Lymphoproliferative Disorder Clinical Trial
Official title:
Pilot (Phase I-II) Study of Pyrimethamine (Daraprim) for the Treatment of the Autoimmune Lymphoproliferative Syndrome (ALPS)
This study will examine whether the drug pyrimethamine can shrink lymph nodes and spleen in
patients with autoimmune lymphoproliferative syndrome (ALPS). In this disease, lymphocytes
(white blood cells) do not die as they normally would. As a result, patients have enlarged
lymph glands, spleen, or liver, and other problems that may involve blood cell counts and
autoimmune disease (overactivity of the immune system). Pyrimethamine is an orally
administered antibiotic that has been used to treat or prevent malaria and toxoplasma, and
may be effective in shrinking lymph nodes and spleen.
Patients with ALPS who are between 2 and 70 years of age and have had lymph gland
enlargement for at least 1 year may be eligible for this study. Candidates will be screened
with a medical history and physical examination, blood tests, and possibly a bone marrow
test. Females of reproductive age will be screened with a urine pregnancy test. Women who
are capable of becoming pregnant must use an effective method of birth control during the
entire study period, because, taken during early months of pregnancy, pyrimethamine can
cause birth defects in the fetus. Women who are pregnant or nursing are excluded from the
study.
Participants will undergo the following tests and procedures:
- CT scan: For this test, the patient lies still in the CT scanner while images are taken
of the neck, chest, and stomach area. A contrast dye is injected into a vein to
brighten the CT images. Very young children will be evaluated on a case by case basis
to determine whether a CT scan will be performed.
- Bone marrow biopsy: Participants undergo this test to rule out underlying bone marrow
disease if they have not had a bone marrow test done in the last six months prior to
enrolling in pyrimethamine study, as pyrimethamine can affect bone marrow function.
Under local anesthesia, a needle is inserted into the back part of the hipbone and a
small amount of marrow is removed. (Children are sedated for this test.)
- Leukapheresis: This is a procedure for collecting a small proportion of circulating
white blood cells while conserving the majority of blood cells. Specifically, blood is
drawn from a needle placed in an arm vein and is directed into a cell separator
machine, which separates the blood cells by spinning. A small proportion of circulating
white cells are removed, and the red cells, platelets, plasma and majority of white
cells are returned to the patient's blood circulation. Only patients who are 7 years of
age or older and weigh at least 55 pounds undergo this procedure. Other participants
who choose not to have apheresis will have about 3 tablespoons of blood drawn instead.
- Pyrimethamine administration: When the above tests are completed, participants begin
taking pyrimethamine. The dose is determined according to the individual's weight and
is gradually increased during the study period. Patients take the drug twice a week for
a total of 12 weeks.
- Blood tests: Blood samples are collected during weeks 2, 4, 6, 8, and 10 after
beginning treatment, and 2 weeks after the last dose of pyrimethamine. The purpose of
these blood tests is to check for possible drug-related side effects. Patients who
develop a skin rash, mouth sores or other side effects may have one or more doses of
the treatment drug withheld. When indicated, the patient will be directed to stop
taking the study drug. If needed, drug side effects will be treated with a vitamin
supplement, folinic acid, taken by mouth, 3 times weekly.
- Evaluations at the NIH Clinical Center will comprise of a pretreatment visit, one end
of treatment visit at the end of 12 weeks and an optional post-treatment visit 3months
after stopping pyrimethamine therapy.
Patients who respond well to treatment may be asked to return to NIH for additional visits
at 3, 6, and 12 months after the treatment has ended for repeat evaluations. If their lymph
glands or spleen become much larger after stopping pyrimethamine, they will be offered
treatment for another 12 weeks. If they respond to the second course of treatment, they will
return to NIH again after 3, 6, and 12 months. If the symptoms return again, patients will
be asked to resume treatment for an additional 6 months or more. They will have blood drawn
periodically by their private physician and will return to NIH for evaluation every 12
weeks.
