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Abatacept for GVHD Prophylaxis After Hematopoietic Stem Cell Transplantation for Pediatric Sickle Cell Disease

Primary Purpose

Sickle Cell Disease, Graft Versus Host Disease

Status
Unknown status
Phase
Phase 1
Locations
United States
Study Type
Interventional
Intervention
Diphenhydramine
Acetaminophen
Methylprednisolone
Meperidine
Alemtuzumab
Thymoglobulin
Fludarabine
Melphalan
Thiotepa
Cyclosporine
Tacrolimus
Methotrexate
Abatacept
Marrow infusion
Sirolimus
Mycophenolate Mofetil
Sponsored by
Monica Bhatia
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Sickle Cell Disease focused on measuring Sickle Cell Disease, Graft Versus Host Disease, Abatacept, Hematopoietic Stem Cell Transplantation

Eligibility Criteria

3 Years - 20 Years (Child, Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  1. Patients with hemoglobin (Hgb) SS or SB0 thalassemia between the ages of 3 and 20.99 years who are at least 10 kg getting an human leukocyte antigen (HLA) matched bone marrow transplant, will be eligible if they are at increased risk for graft versus host disease (GVHD) and have severe SCD.

    (a) Patients falling into one of the following three groups will be considered to be at increased risk for GVHD:

    (i) Are between 10 and 20.99 years and receiving their transplant from an HLA matched related donor.

    (ii) Are between 3 and 9.99 years and receiving their transplant from an HLA matched related donor who is at least 10 years.

    (iii) Are between 3 and 20.99 years and receiving their transplant from an HLA matched unrelated donor. Donors must be matched at the A, B, C and DRB1 loci at the allele level.

    (b) Patients who meet one of the following criteria will qualify as having severe SCD:

    (i) Previous clinical stroke, as evidenced by a neurological deficit lasting longer than 24 hours, which is accompanied by radiographic evidence of ischemic brain injury and cerebral vasculopathy.

    (ii) Asymptomatic cerebrovascular disease, as evidenced by one the following:

    • Progressive silent cerebral infarction, as evidenced by serial MRI scans that demonstrate the development of a succession of lesions (at least two temporally discreet lesions, each measuring at least 3 mm in greatest dimension on the most recent scan) or the enlargement of a single lesion, initially measuring at least 3 mm). Lesions must be visible on T2-weighted MRI sequences.
    • Cerebral arteriopathy, as evidenced by abnormal transcranial doppler (TCD) testing (confirmed elevated velocities in any single vessel of time-averaged maximum mean velocities (TAMMV) > 200 cm/sec for non-imaging TCD) or by significant vasculopathy on magnetic resonance angiogram (MRA) (greater than 50% stenosis of > 2 arterial segments or complete occlusion of any single arterial segment).

    (iii) Frequent ( ≥ 3 per year for preceding 2 years) painful vaso-occlusive episodes (defined as episode lasting ≥ 4 hours and requiring hospitalization or outpatient treatment with parenteral opioids). If patient is on hydroxurea and its use has been associated with a decrease in the frequency of episodes, the frequency should be gauged from the 2 years prior to the start of this drug.

    (iv) Recurrent ( ≥ 3 in lifetime) acute chest syndrome events which have necessitated erythrocyte transfusion therapy.

    (v) Any combination of ≥ 3 acute chest syndrome episodes and vaso-occlusive pain episodes (defined as above) yearly for 3 years. If patient is on hydroxurea and its use has been associated with a decrease in the frequency of episodes, the frequency should be gauged from the 3 years prior to the start of this drug.

  2. All patients and/or their parents or legal guardians must sign a written informed consent. Assent, when appropriate, will be obtained according to institutional guidelines.
  3. Must have been evaluated and adequately counseled regarding treatment options for severe SCD by a pediatric hematologist.
  4. Because of the elective and non-urgent nature of hematopoietic stem cell transplantation (HSCT) for SCD, it is important that all patients and families be counseled regarding fertility preservation measures available to them. All patients and/or their parents or legal guardians must indicate on the consent and assent forms that they have received this counseling.

