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Aggarwal N, Manley AL, Shalhoub R, Durrani J, Rios O, Lotter J, Patel BA, Wu CO, Young NS, Groarke EM. Alemtuzumab in relapsed immune severe aplastic anemia: Long-term results of a phase II study. Am J Hematol 2023; 98:932-939. [PMID: 37021397 PMCID: PMC10360054 DOI: 10.1002/ajh.26924] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/07/2023]
Abstract
Immune severe aplastic anemia (SAA) is characterized by pancytopenia and immune-mediated bone marrow destruction. SAA may be treated with hematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST). However, 30% of patients treated with IST relapse. We previously reported a clinical trial of alemtuzumab in which more than half of 25 relapsed SAA patients (56%) responded hematologically. Here, we present long-term results of a total of 42 patients. Participants with SAA who had previously completed antithymocyte globulin (ATG)-based IST, but had relapsed, were enrolled on this study. Alemtuzumab was administered intravenously (IV) (n = 28) or subcutaneously (SC) (n = 14). The primary endpoint was hematologic response at 6 months. Secondary endpoints included relapse, clonal evolution, and survival. This trial was registered at clinicaltrials.gov (NCT00195624). Patients were enrolled over 9 years, with median follow-up of 6 years. Median age was 32 years, with 57% being female. At 6 months, 18 patients (43%) achieved response; 15 (54%) of those who received IV compared with 3 (21%) who received SC therapy. Six patients (14%) had durable long-term response without need for subsequent AA-directed therapy or HSCT at last follow-up. Nine patients had clonal evolution, with high-risk evolution occurring in 6. Overall survival was 67% at median follow-up of 6 years. Prolonged iatrogenic immunosuppression was observed as long as 2 years after alemtuzumab administration. Alemtuzumab induces responses in relapsed SAA, some of which are durable long-term. However, immunosuppression can persist for years, requiring long-term monitoring.
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Affiliation(s)
- Nidhi Aggarwal
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Ash Lee Manley
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Ruba Shalhoub
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Jibran Durrani
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Olga Rios
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Jennifer Lotter
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Bhavisha A. Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Colin O. Wu
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Neal S. Young
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
| | - Emma M. Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, United States of America
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2
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Ghaderi A, Nodehi SRS, Bakhtiari T, Aslani M, Aghazadeh Z, Matsuo H, Rehm BHA, Cuzzocrea S, Mirshafiey A. Mannuronic Acid in Low-Risk and Intermediate-1-Risk Myelodysplastic Syndromes. J Clin Pharmacol 2020; 60:879-888. [PMID: 32064621 DOI: 10.1002/jcph.1587] [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: 10/10/2019] [Accepted: 01/17/2020] [Indexed: 11/10/2022]
Abstract
The discovery of hematologic improvement and bone marrow modification by the drug β-D mannuronic acid (M2000) during treatment of rheumatoid arthritis in phase 1/2/3 clinical trials prompted us to design a new trial to target hematologic deficits in myelodysplastic syndromes (MDS). In this open-label, randomized phase 2 clinical trial, the potential effect and tolerability of drug M2000 was assessed in patients with low- and intermediate-1-risk MDS. The primary efficacy end point was hematologic improvement after 12 weeks of β-D-mannuronic acid therapy. Among 34 enrolled patients, half received their conventional therapy plus β-D-mannuronic acid, and the other half received only conventional drugs. In the conventional + β-D mannuronic acid treatment group, hematologic improvement and development of transfusion independence and/or reduction in transfusion requirements were seen in 12 patients (92.3%) and 1 patient (7.7%), respectively. Moreover, 5 patients (38.5%), 2 patients (15.4%), and 1 patient (7.7%) in the β-D-mannuronic acid-treated group showed hematologic improvement of the major parameters of erythroid, neutrophil, and platelet responses, respectively, based on the International Working Group criteria), whereas in the conventional treatment group as control, no hematologic improvements including erythroid, neutrophil, and platelet response was seen. In this trial, the addition of β-D mannuronic acid to conventional treatment showed promising results in MDS patients with low and intermediate-1 risk with effects on hematologic improvements without significant adverse effect.
