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Al-Jamaei AAH, Epstein JB, de Visscher JGAM, Spielberger RT, Nakamura R, Raber-Durlacher JE. Comparing the risk of severe oral mucositis associated with methotrexate as graft-versus host-disease prophylaxis to other immunosuppressive prophylactic agents in hematopoietic cell transplantation: a systematic review and meta-analysis. Support Care Cancer 2024; 32:519. [PMID: 39017899 PMCID: PMC11255043 DOI: 10.1007/s00520-024-08722-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/05/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE This study examines the risk of severe oral mucositis (SOM) in graft-versus-host disease prophylaxis (GVHD) compared to other agents in hematopoietic cell transplantation patients. METHODS A comprehensive search of four databases, including PubMed, Embassy, Web of Science, and Scopus, was conducted to identify studies reporting frequency and severity of oral mucositis in association with GVHD prophylactic regimens. RevMan 5.4 was used to perform the meta-analysis. Risk of bias assessment was carried out using the Rob-2 tool for randomized clinical trials (RCTs) and ROBINS-I tool for observational studies. RESULTS Twenty-five papers, including 11 RCTs and 14 observational studies, met the inclusion criteria. The pooled results from eight RCTs showed a higher risk of SOM in patients receiving MTX or MTX-inclusive GVHD prophylaxis versus non-MTX alternatives (RR = 1.50, 95% CI [1.20, 1.87], I2 = 36%, P = 0.0003). Mycophenolate mofetil (MMF) and post-transplant cyclophosphamide (Pt-Cy) consistently showed lower risk of mucositis than MTX. Folinic acid (FA) rescue and mini-dosing of MTX were associated with reduced oral mucositis severity. CONCLUSION Patients receiving MTX have a higher SOM risk compared to other approaches to prevent GVHD, which should be considered in patient care. When appropriate, MMF, FA, and a mini-dose of MTX may be an alternative that is associated with less SOM. This work also underlines the scarcity of RCTs on MTX interventions to provide the best evidence-based recommendations.
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Affiliation(s)
- Aisha A H Al-Jamaei
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Oral Medicine, Periodontics, Diagnostic, and Oral Radiology, Faculty of Dentistry, Sanaá University, Sanaá, Yemen
- Department of Oral Surgery and Oral Medicine, Al-Razi University, Sanaá, Yemen
| | - Joel B Epstein
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Jan G A M de Visscher
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Ricardo T Spielberger
- Department of BMT, Southern California Permanente Medical Group, Kaiser Permanente, Los Angeles, CA, USA
- Department of Hematology &, Center for Stem Cell Transplantation at City of Hope Comprehensive Cancer Center, Hematopoietic Cell Transplantation, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Hematology &, Center for Stem Cell Transplantation at City of Hope Comprehensive Cancer Center, Hematopoietic Cell Transplantation, Duarte, CA, USA
| | - Judith E Raber-Durlacher
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, The Netherlands.
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands.
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Paviglianiti A, Labopin M, Blaise D, Socié G, Bulabois CE, Lioure B, Ceballos P, Blau IW, Guillerm G, Maertens J, Chevallier P, Huynh A, Turlure P, Deconinck E, Forcade E, Nagler A, Mohty M. Comparison of mycophenolate mofetil and calcineurin inhibitor versus calcineurin inhibitor-based graft-versus-host-disease prophylaxis for matched unrelated donor transplant in acute myeloid leukemia. A study from the ALWP of the EBMT. Bone Marrow Transplant 2020; 56:1077-1085. [PMID: 33249424 DOI: 10.1038/s41409-020-01155-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/13/2020] [Accepted: 11/11/2020] [Indexed: 12/28/2022]
Abstract
The association of Cyclosporine A (CsA) and mycophenolate mofetil (MMF) has increased in the setting of reduced intensity conditioning (RIC). Nevertheless, the use of CsA or CsA+MMF has not been reported in a large and uniform cohort. We analyzed 497 patients with acute myeloid leukemia in complete remission (CR) who underwent matched unrelated donor (MUD) hematopoietic stem cell transplantation (HSCT). All patients received a fludarabine busulfan RIC regimen and anti-thymocyte globulin (ATG) with either CsA alone or in combination with MMF. The cumulative incidence (CI) of grade II-IV acute GvHD was 27% (95% CI 21-33%) for CsA and 33% (95% CI 27-38%) for CsA+MMF (p = 0.25). The 2-year CI of chronic GvHD was 38% (95% CI 31-45%) and 33% (95% CI 28-39%) for the CsA and the CsA+MMF group, respectively (p = 0.26). On multivariate analysis, no statistically significant differences with respect to relapse incidence (RI), non-relapse mortality (NRM), leukemia-free survival (LFS), overall survival (OS), acute and chronic GvHD were found between the two groups, also when conducting a subgroup analysis in peripheral blood stem cells (PBSC) recipients. Our results support the importance of randomized trial to identify patients who could benefit from the addition of MMF in MUD HSCT.
