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Wada F, Kondo T, Yamamoto R, Yamagiwa T, Arai Y, Mizumoto C, Kanda J, Kitawaki T, Yamashita K, Takaori-Kondo A. Addition and drug monitoring of mycophenolate mofetil for GVHD prophylaxis in unrelated bone marrow transplantation. Bone Marrow Transplant 2022; 57:1198-1200. [PMID: 35501566 DOI: 10.1038/s41409-022-01692-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Ryusuke Yamamoto
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takero Yamagiwa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Chisato Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Reduced Enterohepatic Recirculation of Mycophenolate and Lower Blood Concentrations are Associated with the Stool Bacterial Microbiome After Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:372.e1-372.e9. [PMID: 35489611 DOI: 10.1016/j.jtct.2022.04.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is an important immunosuppressant used after allogeneic hematopoietic cell transplant (HCT). MMF has a narrow therapeutic index and blood concentrations of mycophenolic acid (MPA), the active component of MMF, are highly variable. Low MPA concentrations are associated with risk of graft vs host disease (GvHD) while high concentrations are associated with toxicity. Reasons for variability are not well known and may be due, at least in part, to the presence of β-glucuronidase producing bacteria in the gastrointestinal tract which enhance MPA enterohepatic recirculation (EHR) by transforming MPA metabolites formed in the liver back to MPA. OBJECTIVE To determine if individuals with high MPA EHR have a greater abundance of β-glucuronidase producing bacteria in their stool and higher MPA concentrations relative to those with low EHR. STUDY DESIGN We conducted a pharmacomicrobiomics study in 20 adult HCT recipients receiving a myeloablative or reduced intensity preparative regimen. Participants received MMF 1g IV every 8 hours with tacrolimus. Intensive pharmacokinetic sampling of mycophenolate was conducted before hospital discharge. Total MPA, MPA glucuronide (MPAG) and acylMPAG were measured. EHR was defined as a ratio of MPA area under the concentration-versus-time curve (AUC)4-8 to MPA AUC0-8. Differences in stool microbiome diversity and composition, determined by shotgun metagenomic sequencing, were compared above and below the median EHR (22%, range 5-44%). RESULTS Median EHR was 12% and 29% in the low and high EHR groups, respectively. MPA troughs, MPA AUC4-8 and acylMPAG AUC4-8/AUC0-8, were greater in the high EHR group vs low EHR group [1.53 vs 0.28 mcg/mL, p = 0.0001], [7.33 vs 1.79 hr*mcg/mL, p = 0.0003] and [0.33 vs 0.24 hr*mcg/mL, p = 0.0007], respectively. MPA AUC0-8 was greater in the high EHR than the low EHR group and trended towards significance [22.8 vs. 15.3 hr*mcg/mL, p=0.06]. Bacteroides vulgatus, stercoris and thetaiotaomicron were 1.2-2.4 times more abundant (p=0.039, 0.024, 0.046, respectively) in the high EHR group. MPA EHR was positively correlated with B. vulgatus (⍴=0.58, p≤0.01) and B. thetaiotaomicron (⍴=0.46, p<0.05) and negatively correlated with Blautia hydrogenotrophica (⍴=-0.53, p<0.05). Therapeutic MPA troughs were achieved in 80% of patients in the high EHR group and 0% in the low EHR. There was a trend towards differences in MPA AUC0-8 and MPA Css mcg/mL in high vs. low EHR groups (p=0.06). CONCLUSION MPA EHR was variable. Patients with high MPA EHR had greater abundance of Bacteroides species in stool and higher MPA exposure than patients with low MPA EHR. Bacteroides may therefore be protective from poor outcomes such as graft vs host disease but in others it may increase the risk of MPA adverse effects. These data need to be confirmed and studied after oral MMF.
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Wada F, Kanda J, Watanabe M, Arai Y, Hishizawa M, Kondo T, Yamashita K, Takaori-Kondo A. Favorable Outcomes after Single Cord Blood Transplantation for Patients with High-Risk Hematologic Diseases: A Single-Institute Retrospective Analysis. Transplant Cell Ther 2021; 27:495.e1-495.e9. [PMID: 33814354 DOI: 10.1016/j.jtct.2021.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/16/2021] [Accepted: 02/21/2021] [Indexed: 11/12/2022]
Abstract
The donor selection algorithm for cord blood (CB) with regards to matched related and unrelated donors has not been fully investigated. To assess the potential of CB transplantation (CBT) in patients with hematologic malignancies, especially for high-risk patients, we performed a single-institute retrospective analysis and compared the clinical outcomes of CBT with those of HLA-matched sibling and unrelated donor transplantation. We included 394 patients aged 16 years and older with hematologic diseases who received their first allogeneic hematopoietic cell transplantation between 1990 and 2018 at Kyoto University Hospital. These included 394 recipients of single unrelated cord blood units (UCB, n = 108), HLA-matched sibling donors (MSDs, n = 143), or HLA-matched unrelated donors (MUDs, n = 143). There was no significant difference in relapse-free survival (RFS) between UCB, MSD, and MUD recipients (P = .975). However, we found a significant interaction between transplant year and CBT outcomes (P = .010), with significantly better outcomes observed in the more recent years. Furthermore, we found that CBT showed better RFS than matched donor transplantation (hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.30 to 0.84). This impact was more prominent in high-risk patients (HR, 0.35; 95% CI, 0.16 to 0.77), with lower relapse rates (HR, 0.25; 95% CI, 0.11 to 0.54), and comparable non-relapse mortality (NRM) compared to matched donor transplantation. Extensive chronic graft-versus-host disease was less frequently observed in CBT (HR, 0.58; 95% CI, 0.26 to 1.28). CBT associated with favorable outcomes, particularly in high-risk patients, with good RFS and low relapse rates without an increase in NRM in the single-institute study. Although the findings should be externally validated, CBT might serve as a reasonable donor choice, particularly in high-risk patients.