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Affiliation(s)
- Afshin Ghaderi
- Department of Internal Medicine, Hematology and Medical Oncology Ward, Cancer Research Centre, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Sayyed Reza Safaee Nodehi
- Department of Internal Medicine, Hematology and Medical Oncology Ward, Cancer Research Centre, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Tahereh Bakhtiari
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Aslani
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Aghazadeh
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Bernd H A Rehm
- Centre for Cell Factories and Biopolymers, Griffith Institute for Drug Discovery, Griffith University, Nathan, Queensland, Australia
| | - Salvatore Cuzzocrea
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
| | - Abbas Mirshafiey
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Research Centre for Immunodeficiencies, Children's Medical Centre, Tehran University of Medical Sciences, Tehran, Iran
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Thota S, Patel BJ, Sadaps M, Balasubramanian S, Sanikommu S, Hirsch C, Marotta S, Sekeres MA, Risitano AM, Maciejewski JP. Therapeutic outcomes using subcutaneous low dose alemtuzumab for acquired bone marrow failure conditions. Br J Haematol 2017; 183:133-136. [PMID: 28905372 DOI: 10.1111/bjh.14907] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Swapna Thota
- Department of Translational Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Bhumika J Patel
- Department of Translational Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH, USA.,Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Meena Sadaps
- Department of Translational Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Suresh Balasubramanian
- Department of Translational Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Srinivasa Sanikommu
- Department of Translational Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Cassandra Hirsch
- Department of Translational Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Serena Marotta
- Haematology, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Mikkael A Sekeres
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Antonio M Risitano
- Haematology, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH, USA
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4
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Boddu PC, Kadia TM. Updates on the pathophysiology and treatment of aplastic anemia: a comprehensive review. Expert Rev Hematol 2017; 10:433-448. [DOI: 10.1080/17474086.2017.1313700] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
| | - Tapan Mahendra Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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5
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Evaluation of efficacy of alemtuzumab in 5 patients with aplastic anemia and/or myelodysplastic neoplasm. Wien Klin Wochenschr 2016; 129:404-410. [PMID: 27743175 PMCID: PMC5486731 DOI: 10.1007/s00508-016-1091-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 09/01/2016] [Indexed: 11/25/2022]
Abstract
Patients with aplastic anemia or hypoplastic myelodysplastic syndrome (MDS) may respond to immunosuppressive therapy, including the anti-CD52 antibody alemtuzumab. We analyzed treatment responses to alemtuzumab in 5 patients with MDS or aplastic anemia (AA) evolving to MDS. Two patients with hypoplastic MDS (hMDS) showed a partial response (PR) to alemtuzumab. In both responding patients, a concomitant paroxysmal nocturnal hemoglobinuria (PNH) clone was detected before therapy. One responder relapsed after 15 months and underwent successful allogeneic stem cell transplantation. Both patients are still alive and in remission after 40 and 20 months, respectively. The other patients showed no response to alemtuzumab. One patient died from pneumonia 4 months after treatment. In summary, our data confirm that alemtuzumab is an effective treatment option for a subset of patients with MDS, even in the presence of a PNH clone.
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[Advances in the treatment of severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 36:711-5. [PMID: 26462649 PMCID: PMC7348265 DOI: 10.3760/cma.j.issn.0253-2727.2015.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Schrezenmeier H, Körper S, Höchsmann B. Immunosuppressive therapy for transplant-ineligible aplastic anemia patients. Expert Rev Hematol 2015; 8:89-99. [PMID: 25572607 DOI: 10.1586/17474086.2015.978759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Aplastic anemia is a rare life-threatening bone marrow failure that is characterized by bicytopenia or pancytopenia in the peripheral blood and a hypoplastic or aplastic bone marrow. The patients are at risk of infection and hemorrhage due to neutropenia and thrombocytopenia and suffer from symptoms of anemia. The main treatment approaches are allogeneic stem cell transplantation and immunosuppression. Here, we review current standard immunosuppression and the attempts that have been made in the past two decades to improve results: review of recent developments also reveals that sometimes not only the advent of new drugs, good ideas and well-designed clinical trials decide the progress in the field but also marketing considerations of pharmaceutical companies. Aplastic anemia experts unfortunately had to face the situation that efficient drugs were withdrawn simply for marketing considerations. We will discuss the current options and challenges in first-line treatment and management of relapsing and refractory patients with an emphasis on adult patients. Some promising new approaches are currently under investigation in prospective, randomized trials.
