Cyclophosphamide Plus Cyclosporine in Treatment-Naive Severe Aplastic Anemia

This study is ongoing, but not recruiting participants.
Sponsor:
Information provided by (Responsible Party):
National Institutes of Health Clinical Center (CC) ( National Heart, Lung, and Blood Institute (NHLBI) )
ClinicalTrials.gov Identifier:
NCT01193283
First received: August 31, 2010
Last updated: June 25, 2014
Last verified: May 2014
  Purpose

Background:

  • Severe aplastic anemia (SAA) can lead to problems with bone marrow health and result in low blood cell counts, which require frequent transfusions. Standard treatment for SAA involves injections of antithymocyte globulin (ATG) plus cyclosporine (CsA). This regimen has been shown to improve the blood counts in about two-thirds of patients. However, the ATG/CsA regimen has the following limitations: (a) the disease can come back (relapse) in about one-third of patients who improve initially; and (b) in about 10% to 15% of cases, certain types of bone marrow cancer (such as myelodysplasia and leukemia) can develop (called evolution). Experience with other drugs in SAA such as cyclophosphamide suggests that similar response rates to ATG/CsA can be achieved with a lower risk of relapse and clonal evolution. However, cyclophosphamide was found to have significant side effects in SAA when investigated over 10 years ago due to increase risk of fungal infections.
  • Better antibiotic drugs against fungus have been developed and are widely used to treat patients who have low white blood cell counts and are at risk of developing infections. In SAA patients in particular, these newer antibiotics have had a large impact in preventing and treating fungus infections. Researchers are revisiting the use of cyclophosphamide in SAA treatment, and plan to give a lower dose of CsA in combination with the immune-suppressing drug cyclophosphamide, as well as antibiotics to protect against infections, as a possible treatment for the disease.

Objectives:

- To determine the safety and effectiveness of the combination of cyclophosphamide and cyclosporine in treating severe aplastic anemia that has not been treated with immunosuppressive therapy.

Eligibility:

- Individuals at least 2 years of age who have severe aplastic anemia that has not been treated with immunosuppressive therapy.

Design:

  • After initial screening, medical history, and blood tests, participants will be admitted to the inpatient unit at the National Institutes of Health Clinical Center.
  • Participants will receive 4 days of cyclophosphamide, followed by cyclosporine. Cyclosporine treatment will begin the day after the end of cyclophosphamide treatment and will continue for the following 6 months. The doses will be monitored and adjusted in response to frequent blood tests and monitoring.
  • Participants will also receive antibiotics and other drugs to protect against bacterial, fungal, and viral infections. Participants will take these drugs regularly until their white blood cell counts improve.
  • After discharge from the clinical center, participants will have follow-up evaluations at 3 months, 6 months, and annually for 5 years. Evaluations will include blood samples and periodic bone marrow biopsies.

Condition Intervention Phase
Aplastic Anemia
Neutropenia
Pancytopenia
Severe Aplastic Anemia
Drug: Cyclophosphamide
Drug: Cyclosporine
Phase 1
Phase 2

Study Type: Interventional
Study Design: Allocation: Non-Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Cyclophosphamide Plus Cyclosporine in Treatment-Naive Severe Aplastic Anemia

Resource links provided by NLM:


Further study details as provided by National Institutes of Health Clinical Center (CC):

Primary Outcome Measures:
  • The primary objective is to evaluate the safety and activity profile of Cy/CsA in SAA. [ Time Frame: 6 months ] [ Designated as safety issue: Yes ]

Secondary Outcome Measures:
  • Secondary endpoints will also be evaluated for the study to include:(a) Hematological response at 3 and 12 months and yearly thereafter; (b) relapse; (c) clonal evolution to PNH, myelodysplasia or acute leukemia; (d) survival. [ Time Frame: 1 to 5 years ]

Enrollment: 22
Study Start Date: August 2010
Estimated Study Completion Date: December 2018
Estimated Primary Completion Date: December 2018 (Final data collection date for primary outcome measure)
Intervention Details:
    Drug: Cyclophosphamide
    30 my/kg for 4 days
    Drug: Cyclosporine
    daily to a trough of 100 t0 200 ng/ml
  Hide Detailed Description

Detailed Description:

