Front Line Ibrutinib Without Corticosteroids for Newly Diagnosed Chronic Graft-versus-Host Disease
NCT ID: NCT04294641
Last Updated: 2025-01-22
Study Results
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View full resultsBasic Information
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ACTIVE_NOT_RECRUITING
PHASE2
10 participants
INTERVENTIONAL
2021-05-10
2026-06-28
Brief Summary
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\- Chronic Graft Versus Host Disease (cGVHD) can occur after a person has had a stem cell or bone marrow transplant. In cGVHD, the donor cells attack the recipient's body. Researchers want to see if a drug called ibrutinib can block one of the proteins that lead to the immune reaction that causes cGVHD.
Objective:
\- To see if ibrutinib as a first-line treatment can help people with newly diagnosed cGVHD.
Eligibility:
\- People age 18 and older with newly diagnosed moderate or severe cGVHD
Design:
* Participants will be screened with:
* Medical and medicine histories
* Physical exam and vital signs
* Electrocardiograms (to measure heart function)
* Assessment of their ability to perform daily activities
* Blood and urine tests
* Assessment of their general well-being.
* Participants will visit the Clinical Center every 2 weeks for the first 2 months. Then they will visit every 4 weeks.
* Participants will take ibrutinib by mouth once every day of every cycle. One cycle is 28 days. Treatment will last up to 2 years. Participants will keep a medicine diary.
* Participants will take tests to measure lung function. They may have computed tomography scans of their chest. They will complete questionnaires about their symptoms and how cGVHD is affecting their body and quality of life. They will repeat the screening tests.
* Participants may have optional blood tests and/or skin biopsies to better understand the drugs effect on the body.
* Participants will be contacted by phone 30 days after treatment ends. They will also be contacted once a year for 2 years to discuss how they are feeling and if they have taken any other medicines to treat cGVHD.
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Detailed Description
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* Chronic graft-versus-host disease (GvHD) is the leading cause of late morbidity and non-relapse mortality following allogeneic hematopoietic stem cell transplantation (alloHSCT), occurring in 40-60% long-term survivors.
* Chronic GvHD occurs due to the dysfunctional peripheral tolerance during post-transplant hematopoietic reconstitution that allows the development and persistence of alloreactive donor-derived T and B cells.
* Prednisone is the front-line therapy; however, about 50% of participants have steroid-refractory disease and there is no standard second-line therapy.
* The most attractive approach for controlling chronic GvHD would be early therapy intervention which could prevent the most severe and irreversible clinical manifestations.
* Anti-B-cell therapy delivered early in chronic GvHD could be effective and steroid-sparing.
* Ibrutinib, reversible small molecule inhibitor of Brutons tyrosine kinase, has been shown to be well-tolerated and effective in phase 1b/2 trial for steroid refractory chronic GvHD.
Objective:
-To evaluate efficacy of ibrutinib as a first-line treatment for persons with newly diagnosed chronic GvHD by measuring the overall response rate (complete response \[CR\] + partial response \[PR\]) at 6 months, according to the 2014 National Institutes of Health (NIH) Consensus Criteria
Eligibility:
* Newly diagnosed, moderate or severe chronic GvHD according to the 2014 NIH Consensus Criteria, requiring systemic immunosuppression
* Age greater than or equal to 18 years old
* Karnofsky performance status greater than or equal to 60%
* History of prior alloHSCT; any donors, conditioning regimens and graft sources are allowed
* Adequate cardiac, hepatic and other organ function
* Adequate laboratory parameters
Design:
* Multi-center, non-randomized, phase II study
* Two-stage design will be used to determine the overall response rate (CR + PR) at 6 months
* Continuous daily dose of ibrutinib 420 mg by mouth, with the potential for dose reductions to 280 mg and 140 mg
* The accrual ceiling will be set at 40 participants, allowing for a total of up to 28 evaluable subjects.
Conditions
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Study Design
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NA
SINGLE_GROUP
TREATMENT
NONE
Study Groups
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Ibrutinib Without Corticosteroids
Determine response rate via continuous daily dose by mouth to determine efficacy
Ibrutinib
140 mg capsules for a dose of 420 mg daily by mouth for up to 12 months.
ECG
At screening.
PFT's
Participants should have PFTs if not performed ≤3 months prior to start of study treatment and Cycle 7, Day 1 (6 months).