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Willis L, Rexwinkle A, Bryan J, Kadia TM. Recent Developments in Drug Therapy for Aplastic Anemia. Ann Pharmacother 2014; 48:1469-78. [DOI: 10.1177/1060028014547078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: This article reviews recent developments in immunosuppressive therapy (IST) for aplastic anemia (AA) patients who are not candidates for stem cell transplant (SCT); including, front-line, salvage, and novel treatment options with a focus on response rates (RRs) and overall survival (OS). Data Sources: A PubMed literature search was performed from 1977 to June 2014 using the search terms aplastic anemia, horse antithymocyte globulin (hATG), rabbit ATG (rATG), thymoglobulin, and cyclosporine (CSA). Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language studies investigating IST for treatment of AA in non–SCT candidates were evaluated. Data Synthesis: Studies indicate addition of CSA and corticosteroids to hATG for treatment of AA improves RRs, decreases relapse rates, and improves 5-year OS. hATG improved RRs, relapse rates, and OS compared to rATG in the front-line setting. Studies support the use of rATG when front-line IST with hATG fails or when hATG is unavailable. Front-line daclizumab can be considered for nonsevere AA (NAA); however, data is limited. Alemtuzumab or eltrombopag are options for relapsed AA in select patients. Conclusions: hATG with methylprednisolone and CSA is recommended for front-line treatment of AA, whereas rATG is reserved for salvage therapy. Front-line use of daclizumab has been studied in NAA patients, but additional prospective trials are needed before this is adopted into clinical practice. Alemtuzumab and eltrombopag have been studied for treatment of AA; recruiting is ongoing in clinical trials to assess the appropriate dosing strategy and place in therapy.
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Affiliation(s)
- Lauren Willis
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amber Rexwinkle
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Bryan
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M. Kadia
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Cerchione C, Catalano L, Cerciello G, Avilia S, Picardi M, Risitano AM, Pisano I, Alfinito F, Pane F. Role of lenalidomide in the management of myelodysplastic syndromes with del(5q) associated with pure red cell aplasia (PRCA). Ann Hematol 2014; 94:531-4. [DOI: 10.1007/s00277-014-2192-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/10/2014] [Indexed: 10/24/2022]
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10
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Blatt K, Herrmann H, Hoermann G, Willmann M, Cerny-Reiterer S, Sadovnik I, Herndlhofer S, Streubel B, Rabitsch W, Sperr WR, Mayerhofer M, Rülicke T, Valent P. Identification of campath-1 (CD52) as novel drug target in neoplastic stem cells in 5q-patients with MDS and AML. Clin Cancer Res 2014; 20:3589-602. [PMID: 24799522 DOI: 10.1158/1078-0432.ccr-13-2811] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE The CD52-targeted antibody alemtuzumab induces major clinical responses in a group of patients with myelodysplastic syndromes (MDS). The mechanism underlying this drug effect remains unknown. EXPERIMENTAL DESIGN We asked whether neoplastic stem cells (NSC) in patients with MDS (n = 29) or acute myelogenous leukemia (AML; n = 62) express CD52. RESULTS As assessed by flow cytometry, CD52 was found to be expressed on NSC-enriched CD34(+)/CD38(-) cells in 8/11 patients with MDS and isolated del(5q). In most other patients with MDS, CD52 was weakly expressed or not detectable on NSC. In AML, CD34(+)/CD38(-) cells displayed CD52 in 23/62 patients, including four with complex karyotype and del(5q) and one with del(5q) and t(1;17;X). In quantitative PCR (qPCR) analyses, purified NSC obtained from del(5q) patients expressed CD52 mRNA. We were also able to show that CD52 mRNA levels correlate with EVI1 expression and that NRAS induces the expression of CD52 in AML cells. The CD52-targeting drug alemtuzumab, was found to induce complement-dependent lysis of CD34(+)/CD38(-)/CD52(+) NSC, but did not induce lysis in CD52(-) NSC. Alemtuzumab also suppressed engraftment of CD52(+) NSC in NSG mice. Finally, CD52 expression on NSC was found to correlate with a poor survival in patients with MDS and AML. CONCLUSIONS The cell surface target Campath-1 (CD52) is expressed on NSC in a group of patients with MDS and AML. CD52 is a novel prognostic NSC marker and a potential NSC target in a subset of patients with MDS and AML, which may have clinical implications and may explain clinical effects produced by alemtuzumab in these patients.
