Infliximab and Basiliximab for Treatment of Steroid Refractory Acute Graft Versus Host Disease

This study is currently recruiting participants. (see Contacts and Locations)
Verified February 2014 by Nationwide Children's Hospital
Sponsor:
Collaborator:
Ohio State University Comprehensive Cancer Center
Information provided by (Responsible Party):
Rajinder Bajwa, Nationwide Children's Hospital
ClinicalTrials.gov Identifier:
NCT01485055
First received: December 1, 2011
Last updated: February 11, 2014
Last verified: February 2014
  Purpose

Acute Graft Versus Host Disease (GVHD) is a serious medical condition that is a common development after Bone Marrow Transplant (BMT). Acute GVHD happens when the donor cells attack and damage your tissues and organs after transplant.

Acute GVHD often causes: Skin rashes, nausea, vomiting, abdominal pain, diarrhea (may have blood), liver damage that can cause inflammation in the liver or jaundice (yellowing of the skin or eyes), damage to other organs

Steroids are the first line of treatment for acute GVHD. About a quarter of the patients that develop acute GVHD may not respond to steroid and have steroid refractory GVHD (SR-aGVHD). Patients with SR-aGVHD may need other medications. SR-aGVHD, is a potentially life threatening condition. There is no standard treatment and it may not respond to treatment.

The goals of this study are to find out if Infliximab and basiliximab can treat SR-aGVHD.

Participants in this study will receive combination therapy (2 drugs: infliximab and basiliximab) once a week for four weeks.


Condition Intervention Phase
Graft Versus Host Disease
Steroid Refractory GVHD
Acute GVH Disease
Drug: Infliximab and Basiliximab
Phase 2

Study Type: Interventional
Study Design: Endpoint Classification: Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Infliximab and Basiliximab for Treatment of Steroid Refractory Acute Graft Versus Host Disease

Resource links provided by NLM:


Further study details as provided by Nationwide Children's Hospital:

Primary Outcome Measures:
  • Treatment [ Time Frame: 28 days ] [ Designated as safety issue: No ]
    To estimate the complete response rate by 28 days after starting study drugs, without additional therapy for patients with steroid refractory aGvHD.


Estimated Enrollment: 44
Study Start Date: December 2011
Estimated Study Completion Date: December 2014
Estimated Primary Completion Date: December 2014 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Infliximab and Basiliximab

Other Names:

Simulect Remicade Monoclonal antibody

Participants in this research study will receive combination therapy (2 drugs: Infliximab and Basiliximab)once a week for four weeks. Both drugs will be given through the participant's broviac, port or through a vein in the arm. It will take about 4-5 hours to complete the 2-drug combination therapy each week. Participants will be given pre-medications to help prevent reactions to the study drugs.

Infliximab will be given at a dose of 10mg per Kg per dose. Basiliximab will be given in 10mg doses to patients who weigh less than 35kg. Patients who weigh weigh more than 35kg will receive 20mg doses. Patients will receive both drugs weekly on days 1,8,15 and 22. Each drug will be given 4 times.

Drug: Infliximab and Basiliximab

Participants in this research study will receive combination therapy (2 drugs: Infliximab and Basiliximab)once a week for four weeks. Both drugs will be given through the participant's broviac, port or through a vein in the arm. It will take about 4-5 hours to complete the 2-drug combination therapy each week. Participants will be given pre-medications to help prevent reactions to the study drugs.

Infliximab will be given at a dose of 10mg per Kg per dose. Basiliximab will be given in 10mg doses to patients who weigh less than 35kg. Patients who weigh weigh more than 35kg will receive 20mg doses. Patients will receive both drugs weekly on days 1,8,15 and 22. Each drug will be given 4 times.

Other Names:
  • Simulect
  • Remicade
  • Monoclonal antibody

  Hide Detailed Description

Detailed Description:

Corticosteroids are the standard initial therapy for Acute GvHD (aGVHD) after HSCT (hematopoietic stem cell transplant aka BMT) and 25-41% patients will respond to prednisone (or methylprednisolone) at a dose of 2mg/kg/day. Complete response of aGvHD is an important predictor of survival; in patients who respond to steroids, survival is around 50%, while it is as low as 11% for non-responders. Patients who do not develop aGvHD are normally discharged by 4-5 weeks after HSCT. However patients with aGvHD may need to be admitted and require prolonged hospitalization. Patients, who do not respond to treatment, usually have worsening skin symptoms, the protracted diarrhea and vomiting leading to severe life threatening dehydration. Secondary bacterial, fungal and/or viral infections are common and they may eventually die of multiorgan failure.

