
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Julie Asch
- Intermountain Healthcare, Salt Lake City, Utah
| | | | | | - Mary Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
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Bejanyan N, Rogosheske J, Cao Q, Lazaryan A, Holtan S, Ustun C, Jacobson P, MacMillan M, Weisdorf DJ, Wagner J, Arora M, Brunstein CG. Weight-based mycophenolate mofetil dosing predicts acute GVHD and relapse after allogeneic hematopoietic cell transplantation. Eur J Haematol 2020; 106:205-212. [PMID: 33084139 DOI: 10.1111/ejh.13537] [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: 08/30/2020] [Revised: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Higher MMF dose can reduce acute GVHD risk after allogeneic hematopoietic cell transplantation (HCT). We examined the effect of MMF dose, relative to patient actual body weight (mg/kg/day), on outcomes of 680 adults after HCT. METHODS MMF was combined with cyclosporine (n = 599) or sirolimus (n = 81). We divided MMF dose/kg/day in quartiles. RESULTS The median time to grade II-IV acute GVHD was 32 days. The incidence of grade II-IV acute GVHD at day 30 was 30% in 1st (<29), 20% in 2nd (29-34), 16% in 3rd (35-41), and 19% in 4th (≥42) quartile (P < .01). Corresponding relapse incidence at 1 year was 16%, 25%, 27%, and 31%, respectively (P = .01). In multivariate analysis, as compared to 1st quartile, higher dose of weight-based MMF reduced grade II-IV acute GVHD (HR = 0.64 for 2nd, HR = 0.48 for 3rd, and HR = 0.55 for 4th quartile), but increased the risk of relapse (HR = 1.63 for 2nd, HR = 1.75 for 3rd, and HR = 2.31 for 4th quartile). CONCLUSIONS Weight-based MMF dose had no significant impact on engraftment, chronic GVHD, or survival. These data suggest that higher weight-based MMF dose reduces the risk of acute GVHD at the expense of increased relapse and supports conducting prospective studies to optimize MMF dosing after HCT.
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Affiliation(s)
- Nelli Bejanyan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Rogosheske
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center. Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Aleksandr Lazaryan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Pamala Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Margaret MacMillan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Muranushi H, Kanda J, Arai Y, Shindo T, Hishizawa M, Yamamoto T, Kondo T, Yamashita K, Matsubara K, Takaori‐Kondo A. Drug monitoring for mycophenolic acid in graft-vs-host disease prophylaxis in cord blood transplantation. Br J Clin Pharmacol 2020; 86:2464-2472. [PMID: 32386102 PMCID: PMC7688537 DOI: 10.1111/bcp.14354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/31/2020] [Accepted: 04/27/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS We performed the retrospective analysis to clarify the significance of drug monitoring for mycophenolic acid (MPA), the active form of mycophenolate mofetil (MMF), in prophylaxis for graft-vs-host disease (GVHD) in cord blood transplantation. METHODS We retrospectively analysed the data of 46 patients who underwent first cord blood transplantation and received GVHD prophylaxis with tacrolimus plus MMF. MPA levels were measured on days 7 and 21, and 24-hour areas under the curve (AUC0-24 ) were estimated. RESULTS The engraftment and 3-year overall survival rates of all patients were 94% and 78%, respectively. The cumulative incidence of sepsis before engraftment was higher in patients with AUC0-24 on day 7 of >60 μg h/mL than in other patients (33 vs 6%, P = .02). The cumulative incidence of grade II-IV acute GVHD was higher in patients with AUC0-24 on day 21 of ≤30 μg h/mL than in other patients (80 vs 50%, P = .04). The cumulative incidence of human herpesvirus 6 reactivation was higher in patients with AUC0-24 on day 21 of ≤48 μg h/mL (median) than in other patients (50 vs 19%, P = .03). CONCLUSION Blood level of MPA was associated with risk of acute GVHD and infection. A prospective trial evaluating the benefit of personalized MMF dosing using MPA levels is needed.