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Affiliation(s)
- Katharina Blatt
- Authors' Affiliations: Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria
| | - Harald Herrmann
- Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Austria
| | - Gregor Hoermann
- Department of Laboratory Medicine, Medical University of Vienna, Austria
| | - Michael Willmann
- Department for Companion Animals and Horses, Clinic for Small Animals, Clinical Unit of Internal Medicine, University of Veterinary Medicine Vienna, Austria
| | - Sabine Cerny-Reiterer
- Authors' Affiliations: Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria; Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Austria
| | - Irina Sadovnik
- Authors' Affiliations: Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria
| | - Susanne Herndlhofer
- Authors' Affiliations: Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria
| | - Berthold Streubel
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Werner Rabitsch
- Department of Internal Medicine I, Bone Marrow Transplantation Unit, Medical University of Vienna, Austria
| | - Wolfgang R Sperr
- Authors' Affiliations: Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria; Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Austria
| | - Matthias Mayerhofer
- Ludwig Boltzmann Institute of Osteology, Hanusch-Hospital, Vienna, Austria; and
| | - Thomas Rülicke
- Institute of Laboratory Animal Science, University of Veterinary Medicine Vienna, Austria
| | - Peter Valent
- Authors' Affiliations: Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria; Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Austria;
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11
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Abstract
Abstract
Refractory aplastic anemia (AA) is defined as a lack of response to first-line immunosuppressive therapy (IST) with antithymocyte globulin and cyclosporin and is manifested as persistence of severe cytopenias at 6 months after IST. Although supportive care is critical for AA patients, it is of paramount importance for refractory disease in view of the longer duration of pancytopenia and susceptibility to life-threatening infections due to IST. Improvements in supportive care have largely contributed to better outcome over the past 2 decades, with 5-year overall survival reaching 57% during 2002 to 2008 for patients with AA unresponsive to initial IST. Exclusion of hypocellular myelodysplastic syndrome and constitutional BM failure masquerading as apparent idiopathic AA should be done in conjunction with centers of excellence. Hematopoietic stem cell transplantation is indicated if refractory AA patients are fit and have a suitably matched donor, either a sibling (> 40-50 years) or unrelated donor. Patients lacking a fully matched donor should be considered for a second course of antithymocyte globulin plus cyclosporin, although response in the refractory setting is only ∼ 30% to 35%. Response may also occur with alemtuzumab or the thrombopoietin mimetic eltrombopag in refractory AA. The emerging data for alternate donor (cord or haploidentical) transplantation in AA has provided additional therapeutic choices to consider in refractory disease.
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12
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Abstract
Abstract
Refractory aplastic anemia (AA) is defined as a lack of response to first-line immunosuppressive therapy (IST) with antithymocyte globulin and cyclosporin and is manifested as persistence of severe cytopenias at 6 months after IST. Although supportive care is critical for AA patients, it is of paramount importance for refractory disease in view of the longer duration of pancytopenia and susceptibility to life-threatening infections due to IST. Improvements in supportive care have largely contributed to better outcome over the past 2 decades, with 5-year overall survival reaching 57% during 2002 to 2008 for patients with AA unresponsive to initial IST. Exclusion of hypocellular myelodysplastic syndrome and constitutional BM failure masquerading as apparent idiopathic AA should be done in conjunction with centers of excellence. Hematopoietic stem cell transplantation is indicated if refractory AA patients are fit and have a suitably matched donor, either a sibling (>40-50 years) or unrelated donor. Patients lacking a fully matched donor should be considered for a second course of antithymocyte globulin plus cyclosporin, although response in the refractory setting is only ∼30% to 35%. Response may also occur with alemtuzumab or the thrombopoietin mimetic eltrombopag in refractory AA. The emerging data for alternate donor (cord or haploidentical) transplantation in AA has provided additional therapeutic choices to consider in refractory disease.
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13
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The optimal immunosuppressive therapy for aplastic anemia. Int J Hematol 2013; 97:564-72. [PMID: 23605367 DOI: 10.1007/s12185-013-1331-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
Abstract
Immunosuppressive treatment (IST) has been the most effective therapeutic modality for patients with aplastic anemia (AA) who are not eligible for allogeneic stem cell transplantation from HLA-matched siblings because of donor unavailability, old age, or comorbidities. The combination of horse anti-thymocyte globulin (ATG) with cyclosporine A (CsA) has shown satisfactory results for these patients, and so it has been regarded as the standard IST regimen. However, treatment failure including unresponsiveness, relapse, and occurrence of clonal evolution remains a major problem, although the results of IST have been improved in the past two decades. Many studies have been conducted to overcome these problems; however, they have yet to show any satisfactory results. This review will discuss immune-mediated pathophysiology of AA, which is associated with therapeutic targets of immunosuppressive agents and clinical outcomes of most commonly used IST regimens. Several trials to improve IST including the addition of other immunosuppressive agents or growth factors to standard IST regimen, comparison between horse ATG/CsA and rabbit ATG/CsA as first-line treatment, and promising alternative agents including alemtuzumab and eltrombopag will also be discussed, focusing on recently published literatures.