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Affiliation(s)
- Annalisa Paviglianiti
- Sorbonne University, Service d'Hématologie Clinique et Thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938, Paris, France.
| | - Myriam Labopin
- Sorbonne University, Service d'Hématologie Clinique et Thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938, Paris, France
| | - Didier Blaise
- Programme de Transplantation & Thérapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Gerard Socié
- Hopital St. Louis, Department of Hematology - BMT, Paris, France
| | - Claude Eric Bulabois
- CHU Grenoble Alpes - Université Grenoble Alpes, Service d'Hématologie, Grenoble, France
| | - Bruno Lioure
- Hopital de Hautepierre, CHU de Strasbourg, Service Hématologie adulte, F-67200, Strasbourg, France
| | - Patrice Ceballos
- CHU Lapeyronie, Département d'Hématologie Clinique, Montpellier, France
| | - Igor Wolfgang Blau
- Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Hämatologie/Onkologie, Berlin, Germany
| | | | - Johan Maertens
- University Hospital Gasthuisberg, Department of Hematology, Leuven, Belgium
| | | | - Anne Huynh
- CHU - Institut Universitaire du Cancer Toulouse, Oncopole, I.U.C.T-O, Toulouse, France
| | - Pascal Turlure
- CHRU Limoges Service d'Hématologie Clinique, Limoges, France
| | - Eric Deconinck
- Hopital Jean Minjoz, Service d'Hématologie, Besancon, France
| | - Edouard Forcade
- CHU Bordeaux, Service d'hematologie et thérapie Cellulaire, F-, 33000, Bordeaux, France
| | - Arnon Nagler
- Chaim Sheba Medical Center, Tel-Hashomer, Tel-Aviv University, Tel-Aviv, Israel.,Acute Leukemia Working Party Office, Paris, France
| | - Mohamad Mohty
- Sorbonne University, Service d'Hématologie Clinique et Thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938, Paris, France
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Comparison of calcineurin inhibitors in combination with conventional methotrexate, reduced methotrexate, or mycophenolate mofetil for prophylaxis of graft-versus-host disease after umbilical cord blood transplantation. Ann Hematol 2019; 98:2579-2591. [DOI: 10.1007/s00277-019-03801-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
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4
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Chhabra S, Liu Y, Hemmer MT, Costa L, Pidala JA, Couriel DR, Alousi AM, Majhail NS, Stuart RK, Kim D, Ringden O, Urbano-Ispizua A, Saad A, Savani BN, Cooper B, Marks DI, Socie G, Schouten HC, Schoemans H, Abdel-Azim H, Yared J, Cahn JY, Wagner J, Antin JH, Verdonck LF, Lehmann L, Aljurf MD, MacMillan ML, Litzow MR, Solh MM, Qayed M, Hematti P, Kamble RT, Vij R, Hayashi RJ, Gale RP, Martino R, Seo S, Hashmi SK, Nishihori T, Teshima T, Gergis U, Inamoto Y, Spellman SR, Arora M, Hamilton BK. Comparative Analysis of Calcineurin Inhibitor-Based Methotrexate and Mycophenolate Mofetil-Containing Regimens for Prevention of Graft-versus-Host Disease after Reduced-Intensity Conditioning Allogeneic Transplantation. Biol Blood Marrow Transplant 2018; 25:73-85. [PMID: 30153491 DOI: 10.1016/j.bbmt.2018.08.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/09/2018] [Indexed: 01/11/2023]
Abstract
The combination of a calcineurin inhibitor (CNI) such as tacrolimus (TAC) or cyclosporine (CYSP) with methotrexate (MTX) or with mycophenolate mofetil (MMF) has been commonly used for graft-versus-host disease (GVHD) prophylaxis after reduced-intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (alloHCT), but there are limited data comparing efficacy of the 2 regimens. We evaluated 1564 adult patients who underwent RIC alloHCT for acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL), chronic myelogenous leukemia (CML), and myelodysplastic syndrome (MDS) from 2000 to 2013 using HLA-identical sibling (matched related donor [MRD]) or unrelated donor (URD) peripheral blood graft and received CYSP or TAC with MTX or MMF for GVHD prophylaxis. Primary outcomes of the study were acute and chronic GVHD and overall survival (OS). The study divided the patient population into 4 cohorts based on regimen: MMF-TAC, MMF-CYSP, MTX-TAC, and MTX-CYSP. In the URD group, MMF-CYSP was associated with increased risk of grade II to IV acute GVHD (relative risk [RR], 1.78; P < .001) and grade III to IV acute GVHD (RR, 1.93; P = .006) compared with MTX-TAC. In the URD group, use of MMF-TAC (versus MTX-TAC) lead to higher nonrelapse mortality. (hazard ratio, 1.48; P = .008). In either group, no there was no difference in chronic GVHD, disease-free survival, and OS among the GVHD prophylaxis regimens. For RIC alloHCT using MRD, there are no differences in outcomes based on GVHD prophylaxis. However, with URD RIC alloHCT, MMF-CYSP was inferior to MTX-based regimens for acute GVHD prevention, but all the regimens were equivalent in terms of chronic GVHD and OS. Prospective studies, targeting URD recipients are needed to confirm these results.