Exclusion Criteria:

  1. Bridging (portal to portal) fibrosis or cirrhosis of the liver.
  2. Parenchymal lung disease stemming from SCD or other process defined as a diffusing capacity of the lungs for carbon monoxide (DLCO) (corrected for hemoglobin) or forced vital capacity of less than 45% of predicted. Children unable to perform pulmonary function testing will be excluded if they require daytime oxygen supplementation.
  3. Renal dysfunction with an estimated glomerular filtration rate (GFR) < 50% of predicted normal for age.
  4. Cardiac dysfunction with shortening fraction < 25%.
  5. Neurologic impairment other than hemiplegia, defined as full-scale IQ ≤70, quadriplegia or paraplegia, inability to ambulate, or any impairment resulting in decline of Lansky performance score to < 70%.
  6. Clinical stroke within 6 months of anticipated transplant.
  7. Karnofsky or Lansky functional performance score < 70%.
  8. Patient is human immunodeficiency virus (HIV) infected.
  9. Donor is HIV infected.
  10. Donor has Hgb SS, SC or SB0 thalassemia.
  11. Patient with unspecified chronic toxicity serious enough to detrimentally affect the patient's capacity to tolerate bone marrow transplantation.
  12. Patient or patient's guardian(s) unable to understand the nature and risks inherent in the bone marrow transplant (BMT) process.
  13. History of lack of compliance with medical care that would jeopardize transplant course.
  14. Donor who for psychological, physiologic, or medical reasons is unable to tolerate a bone marrow harvest or receive general anesthesia.
  15. Active viral, bacterial, fungal or protozoal infection.
  16. Donor is pregnant.
  17. Patient is pregnant.

Sites / Locations

  • Children's National Medical Center
  • Children's Healthcare of Atlanta
  • Ann & Robert H. Lurie Children's Hospital of Chicago
  • Floating Hospital for Children at Tufts Medical Center
  • Columbia University Medical Center
  • North Carolina Cancer Hospital
  • Nationwide Children's Hospital

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

Standard GVHD Prophylaxis + Abatacept

Arm Description

Subjects will receive premedication (Diphenhydramine, Acetaminophen, Methylprednisolone; and Meperidine as needed) immunosuppression (Alemtuzumab, or Thymoglobulin) conditioning regimen (Fludarabine, Thiotepa, and Melphalan) GVHD prophylaxis: calcineurin inhibitor (Cyclosporine,Tacrolimus, Sirolimus or Mycophenolate Mofetil with permission of the sponsor) and Methotrexate plus Abatacept on days -1, +5, +14 and +28, and a marrow infusion on day 0.

Outcomes

Primary Outcome Measures

Number of patients who tolerate abatacept
Patients will be deemed to be evaluable for tolerability if they received all prescribed doses of abatacept. Abatacept will deemed to be tolerated, if no more than one dose is withheld per protocol stipulations, no death from an infection that occurs within 30 days of or develops post-transplant lymphoproliferative disease (PTLD) within 100 days of receiving the last prescribed dose of abatacept.

Secondary Outcome Measures

Bearman Scale Score of Regimen-Related Toxicity (RRT)
RRT will be assessed according to Bearman Scale.
Number of infections
Infections will include viremia, posttransplant lymphoproliferative disease and immune reconstitution.

