A Study to Evaluate Steroid-free Treatment for Standard-Risk aGVHD (BMT CTN 1501)

Acute GVHD Clinical Trial

Official title:

A Randomized, Phase II, Multicenter, Open Label, Study Evaluating Sirolimus and Prednisone in Patients With Refined Minnesota Standard Risk, Ann Arbor 1/2 Confirmed Acute Graft-Versus-Host Disease (BMT CTN 1501)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02806947
• Other study ID #: BMT CTN 1501
• Secondary ID: 2U10HL069294-115
• Status: Completed
• Phase: Phase 2
• Start date: October 2016
• Est. completion date: February 19, 2019

Study information

• Verified date: June 2019
• Source: Medical College of Wisconsin
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The study is a Phase II randomized, open label, multicenter trial designed to identify whether sirolimus is a potential alternative to prednisone as an up-front treatment for patients with standard-risk acute GVHD defined according to clinical and biomarker-based risk stratification. This trial incorporates both a novel up front GVHD therapy (sirolimus) as well as a novel BMT CTN developed acute GVHD biomarker test.

Description:

The study is a Phase II randomized, open label, multicenter trial designed to identify whether sirolimus is a potential alternative to prednisone as an up-front treatment for patients with standard-risk acute GVHD defined according to clinical and biomarker-based risk stratification.

Patients with previously untreated, standard-risk acute GVHD, according to the refined Minnesota Criteria, who are in need of systemic therapy, will have a 5 mL blood sample collected prior to randomization to assess their biomarker Ann Arbor Risk status. Ann Arbor scoring results will be provided 48-72 hours after randomization. Patients will begin their study treatment assignments within 24 hours of randomization. Those with biomarker results of combined AA1/2 risk will continue on their randomized study treatment and will be included for primary endpoint analysis (Day 28 complete or partial response) and all planned study procedures and assessments. In contrast, patients with AA3 biomarker risk and those patients with missing biomarker results may continue on their randomized therapies or start another therapy at their physicians' discretion. In addition, AA3 risk patients and those with missing results will not be considered in primary endpoint analysis, but will be included in a subset analysis.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 127
• Est. completion date: February 19, 2019
• Est. primary completion date: August 17, 2018
• Accepts healthy volunteers: No
• Gender: All
• Age group: N/A and older

Eligibility

Inclusion Criteria:

1. Patients with standard-risk acute GVHD, according to refined Minnesota Criteria. Refined Minnesota Criteria are available at https://redcap.ahc.umn.edu/surveys/?s=bNmFhseJIf.

Standard-risk acute GVHD according to the refined Minnesota Risk Criteria requires meeting one of the criteria below:

1. Single organ involvement (Stage 1-3 skin, Stage 1 upper GI, or Stage 1-2 lower GI)

2. Multiple organ involvement (Stage 1-3 skin plus stage 1 upper GI, Stage 1-3 skin plus stage 1 lower GI, Stage 1-3 skin plus stage 1 lower GI plus stage 1 upper GI, Stage 1-3 skin plus stage 1-4 liver, or Stage 1 lower GI plus stage 1 upper GI)

2. Acute Minnesota Standard Risk GVHD requiring systemic immune suppressive therapy.

3. Acute GVHD developing after allogeneic hematopoietic cell transplantation using either bone marrow, peripheral blood, or umbilical cord blood. Recipients of non-myeloablative, reduced intensity conditioning and myeloablative transplants are eligible. All allogeneic donor sources are permitted, including siblings, unrelated donors, human leukocyte antigen (HLA)-haploidentical related donors and umbilical cord blood.

4. Patients NOT receiving systemic immune suppressive therapy for treatment of active GVHD (topical skin and GI corticosteroids are allowed).

