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Sharma R. Innovative Genoceuticals in Human Gene Therapy Solutions: Challenges and Safe Clinical Trials of Orphan Gene Therapy Products. Curr Gene Ther 2024; 24:46-72. [PMID: 37702177 DOI: 10.2174/1566523223666230911120922] [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: 11/03/2022] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 09/14/2023]
Abstract
The success of gene therapy attempts is controversial and inconclusive. Currently, it is popular among the public, the scientific community, and manufacturers of Gene Therapy Medical Products. In the absence of any remedy or treatment options available for untreatable inborn metabolic orphan or genetic diseases, cancer, or brain diseases, gene therapy treatment by genoceuticals and T-cells for gene editing and recovery remains the preferred choice as the last hope. A new concept of "Genoceutical Gene Therapy" by using orphan 'nucleic acid-based therapy' aims to introduce scientific principles of treating acquired tissue damage and rare diseases. These Orphan Genoceuticals provide new scope for the 'genodrug' development and evaluation of genoceuticals and gene products for ideal 'gene therapy' use in humans with marketing authorization application (MAA). This perspective study focuses on the quality control, safety, and efficacy requirements of using 'nucleic acid-based and human cell-based new gene therapy' genoceutical products to set scientific advice on genoceutical-based 'orphan genodrug' design for clinical trials as per Western and European guidelines. The ethical Western FDA and European EMA guidelines suggest stringent legal and technical requirements on genoceutical medical products or orphan genodrug use for other countries to frame their own guidelines. The introduction section proposes lessknown 'orphan drug-like' properties of modified RNA/DNA, human cell origin gene therapy medical products, and their transgene products. The clinical trial section explores the genoceutical sources, FDA/EMA approvals for genoceutical efficacy criteria with challenges, and ethical guidelines relating to gene therapy of specific rare metabolic, cancer and neurological diseases. The safety evaluation of approved genoceuticals or orphan drugs is highlighted with basic principles and 'genovigilance' requirements (to observe any adverse effects, side effects, developed signs/symptoms) to establish their therapeutic use. Current European Union and Food and Drug Administration guidelines continuously administer fast-track regulatory legal framework from time to time, and they monitor the success of gene therapy medical product efficacy and safety. Moreover, new ethical guidelines on 'orphan drug-like genoceuticals' are updated for biodistribution of the vector, genokinetics studies of the transgene product, requirements for efficacy studies in industries for market authorization, and clinical safety endpoints with their specific concerns in clinical trials or public use.
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Affiliation(s)
- Rakesh Sharma
- Surgery NMR Lab, Plastic Surgery Research, Massachusetts General Hospital, Boston, MA 02114, USA
- CCSU, Government Medical College, Saharanpur, 247232 India
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Klein OR, Ktena YP, Pierce E, Fu HH, Haile A, Liu C, Cooke KR. Defibrotide modulates pulmonary endothelial cell activation and protects against lung inflammation in pre-clinical models of LPS-induced lung injury and idiopathic pneumonia syndrome. Front Immunol 2023; 14:1186422. [PMID: 37441074 PMCID: PMC10335747 DOI: 10.3389/fimmu.2023.1186422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction A multiple organ dysfunction syndrome (MODS) workshop convened by the National Institute of Child Health and Human Development in 2015 identified acute respiratory distress syndrome (ARDS) and complications of allogeneic blood and marrow transplantation (allo-BMT) as contributors to MODS in pediatric patients. Pulmonary dysfunction also remains a significant complication of allo-BMT. Idiopathic pneumonia syndrome (IPS) defines non-infectious, acute, lung injury that occurs post-transplant. Injury and activation to endothelial cells (ECs) contribute to each form of lung inflammation. Methods Two murine models were employed. In an ARDS model, naïve B6 mice receive an intravenous (i.v.) injection of lipopolysaccharide (LPS). In the established model of IPS, naïve B6D2F1 mice receive lethal total body irradiation followed by BMT from either allogeneic (B6) or syngeneic (B6D2F1) donors. Lung inflammation was subsequently assessed in each scenario. Results Intravenous injection of LPS to B6 mice resulted in enhanced mRNA expression of TNFα, IL-6, Ang-2, E-, and P-selectin in whole lung homogenates. The expression of Ang-2 in this context is regulated in part by TNFα. Additionally, EC activation was associated with increased total protein and cellularity in broncho-alveolar lavage fluid (BALF). Similar findings were noted during the development of experimental IPS. We hypothesized that interventions maintaining EC integrity would reduce the severity of ARDS and IPS. Defibrotide (DF) is FDA approved for the treatment of BMT patients with sinusoidal obstruction syndrome and renal or pulmonary dysfunction. DF stabilizes activated ECs and protect them from further injury. Intravenous administration of DF before and after LPS injection significantly reduced mRNA expression of TNFα, IL6, Ang-2, E-, and P-selectin compared to controls. BALF showed decreased cellularity, reflecting less EC damage and leak. Allogeneic BMT mice were treated from day -1 through day 14 with DF intraperitoneally, and lungs were harvested at 3 weeks. Compared to controls, DF treatment reduced mRNA expression of TNFα, IL6, Ang-2, E-, and P- selectin, BALF cellularity, and lung histopathology. Conclusion The administration of DF modulates EC injury in models of ARDS and IPS. Cytokine inhibition in combination with agents that stabilize EC integrity may be an attractive strategy for patients in each setting.
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Affiliation(s)
- Orly R. Klein
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Yiouli P. Ktena
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Elizabeth Pierce
- Department of Pediatrics, Pediatric Blood and Marrow Transplant Program, Case Western Reserve University, School of Medicine, Cleveland, OH, United States
| | - Han-Hsuan Fu
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Azeb Haile
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Chen Liu
- Department of Pathology, Yale School of Medicine, New Haven, CT, United States
| | - Kenneth R. Cooke
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
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Grupp SA, Corbacioglu S, Kang HJ, Teshima T, Khaw SL, Locatelli F, Maertens J, Stelljes M, Stepensky P, Lopez P, Amber V, Pagliuca A, Richardson PG, Mohty M. Defibrotide plus best standard of care compared with best standard of care alone for the prevention of sinusoidal obstruction syndrome (HARMONY): a randomised, multicentre, phase 3 trial. Lancet Haematol 2023; 10:e333-e345. [PMID: 37001534 DOI: 10.1016/s2352-3026(23)00011-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/21/2022] [Accepted: 01/10/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Sinusoidal obstruction syndrome, also known as veno-occlusive disease, is a potentially life-threatening complication of haematopoietic stem-cell transplantation (HSCT). We aimed to compare defibrotide prophylaxis plus best supportive care versus best supportive care alone for sinusoidal obstruction syndrome prevention after HSCT. METHODS This open-label, randomised, multicentre, phase 3 trial was done in 104 centres in 14 countries. Patients who were at least 1 month old, were scheduled to receive allogeneic HSCT (adult [aged >16 years] or paediatric [aged >1 month to ≤16 years] patients) or autologous HSCT (paediatric patients only), and were at high risk or very high risk of developing sinusoidal obstruction syndrome were eligible for inclusion. Patients were randomly assigned (1:1) by an interactive web response system to receive intravenous defibrotide 25 mg/kg per day (four equal doses [6·25 mg/kg per dose]) and best supportive care (determined by individual institutional guidelines; defibrotide prophylaxis group) or best supportive care only (best supportive care group). Randomisation was stratified by sinusoidal obstruction syndrome risk, age, and country. The primary endpoint, sinusoidal obstruction syndrome-free survival at day 30 after HSCT, was assessed by an independent Endpoint Adjudication Committee in the intention-to-treat (ITT) population. Safety was assessed in all patients who received protocol treatment. The trial is registered with ClinicalTrials.gov, NCT02851407. FINDINGS Between Jan 11, 2017, and Oct 20, 2020, 372 patients (172 [46%] women and 200 [54%] men; median age 14·0 years [IQR 4·0-41·0] were randomly assigned to the defibrotide prophylaxis group (n=190) or best supportive care group (n=182; ITT population). On the basis of recommendations from the Independent Data Monitoring Committee following completion of the planned interim analysis in the first 280 recruited patients on April 29, 2020, enrolment was prematurely stopped for presumed futility. At the final analysis, sinusoidal obstruction syndrome-free survival by day 30 after HSCT was 67% (95% CI 58-74) in the defibrotide prophylaxis group and 73% (62-80) in the best supportive care group (HR 1·27 [95% CI 0·84-1·93]; p=0·85). Treatment-emergent adverse events were similar between groups during the randomised prophylaxis phase; most treatment-emergent adverse events were related to the transplantation rather than to study drug. The most common grade 3 or 4 treatment-emergent adverse events were stomatitis (grade 3, 52 [29%] of 181 patients in the defibrotide prophylaxis group and 56 [32%] of 174 patients in the best supportive care group; grade 4, two [1%] in the defibrotide prophylaxis group and two [1%] in the best supportive care group) and febrile neutropaenia (grade 3, 51 [28%] in the defibrotide prophylaxis group and 52 [30%] in the best supportive care group; grade 4, no patients in the defibrotide prophylaxis group and three [2%] in the best supportive care group). Serious treatment-emergent adverse events occurred in 74 (41%) of 181 patients in the defibrotide prophylaxis group and 61 (35%) of 174 patients in the best supportive care group. In the rescue phase, when patients in both treatment groups received defibrotide as rescue treatment, fatal treatment-related adverse events occurred in one (4%) of 25 patients in the defibrotide prophylaxis group (intracranial haemorrhage) and one (3%) of 31 patients in the best supportive care group (sinusoidal obstruction syndrome). INTERPRETATION Defibrotide did not show a benefit in the prophylaxis of sinusoidal obstruction syndrome. Additional studies of carefully selected patients at high risk of sinusoidal obstruction syndrome after HSCT are warranted. FUNDING Jazz Pharmaceuticals.
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Affiliation(s)
- Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Hyoung Jin Kang
- Department of Pediatrics, College of Medicine, Seoul National University Cancer Research Institute and Wide River Institute of Immunology, Seoul National University Children's Hospital, Seoul National University, Seoul, South Korea
| | - Takanori Teshima
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Seong Lin Khaw
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Franco Locatelli
- IRCCS, Bambino Gesù Children's Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, Catholic University Leuven, Leuven, Belgium; Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Matthias Stelljes
- Department of Medicine and Department of Hematology and Oncology, University of Münster, Münster, Germany
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Paty Lopez
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and Kings College London, London, UK; Anthony Nolan, London, UK
| | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Mohamad Mohty
- Department of Haematology, Hôpital Saint-Antoine, Universite Pierre and Marie Curie, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche, Paris, France
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Putta S, Young BA, Levine JE, Reshef R, Nakamura R, Strouse C, Perales MA, Howard A, Pine P, Shi J, Zhang P, Ho VT, Saber W. Prognostic Biomarkers for Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome in Myeloablative Allogeneic Hematopoietic Cell Transplantation: Results from the Blood and Marrow Transplant Clinical Trials Network 1202 Study. Transplant Cell Ther 2023; 29:166.e1-166.e10. [PMID: 36574581 PMCID: PMC10116945 DOI: 10.1016/j.jtct.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of hematopoietic cell transplantation (HCT). This study aimed to determine a blood biomarker signature early post-HCT that identifies patients at high risk for VOD/SOS. A set of 23 plasma biomarkers, selected from the VOD/SOS literature, was measured on days 0, 7, and 14 after myeloablative HCT using blood samples from patients enrolled in the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) Protocol 1202. Eligible cases were diagnosed with VOD/SOS in BMT CTN 1202 using the Baltimore criteria. Controls (without VOD/SOS) were matched to cases for conditioning regimen and age. Significant biomarkers were identified using the Bonferroni-adjusted Wilcoxon rank-sum test (P ≤ .002). Thirty-three patients with mild or severe VOD/SOS were identified (cases) and matched to 107 controls. Two, 8, and 5 biomarkers measured from the plasma of these patients were significantly associated with the development of VOD/SOS at days 0, 7, and 14, respectively, with the strongest associations on days 7 and 14. Biomarker associations were stronger for severe VOD/SOS risk and were stronger prognostic markers for VOD/SOS cases occurring within 28 days of HCT. Hyaluronan was most strongly associated with VOD/SOS risk, with an area under the receiver operating characteristic curve (AUC) of .81 on day 7 and .79 on day 14. Multivariate models of up to 5 biomarkers generated AUCs ranging from .82 to .85. All associations with VOD/SOS risk were independent of clinical risk factors. This study confirms previously identified biomarkers of VOD/SOS risk and identified novel prognostic biomarker signatures that identify patients at risk for VOD/SOS shortly after HCT. Multivariate analysis suggests that a combination of up to 5 of these protein biomarkers may provide a prognostic tool for identifying patients at risk for VOD/SOS.