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Risitano AM, Schrezenmeier H. Alternative immunosuppression in patients failing immunosuppression with ATG who are not transplant candidates: Campath (Alemtuzumab). Bone Marrow Transplant 2012; 48:186-90. [PMID: 23222381 DOI: 10.1038/bmt.2012.245] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Antithymocyte globulin (ATG)-based immunosuppression remains the standard immunosuppressive therapy (IST) for aplastic anemia (AA) patients lacking a sibling donor; however, treatment failures are relatively frequent, including about one-quarter to one-third of patients who do not show any response to initial IST, and about half of the initial responders who may experience subsequent relapses or require continuous maintenance IST. For these patients, there is the option of further IST, which may include additional courses of ATG-based IST, or attempts with alternative IST regimens. Alemtuzumab is a monoclonal anti-CD52 Ab, which has been recently investigated as novel IS agent for the treatment of AA patients. Recent data from different groups have clearly demonstrated the biological efficacy of Alemtuzumab in AA patients, ruling out the initial concerns about possible unacceptable infectious risks secondary to its extremely powerful lympholytic effect. Preliminary data demonstrate a remarkable efficacy, especially in the context of relapsed and, to less extent, refractory patients, whereas data in naïve patients are still limited. On the basis of these results, Alemtuzumab-based immunosuppression is a worthy option for AA and other marrow failure patients requiring a second-line IST. Here we describe a consensus regimen that the European Group for Blood and Marrow Transplantation Severe Aplastic Anemia Working Party suggests for AA patients failing initial IST who are not indicated for SCT.
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Affiliation(s)
- A M Risitano
- Hematology, Department of Biochemistry and Medical Biotechnologies, Federico II University of Naples, Naples, Italy.
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15
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Abstract
Abstract
Advances in hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) have improved survival in severe aplastic anemia (SAA) from 10%-20% in the 1960s to 80%-90% today. A matched sibling HSCT is the treatment of choice in younger patients, whereas IST is often used in older patients or in those who lack a histocompatible sibling. Graft rejection, GVHD, and poor immune reconstitution (with associated infectious complications) limit the success of HSCT, whereas lack of response, relapse, and clonal evolution limit the success of IST. The historically high rate of graft rejection in SAA is now less problematic in the matched setting, but with greater rates observed with unrelated and umbilical cord donors. The correlation of increasing age with the risk of GVHD and the significant morbidity and mortality of this transplantation complication continue to affect the decision to pursue HSCT versus IST as initial therapy in adults with SAA. Outcomes with matched unrelated donor HSCT have improved, likely due to better donor selection, supportive care, and improved transplantation protocols. Results with mismatched unrelated donor and umbilical HSCT are not as favorable, with higher rates of graft rejection, GVHD, and infectious complications. Investigation of several upfront alternative IST protocols has not improved outcomes beyond horse antithymocyte globulin and cyclosporine. More recently, the role of alemtuzumab in SAA has been better defined and an oral thrombomimetic, eltrombopag, is showing promising activity in refractory cases. The most recent advances in HSCT and IST in SAA are discussed in this review.
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Prospective study of rabbit antithymocyte globulin and cyclosporine for aplastic anemia from the EBMT Severe Aplastic Anaemia Working Party. Blood 2012; 119:5391-6. [DOI: 10.1182/blood-2012-02-407684] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Rabbit antithymocyte globulin (rATG; thymoglobulin, Genzyme) in combination with cyclosporine, as first-line immunosuppressive therapy, was evaluated prospectively in a multicenter, European, phase 2 pilot study, in 35 patients with aplastic anemia. Results were compared with 105 age- and disease severity–matched patients from the European Blood and Marrow Transplant registry, treated with horse ATG (hATG; lymphoglobulin) and cyclosporine. The primary end point was response at 6 months. At 3 months, no patients had achieved a complete response to rATG. Partial response occurred in 11 (34%). At 6 months, complete response rate was 3% and partial response rate 37%. There were 10 deaths after rATG (28.5%) and 1 after subsequent HSCT. Infections were the main cause of death in 9 of 10 patients. The best response rate was 60% for rATG and 67% for hATG. For rATG, overall survival at 2 years was 68%, compared with 86% for hATG (P = .009). Transplant-free survival was 52% for rATG and 76% for hATG (P = .002). On multivariate analysis, rATG (hazard ratio = 3.9, P = .003) and age more than 37 years (hazard ratio = 4.7, P = .0008) were independent adverse risk factors for survival. This study was registered at www.clinicaltrials.gov as NCT00471848.
