A Study to Compare T-Guard vs Ruxolitinib for Treatment of Steroid-Refractory Acute Graft-vs-Host Disease (BMT CTN 2002)

Phase 3

Terminated

Conditions: Steroid-Refractory Acute Graft Versus Host Disease

Interventions: Drug: T-Guard
Drug: Ruxolitinib

Registration Number: NCT04934670

Lead Sponsor: Xenikos

Brief Summary: This is an open-label, randomized, Phase 3, multicenter trial, which has been designed to compare the efficacy and safety of T-Guard to ruxolitinib in patients with Grade III or IV Steroid-Refractory acute Graft-Versus-Host Disease (SR-aGVHD). The primary hypothesis is that T-Guard treatment will improve the Day 28 complete response (CR) rate in patients with Grades III and IV SR-aGVHD compared to ruxolitinib.

Detailed Description: Graft-vs-Host Disease (GVHD) is a complication that affects many hematopoietic stem cell transplant (HSCT) patients; it occurs when the new cells from a transplant attack the recipient's body. Acute GVHD (aGVHD) typically develops within the first three months after HSCT and is typically treated with steroid therapy. A significant fraction of the aGVHD population (10-50%) fail to respond to treatment and are deemed steroid-refractory (SR).

Participants that develop Grade III or IV SR aGVHD will be randomized to receive T-Guard or ruxolitinib and will be followed for approximately 180 days. Participants will be stratified by center region (US vs. Europe) and age group (at least 55 years vs. under 55). Participants randomized to the T-Guard arm will receive 4 doses administered intravenously as four 4-hour infusions, and participants randomized to the ruxolitinib arm will receive one dose administered orally twice a day. The primary analysis will include all participants that are randomized.

Recruitment & Eligibility

Status: TERMINATED

Sex: All

Target Recruitment: 12

Inclusion Criteria

To be eligible to participate in this study, patients must meet the following:

Patients must be at least 18.0 years of age at the time of consent.
Patient has undergone first allo-HSCT from any donor source or graft source. Recipients of nonmyeloablative, reduced intensity, and myeloablative conditioning regimens are eligible.
Patients diagnosed with Grade III/IV SR-aGVHD after allo-HSCT. SR includes aGVHD initially treated at a lower steroid dose, but must meet one of the following criteria:
- Progressed or new organ involvement after 3 days of treatment with methylprednisolone (or equivalent) of greater than or equal to 2 mg/kg/day
- No improvement after 7 days of primary treatment with methylprednisolone (or equivalent) of greater than or equal to 2mg/kg/day
- Patients with visceral (GI and/or liver) plus skin aGVHD at methylprednisolone (or equivalent) initiation with improvement in skin GVHD without any improvement in visceral GVHD after 7 days of primary treatment with methylprednisolone (or equivalent) of greater than or equal to 2mg/kg/day
- Patients who have skin GVHD alone and develop visceral aGVHD during treatment with methylprednisolone (or equivalent) of greater than or equal to 1mg/kg/day and do not improve after 3 days of greater than or equal to 2mg/kg/day Improvement or progression in organs is determined by comparing current organ staging to staging at initiation of methylprednisolone (or equivalent) treatment.
Patients must have evidence of myeloid engraftment (e.g., absolute neutrophil count greater than or equal to 0.5 × 109/L for 3 consecutive days if ablative therapy was previously used). Use of growth factor supplementation is allowed.
Patients or an impartial witness (in case the patient is capable of providing verbal consent but not capable of signing the informed consent form (ICF)) should have given written informed consent.

