Sirolimus as Secondary Therapy in Chronic Graft-Versus-Host Disease Not Responding To Prior Treatment

Phase 2

Completed

Brief Summary: This phase II trial studies the side effects and how well sirolimus works as secondary therapy in treating patients with chronic graft-versus-host disease (GVHD) that did not respond to prior treatment. Sirolimus may be an effective treatment for chronic GVHD

Detailed Description: PRIMARY OBJECTIVES:

I. To assess the safety of sirolimus administered at a dose which provides steady-state, whole blood trough levels of 5-10 ng/mL in patients with chronic GVHD.

II. To determine whether administration of sirolimus provides benefit for patients with chronic GVHD that has not responded adequately to previous systemic treatment.

OUTLINE:

Patients receive sirolimus orally (PO) once daily (QD). Patients continue to receive prednisone and cyclosporine or tacrolimus at the discretion of the managing physician.

After completion of study treatment, patients are followed up periodically.

Recruitment & Eligibility

Inclusion Criteria

Biopsy-confirmed diagnosis of clinical extensive chronic GVHD with inadequate response to previous treatment and where secondary systemic therapy is indicated because of
- Clinical progression of signs and symptoms of chronic GVHD in a previously involved organ, or
- Development of signs and symptoms of chronic GVHD in a previously uninvolved organ, or
- Absence of improvement after 3 months of primary treatment, or
- Continued need for treatment with prednisone at doses >= 1.0 mg/kg/day for more than 2 months, without qualification for type of donor, graft or conditioning regimen
Patient or guardian able and willing to provide informed consent
Stated willingness to use contraception in women of child-bearing potential (Food and Drug Administration [FDA] requirement)
Stated willingness of the patient to comply with study procedures and reporting requirements
Stated willingness of the physician most involved in management of chronic GVHD (the "managing physician,") to comply with study procedures and reporting requirements

Exclusion Criteria

Fungal or viral infection with no radiographic evidence of improvement during continued appropriate antimicrobial therapy
Cytomegalovirus (CMV) antigenemia unresponsive to antiviral therapy
Active disseminated varicella zoster virus (VZV) infection with persistent non-crusted lesions
Inability to tolerate oral medications
Absolute neutrophil count (ANC) < 1500/uL
Platelet count < 50,000/uL
Persistent or recurrent malignancy, including histopathologic evidence of myeloma or lymphoma; patients with breakpoint cluster region-abelson (bcr/abl) detected by polymerase chain reaction (PCR) assay as the only evidence of persistent chronic myeloid leukemia may be enrolled
Pregnancy
Known history of hypersensitivity to sirolimus

Arm && Interventions

Group	Intervention	Description
Sirolimus	sirolimus	Study participants receive sirolimus added once daily to their baseline combination therapy of prednisone plus either cyclosporine or tacrolimus at the discretion of the managing physician. Treatment other than cyclosporine (or tacrolimus) and prednisone must be discontinued when administration of sirolimus is started. Topical therapy, including psoralen and UVA irradiation (PUVA), glucocorticoid creams, topical tacrolimus, oral beclomethasone, topical azathioprine and ophthalmic glucocorticoids may be given at the discretion of the managing physician in consultation with the transplant center.

Primary Outcome Measures

Name	Time	Method
Number of Participants Experiencing Treatment Success	Approximately 7 years	Defined as the absence of any immunosuppressive treatment, including sirolimus, with resolution of all reversible manifestations of chronic GVHD and no additional systemic therapy.
Number of Participants Experiencing Treatment Failure	Approximately 7 years	Defined as the initiation of additional systemic therapy, development of bronchiolitis obliterans, or death from causes other than recurrent malignancy during primary treatment for chronic GVHD, whichever occurs first.
Number of Participants Needing Additional Systemic Therapy	Approximately 7 years	Includes any intervention intended to control chronic GVHD through an immunosuppressive effect from oral or parenteral administration of any systemic medication not originally given under auspices of this protocol.
Number of Participants With Recurrent Malignancy	Approximately 7 years	Defined as clinical or histopathologic evidence demonstrating the presence of any malignancy considered as the indication for transplant. Recurrent malignancy will also be defined as any post-transplant intervention not routinely used to prevent the development of overt recurrence, prompted by laboratory evidence of persisting malignant cells but without clinical or histopathologic evidence of recurrence.

Secondary Outcome Measures

Name	Time	Method
Proportion of Patients Who Discontinue Administration of Sirolimus Because of Toxicity	Approximately 7 years
Proportion With Infections Categorized by Organism	Approximately 7 years
Secondary Malignancies	Up to 7 years	Proportion of participants who developed at least one secondary malignancy by 7 years
Duration of Treatment With Prednisone	Approximately 7 years
Probability of Survival Without Recurrent Malignancy	Approximately 7 years	Kaplan-Meier estimate assessed at 7 years for probability of survival without recurrent malignancy.
Probability of Overall Survival	Approximately 7 years	Kaplan-Meier estimate assessed at 7 years
Probability of Cumulative Incidence of Death Without Recurrent Malignancy	Approximately 7 years	Analyzed with recurrent malignancy as a competing risk factor. Assessed at 7 years.
Probability of Cumulative Incidence of Recurrent Malignancy	Approximately 7 years	Analyzed with death as a competing risk factor. Assessed at 7 years.