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Treatment for Acute Graft-Versus-Host Disease (BMT CTN 0302)

Primary Purpose

Graft vs Host Disease, Immune System Disorders

Status
Completed
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Etanercept
Mycophenolate Mofetil
Denileukin Diftitox
Pentostatin
Sponsored by
National Heart, Lung, and Blood Institute (NHLBI)
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Graft vs Host Disease focused on measuring Acute Graft vs Host Disease, GVHD

Eligibility Criteria

2 Years - undefined (Child, Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Prior allogeneic hematopoietic stem cell transplant using either bone marrow, peripheral blood stem cells, or cord blood De novo acute GVHD diagnosed within 48 hours prior to enrollment; biopsy confirmation of GVHD is strongly recommended but not required; enrollment should not be delayed awaiting biopsy or pathology results; the patient must have had no previous systemic immune suppressive therapy given for treatment of acute GVHD except for a maximum 48 hours of prior corticosteroid therapy (at least 1 mg/kg/day methylprednisolone) Patients that have undergone a scheduled donor lymphocyte infusion (DLI) as part of their original transplant therapy plan Absolute neutrophil count (ANC) greater than 500/µL Clinical status at enrollment to allow tapering of steroids to not less than 1 mg/kg/day methylprednisolone (1.4 mg/kg/day prednisone) at Day 28 of therapy (e.g., persisting malignant disease suggesting the need for accelerated taper of immunosuppression) Estimated creatinine clearance greater than 30 mL/minute Assent and educational materials provided to, and reviewed with, patients under the age of 18 Exclusion Criteria: ONTAK, pentostatin, or etanercept given within 7 days of enrollment Active uncontrolled infection Patients that have undergone an unscheduled DLI, or DLI that was not part of their original transplant therapy plan If any prior steroid therapy (for indication other than GVHD), treatment at doses of at least 0.5 mg/kg/day methylprednisolone within 7 days prior to onset of GVHD Patients unlikely to be available at the transplant center on Day 28 and 56 of therapy A clinical syndrome resembling de novo chronic GVHD developing at any time after allotransplantation (see Chapter 2 of the BMT CTN Manual of Procedures for details of de novo chronic GVHD) Other investigational therapeutics for GVHD within 30 days, including agents used for GVHD prophylaxis Patients who are pregnant, breast feeding, or if sexually active, unwilling to use effective birth control for the duration of the study Adults unable to provide informed consent Patients with a history of intolerance to any of the study drugs

Sites / Locations

  • City of Hope National Medical Center
  • University of California
  • Stanford Hospital and Clinics
  • University of Florida College of Medicine (Shands)
  • Johns Hopkins/SKCCC
  • DFCI/Brigham & Women's Hospital
  • University of Michigan Medical Center
  • University of Minnesota
  • Washington University/Barnes Jewish Hospital
  • University of Nebraska Medical Center
  • Hackensack University Medical Center
  • Memorial Sloan-Kettering Cancer Center
  • Duke University Medical Center (Peds)
  • University Hospitals of Cleveland/Case Western
  • Oregon Health Sciences University
  • University of Pennsylvania Cancer Center
  • University of Texas/MD Anderson CRC
  • Texas Transplant Institute
  • Fred Hutchinson Cancer Research Center

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm 4

Arm Type

Experimental

Experimental

Experimental

Experimental

Arm Label

Etanercept

Mycophenolate Mofetil

Denileukin Diftitox

Pentostatin

Arm Description

Enroll within 48 hours of new onset acute GVHD and randomize to Etanercept

Enroll within 48 hours of new onset acute GVHD and randomize to Mycophenolate Mofetil

Enroll within 48 hours of new onset acute GVHD and randomize to Denileukin Diftitox

Enroll within 48 hours of new onset acute GVHD and randomize to Pentostatin

Outcomes

Primary Outcome Measures

Number of Complete Response (CR) at Day 28 of Therapy
Complete response at day 28 after randomization. CR was defined as resolution of all signs and symptoms of Graft-Versus-Host Disease (GVHD) in all evaluable organs in comparison to Day 1 scoring.