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Affiliation(s)
| | | | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ran Reshef
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Christopher Strouse
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, Iowa
| | | | - Alan Howard
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Polly Pine
- Jazz Pharmaceuticals, Palo Alto, California
| | - Ju Shi
- Jazz Pharmaceuticals, Palo Alto, California
| | | | - Vincent T Ho
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin.
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Endothelial Dysfunction Syndromes after Allogeneic Stem Cell Transplantation. Cancers (Basel) 2023; 15:cancers15030680. [PMID: 36765638 PMCID: PMC9913851 DOI: 10.3390/cancers15030680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only therapy with a curative potential for a variety of malignant and non-malignant diseases. The major limitation of the procedure is the significant morbidity and mortality mainly associated with the development of graft versus host disease (GVHD) as well as with a series of complications related to endothelial injury, such as sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD), transplant-associated thrombotic microangiopathy (TA-TMA), etc. Endothelial cells (ECs) are key players in the maintenance of vascular homeostasis and during allo-HSCT are confronted by multiple challenges, such as the toxicity from conditioning, the administration of calcineurin inhibitors, the immunosuppression associated infections, and the donor alloreactivity against host tissues. The early diagnosis of endothelial dysfunction syndromes is of paramount importance for the development of effective prophylactic and therapeutic strategies. There is an urgent need for the better understanding of the pathogenetic mechanisms as well as for the identification of novel biomarkers for the early diagnosis of endothelial damage. This review summarizes the current knowledge on the biology of the endothelial dysfunction syndromes after allo-HSCT, along with the respective therapeutic approaches, and discusses the strengths and weaknesses of possible biomarkers of endothelial damage and dysfunction.
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A case of percutaneous transhepatic stomal varices embolization and partial splenic artery embolization for rectal cancer after CAPOX/BEV chemotherapy: the summary of the stomal varices related to oxaliplatin administration. Clin J Gastroenterol 2023; 16:54-62. [PMID: 36266604 PMCID: PMC9889487 DOI: 10.1007/s12328-022-01720-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/06/2022] [Indexed: 02/04/2023]
Abstract
Capecitabine and oxaliplatin (CAPOX) plus bevacizumab (BEV) therapy (CAPOX/BEV) is a standard treatment recommended as the first-line treatment for colorectal cancer recurrence. Recently, sinusoidal obstruction syndrome (SOS) and resulting portal hypertension have been reported as important side effects of oxaliplatin. We herein report a rectal cancer patient who underwent percutaneous transhepatic stoma variceal embolization (PTO) and partial splenic artery embolization (PSE) for stomal variceal bleeding and splenomegaly due to portal hypertension caused by SOS after CAPOX therapy. A 43-year-old man who underwent robot-assisted laparoscopic abdominoperineal resection for advanced lower rectal cancer was started on CAPOX/BEV therapy for early recurrence 1 month after surgery. In the sixth course, splenomegaly rapidly worsened, stomal varices appeared, and the stoma began bleeding. At 5 months after the appearance of stomal varices, the splenomegaly worsened, the frequency of stomal bleeding increased, and PTO was performed. Five months later, PSE was performed for splenomegaly and thrombocytopenia. At 5 months since the PSE, the stoma bleeding has not recurred, and the thrombocytopenia has been corrected. The patient has been able to continue chemotherapy. We suggest that staged treatment by PTO and PSE be considered an important treatment option for stomal varices and splenomegaly associated with SOS.
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Mohty M, Blaise D, Peffault de Latour R, Labopin M, Bourhis JH, Bruno B, Ceballos P, Detrait M, Gandemer V, Huynh A, Izadifar-Legrand F, Jubert C, Labussière-Wallet H, Lebon D, Maury S, Paillard C, Pochon C, Renard C, Rialland F, Schneider P, Sirvent A, Asubonteng K, Guindeuil G, Yakoub-Agha I, Dalle JH. Real-world use of defibrotide for veno-occlusive disease/sinusoidal obstruction syndrome: the DEFIFrance Registry Study. Bone Marrow Transplant 2022; 58:367-376. [PMID: 36564486 PMCID: PMC10073014 DOI: 10.1038/s41409-022-01900-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of haematopoietic cell transplantation (HCT) conditioning. The DEFIFrance post-marketing registry study evaluated effectiveness and safety in patients who received defibrotide. It collected retrospective/prospective patient data from 53 French HCT centres from July 2014 to March 2020. Primary endpoints were survival and complete response (CR; total serum bilirubin <2 mg/dL, multiorgan failure resolution) at Day 100 post-HCT among patients with severe/very severe VOD/SOS. A secondary endpoint was evaluation of treatment-emergent serious adverse events (TESAEs) of interest. Of 798 patients analysed, 251 and 81 received defibrotide treatment for severe/very severe VOD/SOS and mild/moderate VOD/SOS post-HCT, respectively; 381 received defibrotide for VOD/SOS prophylaxis. In patients with severe/very severe VOD/SOS post-HCT, Kaplan-Meier-estimated CR at Day 100 was 74% (95% confidence interval [CI]: 66%, 81%). At Day 100, 137/251 (55%) were alive and in CR. Kaplan-Meier-estimated Day 100 post-HCT survival was 61% (95% CI: 55%, 67%) in patients with severe/very severe VOD/SOS. TESAEs of interest occurred in 29% of these patients; VOD/SOS-related mortality at 12 months was 15%. DEFIFrance represents the largest collection of real-world data on post-registration defibrotide use, supporting the real-world utility of defibrotide for patients with severe/very severe VOD/SOS post-HCT.
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Affiliation(s)
- Mohamad Mohty
- Hôpital St Antoine, INSERM UMRs 938, Université Sorbonne, Paris, France.
| | - Didier Blaise
- Institut Paoli-Calmettes, Management Sport Cancer Laboratoire (MSC), Aix Marseille Université, Marseille, France
| | | | - Myriam Labopin
- Hôpital St Antoine, INSERM UMRs 938, Université Sorbonne, Paris, France
| | | | | | - Patrice Ceballos
- Département d'Hématologie, CHU de Montpellier, Montpellier, France
| | - Marie Detrait
- CHRU de Nancy, Service d'hématologie, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
| | | | - Anne Huynh
- Département d'Hématologie, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Faezeh Izadifar-Legrand
- Institut Paoli-Calmettes, Management Sport Cancer Laboratoire (MSC), Aix Marseille Université, Marseille, France
| | - Charlotte Jubert
- Département d'Hémato-oncologie Pédiatrique, CHU Bordeaux, Bordeaux, France
| | | | | | - Sébastien Maury
- Hôpital Henri Mondor, Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Catherine Paillard
- Département d'Hémato-oncologie Pédiatrique, CHU de Hautepierre, Strasbourg, France
| | - Cécile Pochon
- CHRU de Nancy, Service d'hématologie, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
| | - Cecile Renard
- Institut d'Hématologie et d'Oncologie Pédiatrique, Lyon, France
| | - Fanny Rialland
- CHU de Nantes, Hôpital Femme-Enfant-Adolescent, Nantes, France
| | - Pascale Schneider
- Département d'Hémato-oncologie Pédiatrique, CHU de Rouen, Rouen, France
| | - Anne Sirvent
- CHU de Montpellier, Hôpital A De Villeneuve, Montpellier, France
| | | | | | | | - Jean-Hugues Dalle
- Hôpital Robert-Debré, GHU APHP Nord et Université de Paris, Paris, France
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Corbacioglu S, Topaloglu O, Aggarwal S. A Systematic Review and Meta-Analysis of Studies of Defibrotide Prophylaxis for Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome. Clin Drug Investig 2022; 42:465-476. [PMID: 35594010 PMCID: PMC9188533 DOI: 10.1007/s40261-022-01140-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/30/2022]
Abstract
Background and Objectives Defibrotide is approved to treat severe veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) after haematopoietic cell transplantation in patients aged > 1 month in the European Union and for VOD/SOS with renal/pulmonary dysfunction post-haematopoietic cell transplantation in the United States. This meta-analysis estimated the incidence and risk of VOD/SOS after intravenous defibrotide prophylaxis using the published literature. Methods PubMed, Embase and Web of Science were searched through 30 November 2021 for defibrotide studies in VOD/SOS “prevention” or “prophylaxis,” excluding phase I studies, case reports, studies with fewer than ten patients and reviews. Results The search identified 733 records; 24 met inclusion criteria, of which 20 (N = 3005) evaluated intravenous defibrotide for VOD/SOS prophylaxis. Overall VOD/SOS incidence with intravenous defibrotide was 5%, with incidences of 5% in adults and 8% in paediatric patients. In eight studies with data on intravenous defibrotide prophylaxis vs controls (e.g. heparin, no prophylaxis), VOD/SOS incidence in controls was 16%. The risk ratio for developing VOD/SOS with defibrotide prophylaxis vs controls was 0.30 (95% confidence interval 0.12–0.71; p = 0.006). Conclusions This analysis suggests a low incidence of VOD/SOS following intravenous defibrotide prophylaxis, regardless of age group, and a lower relative risk for VOD/SOS with defibrotide prophylaxis vs controls in patient populations at high risk of VOD/SOS.
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Affiliation(s)
- Selim Corbacioglu
- Department of Haematology, Oncology, and Stem Cell Transplantation, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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Cai X, Zhang XH. [Advances in the diagnosis and management of sinusoidal obstruction syndrome after allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:1052-1056. [PMID: 35045684 PMCID: PMC8770882 DOI: 10.3760/cma.j.issn.0253-2727.2021.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Indexed: 11/24/2022]
Affiliation(s)
- X Cai
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - X H Zhang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
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Shi H, Gandhi AA, Smith SA, Wang Q, Chiang D, Yalavarthi S, Ali RA, Liu C, Sule G, Tsou PS, Zuo Y, Kanthi Y, Farkash EA, Lin JD, Morrissey JH, Knight JS. Endothelium-protective, histone-neutralizing properties of the polyanionic agent defibrotide. JCI Insight 2021; 6:e149149. [PMID: 34264868 PMCID: PMC8492316 DOI: 10.1172/jci.insight.149149] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/14/2021] [Indexed: 11/30/2022] Open
Abstract
Neutrophil-mediated activation and injury of the endothelium play roles in the pathogenesis of diverse disease states ranging from autoimmunity to cancer to COVID-19. Neutralization of cationic proteins (such as neutrophil extracellular trap–derived [NET-derived] histones) with polyanionic compounds has been suggested as a potential strategy for protecting the endothelium from such insults. Here, we report that the US Food and Drug Administration–approved polyanionic agent defibrotide (a pleiotropic mixture of oligonucleotides) directly engages histones and thereby blocks their pathological effects on endothelium. In vitro, defibrotide counteracted endothelial cell activation and pyroptosis-mediated cell death, whether triggered by purified NETs or recombinant histone H4. In vivo, defibrotide stabilized the endothelium and protected against histone-accelerated inferior vena cava thrombosis in mice. Mechanistically, defibrotide demonstrated direct and tight binding to histone H4 as detected by both electrophoretic mobility shift assay and surface plasmon resonance. Taken together, these data provide insights into the potential role of polyanionic compounds in protecting the endothelium from thromboinflammation with potential implications for myriad NET- and histone-accelerated disease states.
