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Acute GVHD Suppression Using Costimulation Blockade to Expand Non-malignant Transplant (ASCENT)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT03924401
Recruitment Status : Recruiting
First Posted : April 23, 2019
Last Update Posted : September 23, 2019
Sponsor:
Collaborators:
Thrasher Research Fund
Sickle Cell Transplant Advocacy & Research Alliance (STAR)
Information provided by (Responsible Party):
John Horan, Emory University

Brief Summary:

The ASCENT Trial is a single arm, multi-center, phase II study. The primary objective is to determine the rejection-free, severe graft-versus-host disease (GVHD)-free survival in pediatric patients with serious non-malignant hematologic diseases (NMHD) undergoing mismatched unrelated donor (URD) hematopoietic stem cell transplantation (HSCT) with abatacept added to conventional GVHD prophylaxis. The secondary objective is to characterize the impact of abatacept on infection and the reconstitution of protective immunity to infection. Transplanted patients will be followed for 3 years. Weight-based peripheral blood samples will be drawn longitudinally through two years to evaluate immune reconstitution.

The study will enroll 27 pediatric patients with serious NMHD undergoing mismatched URD HSCT. The trial will include two strata: one for patients with sickle cell disease (SCD) (stratum 1, n=10) and one for other diseases, including idiopathic severe aplastic anemia (SAA), Fanconi anemia (FA), inherited marrow failure syndromes, and thalassemia major (stratum 2, n=17). All participants will receive 8 doses of abatacept (10 mg/kg intravenously on days -1, +5, +14, +28, +56, +84, +112, and +150). Recruitment is expected to last for about 2 years and participants will be followed for up to 3 years.

This trial will test the hypothesis that extended abatacept administration (combined with a standard regimen of tacrolimus and mycophenolate mofetil) will effectively prevent acute and chronic GVHD in children and adolescents receiving mismatched URD HSCT, without compromising their engraftment or reconstitution of protective immunity to infection.


Condition or disease Intervention/treatment Phase
Graft Versus Host Disease Drug: Abatacept Phase 2

Detailed Description:

Many serious NMHD affecting children, including SAA, FA, SCD, and thalassemia can be cured by allogeneic HSCT. While the best results are achieved with HSCT from human leukocyte antigen (HLA)-matched siblings, most children lack such donors, and many children with NMHD are therefore transplanted with grafts from adult URD. Because URD grafts are less histocompatible, they are more likely to cause GVHD, a process driven by the reaction of donor T cells against incompatible host tissues. Despite the routine administration of immune suppression for GVHD prophylaxis, GVHD claims the lives of many and plagues others with incapacitating chronic illness. For NMHD, the threat of GVHD limits the use of URD HSCT to only the most severely affected children. In African-Americans and other ethnic minorities, the situation is compounded by the fact that most of these children lack fully matched URD and typically receive mismatched grafts, which carry an increased risk for graft rejection. A more effective form of GVHD prophylaxis that does not compromise engraftment is urgently needed, both to improve outcomes for those children undergoing HSCT as well as to allow expansion of this curative therapy to the many children with NMHD who forego transplantation because of the risk for GVHD.

The researchers have investigated the use of the co-stimulation blocking agent CTLA4-Ig (abatacept) to prevent GVHD. Study results to date indicate that abatacept strongly inhibits allo-reactive donor T cells and is clinically safe and effective. The clinical experience has included a variety of recipients: children and adults, peripheral blood stem cells (PBSC) and bone marrow (BM) grafts, as well as mismatched and matched unrelated and matched related donors; all have involved the administration of four IV doses of abatacept, on days -1, +5, +14, and +28, in combination with standard calcineurin inhibitor-based GVHD prophylaxis. Collectively, the results to date suggest that this combination, including abatacept, very effectively prevents acute GVHD. However, these results also suggest that protection against chronic GVHD is more limited. In this current trial, the researchers will attempt to more effectively prevent chronic GVHD by extending the administration of abatacept, giving eight doses (additional doses days +56, +84, +112, and +150). This trial will test the hypothesis that extended abatacept administration (combined with a standard regimen of tacrolimus and mycophenolate mofetil) will effectively prevent acute and chronic GVHD in children and adolescents receiving mismatched URD HSCT, without compromising their engraftment or reconstitution of protective immunity to infection.

