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Szewczyk NA, Ngo-Huang A, Soones TN, Adekoya LM, Fontillas RC, Ferguson JK, Gale-Capps HE, Kurse BC, Lindsay RJ, Ombres R, Rivera ZR, Gulbis AM, Neumann JL, Braveman BH, Marin D, Shigle TL, Whited L, Wallis WD, Sullivan H, Cao L, Champlin RE, Shpall E, Popat UR. Feasibility and Implementation of a Multimodal Supportive Care Program to Improve Outcomes in Older Patients Undergoing Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2021; 27:1008-1014. [PMID: 34537421 DOI: 10.1016/j.jtct.2021.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/28/2022]
Abstract
Increasingly, patients age ≥65 years are undergoing allogeneic hematopoietic stem cell transplantation (allo-SCT). Although age alone is a well-documented predictor of overall survival (OS) and nonrelapse mortality (NRM), growing evidence suggests that poor functional status and frailty associated with aging may have roles as well. Our goal in the present study was to identify and improve these and other aging-related maladies by developing a multimodal supportive care program for older allo-SCT recipients. We designed and implemented a multimodal supportive care program, Enhanced Recovery in Stem Cell Transplant (ER-SCT), for patients age ≥65 years undergoing allo-SCT. The ER-SCT program consists of evaluation and critical interventions by key health care providers from multiple disciplines starting before hospital admission for transplantation and extending through 100 days post-allo-SCT. We determined the feasibility of implementing this program in a large stem cell transplantation center. After 1 year of ongoing process improvements, multiple evaluations, and enrollment, we found that a dedicated weekly clinic was necessary to coordinate care and evaluate patients early. We successfully enrolled 57 of 64 eligible patients (89%) in the first year. Our data show that a multimodal supportive care program to enhance recovery for older patients undergoing allo-SCT is feasible. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
| | - An Ngo-Huang
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tacara N Soones
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Latoya M Adekoya
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jill K Ferguson
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Brittany C Kurse
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Rachel Ombres
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zandra R Rivera
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alison M Gulbis
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joyce L Neumann
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brent H Braveman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Marin
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Laura Whited
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney D Wallis
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hilary Sullivan
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lihui Cao
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Elizabeth Shpall
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Saberian C, Abdel-Wahab N, Abudayyeh A, Rafei H, Joseph J, Rondon G, Whited L, Gruschkus S, Fa'ak F, Daher M, Knape C, Safa H, Shoukier M, Suarez-Almazor ME, Marcotulli M, Ludford K, Gulbis AM, Konopleva M, Ohanian M, Ravandi F, Garcia-Manero G, Oran B, Popat UR, Mehta R, Alousi AM, Daver N, Champlin R, Diab A, Al-Atrash G. Post-transplantation cyclophosphamide reduces the incidence of acute graft-versus-host disease in patients with acute myeloid leukemia/myelodysplastic syndromes who receive immune checkpoint inhibitors after allogeneic hematopoietic stem cell transplantation. J Immunother Cancer 2021; 9:jitc-2020-001818. [PMID: 33637601 PMCID: PMC7919586 DOI: 10.1136/jitc-2020-001818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 12/27/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) are being used after allogeneic hematopoietic stem cell transplantation (alloHCT) to reverse immune dysfunction. However, a major concern for the use of ICIs after alloHCT is the increased risk of graft-versus-host disease (GVHD). We analyzed the association between GVHD prophylaxis and frequency of GVHD in patients who had received ICI therapy after alloHCT. Methods A retrospective study was performed in 21 patients with acute myeloid leukemia (n=16) or myelodysplastic syndromes (n=5) who were treated with antiprogrammed cell death protein 1 (16 patients) or anticytotoxic T lymphocyte-associated antigen 4 (5 patients) therapy for disease relapse after alloHCT. Associations between the type of GVHD prophylaxis and incidence of GVHD were analyzed. Results Four patients (19%) developed acute GVHD. The incidence of acute GVHD was associated only with the type of post-transplantation GVHD prophylaxis; none of the other variables included (stem cell source, donor type, age at alloHCT, conditioning regimen and prior history of GVHD) were associated with the frequency of acute GVHD. Twelve patients received post-transplantation cyclophosphamide (PTCy) for GVHD prophylaxis. Patients who received PTCy had a significantly shorter median time to initiation of ICI therapy after alloHCT compared with patients who did not receive PTCy (median 5.1 months compared with 26.6 months). Despite early ICI therapy initiation, patients who received PTCy had a lower observed cumulative incidence of grades 2–4 acute GVHD compared with patients who did not receive PTCy (16% compared with 22%; p=0.7). After controlling for comorbidities and time from alloHCT to ICI therapy initiation, the analysis showed that PTCy was associated with a 90% reduced risk of acute GVHD (HR 0.1, 95% CI 0.02 to 0.6, p=0.01). Conclusions ICI therapy for relapsed acute myeloid leukemia/myelodysplastic syndromes after alloHCT may be a safe and feasible option. PTCy appears to decrease the incidence of acute GVHD in this cohort of patients.