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Affiliation(s)
- Hui Shi
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Alex A Gandhi
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Stephanie A Smith
- Department of Biological Chemistry, University of Michigan, Ann Arbor, United States of America
| | - Qiuyu Wang
- Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, United States of America
| | - Diane Chiang
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Srilakshmi Yalavarthi
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Ramadan A Ali
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Chao Liu
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Gautam Sule
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Pei-Suen Tsou
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Yu Zuo
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Yogendra Kanthi
- Division of Intramural Research National Heart, Lung and Blood Institute, Bethesda, United States of America
| | - Evan A Farkash
- Department of Pathology, University of Michigan, Ann Arbor, United States of America
| | - Jiandie D Lin
- University of Michigan, Ann Arbor, United States of America
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan, Ann Arbor, United States of America
| | - Jason S Knight
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
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11
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Shi H, Gandhi AA, Smith SA, Wang Q, Chiang D, Yalavarthi S, Ali RA, Liu C, Sule G, Tsou PS, Zuo Y, Kanthi Y, Farkash EA, Lin JD, Morrissey JH, Knight JS. Endothelium-protective, histone-neutralizing properties of the polyanionic agent defibrotide. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 33655266 DOI: 10.1101/2021.02.21.21252160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Neutrophil-mediated activation and injury of the endothelium play a role in the pathogenesis of diverse disease states ranging from autoimmunity to cancer to COVID-19. Neutralization of cationic proteins (such as neutrophil extracellular trap/NET-derived histones) with polyanionic compounds has been suggested as a potential strategy for protecting the endothelium from such insults. Here, we report that the FDA-approved polyanionic agent defibrotide (a pleiotropic mixture of oligonucleotides) directly engages histones and thereby blocks their pathological effects on endothelium. In vitro , defibrotide counteracted endothelial cell activation and pyroptosis-mediated cell death, whether triggered by purified NETs or recombinant histone H4. In vivo , defibrotide stabilized the endothelium and protected against histone-accelerated inferior vena cava thrombosis in mice. Mechanistically, defibrotide demonstrated direct and tight binding to histone H4 as detected by both electrophoretic mobility shift assay and surface plasmon resonance. Taken together, these data provide insights into the potential role of polyanionic compounds in protecting the endothelium from thromboinflammation with potential implications for myriad NET- and histone-accelerated disease states.
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12
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A multicentre, multinational, prospective, observational registry study of defibrotide in patients diagnosed with veno-occlusive disease/sinusoidal obstruction syndrome after haematopoietic cell transplantation: an EBMT study. Bone Marrow Transplant 2021; 56:2454-2463. [PMID: 34059801 DOI: 10.1038/s41409-021-01265-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/12/2021] [Accepted: 03/01/2021] [Indexed: 11/09/2022]
Abstract
Severe hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of haematopoietic cell transplantation (HCT). This multinational, prospective, observational study (NCT03032016), performed by the EBMT, enrolled patients treated with defibrotide from April 2015 to July 2018. This analysis focused on defibrotide-treated patients with VOD/SOS post-HCT. The primary endpoint was incidence of serious adverse events (SAEs) of interest up to 12 months post-HCT in patients with severe VOD/SOS. Overall, 104 defibrotide-treated patients with VOD/SOS post-HCT were enrolled: 62 had severe VOD/SOS and comprised the primary study population, including 36 with multi-organ dysfunction/failure (MOD/MOF). SAEs of interest occurred in 20 of 62 (32%) severe VOD/SOS patients; the most common by category were infection (24%) and bleeding (13%). In patients with severe VOD/SOS, the Kaplan-Meier-estimated Day 100 survival rate was 73% (95% CI: 60%, 82%) with VOD/SOS resolution by Day 100 in 45 of 62 (73%) patients. MOD/MOF resolved in 19 of 36 (53%) patients with MOD/MOF at VOD/SOS diagnosis. Results from this multicentre registry study build on prior defibrotide studies supporting the utility of defibrotide for the treatment of VOD/SOS post-HCT. These results provide additional real-world evidence of the effectiveness and safety of defibrotide in patients with VOD/SOS post-HCT.
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13
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Tappe W, Aggarwal S, Topaloglu O, Iacobelli M. A Meta-Analysis Evaluating the Incidence of Bleeding Events With Intravenous Defibrotide Treatment Outside the Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome Setting. Clin Appl Thromb Hemost 2021; 26:1076029620935202. [PMID: 32687402 PMCID: PMC7372611 DOI: 10.1177/1076029620935202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Defibrotide is approved to treat hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) with renal/pulmonary dysfunction following hematopoietic cell transplantation (HCT) in adult and pediatric patients in the United States, and to treat severe hepatic VOD/SOS post-HCT in adult and pediatric patients aged >1 month in the European Union. The defibrotide prescribing information warns that defibrotide may increase bleeding risk in VOD/SOS patients. To broaden our understanding of the incidence of bleeding with defibrotide, we performed a meta-analysis of the published literature of defibrotide use outside of the post-HCT VOD/SOS setting. Of 1857 records identified, 125 reported on defibrotide; 23 contained data on bleeding events. The estimated overall incidence of bleeding events was 1% (95% confidence interval [CI]: 0%-2%) and 8% (95% CI: 3%-14%) in studies using intravenous defibrotide and studies with controls, respectively. The risk ratio for bleeding events with intravenous defibrotide versus controls was 0.36 (95% CI: 0.24-0.52; P < .00001) among studies with data on intravenous defibrotide and controls. This meta-analysis of defibrotide use outside of the post-HCT VOD/SOS setting suggests that the incidence of bleeding with defibrotide is lower than controls.
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14
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Calabretta E, Moraleda JM, Iacobelli M, Jara R, Vlodavsky I, O’Gorman P, Pagliuca A, Mo C, Baron RM, Aghemo A, Soiffer R, Fareed J, Carlo‐Stella C, Richardson P. COVID-19-induced endotheliitis: emerging evidence and possible therapeutic strategies. Br J Haematol 2021; 193:43-51. [PMID: 33538335 PMCID: PMC8014053 DOI: 10.1111/bjh.17240] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Eleonora Calabretta
- Department of Oncology and HematologyHumanitas Cancer CenterHumanitas Clinical and Research Center ‐ IRCCSRozzanoMilanItaly
- Department of Biomedical SciencesHumanitas UniversityRozzanoMilanItaly
| | - Jose M. Moraleda
- Department of HematologyStem Cell Transplant and Cell Therapy UnitVirgen de la Arrixaca University HospitalIMIB‐ArrixacaUniversity of MurciaMurciaSpain
| | | | - Ruben Jara
- Department of Critical Care MedicineVirgen de la Arrixaca University HospitalIMIB‐ArrixacaUniversity of MurciaMurciaSpain
| | - Israel Vlodavsky
- The Rappaport Faculty of MedicineTechnion Integrated Cancer Center (TICC)HaifaIsrael
| | - Peter O’Gorman
- Haematology DepartmentMater Misericordiae University HospitalDublinIreland
| | - Antonio Pagliuca
- Department of HaematologyKings College Hospital NHS Foundation TrustLondonUK
| | - Clifton Mo
- Department of Medical OncologyDivision of Hematologic MalignanciesDana‐Farber Cancer InstituteHarvard Medical SchoolBostonMAUSA
| | - Rebecca M. Baron
- Division of Pulmonary and Critical Care MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Alessio Aghemo
- Division of Hepatology and Internal MedicineHumanitas Clinical and Research Center ‐ IRCCSMilanItaly
- Department of Biomedical SciencesHumanitas UniversityRozzanoMilanItaly
| | - Robert Soiffer
- Department of Medical OncologyDivision of Hematologic MalignanciesDana‐Farber Cancer InstituteHarvard Medical SchoolBostonMAUSA
| | | | - Carmelo Carlo‐Stella
- Department of Oncology and HematologyHumanitas Cancer CenterHumanitas Clinical and Research Center ‐ IRCCSRozzanoMilanItaly
- Department of Biomedical SciencesHumanitas UniversityRozzanoMilanItaly
| | - Paul Richardson
- Department of Medical OncologyDivision of Hematologic MalignanciesDana‐Farber Cancer InstituteHarvard Medical SchoolBostonMAUSA
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15
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Abstract
Antiphospholipid syndrome (APS) is a thromboinflammatory disease with a variety of clinical phenotypes. Primary thrombosis prophylaxis should take an individualized risk stratification approach. Moderate-intensity vitamin K antagonist such as warfarin remains the primary strategy for secondary thrombosis prophylaxis among APS patients, especially for patients with predominantly venous disease. For now, direct oral anti-coagulants should be avoided in most APS patients, especially those with history of arterial manifestations. Obstetric APS management should be tailored based on an individual patient's antiphospholipid antibody profile, and obstetric and thrombotic history. Pharmacological agents beyond anticoagulants may be considered for the management of microthrombotic and nonthrombotic manifestations of APS, although more data are needed. A relatively recent discovery in the area of APS pathogenesis is the implication of neutrophil extracellular traps in thrombin generation and initiation of inflammatory cascades. APS is a complex thromboinflammatory disease with a broad clinical spectrum. Personalized therapy according to an individual's unique thrombosis and obstetric risk should be advocated.
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16
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Lang P, Eichholz T, Bakchoul T, Streiter M, Petrasch M, Bösmüller H, Klein R, Rabsteyn A, Lang AM, Adams C, Klingel K, Gessner M, Rosenberger P, Ruef P, Handgretinger R. Defibrotide for the Treatment of Pediatric Inflammatory Multisystem Syndrome Temporally Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection in 2 Pediatric Patients. J Pediatric Infect Dis Soc 2020; 9:622-625. [PMID: 32951037 PMCID: PMC7543556 DOI: 10.1093/jpids/piaa117] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/16/2020] [Indexed: 01/04/2023]
Abstract
The pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 infection is a severe complication of coronavirus disease 2019. Since impaired coagulation and thrombosis/endotheliitis are suspected pathomechanisms, we treated 2 patients with defibrotide, a profibrinolytic, antithrombotic, antiinflammatory oligonucleotide. Symptoms resolved during treatment. Moreover, coagulation parameters indicating hypofibrinolysis and complement activation normalized. The pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 infection is a severe complication of coronavirus disease 2019. Since impaired coagulation and thrombosis/endotheliitis are suspected pathomechanisms, 2 patients received defibrotide, a profibrinolytic, antithrombotic, antiinflammatory oligonucleotide. Symptoms resolved and hypofibrinolysis/complement activation normalized during treatment.