Optional at Cycle 12, Day 28 (12 months) and Cycle 24, Day 28 (24 months).
CT
Non-contrast CT at baseline and later during the study if clinically indicated.
Steroid pulse (prednisone)
0.5-2mg/kg/day allowed for clinical disease stabilization during first 4 weeks after starting Ibrutinib.
Voriconazole
At any dose.
Posaconazole
As clinically indicated. At doses less than or equal to suspension 200 mg twice a day (BID) if ibrutinib dose modified to 280 mg once daily.
OR Posaconazole suspension 200 mg three times a day (TID) or 400 mg BID if Ibrutinib dose modified to 140 mg once daily.
OR Posaconazole injection intravenous (IV) injection 300 mg once daily; or delayed-release capsules 300 mg once daily if Ibrutinib dose modified to 140 mg once daily..
Azithromycin
Treat or prevent bronchiolitis obliterans.
Montelukast
Treat or prevent bronchiolitis obliterans.
Budesonide
Treat or prevent gastrointestinal acute graft-versus host disease (GvHD).
Beclomethasone
Treat or prevent gastrointestinal acute graft-versus host disease (GvHD).
Filgrastim
Neutrophil growth factor permitted per institutional policy
Pegfilgrastim
Neutrophil growth factor permitted per institutional policy.
Erythropoietin
Red cell growth factor permitted per institutional policy.
Transfusions
According to institutional policy.
Oral/Skin biopsy
Optional. Baseline, Cycle 7, Day 1 (6 months), Cycle 12, Day 28 (12 months) and Cycle 24, Day 28.
Interventions
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Ibrutinib
140 mg capsules for a dose of 420 mg daily by mouth for up to 12 months.
ECG
At screening.
PFT's
Participants should have PFTs if not performed ≤3 months prior to start of study treatment and Cycle 7, Day 1 (6 months).
Optional at Cycle 12, Day 28 (12 months) and Cycle 24, Day 28 (24 months).
CT
Non-contrast CT at baseline and later during the study if clinically indicated.
Steroid pulse (prednisone)
0.5-2mg/kg/day allowed for clinical disease stabilization during first 4 weeks after starting Ibrutinib.
Voriconazole
At any dose.
Posaconazole
As clinically indicated. At doses less than or equal to suspension 200 mg twice a day (BID) if ibrutinib dose modified to 280 mg once daily.
OR Posaconazole suspension 200 mg three times a day (TID) or 400 mg BID if Ibrutinib dose modified to 140 mg once daily.
OR Posaconazole injection intravenous (IV) injection 300 mg once daily; or delayed-release capsules 300 mg once daily if Ibrutinib dose modified to 140 mg once daily..
Azithromycin
Treat or prevent bronchiolitis obliterans.
Montelukast
Treat or prevent bronchiolitis obliterans.
Budesonide
Treat or prevent gastrointestinal acute graft-versus host disease (GvHD).
Beclomethasone
Treat or prevent gastrointestinal acute graft-versus host disease (GvHD).
Filgrastim
Neutrophil growth factor permitted per institutional policy
Pegfilgrastim
Neutrophil growth factor permitted per institutional policy.
Erythropoietin
Red cell growth factor permitted per institutional policy.
Transfusions
According to institutional policy.
Oral/Skin biopsy
Optional. Baseline, Cycle 7, Day 1 (6 months), Cycle 12, Day 28 (12 months) and Cycle 24, Day 28.
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
2. History of prior allogeneic Hematopoietic Stem Cell Transplant (HSCT) (any donors, conditioning regimens and graft sources are allowed).
3. Subjects may have ongoing acute GvHD features (e.g., erythematous rash, elevated liver enzymes, diarrhea) which are in the opinion of the investigator responding to therapy.
4. Stable doses of other immunosuppressive medications (e.g., calcineurin inhibitors, mycophenolate mofetil, rapamune, etc.) with no dose increase in the 2 weeks prior to study treatment initiation. Doses may be adjusted for trough levels.
5. Age greater than or equal to 18 years old.
6. Karnofsky performance status greater than or equal to 60%.
7. Laboratory parameters as defined below:
* Serum creatinine less than or equal to 2.0 x upper limit of normal (ULN).
* Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) less than or equal to 3 x ULN (less than or equal to 5 x ULN if unequivocal liver GvHD).