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Kim SJ, Moon JH, Kim H, Kim JS, Hwang YY, Intragumtornchai T, Issaragrisil S, Kwak JY, Lee JJ, Won JH, Reksodiputro AH, Lim ST, Cheng AL, Kim WS, Kwong YL. Non-bacterial infections in Asian patients treated with alemtuzumab: a retrospective study of the Asian Lymphoma Study Group. Leuk Lymphoma 2012; 53:1515-24. [PMID: 22273250 DOI: 10.3109/10428194.2012.659735] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This retrospective study concerns non-bacterial infections in Asian patients receiving alemtuzumab. The clinical data of 182 patients treated with alemtuzumab alone or alemtuzumab-containing chemotherapy between the years 2003 and 2009 was collected from six Asian countries. Alemtuzumab was used in the setting of frontline (n =48) or salvage (n =90) treatment, and as a part of the conditioning regimen for allogeneic stem cell transplant (n =44). Reactivation of cytomegalovirus (66/182) and varicella zoster virus (25/182), and fungal infection (31/182) including invasive pulmonary aspergillosis, were the most common infectious complications in this retrospective analysis. Thus, we recommend routine prophylaxis with valganciclovir and itraconazole, especially when alemtuzumab is used in the conditioning regimen for allogeneic stem cell transplant. Pneumocystis jirovecii pneumonia (PJP) was found in four patients (3%, 4/122) receiving alemtuzumab as conditioning for stem cell transplant or salvage treatment. Three cases of hepatitis B virus reactivation were found in antigen-negative patients, and 16 cases of tuberculosis were observed. Infection is the major complication of alemtuzumab therapy, and these infectious complications are potentially severe and life-threatening. Based on our retrospective analysis, we have constructed a guideline for antimicrobial prophylaxis in Asian patients receiving alemtuzumab therapy.
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Affiliation(s)
- Seok Jin Kim
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Gómez-Almaguer D, Jaime-Pérez JC, Ruiz-Arguelles GJ. Antibodies in the treatment of aplastic anemia. Arch Immunol Ther Exp (Warsz) 2012; 60:99-106. [PMID: 22307362 DOI: 10.1007/s00005-012-0164-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 11/28/2011] [Indexed: 11/30/2022]
Abstract
Antibodies have been the cornerstone of treatment of acquired aplastic anemia for more than 25 years. Treatment with antithymocyte globulin (ATG) is considered pivotal and the addition of cyclosporine improves the overall response rate. This antibody is heterogeneous and horse ATG is apparently more effective than rabbit ATG. Several issues remain unsolved in relation to the combination of ATG and cyclosporine: cost, toxicity and late clonal disorders. In recent years, alternative immunosuppressive therapy has been proposed and new antibodies have emerged: porcine ATG, alemtuzumab, daclizumab, and rituximab. Experience with these antibodies is limited to a few studies with alemtuzumab being the most promising, but the results are interesting and provocative. More studies are needed to find the perfect antibody.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Hospital Universitario, UANL, Paris 3029 Col. Cumbres, 64610, Monterrey, N.L., Mexico.
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Immunosuppressive therapies in the management of acquired immune-mediated marrow failures. Curr Opin Hematol 2012; 19:3-13. [PMID: 22143074 DOI: 10.1097/moh.0b013e32834da9a4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Immunosuppression is a key treatment strategy for patients suffering from aplastic anemia or related immune-mediated bone marrow failure syndromes. Several attempts have been performed to improve the standard immunosuppression regimen of horse antithymocyte globulin (h-ATG) and cyclosporine A (CyA). RECENT FINDINGS The addition of a third immunosuppression agent to h-ATG + CyA did not result in any improvement. Antilymphocyte agents other than h-ATG have been investigated. A rabbit-ATG preparation, which was known to be more immunosuppressive than h-ATG, resulted in markedly inferior outcome in a large randomized study from the National Institutes of Health. These data seem to be confirmed in additional experiences with rabbit-ATG from other groups. Cyclophosphamide and alemtuzumab have been proven to be biologically active in small studies, but available data suggest inferior outcomes when compared with h-ATG. All these alternative agents result in a more pronounced lymphocyte depletion, suggesting that the actual mechanisms of action of immunosuppressive therapy in aplastic anemia are not fully understood. SUMMARY Immunosuppression by h-ATG and CyA remains the standard of care for aplastic anemia patients lacking a low-risk transplant procedure, resulting in a 60-70% response rate. Rabbit-ATG, cyclophosphamide and alemtuzumab demonstrated a biological activity, but resulted in inferior outcome as compared with h-ATG; thus, they are not recommended as front-line therapy of aplastic anemia.