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Affiliation(s)
- Peter Lang
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Thomas Eichholz
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Institute of Transfusion Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Monika Streiter
- Children’s Hospital, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Maurice Petrasch
- Children’s Hospital, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Hans Bösmüller
- Institute of Pathology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Reinhild Klein
- Department of Haematology/Oncology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Armin Rabsteyn
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Anne-Marie Lang
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Constantin Adams
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Karin Klingel
- Institute of Pathology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Michaela Gessner
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Peter Rosenberger
- University Hospital for Intensive Care and Anaesthesiology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Peter Ruef
- Children’s Hospital, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Rupert Handgretinger
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany,Correspondence: Rupert Handgretinger, Children’s University Hospital Tuebingen, Hoppe-Seyler Str. 1, 72076 Tuebingen, Germany ()
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17
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Analysis of Time to Complete Response after Defibrotide Initiation in Patients with Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome after Hematopoietic Cell Transplantation. Transplant Cell Ther 2020; 27:88.e1-88.e6. [PMID: 32950693 PMCID: PMC8549529 DOI: 10.1016/j.bbmt.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 11/21/2022]
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication that occurs after hematopoietic cell transplantation (HCT). The mortality associated with untreated VOD/SOS with multiorgan dysfunction (MOD) has been reported to be >80%. The recommended dose of defibrotide is 6.25 mg/kg every 6 hours, administered as a 2-hour i.v. infusion, for a minimum of 21 days or until resolution of VOD/SOS signs and symptoms. The objective of this analysis was to evaluate the time to complete response (CR) in patients with post-HCT VOD/SOS treated with defibrotide. The time to defibrotide discontinuation due to a CR served as a surrogate for time to CR in an expanded access study (T-IND; ClinicalTrials.govNCT00628498; n = 1000), and was analyzed separately from the time to CR data pooled from a phase 2 randomized dose-finding study (NCT00003966; n = 74 patients who received 25 mg/kg/day) and a phase 3 historically controlled study (NCT00358501; n = 102). For all studies, a CR was defined as total serum bilirubin <2 mg/dL with resolution of VOD/SOS-related MOD (renal and/or pulmonary dysfunction); the phase 2 study also required resolution of central nervous system dysfunction. In the T-IND, 390 patients discontinued treatment due to a CR and had sufficient data for analysis. The median time to discontinuation was 22 days (range, 2 to 64 days). Discontinuation due to CR occurred beyond 21 days in 235 patients (60%) and beyond 28 days in 57 patients (15%). The pooled phase 2 and 3 studies included 60 patients who achieved a CR, with a median time to CR of 24.5 days (range, 7 to 123 days). A CR was achieved beyond 21 days in 32 patients (53%) and beyond 28 days in 24 patients (40%). The Kaplan-Meier estimate of day +100 survival rate was substantially higher in patients who discontinued due to a CR compared with those who did not (92.5% versus 37.3%). Treatment-emergent adverse events occurred in 185 of 390 patients (47%) who discontinued due to a CR in the T-IND and in 55 of 60 patients (92%) who achieved a CR in the pooled phase 2 and 3 studies, and rates did not differ according to duration of treatment (≤21 days versus >21 days). Taken together, these results highlight the importance of continued defibrotide therapy until resolution of VOD/SOS signs and symptoms, as currently indicated in the approved product labels, which may occur beyond the recommended minimum of 21 days.
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18
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Inoue Y, Kosugi S, Sano F. Improvement of High Serum Levels of Biomarkers of Endothelial Injury (Vascular Cell Adhesion Molecule-1) and Inflammation (Tumor Necrosis Factor Receptor Type I) After Allogeneic Hematopoietic Stem Cell Transplantation With Sinusoidal Obstruction Syndrome Using Defibrotide. Am J Ther 2020; 28:e691-e693. [PMID: 32897904 DOI: 10.1097/mjt.0000000000001253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Yasuyuki Inoue
- Division of Hematology, Department of Internal Medicine, St. Marianna University Yokohama-City Seibu Hospital, Yokohama, Japan
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19
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Hildebrandt GC, Chao N. Endothelial cell function and endothelial-related disorders following haematopoietic cell transplantation. Br J Haematol 2020; 190:508-519. [PMID: 32319084 PMCID: PMC7496350 DOI: 10.1111/bjh.16621] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/09/2020] [Indexed: 12/16/2022]
Abstract
Use of haematopoietic cell transplantation (HCT) in the treatment of haematologic and neoplastic diseases may lead to life-threatening complications that cause substantial morbidity and mortality if untreated. In addition to patient- and disease-related factors, toxicity associated with HCT puts patients at risk for complications that share a similar pathophysiology involving endothelial cells (ECs). Normally, the endothelium plays a role in maintaining homeostasis, including regulation of coagulation, vascular tone, permeability and inflammatory processes. When activated, ECs acquire cellular features that may lead to phenotypic changes that induce procoagulant, pro-inflammatory and pro-apoptotic mediators leading to EC dysfunction and damage. Elevated levels of coagulation factors, cytokines and adhesion molecules are indicative of endothelial dysfunction, and endothelial damage may lead to clinical signs and symptoms of pathological post-HCT conditions, including veno-occlusive disease/sinusoidal obstruction syndrome, graft-versus-host disease, transplant-associated thrombotic microangiopathy and idiopathic pneumonia syndrome/diffuse alveolar haemorrhage. The endothelium represents a rational target for preventing and treating HCT complications arising from EC dysfunction and damage. Additionally, markers of endothelial damage may be useful in improving diagnosis of HCT-related complications and monitoring treatment effect. Continued research to effectively manage EC activation, injury and dysfunction may be important in improving patient outcomes after HCT.
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Affiliation(s)
| | - Nelson Chao
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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20
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Incidence of Anicteric Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome and Outcomes with Defibrotide following Hematopoietic Cell Transplantation in Adult and Pediatric Patients. Biol Blood Marrow Transplant 2020; 26:1342-1349. [PMID: 32200121 PMCID: PMC8407521 DOI: 10.1016/j.bbmt.2020.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 12/31/2022]
Abstract
Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of hematopoietic cell transplantation (HCT) that is traditionally diagnosed using Baltimore or modified Seattle criteria. Whereas the Baltimore criteria require the presence of hyperbilirubinemia (bilirubin ≥2 mg/dL) for a diagnosis of VOD/SOS, the modified Seattle criteria do not. Before approval by the US Food and Drug Administration, defibrotide was available in the United States through an expanded-access study (T-IND). The T-IND protocol initially required post-HCT diagnosis of VOD/SOS by the Baltimore criteria or biopsy but was later amended to include patients diagnosed using the modified Seattle criteria. This post hoc analysis examined the incidence of VOD/SOS with a bilirubin level <2 mg/dL before and after Day 21 post-HCT in T-IND patients enrolled following the amendment allowing for diagnosis by the modified Seattle criteria. Survival of adult and pediatric patients with or without hyperbilirubinemia and with or without multiorgan dysfunction (MOD) was also evaluated. Of 803 post-HCT patients with VOD/SOS enrolled following the protocol amendment, 181 (23%) had a bilirubin level <2 mg/dL and would not have been diagnosed if hyperbilirubinemia was required. The bilirubin level at diagnosis was <2 mg/dL in 165 of 331 patients (50%) diagnosed by the modified Seattle criteria and in 16 of 23 patients (70%) diagnosed by biopsy. VOD/SOS with a bilirubin level <2 mg/dL was more common in pediatric patients (29%), although it also occurred in adult patients (15%). Patients with hyperbilirubinemia had lower Day 100 survival (54% versus 87% in patients with bilirubin <2 mg/dL) and a higher incidence of MOD (41% versus 26% in patients with bilirubin <2 mg/dL). The incidence of treatment-emergent adverse events and serious adverse events was lower in patients with a bilirubin level <2 mg/dL. These results indicate that anicteric VOD/SOS occurs in both adult and pediatric patients post-HCT and can be diagnosed before and after Day 21 in both groups. The worse survival in patients with bilirubin ≥2 mg/dL suggests that requiring hyperbilirubinemia may result in a progressed disease stage associated with worse outcomes. Taken together, these results highlight the importance of awareness and the possibility of VOD/SOS in the absence of elevated bilirubin level.
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21
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Cairo MS, Cooke KR, Lazarus HM, Chao N. Modified diagnostic criteria, grading classification and newly elucidated pathophysiology of hepatic SOS/VOD after haematopoietic cell transplantation. Br J Haematol 2020; 190:822-836. [PMID: 32133623 DOI: 10.1111/bjh.16557] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sinusoidal obstruction syndrome (SOS), previously known as hepatic veno-occlusive disease (VOD), remains a multi-organ system complication following haematopoietic cell transplantation (HCT). When SOS/VOD is accompanied by multi-organ dysfunction, overall mortality rates remain >80%. However, the definitions related to the diagnosis and grading of SOS/VOD after HCT are almost 25 years old and require new and contemporary modifications. Importantly, the pathophysiology of SOS/VOD, including the contribution of dysregulated inflammatory and coagulation cascades as well as the critical importance of liver and vascular derived endothelial dysfunction, have been elucidated. Here we summarise new information on pathogenesis of SOS/VOD; identify modifiable and unmodifiable risk factors for disease development; propose novel, contemporary and panel opinion-based diagnostic criteria and an innovative organ-based method of SOS/VOD grading classification; and review current approaches for prophylaxis and treatment of SOS/VOD. This review will hopefully illuminate pathways responsible for drug-induced liver injury and manifestations of disease, sharpen awareness of risk for disease development and enhance the timely and correct diagnosis of SOS/VOD post-HCT.
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Affiliation(s)
- Mitchell S Cairo
- Departments of, Department of, Pediatrics, New York Medical College, Valhalla, NY, USA.,Department of, Medicine, New York Medical College, Valhalla, NY, USA.,Department of, Pathology, New York Medical College, Valhalla, NY, USA.,Department of, Microbiology and Immunology, New York Medical College, Valhalla, NY, USA.,Department of, Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA
| | - Kenneth R Cooke
- Department of Oncology, the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Hillard M Lazarus
- Department of Medicine, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nelson Chao
- Departments of, Department of, Medicine, Duke University, Durham, NC, USA.,Department of, Immunology, Duke University, Durham, NC, USA.,Department of, Pathology, Duke University, Durham, NC, USA
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22
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Prophylactic, preemptive, and curative treatment for sinusoidal obstruction syndrome/veno-occlusive disease in adult patients: a position statement from an international expert group. Bone Marrow Transplant 2019; 55:485-495. [PMID: 31576023 PMCID: PMC7051913 DOI: 10.1038/s41409-019-0705-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Abstract
Sinusoidal obstruction syndrome, also known as veno-occlusive disease (SOS/VOD), is a potentially life-threatening complication that can develop after hematopoietic cell transplantation (HCT). While SOS/VOD may resolve within a few weeks in the majority of patients with mild-to-moderate disease, the most severe forms result in multiorgan dysfunction and are associated with a high mortality rate (>80%). Therefore, careful surveillance may allow early detection of SOS/VOD, particularly as the licensed available drug is proven to be effective and reduce mortality. The aim of this work is to propose an international consensus guideline for the treatment and prevention of SOS/VOD in adult patients, on behalf of an international expert group.
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23
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Shahryari A, Saghaeian Jazi M, Mohammadi S, Razavi Nikoo H, Nazari Z, Hosseini ES, Burtscher I, Mowla SJ, Lickert H. Development and Clinical Translation of Approved Gene Therapy Products for Genetic Disorders. Front Genet 2019; 10:868. [PMID: 31608113 PMCID: PMC6773888 DOI: 10.3389/fgene.2019.00868] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
The field of gene therapy is striving more than ever to define a path to the clinic and the market. Twenty gene therapy products have already been approved and over two thousand human gene therapy clinical trials have been reported worldwide. These advances raise great hope to treat devastating rare and inherited diseases as well as incurable illnesses. Understanding of the precise pathomechanisms of diseases as well as the development of efficient and specific gene targeting and delivery tools are revolutionizing the global market. Currently, human cancers and monogenic disorders are indications number one. The elevated prevalence of genetic disorders and cancers, clear gene manipulation guidelines and increasing financial support for gene therapy in clinical trials are major trends. Gene therapy is presently starting to become commercially profitable as a number of gene and cell-based gene therapy products have entered the market and the clinic. This article reviews the history and development of twenty approved human gene and cell-based gene therapy products that have been approved up-to-now in clinic and markets of mainly North America, Europe and Asia.