Secondary Outcome Measures

Number of Partial Response (PR), Mixed Response (MR), and Progression
Partial response, mixed response, and progression at Day 28 after randomization. Partial response was defined as improvement in one or more organs involved with Graft-Versus-Host Disease (GVHD) symptoms without progression in others. Mixed response was defined as improvement in one or more organs with deterioration in another organ manifesting symptoms of GVHD or development of symptoms of GVHD in a new organ. Progression was defined as deterioration in at least one organ without any improvement in others.
Proportion of Treatment Failure
Number of Patients With Acute Graft-versus-host Disease (GVHD) Flares at Day 90
Flares were defined as any increase in symptoms of or therapy for acute GVHD after an initial response (i.e., progression from an earlier CR or PR).
Number of Patients Discontinuing Immune Suppression Without Flare
Immunosuppression discontinuation was defined as the discontinuation of corticosteroids and all additional immunosuppressives, except cyclosporine or tacrolimus, for treatment of acute GVHD without subsequent flare by Day 90 post-initiation of therapy and later by discontinuation of all immunosuppressive medications, including cyclosporine or tacrolimus.
Number of Patients With Chronic Graft-versus-host Disease (GVHD)
Number of patients with limited and extensive chronic GVHD at 9 months
Number of Patients Surviving at 6 and 9 Months Post Randomization
Cumulative Incidence of Systemic Infections
Incidence of Epstein-Barr Virus (EBV)-Associated Lymphoma

Full Information

First Posted
September 21, 2005
Last Updated
October 19, 2021
Sponsor
National Heart, Lung, and Blood Institute (NHLBI)
Collaborators
National Cancer Institute (NCI), Blood and Marrow Transplant Clinical Trials Network
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1. Study Identification

Unique Protocol Identification Number
NCT00224874
Brief Title
Treatment for Acute Graft-Versus-Host Disease (BMT CTN 0302)
Official Title
Initial Systemic Treatment of Acute GVHD: A Phase II Randomized Trial Evaluating Etanercept, Mycophenolate Mofetil (MMF), Denileukin Diftitox (ONTAK), and Pentostatin in Combination With Corticosteroids (BMT CTN #0302)
Study Type
Interventional

2. Study Status

Record Verification Date
August 2017
Overall Recruitment Status
Completed
Study Start Date
September 2005 (undefined)
Primary Completion Date
January 2009 (Actual)
Study Completion Date
June 2012 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
National Heart, Lung, and Blood Institute (NHLBI)
Collaborators
National Cancer Institute (NCI), Blood and Marrow Transplant Clinical Trials Network

4. Oversight

Data Monitoring Committee
Yes

5. Study Description

Brief Summary
The study is a randomized Phase II, four arm treatment trial. The primary purpose of the study is to define new agents with promising activity against acute graft-versus-host disease (GVHD) suitable for testing against corticosteroids alone in a subsequent Phase III trial.
Detailed Description
BACKGROUND: Acute graft-versus-host disease (GVHD) is the major complication of allogeneic hematopoietic stem cell (HSC) transplantation. Acute GVHD produces significant morbidity and complicates patient management resulting in organ toxicity, frequent infections, malnutrition, and substantial delay in recovery from transplantation. Corticosteroids have been the primary therapy for acute GVHD for over three decades. Various additional immunosuppressive strategies have been tested as GVHD therapy but neither anti-thymocyte globulin (ATG), CD5-immunotoxins, IL-1 antagonists nor other agents have been demonstrably helpful in either control of GVHD symptoms or improvement in survival. Published response rates of complete response (CR) to acute GVHD therapy with corticosteroids range from 25-41%. These rates will be used as benchmarks for assessing efficacy of promising new agents. New immunosuppressive agents and strategies are required to improve the management of GVHD and decrease the toxicities of the immunosuppressive regimens. DESIGN NARRATIVE: In this trial, patients with newly diagnosed acute GVHD will be randomly assigned to receive corticosteroids plus one of four new agents (etanercept, MMF, denileukin diftitox [Ontak], and pentostatin). A control arm of only corticosteroids will not be employed. Each agent will be assessed for safety and efficacy (at least 35% complete remission [CR] rate at Day 28 of therapy can be expected from previously untreated patients).