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Affiliation(s)
- Saurabh Chhabra
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Ying Liu
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Institute for Health and Society, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Hemmer
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Luciano Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph A Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Daniel R Couriel
- Division of Hematology and Hematologic Malignancies, Utah Blood and Marrow Transplant Program, Salt Lake City, Utah
| | - Amin M Alousi
- Department of Stem Cell Transplantation, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Robert K Stuart
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Dennis Kim
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Center, Toronto, Canada
| | - Olle Ringden
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alvaro Urbano-Ispizua
- Department of Hematology, IDIBAPS, Institute of Research Josep Carreras, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brenda Cooper
- Department of Medicine-Hematology and Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Gerard Socie
- Department of Hematology, Hôpital Saint Louis, Paris, France
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, the Netherlands
| | - Helene Schoemans
- Department of Hematology, 26-Department of Pediatrics, University Hospital of Leuven, Leuven, Belgium
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jean Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | - Jean-Yves Cahn
- Department of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - John Wagner
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph H Antin
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Leo F Verdonck
- Departmentt of Hematology/Oncology, Isala Clinic, Zwolle, the Netherlands
| | - Leslie Lehmann
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Margaret L MacMillan
- University of Minnesota Blood and Marrow Transplant Program, Minneapolis, Minnesota
| | - Mark R Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, Minnesota
| | - Melhem M Solh
- Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, Georgia
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Ravi Vij
- Division of Hematology and Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Robert P Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Rodrigo Martino
- Divison of Clinical Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sachiko Seo
- Department of Hematology & Oncology, National Cancer Research Center East, Chiba, Japan
| | - Shahrukh K Hashmi
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia; Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, Minnesota
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Takanori Teshima
- Department of Hematology Kyushu University Hospital, Sapporo, Japan
| | - Usama Gergis
- Hematolgic Malignancies & Bone Marrow Transplant, Department of Medical Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Yoshihiro Inamoto
- Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota.
| | - Betty K Hamilton
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
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Miyashita N, Endo T, Onozawa M, Hashimoto D, Kondo T, Fujimoto K, Kahata K, Sugita J, Goto H, Matsukawa T, Hashino S, Teshima T. Risk factors of human herpesvirus 6 encephalitis/myelitis after allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12682] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/25/2016] [Accepted: 11/19/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Naohiro Miyashita
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Tomoyuki Endo
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Masahiro Onozawa
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Daigo Hashimoto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Takeshi Kondo
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Katsuya Fujimoto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Kaoru Kahata
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Junichi Sugita
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Hideki Goto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Toshihiro Matsukawa
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | | | - Takanori Teshima
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
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Yerushalmi R, Shem‐Tov N, Danylesko I, Shouval R, Nagler A, Shimoni A. The combination of cyclosporine and mycophenolate mofetil is less effective than cyclosporine and methotrexate in the prevention of acute graft-versus host disease after stem-cell transplantation from unrelated donors. Am J Hematol 2017; 92:259-268. [PMID: 28052467 DOI: 10.1002/ajh.24631] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/15/2016] [Accepted: 12/19/2016] [Indexed: 12/24/2022]
Abstract
Acute graft-versus-host disease (GVHD) is the major treatment-related complication after stem-cell transplantation (SCT) from unrelated-donors. Several GVHD prophylaxis regimens have been explored, but no regimen has shown superiority. We analyzed transplantation outcomes in 472 consecutive unrelated-donor SCT recipients, using cyclosporine/methotrexate (MTX, n = 314) or cyclosporine/mycophenolate-mofetil (MMF, n = 158) for GVHD prophylaxis. Neutrophil engraftment was faster after MMF, days 11 and 14, respectively (P = .001). Acute GVHD grade II-IV and III-IV occurred in 47% and 28% after MMF compared to 27% and 12% after MTX, respectively (P < .001). Nonrelapse mortality (NRM) was 44% and 24%, respectively (P < .001). Death associated with GVHD occurred in 25% and 8% (P < .0001), while other NRM causes occurred in 19% and 16%, respectively (P = .39). Relapse mortality was similar. Overall survival was better after MTX, 40% and 29%, respectively (P = .006). However, this difference had only borderline significance when adjusting for differences in patient characteristics (HR, 1.3, P = .08). To minimize potential selection bias we analyzed outcomes on the basis of an intention-to-treat like analysis. During the years 2008-2009, the leading GVHD prophylaxis regimen for unrelated-donor SCT included MMF (89% of transplants). During the other periods, MTX was used predominantly (82% of transplants). The two periods were otherwise well-matched. Acute GVHD occurred more often in 2008-2009. Death associated with GVHD occurred more often, while other NRM causes occurred less often resulting in similar NRM and overall survival. In conclusion, cyclosporine/MMF is associated with faster engraftment and possibly with less organ toxicity than cyclosporine/MTX. However, it is associated with increased rates of acute GVHD and GVHD-associated deaths.
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Affiliation(s)
- Ronit Yerushalmi
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Noga Shem‐Tov
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Ivetta Danylesko
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Roni Shouval
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Arnon Nagler
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Avichai Shimoni
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
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Hamad N, Shanavas M, Michelis FV, Uhm J, Gupta V, Seftel M, Kuruvilla J, Lipton JH, Messner HA, Kim DDH. Mycophenolate-based graft versus host disease prophylaxis is not inferior to methotrexate in myeloablative-related donor stem cell transplantation. Am J Hematol 2015; 90:392-9. [PMID: 25615933 DOI: 10.1002/ajh.23955] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 01/13/2015] [Accepted: 01/15/2015] [Indexed: 01/08/2023]
Abstract
We retrospectively reviewed 242 patients who received related donor myeloablative peripheral blood hematopoietic cell transplantation. We compared patients who received mycophenolate (MMF)/cyclosporine (CSA) (n = 71), to historical controls who received methotrexate (MTX)/CSA (n = 172). There were no differences in overall survival, nonrelapse mortality, and relapse. The MMF/CSA group had significantly faster neutrophil and platelet engraftment: medians of 13 versus 18 days and 10 versus 14 days, respectively (P = 0.001). The cumulative incidence of acute graft versus host disease (GVHD) (Grades, 2-4) was significantly lower in the MMF/CSA group (45.1 vs. 74.4%, P < 0.001). The MMF/CSA group showed a lower incidence of skin (51.5 vs. 72.1%, P < 0.001) and liver acute GVHD (11.3 vs. 54.2%, P < 0.001) and a higher incidence of lung (42.2 vs. 19.0%, P = 0.045), eye (59.7 vs. 30.1%, P < 0.001), and mouth (72.8 vs. 56.4%, P = 0.001) chronic GVHD but only eye chronic GVHD was confirmed in propensity score matching (PSM) analysis. The incidence of cytomegalovirus (CMV) viremia was higher in the MMF/CSA group (55.8 vs. 39.6%, P < 0.001) but this was not confirmed in PSM analysis. MMF/CSA was identified as an independent favorable factor for acute GVHD (P < 0.001, hazard ratio, 0.41) but as a possible adverse risk factor for CMV viremia as this was not found to be statistically significant in PSM analysis. MMF/CSA in myeloablative matched related donor peripheral blood stem cell transplant is not inferior as GVHD prophylaxis in comparison with MTX/CSA and is associated with faster engraftment but a potentially higher risk of CMV viremia.