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Affiliation(s)
- Alireza Shahryari
- Institute of Diabetes and Regeneration Research, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Stem Cell Research, Helmholtz Zentrum München, Neuherberg, Germany
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran
- Department of Molecular Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Marie Saghaeian Jazi
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran
- Metabolic Disorders Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Saeed Mohammadi
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Hadi Razavi Nikoo
- Infectious Disease Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Zahra Nazari
- Department of Biology, School of Basic Sciences, Golestan University, Gorgan, Iran
| | - Elaheh Sadat Hosseini
- Department of Nanobiotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Ingo Burtscher
- Institute of Diabetes and Regeneration Research, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Stem Cell Research, Helmholtz Zentrum München, Neuherberg, Germany
| | - Seyed Javad Mowla
- Department of Molecular Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Heiko Lickert
- Institute of Diabetes and Regeneration Research, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Stem Cell Research, Helmholtz Zentrum München, Neuherberg, Germany
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Duncan C, Kahn J, Grupp SA, Richardson PG. Recent developments with defibrotide for the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1651641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Christine Duncan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Justine Kahn
- Columbia University Irving Medical Center, New York, NY, USA
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The use of defibrotide in blood and marrow transplantation. Blood Adv 2019; 2:1495-1509. [PMID: 29945939 DOI: 10.1182/bloodadvances.2017008375] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 04/30/2018] [Indexed: 12/18/2022] Open
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of conditioning during hematopoietic stem cell transplantation (HSCT) or chemotherapy without HSCT, with a historically reported mean incidence of 13.7% post-HSCT. Typical symptoms of VOD/SOS may include hyperbilirubinemia, painful hepatomegaly, weight gain, and ascites. Defibrotide, a polydisperse mixture of predominantly single-stranded polydeoxyribonucleotides, is currently the only therapy approved to treat hepatic VOD/SOS with pulmonary/renal dysfunction (ie, multiorgan dysfunction/multiorgan failure [MOD/MOF]) following HSCT in the United States and to treat severe hepatic VOD/SOS post-HSCT in the European Union. In preclinical and human studies, defibrotide has demonstrated profibrinolytic, antithrombotic, anti-inflammatory, and angio-protective actions, thus promoting an anticoagulant phenotype of the endothelium that protects and stabilizes the function of endothelial cells. In a phase 3, historically controlled, multicenter trial in adults and children with VOD/SOS and MOD/MOF (defibrotide: n = 102; controls treated before defibrotide availability: n = 32), defibrotide resulted in significantly greater day +100 survival following HSCT (38.2%) vs controls (25.0%; propensity analysis-estimated between-group difference: 23%; P = .0109). The most common adverse events (AEs) were hypotension and diarrhea; rates of common hemorrhagic AEs were similar in the defibrotide and historical control group (64% and 75%, respectively). In a phase 3 prophylaxis trial, defibrotide was found to lower incidence of VOD/SOS in children (not an approved indication) and reduce the incidence of graft-versus-host disease. This review describes the development and clinical applications of defibrotide, focusing on its on-label use in patients with VOD/SOS and MOD/MOF after HSCT.
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Nathan S, Ustun C. Complications of Stem Cell Transplantation that Affect Infections in Stem Cell Transplant Recipients, with Analogies to Patients with Hematologic Malignancies. Infect Dis Clin North Am 2019; 33:331-359. [PMID: 30940464 DOI: 10.1016/j.idc.2019.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article discusses the complications of hematopoietic stem cell transplantion (HSCT) that affect infections in HSCT recipients, with analogies to patients with hematologic malignancies. Mucositis, with mucosal barrier disruption, is common and increases the risk of gram-positive and anaerobic bacterial, and fungal infections, and can evolve to typhlitis. Engraftment syndrome; graft-versus-host disease, hepatic sinusoidal obstruction syndrome; and posterior reversible encephalopathy syndrome can affect the infectious potential either directly from organ dysfunction or indirectly from specific treatment. Pulmonary infections can predispose to life threatening complications including diffuse alveolar hemorrhage, idiopathic pulmonary syndrome, bronchiolitis obliterans syndrome, and bronchiolitis obliterans with organizing pneumonia.
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Affiliation(s)
- Sunita Nathan
- Section of Bone Marrow Transplant and Cellular Therapy, Division of Hematology, Oncology and Cell Therapy, Rush University Medical Center, 1725 West Harrison Street, Suite 809, Chicago, IL 60612, USA
| | - Celalettin Ustun
- Section of Bone Marrow Transplant and Cellular Therapy, Division of Hematology, Oncology and Cell Therapy, Rush University Medical Center, 1725 West Harrison Street, Suite 809, Chicago, IL 60612, USA.
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Ní Chonghaile M, Wolownik K. Identification and Management: Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease Eelated to Hematopoietic Stem Cell Transplantation
. Clin J Oncol Nurs 2019; 22:E7-E17. [PMID: 29350698 DOI: 10.1188/18.cjon.e7-e17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sinusoidal obstruction syndrome (SOS), also called hepatic veno-occlusive disease (VOD), is a potentially life-threatening complication of hematopoietic stem cell transplantation (HSCT) that affects about 1 in 7 patients undergoing this procedure. SOS/VOD is caused by the conditioning regimens administered prior to HSCT; in some cases, SOS/VOD results from chemotherapy alone. SOS/VOD usually develops within three weeks following HSCT; however, it can have later onset.
. OBJECTIVES Clearly understanding how SOS/VOD develops may support prompt detection and treatment when the condition arises.
. METHODS Research on identification and management of SOS/VOD is summarized, and data from clinical trials are reviewed.
. FINDINGS This article describes the syndrome, risk factors, signs and symptoms, and appropriate supportive care and treatment. The authors also offer some practical tips for detecting SOS/VOD and providing patient care, as well as the latest information on treating and preventing this condition.
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Kernan NA, Richardson PG, Smith AR, Triplett BM, Antin JH, Lehmann L, Messinger Y, Liang W, Hume R, Tappe W, Soiffer RJ, Grupp SA. Defibrotide for the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome following nontransplant-associated chemotherapy: Final results from a post hoc analysis of data from an expanded-access program. Pediatr Blood Cancer 2018; 65:e27269. [PMID: 29873895 PMCID: PMC6685707 DOI: 10.1002/pbc.27269] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/18/2018] [Accepted: 05/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially fatal complication of conditioning for hematopoietic stem cell transplantation (HSCT) but can occur after nontransplant-associated chemotherapy. Following HSCT, VOD/SOS with multi-organ dysfunction (MOD) may be associated with >80% mortality. Defibrotide is approved to treat severe hepatic VOD/SOS post-HSCT in patients aged >1 month in the European Union and hepatic VOD/SOS with renal or pulmonary dysfunction post-HSCT in the United States. Prior to US approval, defibrotide was available to treat VOD/SOS through an expanded-access treatment (T-IND) program. A post hoc analysis of nontransplant-associated VOD/SOS patients treated with defibrotide initiated within 30 days of starting chemotherapy and followed for 70 days is presented. PROCEDURE Patients were diagnosed by Baltimore or modified Seattle criteria or biopsy, and received defibrotide 25 mg/kg/day in four divided doses (≥21 days recommended). RESULTS Of the 1,154 patients in the T-IND, 137 had nontransplant-associated VOD/SOS, 82 of whom developed VOD/SOS within 30 days of starting chemotherapy. Of them, 66 (80.5%) were aged ≤16 years. Across all the 82 patients, Kaplan-Meier estimated day +70 survival was 74.1%, 65.8% in patients with MOD (n = 38), and 81.3% in patients without MOD (n = 44). By age group, Kaplan-Meier estimated day +70 survival was 80.1% in pediatric patients (n = 66) and 50.0% in adults (n = 16). Treatment-related adverse events occurred in 26.8%. CONCLUSIONS In this post hoc analysis of 82 patients initiating defibrotide within 30 days of starting chemotherapy, Kaplan-Meier estimated survival was 74.1% at 70 days after defibrotide initiation. Safety profile was consistent with prior defibrotide studies.
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Affiliation(s)
- Nancy A. Kernan
- Pediatric BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul G. Richardson
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Angela R. Smith
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Brandon M. Triplett
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Joseph H. Antin
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Leslie Lehmann
- Center for Stem Cell Transplantation, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Yoav Messinger
- Cancer and Blood Disorders Program, Children’s Minnesota, MN, USA
| | - Wei Liang
- formerly of Jazz Pharmaceuticals, Palo Alto, CA, USA
| | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | - Robert J. Soiffer
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stephan A. Grupp
- Pediatric Oncology, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Kernan NA, Grupp S, Smith AR, Arai S, Triplett B, Antin JH, Lehmann L, Shore T, Ho VT, Bunin N, Iacobelli M, Liang W, Hume R, Tappe W, Soiffer R, Richardson P. Final results from a defibrotide treatment-IND study for patients with hepatic veno-occlusive disease/sinusoidal obstruction syndrome. Br J Haematol 2018; 181:816-827. [PMID: 29767845 PMCID: PMC6032999 DOI: 10.1111/bjh.15267] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/19/2018] [Indexed: 12/17/2022]
Abstract
Hepatic veno‐occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life‐threatening complication of haematopoietic stem cell transplant (HSCT) conditioning and chemotherapy. Defibrotide is approved for treatment of hepatic VOD/SOS with pulmonary or renal dysfunction [i.e., multi‐organ dysfunction (MOD)] after HSCT in the United States and severe VOD/SOS after HSCT in patients aged older than 1 month in the European Union. Defibrotide was available as an investigational drug by an expanded‐access treatment programme (T‐IND; NCT00628498). In the completed T‐IND, the Kaplan–Meier estimated Day +100 survival for 1000 patients with documented defibrotide treatment after HSCT was 58·9% [95% confidence interval (CI), 55·7–61·9%]. Day +100 survival was also analysed by age and MOD status, and post hoc analyses were performed to determine Day +100 survival by transplant type, timing of VOD/SOS onset (≤21 or >21 days) and timing of defibrotide treatment initiation after VOD/SOS diagnosis. Day +100 survival in paediatric patients was 67·9% (95% CI, 63·8–71·6%) and 47·1% (95% CI, 42·3–51·8%) in adults. All patient subgroups without MOD had higher Day +100 survival than those with MOD; earlier defibrotide initiation was also associated with higher Day +100 survival. The safety profile of defibrotide in the completed T‐IND study was similar to previous reports.
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Affiliation(s)
- Nancy A Kernan
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Stephan Grupp
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Sally Arai
- Stanford University Medical Center, Stanford, CA, USA
| | | | - Joseph H Antin
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Leslie Lehmann
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Vincent T Ho
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nancy Bunin
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Wei Liang
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | - Robert Soiffer
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Paul Richardson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Raina R, Abusin GA, Vijayaraghavan P, Auletta JJ, Cabral L, Hashem H, Vogt BA, Cooke KR, Abu-Arja RF. The role of continuous renal replacement therapy in the management of acute kidney injury associated with sinusoidal obstruction syndrome following hematopoietic cell transplantation. Pediatr Transplant 2018; 22. [PMID: 29388370 DOI: 10.1111/petr.13139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 11/28/2022]
Abstract
Maintaining fluid balance, pre- and post-MA-HCT is essential and usually requires frequent administration of diuretics. Hepatic sinusoidal obstructive syndrome is potentially life-threatening, especially when associated with AKI and MOF. This study describes six patients who developed AKI-associated SOS and diuretic-resistant FO who subsequently underwent CRRT using standardized management guidelines for fluid balance post-HCT. Retrospective chart review was done for HCT patients between September 2011 and October 2013 at a tertiary care children's hospital. Thirty-four patients underwent MA-HCT in the study period. Six patients had SOS complicated by diuretic-resistant FO and underwent CRRT. Defibrotide was used in three patients. Median time on CRRT was 10.5 days. Sixty-six percent (N = 4 of 6) of patients had full resolution of SOS symptoms with a mortality rate of 34% (N = 2 of 6). Among patients who had full recovery of SOS symptoms, one patient developed AKI, end-stage renal diseases and underwent kidney transplantation 34-months post-HCT. Thus, of six included patients, two died and one developed ESRD with only 50% (N = 3 of 6) good outcome. Use of a standardized, evidence-based fluid balance protocol and early initiation of CRRT for HCT-related AKI/SOS was associated with good outcomes.