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Affiliation(s)
- Hiroyuki Muranushi
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
- Department of Transfusion Medicine and Cell TherapyKyoto University HospitalKyotoJapan
| | - Takero Shindo
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Masakatsu Hishizawa
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Takashi Yamamoto
- Department of Clinical Pharmacology and TherapeuticsKyoto University HospitalKyotoJapan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Kohei Yamashita
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and TherapeuticsKyoto University HospitalKyotoJapan
| | - Akifumi Takaori‐Kondo
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
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10
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McCune JS, McKiernan JS, van Maarseveen E, Huitema ADR, Randolph TW, Deeg HJ, Nakamura R, Baker KS. Prediction of Acute Graft versus Host Disease and Relapse by Endogenous Metabolomic Compounds in Patients Receiving Personalized Busulfan-Based Conditioning. J Proteome Res 2020; 20:684-694. [PMID: 33064008 DOI: 10.1021/acs.jproteome.0c00599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Busulfan-based conditioning is the most commonly used high-dose conditioning regimen for allogeneic hematopoietic cell transplant (HCT). The alkylating agent busulfan has a narrow therapeutic index, with busulfan doses personalized to a target plasma exposure (targeted busulfan). Using a global pharmacometabonomics approach, we sought to identify novel biomarkers of relapse or acute graft versus host disease (GVHD) in a cohort of 84 patients receiving targeted busulfan before allogeneic HCT. A total of 763 endogenous metabolomic compounds (EMCs) were quantitated in 230 longitudinal blood samples before, during, and shortly after intravenous busulfan administration. We performed both univariate linear regression and pathway enrichment analyses using global testing. The cysteine/methionine pathway and the glycine, serine, and threonine metabolism pathway were most associated with relapse. The latter be explained by the fact that glutathione S-transferases conjugate both busulfan and glutathione, which contains glycine as a component. The d-arginine and d-ornithine metabolism pathway and arginine and proline metabolism pathway were most associated with acute GVHD. None of these associations were significant after correcting for false discovery rate (FDR) with a strict cutoff of FDR-adjusted p < 0.1. Although larger studies are needed to substantiate these findings, the results show that EMCs may be used as predictive biomarkers in HCT patients.
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Affiliation(s)
- Jeannine S McCune
- City of Hope, Department of Population Sciences, Duarte, California 91010, United States.,City of Hope, Department of Hematology & HCT, Duarte, California 91010, United States
| | - Jožefa S McKiernan
- City of Hope, Department of Population Sciences, Duarte, California 91010, United States
| | - Erik van Maarseveen
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, 3584 CS Utrecht, The Netherlands.,Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Timothy W Randolph
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, United States
| | - H Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, United States.,Department of Medicine, University of Washington, Seattle, Washington 98195, United States
| | - Ryotaro Nakamura
- City of Hope, Department of Hematology & HCT, Duarte, California 91010, United States
| | - K Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, United States.,Department of Pediatrics, University of Washington, Seattle, Washington 98195, United States
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11
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Inferior Outcomes with Cyclosporine and Mycophenolate Mofetil after Myeloablative Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1744-1755. [PMID: 31158502 DOI: 10.1016/j.bbmt.2019.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 01/06/2023]
Abstract
Combination therapy with a calcineurin inhibitor (CNI), such as cyclosporine (CSA) or tacrolimus (Tac), and methotrexate (MTX) or mycophenolate mofetil (MMF) is a widely used approach to graft-versus-host disease (GVHD) prevention. Data on the comparative effectiveness of MMF compared with MTX are limited and conflicting, however. We analyzed data from the Center for International Blood and Marrow Transplant Research for adult patients undergoing first myeloablative hematopoietic cell transplantation (HCT) from an HLA-identical matched related donor (MRD; n = 3979) or matched unrelated donor (URD; n = 4163) using CSA+MMF, CSA+MTX, Tac+MMF, or Tac+MTX for GVHD prevention between 2000 and 2013. Within the MRD cohort, 2252 patients received CSA+MTX, 1391 received Tac+MTX, 114 received CSA+MMF, and 222 received Tac+MMF. Recipients of CSA+MMF had a higher incidence of acute GVHD grade II-IV (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.24 to 2.20; P < .001) and grade III-IV (HR, 1.92; 95% CI, 1.31 to 2.83; P < .001) compared with Tac+MTX. The use of CSA+MMF was also associated with inferior overall survival (OS) (HR, 2.31; 95% CI, 1.73 to 3.09; P < .001) due to higher transplantation-related mortality (TRM) (HR, 4.03; 95% CI, 2.61 to 6.23; P < .001) compared with Tac+MTX. Within the URD cohort, 974 patients received CSA+MTX, 2697 received Tac+MTX, 68 received CSA+MMF, and 424 received Tac+MMF. CSA+MMF was again significantly associated with a higher incidence of grade III-IV acute GVHD (HR, 2.31; 95% CI, 1.57 to 3.42; P <0001), worse OS (HR, 2.36; 95% CI, 1.67 to 3.35; P < .001), and higher TRM (HR, 3.09; 95% CI, 2.00 to 4.77; P < .001), compared with Tac+MTX and other regimens. Thus, this large retrospective comparison of MMF versus MTX in combination with CSA or Tac demonstrates significantly worse GVHD and survival outcomes with CSA+MMF compared with Tac+MTX.
