Cyclosporine A and Mycophenolate Mofetil vs Cyclosporine A ... - Nature

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Cyclosporine A and Mycophenolate Mofetil vs Cyclosporine A and Methotrexate for graft-versus-host disease prophylaxis after stem cell transplantation from HLA-identical siblings F Neumann1, T Graef1, C Tapprich1, M Vaupel1, U Steidl1, U Germing1, R Fenk1, A Hinke2, R Haas1 and G Kobbe1 1

Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Duesseldorf, Germany, Moorenstr. 5, Duesseldorf, Germany; and 2Wissenschaftlicher Service Pharma Gmbh, WISP, Karl-Benz-Str. 1, Langenfeld, Germany

Summary: The combination of Cyclosporin A (CSA) and Methotrexate (MTX) is considered to be the standard regimen for the prevention of graft-versus-host disease (GVHD) after stem cell transplantation (SCT) from HLA-identical siblings. Mycophenolate Mofetil (MMF) has been widely used for GVHD prophylaxis after nonmyeloablative SCT, but experience following myeloablative therapy is still limited. We retrospectively compared CSA/MTX and CSA/MMF in 93 patients (median age 35 years, range 17–59 years, male subjects 48, female subjects 45) with acute myeloid leukemia (n ¼ 33), myelodysplastic syndrome (MDS) (n ¼ 3), acute lymphoblastic leukemia (ALL) (n ¼ 20) or chronic myeloid leukemia (n ¼ 37) who received CSA/MMF (n ¼ 26) or CSA/MTX (n ¼ 67) as GVHD prophylaxis following high-dose therapy and allogeneic SCT from HLA-identical siblings. No statistically significant differences were found in overall survival, relapse rate, treatment-related mortality and acute or chronic GVHD. Time to myeloid recovery was significantly shorter in patients who received CSA/MMF. We conclude that the combination of CSA/MMF appears equivalent to CSA/MTX for GVHD prophylaxis in patients receiving conventional-intensity SCT from HLA-identical siblings. Bone Marrow Transplantation (2005) 35, 1089–1093. doi:10.1038/sj.bmt.1704956 Published online 11 April 2005 Keywords: Methotrexate; Cyclosporine; Mycophenolate Mofetil; GVHD; stem cell transplantation

Graft-versus-host disease (GVHD) is a major cause of morbidity and mortality after allogeneic stem cell trans-

Correspondence: Dr F Neumann, Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Duesseldorf, Germany, Moorenstr. 5, 40225 Duesseldorf, Germany; E-mail: [email protected] Received 14 January 2005; accepted 7 February 2005 Published online 11 April 2005

plantation (SCT).1 Intensive immunosuppression using in vivo or in vitro T-cell-depleting agents reduces GVHD but results in a high rate of graft failure and relapse, whereas less intense regimens result in a higher risk of severe acute and chronic GVHD.2–7 The combination of Cyclosporin A (CSA) and Methotrexate (MTX) has been shown to be an effective regimen and has become the standard therapy for the prevention of GVHD.8–10 Mycophenolate Mofetil (MMF) is an inhibitor of purine nucleotide synthesis leading to impaired proliferation of activated lymphocytes and has been successfully used after allogeneic renal transplantation.11 MMF alone or in combination with other immunosuppressive agents can be effectively used for the treatment of acute GVHD as well as chronic GVHD12–15 after allogeneic bone marrow or peripheral blood SCT in adults. It has also been used for GVHD prophylaxis after nonmyeloablative SCT.16 However, data on the use of MMF in combination with CSA as GVHD prophylaxis following conventional-intensity SCT from HLA-identical siblings are limited.17–19 We performed a retrospective single center analysis comparing CSA/MTX and CSA/MMF.

Patients and methods We retrospectively studied 93 patients (median age 35 years, range 17–59 years; male subjects 48, female subjects 45) with acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) (n ¼ 33/3), acute lymphoblastic leukemia (ALL) (n ¼ 20) or chronic myeloid leukemia (CML) (n ¼ 37) who received either CSA/MMF (n ¼ 26) or CSA/ MTX (n ¼ 67) as GVHD prophylaxis following high-dose chemotherapy alone (n ¼ 31) or in combination with TBI (n ¼ 62) and consecutive allogeneic SCT from HLAidentical siblings between 1989 and 2003. The date of last study entry and time point of analysis was June 2004. At the time of transplant, all patients were in complete remission (CR) or chronic phase (CP). The median follow-up after transplantation for patients was 17 months (range 2–65) in the CSA/MMF group and 39 months (range 1–173) in the CSA/MTX group. These different follow-up periods reflect the introduction and exclusive

