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Klyuchnikov E, Langebrake C, Badbaran A, Dadkhah A, Massoud R, Freiberger P, Ayuk F, Janson D, Wolschke C, Bacher U, Kröger N. Individualized busulfan dosing improves outcomes compared to fixed-dose administration in pre-transplant minimal residual disease-positive acute myeloid leukemia patients with intermediate-risk undergoing allogeneic stem cell transplantation in CR. Eur J Haematol Suppl 2023; 110:188-197. [PMID: 36335432 DOI: 10.1111/ejh.13893] [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] [Received: 09/01/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2022]
Abstract
Pre-transplant minimal residual disease (MRD) impacts negatively on post-transplant relapse risk in acute myeloid leukemia (AML). Therapeutic drug monitoring by calculating area under the curve (AUC) was developed to optimize busulfan (Bu) exposure. Here, we compared post-transplant outcomes after individualized versus fixed busulfan dosage in intermediate-risk AML who achieved CR prior to allograft focusing on pre-transplant flow-MRD. Eighty-seven patients (median, 56 years) with intermediate-risk AML and pre-transplant flow-MRD ("different from normal") were included. Thirty-two patients received individualized busulfan; 54 fixed dosages. Individualized dosage was adjusted in 25/32 patients: increased, n = 18/25 (72%); decreased: n = 7/25 (28%). After median follow-up of 27 months, we observed lower 3-year relapses (6%, 2%-19% vs. 35%, 23%-49% p = 0.02), improved 3-year leukemia-free survival (LFS) (78%, 54%-91% vs. 55%, 40%-70% p = 0.009) and - overall survival (OS) (82%, 60%-93% vs. 69%, 54%-81% p = 0.05) after individualized compared to fixed Bu. Non-relapsed mortality (NRM) and acute graft versus host disease (GvHD) were not different. In multivariate analysis, fixed Bu showed unfavorable impact on OS (hazard ratio [HR] 4.6, p = 0.044), LFS (HR 3.6, p = 0.018) and relapses (HR 3.6, p = 0.033). Fixed Bu also had unfavorable impact on LFS (3.6, 1.1-12.6, p = 0.041) in pre-transplant MRD-positive patients. Individualized, AUC-based, busulfan is associated with lower relapses in intermediate-risk AML patients allografted in CR and may overcome pre-transplant MRD-positivity.
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Affiliation(s)
- Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Claudia Langebrake
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Adrin Dadkhah
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Radwan Massoud
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Petra Freiberger
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Ulrike Bacher
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
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Du X, Huang C, Xue L, Jiao Z, Zhu M, Li J, Lu J, Xiao P, Zhou X, Mao C, Zhu Z, Dong J, Liu X, Chen Z, Zhang S, Ding Y, Hu S, Miao L. The Correlation Between Busulfan Exposure and Clinical Outcomes in Chinese Pediatric Patients: A Population Pharmacokinetic Study. Front Pharmacol 2022; 13:905879. [PMID: 35784763 PMCID: PMC9243314 DOI: 10.3389/fphar.2022.905879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022] Open
Abstract
Aims: The aims of the study were to 1) establish a population pharmacokinetic (Pop-PK) model for busulfan in Chinese pediatric patients undergoing hematopoietic stem cell transplantation (HSCT) and then estimate busulfan exposure and 2) explore the association between busulfan exposure and clinical outcomes. Methods: A total of 128 patients with 467 busulfan concentrations were obtained for Pop-PK modeling using nonlinear mixed effect model (NONMEM) software. Sixty-three patients who received the 16-dose busulfan conditioning regimen were enrolled to explore the correlations between clinical outcomes and the busulfan area under the concentration–time curve (AUC) using the Cox proportional hazards regression model, Kaplan–Meier method and logistic regression. Results: The typical values for clearance (CL) and distribution volume (V) of busulfan were 7.71 L h−1 and 42.4 L, respectively. The allometric normal fat mass (NFM) and maturation function (Fmat) can be used to describe the variability in CL, and the fat-free mass (FFM) can be used to describe the variability in V. Patients with AUCs of 950–1,600 µM × min had 83.7% (95% CI: 73.3–95.5) event-free survival (EFS) compared with 55.0% (95% CI: 37.0–81.8) for patients with low or high exposure (p = 0.024). The logistic regression analysis results showed no association between transplant-related toxicities and the busulfan AUC (p > 0.05). Conclusions: The variability in busulfan CL was related to the NFM and Fmat, while busulfan V was related to the FFM. Preliminary analysis results suggested that a busulfan AUC of 950–1,600 µM × min was associated with better EFS in children receiving the 16-dose busulfan regimen.