Full Information

First Posted
August 11, 2016
Last Updated
August 4, 2021
Sponsor
Monica Bhatia
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1. Study Identification

Unique Protocol Identification Number
NCT02867800
Brief Title
Abatacept for GVHD Prophylaxis After Hematopoietic Stem Cell Transplantation for Pediatric Sickle Cell Disease
Official Title
Abatacept for Graft Versus Host Disease Prophylaxis After Hematopoietic Stem Cell Transplantation for Pediatric Sickle Cell Disease: a Sickle Transplant Alliance for Research Trial
Study Type
Interventional

2. Study Status

Record Verification Date
August 2021
Overall Recruitment Status
Unknown status
Study Start Date
July 2016 (Actual)
Primary Completion Date
December 30, 2021 (Anticipated)
Study Completion Date
December 30, 2021 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor-Investigator
Name of the Sponsor
Monica Bhatia

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
To assess the tolerability of the costimulation blocking agent abatacept (CTLA4-Ig) when added to the standard graft versus host disease (GVHD) prophylaxis regimen of a calcineurin inhibitor and methotrexate in patients receiving early alemtuzumab followed by fludarabine, thiotepa, melphalan, and alemtuzumab for conditioning.
Detailed Description
Outcomes of hematopoietic stem cell transplantation (HSCT) for children and adolescents with sickle cell disease (SCD) have improved. Graft versus host disease (GVHD), however, remains a barrier to success. GVHD accounts for most of the transplant related mortality and much of the morbidity in this setting-in part through the injury it directly causes and in part through the deleterious effects of steroids and the other immunosuppressive agents used to prevent and treat it. The results of pre-clinical studies and a phase I clinical study in patients with hematologic malignancies suggest that the costimulation blocking agent CTLA4-Ig may hold promise an agent for GVHD prophylaxis. In the present trial, the investigators are assessing the tolerability of adding abatacept to standard GVHD prophylaxis-a calcineurin inhibitor and methotrexate-in pediatric SCD patients receiving early alemtuzumab (completed by day -18) followed by fludarabine, thiotepa, and melphalan for conditioning. This trial will provide the foundation for subsequent trials designed to test the long-term hypothesis that abatacept is a safe, steroid-sparing effective adjunct to standard GVHD prophylaxis in this setting.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Sickle Cell Disease, Graft Versus Host Disease
Keywords
Sickle Cell Disease, Graft Versus Host Disease, Abatacept, Hematopoietic Stem Cell Transplantation