Mycophenolate mofetil for GVHD prophylaxis F Neumann et al

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use of CSA/MMF instead of CSA/MTX in 1998 in our department which was the result of studies published on the efficacy of this combination after dose-reduced conditioning. All patients transplanted with hematopoietic stem cells from HLA identical sibling donors for AML/MDS, ALL and CML in early disease stages from 1989 to 2004 were included in the analysis. Detailed patients’ characteristics are shown in Table 1. Although we restricted our analysis to patients in CR or first CP, there were still significant differences among the two treatment groups reflecting the retrospective character of the study. The patients in the CSA/MTX group contained a higher proportion of patients with CML, a more frequent use of TBI for conditioning and the use of bone marrow as stem cell source in about half of the patients. Therefore, we paid special attention to these factors during multivariate analysis. All patients gave written informed consent and were treated according to approved protocols of the Department of Hematology at the Heinrich-Heine University, Duesseldorf. GVHD prophylaxis in the CSA/MTX group consisted of a combination of intravenous CSA of 3 mg/kg/day starting on day 1 and intravenous MTX given at a dosage of 15 mg/m2 on day þ 1 followed by 10 mg/m2 on days þ 3 and þ 6. Thereafter, oral or intravenous CSA was adapted according to the blood through level that was intended to be 200–300 ng/dl. Patients in the CSA/MMF group received MMF at a dosage of 1000 mg twice or three times daily instead of MTX. MMF was given orally or intravenously depending on the degree of mucositis as well as nausea and vomiting. CSA and MMF were tapered on an individual basis depending on the risk of relapse and the appearance of GVHD. All patients received prophylactic

Table 1

Patients’ characteristics CSA/MTX

CSA/MMF

Total

No. of patients Male Female Median age (years) Range (years)

67 36(54%) 31(46%) 32 17–51

26 12(46%) 14(54%) 39 22–57

93 48 45 35 17–57

Diagnosis AML ALL MDS CML

19(28%) 14(21%) 2(3%) 32(48%)

14(54%) 6(23%) 1(4%) 5(19%)

33 20 3 37

39 1–173

17 2–65

18 1–173

Stem cell source Bone marrow Peripheral blood

39(58%) 28(42%)

0(0%) 26(100%)

39 54

Conditioning regimen Chemotherapy Chemotherapy and TBI

12(18%) 55(82%)

19(73%) 7(27%)

31 62

Median follow up time (months) Range (months)

AML ¼ acute myeloid leukaemia; MDS ¼ myelodysplastic syndrome; ALL ¼ acute lymphoblastic leukemia; CML ¼ chronic myeloid leukemia; CSA ¼ Cyclosporin A; MTX ¼ Methotrexate; MMF ¼ Mycophenolate Mofetil.

Bone Marrow Transplantation

antibiotic, antimycotic and virostatic therapy depending on the results of surveillance cultures and CMV serologic status. Chronic and acute GVHD were graded according to published criteria. The data for survival, relapse rate, treatment-related mortality (TRM) and time to hematopoietic reconstitution were examined using the Kaplan–Meier method, measured from the date of transplantation, and compared using the log rank test. Multivariate analyses were carried out using the Cox proportional hazard model to adjust for the following covariates: diagnosis (CML, ALL, AML/MDS), stem cell source (bone marrow, peripheral blood), conditioning regimen (chemotherapy, chemotherapy and TBI), age (o35, X35 years), sex of patient and donor, CMVseropositivity of patient and donor. Factors that were significant or marginally significant (Po0.2) in the univariate analyses and the treatment arm were entered into the model. Stepwise procedures were used to identify the best model, starting with all variables and successively removing variables with P40.10. Acute and chronic GVHD were examined using Fisher’s Exact test and logistic regression in an analogous way. All reported Pvalues are two-sided. These analyses were performed for all patients receiving CSA/MTX and CSA/MMF including bone marrow- and peripheral blood stem cell-transplanted patients and separately for the group of patients who received peripheral blood stem cells to definitely exclude the influence of graft source.

