Sirolimus for Autoimmune Disease of Blood Cells - Full Text View

Purpose

Treatment for patients with autoimmune destruction of blood cells is poor. The part of the body that fights infections is called the immune system and white blood cells (WBCs) are part of the immune system. Normally, a person's body creates WBCs to fight infections and eliminates WBCs which have stopped helping the body function. Patients with autoimmune destruction of blood cells have difficulty eliminating old WBCs. The abnormal WBCs build up and can damage other healthy cells, which can lead to anemia, fatigue, jaundice, internal bleeding, infection, and cancer. Few effective medications exist for treatment for patients with autoimmune cytopenias and those commonly used are fraught with side effects. Nevertheless, as scientific understanding of autoimmune diseases has improved, more directed and less toxic therapies are becoming available. A number of groups have been studying the efficacy of a medication called sirolimus in patients with autoimmune diseases. This medicine has been FDA-approved for over 20 years. Sirolimus is a medicine used in children with other diseases. Sirolimus works, in part, by eliminating old and abnormal WBCs. Our group and others have shown that sirolimus is effective in mice with autoimmunity and in children with a rare condition called Autoimmune Lymphoproliferative Syndrome (ALPS). We believe sirolimus will help children with autoimmune cytopenias. We believe it will improve their symptoms and make them less sick. We propose to study sirolimus in children with chronic and/or refractory autoimmune cytopenias.

Condition	Intervention	Phase
Autoimmune Pancytopenia Autoimmune Lymphoproliferative Syndrome (ALPS) Evans Syndrome Idiopathic Thrombocytopenic Purpura Anemia, Hemolytic, Autoimmune Autoimmune Neutropenia Lupus Erythematosus, Systemic Inflammatory Bowel Disease Rheumatoid Arthritis	Drug: sirolimus	Phase 1 Phase 2


Study Type:	Interventional
Study Design:	Endpoint Classification: Safety/Efficacy Study Intervention Model: Single Group Assignment Masking: Open Label Primary Purpose: Treatment
Official Title:	Sirolimus for Patients With Chronic and/or Refractory Autoimmune Cytopenias: A Pilot Series

Resource links provided by NLM:

Genetics Home Reference related topics: autoimmune lymphoproliferative syndrome cyclic neutropenia immune thrombocytopenia rheumatoid arthritis thrombotic thrombocytopenic purpura

MedlinePlus related topics: Anemia Autoimmune Diseases

Drug Information available for: Sirolimus Everolimus Temsirolimus

Genetic and Rare Diseases Information Center resources: Idiopathic Thrombocytopenic Purpura Immune Thrombocytopenia Granulocytopenia Autoimmune Lymphoproliferative Syndrome Evans Syndrome

U.S. FDA Resources

Further study details as provided by Children's Hospital of Philadelphia:

Primary Outcome Measures:

To define the toxicities of administration of oral sirolimus in children with autoimmune cytopenias [ Time Frame: 6 months ] [ Designated as safety issue: Yes ]

Secondary Outcome Measures:

To evaluate the efficacy of oral sirolimus in children with autoimmune cytopenias [ Time Frame: 6 months ] [ Designated as safety issue: Yes ]
To characterize the trough levels produced by administration of oral sirolimus in children with autoimmune cytopenias [ Time Frame: 6 months ] [ Designated as safety issue: No ]
To evaluate the effect of sirolimus on intracellular targets [ Time Frame: 6 months ] [ Designated as safety issue: No ]


Enrollment:	32
Study Start Date:	December 2006
Estimated Study Completion Date:	February 2017
Primary Completion Date:	February 2016 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
Experimental: Sirolimus treatment Sirolimus treatment	Drug: sirolimus Tablet or liquid; taken once or twice daily; dosage is based on establishing a serum trough of 5-15 ng/ml by high-performance liquid chromatography (initial loading dose of 3 mg/m2 then 2.5 mg/m2 with adjustment based on serum trough) Other Names: rapamycin rapamune