* Total bilirubin less than or equal to 3 x ULN.
* Absolute neutrophil count greater than or equal to 1.0 x 10(9)/L (no growth factor support allowed).
* Platelets \> 50 x 10(9)/L (no transfusions allowed less than or equal to 7 days prior to enrollment).
8. Ability to understand and willingness to sign a written informed consent form.
9. The effects of ibrutinib on the developing fetus are unknown. For this reason and because tyrosine kinase inhibitors may be teratogenic, female subjects of childbearing potential and men must agree to use highly effective methods of birth control (hormonal or barrier method of birth control; abstinence) prior to study entry, during the period of therapy, and for 30 days after the last dose of study drug.
Exclusion Criteria
2. History of other malignant diseases, including post-transplant lymphoproliferative disease, with the following exceptions:
* Malignancy treated with curative intent and with no evidence of active disease present for more than 3 years prior to prior to study treatment initiation and felt to be at low risk for recurrence.
* Adequately treated non-melanomatous skin cancer or lentigo malignant melanoma without current evidence of disease.
* Adequately treated cervical carcinoma in situ without current evidence of disease.
3. Received previous systemic treatment for chronic GvHD other than less than or equal to 0.5 mg/kg/day of prednisone equivalent for more than 7 days. Subject may be on steroids that were used to treat acute GvHD and then developed chronic GvHD before completing a taper. At the time of enrollment, the dose should be less than or equal to 0.5 mg/kg/day of prednisone equivalent with no dose increase in the preceding 2 weeks before study treatment initiation.
4. Prior or current treatment with:
* Ibrutinib since the time of transplant (participants may have received ibrutinib prior to transplant for indications other than chronic GvHD).
* Extracorporeal photopheresis (ECP) for acute GvHD less than or equal to 2 weeks prior to study treatment initiation; including any treatment with ECP for chronic GvHD.
* Rituximab or other anti-B cell specific antibodies less than or equal to 4 weeks prior to study treatment initiation.
* Any systemic investigational agents less than or equal to 4 weeks prior to study treatment initiation.
5. Impaired cardiac function including any one of the following:
* Myocardial infarction, unstable angina or acute coronary syndrome less than or equal to 6 months prior to study treatment initiation.
* Class 3 or 4 congestive heart failure, uncontrolled arrhythmia or uncontrolled hypertension at any time.
6. Uncontrolled infections (including prior aspergillosis) not responsive to antibiotics, antiviral medicines, or antifungal medicines.
7. Known bleeding disorder or subjects who received a strong cytochrome P450 (CYP) 3A inhibitor less than or equal to 7 days prior to the first dose of ibrutinib or requirement for continuous treatment with a strong CYP3A inhibitor.
8. Active hepatitis C virus (HCV) or hepatitis B virus (HBV). Subjects who are positive for hepatitis B core antibody or hepatitis B surface antigen or hepatitis C antibody must have a negative polymerase chain reaction (PCR) result to be enrolled.
9. Known hypersensitivity to ibrutinib.
10. Pregnant women are excluded from this study because ibrutinib has potential for teratogenic and abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with ibrutinib, breastfeeding should be discontinued if the mother is treated with ibrutinib. Women who are planning to become pregnant and men who plan to father a child while enrolled in this study or less than or equal to 30 days after the last dose of study drug are excluded.
11. Any other reason at the discretion of the investigators and documented in the medical record that may raise concerns about the subject safety or ability to participate on this study.
12. Currently active, severe hepatic impairment Child-Pugh class C according to the Child Pugh classification.
18 Years
ALL
No
Sponsors
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National Cancer Institute (NCI)
NIH
Responsible Party
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Steven Pavletic, M.D.
Investigator
Principal Investigators
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Steven Z Pavletic, M.D.
Role: PRINCIPAL_INVESTIGATOR
National Cancer Institute (NCI)
Locations
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National Institutes of Health Clinical Center
Bethesda, Maryland, United States
Washington University, School of Medicine
St Louis, Missouri, United States
Countries
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Provided Documents
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Document Type: Study Protocol and Statistical Analysis Plan
Document Type: Informed Consent Form
Related Links
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NIH Clinical Center Detailed Web Page
Other Identifiers
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20-C-0058
Identifier Type: -
Identifier Source: secondary_id
200058
Identifier Type: -
Identifier Source: org_study_id
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