Results Using univariate tests as well as multivariate analysis to adjust for covariates, we found no statistically significant difference in overall survival with 2-year survival rates between 55% (CSA/MTX) and 76% (CSA/MMF, Figure 1a), nor in relapse rate (Figure 1b) or TRM (Figure 1c and Table 2) between the two treatment groups. Moreover, the incidences of acute and chronic GVHD did not differ significantly among the two regimens. Acute GVHD grade II–IV occurred in 40 of 67 (61%) patients who were treated with CSA/MTX and in 10 of 26 (38%) patients who received CSA/MMF. In all, 25 of 56 (45%, CSA/MTX) and 12 of 24 (50%, CSA/MMF) patients at risk developed chronic GVHD, respectively (Table 3). Interestingly, the time until leukocyte reconstitution differed significantly in favor of CSA/MMF (Po0.0001, log rank test; hazard ratio 5.46; 95%-CI 2.94–10.14) even independent of stem cell source or conditioning regimen within the two treatment groups (Figure 1d, Table 2). Patients in the CSA/MMF group recovered a WBC41000/ ml after a median of 12 days (range 7–19 days) in contrast to 18 days (range 11–62 days) in the CSA/MTX group. Although multivariate analysis showed no influence of stem cell source, we looked separately on the leukocyte reconstitution of patients receiving peripheral blood stem cells. The results were confirmed with a median engraftment time of 12 days (range 7–19 days) in patients receiving CSA/MMF and 18 days (range 11–41 days) in the CSA/ MTX group (P ¼ 0.001, log rank test; hazard ratio 3,24; 95% CI 11–13/13–19) (Table 2; Figure 1e).


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b 1.0

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Patients in %

Patients in %

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0.6 0.4

Logrank Test P = 0.21

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CSA/MTX: n = 67 events

0

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Logrank Test: P = 0.17

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CSA/MTX: n = 26 events

0.0

CSA/MTX: n = 67 events CSA/MMF: n = 26 events

0.0

9 10 11 12 13 14 15

0

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d


0.8 Patients in %

8

10

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14

1.0

1.0

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LogrankTest P = 0.41

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c

6 Years

Years

0.6

0.2 0.0

0.4

Logrank Test: P < 0.0001

0.2


0.0 0

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3

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8

9 10 11 12 13 14 15

0

10

20

Years

30

40 Days

50

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70

e 1.0

Patients in %

0.8 0.6 Logrank Test P < 0.0001

0.4 0.2

CSA/MTX (PB): n = 28 events CSA/MMF (PB): n = 26 events

0.0 0

10

20

40

30

50

Days Figure 1

Overall survival (a), relapse rate (b), TRM (c) and time to hematopoietic reconstitution (d) of all patients treated with CSA/MMF vs CSA/MTX and hematopoietic reconstitution of patients after peripheral blood (PB) SCT (e) treated with CSA/MMF vs CSA/MTX.

Table 2 Overall survival, relapse rate and treatment-related mortality (TRM) 2 years after transplantation in % and median time to hematopoietic reconstitution in days

Overall survival Relapse rate TRM Engraftment (days)

CSA/MTX

CSA/MMF

Pa

Pb

HR

55(50)% 21(14)% 27(36)% 18(18)

76% 10% 17% 12

0.21(0.33) 0.17(0.46) 0.41(0.29) o0.0001(o0.0001)

0.36(0.54) 0.63(0.95) —*** o0.0001(0.001)

0.61(0.71) 0.64(1.06) — 4.69(3.24)

a

Univariate log rank test. Multivariate Cox proportional hazard model. ***No univariate significant parameters. HR ¼ hazard ratio; CSA ¼ Cyclosporin A; MTX ¼ Methotrexate; MMF ¼ Mycophenolate Mofetil. Values in brackets for peripheral blood SCT only. b



1092 Table 3 Rate of acute (gradeXII) and chronic GVHD (limited and extensive) (%) CSA/MTX CSA/MMF aGVHD cGVHD

61(64)% 45(46)%

38% 50%

Pa

Pb

OR

0.11(0.32) 0.63(0.54) 0.75(0.34) 0.81(0.70) 0.69(0.52) 0.73(0.98)

a

Univariate Fisher’s exact test. Multivariate logistic regression. OR ¼ odds ratio; CSA ¼ Cyclosporin A; MTX ¼ Methotrexate; MMF ¼ Mycophenolate Mofetil. Values in brackets for peripheral blood SCT only.