Detailed Description:

Patients with autoimmune destruction of hematopoietic cells frequently have severe and debilitating disease requiring aggressive and frequent medical management. These patients are often treated with non-specific immunosuppressive medications with limited efficacy and untoward side-effect profiles. We have been investigating the use of an immunosuppressive and anti-cancer agent, sirolimus in patients with an autoimmune cytopenias syndrome: Autoimmune Lymphoproliferative Syndrome (ALPS). ALPS is a primary immune deficiency caused by mutations in the Fas apoptotic pathway, leading to abnormal lymphocyte survival. Clinical manifestations in patients with ALPS typically include autoimmune cytopenias, lymphadenopathy, hepatosplenomegaly, and a propensity to develop secondary malignancies. Thus, far we have found excellent results albeit the total number of patients treated is small.

Sirolimus is a signal transduction inhibitor with a tolerable side effect profile. Sirolimus has two properties making it an attractive agent to treat patients with autoimmune cytopenias syndromes, including ALPS. First, sirolimus induces apoptosis in normal and abnormal white blood cells, the cell type dysregulated in patients with autoimmune disease. In addition, sirolimus increases a T cell subset called Regulatory T cells (Tregs). Tregs are a cell population designed to suppress the immune system and control autoimmunity. These combined properties make sirolimus unique as compared with other immunosuppressive agents. Ample preclinical and clinical data exists demonstrating sirolimus in effective in patients with autoimmunity. Accordingly, we hypothesize sirolimus is a safe and efficacious medication for patients with autoimmune destruction of blood cells..

We plan to confirm our hypotheses by performing a pilot series in children with autoimmune cytopenias who are either refractory to standard therapy or have significant toxicity from standard treatments. Our primary aim is to define the toxicities of administration of oral sirolimus in children with autoimmune cytopenias. Our secondary aims are to evaluate the efficacy of sirolimus in children with autoimmune cytopenias, to determine the trough levels of sirolimus when used in these patients, and to evaluate the effects of sirolimus on intracellular targets of mammalian target of rapamycin (mTOR). We intend to enroll 50 children with autoimmune cytopenias and treat for a 6 month period, however, if we find sirolimus is effective, we anticipate these children will continue to take sirolimus for a longer period of time. We anticipate the results of this work will establish sirolimus is an effective and well tolerated medication and will lead directly to a larger national phase II clinical trial.

Eligibility


Ages Eligible for Study:	1 Year to 30 Years (Child, Adult)
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

Age > 12 months and < 30 years at the time of study entry
Diagnosis of autoimmune cytopenias requiring treatment with medications
At least one of the following: Autoimmune Neutropenia, Autoimmune Hemolytic Anemia, and/or Autoimmune Thrombocytopenia
Must be proven autoimmune by either a documented autoantibody (positive direct anti globulin test, positive anti-neutrophil, and/or anti-platelet antibody) and/or a documented clinical response to immunosuppression
Autoimmune Cytopenias can be idiopathic (Idiopathic Thrombocytopenic Purpura (ITP), Autoimmune Hemolytic Anemia (AIHA), Autoimmune Neutropenia (AIN), or Evans syndrome) or secondary to one of following conditions: Lupus, Rheumatoid Arthritis (RA), ALPS (Autoimmune Lymphoproliferative Syndrome), or Inflammatory bowel disease (IBD)
Patients must have chronic disease diagnosed by either a documented cytopenia syndrome (Lupus, ALPS, RA, or IBD), or by having Evans syndrome defined as idiopathic destruction of multiple blood cell types, and/or by having disease >6 months
Patients must be refractory to or unable to tolerate standard front-line therapies for autoimmune cytopenias (corticosteroids and/or IVIG)
Patients may be taking second-line agents for autoimmune cytopenias (mycophenolate mofetil, cyclosporine, tacrolimus, mercaptopurine, and/or methotrexate) at time of study entry; however, attempts should be made to wean these agents. Patients may not stay on a combination of sirolimus and a calcineurin inhibitor for greater than 4 weeks
Informed consent/assent MUST be obtained prior to initiating treatment
Patient must be able to consume oral medication in the form of tablets or solution