Exclusion Criteria

Patients will be excluded from study entry if they meet any of the following exclusion criteria:

Patients who have a creatinine greater than or equal to 2mg/dL or estimated creatinine clearance less than 40 mL/min or those requiring hemodialysis.
Patients who have been diagnosed with active thrombotic microangiopathy (TMA), defined as meeting all the following criteria:
- Greater than 4% schistocytes in blood (or equivalent if semiquantitative scale is used e.g., 3+ or 4+ schistocytes on peripheral blood smear)
- De novo, prolonged or progressive thrombocytopenia (platelet count less than 50 x 109/L or 50% or greater reduction from previous counts)
- Sudden and persistent increase in lactate dehydrogenase concentration greater than 2x the upper level of normal (ULN)
- Decrease in hemoglobin concentration or increased transfusion requirement attributed to Coombs-negative hemolysis
- Decrease in serum haptoglobin
Patients who have previously received treatment with eculizumab.
Patients who have previously received checkpoint inhibitors (either before or after allo-HCT).
Patients who have been diagnosed with overlap syndrome, that is, with any concurrent features of cGVHD.
Patients requiring mechanical ventilation or vasopressor support.
Patients who have received any systemic treatment, besides steroids, as upfront treatment of aGVHD or as treatment for SR-aGVHD. Reinstitution of previously used GVHD prophylaxis agents (e.g., tacrolimus, cyclosporin, methotrexate [MTX], MMF) or substitutes in cases with previously documented intolerance will be permitted. Previous treatment with a janus kinase (JAK) inhibitor as part of GVHD prophylaxis or treatment is not allowed.
Patients who have severe hypoalbuminemia, with an albumin of less than or equal to 1 g/dl.
Patients who have a creatine kinase (CK) level of greater than 5 times the upper limit of normal.
Patients with uncontrolled infections. Infections are considered controlled if appropriate therapy has been instituted and, at the time of enrollment, no signs of progression are present. Persisting fever without other signs or symptoms will not be interpreted as progressing infection. Progression of infection is defined as:
- hemodynamic instability attributable to sepsis OR
- new symptoms attributable to infection OR
- worsening physical signs attributable to infection OR
- worsening radiographic findings attributable to infection Patients with radiographic findings attributable to infection within 4 weeks prior to enrollment must have a repeat radiographic exam within one week of enrollment that documents absence of worsening.
Patients with evidence of relapsed, progressing, or persistent malignancy, or who have been treated for relapse after transplant, or who may require rapid immune suppression withdrawal as pre-emergent treatment of early malignancy relapse.
Patients with evidence of minimal residual disease requiring withdrawal of systemic immune suppression.
Patients with unresolved serious toxicity or complications (other than aGVHD) due to previous transplant.
History of sinusoidal obstruction syndrome (SOS)/veno-occlusive disease (VOD).
Patients with known hypersensitivity to any of the components murine monoclonal antibodies (mAb) or Recombinant Ricin Toxin A-chain (RTA).
Patients who have had treatment with any other investigational agent, device, or procedure within 21 days (or 5 half-lives, whichever is greater) prior to enrollment. An investigational agent is defined as medications without any known FDA or European Medicines Agency (EMA) approved indications.
Patients who have received more than one allo-HSCT.
Patients with known human immunodeficiency virus infection.
Patients who have a BMI greater than or equal to 35 kg/m2.
Patients who are taking sirolimus must discontinue prior to starting study treatment.

The sirolimus blood level must be less than 2 ng/mL prior to starting study treatment.
Female patients who are pregnant, breast feeding, or, if sexually active and of childbearing potential, unwilling to use effective birth control from start of treatment until 30 days after the last study treatment.
Male patients who are, if sexually active and with a female partner of childbearing potential, unwilling to use effective birth control from start of treatment until 65 days after the last study treatment.
Patients with any condition that would, in the investigator's judgment, interfere with full participation in the study, including administration of study drug and attending required study visits; pose a significant risk to the patient; or interfere with interpretation of study data.
Patients whose decision to participate might be unduly influenced by perceived expectation of gain or harm by participation, such as patients in detention due to official or legal order.