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Affiliation(s)
- Nada Hamad
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Mohamed Shanavas
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Fotios V. Michelis
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Jieun Uhm
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Vikas Gupta
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Matthew Seftel
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - John Kuruvilla
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Jeffrey H. Lipton
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Hans A. Messner
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
| | - Dennis Dong Hwan Kim
- Allogeneic Blood and Marrow Transplant Program; Princess Margaret Cancer Center, University of Toronto; Canada
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Kharfan‐Dabaja M, Mhaskar R, Reljic T, Pidala J, Perkins JB, Djulbegovic B, Kumar A. Mycophenolate mofetil versus methotrexate for prevention of graft-versus-host disease in people receiving allogeneic hematopoietic stem cell transplantation. Cochrane Database Syst Rev 2014; 2014:CD010280. [PMID: 25061777 PMCID: PMC10945354 DOI: 10.1002/14651858.cd010280.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HCT) is associated with improved outcomes for people with various hematologic diseases; however, the morbidity and mortality resulting from acute and subsequently chronic graft-versus-host disease (GVHD) pose a serious challenge to wider applicability of allo-HCT. Intravenous methotrexate in combination with a calcineurin inhibitor, cyclosporine or tacrolimus, is a widely used regimen for the prophylaxis of acute GVHD, but the administration of methotrexate is associated with a number of adverse events. Mycophenolate mofetil, in combination with a calcineurin inhibitor, has been used extensively in people undergoing allo-HCT. Conflicting results regarding various clinical outcomes following allo-HCT have been observed when comparing mycophenolate mofetil-based regimens against methotrexate-based regimens for acute GVHD prophylaxis. OBJECTIVES PRIMARY OBJECTIVE to assess the effect of mycophenolate mofetil versus methotrexate for prevention of acute GVHD in people undergoing allo-HCT. SECONDARY OBJECTIVES to evaluate the effect of mycophenolate mofetil versus methotrexate for overall survival, prevention of chronic GVHD, incidence of relapse, treatment-related harms, nonrelapse mortality, and quality of life. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE from inception to March 2014. We handsearched conference abstracts from the last two meetings (2011 and 2012) of relevant societies in the field. We searched ClinicalTrials.gov, Novartis clinical trials database (www.novctrd.com), Roche clinical trial protocol registry (www.roche-trials.com), Australian New Zealand Clinical Trials Registry (ANZCTR), and the metaRegister of Controlled Trials for ongoing trials. SELECTION CRITERIA Two review authors independently reviewed all titles/abstracts and selected full-text articles for inclusion. We included all references that reported results of randomized controlled trials (RCTs) of mycophenolate mofetil versus methotrexate for the prophylaxis of GVHD among people undergoing allo-HCT in this review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on outcomes from all studies and compared prior to data entry and analysis. We expressed results as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes and hazard ratios (HR) and 95% CIs for time-to-event outcomes. We pooled the individual study effects using the random-effects model. Estimates lower than one indicate that mycophenolate mofetil was favored over methotrexate. MAIN RESULTS We included three trials enrolling 177 participants (174 participants analyzed). All participants in the trials by Keihl et al. and Bolwell et al. received cyclosporine while all participants enrolled in the trial by Perkins et al. received tacrolimus. However, the results did not differ by the type of calcineurin inhibitor employed (cyclosporine versus tacrolimus). There was no evidence for a difference between mycophenolate mofetil versus methotrexate for the outcomes of incidence of acute GVHD (RR 1.25; 95% CI 0.75 to 2.09; P value = 0.39, very low quality evidence), overall survival (HR 0.73; 95% CI 0.45 to 1.17; P value = 0.19, low-quality evidence), median days to neutrophil engraftment (HR 0.77; 95% CI 0.51 to 1.17; P value = 0.23, low-quality evidence), incidence of relapse (RR 0.84; 95% CI 0.52 to 1.38; P value = 0.50, low-quality evidence), non-relapse mortality (RR 1.21; 95% CI 0.62 to 2.36; P value = 0.57, low-quality evidence), and incidence of chronic GVHD (RR 0.92; 95% CI 0.65 to 1.30; P value = 0.62, low-quality evidence). There was low-quality evidence that mycophenolate mofetil compared with methotrexate improved platelet engraftment period (HR 0.87; 95% CI 0.81 to 0.93; P value < 0.0001, low-quality evidence). There was low-quality evidence that mycophenolate mofetil compared with methotrexate resulted in decreased incidence of severe mucositis (RR 0.48; 95% CI 0.32 to 0.73; P value = 0.0006, low-quality evidence), use of parenteral nutrition (RR 0.48; 95% CI 0.26 to 0.91; P value = 0.02, low-quality evidence), and medication for pain control (RR 0.76; 95% CI 0.63 to 0.91; P value = 0.002, low-quality evidence). Overall heterogeneity was not detected in the analysis except for the outcome of neutrophil engraftment. None of the included studies reported any outcomes related to quality of life. Overall quality of evidence was low. AUTHORS' CONCLUSIONS The use of mycophenolate mofetil compared with methotrexate for primary prevention of GVHD seems to be associated with a more favorable toxicity profile, without an apparent compromise on disease relapse, transplant-associated mortality, or overall survival. The effects on incidence of GVHD between people receiving mycophenolate mofetil compared with people receiving methotrexate were uncertain. There is a need for additional high-quality RCTs to determine the optimal GVHD prevention strategy. Future studies should take into account a comprehensive view of clinical benefit, including measures of morbidity, symptom burden, and healthcare resource utilization associated with interventions.