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Affiliation(s)
- Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Ghada A Abusin
- Pediatric Bone Marrow Transplant, University of Michigan, Ann Arbor, MI, USA
| | | | - Jeffery J Auletta
- Pediatric Blood and Marrow Transplant Program, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | - Linda Cabral
- Pediatric Blood and Marrow Transplant Program, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Hasan Hashem
- Pediatric Blood and Marrow Transplant Program, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | - Beth A Vogt
- Pediatric Nephrology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Kenneth R Cooke
- Department of Oncology, Pediatric Blood and Marrow Transplantation Program, The Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Rolla F Abu-Arja
- Pediatric Blood and Marrow Transplant Program, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
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Richardson PG, Triplett BM, Ho VT, Chao N, Dignan FL, Maglio M, Mohty M. Defibrotide sodium for the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome. Expert Rev Clin Pharmacol 2018; 11:113-124. [PMID: 29301447 DOI: 10.1080/17512433.2018.1421943] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is an unpredictable condition associated with endothelial-cell damage due to conditioning for hematopoietic stem-cell transplantation (HSCT) or chemotherapy without HSCT. Mortality in patients with VOD/SOS and multi-organ dysfunction (MOD) may be >80%. Areas covered: Defibrotide is the only approved drug for the treatment of severe hepatic VOD/SOS after HSCT in the European Union and hepatic VOD/SOS with renal or pulmonary dysfunction in the United States. Its efficacy in patients with VOD/SOS with MOD post-HSCT was demonstrated in a clinical-trial program that included a historically controlled treatment study, a phase 2 trial, and a large T-IND expanded-access program that also included patients without MOD and who received chemotherapy without HSCT. Expert commentary: Defibrotide appears to protect endothelial cells and restore the thrombolytic-fibrinolytic balance. It addresses a significant clinical need and has demonstrated favorable Day +100 survival and overall adverse-event rates that seem similar to control groups receiving supportive care alone. Currently, defibrotide is under investigation for the prevention of VOD/SOS in high-risk pediatric and adult patients.
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Affiliation(s)
- Paul G Richardson
- a Hematologic Oncology , Harvard Medical School, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute , Boston , MA , USA.,b Hematopoietic Stem Cell Transplantation Program , Dana-Farber Cancer Institute , Boston , MA , USA
| | - Brandon M Triplett
- c Bone Marrow Transplantation and Cellular Therapy , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Vincent T Ho
- b Hematopoietic Stem Cell Transplantation Program , Dana-Farber Cancer Institute , Boston , MA , USA
| | - Nelson Chao
- d Division of Hematologic Malignancies and Cellular Therapy , Duke Cancer Institute, Duke University , Durham , NC , USA
| | - Fiona L Dignan
- e Department of Clinical Haematology , Central Manchester NHS Foundation Trust , Manchester , UK
| | - Michelle Maglio
- a Hematologic Oncology , Harvard Medical School, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute , Boston , MA , USA
| | - Mohamad Mohty
- f Hematology Department , Hôpital Saint Antoine, AP-HP, Université Pierre & Marie Curie , Paris , France
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Richardson PG, Grupp SA, Pagliuca A, Krishnan A, Ho VT, Corbacioglu S. Defibrotide for the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome with multiorgan failure. Int J Hematol Oncol 2017; 6:75-93. [PMID: 30302228 PMCID: PMC6171967 DOI: 10.2217/ijh-2017-0015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/30/2017] [Indexed: 12/12/2022] Open
Abstract
Hepatic veno-occlusive disease, also called sinusoidal obstruction syndrome (VOD/SOS), is a potentially life-threatening and unpredictable complication of hematopoietic stem cell transplantation (HSCT). Characterized by a prothrombotic-hypofibrinolytic state, VOD/SOS typically presents with hyperbilirubinemia, ascites, weight gain and painful hepatomegaly; VOD/SOS with multiorgan failure may be associated with >80% mortality. Treatment has been mainly supportive. However, defibrotide is now approved in the USA for treatment of hepatic VOD/SOS with renal or pulmonary dysfunction following HSCT and in the European Union for treatment of severe hepatic VOD/SOS post-HSCT. In vitro evidence suggests defibrotide may restore thrombotic-fibrinolytic balance at the endothelial level and protect endothelial cells. Defibrotide has demonstrated significant reduction in VOD/SOS-related mortality and resolved VOD/SOS-related symptoms, with a manageable safety profile.
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Affiliation(s)
- Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Stephan A Grupp
- Pediatric Oncology, The Children's Hospital of Philadelphia & the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital, London, UK
| | - Amrita Krishnan
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Vincent T Ho
- Hematopoietic Stem Cell Transplantation, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology & Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
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Defibrotide for the treatment of sinusoidal obstruction syndrome: evaluation of response to therapy and patient outcomes. Support Care Cancer 2017; 26:947-955. [PMID: 29022099 DOI: 10.1007/s00520-017-3915-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 10/02/2017] [Indexed: 01/22/2023]
Abstract
PURPOSE Defibrotide is an agent used to treat sinusoidal obstruction syndrome (SOS/VOD) in patients undergoing haemopoietic stem cell transplantation. The aim of this study was to evaluate the effectiveness of defibrotide used within institutional guidelines for the treatment of SOS/VOD in patients undergoing haemopoietic stem cell transplantation (HSCT). METHODS Data for 23 patients was retrospectively reviewed to evaluate the effectiveness of defibrotide and the utility of response criteria to direct therapy as specified within institution guidelines. Patients met institutional criteria for a diagnosis of SOS/VOD based on predominantly Baltimore criteria and received defibrotide. Stabilisation or improvement in symptoms and biochemical markers was required for continuation of therapy with defibrotide. RESULTS Overall, 14 patients responded to therapy. Survival at day 100 post HSCT was 70%. Median serum (total) bilirubin concentrations in all evaluable patients had decreased at days 5 and 10 (p < 0.001). There was a proportional reduction in median weight of 4% by day 5 and 6.6% by day 10 (p < 0.001). On cessation of defibrotide, there was a decrease in the proportion of patients exhibiting hepatomegaly (p = 0.02), ascites (p < 0.01) and requiring oxygen supplementation (p < 0.01), with 70% survival at day 100 post HSCT. CONCLUSION Defibrotide to treat SOS/VOD and continued based on attainment of early response was effective management of this condition. Defibrotide should be considered in any consensus protocol providing guidance on the management of SOS/VOD, with future studies considered to assess appropriate time points for response to therapy during treatment.
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Corbacioglu S, Richardson PG. Defibrotide for children and adults with hepatic veno-occlusive disease post hematopoietic cell transplantation. Expert Rev Gastroenterol Hepatol 2017; 11:885-898. [PMID: 28825848 DOI: 10.1080/17474124.2017.1370372] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a complication that is typically associated with conditioning for hematopoietic stem cell transplantation (HSCT). In patients with concomitant multi-organ dysfunction, mortality may be >80%. Recently, the European Society for Blood and Marrow Transplantation established separate criteria for diagnosis and severity of VOD/SOS for adults and children, to better reflect current understanding of the disease. Areas covered: This review provides an overview of post-HSCT hepatic VOD/SOS and defibrotide, including its pharmacological, clinical, and regulatory profile. In children and adults following HSCT, defibrotide is approved for the treatment of hepatic VOD/SOS with concomitant renal or pulmonary dysfunction in the United States and for the treatment of severe hepatic VOD/SOS in the European Union. Day +100 survival rates with defibrotide are superior to those of historical controls receiving best supportive care only, and safety profiles are similar. Expert commentary: Defibrotide appears to act through multiple mechanisms to restore thrombo-fibrinolytic balance and protect endothelial cells, and there are promising data on the use of defibrotide for VOD/SOS prophylaxis in high-risk children undergoing HSCT. An ongoing randomized controlled trial in children and adults will better assess the clinical value of defibrotide as a preventive medication.
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Affiliation(s)
- Selim Corbacioglu
- a Department of Pediatric Hematology, Oncology and Stem Cell Transplantation , University of Regensburg , Regensburg , Germany
| | - Paul G Richardson
- b Harvard Medical School, Jerome Lipper Multiple Myeloma Center , Dana-Farber Cancer Institute , Boston , MA , USA
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Squadrito F, Bitto A, Irrera N, Pizzino G, Pallio G, Minutoli L, Altavilla D. Pharmacological Activity and Clinical Use of PDRN. Front Pharmacol 2017; 8:224. [PMID: 28491036 PMCID: PMC5405115 DOI: 10.3389/fphar.2017.00224] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/10/2017] [Indexed: 12/26/2022] Open
Abstract
PDRN is a proprietary and registered drug that possesses several activities: tissue repairing, anti-ischemic, and anti-inflammatory. These therapeutic properties suggest its use in regenerative medicine and in diabetic foot ulcers. PDRN holds a mixture of deoxyribonucleotides with molecular weights ranging between 50 and 1,500 KDa, it is derived from a controlled purification and sterilization process of Oncorhynchus mykiss (Salmon Trout) or Oncorhynchus keta (Chum Salmon) sperm DNA. The procedure guarantees the absence of active protein and peptides that may cause immune reactions. In vitro and in vivo experiments have suggested that PDRN most relevant mechanism of action is the engagement of adenosine A2A receptors. Besides engaging the A2A receptor, PDRN offers nucleosides and nucleotides for the so called “salvage pathway.” The binding to adenosine A2A receptors is a unique property of PDRN and seems to be linked to DNA origin, molecular weight and manufacturing process. In this context, PDRN represents a new advancement in the pharmacotherapy. In fact adenosine and dipyridamole are non-selective activators of adenosine receptors and they may cause unwanted side effects; while regadenoson, the only other A2A receptor agonist available, has been approved by the FDA as a pharmacological stress agent in myocardial perfusion imaging. Finally, defibrotide, another drug composed by a mixture of oligonucleotides, has different molecular weight, a DNA of different origin and does not share the same wound healing stimulating effects of PDRN. The present review analyses the more relevant experimental and clinical evidences carried out to characterize PDRN therapeutic effects.
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Affiliation(s)
- Francesco Squadrito
- Section of Pharmacology, Department of Clinical and Experimental Medicine, University of MessinaMessina, Italy
| | - Alessandra Bitto
- Section of Pharmacology, Department of Clinical and Experimental Medicine, University of MessinaMessina, Italy
| | - Natasha Irrera
- Section of Pharmacology, Department of Clinical and Experimental Medicine, University of MessinaMessina, Italy
| | - Gabriele Pizzino
- Section of Pharmacology, Department of Clinical and Experimental Medicine, University of MessinaMessina, Italy
| | - Giovanni Pallio
- Section of Pharmacology, Department of Clinical and Experimental Medicine, University of MessinaMessina, Italy
| | - Letteria Minutoli
- Section of Pharmacology, Department of Clinical and Experimental Medicine, University of MessinaMessina, Italy
| | - Domenica Altavilla
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of MessinaMessina, Italy
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Richardson PG, Smith AR, Triplett BM, Kernan NA, Grupp SA, Antin JH, Lehmann L, Miloslavsky M, Hume R, Hannah AL, Nejadnik B, Soiffer RJ. Earlier defibrotide initiation post-diagnosis of veno-occlusive disease/sinusoidal obstruction syndrome improves Day +100 survival following haematopoietic stem cell transplantation. Br J Haematol 2017; 178:112-118. [PMID: 28444784 DOI: 10.1111/bjh.14727] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/14/2017] [Indexed: 11/28/2022]
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a progressive, potentially fatal complication of conditioning for haematopoietic stem cell transplant (HSCT). The VOD/SOS pathophysiological cascade involves endothelial-cell activation and damage, and a prothrombotic-hypofibrinolytic state. Severe VOD/SOS (typically characterized by multi-organ dysfunction) may be associated with >80% mortality. Defibrotide is approved for treating severe hepatic VOD/SOS post-HSCT in the European Union, and for hepatic VOD/SOS with renal or pulmonary dysfunction post-HSCT in the United States. Previously, defibrotide (25 mg/kg/day in 4 divided doses for a recommended ≥21 days) was available through an expanded-access treatment protocol for patients with VOD/SOS. Data from this study were examined post-hoc to determine if the timing of defibrotide initiation post-VOD/SOS diagnosis affected Day +100 survival post-HSCT. Among 573 patients, defibrotide was started on the day of VOD/SOS diagnosis in approximately 30%, and within 7 days in >90%. The relationship between Day +100 survival and treatment initiation before/after specific days post-diagnosis showed superior survival when treatment was initiated closer to VOD/SOS diagnosis with a statistically significant trend over time for better outcomes with earlier treatment initiation (P < 0·001). These results suggest that initiation of defibrotide should not be delayed after diagnosis of VOD/SOS.