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Graft vs Host Disease, Immune System Disorders
Keywords
Acute Graft vs Host Disease, GVHD

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
180 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Etanercept
Arm Type
Experimental
Arm Description
Enroll within 48 hours of new onset acute GVHD and randomize to Etanercept
Arm Title
Mycophenolate Mofetil
Arm Type
Experimental
Arm Description
Enroll within 48 hours of new onset acute GVHD and randomize to Mycophenolate Mofetil
Arm Title
Denileukin Diftitox
Arm Type
Experimental
Arm Description
Enroll within 48 hours of new onset acute GVHD and randomize to Denileukin Diftitox
Arm Title
Pentostatin
Arm Type
Experimental
Arm Description
Enroll within 48 hours of new onset acute GVHD and randomize to Pentostatin
Intervention Type
Drug
Intervention Name(s)
Etanercept
Other Intervention Name(s)
ENBREL®
Intervention Description
Etanercept [25 mg subcutaneously twice weekly for up to 4 weeks; discontinue if in complete response by 4 weeks].
Intervention Type
Drug
Intervention Name(s)
Mycophenolate Mofetil
Other Intervention Name(s)
CellCept®
Intervention Description
Mycophenolate mofetil (MMF) [20 mg/kg (maximum 1 gm) orally or intravenously twice daily; continue through prednisone taper, then taper MMF over 4 weeks].
Intervention Type
Drug
Intervention Name(s)
Denileukin Diftitox
Other Intervention Name(s)
ONTAK®
Intervention Description
Denileukin Diftitox (ONTAK®) [9 mcg/kg intravenously Days 1, 3, 5, 15, 17, 19].
Intervention Type
Drug
Intervention Name(s)
Pentostatin
Other Intervention Name(s)
Nipent®
Intervention Description
Pentostatin [1.5 mg/m2 daily for 3 days; Days 1-3 and repeat Days 15-17
Primary Outcome Measure Information:
Title
Number of Complete Response (CR) at Day 28 of Therapy
Description
Complete response at day 28 after randomization. CR was defined as resolution of all signs and symptoms of Graft-Versus-Host Disease (GVHD) in all evaluable organs in comparison to Day 1 scoring.
Time Frame
Measured at Day 28
Secondary Outcome Measure Information:
Title
Number of Partial Response (PR), Mixed Response (MR), and Progression
Description
Partial response, mixed response, and progression at Day 28 after randomization. Partial response was defined as improvement in one or more organs involved with Graft-Versus-Host Disease (GVHD) symptoms without progression in others. Mixed response was defined as improvement in one or more organs with deterioration in another organ manifesting symptoms of GVHD or development of symptoms of GVHD in a new organ. Progression was defined as deterioration in at least one organ without any improvement in others.
Time Frame
Measured at Day 28
Title
Proportion of Treatment Failure
Time Frame
Measured at Day 56
Title
Number of Patients With Acute Graft-versus-host Disease (GVHD) Flares at Day 90
Description
Flares were defined as any increase in symptoms of or therapy for acute GVHD after an initial response (i.e., progression from an earlier CR or PR).
Time Frame
Measured at Day 90
Title
Number of Patients Discontinuing Immune Suppression Without Flare
Description
Immunosuppression discontinuation was defined as the discontinuation of corticosteroids and all additional immunosuppressives, except cyclosporine or tacrolimus, for treatment of acute GVHD without subsequent flare by Day 90 post-initiation of therapy and later by discontinuation of all immunosuppressive medications, including cyclosporine or tacrolimus.
Time Frame
Measured at Days 90, 180, and 270 post-treatment
Title
Number of Patients With Chronic Graft-versus-host Disease (GVHD)
Description
Number of patients with limited and extensive chronic GVHD at 9 months
Time Frame
Measured at 9 months
Title
Number of Patients Surviving at 6 and 9 Months Post Randomization
Time Frame
Measured at 6 and 9 months
Title
Cumulative Incidence of Systemic Infections
Time Frame
Measured at Day 270
Title
Incidence of Epstein-Barr Virus (EBV)-Associated Lymphoma
Time Frame
Measured at 9 months