Exclusion Criteria:

Pregnancy or breast feeding
Uncontrolled infection
Known allergy to Sirolimus or its components
Patients with a documented malignancy on therapy or not in remission
Patients who do not meet organ function requirements listed in protocol
Patients with a documented history of severe combined immunodeficiency or human immunodeficiency virus infection (HIV)

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: NCT00392951

Locations


United States, Pennsylvania
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States, 19104

Sponsors and Collaborators

Children's Hospital of Philadelphia

Investigators


Principal Investigator:	David T. Teachey, MD	Children's Hospital of Philadelphia

More Information

Publications:

Teachey DT, Greiner R, Seif A, Attiyeh E, Bleesing J, Choi J, Manno C, Rappaport E, Schwabe D, Sheen C, Sullivan KE, Zhuang H, Wechsler DS, Grupp SA. Treatment with sirolimus results in complete responses in patients with autoimmune lymphoproliferative syndrome. Br J Haematol. 2009 Apr;145(1):101-6. doi: 10.1111/j.1365-2141.2009.07595.x. Epub 2009 Feb 4.

Teachey DT, Obzut DA, Axsom K, Choi JK, Goldsmith KC, Hall J, Hulitt J, Manno CS, Maris JM, Rhodin N, Sullivan KE, Brown VI, Grupp SA. Rapamycin improves lymphoproliferative disease in murine autoimmune lymphoproliferative syndrome (ALPS). Blood. 2006 Sep 15;108(6):1965-71. Epub 2006 Jun 6.

Teachey DT, Manno CS, Axsom KM, Andrews T, Choi JK, Greenbaum BH, McMann JM, Sullivan KE, Travis SF, Grupp SA. Unmasking Evans syndrome: T-cell phenotype and apoptotic response reveal autoimmune lymphoproliferative syndrome (ALPS). Blood. 2005 Mar 15;105(6):2443-8. Epub 2004 Nov 12.

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Bride KL, Vincent T, Smith-Whitley K, Lambert MP, Bleesing JJ, Seif AE, Manno CS, Casper J, Grupp SA, Teachey DT. Sirolimus is effective in relapsed/refractory autoimmune cytopenias: results of a prospective multi-institutional trial. Blood. 2016 Jan 7;127(1):17-28. doi: 10.1182/blood-2015-07-657981. Epub 2015 Oct 26.


Responsible Party:	Children's Hospital of Philadelphia
ClinicalTrials.gov Identifier:	NCT00392951 History of Changes
Other Study ID Numbers:	2006-7-4873
Study First Received:	October 24, 2006
Last Updated:	April 22, 2016
Health Authority:	United States: Institutional Review Board

Keywords provided by Children's Hospital of Philadelphia:


ALPS Autoimmune Cytopenias Treatment Sirolimus Rapamycin Lymph Nodes	Spleen Hemolytic Anemia Immune Thrombocytopenia Neutropenia ITP Lupus

Additional relevant MeSH terms:


Autoimmune Lymphoproliferative Syndrome Syndrome Arthritis, Rheumatoid Intestinal Diseases Inflammatory Bowel Diseases Neutropenia Purpura Purpura, Thrombocytopenic Hemolysis Purpura, Thrombocytopenic, Idiopathic Lupus Erythematosus, Systemic Pancytopenia Anemia, Hemolytic Anemia, Hemolytic, Autoimmune Disease	Pathologic Processes Arthritis Joint Diseases Musculoskeletal Diseases Rheumatic Diseases Connective Tissue Diseases Autoimmune Diseases Immune System Diseases Gastrointestinal Diseases Digestive System Diseases Gastroenteritis Agranulocytosis Leukopenia Leukocyte Disorders Hematologic Diseases

ClinicalTrials.gov processed this record on September 26, 2016