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12
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Militano O, Ozkaynak MF, Mehta B, van deVen C, Hamby C, Cairo MS. Mycophenolate mofetil administered every 8 hours in combination with tacrolimus is efficacious in the prophylaxis of acute graft versus host disease in childhood, adolescent, and young adult allogeneic stem cell transplantation recipients. Pediatr Blood Cancer 2018; 65:e27091. [PMID: 29667720 DOI: 10.1002/pbc.27091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/26/2018] [Accepted: 03/20/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND The optimal dose and schedule of mycophenolate mofetil (MMF) in pediatric allogeneic stem cell transplant recipients remains to be determined. We previously reported safety and pharmacokinetics of MMF at 900 mg/m2 q6h dosing. This study was conducted to investigate the efficacy of tacrolimus plus q8h MMF dosing for acute graft versus host disease (GVHD) prophylaxis in a heterogeneous population of children, adolescent, young adult allogeneic stem cell transplant recipients, utilizing multiple allogeneic donor sources. PROCEDURE GVHD prophylaxis consisted of tacrolimus 0.03-0.04 mg/kg/day intravenous continuous infusion or 0.12-0.16 mg/kg/day orally divided q8-12h and MMF 900 mg/m2 /dose (max. 1.5 g) or 15 mg/kg/dose intravenous/orally (age ≥18 years) q8h starting on Day +1. MMF was discontinued on Day +30 or Day +60 in the absence of acute GVHD. Thirty-five children, adolescents, and young adult allogeneic stem cell transplant recipients with malignant and nonmalignant disorders were enrolled. RESULTS Kaplan-Meier probability of grade II-IV and grade III-IV acute GVHD was 22.8% (CI95 : 5.2-47.9 [where CI stands for confidence interval]) and 5.7% (CI95 : 0-48.9), respectively. Probability of extensive and limited chronic GVHD was 22.6% (CI95 : 3.4-52.2) and 12.2% (CI95 : 0.3-45.7), respectively. Probability of 1 year overall survival was 82% (CI95 : 64.1-99.8). Myeloablative conditioning was predictive of higher risk of acute GVHD in the univariate analysis (P = 0.01, hazard ratio = 6.6, CI95 : 0.91-48). CONCLUSION This study demonstrated a low probability of acute and chronic GVHD in a diverse cohort of childhood, adolescent, and young adult allogeneic stem cell transplant recipients following MMF q8h plus tacrolimus prophylaxis.
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Affiliation(s)
- Olga Militano
- Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York.,Children's Oncology Group, Monrovia, California
| | - Mehmet F Ozkaynak
- Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Brinda Mehta
- Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Carmella van deVen
- Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Carl Hamby
- Department of Microbiology and Immunology, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Mitchell S Cairo
- Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York.,Department of Microbiology and Immunology, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York.,Departments of Medicine, Pathology, and Cell Biology and Anatomy, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
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13
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McCune JS, Storer B, Thomas S, McKiernan J, Gupta R, Sandmaier BM. Inosine Monophosphate Dehydrogenase Pharmacogenetics in Hematopoietic Cell Transplantation Patients. Biol Blood Marrow Transplant 2018; 24:1802-1807. [PMID: 29656138 DOI: 10.1016/j.bbmt.2018.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/03/2018] [Indexed: 01/18/2023]
Abstract
We evaluated inosine monophosphate dehydrogenase (IMPDH) 1 and IMPDH2 pharmacogenetics in 247 recipient-donor pairs after nonmyeloablative hematopoietic cell transplant (HCT). Patients were conditioned with total body irradiation + fludarabine and received grafts from related or unrelated donors (10% HLA mismatch), with postgraft immunosuppression of mycophenolate mofetil (MMF) with a calcineurin inhibitor. Recipient and donor IMPDH genotypes (rs11706052, rs2278294, rs2278293) were not associated with day 28 T cell chimerism, acute graft-versus-host disease (GVHD), disease relapse, cytomegalovirus reactivation, nonrelapse mortality, or overall survival. Recipient IMPDH1 rs2278293 genotype was associated with a lower incidence of chronic GVHD (hazard ratio, .72; P = .008) in nonmyeloablative HCT recipients. Additional studies are needed to confirm these results with the goal of identifying predictive biomarkers to MMF that lower GVHD.
