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Freyer CW, Gier S, Moyer ME, Berryman N, Carulli A, Ganetsky A, Timlin C, Babushok DV, Frey NV, Gill SI, Hexner EO, Loren AW, Mangan JK, Martin ME, McCurdy S, Perl AE, Smith J, Luger SM, Stadtmauer EA, Porter DL. Leucovorin Rescue After Methotrexate Graft-Versus-Host Disease Prophylaxis Shortens the Duration of Mucositis, Time to Neutrophil Engraftment, and Hospital Length of Stay. Transplant Cell Ther 2021; 27:431.e1-431.e8. [PMID: 33965188 DOI: 10.1016/j.jtct.2021.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/26/2021] [Accepted: 01/31/2021] [Indexed: 11/27/2022]
Abstract
Oropharyngeal mucositis (OPM) is common following conditioning for allogeneic hematopoietic cell transplantation (alloHCT) and results in pain, functional status decline, need for nutritional support, infections, and prolonged length of stay (LOS). Methotrexate (MTX) graft-versus-host disease (GVHD) prophylaxis exacerbates OPM and slows hematopoietic engraftment, which may prolong LOS. Previous studies have demonstrated reduced OPM and more rapid engraftment when leucovorin (LCV) is added following MTX GVHD prophylaxis, yet this practice is controversial. The primary objective of this study was to determine if the routine addition of LCV to MTX GVHD prophylaxis impacted the duration of grade 2 to 4 OPM. Secondary objectives included determination of the incidence of grade 2 to 4 and grade 3 to 4 OPM, time to engraftment, ability to receive all four planned MTX doses, use of total parenteral nutrition (TPN), use of patient-controlled analgesia (PCA), LOS, incidence of acute or chronic GVHD, relapse-free survival (RFS), and overall survival (OS). This single-center, retrospective cohort study compared alloHCT outcomes for 46 adult patients who received MTX 15 mg/m2 day +1; MTX 10 mg/m2 days +3, +6, and +11 (15-10-10-10); and LCV following days +3, +6, and +11 MTX compared to historical controls who did not. Patients who received myeloablative conditioning (MAC) and matched related donor (MRD) or matched unrelated donor (MUD) alloHCT were included. The addition of LCV resulted in significant reductions in the duration of grade 2 to 4 OPM (median, 6 days versus 10.5 days; P = .0004), duration of TPN (7 days versus 16 days; P = .001), PCA use (16% versus 39%; P = .0001), time to neutrophil engraftment (median, 18 versus 20 days; P = .008), and LOS (median, 27.5 versus 31 days; P = .017) compared to historical controls. Patients who received routine LCV had similar incidences of grade 2 to 4 acute GVHD (30% versus 28%; relative risk [RR], 1.08; 95% confidence interval [CI], .57 to 2.03; P = 1.0), grade 3 or 4 acute GVHD (2% versus 7%; RR, .33; 95% CI, .04 to 3.09; P = .62) and chronic GVHD (37% versus 30%; RR, 1.21; 95% CI, .67 to 2.16; P = .66) compared to historical controls. Graft failure occurred in 2% of patients in each group. In a multivariable logistic regression analysis, RFS was similar in the LCV group compared to historical controls (HR, .86; 95% CI, .24 to 1.2; P = .13); however, OS was improved in patients who received LCV (HR, .33; 95% CI, .13 to .83; P = .01). In patients undergoing MAC MRD/MUD alloHCT with four planned doses of MTX GVHD prophylaxis (15-10-10-10), LCV was associated with reduced duration of grade 2 to 4 OPM, faster neutrophil engraftment, reduced utilization of TPN and PCA, and shortened LOS compared to historical controls not receiving routine LCV. These benefits were apparent without an increased risk of acute or chronic GVHD or adverse effect on RFS. LCV improved OS; however, it is unclear if this was due to the intervention or an unmeasured confounder. A randomized, prospective trial of LCV prophylaxis in patients receiving MAC alloHCT and MTX 15-10-10-10 GVHD prophylaxis is warranted to confirm our findings.
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Affiliation(s)
- Craig W Freyer
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Shannon Gier
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary E Moyer
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Natasha Berryman
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison Carulli
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alex Ganetsky
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen Timlin
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daria V Babushok
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noelle V Frey
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saar I Gill
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth O Hexner
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison W Loren
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James K Mangan
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Ellen Martin
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shannon McCurdy
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander E Perl
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline Smith
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Selina M Luger
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward A Stadtmauer
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David L Porter
- Blood and Marrow Transplant and Cellular Therapy Program, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Yeshurun M, Rozovski U, Pasvolsky O, Wolach O, Ram R, Amit O, Zuckerman T, Pek A, Rubinstein M, Sela-Navon M, Raanani P, Shargian-Alon L. Efficacy of folinic acid rescue following MTX GVHD prophylaxis: results of a double-blind, randomized, controlled study. Blood Adv 2020; 4:3822-3828. [PMID: 32790844 PMCID: PMC7448592 DOI: 10.1182/bloodadvances.2020002039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/07/2020] [Indexed: 12/22/2022] Open
Abstract
The use of methotrexate (MTX) for graft-versus-host disease (GVHD) prophylaxis is associated with increased rates of organ-specific toxicities. Despite limited data, the European Society for Blood and Marrow Transplantation-European LeukemiaNet working group recommend the use of folinic acid (FA) rescue to reduce MTX toxicity after allogeneic hematopoietic cell transplantation (allo-HCT). In a multicenter, double-blind, randomized, controlled trial, we explored whether FA rescue reduces MTX-induced toxicity. We enrolled patients undergoing allo-HCT with myeloablative conditioning with peripheral blood stem cell grafts, with GVHD prophylaxis consisting of cyclosporine and MTX. Patients were randomized to receive FA or placebo starting 24 hours after each MTX dose and continuing over 24 hours in 3 to 4 divided doses. The primary end point was the rate of grades 3 and 4 oral mucositis. After enrollment of 52 patients (FA, n = 28; placebo, n = 24), preplanned interim analysis revealed similar rates of grade 3 and 4 (46.6% vs 45.8%; P = .97) and grades 1 to 4 (83.3% vs 77.8%; P = .65) oral mucositis. With a median follow-up of 17 (range, 4.5-50) months, there was no difference in the rates of acute and chronic GVHD, disease relapse, nonrelapse mortality, and overall survival. These interim results did not support continuation of the study. We conclude that FA rescue after MTX GVHD prophylaxis does not decrease regimen-related toxicity or affect transplantation outcomes. This study was registered at clinicaltrials.gov as #NCT02506231.