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Affiliation(s)
- Xiaohuan Du
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Pharmacy, The Children’s Hospital of Soochow University, Suzhou, China
| | - Chenrong Huang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Science, Soochow University, Suzhou, China
| | - Ling Xue
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Pharmacology, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Min Zhu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Li
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Jun Lu
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Peifang Xiao
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Xuemei Zhou
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Chenmei Mao
- Department of Pharmacy, The Children’s Hospital of Soochow University, Suzhou, China
| | - Zengyan Zhu
- Department of Pharmacy, The Children’s Hospital of Soochow University, Suzhou, China
| | - Ji Dong
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoxue Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhiyao Chen
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shichao Zhang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiduo Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shaoyan Hu
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
- *Correspondence: Liyan Miao, ; Shaoyan Hu,
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Science, Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Liyan Miao, ; Shaoyan Hu,
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3
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Salhotra A, Yang D, Mokhtari S, Hui S, Al Malki MM, Armenian S, Sigala B, Aldoss I, Pullarkat V, Forman S, Marcucci G, Nakamura R, Artz A, Wong J, Stein A. Long-term follow-up of patients with poor-risk acute leukemia treated on a phase 2 trial undergoing intensified conditioning regimen prior to allogeneic hematopoietic cell transplantation. Leuk Lymphoma 2021; 63:1220-1226. [PMID: 34879769 DOI: 10.1080/10428194.2021.2012661] [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: 10/19/2022]
Abstract
Patients with acute leukemia who undergo allogenic hematopoietic cell transplantation with active disease have high rates of relapse and poor overall survival (OS) post-transplant compared to patients undergoing HCT in remission. Here, we report the long-term outcomes in 32 patients who received a high-intensity conditioning regimen comprising fractionated total body irradiation (FTBI; 1200 cGy) with pharmacokinetic (PK) dosing of intravenous Busulfan (IV BU) targeted to first dose area under curve (AUC) of 700-900 µM/min and etoposide (30 mg/kg) in a prospective phase 2 clinical trial. The median age of the patients at the time of HCT was 37 years (range: 18-50) presenting with high-risk (n = 6) and relapsed/refractory(r/r) acute leukemias (n = 26). All but one patient underwent HCT using peripheral blood stem cells from matched sibling donors. At a median follow-up of 17.3 years (range 14.4-19.0), 11 patients remained alive. The disease-free survival and OS at 15 years was 34% (versus 40% at 5-years post-HCT). The 15-year cumulative incidence of relapse was 26% and non-relapse mortality (NRM) was 38% (95% CI: 21-54%) and the cumulative incidence of chronic GVHD at 15 years was 33% using a prophylactic regimen of cyclosporine A and mycophenolate mofetil. The most common life-threatening late effects were secondary malignancies, metabolic, or cardiac complications with a cumulative incidence of 6.6%, 6.6%, and 13.3%, respectively. No unusual late effects or patterns of relapse were noted on longer followed on patients treated with intensified myeloablative condition regimen. Results from this study supports continued development of intensive conditioning regimens in patients with r/r acute leukemias to improve leukemia free (LFS) and OS in this high-risk population.
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Affiliation(s)
- Amandeep Salhotra
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - Sally Mokhtari
- Department of Clinical Translational Project Development, City of Hope National Medical Center, Duarte, CA, USA
| | - Susanta Hui
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Monzr M Al Malki
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Saro Armenian
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Brianna Sigala
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Vinod Pullarkat
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Stephen Forman
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Guido Marcucci
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Andrew Artz
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
| | - Jeffery Wong
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Anthony Stein
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA, USA
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4
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Long-term survival with mixed chimerism in patients with AML and MDS transplanted after conditioning with targeted busulfan, fludarabine, and thymoglobulin. Bone Marrow Transplant 2021; 57:198-206. [PMID: 34741096 DOI: 10.1038/s41409-021-01518-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 11/08/2022]
Abstract
We evaluated long-term outcome in 40 patients with MDS or AML, transplanted from related or unrelated donors following conditioning with targeted busulfan (Bu, over 4 days), fludarabine (Flu, 120 [n = 23] or 250 [n = 17] mg/m2) and thymoglobulin (THY). Compared to 95 patients conditioned with Bu/Cyclophosphamide (Cy) without THY, BuFluTHY-conditioned patients had lower rates of chronic graft-vs.-host disease (GVHD). Adjusted hazard ratios (HR) for BuFlu(120)THY and BuFlu(250)THY-conditioned patients were 1.60 (95% confidence interval (CI) 0.66-3.86) and 1.87 (0.68-5.11), respectively, for relapse; 0.77 (0.30-1.99) and 1.32 (0.54-3.23) for non-relapse mortality; 0.81 (0.42-1.57) and 1.38 (0.72-2.57) for overall mortality; and 0.78 (0.30-2.05) and 1.62 (0.63-4.41) for relapse or death (failure for relapse-free survival). At one year, 45% of BuFlu(120 or 250)THY-conditioned patients had mixed CD3+ chimerism compared to 0% with BuCy (p < 0.0001). None of 7 patients with long-term mixed chimerism had chronic GVHD; two relapsed, five remained stable mixed chimeras. THY is effective in reducing chronic GVHD, and long-term mixed T-cell chimerism can be compatible with relapse-free survival. However, Thy may also be associated with an increased risk of relapse and, dose-dependent, with non-relapse mortality.
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Ohwada C, Yamazaki S, Shono K, Kayamori K, Hino Y, Oshima-Hasegawa N, Muto T, Tsukamoto S, Mitsukawa S, Takeda Y, Mimura N, Takeuchi M, Iseki T, Onoda M, Yokota A, Suzuki T, Ishii I, Nakaseko C, Sakaida E. Pharmacokinetically guided, once-daily intravenous busulfan in combination with fludarabine for elderly AML/MDS patients as a conditioning regimen for allogeneic stem cell transplantation. Int J Hematol 2021; 114:664-673. [PMID: 34523110 DOI: 10.1007/s12185-021-03188-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
The efficacy of pharmacokinetically (PK) guided, once-daily administration of busulfan (BU) was evaluated in elderly patients with acute myeloid leukemia/myelodysplastic syndrome (AML/MDS). Twenty-one patients (median age 61) received 30 mg/m2 fludarabine for 6 days and BU for 4 days, starting from 3.2 mg/m2 and subsequently adjusted to the target area under the curve (AUC) of 6000 µmol-min/L. The median AUC of day 1 (AUC1), AUC4, and their average were 4871.3, 6021.0, and 5368.1 µmol-min/L, respectively. Veno-occlusive disease/sinusoidal obstructive syndrome (VOD/SOS) occurred in five patients (24%) but all recovered well. Four patients (20%) had non-infectious pulmonary complications (NIPCs). Patients with high AUC1 had frequent gastrointestinal adverse events, but similar incidence of VOD/SOS and NIPCs. Two-year overall survival (OS), non-relapse mortality (NRM), and relapse rates were 44.4%, 28.6%, and 29.1%, respectively. Patients with high AUC1 had significantly high NRM (57.1% vs. 14.3%, P = 0.04) and inferior OS (14.3% vs. 60.1%, P = 0.002), while patients with high AUC4 had a significantly low relapse rate (8.3% vs. 55.6%, P = 0.02). In conclusion, once-daily BU and a PK-guided dose intensification were beneficial for reducing relapse in elderly patients with AML/MDS. However, caution should be exercised as rapid BU dose elevation may contribute to NRM.