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Affiliation(s)
- Jeannine S McCune
- School of Pharmacy, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Population Sciences, City of Hope, Duarte, California; Department of Hematology and HCT, City of Hope, Duarte, California.
| | - Barry Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sushma Thomas
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jožefa McKiernan
- Department of Population Sciences, City of Hope, Duarte, California
| | - Rohan Gupta
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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14
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Zhang D, Chow DSL. Clinical Pharmacokinetics of Mycophenolic Acid in Hematopoietic Stem Cell Transplantation Recipients. Eur J Drug Metab Pharmacokinet 2017; 42:183-189. [PMID: 27677732 DOI: 10.1007/s13318-016-0378-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mycophenolate mofetil (MMF), an ester prodrug of mycophenolic acid (MPA), is widely used as a maintenance immunosuppressive regimen in solid organ transplant patients. It is increasingly used for the prophylaxis and treatment of graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation (HSCT) patients. MPA displays extensive binding to serum albumin and glucuronidation to the inactive MPA-7-O-glucuronide (MPAG). Here, we review and discuss the pertinent information regarding the clinical pharmacokinetics of MPA in HSCT patients. The pharmacokinetics of MPA are altered in HSCT patients with lower oral bioavailability, shorter half-life and higher clearance than those in healthy volunteers and renal transplant recipients. Moreover, clearance may be increased in young pediatric patients. The optimal MMF dosing and preferred targets are still under investigation in HSCT patients due to the substantial intra- and inter-individual pharmacokinetic variability of MPA and broad range of transplants (malignant vs. nonmalignant, related vs. unrelated donor, and human leukocyte antigen mismatch). The complex pharmacokinetics of MPA have partly hampered the efficient use of MMF, and pharmacokinetic studies in HSCT patients have been limited in size and mostly inconclusive. Future research should be multi-institutional and focus on developing clinical decisions with adequate statistical power to improve clinical care of HSCT recipients.
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Affiliation(s)
- Daping Zhang
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA.
| | - Diana S-L Chow
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA
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15
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Yerushalmi R, Shem‐Tov N, Danylesko I, Shouval R, Nagler A, Shimoni A. The combination of cyclosporine and mycophenolate mofetil is less effective than cyclosporine and methotrexate in the prevention of acute graft-versus host disease after stem-cell transplantation from unrelated donors. Am J Hematol 2017; 92:259-268. [PMID: 28052467 DOI: 10.1002/ajh.24631] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/15/2016] [Accepted: 12/19/2016] [Indexed: 12/24/2022]
Abstract
Acute graft-versus-host disease (GVHD) is the major treatment-related complication after stem-cell transplantation (SCT) from unrelated-donors. Several GVHD prophylaxis regimens have been explored, but no regimen has shown superiority. We analyzed transplantation outcomes in 472 consecutive unrelated-donor SCT recipients, using cyclosporine/methotrexate (MTX, n = 314) or cyclosporine/mycophenolate-mofetil (MMF, n = 158) for GVHD prophylaxis. Neutrophil engraftment was faster after MMF, days 11 and 14, respectively (P = .001). Acute GVHD grade II-IV and III-IV occurred in 47% and 28% after MMF compared to 27% and 12% after MTX, respectively (P < .001). Nonrelapse mortality (NRM) was 44% and 24%, respectively (P < .001). Death associated with GVHD occurred in 25% and 8% (P < .0001), while other NRM causes occurred in 19% and 16%, respectively (P = .39). Relapse mortality was similar. Overall survival was better after MTX, 40% and 29%, respectively (P = .006). However, this difference had only borderline significance when adjusting for differences in patient characteristics (HR, 1.3, P = .08). To minimize potential selection bias we analyzed outcomes on the basis of an intention-to-treat like analysis. During the years 2008-2009, the leading GVHD prophylaxis regimen for unrelated-donor SCT included MMF (89% of transplants). During the other periods, MTX was used predominantly (82% of transplants). The two periods were otherwise well-matched. Acute GVHD occurred more often in 2008-2009. Death associated with GVHD occurred more often, while other NRM causes occurred less often resulting in similar NRM and overall survival. In conclusion, cyclosporine/MMF is associated with faster engraftment and possibly with less organ toxicity than cyclosporine/MTX. However, it is associated with increased rates of acute GVHD and GVHD-associated deaths.