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Affiliation(s)
- Mohamed Kharfan‐Dabaja
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
- American University of BeirutDivision of Hematology‐Oncology and Bone Marrow Transplantation ProgramBeirutLebanon
| | - Rahul Mhaskar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Tea Reljic
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
| | - Janelle B Perkins
- Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center12902 Magnolia Dr.TampaFloridaUSA33612
| | - Benjamin Djulbegovic
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
- University of South FloridaUSF Clinical Translational Science Institute, Departments of Medicine, Hematology and Health Outcome Research12901 Bruce B. Downs Boulevard, CMS 3057TampaFloridaUSA33612
| | - Ambuj Kumar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
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Iida M, Fukuda T, Uchida N, Murata M, Aotsuka N, Minagawa K, Oohashi K, Fukushima K, Kondo T, Eto T, Miyamoto T, Morishima Y, Nagamura T, Atsuta Y, Suzuki R. Mycophenolate mofetil use after unrelated hematopoietic stem cell transplantation for prophylaxis and treatment of graft-vs.-host disease in adult patients in Japan. Clin Transplant 2014; 28:980-9. [PMID: 24943923 DOI: 10.1111/ctr.12405] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2014] [Indexed: 01/08/2023]
Abstract
Our previous study of 301 patients who received hematopoietic stem cell transplantation (HSCT) from related donors demonstrated the efficacy of mycophenolate mofetil (MMF) for prophylaxis and treatment of graft-vs.-host disease (GVHD). In this study, we investigated the safety and efficacy of MMF in 716 adult patients who received unrelated HSCT. The incidences of Grade II-IV and III-IV acute GVHD in the prophylactic administration group were 38.3% and 14.3%, respectively. These rates were not statistically significant when evaluating the MMF dosage and graft source. The incidences of limited and extensive chronic GVHD were 16.6% and 11.1%, respectively. In the therapeutic administration group, 69.1% of the subjective symptoms for both acute and chronic GVHD improved. With respect to the adverse events, 75 infections and 50 cases of diarrhea were observed, and the frequency of these events increased with increasing MMF dose. The overall survival rate was 36.4% after a median follow-up period of three yr. This study shows that MMF is safe and effective for the prevention and treatment of GVHD in patients who have received HSCT from unrelated donors.
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Affiliation(s)
- Minako Iida
- Department of HSCT Data Management and Biostatistics, Nagoya University School of Medicine, Nagoya, Japan; Department of Promotion for Blood and Marrow Transplantation, Aichi Medical University School of Medicine, Aichi, Japan
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10
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Ram R, Yeshurun M, Vidal L, Shpilberg O, Gafter-Gvili A. Mycophenolate mofetil vs. methotrexate for the prevention of graft-versus-host-disease – Systematic review and meta-analysis. Leuk Res 2014; 38:352-60. [DOI: 10.1016/j.leukres.2013.12.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 12/11/2013] [Accepted: 12/17/2013] [Indexed: 11/15/2022]
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11
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Ram R, Storb R. Pharmacologic prophylaxis regimens for acute graft-versus-host disease: past, present and future. Leuk Lymphoma 2013; 54:1591-601. [PMID: 23278640 DOI: 10.3109/10428194.2012.762978] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract Acute graft-versus-host disease (GVHD) has compromised and continues to compromise the benefits associated with allogeneic hematopoietic cell transplant to cure malignant and non-malignant diseases. Pharmacologic interventions to prevent GVHD have emerged as a major objective of research in the immunology and transplant fields. A better understanding of the pathobiology behind the GVHD process has led the way to novel approaches and medications. Here we review the present arsenal of medications used to prevent GVHD, focusing on past experience and the current evidence, and discuss future potential targets.
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Affiliation(s)
- Ron Ram
- Bone Marrow Transplantation Unit, Rabin Medical Center, Beilinson Hospital and the Sackler School of Medicine, Tel Aviv University, Israel.