b

Discussion The combination of CSA and MTX has been used as the standard GVHD prophylaxis for more than 20 years.8–10 In an attempt to reduce the toxicity of unmanipulated allogeneic stem cell transplantation from HLA identical siblings, we substituted MMF for methotrexate in 1998, which we believed to cause excess toxicity after intensive myeloablative conditioning. MMF has been shown to be well tolerated and effective in promoting engraftment as well as preventing severe GVHD after dose-reduced conditioning.20–22 Clinical trials have suggested that there may be a benefit of CSA/MMF after myeloablative conditioning as well.1,17–19 However, as a limitation of these studies, they included limited patient numbers and very heterogeneous patient groups in terms of the risk to develop acute or chronic GVHD. We therefore focused our retrospective single center study on 93 patients with acute and chronic leukemias who received unmanipulated bone marrow or G-CSF-mobilized peripheral blood stem cell grafts from HLA-identical siblings. Although we selected patients on the basis of diagnosis and disease status at transplantation, the two groups were not very well balanced for all relevant parameters known to represent prognostic factors for TRM, relapse, GVHD and survival after HLA-identical sibling transplantation. Among the patients of the CSA/MTX group, there was a higher proportion of patients with CML, greater use of TBI for conditioning and bone marrow as graft source. We saw no significant differences in terms of overall survival, TRM and relapse rate as well as the rate of acute or chronic GVHD between patients who had received CSA/ MTX and those who had received CSA/MMF. However, in all analyses including the analysis of patients receiving peripheral blood SCT, the CSA/MMF group tended to have favorable results although they did not reach statistical significance, which may be due to limited patient numbers or short follow-up. Looking on time to engraftment, patients on CSA/MMF recovered about 1 week earlier from severe cytopenia, which was statistically significant. The difference remained significant in the multivariate analysis and was confirmed in the separate analysis of patients receiving peripheral blood SCT. Kiehl et al1 reported reduced mucositis and a trend to earlier engraftment with the use of CSA/MMF after transplantation of hematopoietic stem cells from unrelated or mismatched related donors. In addition, Bolwell et al19 also found significantly reduced mucositis and earlier Bone Marrow Transplantation

engraftment in patients receiving CSA/MMF as compared to those who were treated with CSA/MTX which resulted in early closure of a prospective randomized trial. In contrast to our study, where the majority of patients received mobilized allogeneic peripheral blood stem cells, the patients reported by Bolwell et al.19 were transplanted with unmanipulated bone marrow. In line with our findings, Kiehl1 and Bolwell19 did not see significant differences in the rate and severity of acute or chronic GVHD. Taken together, cumulative evidence suggests that the combination of CSA and MMF is at least as effective as the standard regimen of CSA and MTX in the prevention of GVHD after hematopoietic stem cell transplantation, while it offers a markedly reduced toxicity profile. This may allow a further increase in the antileukemic efficacy of the conditioning regimen, which has not been successful so far because of intolerable toxicity with the use of MTX for GVHD prophylaxis. The lack of clear superiority of the CSA/MMF regimen in terms of GVHD prevention may be due to suboptimal dosing reflected by low serum concentrations of mycophenolate acid after hematopoietic SCT as compared to the use of MMF in solid organ transplantation. Using a dose of 2 g/day, Bornhauser et al17 reported reduced peak levels of mycophenolic acid (MPA) early after transplantation.17,23 This may be due to altered MPA kinetics caused by disturbances in the gastrointestinal tract of patients undergoing hematopoietic SCT. We and others have therefore increased the daily MMF dose to 3 g/day, but patient numbers are still too low to show any differences between these two dosing regimens, which is the reason why we have pooled patients within this analysis. In conclusion, the results from our single center retrospective analysis suggest that the combination of CSA and MMF is at least equivalent to the standard regimen of CSA and MTX for GVHD prophylaxis following transplantation of allogeneic mobilized peripheral blood stem cells from HLA-identical siblings. The toxicity profile of CSA/ MMF is superior as reflected by a significantly shorter time to engraftment. We would like to point out that the small size of the CSA/MMF group and the differences of the two treatment groups even if they do not result in statistical relevance do hamper the interpretation of our study. In addition to this there have been substantial advances in supportive care which might effect the results of the CSA/ MTX group, which was treated between 1989 and 1998.

Acknowledgements We thank the clinical and laboratory staff of the Department of Haematology, Oncology and Clinical Immunology of the Heinrich-Heine University Duesseldorf as well as our colleagues from the Institute for transplant diagnostics and cellular therapy (ITZ). This work was generously supported by the Leuka¨mieLiga e.V.

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