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 1
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
24 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Standard GVHD Prophylaxis + Abatacept
Arm Type
Experimental
Arm Description
Subjects will receive premedication (Diphenhydramine, Acetaminophen, Methylprednisolone; and Meperidine as needed) immunosuppression (Alemtuzumab, or Thymoglobulin) conditioning regimen (Fludarabine, Thiotepa, and Melphalan) GVHD prophylaxis: calcineurin inhibitor (Cyclosporine,Tacrolimus, Sirolimus or Mycophenolate Mofetil with permission of the sponsor) and Methotrexate plus Abatacept on days -1, +5, +14 and +28, and a marrow infusion on day 0.
Intervention Type
Drug
Intervention Name(s)
Diphenhydramine
Other Intervention Name(s)
Benadryl
Intervention Description
(Standard of Care) Premedication Diphenhydramine: 1 mg/kg IV or PO q 8 hours (maximum=50 mg)
Intervention Type
Drug
Intervention Name(s)
Acetaminophen
Other Intervention Name(s)
Tylenol
Intervention Description
(Standard of Care) Premedication Acetaminophen: 10-15 mg/kg PO q 6 hours (maximum=1000 mg)
Intervention Type
Drug
Intervention Name(s)
Methylprednisolone
Other Intervention Name(s)
Medrol
Intervention Description
(Standard of Care) Premedication Methylprednisolone: 0.25-0.5 mg/kg IV q 6 hours
Intervention Type
Drug
Intervention Name(s)
Meperidine
Other Intervention Name(s)
Demerol
Intervention Description
(Standard of Care) Premedication Use as needed (PRN) Meperidine: 0.5 mg/kg IV q 4-6 hours (for rigors)
Intervention Type
Drug
Intervention Name(s)
Alemtuzumab
Other Intervention Name(s)
Lemtrada
Intervention Description
(Standard of Care) Immunosuppression Alemtuzumab: A test dose of alemtuzumab, 3 mg, should be administered IV over 2 hours the first day. If the test dose is tolerated, administration of three treatment doses should begin within 24 hours. The three treatment doses should be administered on consecutive days. 10 mg/m2 should be given the first day, 15 mg/m2 the second and 20 mg/m2 the third.
Intervention Type
Drug
Intervention Name(s)
Thymoglobulin
Other Intervention Name(s)
Genzyme
Intervention Description
(Standard of Care) Immunosuppression Thymoglobulin: A 4 mg/kg dose of anti-thymocyte globulin should be administered in place of each alemtuzumab dose not completed.
Intervention Type
Drug
Intervention Name(s)
Fludarabine
Other Intervention Name(s)
Fludara
Intervention Description
(Standard Conditioning Regimen) Fludarabine should be administered 30 mg/m2 IV daily for five days. It should be infused over 30 to 60 minutes.
Intervention Type
Drug
Intervention Name(s)
Melphalan
Other Intervention Name(s)
Alkeran
Intervention Description
(Standard Conditioning Regimen) Melphalan should be administered 140 mg/m2 IV 3 days before marrow infusion. It should be infused within 60 minutes of preparation and over a maximum of 30 minutes. It should be infused immediately after the fludarabine infusion is complete.
Intervention Type
Drug
Intervention Name(s)
Thiotepa
Other Intervention Name(s)
Thioplex
Intervention Description
(Standard Conditioning Regimen) Thiotepa should be administered 8 mg/kg IV 3 days before marrow infusion. It should be infused immediately after the fludarabine infusion is complete. The thiotepa should be infused over one hour.
Intervention Type
Drug
Intervention Name(s)
Cyclosporine
Other Intervention Name(s)
Neoral
Intervention Description
(Standard GVHD Prophylaxis) Calcineurin inhibitor Cyclosporine: Administration will commence no later than at least 36 hours before marrow infusion; Cyclosporine doses will be adjusted to maintain a level of 150-300 ng/ml.