10. Eligibility

Sex
All
Minimum Age & Unit of Time
2 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Prior allogeneic hematopoietic stem cell transplant using either bone marrow, peripheral blood stem cells, or cord blood De novo acute GVHD diagnosed within 48 hours prior to enrollment; biopsy confirmation of GVHD is strongly recommended but not required; enrollment should not be delayed awaiting biopsy or pathology results; the patient must have had no previous systemic immune suppressive therapy given for treatment of acute GVHD except for a maximum 48 hours of prior corticosteroid therapy (at least 1 mg/kg/day methylprednisolone) Patients that have undergone a scheduled donor lymphocyte infusion (DLI) as part of their original transplant therapy plan Absolute neutrophil count (ANC) greater than 500/µL Clinical status at enrollment to allow tapering of steroids to not less than 1 mg/kg/day methylprednisolone (1.4 mg/kg/day prednisone) at Day 28 of therapy (e.g., persisting malignant disease suggesting the need for accelerated taper of immunosuppression) Estimated creatinine clearance greater than 30 mL/minute Assent and educational materials provided to, and reviewed with, patients under the age of 18 Exclusion Criteria: ONTAK, pentostatin, or etanercept given within 7 days of enrollment Active uncontrolled infection Patients that have undergone an unscheduled DLI, or DLI that was not part of their original transplant therapy plan If any prior steroid therapy (for indication other than GVHD), treatment at doses of at least 0.5 mg/kg/day methylprednisolone within 7 days prior to onset of GVHD Patients unlikely to be available at the transplant center on Day 28 and 56 of therapy A clinical syndrome resembling de novo chronic GVHD developing at any time after allotransplantation (see Chapter 2 of the BMT CTN Manual of Procedures for details of de novo chronic GVHD) Other investigational therapeutics for GVHD within 30 days, including agents used for GVHD prophylaxis Patients who are pregnant, breast feeding, or if sexually active, unwilling to use effective birth control for the duration of the study Adults unable to provide informed consent Patients with a history of intolerance to any of the study drugs
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Mary Horowitz, MD
Organizational Affiliation
Center for International Blood and Marrow Transplant Research
Official's Role
Study Director
Facility Information:
Facility Name
City of Hope National Medical Center
City
Duarte
State/Province
California
ZIP/Postal Code
91010
Country
United States
Facility Name
University of California
City
San Diego
State/Province
California
ZIP/Postal Code
92093
Country
United States
Facility Name
Stanford Hospital and Clinics
City
Stanford
State/Province
California
ZIP/Postal Code
94305
Country
United States
Facility Name
University of Florida College of Medicine (Shands)
City
Gainesville
State/Province
Florida
ZIP/Postal Code
32610
Country
United States
Facility Name
Johns Hopkins/SKCCC
City
Baltimore
State/Province
Maryland
ZIP/Postal Code
21231
Country
United States
Facility Name
DFCI/Brigham & Women's Hospital
City
Boston
State/Province
Massachusetts
ZIP/Postal Code
02114
Country
United States
Facility Name
University of Michigan Medical Center
City
Ann Arbor
State/Province
Michigan
ZIP/Postal Code
48109
Country
United States
Facility Name
University of Minnesota
City
Minneapolis
State/Province
Minnesota
ZIP/Postal Code
55455
Country
United States
Facility Name
Washington University/Barnes Jewish Hospital
City
Saint Louis
State/Province
Missouri
ZIP/Postal Code
63110
Country
United States
Facility Name
University of Nebraska Medical Center