The study will enroll 27 pediatric patients with serious NMHD undergoing 7/8 HLA locus matched URD HSCT. The trial will include two strata: one for patients with SCD (stratum 1, n=10) and one for other diseases, including idiopathic SAA, FA, inherited marrow failure syndromes, and thalassemia major (stratum 2, n=17). Study participants will be admitted to the hospital ten or eleven days prior to the day of transplant (day -10 or day -11) to complete a conditioning regimen to prevent the donor cells from being rejected.

Patients will receive one of three reduced toxicity or intensity conditioning regimens based upon underlying disease and/or physician preference: (1) anti-thymocyte globulin, fludarabine, and a low dose of cyclophosphamide (FA patients only); (2) anti-thymocyte globulin, fludarabine, cyclophosphamide, and a low dose of total body radiation (SAA and other bone marrow failure disorders); or (3) alemtuzumab, fludarabine, melphalan, and thiotepa (hemoglobinopathy and non-SAA bone marrow failure disorders). All participants will receive 8 doses of abatacept (10 mg/kg intravenously on days -1, +5, +14, +28, +56, +84, +112, and +150). Recruitment is expected to last for about 2 years and participants will be followed for up to 3 years.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 27 participants
Intervention Model: Single Group Assignment
Intervention Model Description: The trial will include two strata: one for patient with SCD (n=10) and one for other diseases, including idiopathic SAA, FA, inherited marrow failure syndromes, and thalassemia major (n=17).
Masking: None (Open Label)
Primary Purpose: Prevention
Official Title: Acute GVHD Suppression Using Costimulation Blockade to Expand Non-malignant Transplant (ASCENT)
Actual Study Start Date : August 22, 2019
Estimated Primary Completion Date : December 2023
Estimated Study Completion Date : December 2023


Arm Intervention/treatment
Experimental: Participants Receiving Abatacept
Pediatric participants who are undergoing 7/8 URD HSCT for serious NMHD will receive 8 doses of abatacept in addition to conventional GVHD prophylaxis.
Drug: Abatacept
All patients will receive 8 doses of abatacept (10 mg/kg intravenously on days -1, +5, +14, +28, +56, +84, +112, and +150) in addition to conventional GVHD prophylaxis.
Other Name: Orencia




Primary Outcome Measures :
  1. Event-free survival [ Time Frame: Up to 3 years ]
    Event-free survival is a composite endpoint defined as rejection-free, severe GVHD-free survival. Events for this outcome include death, severe (grade II-IV) acute GVHD up to day 100, moderate to severe chronic GVHD up to 1 year, and/or graft rejection up to 1 year.


Secondary Outcome Measures :
  1. Cytomegalovirus (CMV) Viremia [ Time Frame: Up to Day 180 ]
    The number of participants experiencing cytomegalovirus (CMV) viremia will be reported. CMV viremia will be defined as the occurrence of a positive polymerase chain reaction (PCR) test prior to Day 180.

  2. CMV Invasive Disease [ Time Frame: Up to 2 years ]
    The number of participants experiencing CMV invasive disease will be reported. CMV invasive disease will be defined in accordance with the Blood and Marrow Transplant Clinical Trials Network Manual of Procedures.

  3. Post-transplant lymphoproliferative disease (PTLD) [ Time Frame: Up to 2 years ]
    The number of participants experiencing post-transplant lymphoproliferative disease (PTLD) will be reported. PTLD will be defined in accordance with the World Health Organization's (WHO) Classification of Tumours of Haematopoietic and Lymphoid Tissues.

  4. Regimen-Related Toxicity [ Time Frame: Day 42 Post-transplant ]
    The number of participants experiencing regimen-related toxicity (RRT) will be reported. RRT will be scored according to the Bearman scale. Major RRT, defined as grade 4 (causing death) in any organ system or grade 3 for pulmonary, cardiac, renal, oral mucosal, neurologic, or hepatic, will be recorded.

  5. Neutrophil Recovery [ Time Frame: Up to Day 60 ]
    The time to neutrophil recover, in days, will be reported. Neutrophil recovery will be defined as the first of 3 consecutive days following the nadir that the absolute neutrophil count is at least 500/microliter of blood.