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Affiliation(s)
- Moshe Yeshurun
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Pasvolsky
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Wolach
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Bone Marrow Transplant Unit, Tel Aviv Medical Center, Tel Aviv, Israel; and
| | - Odelia Amit
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Bone Marrow Transplant Unit, Tel Aviv Medical Center, Tel Aviv, Israel; and
| | | | - Anat Pek
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Maly Rubinstein
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Sela-Navon
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Shargian-Alon
- Institution of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Su YW, Chen KM, Hassanshahi M, Tang Q, Howe PR, Xian CJ. Childhood cancer chemotherapy-induced bone damage: pathobiology and protective effects of resveratrol and other nutraceuticals. Ann N Y Acad Sci 2017; 1403:109-117. [PMID: 28662275 DOI: 10.1111/nyas.13380] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/13/2017] [Accepted: 04/18/2017] [Indexed: 11/30/2022]
Abstract
Intensive cancer chemotherapy causes significant bone loss, for which the mechanisms remain unclear and effective treatments are lacking. This is a significant issue particularly for childhood cancers, as the most common ones have a >75% cure rate following chemotherapy; there is an increasing population of survivors who live with chronic bone defects. Studies suggest that these defects are the result of reduced bone from increased marrow fat formation and increased bone resorption following chemotherapy. These changes probably result from altered expression/activation of regulatory molecules or pathways regulating skeletal cell formation and activity. Treatment with methotrexate, an antimetabolite commonly used in childhood oncology, has been shown to increase levels of proinflammatory/pro-osteoclastogenic cytokines (e.g., enhanced NF-κB activation), leading to increased osteoclast formation and bone resorption, as well as to attenuate Wnt signaling, leading to both decreased bone and increased marrow fat formation. In recent years, understanding the mechanisms of action and potential health benefits of selected nutraceuticals, including resveratrol, genistein, icariin, and inflammatory fatty acids, has led to preclinical studies that, in some cases, indicate efficacy in reducing chemotherapy-induced bone defects. We summarize the supporting evidence.
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Affiliation(s)
- Yu-Wen Su
- Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Ke-Ming Chen
- Institute of Orthopaedics, Lanzhou General Hospital, Lanzhou Command of People's Liberation Army, Lanzhou, PR China
| | - Mohammadhossein Hassanshahi
- Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Qian Tang
- Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Peter R Howe
- Clinical Nutrition Research Centre, University of Newcastle, Callaghan, New South Wales, Australia
| | - Cory J Xian
- Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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Raghu Nadhanan R, Fan CM, Su YW, Howe PRC, Xian CJ. Fish oil in comparison to folinic acid for protection against adverse effects of methotrexate chemotherapy on bone. J Orthop Res 2014; 32:587-96. [PMID: 24346859 DOI: 10.1002/jor.22565] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 11/25/2013] [Indexed: 02/04/2023]
Abstract
Methotrexate (MTX) chemotherapy is known to cause bone loss which lacks specific preventative treatments, although clinically folinic acid is often used to reduce MTX toxicity in soft tissues. This study investigated damaging effects of MTX injections (0.75 mg/kg/day for 5 days) in rats and potential protective benefits of fish oil (0.25, 0.5, or 0.75 ml/100 g/day) in comparison to folinic acid (0.75 mg/kg) in the tibial metaphysis. MTX treatment significantly reduced height of primary spongiosa and volume of trabecular bone while reducing density of osteoblasts. Consistently, MTX reduced osteogenic differentiation but increased adipogenesis of bone marrow stromal cells, accompanied by lower mRNA expression of osteogenic transcription factors Runx2 and Osx, but an up-regulation of adipogenesis-related genes FABP4 and PPAR-γ. MTX also increased osteoclast density, bone marrow osteoclast formation, and mRNA expression of proinflammatory cytokines IL-1, IL-6, TNF-α, and RANKL/OPG ratio in bone. Fish oil (0.5 or 0.75 ml/100 g) or folinic acid supplementation preserved bone volume, osteoblast density, and osteogenic differentiation, and suppressed MTX-induced cytokine expression, osteoclastogenesis, and adipogenesis. Thus, fish oil at 0.5 ml/100 g or above is as effective as folinic acid in counteracting MTX-induced bone damage, conserving bone formation, suppressing resorption and marrow adiposity, suggesting its therapeutic potential in preventing bone loss during MTX chemotherapy.
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Affiliation(s)
- Rethi Raghu Nadhanan
- Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, 5001, Australia
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