5. Ability to tolerate oral or enterically-administered medications.

6. Patients of all ages.

7. Absolute neutrophil count (ANC) greater than 500/µL.

8. Biopsy confirmation of GVHD is not required. Enrollment should not be delayed for biopsy or pathology results unless local institutional practice mandates biopsy confirmation to make a GVHD treatment decision.

9. Written informed consent and/or assent from patient, parent or guardian.

10. Collection of a 5 ml blood sample (red top for serum) from the patient for Ann Arbor Scoring and ready to be shipped immediately after randomization.

Exclusion Criteria:

1. Patients receiving sirolimus (for any indication including GVHD prophylaxis) within 14 days of screening for enrollment.

2. Relapsed, progressing or persistent malignancy requiring withdrawal of systemic immune suppression.

3. Patients with acute GVHD developing after a donor lymphocyte infusion.

4. Active or recent (within 7 days) episode of transplant associated microangiopathy.

5. Patients with uncontrolled infections will be excluded. Infections are considered controlled if appropriate therapy has been instituted and, at the time of enrollment, no signs of progression are present. Progression of infection is defined as hemodynamic instability attributable to sepsis, new symptoms, worsening physical signs or radiographic findings attributable to infection. Persisting fever without other signs or symptoms will not be interpreted as progressing infection.

6. Patients unlikely to be available for evaluation at the transplant center on Day 28 and 56 of therapy.

7. A clinical presentation resembling de novo chronic GVHD or overlap syndrome developing before or present at the time of enrollment.

8. Patients receiving corticosteroids for any indication within 7 days before the onset of acute GVHD, except the following: Stable replacement doses of corticosteroids for adrenal insufficiency are permitted (e.g. hydrocortisone total dose of 10-12 mg/m^2/day or prednisone 5-7.5mg daily or equivalent). Corticosteroids administered as premedication before transfusion of blood products or before intravenous medications to prevent infusion reactions are allowed.

9. Patients who are pregnant or breastfeeding.

10. Females of childbearing potential (FCBP) or a man who has sexual contact with a FCBP and is unwilling to use effective birth control for the duration of the study.

11. Patients on dialysis.

12. Patients on mechanical ventilation.

13. Patients with severe hepatic sinusoidal obstruction syndrome who in the judgment of the treating physician are not expected to have normalized bilirubin by Day 56 after enrollment.

14. Patients with a history of hypersensitivity to sirolimus or any component of the formulation.

Related Conditions & MeSH terms

• Acute GVHD

Intervention

Drug:
• Sirolimus
Sirolimus will be administered with a starting dose of 6 mg for patients older than 12 years, or 5 mg/m^2 for patients = 12 years. Trough levels will be routinely measured and sirolimus will be kept at maintenance dosing for target therapeutic levels for minimum duration through Day 56 post-randomization.
• Prednisone
Prednisone will be administered at 2mg/kg/day x 3 days, and then tapered according to individual treating clinician judgment.

Locations

Country	Name	City	State
United States	University of Michigan Medical Center	Ann Arbor	Michigan
United States	Blood & Marrow Transplant Program at Northside Hospital	Atlanta	Georgia
United States	Children's Healthcare of Atlanta	Atlanta	Georgia
United States	Emory University	Atlanta	Georgia
United States	Cleveland Clinic Foundation	Cleveland	Ohio
United States	Ohio State/Arthur G. James Cancer Hospital	Columbus	Ohio
United States	City of Hope National Medical Center	Duarte	California
United States	Duke University Medical Center	Durham	North Carolina
United States	University of Florida College of Medicine (Shands)	Gainesville	Florida
United States	University of Texas/MD Anderson Cancer Center	Houston	Texas
United States	University of Kansas Hospital	Kansas City	Kansas
United States	Children's Hospital Los Angeles	Los Angeles	California
United States	Medical College of Wisconsin	Milwaukee	Wisconsin
United States	University of Minnesota	Minneapolis	Minnesota
United States	Vanderbilt University Medical Center	Nashville	Tennessee
United States	Icahn School of Medicine at Mount Sinai	New York	New York
United States	Virginia Commonwealth University MCV Hospitals	Richmond	Virginia
United States	Mayo Clinic Rochester	Rochester	Minnesota
United States	Washington University/Barnes Jewish Hospital	Saint Louis	Missouri
United States	Fred Hutchinson Cancer Research Center	Seattle	Washington
United States	H. Lee Moffitt Cancer Center	Tampa	Florida