Severe aplastic anemia (SAA) is a life-threatening bone marrow failure disorder characterized by pancytopenia and a hypocellular bone marrow. Allogeneic hematopoietic stem cell transplantation (HSCT) offers the opportunity for cure in 70 percent of patients, but most patients are not suitable candidates for this treatment modality due to advanced age, comorbidities or lack of a histocompatible donor. For these patients, comparable long-term survival is attainable with immunosuppressive treatment (IST) with anti-thymocyte globulin (ATG) and cyclosporine (CsA). However, approximately 1/3 of patients do not show blood count improvement after ATG/CsA and are considered to have refractory disease. Furthermore, analysis of our own extensive clinical data suggests that poor blood count responses to a single course of ATG (non-robust responders), even when transfusion-independence is achieved, predicts a markedly worse prognosis compared to those who achieve a robust hematologic improvement (protocol 90-H-0146).

The current limitations of IST in SAA are: 1) the majority of the responses observed following initial h-ATG/CsA are partial with only a few patients achieving normal blood counts; 2) 1/3 of patients are refractory to initial h-ATG/CsA; 3) hematologic relapses occur in 35 percent of responders following initial response to h-ATG/CsA; 4) among relapsed patients chronic use of CsA is not infrequent which often leads to toxicities from the long term exposure to this drug (especially in older patients); 5) and clonal evolution is still observed in 10-15 percent of patients. Efforts to improve initial IST in treatment-na(SqrRoot) ve patients with the addition of mycophenolate mofetil and sirolimus to standard h-ATG/CsA or use of lymphocytotoxic agents such as r-ATG/CsA or alemtuzumab have not yielded the expected better outcomes when compared to standard h-ATG/CsA (protocols 00-H-0032, 03-H-0193, and 06-H-0034). Because the majority of SAA patients in the US and worldwide are treated with IST due to lack of an HLA-matched donor or inaccessibility to transplant, novel regimens are needed to overcome the current limitations of IST in SAA. Towards the goal of addressing these limitations we are proposing a regimen of cyclophosphamide (Cy) plus low dose CsA.

Cy has been proposed by the investigators at Johns Hopkins as an alternative IST regimen to h-ATG/CsA. In a pilot study, high dose Cy (200 mg/kg) yielded similar results to that observed for h-ATG/CsA. In a randomized study at NHLBI comparing high dose Cy (200 mg/kg) and h-ATG/CsA in treatment-na(SqrRoot) ve patients (protocol 97-H-0117), excess toxicity and deaths from invasive fungal infections were observed in the Cy arm which led to the discontinuation of this regimen. Recently reported long-term results from Johns Hopkins of 44 treatment-na(SqrRoot) ve patients who received high dose Cy (200 mg/kg) as sole therapy for SAA showed that a greater number of complete responses were observed with few instances of relapse and clonal evolution noted with Cy when compared to h-ATG/CsA (historical comparison). In an accompanying editorial, the incidence of invasive fungal infections in this cohort were highlighted. Of note, antifungal prophylaxis against Aspergillus sp, the deadliest culprit when neutropenia is severe and prolonged, was not employed in the Hopkins high dose Cy protocol. In the Chinese experience, data presented in a recent meeting in Japan showed that lower doses of Cy (120 mg/kg) plus CsA achieved similar results reported by the Hopkins investigators with reduced toxicity. These data suggest that Cy has activity in SAA and could be a viable alternative to standard h-ATG/CsA if the immediate toxicities associated to prolonged neutropenia could be overcome.

In recent years we have observed a marked improvement in survival in our SAA patients especially among those who are non-responders to IST where pancytopenia remain persistent for months. A detailed analysis (shown in Section 2.4 Scientific and Clinical Justification of Protocol) showed that better antifungal supportive care in recent years contributed to a reduction of infection-related mortality in the months following IST among non-responders, who remain persistently neutropenic. This observation suggests that nowadays patients can be better supported through periods of neutropenia due to improved antifungal supportive care with agents that are better tolerated (compared to deoxycholate amphotericin B), retain a broad-spectrum of activity (especially against Aspergillus sp), and can be administered orally as an outpatient.