There is no consensus to the definition of steroid refractory (SR) aGvHD, but generally aGvHD is considered to be SR, when there is progression of GvHD after 3 days or no response after 7 days of treatment with 2mg/kg/day of methyl prednisolone. There is no standard of care for such patients and treatment varies from institution to institution. Salvage regimens for SR GvHD have included high dose steroids, antithymocyte globulin (ATG), monoclonal antibodies (infliximab, daclizumab, basiliximab etc.),pentostatin, mesenchymal stem cells and immunotoxins. Generally if the manifestations of aGvHD worsen over 3 days after starting steroids, or if there is no improvement within 5 days, then it is unlikely that a response will be achieved and secondary therapy should be initiated.

High dose steroids have not been associated with any improvement in response rates for SR aGvHD. In a prospective trial comparing 2mg/kg/day with 10mg/kg/day of methylprednisolone in 94 patients with grade II-IV aGvHD, response rates, progression to grade III-IV disease, non- relapse mortality (NRM) and overall survival were similar in both treatment groups. In addition high dose steroids are associated with many acute and long term complications. Hyperglycemia, hypertension, infections, aseptic necrosis and neurological complications are commonly seen.

Outcome of patients with SR aGvHD is poor. Only 7/57 (12%) patients achieved CR (complete Response)after secondary therapy for aGvHD as reported by Weisdorf et al and only 4/45 (9 %) patients who received high dose methylprednisolone as secondary therapy responded. ATG has been extensively used for treatment of SR GvHD and CR rates of 14-20 % have been reported.

Rationale for using Infliximab and Basiliximab:

The pathophysiology of GvHD is triphasic involving tissue damage from the conditioning regimen, followed by donor T cell activation leading to the effector phase of cytokine dysregulation. The cytokines interleukin (IL) 2 and tumor necrosis factor-α (TNF-α) play a central role in mediating tissue damage and causing proliferation of the activated alloreactive T cells. Over the last few years monoclonal antibodies have been used to treat such patients as monotherapy and recently as combination therapy with more promising results. The anti-CD25 MoAb - daclizumab provides competitive inhibition of binding of IL-2 to the high affinity α subunit IL2 receptor. It has been used as monotherapy for steroid refractory aGvHD with promising results. TNF is another cytokine involved in GvHD and early studies with anti-TNF-α administration have shown encouraging results. Antibodies to TNF (infliximab) or to TNF receptor (etanercept) have been developed. Infliximab blocks the interaction between TNF-and its receptors and causes lysis of the cells that produce TNF- . Srinivasan et al used infliximab and daclizumab in combination therapy for patients who developed SR GvHD after non myeloablative HSCT in adult patients. All 12 patients treated with the combination therapy had complete resolution of GvHD in all involved organs. The Kaplan-Meier probability of survival was 100% at 100 days and 73% at 200 days after transplantation. Rao et al in their study used the same regimen (infliximab and daclizumab) in pediatric population who underwent HSCT for immunodeficiency. In their study 86% (19/22) patients responded with a median response time of 15 days after start of monoclonal antibody therapy. 12/22 (54%) had CR, and 7/22 (32%) had a PR while 3 patients had no response to treatment. At a median follow-up of 31 months 68% of the patients were alive.

As of Jan 2010 Daclizumab is not available due to manufacturer related issues. Basiliximab is another chimeric murine-human IL-2 receptor antagonist, with a half-life of around 7 days. It's mechanism of action is similar to daclizumab and it has been used in SR GVHD as monotherapy. Massenkeil et al in their study of 17 patients with steroid refractory GvHD showed the 53% of patients had a complete response, 18% had a partial response and 29% had no response. Recently Funke et al in their study of 34 patients with SR GvHD, showed a CR rate of 84% for skin, 48% of gut and 26% of patients with liver GvHD. However it is difficult to compare one study with another due to lack of uniformity in response definitions, dosing schedules and the number of doses used.