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12
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Mycophenolate mofetil: fully utilizing its benefits for GvHD prophylaxis. Int J Hematol 2012; 96:10-25. [DOI: 10.1007/s12185-012-1086-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 04/18/2012] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
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13
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Johnston L, Florek M, Armstrong R, McCune JS, Arai S, Brown J, Laport G, Lowsky R, Miklos D, Shizuru J, Sheehan K, Lavori P, Negrin R. Sirolimus and mycophenolate mofetil as GVHD prophylaxis in myeloablative, matched-related donor hematopoietic cell transplantation. Bone Marrow Transplant 2011; 47:581-8. [PMID: 21552302 PMCID: PMC3163055 DOI: 10.1038/bmt.2011.104] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We investigated sirolimus and mycophenolate mofetil (MMF) as graft-versus-host disease (GVHD) prophylaxis in patients with advanced hematologic malignancies receiving myeloablative hematopoietic cell transplantation (HCT) from HLA-identical sibling donors. Based on pre-study stopping rules, the trial was closed to accrual after enrollment of 11 adult patients. Seven of the 11 patients received busulfan-containing preparative regimens. Sirolimus was discontinued in 3 patients due to toxicity-related events of severe sinusoidal obstructive syndrome, portal vein thrombosis, altered mental status and in 1 patient due to risk of poor wound healing. Six of the 11 patients developed grade II-IV acute GVHD (AGVHD) a median of 15.5 days post-HCT. Two of 3 patients with grade IV AGVHD had sirolimus discontinued by 9 days post-HCT. All patients responded to AGVHD therapy without GVHD-related deaths. There were 2 nonrelapse- and 2 relapse-related deaths. At a median follow-up of 38 months (2–47 months), 7 of 11 patients were alive without disease. MMF and sirolimus GVHD prophylaxis did not reduce the risk of acute GVHD, however, there were no GVHD-related deaths. The severe toxicities in the patients receiving the busulfan-containing preparative regimens limited the continued use of sirolimus and MMF for the prevention of AGVHD.
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Affiliation(s)
- L Johnston
- Department of Medicine, Stanford University, Stanford, CA, USA.
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14
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Hiwarkar P, Shaw B, Tredger J, Brown N, Kulkarni S, Saso R, Evans S, Treleaven J, Davies F, Ethell M, Morgan G, Potter M. Mycophenolic acid trough level monitoring: relevance in acute and chronic graft versus host disease and its relation with albumin. Clin Transplant 2011; 25:222-7. [DOI: 10.1111/j.1399-0012.2010.01226.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Piñana JL, Valcárcel D, Fernández-Avilés F, Martino R, Rovira M, Barba P, Martínez C, Brunet S, Sureda A, Carreras E, Sierra J. MTX or mycophenolate mofetil with CsA as GVHD prophylaxis after reduced-intensity conditioning PBSCT from HLA-identical siblings. Bone Marrow Transplant 2010; 45:1449-56. [PMID: 20140024 DOI: 10.1038/bmt.2009.362] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Mycophenolate mofetil (MMF) in combination with CsA seems to lead to earlier post transplant hematological recovery and less mucositis than MTX, with a similar incidence of GVHD. In this study we analyzed the post transplant outcomes of two cohorts of patients who underwent an HLA-identical sibling reduced intensity conditioning transplantation (allo-RIC) with GVHD prophylaxis consisting of CsA in combination with either MMF or a short course of MTX. We included 145 consecutive allo-RIC transplants performed between April 2000 and August 2007. The median follow-up for survivors was 41 months (4-105 months). The study group included 91 males. Median age was 55 years (range 18-71 years). Diagnoses included myeloid (n=65) and lymphoid (n=80) malignancies. GVHD prophylaxis consisted of CsA/MMF in 52 and CsA/MTX in 93 patients. The conditioning regimen was based on fludarabine in combination with BU (n=59) or melphalan (n=86). The occurrence of grade 2-4 mucositis was higher in the CsA/MTX group than in the CsA/MMF group (57 vs 23%, P=0.001). The cumulative incidence of acute and chronic GVHD was similar, 48 vs 50% and 71 vs 68%, respectively (P>0.7). The 2-year relapse and OS were similar in the CsA/MTX and CsA/MMF groups (29 vs 21%, P=0.3 and 52 vs 51%, P=0.7, respectively). Our results support further prospective studies comparing the use of the CsA/MMF combination with CsA/MTX as GVHD prophylaxis in HLA-identical sibling donor allo-RIC recipients.