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Affiliation(s)
- Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Brandon M Triplett
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nancy A Kernan
- Pediatric BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephan A Grupp
- Pediatric Oncology, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H Antin
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Leslie Lehmann
- Center for Stem Cell Transplantation, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | | | - Robert J Soiffer
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Richardson PG, Smith AR, Triplett BM, Kernan NA, Grupp SA, Antin JH, Lehmann L, Shore T, Iacobelli M, Miloslavsky M, Hume R, Hannah AL, Nejadnik B, Soiffer RJ. Defibrotide for Patients with Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome: Interim Results from a Treatment IND Study. Biol Blood Marrow Transplant 2017; 23:997-1004. [PMID: 28285079 DOI: 10.1016/j.bbmt.2017.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/06/2017] [Indexed: 12/14/2022]
Abstract
Hepatic veno-occlusive disease, or sinusoidal obstruction syndrome (VOD/SOS), is a serious and potentially fatal complication of conditioning for hematopoietic stem cell transplantation (HSCT) or of chemotherapy regimens alone. Defibrotide is a complex mixture of single-stranded polydeoxyribonucleotides that is approved in the United States for treating hepatic VOD/SOS with renal or pulmonary dysfunction post-HSCT and in the European Union, Israel, and South Korea for treating severe hepatic VOD/SOS post-HSCT. Defibrotide was previously available in the United States as an investigational drug through a treatment protocol (treatment IND) study. Interim results of that large, treatment IND study of patients with VOD/SOS and with or without multiorgan dysfunction (MOD; also known as multiorgan failure) are presented here. Defibrotide was administered i.v. at 6.25 mg/kg every 6 hours (25 mg/kg/day), with a recommended treatment duration of at least 21 days. Enrolled patients (n = 681) were diagnosed with VOD/SOS based on Baltimore or modified Seattle criteria or liver biopsy analysis. Among the 573 HSCT recipients, 288 (50.3%; 95% confidence interval [CI], 46.2% to 54.4%) were alive at day +100 post-HSCT. Day +100 survival for the pediatric (≤16 years) and adult (>16 years) subgroups was 54.5% (95% CI, 49.1% to 60.0%; n = 174 of 319) and 44.9% (95% CI, 38.8% to 51.0%; n = 114 of 254), respectively. In the MOD subgroup, 159 of 351 patients (45.3%; 95% CI, 40.1% to 50.5%) of patients were alive at day +100 post-HSCT. Treatment with defibrotide was generally well tolerated, and drug-related toxicities were consistent with previous studies. Adverse events were reported in 69.6% of safety-evaluable patients (399 of 573). Other than VOD/SOS and associated MOD symptoms, the most commonly reported treatment-emergent adverse event was hypotension (13.8%). Day +100 survival results observed in this trial were consistent with results seen in previous trials of defibrotide for VOD/SOS in adult and pediatric patients. These data support the potential benefit of defibrotide in treating a VOD/SOS patient population that includes those with and without MOD.
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Affiliation(s)
- Paul G Richardson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
| | | | | | - Nancy A Kernan
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Stephan A Grupp
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph H Antin
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Leslie Lehmann
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, California
| | | | | | - Robert J Soiffer
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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38
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Wallhult E, Kenyon M, Liptrott S, Mank A, Ní Chonghaile M, Babic A, Bijkerk J, Bompoint C, Corbacioglu S, de Weijer R, Fink C, Marktel S, Soni V, Sprenger S, Arjona ET, Mohty M. Management of veno-occlusive disease: the multidisciplinary approach to care. Eur J Haematol 2017; 98:322-329. [DOI: 10.1111/ejh.12840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Elisabeth Wallhult
- Section of Haematology and Coagulation; Department of Internal Medicine; Sahlgrenska University Hospital; Göteborg Sweden
| | - Michelle Kenyon
- Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
| | | | - Arno Mank
- Academic Medical Centre; Amsterdam The Netherlands
| | - Mairéad Ní Chonghaile
- National Stem Cell Transplant Unit (Adults); Department of Haematology; St James's Hospital; Dublin Ireland
| | - Aleksandra Babic
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona Switzerland
| | - Jacobine Bijkerk
- UMC Utrecht Cancer Center, Hematologie; University Medical Center Utrecht; Utrecht The Netherlands
| | - Caroline Bompoint
- Département d'Hématologie et de Thérapie Cellulaire; CHRU Montpellier-site Saint Eloi; Montpellier France
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation; University of Regensburg; Regensburg Germany
| | - Roel de Weijer
- UMC Utrecht Cancer Center, Hematologie; University Medical Center Utrecht; Utrecht The Netherlands
| | - Claudia Fink
- Klinik für Hämat, Onkol, Klin.Immun.; Heinrich Heine Universität; Düsseldorf Germany
| | - Sarah Marktel
- Hematology and BMT Unit; San Raffaele Hospital; Milan Italy
| | - Vivek Soni
- Royal Marsden NHS Foundation Trust; Sutton UK
| | - Sarah Sprenger
- Department of Stem cell Transplantation; University Hospital Eppendorf; Hamburg Germany
| | | | - Mohamad Mohty
- Hematology Department; Hôpital Saint-Antoine, and Université Pierre & Marie Curie; Paris France
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Colecchia A, Marasco G, Ravaioli F, Kleinschmidt K, Masetti R, Prete A, Pession A, Festi D. Usefulness of liver stiffness measurement in predicting hepatic veno-occlusive disease development in patients who undergo HSCT. Bone Marrow Transplant 2016; 52:494-497. [PMID: 27941774 DOI: 10.1038/bmt.2016.320] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- A Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - G Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - F Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - K Kleinschmidt
- Pediatric Oncology and Hematology Unit, University of Bologna Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - R Masetti
- Pediatric Oncology and Hematology Unit, University of Bologna Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - A Prete
- Pediatric Oncology and Hematology Unit, University of Bologna Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - A Pession
- Pediatric Oncology and Hematology Unit, University of Bologna Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - D Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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40
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Defibrotide in Severe Sinusoidal Obstruction Syndrome: Medicine and Economic Issues. Biol Blood Marrow Transplant 2016; 23:347-356. [PMID: 27939616 DOI: 10.1016/j.bbmt.2016.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/28/2016] [Indexed: 11/23/2022]
Abstract
In Europe, Defitelio (defibrotide) has a Market Authorization in curative treatment of severe sinusoidal obstruction syndrome (SOS) but not in prophylaxis (2013). In France, defibrotide has had a compassionate-use program since 2009. Today, the high cost of defibrotide remains a major hurdle for hospital budgets. Medicine and economic issues were evaluated for the 39 hospitals of the French Public Assistance-Hospitals of Paris (AP-HP). We analyzed literature reviews, consumption, and expenditures through AP-HP data in 2014 and patient profiles with defibrotide in the corresponding diagnostic-related groups (DRGs) and consulted a board of hematologists. Finally, 18 publications were selected. Between 2011 and 2014 consumption increased to €5.2M. In 2014, 80 patients receiving defibrotide were mainly ascribed to the DRG "hematopoietic stem cell transplantation" levels 3 or 4. The tariffs attributed to drugs (€3544 to 4084) cover a small part of treatment costs (€97,524 for an adult). French experts thus recommended a harmonization of indications in prophylaxis (off-label use), improvement of pretransplant care, and optimization of the number of vials used. The economic impact led experts to change their practices. They recommended the restriction of defibrotide use to SOS curative treatment and to high-risk situations in prophylaxis.
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Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), represents the most frequent complication in patients in early phase following hematopoietic stem-cell transplantation (HSCT). In its severe form, VOD/SOS can be associated with multiorgan failure and with a mortality rate >80% by day +100. Defibrotide (DF) (a mixture of 90% single-stranded phosphodiester oligonucleotides and 10% double-stranded phosphodiester oligonucleotides derived from controlled depolarization of porcine intestinal mucosal DNA) has been proposed for the treatment of SOS due to its ability to restore thrombo-fibrinolytic balance and protect endothelial cells. The present review highlights why the mechanisms of action of DF allow its successful use in the prevention and treatment of SOS following HSCT.
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Affiliation(s)
- Alessandro Fulgenzi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Maria Elena Ferrero
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Abstract
Sinusoidal obstruction syndrome (SOS) is characterized by damage to small hepatic vessels affecting particularly sinusoidal endothelium. Damaged sinusoids can be associated with a partial or complete occlusion of small hepatic veins, hence the previous denomination of hepatic veno-occlusive disease (VOD). Exposure to certain exogenous toxins appears to be specific to this condition and is frequently included in its definition. Typical histopathological features of SOS in a liver biopsy specimen are presented in the text. The purpose of this article is to provide an overview on the different entities corresponding to this general definition. Such entities include: (i) liver disease related to pyrrolizidine alcaloids; (ii) liver injury related to conditioning for hematopoietic stem cell transplantation; (iii) vascular liver disease occurring in patients treated with chemotherapy for liver metastasis of colorectal cancer; and (iv) other liver diseases related to toxic agents.
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Tocchetti P, Tudone E, Marier JF, Marbury TC, Zomorodi K, Eller M. Pharmacokinetic profile of defibrotide in patients with renal impairment. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:2631-41. [PMID: 27574402 PMCID: PMC4993270 DOI: 10.2147/dddt.s112181] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hepatic veno-occlusive disease, also called sinusoidal obstruction syndrome (VOD/SOS), is an unpredictable, potentially life-threatening complication of hematopoietic stem cell transplant conditioning. Severe VOD/SOS, generally associated with multiorgan dysfunction (pulmonary or renal dysfunction), may be associated with >80% mortality. Defibrotide, recently approved in the US, has demonstrated efficacy treating hepatic VOD/SOS with multiorgan dysfunction. Because renal impairment is prevalent in patients with VOD/SOS, this Phase I, open-label, two-part study in adults examined the effects of hemodialysis and severe or end-stage renal disease (ESRD) on defibrotide pharmacokinetics (PK). Part 1 compared defibrotide PK during single 6.25 mg/kg doses infused with and without dialysis. Part 2 assessed defibrotide plasma PK after multiple 6.25 mg/kg doses in nondialysis-dependent subjects with severe/ESRD versus healthy matching subjects. Among six subjects enrolled in Part 1, percent ratios of least-squares mean and 90% confidence intervals (CIs) on dialysis and nondialysis days were 109.71 (CI: 97.23, 123.78) for maximum observed plasma concentration (Cmax); 108.39 (CI: 97.85, 120.07) for area under the concentration–time curve to the time of the last quantifiable plasma concentration (AUC0–t); and 109.98 (CI: 99.39, 121.70) for AUC extrapolated to infinity (AUC0–∞). These ranges were within 80%–125%, indicating no significant effect of dialysis on defibrotide exposure/clearance. In Part 2, defibrotide exposure parameters in six subjects with severe/ESRD after multiple doses (AUC0–t, 113 µg·h/mL; AUC over dosing interval, 113 µg·h/mL; Cmax, 53.8 µg/mL) were within 5%–8% of parameters after the first dose (AUC0–t, 117 µg·h/mL; AUC0–∞, 118 µg·h/mL; Cmax, 54.9 µg/mL), indicating no accumulation. Defibrotide peak and extent of exposures in those with severe/ESRD were ~35%–37% and 50%–60% higher, respectively, versus controls, following single and multiple doses. One adverse event (vomiting, possibly drug-related) was reported. These findings support defibrotide prescribing guidance stating no dose adjustment is necessary for hemodialysis or severe/ESRD.