The higher CR rates and survival in the studies by Srinivasan and Rao et al were possibly due to the following factors:

  1. Use of combination therapy of monoclonal antibodies, selectively inhibiting alloreactive T cells by targeting 2 different cytokines involved in the pathophysiology of GvHD;
  2. Rapid taper of steroids, thereby decreasing the steroid induced side effects like infections;
  3. Prophylactic use of antimicrobials (antibiotics and antifungals) and close monitoring for viral reactivation.

These factors led to decrease in infection related morbidity and mortality in this population of heavily immunosuppressed patients; thus contributing to the improved survival in these studies.

Overall CR rates for SR GvHD have ranged from 9% to 54% with a median of 26%. Mostly these results are based on single center experience, with small sample sizes, and these studies are not comparable. There is no standard of care; however infliximab may be used as monotherapy if a diagnosis of SR GvHD has been made. The only promising treatment with infliximab and daclizumab is not possible to give now due to unavailability of daclizumab from January 2010. Basiliximab has not been used in combination therapy with other monoclonal antibodies. Combination therapy with infliximab and basiliximab will target two different points in the cytokine cascade and selectively control proliferation of activated T cells. As this combination has not been used before it is difficult to predict the safety and efficacy profile.

  Eligibility

Ages Eligible for Study:   6 Months to 75 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Any patient with either progressive aGvHD or Steroid Refractory aGvHD after Bone marrow transplant
  • Prophylactic GvHD therapy with cyclosporine, tacrolimus, MMF, or sirolimus can be continued.
  • Patients with late onset acute GvHD will be eligible
  • Patients should have an absolute neutrophil count (ANC) of >500µL
  • Patients with renal dysfunction or veno-occlusive disease are eligible

Exclusion Criteria:

  • Patient should not be getting any other experimental therapy for aGvHD
  • Patients with active uncontrolled life threatening infection (s) from viral, bacterial, fungal or other organisms will be excluded. Patients with HIV infection will be excluded
  • Patients who are pregnant, breast feeding, or if sexually active and unwilling to use effective birth control for the duration of this study will be excluded
  • Patients with NYHA Class III or IV heart failure will be excluded
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01485055

Contacts
Contact: Rajinder S. Bajwa, MD 614-722-3583 rajinder.bajwa@nationwidechildrens.org
Contact: Megan M Jaeger, MPH 614 722 3686 megan.jaeger@nationwidechildrens.org

Locations
United States, Ohio
Nationwide Children's Hospital Recruiting
Columbus, Ohio, United States, 43205
Contact: Megan M Jaeger, MPH    614-722-3686    megan.jaeger@nationwidechildrens.org   
Principal Investigator: Rajinder S. Bajwa, MD         
Sponsors and Collaborators
Nationwide Children's Hospital
Ohio State University Comprehensive Cancer Center
Investigators
Principal Investigator: Rajinder S Bajwa, MD Nationwide Children's Hospital
  More Information

Publications:
Responsible Party: Rajinder Bajwa, Rajinder.P.S. Bajwa, MBBS, MD, MRCP Assitant Professor of Pediatrics at Ohio State University Department of Hematology/Oncology/BMT, Nationwide Children's Hospital
ClinicalTrials.gov Identifier: NCT01485055     History of Changes
Other Study ID Numbers: NCH-IRB11-00659
Study First Received: December 1, 2011
Last Updated: February 11, 2014
Health Authority: United States: Institutional Review Board

Keywords provided by Nationwide Children's Hospital:
aGVHD
GVHD
Graft versus host disease
Acute graft versus host disease
Steroid refractory graft versus host disease
Bone marrow transplant
BMT
HSCT
infliximab
basiliximab
Monoclonal antibody treatment

Additional relevant MeSH terms:
Graft vs Host Disease
Immune System Diseases
Antibodies
Antibodies, Monoclonal
Basiliximab
Infliximab
Immunologic Factors
Physiological Effects of Drugs
Pharmacologic Actions
Immunosuppressive Agents
Anti-Inflammatory Agents, Non-Steroidal
Analgesics, Non-Narcotic
Analgesics
Sensory System Agents
Peripheral Nervous System Agents
Anti-Inflammatory Agents
Therapeutic Uses
Antirheumatic Agents
Dermatologic Agents
Gastrointestinal Agents
Central Nervous System Agents

ClinicalTrials.gov processed this record on September 30, 2014