City
Omaha
State/Province
Nebraska
ZIP/Postal Code
68198
Country
United States
Facility Name
Hackensack University Medical Center
City
Hackensack
State/Province
New Jersey
ZIP/Postal Code
07601
Country
United States
Facility Name
Memorial Sloan-Kettering Cancer Center
City
New York
State/Province
New York
ZIP/Postal Code
10021
Country
United States
Facility Name
Duke University Medical Center (Peds)
City
Durham
State/Province
North Carolina
ZIP/Postal Code
27705
Country
United States
Facility Name
University Hospitals of Cleveland/Case Western
City
Cleveland
State/Province
Ohio
ZIP/Postal Code
44106
Country
United States
Facility Name
Oregon Health Sciences University
City
Portland
State/Province
Oregon
ZIP/Postal Code
97239
Country
United States
Facility Name
University of Pennsylvania Cancer Center
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
Facility Name
University of Texas/MD Anderson CRC
City
Houston
State/Province
Texas
ZIP/Postal Code
77030
Country
United States
Facility Name
Texas Transplant Institute
City
San Antonio
State/Province
Texas
ZIP/Postal Code
78229
Country
United States
Facility Name
Fred Hutchinson Cancer Research Center
City
Seattle
State/Province
Washington
ZIP/Postal Code
98109
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
Yes
IPD Sharing Plan Description
Results will be published in a manuscript and supporting information submitted to NIH BioLINCC (including data dictionaries, case report forms, data submission documentation, documentation for outcomes dataset, etc where indicated).
IPD Sharing Time Frame
Within 6 months of official study closure at participating sites.
IPD Sharing Access Criteria
Available to the public
IPD Sharing URL
https://biolincc.nhlbi.nih.gov/home/
Citations:
PubMed Identifier
19443659
Citation
Alousi AM, Weisdorf DJ, Logan BR, Bolanos-Meade J, Carter S, Difronzo N, Pasquini M, Goldstein SC, Ho VT, Hayes-Lattin B, Wingard JR, Horowitz MM, Levine JE; Blood and Marrow Transplant Clinical Trials Network. Etanercept, mycophenolate, denileukin, or pentostatin plus corticosteroids for acute graft-versus-host disease: a randomized phase 2 trial from the Blood and Marrow Transplant Clinical Trials Network. Blood. 2009 Jul 16;114(3):511-7. doi: 10.1182/blood-2009-03-212290. Epub 2009 May 14.
Results Reference
result
PubMed Identifier
19925875
Citation
Jacobson PA, Huang J, Wu J, Kim M, Logan B, Alousi A, Grimley M, Bolanos-Meade J, Ho V, Levine JE, Weisdorf D. Mycophenolate pharmacokinetics and association with response to acute graft-versus-host disease treatment from the Blood and Marrow Transplant Clinical Trials Network. Biol Blood Marrow Transplant. 2010 Mar;16(3):421-9. doi: 10.1016/j.bbmt.2009.11.010.
Results Reference
result
PubMed Identifier
20541024
Citation
Levine JE, Logan B, Wu J, Alousi AM, Ho V, Bolanos-Meade J, Weisdorf D; Blood and Marrow Transplant Clinical Trials Network. Graft-versus-host disease treatment: predictors of survival. Biol Blood Marrow Transplant. 2010 Dec;16(12):1693-9. doi: 10.1016/j.bbmt.2010.05.019. Epub 2010 Jun 9.
Results Reference
result
PubMed Identifier
22383800
Citation
Levine JE, Logan BR, Wu J, Alousi AM, Bolanos-Meade J, Ferrara JL, Ho VT, Weisdorf DJ, Paczesny S. Acute graft-versus-host disease biomarkers measured during therapy can predict treatment outcomes: a Blood and Marrow Transplant Clinical Trials Network study. Blood. 2012 Apr 19;119(16):3854-60. doi: 10.1182/blood-2012-01-403063. Epub 2012 Mar 1.
Results Reference
derived

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Treatment for Acute Graft-Versus-Host Disease (BMT CTN 0302)

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