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20
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Activity of alemtuzumab monotherapy in treatment-naive, relapsed, and refractory severe acquired aplastic anemia. Blood 2011; 119:345-54. [PMID: 22067384 DOI: 10.1182/blood-2011-05-352328] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antithymocyte globulin (ATG) + cyclosporine is effective in restoring hematopoiesis in severe aplastic anemia (SAA). We hypothesized that the humanized anti-CD52 mAb alemtuzumab might be active in SAA because of its lymphocytotoxic properties. We investigated alemtuzumab monotherapy from 2003-2010 in treatment-naive, relapsed, and refractory SAA in 3 separate research protocols at the National Institutes of Health. Primary outcome was hematologic response at 6 months. For refractory disease, patients were randomized between rabbit ATG + cyclosporine (n = 27) and alemtuzumab (n = 27); the response rate for alemtuzumab was 37% (95% confidence interval [CI], 18%-57%) and for rabbit ATG 33% (95% CI, 14%-52%; P = .78). The 3-year survival was 83% (95% CI, 68%-99%) for alemtuzumab and 60% (95% CI, 43%-85%) for rabbit ATG (P = .16). For relapsed disease (n = 25), alemtuzumab was administered in a single-arm study; the response rate was 56% (95% CI, 35%-77%) and the 3-year survival was 86% (95% CI, 72%-100%). In treatment-naive patients (n = 16), alemtuzumab was compared with horse and rabbit ATG in a 3-arm randomized study; the response rate was 19% (95% CI 0%-40%), and the alemtuzumab arm was discontinued early. We conclude that alemtuzumab is effective in SAA, but best results are obtained in the relapsed and refractory settings. The present trials were registered at www.clinicaltrials.gov as NCT00195624, NCT00260689, and NCT00065260.
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Risitano AM, Perna F. Aplastic anemia: immunosuppressive therapy in 2010. Pediatr Rep 2011; 3 Suppl 2:e7. [PMID: 22053283 PMCID: PMC3206528 DOI: 10.4081/pr.2011.s2.e7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 06/04/2011] [Indexed: 11/23/2022] Open
Abstract
Acquired aplastic anemia (AA) is the typical bone marrow failure syndrome characterized by an empty bone marrow; an immune-mediated pathophysiology has been demonstrated by experimental works as well as by clinical observations. Immunusuppressive therapy (IST) is a key treatment strategy for aplastic anemia; since 20 years the standard IST for AA patients has been anti-thymocyte globuline (ATG) plus cyclosporine A (CyA), which results in response rates ranging between 50% and 70%, and even higher overall survival. However, primary and secondary failures after IST remain frequent, and to date all attempts aiming to overcome this problem have been unfruitful. Here we review the state of the art of IST for AA in 2010, focusing on possible strategies to improve current treatments. We also discuss very recent data which question the equality of different ATG preparations, leading to a possible reconsideration of the current standards of care for AA patients.
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Affiliation(s)
- Antonio M Risitano
- Department of Biochemistry and Medical Biotechnologies, Federico II University of Naples, Naples, Italy
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22
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Füreder W, Valent P. Treatment of refractory or relapsed acquired aplastic anemia: review of established and experimental approaches. Leuk Lymphoma 2011; 52:1435-45. [DOI: 10.3109/10428194.2011.568646] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Risitano AM. Immunosuppressive therapies in the management of immune-mediated marrow failures in adults: where we stand and where we are going. Br J Haematol 2010; 152:127-40. [PMID: 21118194 DOI: 10.1111/j.1365-2141.2010.08439.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Immunosuppression is a key treatment strategy for aplastic anaemia (AA) and the related immune-mediated bone marrow failure syndromes (BMFS). For the last 20 years the standard immunosuppressive regimen for AA patients has been anti-thymocyte globulin (ATG) plus ciclosporin A (CyA), which results in response rates ranging between 50% and 70%, and even higher overall survival. However, primary and secondary failures after immunosuppressive therapy remain frequent, and to date all attempts aiming to overcome this problem have been unfruitful. This article reviews the state of the art of current immunosuppressive therapies for AA, focusing on open questions linked to standard immunosuppressive treatment, and on experimental immunosuppressive strategies which could lead to future improvement of current treatments. Specific immunosuppressive strategies employed for other BMFS, such as lineage-restricted marrow failures, myelodysplastic syndromes and large granular lymphocyte leukaemia-associated cytopenias, are also briefly discussed.
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Affiliation(s)
- Antonio M Risitano
- Department of Biochemistry and Medical Biotechnologies, Federico II University of Naples, Italy.