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Affiliation(s)
- Ronit Yerushalmi
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Noga Shem‐Tov
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Ivetta Danylesko
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Roni Shouval
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Arnon Nagler
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Avichai Shimoni
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
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16
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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17
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A Pilot Study of Continuous Infusion of Mycophenolate Mofetil for Prophylaxis of Graft-versus-Host-Disease in Pediatric Patients. Biol Blood Marrow Transplant 2016; 22:682-689. [DOI: 10.1016/j.bbmt.2015.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/15/2015] [Indexed: 12/30/2022]
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18
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Harnicar S, Ponce DM, Hilden P, Zheng J, Devlin SM, Lubin M, Pozotrigo M, Mathew S, Adel N, Kernan NA, O'Reilly R, Prockop S, Scaradavou A, Hanash A, Jenq R, van den Brink M, Giralt S, Perales MA, Young JW, Barker JN. Intensified Mycophenolate Mofetil Dosing and Higher Mycophenolic Acid Trough Levels Reduce Severe Acute Graft-versus-Host Disease after Double-Unit Cord Blood Transplantation. Biol Blood Marrow Transplant 2015; 21:920-5. [PMID: 25687796 DOI: 10.1016/j.bbmt.2015.01.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/28/2015] [Indexed: 12/18/2022]
Abstract
Although mycophenolate mofetil (MMF) has replaced corticosteroids as immunosuppression in cord blood transplantation (CBT), optimal MMF dosing has yet to be established. We intensified MMF dosing from every 12 to every 8 hours to augment graft-versus-host disease (GVHD) prophylaxis in double-unit cord blood transplantation (dCBT) and evaluated outcomes according to the total daily MMF dose/kg in 174 dCBT recipients (median age, 39 years; range, 1 to 71) who underwent transplantation for hematologic malignancies. Recipients of an MMF dose ≤ the median (36 mg/kg/day) had an increased day 100 grade III and IV acute GVHD (aGVHD) incidence compared with patients who received >36 mg/kg/day (24% versus 8%, P = .008). Recipients of ≤ the median dose who had highly HLA allele (1 to 3 of 6) mismatched dominant units had the highest day 100 grade III and IV aGVHD incidence of 37% (P = .009). This finding was confirmed in multivariate analysis (P = .053). In 83 patients evaluated for mycophenolic acid (MPA) troughs, those with a mean week 1 and 2 trough < .5 μg/mL had an increased day 100 grade III and IV aGVHD of 26% versus 9% (P = .063), and those who received a low total daily MMF dose and had a low mean week 1 and 2 MPA trough had a 40% incidence (P = .008). Higher MMF dosing or MPA troughs had no impact on engraftment after myeloablation. This analysis supports intensified MMF dosing in milligram per kilogram per day and MPA trough level monitoring early after transplantation in dCBT recipients.
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Affiliation(s)
- Stephen Harnicar
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Doris M Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marissa Lubin
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Pozotrigo
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York; Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sherry Mathew
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelly Adel
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy A Kernan
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard O'Reilly
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan Prockop
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andromachi Scaradavou
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alan Hanash
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Robert Jenq
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Marcel van den Brink
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel A Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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19
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Bejanyan N, Rogosheske J, DeFor T, Lazaryan A, Esbaum K, Holtan S, Arora M, MacMillan ML, Weisdorf D, Jacobson P, Wagner J, Brunstein CG. Higher Dose of Mycophenolate Mofetil Reduces Acute Graft-versus-Host Disease in Reduced-Intensity Conditioning Double Umbilical Cord Blood Transplantation. Biol Blood Marrow Transplant 2015; 21:926-33. [PMID: 25655791 DOI: 10.1016/j.bbmt.2015.01.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/29/2015] [Indexed: 10/24/2022]
Abstract
Mycophenolate mofetil (MMF) is frequently used in hematopoietic cell transplantation (HCT) for graft-versus-host disease (GVHD) prophylaxis and to facilitate engraftment. We previously reported that a higher level of mycophenolic acid can be achieved with an MMF dose of 3 g/day than with 2 g/day. Here, we retrospectively compared clinical outcomes of reduced-intensity conditioning (RIC) double umbilical cord blood (dUCB) HCT recipients receiving cyclosporine A with MMF 2 g (n = 93) versus 3 g (n = 175) daily. Multiple regression analysis adjusted for antithymocyte globulin in the conditioning revealed that MMF 3 g/day led to a 49% relative risk (RR) reduction in grade II to IV acute GVHD rate (RR, .51; 95% confidence interval, .36 to .72; P < .01). However, the higher MMF dose was not protective for chronic GVHD. Additionally, MMF dose was not an independent predictor of neutrophil engraftment or treatment-related mortality at 6 months or 2-year post-transplantation disease relapse, disease-free survival, or overall survival. Higher MMF dose did not increase risk of infectious complications, and infection-related mortality was similar for both MMF doses. Our data indicate that MMF 3 g/day reduces the risk of acute GVHD without affecting other clinical outcomes and should be used for GVHD prophylaxis after RIC dUCB transplantation.
