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Pattipaka T, Sarp S, Nakhaei P, Güneş S. Ruxolitinib in patients with graft versus host disease (GvHD): findings from a compassionate use program. Bone Marrow Transplant 2024; 59:637-646. [PMID: 38361117 PMCID: PMC11073975 DOI: 10.1038/s41409-024-02207-4] [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: 06/16/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
The ruxolitinib compassionate use (CU) program offered ruxolitinib to patients ≥2 years of age with confirmed steroid-resistant acute or chronic graft-versus-host disease (aGvHD and cGvHD, respectively). Data from 1180 patients (n = 775, 370 and 35 with cGvHD, aGvHD, and non-specified GvHD, respectively) were analyzed. Most patients had severe cGvHD (56%) or stage III/IV aGvHD (70%) disease and had previously received corticosteroids ( > 80%); ruxolitinib was requested primarily as a second-/third-line option. Patients <12 and ≥12 years old most often received the recommended ruxolitinib doses (5 mg twice daily [BID] and 10 mg BID, respectively); however, 23% and 30% of ≥12 year olds with cGvHD and aGvHD, respectively, received the lower dose of 5 mg BID. Notably, corticosteroid usage decreased with ruxolitinib treatment; at the initial ruxolitinib request, 81% and 91% of patients with cGvHD and aGvHD, respectively, were receiving corticosteroids whereas at resupply, 62% and 64%, respectively, were receiving corticosteroids. Eighty two percent of evaluable patients with cGvHD had a complete or partial response to treatment and 56% of evaluable patients with aGvHD had a best response of grade 0/I. These findings demonstrate the rapid and positive effects of ruxolitinib in patients with GvHD in a real-world setting.
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Affiliation(s)
| | | | - Peyman Nakhaei
- Novartis Pharmaceuticals Canada Inc, Montreal, QC, Canada
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Kim DDH, Popradi G, Lepic K, Paulson K, Allan D, Nampoothiri RV, Lachance S, Deotare U, White J, Elemary M, Jamani K, Fraga C, Lemieux C, Novitzky-Basso I, Law AD, Kumar R, Walker I, Schultz KR. Cell Therapy Transplant Canada (CTTC) Consensus-Based Guideline 2024 for Management and Treatment of Chronic Graft-Versus-Host Disease and Future Directions for Development. Curr Oncol 2024; 31:1426-1444. [PMID: 38534941 PMCID: PMC10968999 DOI: 10.3390/curroncol31030108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 01/28/2024] [Accepted: 02/28/2024] [Indexed: 05/26/2024] Open
Abstract
This is a consensus-based Canadian guideline whose primary purpose is to standardize and facilitate the management of chronic graft-versus-host disease (cGvHD) across the country. Creating uniform healthcare guidance in Canada is a challenge for a number of reasons including the differences in healthcare authority structure, funding and access to healthcare resources between provinces and territories, as well as the geographic size. These differences can lead to variable and unequal access to effective therapies for GvHD. This document will provide comprehensive and practical guidance that can be applied across Canada by healthcare professionals caring for patients with cGvHD. Hopefully, this guideline, based on input from GvHD treaters across the country, will aid in standardizing cGvHD care and facilitate access to much-needed novel therapies. This consensus paper aims to discuss the optimal approach to the initial assessment of cGvHD, review the severity scoring and global grading system, discuss systemic and topical treatments, as well as supportive therapies, and propose a therapeutic algorithm for frontline and subsequent lines of cGvHD treatment in adults and pediatric patients. Finally, we will make suggestions about the future direction of cGvHD treatment development such as (1) a mode-of-action-based cGvHD drug selection, according to the pathogenesis of cGvHD, (2) a combination strategy with the introduction of newer targeted drugs, (3) a steroid-free regimen, particularly for front line therapy for cGvHD treatment, and (4) a pre-emptive approach which can prevent the progression of cGvHD in high-risk patients destined to develop severe and highly morbid forms of cGvHD.