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Affiliation(s)
- Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Mizuki Watanabe
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masakatsu Hishizawa
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Muranushi H, Kanda J, Arai Y, Shindo T, Hishizawa M, Yamamoto T, Kondo T, Yamashita K, Matsubara K, Takaori‐Kondo A. Drug monitoring for mycophenolic acid in graft-vs-host disease prophylaxis in cord blood transplantation. Br J Clin Pharmacol 2020; 86:2464-2472. [PMID: 32386102 PMCID: PMC7688537 DOI: 10.1111/bcp.14354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/31/2020] [Accepted: 04/27/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS We performed the retrospective analysis to clarify the significance of drug monitoring for mycophenolic acid (MPA), the active form of mycophenolate mofetil (MMF), in prophylaxis for graft-vs-host disease (GVHD) in cord blood transplantation. METHODS We retrospectively analysed the data of 46 patients who underwent first cord blood transplantation and received GVHD prophylaxis with tacrolimus plus MMF. MPA levels were measured on days 7 and 21, and 24-hour areas under the curve (AUC0-24 ) were estimated. RESULTS The engraftment and 3-year overall survival rates of all patients were 94% and 78%, respectively. The cumulative incidence of sepsis before engraftment was higher in patients with AUC0-24 on day 7 of >60 μg h/mL than in other patients (33 vs 6%, P = .02). The cumulative incidence of grade II-IV acute GVHD was higher in patients with AUC0-24 on day 21 of ≤30 μg h/mL than in other patients (80 vs 50%, P = .04). The cumulative incidence of human herpesvirus 6 reactivation was higher in patients with AUC0-24 on day 21 of ≤48 μg h/mL (median) than in other patients (50 vs 19%, P = .03). CONCLUSION Blood level of MPA was associated with risk of acute GVHD and infection. A prospective trial evaluating the benefit of personalized MMF dosing using MPA levels is needed.
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Affiliation(s)
- Hiroyuki Muranushi
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
- Department of Transfusion Medicine and Cell TherapyKyoto University HospitalKyotoJapan
| | - Takero Shindo
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Masakatsu Hishizawa
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Takashi Yamamoto
- Department of Clinical Pharmacology and TherapeuticsKyoto University HospitalKyotoJapan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Kohei Yamashita
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and TherapeuticsKyoto University HospitalKyotoJapan
| | - Akifumi Takaori‐Kondo
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
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Yamamoto H. Single cord blood transplantation in Japan; expanding the possibilities of CBT. Int J Hematol 2019; 110:39-49. [PMID: 31152417 DOI: 10.1007/s12185-019-02672-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022]
Abstract
Cord blood (CB) has been an alternative stem cell source for patients with a wide variety of hematological diseases. Cord blood confers the advantages of rapid availability and higher tolerance to two HLA antigen mismatches compared with unrelated donors, and this has increased opportunities for patients who do not have suitable donors or require urgent transplantation. Although the higher rate of engraftment failure remains a serious concern after cord blood transplantation (CBT), the mechanisms underlying this risk have gradually been clarified, which has helped to improve engraftment. Recent studies of CBT and other alternatives have reported comparable outcomes. Moreover, CBT shows promise even when patients are in a non-remission status, which may reflect the potent graft-versus-leukemia effect of CB. Here we compare the most recent outcomes of CBT with those of other stem cell sources and discuss the potential of CB and several outstanding issues that require resolution.
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Affiliation(s)
- Hisashi Yamamoto
- Department of Hematology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
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Yoshimura K, Yano I, Yamamoto T, Kondo T, Kawanishi M, Isomoto Y, Yonezawa A, Takaori-Kondo A, Matsubara K. Pharmacokinetic and Pharmacodynamic Markers of Mycophenolic Acid Associated with Effective Prophylaxis for Acute Graft-Versus-Host Disease and Neutrophil Engraftment in Cord Blood Transplant Patients. Biol Blood Marrow Transplant 2018; 24:1441-1448. [DOI: 10.1016/j.bbmt.2018.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
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Yoshimura K, Yano I, Yamamoto T, Kawanishi M, Isomoto Y, Yonezawa A, Kondo T, Takaori-Kondo A, Matsubara K. Population pharmacokinetics and pharmacodynamics of mycophenolic acid using the prospective data in patients undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2017; 53:44-51. [DOI: 10.1038/bmt.2017.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 07/20/2017] [Accepted: 08/27/2017] [Indexed: 11/09/2022]
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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Umbilical cord blood transplantation for adults using tacrolimus with two-day very-short-term methotrexate for graft-versus-host disease prophylaxis. Leuk Res 2016; 47:161-5. [DOI: 10.1016/j.leukres.2016.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 01/15/2023]
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Murata M. Prophylactic and therapeutic treatment of graft-versus-host disease in Japan. Int J Hematol 2015; 101:467-86. [DOI: 10.1007/s12185-015-1784-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/17/2015] [Indexed: 11/29/2022]
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