The fact that about one-thirdof initial refractory patients respond to retreatment and that late complications (relapse and clonal evolution) occur in about 40-50 percent of cases suggest that initial IST with h-ATG/CsA has important limitations. Therefore, we propose to investigate Cy + CsA as initial therapy in SAA. Our intention is not to recapitulate the high dose Cy regimen initially proposed by Hopkins (200 mg/kg) but instead, investigate lower doses proposed by the Chinese (120 mg/kg) in addition to low dose CsA (target therapeutic level 100 200 microg/L). The ability to better support patients during periods of neutropenia with better antifungals should allow for the immediate toxicity to be overcome and assess the activity of Cy in SAA.

The main objective of this study is to assess the safety and efficacy of Cy 120 mg/kg + low dose CsA (100 200 microg/L) in treatment-naive SAA. The primary endpoint will be hematologic response, defined as no longer meeting criteria for SAA, at 6 months. Secondary endpoints are relapse, robustness of hematologic recovery at 6 months, response at 3 months and 12 months, survival, clonal evolution to PNH, myelodysplasia and acute leukemia. The primary endpoint will be changes in absolute neutrophil count, platelet count, and reticulocyte count at 6 months. Secondary endpoints will include time to relapse, changes in cytogenetics, and time to death.

  Eligibility

Ages Eligible for Study:   2 Years and older
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria
  • INCLUSION CRITERIA:

Severe aplastic anemia characterized by:

Bone marrow cellularity less than 30 percent (excluding lymphocytes)

AND

At least two of the following:

Absolute neutrophil count less than 500/ microL

Platelet count less than 20,000/ microL

Absolute reticulocyte count less than 60,000/ microL

Age greater than or equal to 2 years old

Weight greater than or equal to 12 kg

EXCLUSION CRITERIA:

Diagnosis of Fanconi anemia

Cardiac ejection fraction less than 30 percent (evaluated by ECHO)

Evidence of a clonal hematologic bone marrow disorder on cytogenetics. Patients with the presence of trisomy 8, loss of Y or del(20q) will not be excluded in the absence of dysplastic changes in the marrow. Patients with very severe neutropenia (ANC less than 200 /microL) will not be excluded initially if cytogenetics are not available or pending. If evidence of a clonal disorder is later identified, the patient will go off study.

Prior immunosuppressive therapy with high dose Cy or ATG

Infection not adequately controlled with appropriate therapy

Serologic evidence of HIV infection

Moribund status or concurrent hepatic, renal, cardiac, neurologic, pulmonary, infectious, or metabolic disease of such severity that it would preclude the patient s ability to tolerate protocol therapy, or that death within 30 days is likely

Subjects with cancer who are not considered cured, are on active chemotherapeutic treatment or who take drugs with hematological effects

Current pregnancy or unwillingness to take oral contraceptives or refrain from pregnancy if of childbearing potential

Not able to understand the investigational nature of the study or to give informed consent.

  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01193283

Locations
United States, Maryland
National Institutes of Health Clinical Center, 9000 Rockville Pike
Bethesda, Maryland, United States, 20892
Sponsors and Collaborators
Investigators
Principal Investigator: Danielle M Townsley, M.D. National Heart, Lung, and Blood Institute (NHLBI)
  More Information

Additional Information:
Publications:
Responsible Party: National Institutes of Health Clinical Center (CC) ( National Heart, Lung, and Blood Institute (NHLBI) )
ClinicalTrials.gov Identifier: NCT01193283     History of Changes
Other Study ID Numbers: 100176, 10-H-0176
Study First Received: August 31, 2010
Last Updated: June 25, 2014
Health Authority: United States: Federal Government

Keywords provided by National Institutes of Health Clinical Center (CC):
Aplastic Anemia
Immunosuppression
T-Cells
Hematopoiesis
Autoimmunity
Severe Aplastic Anemia

Additional relevant MeSH terms:
Anemia
Neutropenia
Anemia, Aplastic
Pancytopenia
Hematologic Diseases
Agranulocytosis
Leukopenia
Leukocyte Disorders
Bone Marrow Diseases
Cyclophosphamide
Cyclosporins
Cyclosporine
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Pharmacologic Actions
Antirheumatic Agents
Therapeutic Uses
Antineoplastic Agents, Alkylating
Alkylating Agents
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Myeloablative Agonists
Enzyme Inhibitors
Antifungal Agents
Anti-Infective Agents
Dermatologic Agents

ClinicalTrials.gov processed this record on September 22, 2014