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Affiliation(s)
- J L Piñana
- Division of Clinical Hematology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
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16
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Saint-Marcoux F, Royer B, Debord J, Larosa F, Legrand F, Deconinck E, Kantelip JP, Marquet P. Pharmacokinetic modelling and development of Bayesian estimators for therapeutic drug monitoring of mycophenolate mofetil in reduced-intensity haematopoietic stem cell transplantation. Clin Pharmacokinet 2009; 48:667-75. [PMID: 19743888 DOI: 10.2165/11317140-000000000-00000] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Mycophenolate mofetil, a prodrug of mycophenolic acid (MPA), is used during non-myeloablative and reduced-intensity conditioning haematopoetic stem cell transplantation (HCT) to improve engraftment and reduce graft-versus-host disease (GVHD). However, information about MPA pharmacokinetics is sparse in this context and its use is still empirical. OBJECTIVES To perform a pilot pharmacokinetic study and to develop maximum a posteriori Bayesian estimators (MAP-BEs) for the estimation of MPA exposure in HCT. PATIENTS AND METHODS Fourteen patients administered oral mycophenolate mofetil 15 g/kg three times daily were included. Two consecutive 8-hour pharmacokinetic profiles were performed on the same day, 3 days before and 4 days after the HCT. One 8-hour pharmacokinetic profile was performed on day 27 after transplantation. For these 8-hour pharmacokinetic profiles, blood samples were collected predose and 20, 40, 60, 90 minutes and 2, 4, 6 and 8 hours post-dose. Using the iterative two-stage (ITS) method, two different one-compartment open pharmacokinetic models with first-order elimination were developed to describe the data: one with two gamma laws and one with three gamma laws to describe the absorption phase. For each pharmacokinetic profile, the Akaike information criterion (AIC) was calculated to evaluate model fitting. On the basis of the population pharmacokinetic parameters, MAP-BEs were developed for the estimation of MPA pharmacokinetics and area under the plasma concentration-time curve (AUC) from 0 to 8 hours at the different studied periods using a limited-sampling strategy. These MAP-BEs were then validated using a data-splitting method. RESULTS The ITS approach allowed the development of MAP-BEs based either on 'double-gamma' or 'triple-gamma' models, the combination of which allowed correct estimation of MPA pharmacokinetics and AUC on the basis of a 20 minute-90 minute-240 minute sampling schedule. The mean bias of the Bayesian versus reference (trapezoidal) AUCs was <5% with <16% of the patients with absolute bias on AUC >20%. AIC was systematically calculated for the choice of the most appropriate model fitting the data. CONCLUSION Pharmacokinetic models and MAP-BEs for mycophenolate mofetil when administered to HCT patients have been developed. In the studied population, they allowed the estimation of MPA exposure based on three blood samples, which could be helpful in conducting clinical trials for the optimization of MPA in reduced-intensity HCT. However, prior studies will be needed to validate them in larger populations.
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Ostronoff F, Ostronoff M, Souto-Maior AP, Domingues M, Sucupira A, Manso DA, de Lima AKF, Monteiro PG, Florêncio R, Calixto R. Prospective trial of mycophenolate mofetil-cyclosporine A prophylaxis for acute GVHD after G-CSF stimulated allogeneic bone marrow transplantation with HLA-identical sibling donors in patients with severe aplastic anemia and hematological malignancies. Clin Transplant 2009; 23:33-8. [DOI: 10.1111/j.1399-0012.2008.00894.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Pharmacokinetics-based optimal dose-exploration of mycophenolate mofetil in allogeneic hematopoietic stem cell transplantation. Int J Hematol 2008; 88:104-110. [PMID: 18473127 DOI: 10.1007/s12185-008-0093-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 03/14/2008] [Accepted: 04/04/2008] [Indexed: 10/22/2022]
Abstract
For better clinical outcomes of mycophenolate mofetil (MMF) in allogeneic hematopoietic stem cell transplantation (alloSCT), higher mycophenolic acid (MPA) plasma levels are proposed to be desirable. Here, we investigate the optimal MMF dosing strategy based on pharmacokinetic studies in 20 Japanese alloSCT patients. The first 11 patients received MMF twice daily at an escalated dose from 15 mg/kg, according to real-time pharmacokinetic monitoring of the total MPA area under the curve (AUC). In the subsequent nine patients, MMF was given at a fixed dose of 1,000 mg three-times daily. The pharmacokinetic data revealed that the dose escalation in each individual did not always increase the AUC. In contrast, the increase of dosing frequency could statistically keep higher MPA plasma levels, as reflected in higher concentration at steady state (C (ss)) or trough value (C (trough)). There was no symptomatic adverse event in both groups. These results suggest that MMF administration of every 8 h after alloSCT would be better to maintain higher MPA plasma levels than that of every 12 h even in the same daily dose. Further studies are necessary to confirm the clinical benefit of MMF to prevent graft failure, as well as severe aGVHD.
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19
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Soiffer RJ. Biologic Principles of Hematopoietic Stem Cell Transplantation. Oncology 2007. [DOI: 10.1007/0-387-31056-8_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Kawamori Y, Yakushijin K, Okamura A, Nishikawa S, Minagawa K, Shimoyama M, Yamamoto K, Katayama Y, Matsui T. Successful engraftment in reduced-intensity cord blood transplantation (CBT) as a salvage therapy for graft failure after primary CBT in adults. Transplantation 2007; 83:1281-2. [PMID: 17496548 DOI: 10.1097/01.tp.0000260635.19245.65] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Pohlreich D, Vitek A, Maalouf J, Cetkovsky P. Decreased risk of acute gastrointestinal toxicity when substituting methotrexate with mycophenolate mofetil in the prevention of graft-versus-host disease in stem cell transplantation following myeloablative conditioning regimens. Bone Marrow Transplant 2006; 37:235-6; author reply 236-7. [PMID: 16284607 DOI: 10.1038/sj.bmt.1705227] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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22
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Neumann F, Graef T, Tapprich C, Vaupel M, Steidl U, Germing U, Fenk R, Hinke A, Haas R, Kobbe G. Cyclosporine A and Mycophenolate Mofetil vs Cyclosporine A and Methotrexate for graft-versus-host disease prophylaxis after stem cell transplantation from HLA-identical siblings. Bone Marrow Transplant 2005; 35:1089-93. [PMID: 15821769 DOI: 10.1038/sj.bmt.1704956] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The combination of Cyclosporin A (CSA) and Methotrexate (MTX) is considered to be the standard regimen for the prevention of graft-versus-host disease (GVHD) after stem cell transplantation (SCT) from HLA-identical siblings. Mycophenolate Mofetil (MMF) has been widely used for GVHD prophylaxis after nonmyeloablative SCT, but experience following myeloablative therapy is still limited. We retrospectively compared CSA/MTX and CSA/MMF in 93 patients (median age 35 years, range 17-59 years, male subjects 48, female subjects 45) with acute myeloid leukemia (n=33), myelodysplastic syndrome (MDS) (n=3), acute lymphoblastic leukemia (ALL) (n=20) or chronic myeloid leukemia (n=37) who received CSA/MMF (n=26) or CSA/MTX (n=67) as GVHD prophylaxis following high-dose therapy and allogeneic SCT from HLA-identical siblings. No statistically significant differences were found in overall survival, relapse rate, treatment-related mortality and acute or chronic GVHD. Time to myeloid recovery was significantly shorter in patients who received CSA/MMF. We conclude that the combination of CSA/MMF appears equivalent to CSA/MTX for GVHD prophylaxis in patients receiving conventional-intensity SCT from HLA-identical siblings.