Intervention Type
Drug
Intervention Name(s)
Tacrolimus
Other Intervention Name(s)
Protopic
Intervention Description
(Standard GVHD Prophylaxis) Calcineurin inhibitor Tacrolimus: Administration will commence no later than at least 36 hours before marrow infusion; Tacrolimus doses will be adjusted to maintain a level of 8-15 ng/ml.
Intervention Type
Drug
Intervention Name(s)
Methotrexate
Other Intervention Name(s)
Trexall
Intervention Description
(Standard GVHD Prophylaxis) Methotrexate will be given at a dose of 15 mg/m2 IV on day 1 and a dose of 10 mg/m2 IV on days 3, 6 and 11. Dosing shall be based on actual weight.
Intervention Type
Drug
Intervention Name(s)
Abatacept
Other Intervention Name(s)
CTLA4-Ig, Orencia
Intervention Description
(Investigational) Abatacept will be administered intravenously at a dose of 10 mg/kg based on actual weight with a maximum of 750 mg. In cases where the calculated dose is less than or equal to 110% of a simple multiple of a 250 mg vial: 250 mg (275mg), 500 mg (550 mg) or 750 mg (825 mg), the dose may be rounded down to the nearest multiple. No rounding up of the abatacept dose is permitted.
Intervention Type
Procedure
Intervention Name(s)
Marrow infusion
Other Intervention Name(s)
stem cell transplant
Intervention Description
(Standard) A procedure that infuses healthy cells, called stem cells, into your body to replace damaged or diseased bone marrow. A bone marrow transplant may also be used to treat certain types of cancer
Intervention Type
Drug
Intervention Name(s)
Sirolimus
Other Intervention Name(s)
Rapamune
Intervention Description
(Standard GVHD Prophylaxis) Calcineurin inhibitor (cyclosporine or tacrolimus or with permission of the sponsor: sirolimus or mycophenolate mofetil (MMF)) administration will commence no later than day -2 (at least 36 hours before the stem cell infusion); cyclosporine doses will be adjusted to maintain a level of 150-300 ng/ml. This range assumes monitoring by mass spectrometry. If an immunoassay is used instead, the equivalent range for that immunoassay should be used.
Intervention Type
Drug
Intervention Name(s)
Mycophenolate Mofetil
Other Intervention Name(s)
MMF
Intervention Description
(Standard GVHD Prophylaxis) Calcineurin inhibitor (cyclosporine or tacrolimus or with permission of the sponsor: sirolimus or mycophenolate mofetil (MMF)) administration will commence no later than day -2 (at least 36 hours before the stem cell infusion); cyclosporine doses will be adjusted to maintain a level of 150-300 ng/ml. This range assumes monitoring by mass spectrometry. If an immunoassay is used instead, the equivalent range for that immunoassay should be used.
Primary Outcome Measure Information:
Title
Number of patients who tolerate abatacept
Description
Patients will be deemed to be evaluable for tolerability if they received all prescribed doses of abatacept. Abatacept will deemed to be tolerated, if no more than one dose is withheld per protocol stipulations, no death from an infection that occurs within 30 days of or develops post-transplant lymphoproliferative disease (PTLD) within 100 days of receiving the last prescribed dose of abatacept.
Time Frame
Within 100 days of receiving the last prescribed dose of abatacept
Secondary Outcome Measure Information:
Title
Bearman Scale Score of Regimen-Related Toxicity (RRT)
Description
RRT will be assessed according to Bearman Scale.
Time Frame
Day 42 post-transplant
Title
Number of infections
Description
Infections will include viremia, posttransplant lymphoproliferative disease and immune reconstitution.
Time Frame
Up to 180 days post transplant