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Affiliation(s)
- Chikako Ohwada
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan.
- Department of Hematology, International University of Health and Welfare Narita Hospital, Narita, Japan.
| | - Shingo Yamazaki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Katsuhiro Shono
- Department of Hematology, Aoba Municipal Hospital, Chiba, Japan
| | - Kensuke Kayamori
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Yutaro Hino
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Nagisa Oshima-Hasegawa
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Tomoya Muto
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Shokichi Tsukamoto
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Shio Mitsukawa
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
| | - Yusuke Takeda
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Naoya Mimura
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
| | | | - Tohru Iseki
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
| | - Masahiro Onoda
- Department of Hematology, Aoba Municipal Hospital, Chiba, Japan
| | - Akira Yokota
- Department of Hematology, Aoba Municipal Hospital, Chiba, Japan
| | - Takaaki Suzuki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Itsuko Ishii
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Chiaki Nakaseko
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Hematology, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
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6
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Oran B, Ahn KW, Fretham C, Beitinjaneh A, Bashey A, Pawarode A, Wirk B, Scott BL, Savani BN, Bredeson C, Weisdorf D, Marks DI, Rizzieri D, Copelan E, Hildebrandt GC, Hale GA, Murthy HS, Lazarus HM, Cerny J, Liesveld JL, Yared JA, Yves-Cahn J, Szer J, Verdonck LF, Aljurf M, van der Poel M, Litzow M, Kalaycio M, Grunwald MR, Diaz MA, Sabloff M, Kharfan-Dabaja MA, Majhail NS, Farhadfar N, Reshef R, Olsson RF, Gale RP, Nakamura R, Seo S, Chhabra S, Hashmi S, Farhan S, Ganguly S, Nathan S, Nishihori T, Jain T, Agrawal V, Bacher U, Popat U, Saber W. Fludarabine and Melphalan Compared with Reduced Doses of Busulfan and Fludarabine Improve Transplantation Outcomes in Older Patients with Myelodysplastic Syndromes. Transplant Cell Ther 2021; 27:921.e1-921.e10. [PMID: 34403791 DOI: 10.1016/j.jtct.2021.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/27/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Reduced-intensity conditioning (RIC) regimens developed to extend the use of allogeneic hematopoietic stem cell transplantation (HSCT) to older patients have resulted in encouraging outcomes. We aimed to compare the 2 most commonly used RIC regimens, i.v. fludarabine with busulfan (FluBu) and fludarabine with melphalan (FluMel), in patients with myelodysplastic syndrome (MDS). Through the Center for International Blood and Marrow Transplant Research (CIBMTR), we identified 1045 MDS patients age ≥60 years who underwent first HSCT with a matched related or matched (8/8) unrelated donor using an RIC regimen. The CIBMTR's definition of RIC was used: a regimen that incorporated an i.v. busulfan total dose ≤7.2 mg/kg or a low-dose melphalan total dose ≤150 mg/m2. The 2 groups, recipients of FluBu (n = 697) and recipients of FluMel (n = 448), were comparable in terms of disease- and transplantation-related characteristics except for the more frequent use of antithymocyte globulin or alemtuzumab in the FluBu group (39% versus 31%). The median age was 67 years in both groups. FluMel was associated with a reduced relapse incidence (RI) compared with FluBu, with a 1-year adjusted incidence of 26% versus 44% (P ≤ .0001). Transplantation-related mortality (TRM) was higher in the FluMel group (26% versus 16%; P ≤ .0001). Because the magnitude of improvement with FluMel in RI was greater than the improvement in TRM with FluBu, disease-free survival (DFS) was better at 1 year and beyond with FluMel compared with FluBu (48% versus 40% at 1 year [P = .02] and 35% versus 27% at 3 years [P = .01]). Overall survival (OS) was comparable in the 2 groups at 1 year (63% versus 61%; P = .4) but was significantly improved with FluMel compared with FluBu at 3 years (46% versus 39%; P = .03). Our results suggest that FluMel is associated with superior DFS compared with FluBu owing to reduced RI in older patients with MDS patients. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Betul Oran
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Caitrin Fretham
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, Florida
| | - Asad Bashey
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, Florida
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, Division of Hematology/Oncology, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Mchigan
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - David Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Edward Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | | | - Gregory A Hale
- Department of Hematology/Oncology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Hemant S Murthy
- Blood and Marrow Transplantation Program, Division of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Jane L Liesveld
- Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Jean A Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, Maryland
| | - Jean Yves-Cahn
- Department of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - Jeffrey Szer
- Clinical Haematology at Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Leo F Verdonck
- Department of Hematology/Oncology, Isala Clinic, Zwolle, The Netherlands
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | | | - Mark Litzow
- Division of Hematology and Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Matt Kalaycio
- Hematology and Medical Oncology, Transplantation Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Nino Jesus, Madrid, Spain
| | - Mitchell Sabloff
- Division of Hematology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mohamed A Kharfan-Dabaja
- Blood and Marrow Transplantation Program, Division of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Richard F Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Shahrukh Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Shatha Farhan
- Henry Ford Hospital Bone Marrow Transplant Program, Henry Ford Health System, Detroit, Michigan
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, Kansas
| | | | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | - Tania Jain
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vaibhav Agrawal
- Division of Hematology-Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ulrike Bacher
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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7
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Rasor B, Dickerson T, Zhao Q, Elder P, Brammer JE, Larkin K, Jaglowski S, Mims A, Penza S, Vasu S, Wall SA, William B, Saad A, Roddy JVF, Choe H, Puto M. Comparison of fixed dose reduced-intensity conditioning with fludarabine and busulfan to PK-guided busulfan AUC (FluBu4K) in hematopoietic stem cell transplant for AML/MDS. Leuk Lymphoma 2021; 62:944-951. [PMID: 33231122 PMCID: PMC8012251 DOI: 10.1080/10428194.2020.1849677] [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: 08/01/2020] [Revised: 11/01/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
A retrospective cohort study was conducted to assess differences in efficacy and tolerability between a busulfan AUC target of 16.4 mg × Hr/L per day (FluBu4K) and a conventional RIC regimen (FluBu2). Adult patients with a diagnosis of AML or MDS who received fludarabine + busulfan conditioning with or without antithymocyte globulin between 2015 and 2018 were included. The primary outcome was relapse free survival. Overall, 74 patients received conditioning with either FluBu4K or FluBu2. At 18 months, relapse-free survival was not significantly different, at 63.9% with FluBu4k compared to 57.5% with FluBu2 (p = 0.49). There was a statistically significant difference in the cumulative incidence of relapse at 18 months in favor of the FluBu4K regimen, at 12.0% vs 32.5% (p = 0.047). The results of this study indicate that for select patients, there may be benefit in choosing targeted FluBu4K over FluBu2. Adverse effects other than mucositis were not significantly different.