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Affiliation(s)
| | - Elena Tudone
- Clinical Operations, Gentium, Villa Guardia, Como, Italy
| | - Jean-Francois Marier
- Reporting and Analysis Services, Pharsight, a Certara Company, Montreal, Quebec, Canada
| | | | - Katie Zomorodi
- Early Development and Clinical Pharmacology, Jazz Pharmaceuticals
| | - Mark Eller
- Early Drug Development, Jazz Pharmaceuticals, Palo Alto, CA, USA
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Botti S, Orlando L, Gargiulo G, Cecco VD, Banfi M, Duranti L, Samarani E, Netti MG, Deiana M, Galuppini V, Pignatelli AC, Ceresoli R, Vedovetto A, Rostagno E, Bambaci M, Dellaversana C, Luminari S, Bonifazi F. Veno-occlusive disease nurse management: development of a dynamic monitoring tool by the GITMO nursing group. Ecancermedicalscience 2016; 10:661. [PMID: 27594906 PMCID: PMC4990055 DOI: 10.3332/ecancer.2016.661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Indexed: 01/17/2023] Open
Abstract
Veno-occlusive disease (VOD) is a complication arising from the toxicity of conditioning regimens that have a significant impact on the survival of patients who undergo stem cell transplantation. There are several known risk factors for developing VOD and their assessment before the start of conditioning regimens could improve the quality of care. Equally important are early identification of signs and symptoms ascribable to VOD, rapid diagnosis, and timely adjustment of support therapy and treatment. Nurses have a fundamental role at the stages of assessment and monitoring for signs and symptoms; therefore, they should have documented skills and training. The literature defines nurses’ areas of competence in managing VOD, but in the actual clinical practice, this is not so clear. Moreover, there is an intrinsic difficulty in managing VOD due to its rapid and often dramatic evolution, together with a lack of care tools to guide nurses. Through a complex evidence-based process, the Gruppo Italiano per il Trapianto di Midollo Osseo (GITMO), cellule staminali emopoietiche e terapia cellulare nursing board has developed an operational flowchart and a dynamic monitoring tool applicable to haematopoietic stem cell transplantation patients, whether they develop this complication or not.
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Affiliation(s)
- Stefano Botti
- Haematology Unit, Arcispedale Santa Maria Nuova-IRCCS Reggio Emilia, Italy
| | - Laura Orlando
- Division of Clinical Haemato-Oncology, Istituto Europeo di Oncologia, Milan, Italy
| | | | - Valentina De Cecco
- Paediatric Haemato-Oncology Unit, Policlinico S Matteo Pavia, Viale Camillo Golgi, 19, 27100 Pavia PV, Italy
| | - Marina Banfi
- BMT Unit, Ospedale Maggiore IRCCS Milano, Milan, Italy
| | - Lorenzo Duranti
- Haematology and BMT Unit, Ospedale Silvestrini, Perugia, Italy
| | | | - Maria Giovanna Netti
- SODc Paediatric Tumours and BMT Unit, Ospedale Pediatrico Meyer Firenze, Florence, Italy
| | - Marco Deiana
- Paediatric Haematology/Oncology Department, IRCCS G Gaslini, Genova, Italy
| | | | | | | | - Alessio Vedovetto
- Paediatric Haemato-Oncology and BMT Unit, Azienda Ospedaliera di Padova, Via Nicolò Giustiniani, 2, 35128 Padova PD, Italy
| | - Elena Rostagno
- Paediatric Haematology/Oncology and BMT Department, Azienda Ospedaliero, Universitaria S Orsola Malpighi, Bologna, Italy
| | - Marilena Bambaci
- Paediatric Haemato-Oncology and BMT Unit , Ospedale Regina Margherita, Torino, Italy
| | | | - Stefano Luminari
- Haematology Unit, Arcispedale Santa Maria Nuova-IRCCS Reggio Emilia, Italy
| | - Francesca Bonifazi
- Haematology and BMT Unit, Azienda Ospedaliero, Universitaria S Orsola Malpighi, Bologna, Italy
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45
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Tavabie O, Suddle AR. Lymphoma and hematological conditions: I. Lymphoma and liver complications of bone marrow transplant. Clin Liver Dis (Hoboken) 2016; 8:1-5. [PMID: 31041053 PMCID: PMC6490187 DOI: 10.1002/cld.560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 04/13/2016] [Accepted: 05/04/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Oliver Tavabie
- Institute of Liver StudiesKing's College HospitalLondonSE5 9RSUnited Kingdom
| | - Abid R. Suddle
- Institute of Liver StudiesKing's College HospitalLondonSE5 9RSUnited Kingdom
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46
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Corbacioglu S, Carreras E, Mohty M, Pagliuca A, Boelens JJ, Damaj G, Iacobelli M, Niederwieser D, Olavarría E, Suarez F, Ruutu T, Verdonck L, Hume R, Nejadnik B, Lai C, Finetto G, Richardson P. Defibrotide for the Treatment of Hepatic Veno-Occlusive Disease: Final Results From the International Compassionate-Use Program. Biol Blood Marrow Transplant 2016; 22:1874-1882. [PMID: 27397724 DOI: 10.1016/j.bbmt.2016.07.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/04/2016] [Indexed: 01/04/2023]
Abstract
Hepatic veno-occlusive disease, also called sinusoidal obstruction syndrome (VOD/SOS), is an unpredictable and potentially fatal complication of hematopoietic cell transplantation (HCT) or nontransplantation-associated chemotherapy/radiotherapy. In cases of severe hepatic VOD/SOS, typically defined by associated multiorgan failure (MOF, also known as multiorgan dysfunction), mortality exceeds 80%. Preclinical and early clinical data have provided a rationale for defibrotide treatment in hepatic VOD/SOS. Based on this evidence and in recognition of the dismal prognosis for these patients, defibrotide was made available through an international multicenter compassionate-use program conducted from December 1998 to March 2009. Physicians participating in the program voluntarily provided demographic and outcome data for patients given defibrotide. Efficacy and safety analyses were performed using the data received for 710 treated patients. Defibrotide was given at 10, 25, 40, 60, or 80 mg/kg/day for a median of 15 days (range, 1 to 119 days). By Kaplan-Meier analysis, the estimated overall day +100 survival was 54% (58% in the 25 mg/kg/day dose group). Adverse events (AEs) were reported in 53% of patients. The most common AEs were MOF, progression of hepatic VOD/SOS, sepsis, and graft-versus-host disease, which were consistent with the AEs expected for this patient population. No clinically meaningful trends in AEs were identified by gender, age, or dose group. Safety and efficacy resultswere consistent with prior studies of defibrotide in hepatic VOD/SOS, and subgroup analyses lend support to the use of the 25 mg/kg/day dose.
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Affiliation(s)
- Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Hospital Regensburg, Regensburg, Germany.
| | - Enric Carreras
- Spanish Bone Marrow Donor Program, Josep Carreras Foundation, and Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Mohamad Mohty
- Department of Hematology, Hopital Saint-Antoine, Paris, France; University Pierre & Marie Curie, Paris, France; INSERM UMRs 938, Paris, France
| | - Antonio Pagliuca
- Department of Hematology, King's College Hospital, London, United Kingdom
| | - Jaap Jan Boelens
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, The Netherlands; UMC Utrecht, Laboratory of Translational Immunology, The Netherlands
| | - Gandhi Damaj
- Department of Hematology, University Hospital Center of Caen, School of Medicine, France
| | | | | | - Eduardo Olavarría
- Blood and Marrow Transplantation Unit, Hammersmith Hospital, London, United Kingdom
| | - Felipe Suarez
- Department of Hematology, Necker-Enfants Malades University Hospital, Paris, France
| | - Tapani Ruutu
- Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | | | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, California
| | | | | | | | - Paul Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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47
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What is going on between defibrotide and endothelial cells? Snapshots reveal the hot spots of their romance. Blood 2016; 127:1719-27. [PMID: 26755708 DOI: 10.1182/blood-2015-10-676114] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/25/2015] [Indexed: 12/27/2022] Open
Abstract
Defibrotide (DF) has received European Medicines Agency authorization to treat sinusoidal obstruction syndrome, an early complication after hematopoietic cell transplantation. DF has a recognized role as an endothelial protective agent, although its precise mechanism of action remains to be elucidated. The aim of the present study was to investigate the interaction of DF with endothelial cells (ECs). A human hepatic EC line was exposed to different DF concentrations, previously labeled. Using inhibitory assays and flow cytometry techniques along with confocal microscopy, we explored: DF-EC interaction, endocytic pathways, and internalization kinetics. Moreover, we evaluated the potential role of adenosine receptors in DF-EC interaction and if DF effects on endothelium were dependent of its internalization. Confocal microscopy showed interaction of DF with EC membranes followed by internalization, though DF did not reach the cell nucleus even after 24 hours. Flow cytometry revealed concentration, temperature, and time dependent uptake of DF in 2 EC models but not in other cell types. Moreover, inhibitory assays indicated that entrance of DF into ECs occurs primarily through macropinocytosis. Our experimental approach did not show any evidence of the involvement of adenosine receptors in DF-EC interaction. The antiinflammatory and antioxidant properties of DF seem to be caused by the interaction of the drug with the cell membrane. Our findings contribute to a better understanding of the precise mechanisms of action of DF as a therapeutic and potential preventive agent on the endothelial damage underlying different pathologic situations.
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48
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Richardson PG, Krishnan A, Giralt S, Soiffer RJ. Defibrotide for the treatment of severe hepatic veno-occlusive disease/sinusoidal obstruction syndrome: evidence for clinical benefit. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1114455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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49
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Triplett BM, Kuttab HI, Kang G, Leung W. Escalation to High-Dose Defibrotide in Patients with Hepatic Veno-Occlusive Disease. Biol Blood Marrow Transplant 2015; 21:2148-2153. [PMID: 26278046 DOI: 10.1016/j.bbmt.2015.08.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 08/06/2015] [Indexed: 01/04/2023]
Abstract
Hepatic veno-occlusive disease (VOD) is a serious complication of high-dose chemotherapy regimens, such as those used in hematopoietic cell transplantation recipients. Defibrotide is considered a safe and effective treatment when dosed at 25 mg/kg/day. However, patients who develop VOD still have increased mortality despite the use of defibrotide. Data are limited on the use of doses above 60 mg/kg/day for persistent VOD. In this prospective clinical trial 34 patients received escalating doses of defibrotide. For patients with persistent VOD despite doses of 60 mg/kg/day, doses were increased to a maximum of 110 mg/kg/day. Increased toxicity was not observed until doses rose beyond 100 mg/kg/day. Patients receiving doses between 10 and 100 mg/kg/day experienced an average of 3 bleeding episodes per 100 days of treatment, whereas those receiving doses >100 mg/kg/day experienced 13.2 bleeding episodes per 100 days (P = .008). Moreover, dose reductions due to toxicity were needed at doses of 110 mg/kg/day more often than at lower doses. Defibrotide may be safely escalated to doses well above the current standard without an increase in bleeding risk. However, the efficacy of this dose-escalation strategy remains unclear, because outcomes were similar to published cohorts of patients receiving standard doses of defibrotide for VOD.
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Affiliation(s)
- Brandon M Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee.
| | - Hani I Kuttab
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wing Leung
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee
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50
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Defibrotide: a review of its use in severe hepatic veno-occlusive disease following haematopoietic stem cell transplantation. Clin Drug Investig 2015; 34:895-904. [PMID: 25351934 DOI: 10.1007/s40261-014-0242-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Defibrotide (Defitelio(®)) was recently approved in the EU for the treatment of severe hepatic veno-occlusive disease (VOD), also known as sinusoidal obstructive syndrome, in haematopoietic stem cell transplantation (HSCT) therapy. It is indicated in adults, adolescents, children and infants over 1 month of age. Defibrotide is also available in the US via an expanded-access protocol. Defibrotide is thought to protect endothelial cells and restore the thrombo-fibrinolytic balance in VOD. In a multicentre, phase III trial, the complete response rate by day +100 (primary endpoint) was significantly higher, and mortality at day +100 was significantly lower, in patients with severe hepatic VOD and multiorgan failure following HSCT who received intravenous defibrotide 6.25 mg/kg every 6 h than in a group of historical controls. The efficacy of defibrotide in severe hepatic VOD following HSCT was also supported by findings from a phase II dose-finding study, compassionate-use data and information provided from an independent transplant registry. Intravenous defibrotide was generally well tolerated in patients with severe hepatic VOD following HSCT, and was not associated with an increased risk of haemorrhagic adverse events. In conclusion, defibrotide is the only agent approved (in the EU) for use in severe hepatic VOD following HSCT and represents a useful advance in the treatment of this condition.
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