Sponsors (5)

Lead Sponsor	Collaborator
Medical College of Wisconsin	Blood and Marrow Transplant Clinical Trials Network, National Cancer Institute (NCI), National Heart, Lung, and Blood Institute (NHLBI), National Marrow Donor Program

Country where clinical trial is conducted

United States, 

References & Publications (1)

Filipovich AH, Weisdorf D, Pavletic S, Socie G, Wingard JR, Lee SJ, Martin P, Chien J, Przepiorka D, Couriel D, Cowen EW, Dinndorf P, Farrell A, Hartzman R, Henslee-Downey J, Jacobsohn D, McDonald G, Mittleman B, Rizzo JD, Robinson M, Schubert M, Schultz K, Shulman H, Turner M, Vogelsang G, Flowers ME. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant. 2005 Dec;11(12):945-56. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Percentage of Participants With Complete or Partial Response (CR/PR) to Acute GVHD Treatment	Scoring of CR/PR is in comparison to the participant's acute GVHD status at randomization. Complete response (CR) is defined as staging of 0 for in all target organs for GVHD - skin, GI tract, and liver. Partial response (PR) is defined as improvement in some target organ(s) without worsening in others. Death and initiation of systemic acute GVHD treatment beyond randomized treatment are considered failures for this endpoint. Organ staging is defined below: Skin stage: 0: No rash; Rash <25% of body surface area (BSA); Rash on 25-50% of BSA; Rash on >50% of BSA; Generalized erythroderma with bullous formation; Liver stage (based on bilirubin level): 0: <2 mg/dL; 2-3 mg/dL; 3.01-6 mg/dL; 6.01-15.0 mg/dL; >15 mg/dL; GI stage: 0: No diarrhea or diarrhea <500 mL/day; Diarrhea 500-999 mL/day or persistent nausea with histologic evidence of GVHD; Diarrhea 1000-1499 mL/day; Diarrhea >1500 mL/day; Severe abdominal pain with or without ileus	Days 28 and 56 Post-randomization
Secondary	Percentage of Participants With Complete or Partial Response (CR/PR) and Steroid Dose Less Than 0.25 mg/kg Per Day	The proportion of patients with CR/PR and on a prednisone-equivalent steroid dose of 0.25 mg/kg/day or less is evaluated. CR/PR scoring is in comparison to acute GVHD status at randomization. CR is defined as staging of 0 in all target organs. PR is defined as improvement in some organ(s) without worsening in others. Death and initiation of steroid-free, systemic acute GVHD treatment beyond randomized therapy are considered failures for this endpoint. Organ staging is defined as: Skin stage: 0: No rash; Rash <25% of body surface area (BSA); Rash 25-50% of BSA; Rash >50% of BSA; Generalized erythroderma with bullous formation; Liver stage (based on bilirubin level in mg/dL): 0: <2; 2-3; 3.01-6; 6.01-15.0; >15 mg/dL; GI stage: 0: No diarrhea or diarrhea <500 mL/day; Diarrhea 500-999 mL/day or persistent nausea with histologic evidence of GVHD; Diarrhea 1000-1499 mL/day; Diarrhea >1500 mL/day; Severe abdominal pain with or without ileus	Day 28 Post-randomization
Secondary	Acute GVHD Response	Acute GVHD response is classified as CR, PR, mixed response (MR), no response (NR), and progression and scored by comparison to acute GVHD status at randomization. MR is defined as improvement in some organ(s) with worsening in another, progression as worsening in some organ(s) without improvement in others, and NR as absence of any improvement or worsening. Death and initiation of systemic acute GVHD treatment beyond randomized treatment are classified as NR. Organ staging is defined as: Skin stage: 0: No rash; Rash <25% of body surface area (BSA); Rash 25-50% of BSA; Rash >50% of BSA; Generalized erythroderma with bullous formation; Liver stage (based on bilirubin level in mg/dL): 0: <2; 2-3; 3.01-6; 6.01-15.0; >15; GI stage: 0: No diarrhea or diarrhea <500 mL/day; Diarrhea 500-999 mL/day or persistent nausea with histologic evidence of GVHD; Diarrhea 1000-1499 mL/day; Diarrhea >1500 mL/day; Severe abdominal pain with or without ileus	Days 28 and 56 Post-randomization