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Affiliation(s)
- Brendan Rasor
- Department of Pharmacy, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Pharmacy, Kettering Health Network, Kettering, OH, USA
| | - Tyler Dickerson
- Department of Pharmacy, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qiuhong Zhao
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick Elder
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jonathan E Brammer
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Karilyn Larkin
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Samantha Jaglowski
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alice Mims
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sam Penza
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sumithira Vasu
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sarah A Wall
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Basem William
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ayman Saad
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julianna V F Roddy
- Department of Pharmacy, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hannah Choe
- Division of Hematology, Department of Internal Medicine, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Marcin Puto
- Department of Pharmacy, James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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8
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Langenhorst JB, Boss J, van Kesteren C, Lalmohamed A, Kuball J, Egberts ACG, Boelens JJ, Huitema ADR, van Maarseveen EM. A semi-mechanistic model based on glutathione depletion to describe intra-individual reduction in busulfan clearance. Br J Clin Pharmacol 2020; 86:1499-1509. [PMID: 32067250 PMCID: PMC7373715 DOI: 10.1111/bcp.14256] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 12/17/2022] Open
Abstract
Aim To develop a semi‐mechanistic model, based on glutathione depletion and predict a previously identified intra‐individual reduction in busulfan clearance to aid in more precise dosing. Methods Busulfan concentration data, measured as part of regular care for allogeneic hematopoietic cell transplantation (HCT) patients, were used to develop a semi‐mechanistic model and compare it to a previously developed empirical model. The latter included an empirically estimated time effect, where the semi‐mechanistic model included theoretical glutathione depletion. As older age has been related to lower glutathione levels, this was tested as a covariate in the semi‐mechanistic model. Lastly, a therapeutic drug monitoring (TDM) simulation was performed comparing the two models in target attainment. Results In both models, a similar clearance decrease of 7% (range −82% to 44%), with a proportionality to busulfan metabolism, was found. After 40 years of age, the time effect increased with 4% per year of age (0.6–8%, P = 0.009), causing the effect to increase more than a 2‐fold over the observed age‐range (0–73 years). Compared to the empirical model, the final semi‐mechanistic model increased target attainment from 74% to 76%, mainly through better predictions for adult patients. Conclusion These results suggest that the time‐dependent decrease in busulfan clearance may be related to gluthathione depletion. This effect increased with older age (>40 years) and was proportional to busulfan metabolism. The newly constructed semi‐mechanistic model could be used to further improve TDM‐guided exposure target attainment of busulfan in patients undergoing HCT.
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Affiliation(s)
- Jurgen B Langenhorst
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Model-informed Drug Development Consultant, Pharmetheus AB, Uppsala, Sweden
| | - Jill Boss
- Hospital Pharmacy, St Jansdal Hospital, Harderwijk, The Netherlands
| | | | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jürgen Kuball
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Hematology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Antoine C G Egberts
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacoepidemiology & Clinical Pharmacology, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Stem Cell Transplant and Cellular Therapies; Pediatrics, Memorial Sloan Kettering Cancer Centre, New York City, New York, USA
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Erik M van Maarseveen
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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9
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Sora F, Grazia CD, Chiusolo P, Raiola AM, Bregante S, Mordini N, Olivieri A, Iori AP, Patriarca F, Grisariu S, Terruzzi E, Rambaldi A, Sica S, Bruno B, Angelucci E, Bacigalupo A. Allogeneic Hemopoietic Stem Cell Transplants in Patients with Acute Myeloid Leukemia (AML) Prepared with Busulfan and Fludarabine (BUFLU) or Thiotepa, Busulfan, and Fludarabine (TBF): A Retrospective Study. Biol Blood Marrow Transplant 2019; 26:698-703. [PMID: 31875522 DOI: 10.1016/j.bbmt.2019.12.725] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/25/2019] [Accepted: 12/13/2019] [Indexed: 12/22/2022]
Abstract
This is a multicenter retrospective comparison of 2 myeloablative conditioning regimens in 454 patients with acute myeloid leukemia (AML) in remission: busulfan (4 days) and fludarabine (BUFLU) versus thiotepa, busulfan, and fludarabine (TBF). Eligible for this study were patients allografted between January 2008 and December 2018 in 10 transplant centers, with AML in first or second remission: 201 patients received BUFLU, whereas 253 received TBF. The 2 groups (BUFLU and TBF) were comparable for age (P = .13) and adverse AML risk factors (P = .3). The TBF group had more second remissions and more haploidentical grafts. The donor type included HLA-identical siblings, unrelated donors, and family haploidentical donors. The 5-year cumulative incidence of nonrelapse mortality (NRM) was 19% for BUFLU and 22% for TBF (P = .8), and the 5-year cumulative incidence of relapse was 30% and 15%, respectively (P = .0004). The 5-year actuarial survival was 51% for BUFLU and 68% for TBF (P = .002). In a multivariate Cox analysis, after correcting for confounding factors, the use of TBF reduced the risk of relapse compared with BUFLU (P = .03) and the risk of death (P = .03). In a matched pair analysis of 108 BUFLU patients matched with 108 TBF patients, with the exclusion of haploidentical grafts, TBF reduced the risk of relapse (P = .006) and there was a trend for improved survival (P = .07). Superior survival of patients receiving TBF as compared with BUFLU is due to a reduced risk of relapse, with comparable NRM. The survival advantage is independent of donor type and AML risk factors.