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Affiliation(s)
- F Neumann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Duesseldorf, Germany, Moorenstrasse 5, Duesseldorf, Germany.
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Mohty M, de Lavallade H, Faucher C, Bilger K, Vey N, Stoppa AM, Gravis G, Coso D, Viens P, Gastaut JA, Blaise D. Mycophenolate mofetil and cyclosporine for graft-versus-host disease prophylaxis following reduced intensity conditioning allogeneic stem cell transplantation. Bone Marrow Transplant 2005; 34:527-30. [PMID: 15286687 DOI: 10.1038/sj.bmt.1704640] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The use of reduced intensity conditioning (RIC) regimens for allogeneic stem cell transplantation (allo-SCT) can result in a significant decrease in early procedure-related toxicity in patients not eligible for standard myeloablative regimens. However, acute graft-versus-host disease (aGVHD) remains a matter of concern after RIC allo-SCT, and its incidence might be expected to be higher in elderly and high-risk patients. This report investigated mycophenolate mofetil (MMF) and cyclosporin A (CsA) combination (n=14) in comparison to CsA alone (n=20) for GVHD prophylaxis in cancer patients aged over 50 years (27 haematological malignancies and seven solid tumours) receiving an HLA-identical sibling antithymocyte-globulin (ATG)-based RIC allo-SCT. Baseline demographic characteristics and risk factors for aGVHD were comparable between both groups. Although MMF administration was not associated with any significant toxicity, the cumulative incidence of any form of GVHD was comparable between both groups (cumulative incidence of grade II-IV aGVHD, 50% (95% CI, 28-72%) for CsA alone, as compared to 64% (95% CI, 39-89%) to CsA and MMF, P=NS), suggesting that adjunction of MMF to CsA is feasible, but does not translate towards a significant reduction of aGVHD, at least in the context ATG-based RIC allo-SCT.
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Affiliation(s)
- M Mohty
- Unité de Transplantation et de Thérapie Cellulaire (UTTC), Institut Paoli-Calmettes, Marseille, France.
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Boyiadzis M, Pavletic S. Haematopoietic stem cell transplantation: indications, clinical developments and future directions. Expert Opin Pharmacother 2004; 5:97-108. [PMID: 14680439 DOI: 10.1517/14656566.5.1.97] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Haematopoietic stem cell transplantation (HSCT) is an established curative treatment for many malignant and non-malignant diseases. Over the last two decades, novel approaches have resulted in significant reductions in the morbidity and mortality associated with HSCT. These include the utilisation of reduced intensity regimens, more effective graft versus host disease prophylaxis, exploration of new sources of progenitor haematopoietic stem cells and better prophylaxis and treatment of infections. Despite current advances, new strategies are needed to further reduce the complications associated with HSCT. This article reviews the current indications for HSCT and the recent progress in the field of both allogeneic- and autologous HSCT.
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Affiliation(s)
- Michael Boyiadzis
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Building 10, Room 12N226, 10 Center Drive, Bethesda, MD 20892, USA.
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Abstract
Acute and chronic graft-versus-host disease (GvHD) remain major obstacles to successful allogeneic hematopoietic stem cell transplantation, contributing substantially to morbidity and non-relapse mortality. Better understanding of the immunopathophysiology of GvHD has identified a number of targets for intervention. Among newly developed agents suitable for the prevention and treatment of GvHD, monoclonal antibodies hold much promise. Monoclonal antibodies currently available, such as infliximab and anti-interferon-gamma (anti-IFN-gamma), are capable of blocking of the action of initiating and effector cytokines. Antibodies directed against activated T cells, including daclizumab, visilizumab and ABX-CBL, may offer more specificity than the more broadly acting pan-T-cell-depleting agents. Finally, the clinical investigation of antibodies to adhesion molecules (such as LFA-1), or distal effector mechanisms (such as FasL) may offer another level of specificity. Many of these monoclonal antibodies have already undergone clinical testing. Campath-1H has been used for the prevention of acute GvHD with success. Daclizumab, infliximab, visilizumab, and ABX-CBL have shown promising activity in steroid-resistant acute GvHD in early clinical testing. This review summarizes current experience with monoclonal antibodies in the management of acute and chronic GvHD. Over the next decade, however, the challenge will be to define the relative place of these antibodies in the therapeutic armamentarium for GvHD and their impact on long-term survival.
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Affiliation(s)
- Rebecca J Bruner
- Bone Marrow Transplantation Program, The Ohio State University Comprehensive Cancer Center, Columbus, USA
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