Secondary	Percentage of Participants With Treatment Failure	Treatment failure is defined as either no response (NR) or progression and scored by comparison to acute GVHD status at randomization. Progression is defined as worsening in some target organ(s) without improvement in others and NR is defined as absence of any improvement or worsening in target organs. Death and initiation of systemic acute GVHD treatment beyond randomized treatment are classified as NR. Organ staging is defined as: Skin stage: 0: No rash; Rash <25% of body surface area (BSA); Rash 25-50% of BSA; Rash >50% of BSA; Generalized erythroderma with bullous formation; Liver stage (based on bilirubin level in mg/dL): 0: <2; 2-3; 3.01-6; 6.01-15.0; >15; GI stage: 0: No diarrhea or diarrhea <500 mL/day; Diarrhea 500-999 mL/day or persistent nausea with histologic evidence of GVHD; Diarrhea 1000-1499 mL/day; Diarrhea >1500 mL/day; Severe abdominal pain with or without ileus	Days 28 and 56 Post-randomization
Secondary	Percentage of Participants With Overall Survival	Overall survival is defined as survival of death from any cause.	6 and 12 Months Post-randomization
Secondary	Percentage of Participants With Disease-free Survival	Disease-free survival is defined as freedom from death and relapse of the underlying malignancy.	6 and 12 Months Post-randomization
Secondary	Proportion of Participants With Event-free Survival	Event-free survival is defined as freedom from acute GVHD progression, chronic GVHD, malignancy relapse, and death.	6 and 12 Months Post-randomization
Secondary	Percentage of Participants With Non-relapse Mortality	Non-relapse mortality is defined as death due to any cause other than relapse of the underlying malignancy. The cumulative incidence of non-relapse mortality is described, with malignancy relapse treated as a competing risk.	6 and 12 Months Post-randomization
Secondary	Percentage of Participants With Malignancy Relapse	The cumulative incidence of relapse of the primary malignancy is described, with death treated as a competing risk.	6 and 12 Months Post-randomization
Secondary	Percentage of Participants With Chronic GVHD	Chronic GVHD is classified per 2005 NIH Consensus Criteria (Filipovich et al. 2005) into categories of severity: none, mild, moderate, and severe. Occurrence of chronic GVHD is defined as the occurrence of mild, moderate, or severe chronic GVHD per this classification. The cumulative incidence of chronic GVHD is described, with death and malignancy relapse treated as competing risks.	6 and 12 Months Post-randomization
Secondary	Percentage of Participants With GVHD-free Survival	GVHD-free survival is defined as freedom from acute GVHD, chronic GVHD, and death. The proportion of participants alive and free of both acute and chronic GVHD are described at 6 and 12 months post-randomization.	6 and 12 Months Post-randomization
Secondary	Percentage of Participants With Serious Infections	The cumulative incidence of serious infections (Grade 2 or 3 per BMT CTN MOP) is described, with death treated as a competing risk.	6 and 12 Months Post-randomization

External Links

•   Blood and Marrow Transplant Clinical Trials Network Website
•   National Marrow Donor Program