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Affiliation(s)
- Dennis Dong Hwan Kim
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Gizelle Popradi
- Health Centre, McGill University, Montreal, QC H4P 2P5, Canada
| | - Kylie Lepic
- Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Kristjan Paulson
- CancerCare Manitoba, University of Manitoba, Winnipeg, Manitoba, MB R3E 0V9, Canada
| | - David Allan
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | | | - Sylvie Lachance
- Hôpital Maisonneuve-Rosemont, Department of Medicine, University of Montreal, Montreal, QC H3C 3J7, Canada;
| | - Uday Deotare
- London Health Sciences Centre, University of Western Ontario, London, ON N6A 5A5, Canada
| | - Jennifer White
- Vancouver General Hospital, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Mohamed Elemary
- Saskatchewan Cancer Agency, University of Saskatchewan, Saskatchewan, SK S7N 4H4, Canada
| | - Kareem Jamani
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB T2N 4N2, Canada;
| | - Christina Fraga
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Christopher Lemieux
- CHU de Québec—Université Laval, Université Laval, Québec, QC G1R 2J6, Canada
| | - Igor Novitzky-Basso
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Arjun Datt Law
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Rajat Kumar
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Irwin Walker
- Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Kirk R. Schultz
- British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC V6H 3N1, Canada
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Linn SM, Novitzky-Basso I, Patriquin C, Pasic I, Lam W, Law A, Michelis FV, Gerbitz A, Viswabandya A, Lipton J, Kumar R, Mattsson J, Barth D, Kim DDH. Single centre retrospective analysis of extracorporeal photopheresis (ECP) therapy in patients heavily pre-treated for chronic graft-versus-host disease (cGvHD) with steroid failure. Leuk Res 2023; 134:107387. [PMID: 37734221 DOI: 10.1016/j.leukres.2023.107387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is recommended as a second- or later-line therapy for chronic GvHD (cGvHD). Benefits include reasonable response with avoidance of intense systemic immunosuppression, which can translate into lowering the risk of systemic toxicity and opportunistic infection. METHODS We evaluated 75 patients treated with ECP for cGvHD from 2007 to 2021 at Princess Margaret Cancer Centre, and analyzed overall response rate (ORR) and clinical benefit (CB) at 3, 6 and 12 months plus other long-term treatment outcomes. RESULTS With a median follow-up of 72 months, a gradual increase in ORR was noted over time: 21% (16 out of 75 patients), 57% (36/63) and 70% (32/46) at month 3, 6 and 12, respectively. Gradual increase in CB was also observed over time with CB rate of 23% (17/75), 62% (39/63), and 76% (35/46) at months 3, 6 and 12, respectively. A total of 27 failures (36%) were noted, due to: 1) ECP resistance requiring switch to other therapy (n = 14, 19%), 2) non-relapse mortality (n = 10, 13%), 3) relapse of primary disease (n = 1, 1%) or 4) ECP procedure-related complication (n = 1, 1%, line infection), with 20 deaths (27%) observed. Failure-free survival (FFS) and overall survival (OS) rates were 68.3% and 85.9% at 12 months, respectively. After starting ECP, the proportions of patients who completely discontinued steroids were 17%, 32%, and 64% at months 3, 6 and 12, respectively. CONCLUSION ECP is an effective treatment option for heavily pre-treated cGvHD patients.
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Affiliation(s)
- Swe Mar Linn
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Igor Novitzky-Basso
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Christopher Patriquin
- Apheresis Program, Division of Medical Oncology and Haematology, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Ivan Pasic
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Wilson Lam
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Arjun Law
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Fotios V Michelis
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Armin Gerbitz
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Auro Viswabandya
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Jeffrey Lipton
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Rajat Kumar
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Jonas Mattsson
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - David Barth
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Dennis Dong Hwan Kim
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada.
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Algeri M, Becilli M, Locatelli F. Ruxolitinib as the first post-steroid treatment for acute and chronic graft-versus-host disease. Expert Rev Clin Immunol 2023; 19:1299-1313. [PMID: 37606511 DOI: 10.1080/1744666x.2023.2249230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 08/14/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Acute and chronic graft-versus-host disease (GvHD) are potentially life-threatening complications occurring after allogeneic stem cell transplantation (allo-HSCT). Although steroids represent the first-line treatment for both conditions, in those patients who do not adequately benefit from steroid therapy, standardized treatment algorithms are lacking. In recent years, ruxolitinib has emerged as the most promising agent for the second-line therapy of steroid-refractory (SR)-GvHD. AREAS COVERED This review will summarize the biological properties and the mechanistic aspects that justify the therapeutic role of ruxolitinib in GvHD. In addition, current treatment options for SR-GvHD will be briefly discussed. Finally, results of the most relevant clinical trials on the use of ruxolitinib for SR-GvHD will be analyzed, with a particular focus on two phase-III randomized trials in which ruxolitinib demonstrated its superiority in comparison with the best available therapy. EXPERT OPINION Ruxolitinib has considerably improved the outcome of patients with SR-acute/chronic-GvHD and should be regarded as the standard-of-care option when corticosteroids fail or cannot be tapered. Nevertheless, a number of questions still remain unanswered and significant room for improvement exists. Additional observations derived from a longer follow-up will certainly increase our expertise in the management of this powerful therapy.
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Affiliation(s)
- Mattia Algeri
- Department of Haematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
- Department of Health Science, Magna Grecia University of Catanzaro, Catanzaro, Italy
| | - Marco Becilli
- Department of Haematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Locatelli
- Department of Haematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
- Department of Life Sciences and Public Health, Catholic University of the Sacred Heart, Rome, Italy
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Maurer K, Soiffer RJ. The delicate balance of graft versus leukemia and graft versus host disease after allogeneic hematopoietic stem cell transplantation. Expert Rev Hematol 2023; 16:943-962. [PMID: 37906445 PMCID: PMC11195539 DOI: 10.1080/17474086.2023.2273847] [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: 08/04/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION The curative basis of allogeneic hematopoietic stem cell transplantation (HSCT) relies in part upon the graft versus leukemia (GvL) effect, whereby donor immune cells recognize and eliminate recipient malignant cells. However, alloreactivity of donor cells against recipient tissues may also be deleterious. Chronic graft versus host disease (cGvHD) is an immunologic phenomenon wherein alloreactive donor T cells aberrantly react against host tissues, leading to damaging inflammatory symptoms. AREAS COVERED Here, we discuss biological insights into GvL and cGvHD and strategies to balance the prevention of GvHD with maintenance of GvL in modern HSCT. EXPERT OPINION/COMMENTARY Relapse remains the leading cause of mortality after HSCT with rates as high as 40% for some diseases. GvHD is a major cause of morbidity after HSCT, occurring in up to half of patients and responsible for 15-20% of deaths after HSCT. Intriguingly, the development of chronic GvHD may be linked to lower relapse rates after HSCT, suggesting that GvL and GvHD may be complementary sides of the immunologic foundation of HSCT. The ability to fine tune the balance of GvL and GvHD will lead to improvements in survival, relapse rates, and quality of life for patients undergoing HSCT.
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Affiliation(s)
- Katie Maurer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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