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Affiliation(s)
- Nelli Bejanyan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - John Rogosheske
- Departments of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Todd DeFor
- Biostatistics and Bioinformatics Core, Masonic Cancer Center, Minneapolis, Minnesota
| | - Aleksandr Lazaryan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kelli Esbaum
- Departments of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Pamala Jacobson
- Departments of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - John Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Hamilton BK, Rybicki L, Dean R, Majhail NS, Haddad H, Abounader D, Hanna R, Sobecks R, Duong H, Hill BT, Copelan E, Bolwell B, Kalaycio M. Cyclosporine in combination with mycophenolate mofetil versus methotrexate for graft versus host disease prevention in myeloablative HLA-identical sibling donor allogeneic hematopoietic cell transplantation. Am J Hematol 2015; 90:144-8. [PMID: 25353395 DOI: 10.1002/ajh.23882] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 10/23/2014] [Accepted: 10/27/2014] [Indexed: 11/06/2022]
Abstract
Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality in allogeneic hematopoietic cell transplantation (HCT) despite current prophylaxis. Methotrexate (MTX) with a calcineurin inhibitor (CNI) is the current standard, however, has several toxicities. Mycophenolate mofetil (MMF) is frequently used in reduced-intensity HCT, but data in myeloablative transplants is limited. We thus retrospectively identified 241 patients who underwent myeloablative HCT from an HLA-identical sibling donor; 174 patients received cyclosporine (CSA) + MMF and 67 received CSA+MTX. Patients receiving MMF + CSA had rapid neutrophil (median 11 vs. 19 days with MTX+CSA), and platelet recovery (median 19 vs. 25 days), lower incidence of severe mucositis by OMAS (19% vs. 53%), and shorter length of hospital stay (median 25 vs. 36 days) (P < 0.001 for all comparisons). There were no significant differences in incidence of grade 2-4 (MMF+CSA 37% vs. MTX+CSA 39%) or 3-4 acute GVHD (17% vs. 12%), chronic GVHD (46% vs. 56%), relapse (28% vs. 27%), non-relapse mortality (20% vs. 27%), or overall survival (47% vs. 44%) (P = NS for all). However, in multivariable analysis, the use of MMF+CSA was associated with an increased risk of severe grade 3-4 acute GVHD (HR 2.92, 95% CI 1.2-7.15, P = 0.019). There were no differences between the two regimens in multivariable analyses for other survival outcomes. This analysis demonstrates that the use of MMF in myeloablative sibling donor transplantation is well tolerated. However, there may be an increased risk of severe GVHD with MMF+CSA compared to MTX+CSA. Further studies evaluating optimal dosing strategies are needed.
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Affiliation(s)
- Betty K. Hamilton
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Lisa Rybicki
- Quantitative Health Sciences; Cleveland Clinic Lerner Research Institute; Cleveland Ohio
| | - Robert Dean
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Navneet S. Majhail
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Housam Haddad
- Hematology/Oncology; Staten Island University Hospital; New York New York
| | - Donna Abounader
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Rabi Hanna
- Pediatric Hematology Oncology; Cleveland Clinic; Cleveland Ohio
| | - Ronald Sobecks
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Hien Duong
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Brian T. Hill
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Edward Copelan
- Levine Cancer Institute; Carolinas HealthCare System; Charlotte North Carolina
| | - Brian Bolwell
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Matt Kalaycio
- Blood & Marrow Transplant Program; Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
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21
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Eapen M, Logan BR, Horowitz MM, Zhong X, Perales MA, Lee SJ, Rocha V, Soiffer RJ, Champlin RE. Bone marrow or peripheral blood for reduced-intensity conditioning unrelated donor transplantation. J Clin Oncol 2014; 33:364-9. [PMID: 25534391 DOI: 10.1200/jco.2014.57.2446] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There have been no randomized trials that have compared peripheral blood (PB) with bone marrow (BM) grafts in the setting of reduced-intensity conditioning (RIC) transplantations for hematologic malignancy. Because immune modulation plays a significant role in sustaining clinical remission after RIC, we hypothesize that higher graft-versus-host disease (GVHD) associated with PB transplantation may offer a survival advantage. PATIENTS AND METHODS The primary outcome evaluated was overall survival. Cox regression models were built to study outcomes after transplantation of PB (n = 887) relative to BM (n = 219) for patients with acute myeloid leukemia, myelodysplastic syndrome, or non-Hodgkin lymphoma, the three most common indications for unrelated RIC transplantation. Transplantations were performed in the United States between 2000 and 2008. Conditioning regimens consisted of an alkylating agent and fludarabine, and GVHD prophylaxis involved a calcineurin inhibitor (CNI) with either methotrexate (MTX) or mycophenolate mofetil (MMF). RESULTS After adjusting for age, performance score, donor-recipient HLA-match, disease, and disease status at transplantation (factors associated with overall survival), there were no significant differences in 5-year rates of survival after transplantation of PB compared with BM: 34% versus 38% with CNI-MTX and 27% versus 20% with CNI-MMF GVHD prophylaxis. CONCLUSION Survival after transplantation of PB and BM are comparable in the setting of nonirradiation RIC regimens for hematologic malignancy. The effect of GVHD prophylaxis on survival merits further evaluation.