10. Eligibility

Sex
All
Minimum Age & Unit of Time
3 Years
Maximum Age & Unit of Time
20 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients with hemoglobin (Hgb) SS or SB0 thalassemia between the ages of 3 and 20.99 years who are at least 10 kg getting an human leukocyte antigen (HLA) matched bone marrow transplant, will be eligible if they are at increased risk for graft versus host disease (GVHD) and have severe SCD. (a) Patients falling into one of the following three groups will be considered to be at increased risk for GVHD: (i) Are between 10 and 20.99 years and receiving their transplant from an HLA matched related donor. (ii) Are between 3 and 9.99 years and receiving their transplant from an HLA matched related donor who is at least 10 years. (iii) Are between 3 and 20.99 years and receiving their transplant from an HLA matched unrelated donor. Donors must be matched at the A, B, C and DRB1 loci at the allele level. (b) Patients who meet one of the following criteria will qualify as having severe SCD: (i) Previous clinical stroke, as evidenced by a neurological deficit lasting longer than 24 hours, which is accompanied by radiographic evidence of ischemic brain injury and cerebral vasculopathy. (ii) Asymptomatic cerebrovascular disease, as evidenced by one the following: Progressive silent cerebral infarction, as evidenced by serial MRI scans that demonstrate the development of a succession of lesions (at least two temporally discreet lesions, each measuring at least 3 mm in greatest dimension on the most recent scan) or the enlargement of a single lesion, initially measuring at least 3 mm). Lesions must be visible on T2-weighted MRI sequences. Cerebral arteriopathy, as evidenced by abnormal transcranial doppler (TCD) testing (confirmed elevated velocities in any single vessel of time-averaged maximum mean velocities (TAMMV) > 200 cm/sec for non-imaging TCD) or by significant vasculopathy on magnetic resonance angiogram (MRA) (greater than 50% stenosis of > 2 arterial segments or complete occlusion of any single arterial segment). (iii) Frequent ( ≥ 3 per year for preceding 2 years) painful vaso-occlusive episodes (defined as episode lasting ≥ 4 hours and requiring hospitalization or outpatient treatment with parenteral opioids). If patient is on hydroxurea and its use has been associated with a decrease in the frequency of episodes, the frequency should be gauged from the 2 years prior to the start of this drug. (iv) Recurrent ( ≥ 3 in lifetime) acute chest syndrome events which have necessitated erythrocyte transfusion therapy. (v) Any combination of ≥ 3 acute chest syndrome episodes and vaso-occlusive pain episodes (defined as above) yearly for 3 years. If patient is on hydroxurea and its use has been associated with a decrease in the frequency of episodes, the frequency should be gauged from the 3 years prior to the start of this drug. All patients and/or their parents or legal guardians must sign a written informed consent. Assent, when appropriate, will be obtained according to institutional guidelines. Must have been evaluated and adequately counseled regarding treatment options for severe SCD by a pediatric hematologist. Because of the elective and non-urgent nature of hematopoietic stem cell transplantation (HSCT) for SCD, it is important that all patients and families be counseled regarding fertility preservation measures available to them. All patients and/or their parents or legal guardians must indicate on the consent and assent forms that they have received this counseling. Exclusion Criteria: Bridging (portal to portal) fibrosis or cirrhosis of the liver. Parenchymal lung disease stemming from SCD or other process defined as a diffusing capacity of the lungs for carbon monoxide (DLCO) (corrected for hemoglobin) or forced vital capacity of less than 45% of predicted. Children unable to perform pulmonary function testing will be excluded if they require daytime oxygen supplementation. Renal dysfunction with an estimated glomerular filtration rate (GFR) < 50% of predicted normal for age. Cardiac dysfunction with shortening fraction < 25%. Neurologic impairment other than hemiplegia, defined as full-scale IQ ≤70, quadriplegia or paraplegia, inability to ambulate, or any impairment resulting in decline of Lansky performance score to < 70%. Clinical stroke within 6 months of anticipated transplant. Karnofsky or Lansky functional performance score < 70%. Patient is human immunodeficiency virus (HIV) infected. Donor is HIV infected. Donor has Hgb SS, SC or SB0 thalassemia. Patient with unspecified chronic toxicity serious enough to detrimentally affect the patient's capacity to tolerate bone marrow transplantation. Patient or patient's guardian(s) unable to understand the nature and risks inherent in the bone marrow transplant (BMT) process. History of lack of compliance with medical care that would jeopardize transplant course. Donor who for psychological, physiologic, or medical reasons is unable to tolerate a bone marrow harvest or receive general anesthesia. Active viral, bacterial, fungal or protozoal infection. Donor is pregnant. Patient is pregnant.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Monica Bhatia, MD
Organizational Affiliation
Columbia University
Official's Role
Study Chair
Facility Information:
Facility Name
Children's National Medical Center
City
Washington
State/Province
District of Columbia
ZIP/Postal Code
20010
Country
United States
Facility Name
Children's Healthcare of Atlanta
City
Atlanta
State/Province
Georgia
ZIP/Postal Code
30322
Country
United States
Facility Name
Ann & Robert H. Lurie Children's Hospital of Chicago
City
Chicago
State/Province
Illinois
ZIP/Postal Code
60611
Country
United States
Facility Name
Floating Hospital for Children at Tufts Medical Center
City
Boston
State/Province
Massachusetts
ZIP/Postal Code
02111
Country
United States
Facility Name
Columbia University Medical Center
City
New York
State/Province
New York
ZIP/Postal Code
10032
Country
United States
Facility Name
North Carolina Cancer Hospital
City
Chapel Hill
State/Province
North Carolina
ZIP/Postal Code
27514
Country
United States
Facility Name
Nationwide Children's Hospital
City
Columbus
State/Province
Ohio
ZIP/Postal Code
43205
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
No

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Abatacept for GVHD Prophylaxis After Hematopoietic Stem Cell Transplantation for Pediatric Sickle Cell Disease

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