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Affiliation(s)
- Federica Sora
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Carmen Di Grazia
- UOC Ematologia e Trapianto di Midollo Osseo, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Patrizia Chiusolo
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Maria Raiola
- UOC Ematologia e Trapianto di Midollo Osseo, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Stefania Bregante
- UOC Ematologia e Trapianto di Midollo Osseo, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Nicola Mordini
- Division of Hematology, Azienda Ospedaliera S. Croce e Carlo, Cuneo, Italy
| | - Attilio Olivieri
- Division of Hematology, Azienda Ospedaliera Universitaria Ospedali Riuniti, Ancona, Italy
| | - Anna Paola Iori
- Dipartimento di Medicina Traslazionale e di Precisione, Azienda Policlinico Umberto I, Università La Sapienza, Rome, Italy
| | | | - Sigal Grisariu
- Adult Bone Marrow Transplantation Inpatient Unit, Hadassah University Hospital, Jerusalem, Israel
| | | | - Alessandro Rambaldi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Simona Sica
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Benedetto Bruno
- Department of Hematology, Universita' di Torino, Turin, Italy
| | - Emanuele Angelucci
- UOC Ematologia e Trapianto di Midollo Osseo, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Andrea Bacigalupo
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Universita' Cattolica del Sacro Cuore, Rome, Italy.
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10
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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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11
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McCune JS, Quinones CM, Ritchie J, Carpenter PA, van Maarseveen E, Yeh RF, Anasetti C, Boelens JJ, Hamerschlak N, Hassan M, Kang HJ, Kanda Y, Paci A, Perales MA, Shaw PJ, Seewaldt VL, Savani BN, Hsieh A, Poon B, Mohty M, Pulsipher MA, Pasquini M, Dupuis LL. Harmonization of Busulfan Plasma Exposure Unit (BPEU): A Community-Initiated Consensus Statement. Biol Blood Marrow Transplant 2019; 25:1890-1897. [PMID: 31136799 DOI: 10.1016/j.bbmt.2019.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022]
Abstract
Busulfan therapeutic drug monitoring (TDM) is often used to achieve target plasma exposures. Variability in busulfan plasma exposure units (BPEU) is a potential source for misinterpretation of publications and protocols and is a barrier to data capture by hematopoietic cell transplantation (HCT) registry databases. We sought to harmonize to a single BPEU for international use. Using Delphi consensus methodology, iterative surveys were sent to an increasing number of relevant clinical stakeholders. In survey 1, 14 stakeholders were asked to identify ideal properties of a BPEU. In survey 2, 52 stakeholders were asked (1) to evaluate BPEU candidates according to ideal BPEU properties established by survey 1 and local position statements for TDM and (2) to identify potential facilitators and barriers to adoption of the harmonized BPEU. The most frequently used BPEU identified, in descending order, were area under the curve (AUC) in μM × min, AUC in mg × h/L, concentration at steady state (Css) in ng/mL, AUC in μM × h, and AUC in μg × h/L. All respondents conceptually agreed on the ideal properties of a BPEU and to adopt a harmonized BPEU. Respondents were equally divided between selecting AUC in μM × min versus mg × h/L for harmonization. AUC in mg × h/L was finally selected as the harmonized BPEU, because it satisfied most of the survey-determined ideal properties for the harmonized BPEU and is read easily understood in the clinical practice environment. Furthermore, 10 major professional societies have endorsed AUC in mg × h/L as the harmonized unit for reporting to HCT registry databases and for use in future protocols and publications.
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Affiliation(s)
- Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Pharmaceutics, University of Washington, Seattle, WA, USA; Molecular Prevention, Intervention and Technology Division, Beckman Research Institute, City of Hope, Duarte, CA, USA.