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Sloand EM, Olnes MJ, Shenoy A, Weinstein B, Boss C, Loeliger K, Wu CO, More K, Barrett AJ, Scheinberg P, Young NS. Alemtuzumab treatment of intermediate-1 myelodysplasia patients is associated with sustained improvement in blood counts and cytogenetic remissions. J Clin Oncol 2010; 28:5166-73. [PMID: 21041705 DOI: 10.1200/jco.2010.29.7010] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis and progression to leukemia. Clinical and experimental evidence suggests an immune-mediated pathophysiology in some patients, in whom immunosuppressive therapy (IST) with horse antithymocyte globulin (h-ATG) and cyclosporine (CsA) can be effective. Because of the toxicities associated with h-ATG/CsA, we investigated an alternative regimen with alemtuzumab in MDS. PATIENTS AND METHODS We conducted a nonrandomized, off-label, pilot, phase I/II study of alemtuzumab monotherapy in patients with MDS who were judged likely to respond to IST based on the following criteria: HLA-DR15-negative patients whose age plus the number of months of RBC transfusion dependence (RCTD) was less than 58; and HLA-DR15-positive patients whose age plus RCTD was less than 72. In total, 121 patients with MDS were screened, of whom 32 met eligibility criteria to receive alemtuzumab 10 mg/d intravenously for 10 days. Primary end points were hematologic responses at 3, 6, and 12 months after alemtuzumab. RESULTS Seventeen (77%) of 22 evaluable intermediate-1 patients and four (57%) of seven evaluable intermediate-2 patients responded to treatment with a median time to response of 3 months. Four of seven evaluable responders with cytogenetic abnormalities before treatment had normal cytogenetics by 1 year after treatment. Five (56%) of nine responding patients evaluable at 12 months had normal blood counts, and seven (78%) of nine patients were transfusion independent. CONCLUSION Alemtuzumab is safe and active in MDS and may be an attractive alternative to ATG in selected patients likely to respond to IST.
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Affiliation(s)
- Elaine M Sloand
- Hematology Branch, National Heart, Lung, and Blood Institute, Bldg 10 CRC 4-5230, Bethesda, MD 20892, USA.
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Risitano AM, Selleri C, Serio B, Torelli GF, Kulagin A, Maury S, Halter J, Gupta V, Bacigalupo A, Sociè G, Tichelli A, Schrezenmeier H, Marsh J, Passweg J, Rotoli B. Alemtuzumab is safe and effective as immunosuppressive treatment for aplastic anaemia and single-lineage marrow failure: a pilot study and a survey from the EBMT WPSAA. Br J Haematol 2010; 148:791-6. [DOI: 10.1111/j.1365-2141.2009.08027.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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26
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Gómez-Almaguer D, Jaime-Pérez JC, Garza-Rodríguez V, Chapa-Rodríguez A, Tarín-Arzaga L, Herrera-Garza JL, Ruiz-Argüelles GJ, López-Otero A, González-Llano O, Rodríguez-Romo L. Subcutaneous alemtuzumab plus cyclosporine for the treatment of aplastic anemia. Ann Hematol 2009; 89:299-303. [PMID: 19705116 DOI: 10.1007/s00277-009-0816-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 08/09/2009] [Indexed: 11/28/2022]
Abstract
Aplastic anemia (AA) is most frequently due to autoimmune attack on its own stem cells. Alemtuzumab is a monoclonal antibody which recognizes the CD52 antigen on the surface of T and B cells. It has proved useful in autoimmune diseases, lymphoproliferative conditions, and graft versus host disease. Based on its immunosuppressive properties, we treated 14 AA patients with alemtuzumab. Median age was 23 years. Ten milligrams of alemtuzumab were injected subcutaneously each day for five consecutive days. Cyclosporine A was also administered orally at a dose of 2 mg/kg every 12 h for 3 months, and then gradually tapered. Response to alemtuzumab was followed for a median of 20 months. There were eight responses (57.1%), two complete and six partial. Whereas six (42.8%) patients were non-responders. Median complete blood count values on alemtuzumab responders were Hb 13.1 mg/dL, absolute neutrophil count 2.4 x 10(9)/L, and platelets 97.5 x 10(9)/L. A good response was produced in 57% of AA patients with the administration of alemtuzumab, who lacked a stem cell donor.
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Abstract
In comparison to past decades, children who have acquired aplastic anemia (AA) enjoy excellent overall survival that reflects improvements in supportive care, more accurate exclusion of children who have alternate diagnoses, and advances in transplantation and immunosuppressive therapy (IST). Matched sibling-donor hematopoietic stem cell transplants (HSCT) routinely provide long-term survival in the range of 90%, and 75% of patients respond to IST. In this latter group, the barriers to overall and complication-free survival include recurrence of AA, clonal evolution with transformation to myelodysplasia/acute myelogenous leukemia, and therapy-related toxicities. Improvements in predicting responses to IST, in alternative-donor HSCT, and in rationalizing therapy by understanding the pathophysiology in individual patients are likely to improve short- and long-term outcomes for these children.
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