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Affiliation(s)
- Chantal Saberian
- Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Noha Abdel-Wahab
- Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Rheumatology and Rehabilitation, Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hind Rafei
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jacinth Joseph
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Laura Whited
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Gruschkus
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Faisal Fa'ak
- Department of Internal Medicine, Piedmont Athens Regional Medical Center Athens, Athens, Georgia, USA
| | - May Daher
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cristina Knape
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Houssein Safa
- Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mahran Shoukier
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria E Suarez-Almazor
- Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Health Service Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Megan Marcotulli
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kaysia Ludford
- Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alison M Gulbis
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rotesh Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adi Diab
- Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gheath Al-Atrash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA .,Department of Hematopoietic Biology and Malignancy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Whited L, Grove M, Rose D, Rhodes NJ, Scheetz MH, O'Donnell JN, Neeb J, Thoele K, Jones DR, Lowe C, Moore D, Kiel PJ. Pharmacokinetics of Cefepime in Patients with Cancer and Febrile Neutropenia in the Setting of Hematologic Malignancies or Hematopoeitic Cell Transplantation. Pharmacotherapy 2016; 36:1003-10. [PMID: 27496678 DOI: 10.1002/phar.1807] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE To evaluate the steady-state pharmacokinetic parameters of standard cefepime dosing regimens in a hematologic malignancy and hematopoietic cell transplant patient population with febrile neutropenia. DESIGN Open-label, single-center, prospective pharmacokinetic study. SETTING National Cancer Institute-designated cancer center. PATIENTS Nine adults with hematologic malignancies or hematopoietic cell transplants who had febrile neutropenia and were admitted to a hematology-oncology service between January and July 2014. INTERVENTION Patients received empirical cefepime 2 g every 8 hours, administered as a 30-minute intravenous infusion, for febrile neutropenia. MEASUREMENTS AND MAIN RESULTS Steady-state cefepime serum concentrations were measured after at least 2 days of continuous therapy. Venous blood samples were intensively sampled between 0 and 8 hours after the start of the 30-minute infusion at steady state. Seven of the nine patients had a hematologic malignancy diagnosis of acute leukemia, lymphoma, or myeloma, and two patients had a germ cell tumor diagnosis. Noncompartmental analysis revealed mean ± SD parameters as follows at steady state: area under the plasma concentration-time curve from 0-8 hours 222.9 ± 72.9 mg hour/L, maximum concentration 120.9 ± 21.8 mg/L, clearance 9.7 ± 3.7 L/hour, apparent volume of distribution 19.2 ± 4.65 L, and elimination half-life 1.4 ± 0.3 hours. A one-compartment pharmacokinetic model identified a mean ± SD volume of distribution of 20.9 ± 1.3 L and an elimination rate constant of 0.39 ± 0.03 hour(-1) . The mean estimated percentage of time that drug concentration remains above the pathogen minimum inhibitory concentration (fT>MIC) in serum was 55%, 77%, and 99% at MICs of 16, 8, and 4 mg/L, respectively. CONCLUSION Patients with hematologic malignancies or hematopoietic cell transplants who had febrile neutropenia demonstrated homogeneous calculated cefepime volumes and clearances. The population parameters presented in this study may aid in the calculation of patient-specific fT>MIC for similar patients.
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Affiliation(s)
- Laura Whited
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana
| | - Meagan Grove
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana
| | - Dusten Rose
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana
| | - Nathaniel J Rhodes
- Department of Pharmacy, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Marc H Scheetz
- Department of Pharmacy, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois.,Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
| | - J Nicholas O'Donnell
- Department of Pharmacy, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Jessica Neeb
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana
| | - Kelli Thoele
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana
| | - David R Jones
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Christopher Lowe
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana
| | - Dawn Moore
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana
| | - Patrick J Kiel
- Indiana University Simon Cancer Center-Indiana University Health, Indianapolis, Indiana. .,Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana.
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