| | - Christine M Quinones
- Molecular Prevention, Intervention and Technology Division, Beckman Research Institute at City of Hope, Duarte, CA, USA
| | - James Ritchie
- Pathology & Laboratory Medicine Department, Emory University, Atlanta, GA, USA
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Erik van Maarseveen
- Clinical Pharmacology, University Medical Center Utrecht, Utrecht, Princess Maxima Center for Pediatric Oncology, Utrecht and Drug Analysis and Toxicology division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Utrecht, Netherlands
| | - Rosa F Yeh
- Pharmacokinetics Laboratory, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Molecular Prevention, Intervention and Technology Division, Beckman Research Institute, City of Hope, Duarte, CA, USA
| | - Jaap J Boelens
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands; Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson Hamerschlak
- Hematology and Bone Marrow Transplantation Department, Hospital Israelita Albert Einstein, São Paulo Area, Brazil
| | - Moustapha Hassan
- Division of Experimental Cancer Medicine, Department of Laboratory Medicine at Karolinska Institutet and Division of Clinical Research Centrum at Karolinska University Hospital, Stockholm, Sweden
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National Univeristy College of Medicine, Seoul National University Cancer Research Institute, Seoul National University Children's Hospital, Seoul, Korea
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University and Division of Hematology, Saitama Medical Center, Jichi Medical University, Japan
| | - Angelo Paci
- Department of Pharmacology, Institute Gustave Roussy Cancer Center, Grand Paris, School of Pharmacy - Paris Sud University, France
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical College New York, NY, USA
| | - Peter J Shaw
- BMT Services, The Children's Hospital at Westmead, Westmead, New South Wales, and Discipline of Child and Adolescent Health, University of Sydney, Australia
| | - Victoria L Seewaldt
- Molecular Prevention, Intervention and Technology Division, Beckman Research Institute at City of Hope, Duarte, CA, USA
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Angela Hsieh
- Medical Content Manager at McKesson Specialty Health, Seattle, WA, USA
| | - Betsy Poon
- Department of Pharmacy, AdventHealth for Children, Orlando, FL, USA
| | - Mohamad Mohty
- Department of Hematology and Cell Therapy, Acute Leukemia Working Party EBMT Paris Office, Hôpital Saint-Antoine, Paris, France
| | - Michael A Pulsipher
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - L Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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12
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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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13
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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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14
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Kim MG, Kwak A, Choi B, Ji E, Oh JM, Kim K. Effect of glutathione S-transferase genetic polymorphisms on busulfan pharmacokinetics and veno-occlusive disease in hematopoietic stem cell transplantation: A meta-analysis. Basic Clin Pharmacol Toxicol 2018; 124:691-703. [PMID: 30511436 DOI: 10.1111/bcpt.13185] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/28/2018] [Indexed: 12/25/2022]
Abstract
This meta-analysis was conducted to derive an integrated conclusion about the influence of glutathione S-transferase (GST) genetic polymorphisms on busulfan pharmacokinetic (PK) parameters and veno-occlusive disease (VOD). Studies which analysed the effect of GST genetic polymorphisms on area under the curve (AUC), clearance (CL) or VOD were searched for and selected. A pooled analysis was conducted using Comprehensive Meta-Analysis programme. Nineteen studies were included in this meta-analysis. GSTA1*B and GSTM1 null genotypes significantly decreased CLIV of busulfan (standardized difference in means (SDM) = -1.103; P = 0.019 and SDM = -0.418; P = 0.002, respectively). GSTA1*B significantly increased AUCIV of busulfan (SDM = 0.832; P = 0.046), whereas GSTM1 did not (SDM = 0.155; P = 0.478). The PK parameters of oral busulfan did not differ according to GST genotype. GSTA1, GSTM1 and GSTP1 were not significantly associated with VOD occurrence. GSTA1 and GSTM1 genotypes affected CLIV of busulfan, but only GSTA1 affected AUCIV . There was no significant difference in the PK parameters of oral busulfan (CLPO and AUCPO ) and VOD when only GST genotypes were considered.
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Affiliation(s)
- Myeong Gyu Kim
- Graduate School of Clinical Pharmacy, CHA University, Pocheon, Korea
| | - Arim Kwak
- College of Pharmacy, Korea University, Sejong, Korea
| | - Boyoon Choi
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Korea
| | - Eunhee Ji
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Gachon University, Incheon, Korea
| | - Jung Mi Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Korea
| | - Kyungim Kim
- College of Pharmacy, Korea University, Sejong, Korea
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15
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Xu Y, Thall PF, Hua W, Andersson BS. Bayesian non-parametric survival regression for optimizing precision dosing of intravenous busulfan in allogeneic stem cell transplantation. J R Stat Soc Ser C Appl Stat 2018; 68:809-828. [PMID: 31467455 DOI: 10.1111/rssc.12331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Allogeneic stem cell transplantation (allo-SCT) is now part of standard of care for acute leukemia (AL). To reduce toxicity of the pre-transplant conditioning regimen, intravenous busulfan is usually used as a preparative regimen for AL patients undergoing allo-SCT. Systemic busulfan exposure, characterized by the area under the plasma concentration versus time curve (AUC), is strongly associated with clinical outcome. An AUC that is too high is associated with severe toxicities, while an AUC that is too low carries increased risks of disease recurrence and failure to engraft. Consequently, an optimal AUC interval needs to be determined for therapeutic use. To address the possibility that busulfan pharmacokinetics and pharmacodynamics vary significantly with patient characteristics, we propose a tailored approach to determine optimal covariate-specific AUC intervals. To estimate these personalized AUC intervals, we apply a flexible Bayesian nonparametric regression model based on a dependent Dirichlet process and Gaussian process, DDP-GP. Our analyses of a dataset of 151 patients identified optimal therapeutic intervals for AUC that varied substantively with age and whether the patient was in complete remission or had active disease at transplant. Extensive simulations to evaluate the DDP-GP model in similar settings showed that its performance compares favorably to alternative methods. We provide an R package, DDPGPSurv, that implements the DDP-GP model for a broad range of survival regression analyses.