  6. Platelet Recovery [ Time Frame: Up to Day 60 ]
    The time to platelet recover, in days, will be reported. Platelet recovery will be defined as the first day that the platelet count is at least 50,000/microliter of blood, without a transfusion in the preceding 7 days.

  7. Non-Engraftment [ Time Frame: Day 28 ]
    The number of participants experiencing non-engraftment will be reported. Non-engraftment will be defined as lack of neutrophil recovery, or neutrophil recovery with lack of myeloid donor chimerism.

  8. Secondary Graft Failure [ Time Frame: Up to 3 years ]
    The number of participants experiencing secondary graft failure will be reported. Secondary graft failure will be defined by initial engraftment but subsequent development of an absolute neutrophil count (ANC) < 500/μl for fourteen consecutive days.

  9. Graft Loss [ Time Frame: Up to 3 years ]
    The number of participants experiencing graft loss will be reported. Graft loss will be defined by initial engraftment (assessed by neutrophil recovery and donor chimerism) with the subsequent loss of donor myeloid chimerism (regardless whether persistent neutropenia develops).

  10. Acute GVHD [ Time Frame: Up to 1 year ]
    The number of participants experiencing acute GVHD (including all grades and stratified by grades) will be reported. Acute GVHD will be assessed according to the Blood and Marrow Transplant Clinical Trials Network Manual of Procedures.

  11. Chronic GVHD [ Time Frame: Up to 2 years ]
    The number of participants experiencing chronic GVHD (including overlap syndrome) will be reported. Chronic GVHD will be assessed according to the Blood and Marrow Transplant Clinical Trials Network Manual of Procedures.

  12. Immune Suppression-Free Survival [ Time Frame: Year 2 ]
    The number of participants experiencing immune suppression-free survival will be reported. Immune suppression-free survival is measured as participant survival while off all systemic immunosuppressive agents.

  13. Immune Suppression-Free/Disease-Free Survival [ Time Frame: Year 2 ]
    The number of participants experiencing immune suppression-free/disease-free survival will be reported. Immune suppression-free/disease-free survival will be defined as rejection-free survival off all systemic immunosuppressive agents.

  14. Rejection-free survival [ Time Frame: Up to 3 years ]
    The number of participants experiencing rejection-free survival will be reported. Rejection-free survival will be defined as survival without non-engraftment, secondary graft failure, or graft loss.

  15. Overall survival [ Time Frame: Up to 3 years ]
    The number of participants experiencing surviving at the end of the study follow up period will be reported.



Information from the National Library of Medicine

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, Learn About Clinical Studies.


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Ages Eligible for Study:   up to 20 Years   (Child, Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Patients with sickle cell disease (stratum 1) must be between the ages of 3-20.99 years and patients with other diseases (stratum 2) between the ages of 0-20.99 years at the time of admission for transplant.
  • Must have one of the following diseases:

    • Acquired or inherited bone marrow failure

      • Diamond-Blackfan anemia (transfusion dependent, including steroid failure or inability to wean steroids)
      • Fanconi anemia
      • Dyskeratosis-congenita
      • Acquired (immune; non-inherited, non-congenital) severe aplastic anemia
      • Other inherited or congenital marrow failure syndromes complicated by severe aplastic anemia
      • Other inherited or congenital red blood cell disorders requiring monthly chronic transfusion therapy
      • Inherited or congenital platelet disorders requiring frequent platelet transfusions (defined as ≥ 10 transfusions in the preceding 3 years)
      • Congenital neutrophil disorders, including severe congenital neutropenia, chronic granulomatous disease, and leukocyte adhesion deficiency.
    • Hemoglobinopathy

      • Thalassemia major
      • Sickle cell disease (Hgb SS or Sβ0 thalassemia) between the ages of 3 and 20.99 and with one of the following severe complications. Patients with a 7/8 donor will only be eligible if they have a history of clinical stroke.