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Affiliation(s)
- Mary Eapen
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX.
| | - Brent R Logan
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Mary M Horowitz
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Xiaobo Zhong
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Miguel-Angel Perales
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Stephanie J Lee
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Vanderson Rocha
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Robert J Soiffer
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Richard E Champlin
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
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22
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Optimizing drug therapy in pediatric SCT: focus on pharmacokinetics. Bone Marrow Transplant 2014; 50:165-72. [PMID: 25347008 DOI: 10.1038/bmt.2014.235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 08/08/2014] [Accepted: 08/27/2014] [Indexed: 12/19/2022]
Abstract
Given age-related differences in drug metabolism and indications for hematopoietic SCT (HSCT), personalized drug dosing of the conditioning regimen and post-transplant immunosuppression may reduce graft rejection, relapse rates and toxicity in pediatric HSCT recipients. This manuscript summarizes the pharmacokinetic/dynamic data of HSCT conditioning and post-grafting immunosuppression, presented at the First Annual Pediatric Bone Marrow Transplant Consortium (PBMTC) meeting in April 2013. Personalized dosing of BU to a target plasma exposure reduces graft rejection in children and improves relapse/toxicity rates in adults. Current weight-based dosing achieves the target BU exposure in only a minority (24.3%) of children. The initial BU dose should be based on the European Medicines Agency nomogram or population pharmacokinetic models to improve the numbers of children achieving the target exposure. There are limited pharmacokinetic data for treosulfan, CY, fludarabine and alemtuzumab as HSCT conditioning in children. For post-grafting immunosuppression, mycophenolic acid (MPA) clearance may be increased in younger children (<12 years). The preferred MPA pharmacokinetic monitoring parameters and target range are still evolving in HSCT recipients. Multi-institutional trials incorporating properly powered pharmacokinetic/dynamic studies are needed to assess the effect of variability in the plasma exposure of drugs/metabolites on clinical outcomes in pediatric HSCT recipients.
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23
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Bemer MJ, Risler LJ, Phillips BR, Wang J, Storer BE, Sandmaier BM, Duan H, Raccor BS, Boeckh MJ, McCune JS. Recipient pretransplant inosine monophosphate dehydrogenase activity in nonmyeloablative hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20:1544-52. [PMID: 24923537 PMCID: PMC4163086 DOI: 10.1016/j.bbmt.2014.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/30/2014] [Indexed: 10/25/2022]
Abstract
Mycophenolic acid, the active metabolite of mycophenolate mofetil (MMF), inhibits inosine monophosphate dehydrogenase (IMPDH) activity. IMPDH is the rate-limiting enzyme involved in de novo synthesis of guanosine nucleotides and catalyzes the oxidation of inosine 5'-monophosphate to xanthosine 5'-monophosphate (XMP). We developed a highly sensitive liquid chromatography-mass spectrometry method to quantitate XMP concentrations in peripheral blood mononuclear cells (PMNCs) isolated from the recipient pretransplant and used this method to determine IMPDH activity in 86 nonmyeloablative allogeneic hematopoietic cell transplantation (HCT) patients. The incubation procedure and analytical method yielded acceptable within-sample and within-individual variability. Considerable between-individual variability was observed (12.2-fold). Low recipient pretransplant IMPDH activity was associated with increased day +28 donor T cell chimerism, more acute graft-versus-host disease (GVHD), lower neutrophil nadirs, and more cytomegalovirus reactivation but not with chronic GVHD, relapse, nonrelapse mortality, or overall mortality. We conclude that quantitation of the recipient's pretransplant IMPDH activity in PMNC lysate could provide a useful biomarker to evaluate a recipient's sensitivity to MMF. Further trials should be conducted to confirm our findings and to optimize postgrafting immunosuppression in nonmyeloablative HCT recipients.
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Affiliation(s)
- Meagan J Bemer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Linda J Risler
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Brian R Phillips
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Joanne Wang
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Medicine, University of Washington, Seattle, Washington
| | - Haichuan Duan
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Brianne S Raccor
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Michael J Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Medicine, University of Washington, Seattle, Washington
| | - Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington.