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Affiliation(s)
- Yanxun Xu
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, USA
| | - Peter F Thall
- Department of Biostatistics, U.T. M.D. Anderson Cancer Center, Houston, USA
| | - William Hua
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, USA
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, U.T. M.D. Anderson Cancer Center, Houston, USA
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16
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Reduced intensity vs. myeloablative conditioning with fludarabine and PK-guided busulfan in allogeneic stem cell transplantation for patients with AML/MDS. Bone Marrow Transplant 2018; 54:1245-1253. [PMID: 30532055 DOI: 10.1038/s41409-018-0405-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/16/2022]
Abstract
Conditioning regimens contribute significantly to outcomes following allogeneic stem cell transplantation (allo-SCT). Reduced-intensity conditioning (RIC) regimens provide lower toxicity at the cost of reduced efficacy compared with myeloablative conditioning (MAC) regimens. However, because pre-transplant prognostic variables often determine the conditioning regimen, studies of RIC vs. MAC have been inconclusive. We present a retrospective analysis of 242 acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) patients, 112 of whom were in 56 pairs matched using propensity scores, to account for variation that may confound clinical outcomes. The uniform conditioning regimens consisted of fludarabine with pharmacokinetic (PK)-guided intravenous busulfan (Bu). The RIC and MAC regimens were dosed at the average daily area under the concentration-vs-time curve (AUC) of 4000 µMol min and 5000-6000 µMol min, or total course AUC of 16,000 µMol min and 20,000-24,000 µMol min, respectively; PK-guided dosing removes overlap in systemic Bu exposure. When patients' data were propensity-matched, there was a trend toward significantly increased full donor chimerism and decreased chronic graft vs. host disease in RIC, and no significant differences in progression free survival and overall survival between RIC and MAC. Our results also elucidate the efficacy of PK-guided-dosing in the setting of allo-SCT for AML and MDS.
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17
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Ueda T, Maeda T, Kusakabe S, Fujita J, Fukushima K, Yokota T, Shibayama H, Tomiyama Y, Kanakura Y. Addition of melphalan to fludarabine/busulfan (FLU/BU4/MEL) provides survival benefit for patients with myeloid malignancy following allogeneic bone-marrow transplantation/peripheral blood stem-cell transplantation. Int J Hematol 2018; 109:197-205. [DOI: 10.1007/s12185-018-2562-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 12/14/2022]
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18
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Willcox A, Wong E, Nath C, Janson B, Harrison SJ, Hoyt R, Bajel A, Shaw P, Ritchie D, Grigg A. The pharmacokinetics and pharmacodynamics of busulfan when combined with melphalan as conditioning in adult autologous stem cell transplant recipients. Ann Hematol 2018; 97:2509-2518. [DOI: 10.1007/s00277-018-3447-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 07/17/2018] [Indexed: 11/25/2022]
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19
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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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20
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Nava T, Rezgui MA, Uppugunduri CRS, Curtis PHD, Théoret Y, Duval M, Daudt LE, Ansari M, Krajinovic M, Bittencourt H. GSTA1 Genetic Variants and Conditioning Regimen: Missing Key Factors in Dosing Guidelines of Busulfan in Pediatric Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1918-1924. [PMID: 28807770 DOI: 10.1016/j.bbmt.2017.07.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/23/2017] [Indexed: 12/14/2022]
Abstract
Busulfan (Bu) is a key component of conditioning regimens used before hematopoietic stem cell transplantation (SCT) in children. Different predictive methods have been used to calculate the first dose of Bu. To evaluate the necessity of further improvements, we retrospectively analyzed the currently available weight- and age-based guidelines to calculate the first doses in 101 children who underwent allogenic SCT in CHU Sainte-Justine, Montreal, after an intravenous Bu-containing conditioning regimen according to genetic and clinical factors. The measured areas under the curve (AUCs) were within target (900 to 1500 µM/min) in 38.7% of patients after the administration of the first dose calculated based on age and weight, as locally recommended. GSTA1 diplotypes linked to poor Bu metabolism (G3) and fludarabine-containing regimens were the only factors associated with AUC within target (OR, 4.7 [95% CI, 1.1 to 19.8, P = .04]; and OR, 9.9 [95% CI, 1.6 to 61.7, P = .01], respectively). From the 11 methods selected for dose calculation, the percentage of AUCs within the target varied between 16% and 74%. In some models G3 was associated with AUCs within the therapeutic and the toxic range, whereas rapid metabolizers (G1) were correlated with subtherapeutic AUCs when different methods were used. These associations were confirmed by clearance-prediction analysis, in which GSTA1 diplotypes consistently influenced the prediction errors of the methods. These findings suggest that these factors should be considered in Bu dose prediction in addition to the anthropometric data from patients. Furthermore, our data indicated that GSTA1 diplotypes was a factor that should be included in future population pharmacokinetic models, including similar conditioning regiments, to improve the prediction of Bu exposure after its initial dose.