        • Previous clinical stroke, as evidenced by a neurological deficit lasting longer than 24 hours, which is accompanied by radiographic evidence of ischemic brain injury and cerebral vasculopathy.
        • Asymptomatic cerebrovascular disease, as evidenced by one of the following:

          • Progressive silent cerebral infarction, as evidenced by serial MRI scans that demonstrate the development of a succession of lesions (at least two temporally discreet lesions, each measuring at least 3 mm in greatest dimension on the most recent scan, or the enlargement of a single lesion, initially measuring at least 3 mm). Lesions must be visible on T2-weighted MRI sequences.
          • Cerebral arteriopathy, as evidenced by abnormal TCD testing (confirmed elevated velocities in any single vessel of time-averaged maximum mean velocity [TAMMV] ≥ 200 cm/sec for non-imaging TCD) or by significant vasculopathy on magnetic resonance angiogram (MRA; greater than 50% stenosis of ≥ 2 arterial segments or complete occlusion of any single arterial segment).
  • Must have an unrelated adult donor (marrow or PBSC) who is a 7/8 match
  • All patients and/or their parents or legal guardians must sign a written informed consent. Assent, when appropriate, will be obtained according to institutional guidelines.
  • Must have been evaluated and adequately counseled regarding treatment options by a pediatric hematologist.
  • Negative serum pregnancy test for females of childbearing potential only. Pregnancy must be excluded before the start of treatment with study drugs and prevented thereafter by reliable contraceptive methods.

Exclusion Criteria:

  • HLA matched related or unrelated donor
  • Pulmonary dysfunction defined as diffusing capacity of the lungs for carbon monoxide (DLCO; corrected for hemoglobin), forced expiratory volume in one second (FEV1), or forced vital capacity (FVC) < 40% of predicted. In a child unable to perform pulmonary function testing, a chronic need for supplemental oxygen will serve as the exclusionary criterion.
  • Renal dysfunction defined as estimated glomerular filtration rate (GFR) of <60 ml/min/1.73m^2.
  • Severe cardiac dysfunction defined as shortening fraction < 25%.
  • Bridging (portal to portal) fibrosis or cirrhosis of the liver
  • Clinical stroke within 6 months of anticipated transplant
  • Karnofsky or Lansky functional performance score < 50%
  • HIV infection
  • Uncontrolled viral bacterial, fungal, or protozoal infection at the time of study enrollment.
  • Patient with unspecified chronic toxicity serious enough to detrimentally affect the patient's capacity to tolerate HSCT.
  • Patient or patient's guardian(s) unable to understand the nature and risks inherent in the HSCT process.
  • History of non-compliance severe enough in the estimation of the treating team to preclude the patient from undergoing unrelated donor transplantation.
  • Patient is pregnant or lactating.
  • Patient's HLA antibody testing demonstrates an antibody directed against a disparate HLA molecule.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03924401


Contacts
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Contact: Ben Watkins, MD 404-785-1272 benjamin.watkins@emory.edu
Contact: Elizabeth Stenger, MD, MSc stengereo@upmc.edu

Locations
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United States, Alabama
Children's of Alabama Not yet recruiting
Birmingham, Alabama, United States, 35233
United States, Delaware
Nemours/Alfred I. DuPont Hospital for Children Not yet recruiting
Wilmington, Delaware, United States, 19803
United States, Georgia
Childrens Healthcare of Atlanta Recruiting
Atlanta, Georgia, United States, 30322
United States, Illinois
Ann & Robert H. Lurie Children's Hospital of Chicago Recruiting
Chicago, Illinois, United States, 60611
United States, Massachusetts
Dana-Farber Cancer Institute Not yet recruiting
Boston, Massachusetts, United States, 02215
United States, New Jersey
Hackensack Meridian Health Recruiting
Hackensack, New Jersey, United States, 07601
United States, New York
Oishei Children's Hospital Not yet recruiting
Buffalo, New York, United States, 14203
Sponsors and Collaborators
Emory University
Thrasher Research Fund
Sickle Cell Transplant Advocacy & Research Alliance (STAR)
Investigators
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Principal Investigator: John Horan, MD Emory University

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Responsible Party: John Horan, Associate Professor, Emory University
ClinicalTrials.gov Identifier: NCT03924401    
Other Study ID Numbers: IRB00108549
First Posted: April 23, 2019    Key Record Dates
Last Update Posted: September 23, 2019
Last Verified: September 2019
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by John Horan, Emory University:
Pediatrics
Non-malignant hematologic diseases
Severe aplastic anemia
Fanconi anemia
Sickle cell disease
Hematopoietic stem cell transplantation
Thalassemia
Mismatched unrelated donor
Additional relevant MeSH terms:
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Graft vs Host Disease
Immune System Diseases
Abatacept
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Antirheumatic Agents