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24
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Hamilton BK, Kalaycio M. Maximizing the benefits of mycophenolate mofetil as graft-versus-host disease prophylaxis. Biol Blood Marrow Transplant 2014; 20:1869-70. [PMID: 25065905 DOI: 10.1016/j.bbmt.2014.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 07/16/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Betty Ky Hamilton
- Blood and Marrow Transplant Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio.
| | - Matt Kalaycio
- Blood and Marrow Transplant Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
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25
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Li H, Mager DE, Sandmaier BM, Storer BE, Boeckh MJ, Bemer MJ, Phillips BR, Risler LJ, McCune JS. Pharmacokinetic and pharmacodynamic analysis of inosine monophosphate dehydrogenase activity in hematopoietic cell transplantation recipients treated with mycophenolate mofetil. Biol Blood Marrow Transplant 2014; 20:1121-9. [PMID: 24727337 DOI: 10.1016/j.bbmt.2014.03.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 03/31/2014] [Indexed: 10/25/2022]
Abstract
A novel approach to personalizing postgrafting immunosuppression in hematopoietic cell transplantation (HCT) recipients is evaluating inosine monophosphate dehydrogenase (IMPDH) activity as a drug-specific biomarker of mycophenolic acid (MPA)-induced immunosuppression. This prospective study evaluated total MPA, unbound MPA, and total MPA glucuronide plasma concentrations and IMPDH activity in peripheral blood mononuclear cells (PMNCs) at 5 time points after the morning dose of oral mycophenolate mofetil (MMF) on day +21 in 56 nonmyeloablative HCT recipients. Substantial interpatient variability in pharmacokinetics and pharmacodynamics was observed and accurately characterized by the population pharmacokinetic-dynamic model. IMPDH activity decreased with increasing MPA plasma concentration, with maximum inhibition coinciding with maximum MPA concentration in most patients. The overall relationship between MPA concentration and IMPDH activity was described by a direct inhibitory maximum effect model with an IC50 of 3.23 mg/L total MPA and 57.3 ng/mL unbound MPA. The day +21 IMPDH area under the effect curve (AUEC) was associated with cytomegalovirus reactivation, nonrelapse mortality, and overall mortality. In conclusion, a pharmacokinetic-dynamic model was developed that relates plasma MPA concentrations with PMNC IMPDH activity after an MMF dose in HCT recipients. Future studies should validate this model and confirm that day +21 IMPDH AUEC is a predictive biomarker.
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Affiliation(s)
- Hong Li
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, New York
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, New York
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Schools of Medicine, University of Washington, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Michael J Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Schools of Medicine, University of Washington, Seattle, Washington
| | - Meagan J Bemer
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Brian R Phillips
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Linda J Risler
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington.
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26
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Al-Kadhimi Z, Gul Z, Chen W, Smith D, Abidi M, Deol A, Ayash L, Lum L, Waller EK, Ratanatharathorn V, Uberti J. High incidence of severe acute graft-versus-host disease with tacrolimus and mycophenolate mofetil in a large cohort of related and unrelated allogeneic transplantation patients. Biol Blood Marrow Transplant 2014; 20:979-85. [PMID: 24709007 DOI: 10.1016/j.bbmt.2014.03.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/16/2014] [Indexed: 01/01/2023]
Abstract
Both acute and chronic graft-versus-host disease (GVHD) are major causes of morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (AHSCT). The optimal pharmacological regimen for GVHD prophylaxis is unclear, but combinations of a calcineurin inhibitor (cyclosporin or tacrolimus [Tac]) and an antimetabolite (methotrexate or mycophenolate mofetil [MMF]) are typically used. We retrospectively evaluated the clinical outcomes of 414 consecutive patients who underwent AHSCT from sibling (SD) or unrelated donors (UD) with Tac/MMF combination, between January 2005 and August 2010. The median follow-up was 60 months. Less than one third of the patients received a reduced-intensity chemoregimen. The incidence of grades III and IV acute GVHD was 22.3% and 36.5% in SD and UD groups, respectively (P = .0007). The incidence of chronic GVHD was 47.1% and 52.7% in the SD and UD groups, respectively. Nonrelapse mortality (NRM) at 60 months was 33.3% and 46.5% in the SD and UD groups, respectively (P = .0016). The incidence of relapse was 22.4% for UD and 28.8% for SD. Five-year overall survival was 43% and 34% in the SD and UD groups, respectively (P = .0183). GVHD was the leading cause of death for the entire cohort. Multivariable analysis showed that 8/8 HLA match, patient's age < 60, and low-risk disease were associated with better survival. The use of Tac/MMF for GVHD prophylaxis was associated with a relatively high incidence of severe acute GVHD and NRM in AHSCT from sibling and unrelated donors.
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Affiliation(s)
- Zaid Al-Kadhimi
- Department of Hematology and Medical Oncology, Emory University and Winship Cancer Center, Atlanta, Georgia.
| | - Zartash Gul
- Division of Hematology/BMT, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Wei Chen
- Biostatistics Core, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Daryn Smith
- Biostatistics Core, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Muneer Abidi
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Abhinav Deol
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Lois Ayash
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Lawrence Lum
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Emory University and Winship Cancer Center, Atlanta, Georgia
| | - Voravit Ratanatharathorn
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Joseph Uberti
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
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