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Affiliation(s)
- Tiago Nava
- Department of Pediatrics, Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, Quebec, Canada; Department of Pediatrics, Faculty of Medicine, CANSEARCH Research Laboratory, Geneva, Switzerland; Department of Pediatrics, Onco-Hematology Unit, Geneva University Hospital, Geneva University, Geneva, Switzerland; Post-Graduate Program in Child and Adolescent Health, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
| | - Mohamed A Rezgui
- Department of Pediatrics, Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Chakradhara R S Uppugunduri
- Department of Pediatrics, Faculty of Medicine, CANSEARCH Research Laboratory, Geneva, Switzerland; Department of Pediatrics, Onco-Hematology Unit, Geneva University Hospital, Geneva University, Geneva, Switzerland
| | - Patricia Huezo-Diaz Curtis
- Department of Pediatrics, Faculty of Medicine, CANSEARCH Research Laboratory, Geneva, Switzerland; Department of Pediatrics, Onco-Hematology Unit, Geneva University Hospital, Geneva University, Geneva, Switzerland
| | - Yves Théoret
- Department of Pediatrics, Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, Quebec, Canada; Department of Pharmacology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Clinical Pharmacology Unit, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Michel Duval
- Department of Pediatrics, Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, Quebec, Canada; Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Liane E Daudt
- Post-Graduate Program in Child and Adolescent Health, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Marc Ansari
- Department of Pediatrics, Faculty of Medicine, CANSEARCH Research Laboratory, Geneva, Switzerland; Department of Pediatrics, Onco-Hematology Unit, Geneva University Hospital, Geneva University, Geneva, Switzerland
| | - Maja Krajinovic
- Department of Pediatrics, Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, Quebec, Canada; Department of Pharmacology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Clinical Pharmacology Unit, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Henrique Bittencourt
- Department of Pediatrics, Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, Quebec, Canada; Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
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21
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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: 40] [Impact Index Per Article: 5.0] [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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22
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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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23
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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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24
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Admiraal R, Boelens JJ. Individualized conditioning regimes in cord blood transplantation: Towards improved and predictable safety and efficacy. Expert Opin Biol Ther 2016; 16:801-13. [DOI: 10.1517/14712598.2016.1164688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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25
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Zao JH, Schechter T, Liu WJ, Gerges S, Gassas A, Egeler RM, Grunebaum E, Dupuis LL. Performance of Busulfan Dosing Guidelines for Pediatric Hematopoietic Stem Cell Transplant Conditioning. Biol Blood Marrow Transplant 2015; 21:1471-8. [DOI: 10.1016/j.bbmt.2015.05.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 05/05/2015] [Indexed: 01/20/2023]
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26
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Sato M, Kako S, Matsumoto K, Oshima K, Akahoshi Y, Nakano H, Ugai T, Yamasaki R, Wada H, Ishihara Y, Sakamoto K, Kawamura K, Ashizawa M, Terasako-Saito K, Kimura SI, Nakasone H, Kikuchi M, Tanihara A, Yamazaki R, Tanaka Y, Kanda J, Nishida J, Morita K, Kanda Y. Pharmacokinetics study of once-daily intravenous busulfan in conditioning regimens for hematopoietic stem cell transplantation. Int J Hematol 2015; 101:497-504. [DOI: 10.1007/s12185-015-1756-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/02/2015] [Accepted: 02/02/2015] [Indexed: 12/15/2022]
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27
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Wang Y, Kato K, Le Gallo C, Armstrong E, Rock E, Wang X. Dosing algorithm revisit for busulfan following IV infusion. Cancer Chemother Pharmacol 2015; 75:505-12. [PMID: 25561350 DOI: 10.1007/s00280-014-2660-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 12/22/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE Busulfan (Bu) exposure is critical for efficacy and safety. Body weight (BW), or adjusted ideal body weight (AIBW)-based dosing (WBD) algorithm, has been used in hematopoietic stem cell transplantation (HSCT). A recently completed phase 2 study revealed that 33.6 % of the subjects were under-, or over-exposed, with this WBD algorithm. This paper was to investigate Bu dosing algorithm in an attempt to improve the suboptimal Bu exposure. METHODS Population PK modeling was conducted using the data from 207 patients. Dosing algorithm was developed based on derived covariate model of CL. Model-based simulation was conducted to assist test PK study design. A simplified CL estimation method was proposed based on the PK structure model for Bu. RESULTS A one-compartment structure model adequately described the PK profile of Bu following an IV infusion. BSA best described the inter-individual variability of CL. The proposed dosing algorithm was dose (mg) = (31.7 × BSA - 11.6) × target AUC [µM min]/1,000. With this dosing algorithm, 14.3 % patients could be under- or over-exposed. A test PK study with reduced study duration and three PK samples can provide as nearly as good an estimate of CL compared to 12 PK samples on two different occasions. CONCLUSION The proposed dosing algorithm can significantly improve the sub-exposure of Bu. A shortened test PK study duration with reduced PK samples can provide as near as good estimate for Bu CL. A simplified CL estimation method is valid.
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Affiliation(s)
- Yanlin Wang
- Otsuka Pharmaceutical Development and Commercialization, Inc., 506 Carnegie Center Drive, Princeton, NJ, 08540, USA
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28
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Bubalo J, Carpenter PA, Majhail N, Perales MA, Marks DI, Shaughnessy P, Pidala J, Leather HL, Wingard J, Savani BN. Conditioning chemotherapy dose adjustment in obese patients: a review and position statement by the American Society for Blood and Marrow Transplantation practice guideline committee. Biol Blood Marrow Transplant 2014; 20:600-16. [PMID: 24462742 DOI: 10.1016/j.bbmt.2014.01.019] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/15/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) is a potentially life-saving therapy for patients with malignant and nonmalignant disease states. This article reviews the current published literature on the dosing of pharmacologic agents used for HCT preparative regimens with specific focus on the obese patient population. The review found that dose adjustments for obesity have, to date, been based empirically or extrapolated from published data in the nontransplantation patient population. As a result, the Committee determined that clear standards or dosing guidelines are unable to be made for the obese population because Level I and II evidence are unavailable at this time. Instead, the Committee provides a current published literature review to serve as a platform for conditioning agent dose selection in the setting of obesity. A necessary goal should be to encourage future prospective trials in this patient population because further information is needed to enhance our knowledge of the pharmacokinetics and pharmacodynamics of conditioning agents in the setting of obesity.
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Affiliation(s)
- Joseph Bubalo
- Department of Pharmacy Services, Oregon Health and Science University Hospital, Portland, Oregon.
| | | | - Navneet Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - David I Marks
- Bristol Bone Marrow Transplant Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Paul Shaughnessy
- Adult Bone Marrow Transplant, Texas Transplant Institute, San Antonio, Texas
| | - Joseph Pidala
- Division of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, Florida
| | - Helen L Leather
- Division of Hematology/Oncology, University of Florida Health Cancer Center, Gainesville, Florida
| | - John Wingard
- Division of Hematology/Oncology, University of Florida Health Cancer Center, Gainesville, Florida
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
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