Status | Completed |
Enrollment | 8 |
Est. completion date | June 2005 |
Est. primary completion date | |
Accepts healthy volunteers | No |
Gender | Both |
Age group | N/A and older |
Eligibility |
INCLUSION CRITERIA: All subjects must fulfill the published criteria for the diagnosis of ALPS (documented nonmalignant lymphadenopathy and/or splenomegaly of at least 1 year duration; greater than or equal to 1% TCR alpha/beta(+) CD4(-)CD8(-) T cells in the peripheral blood and defective apoptosis by in vitro assay). This must include clinically documented lymphadenopathy involving more than two nodes in more than one regional group of nodes measuring greater than 1 cm in size and/or a palpable spleen. Age greater than 2 years and less than 70 years. Must have a personal primary care physician. Women of reproductive age and potential must have a negative pregnancy test at study entry and commit to using an acceptable method of barrier or hormonal contraception (e.g. condoms, diaphragms, oral contraceptives and long acting progestin agents) if sexually active during the study and for 3 months after the last dose of pyrimethamine. Must be willing to sign a consent form. EXCLUSION CRITERIA: Patient will be excluded if any of the following is present: Weight of less than 10 kilograms (22 lbs). Patients receiving and requiring anti-folate drugs such as sulfonamides, trimethoprim, pyrimethamine and methotrexate for any other purpose. They should be off these medications, including Bactrim, for at least 7 days prior to enrolling in this protocol. Megaloblastic anemia, folate deficiency or a mean corpuscular volume greater than 125 in last three months with evidence of megaloblastic changes in the bone marrow. A hemoglobin concentration of less than 8 gm/dl, a platelet count of less than 50 K/mm(3), or an absolute neutrophil count of less than 500/mm(3), at study entry or during the study period. Liver disease determined by an ALT, AST or bilirubin 3 times above the upper limit of normal. Renal dysfunction determined by a calculated urine creatinine clearance of less than or equal to 70 ml/min/1.73 m(2) in children and less than or equal to 60 ml/min in adults or using the Schwartz formula or Levy formula based on serum creatinine. Patients on immunosuppression (eg: corticosteroid, azathioprine, cyclosphosphamide, etc) are eligible if the dose of the immunosuppressive drug has been stable for at least 3 months prior to enrollment and their hematologic parameters meet the criteria outlined in item 4 (above). Pregnancy. Women of reproductive age and potential must have a negative pregnancy test at study entry and commit to using an acceptable method of barrier or hormonal contraception (e.g. condoms, diaphragms, oral contraceptives and long acting progestin agents) if sexually active during the study and for 3 months after the last dose of pyrimethamine. Lactating mothers who are breast feeding their babies will not be eligible. ALPS patients who have been treated with bone marrow toxic chemotherapy regimens for Hodgkins and Non-Hodgkins lymphoma or other malignancies are not eligible for this pilot study. Unwilling or unable to comply with the need to have periodic blood tests to monitor possible side effects of treatment, or other major requirements of this study. |
Endpoint Classification: Safety Study, Primary Purpose: Treatment
Country | Name | City | State |
---|---|---|---|
United States | National Institute of Allergy and Infectious Diseases (NIAID) | Bethesda | Maryland |
Lead Sponsor | Collaborator |
---|---|
National Institute of Allergy and Infectious Diseases (NIAID) |
United States,
Avila NA, Dwyer AJ, Dale JK, Lopatin UA, Sneller MC, Jaffe ES, Puck JM, Straus SE. Autoimmune lymphoproliferative syndrome: a syndrome associated with inherited genetic defects that impair lymphocytic apoptosis--CT and US features. Radiology. 1999 Jul;212(1):257-63. — View Citation
Sneller MC, Wang J, Dale JK, Strober W, Middelton LA, Choi Y, Fleisher TA, Lim MS, Jaffe ES, Puck JM, Lenardo MJ, Straus SE. Clincal, immunologic, and genetic features of an autoimmune lymphoproliferative syndrome associated with abnormal lymphocyte apoptosis. Blood. 1997 Feb 15;89(4):1341-8. — View Citation
Straus SE, Sneller M, Lenardo MJ, Puck JM, Strober W. An inherited disorder of lymphocyte apoptosis: the autoimmune lymphoproliferative syndrome. Ann Intern Med. 1999 Apr 6;130(7):591-601. Review. — View Citation
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