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
T-Guard	T-Guard	Participants will be administered four doses of T-Guard intravenously for a 4-hour period every other day
Ruxolitinib	Ruxolitinib	Participants will take ruxolitinib twice daily for continuous daily dosing

Primary Outcome Measures

Name	Time	Method
Complete Response (CR)	Day 28	The primary objective of this trial is to assess the rate of CR on Day 28 post-randomization in Grades III and IV SR-aGVHD patients treated with T-Guard treatment in comparison to ruxolitinib. Participants were classified as Day 28 CR if these three conditions were satisfied: 1. Stage 0 aGVHD (no remaining symptoms) in the three target organs skin, bowel and liver, 2 . The participant is still alive at Day 28, 3 . No additional systemic treatment for aGVHD has been administered through Day 28.

Secondary Outcome Measures

Name	Time	Method
Overall Survival (OS)	Day 180	OS is defined as survival of death from any cause. The time from randomization until death from any cause will be described for each arm.
Duration of Complete Response (DoCR)	Day 28	DoCR will be evaluated only in the set of participants who are in CR at Day 28 post-randomization. The primary definition of DoCR is the time from Day 28 until an aGVHD target organ worsens by at least 1 stage and requires a significant escalation in treatment, or death.

Trial Locations

Locations (48): University of Alabama
🇺🇸
Birmingham, Alabama, United States
Mount Sinai Medical Center
🇺🇸
New York, New York, United States
Sarah Cannon Research Institute
🇺🇸
Nashville, Tennessee, United States
University of Utah
🇺🇸
Salt Lake City, Utah, United States
Site BE301
🇧🇪
Brussels, Belgium
Site BE307
🇧🇪
Gent, Belgium
Site BE305
🇧🇪
Leuven, Belgium
Site BE302
🇧🇪
Liège, Belgium
Site FR355
🇫🇷
Lille, France
Site FR341
🇫🇷
Angers, France
Site DE371
🇩🇪
Hannover, Germany
Site FR351
🇫🇷
Saint-Priest-en-Jarez, France
Site FR346
🇫🇷
La Tronche, France
Site DE361
🇩🇪
Muenster, Germany
SiteFR348
🇫🇷
Paris, France
SiteFR354
🇫🇷
Nantes, France
Site FR356
🇫🇷
Pierre-Bénite, France
SiteFR342
🇫🇷
Paris, France
Site FR352
🇫🇷
Toulouse, France
Site DE367
🇩🇪
Dresden, Germany
Site DE364
🇩🇪
Essen, Germany
Site DE360
🇩🇪
Leipzig, Germany
Site NL460
🇳🇱
Maastricht, Netherlands
Site NL463
🇳🇱
Nijmegen, Netherlands
Site ES451
🇪🇸
Santander, Spain
H. Lee Moffitt Cancer Center
🇺🇸
Tampa, Florida, United States
Site BE303
🇧🇪
Yvoir, Belgium
Site FR345
🇫🇷
Créteil, France
Washington University St. Louis
🇺🇸
Saint Louis, Missouri, United States
Duke University Medical Center
🇺🇸
Durham, North Carolina, United States
Ohio State University
🇺🇸
Columbus, Ohio, United States
Oregon Health & Science University
🇺🇸
Portland, Oregon, United States
Site HR320
🇭🇷
Zagreb, Croatia
Site DE368
🇩🇪
Heidelberg, Germany
Site DE362
🇩🇪
Mainz, Germany
Site IT384
🇮🇹
Milan, Italy
Site ES447
🇪🇸
Barcelona, Spain
Site ES446
🇪🇸
Madrid, Spain
Site NL461
🇳🇱
Groningen, Netherlands
Site ES442
🇪🇸
Salamanca, Spain
Site ES452
🇪🇸
Sevilla, Spain
Site ES453
🇪🇸
Valencia, Spain
Site GB483
🇬🇧
Cardiff, United Kingdom
Site ES454
🇪🇸
Valencia, Spain
Wake Forest University
🇺🇸
Winston-Salem, North Carolina, United States
Site BE300
🇧🇪
Bruxelles, Belgium
City of Hope National Medical Center
🇺🇸
Duarte, California, United States
University of Wisconsin
🇺🇸
Madison, Wisconsin, United States