Bronchiolitis, Exudative, Bronchiolitis Obliterans, Bronchiolitis, Proliferative, Constructive Bronchiolitis, Graft Versus Host Disease, Graft-Versus-Host Disease
Conditions
Keywords
Peripheral Blood Stem Cell Transplant, Inhaled Cyclosporine, Graft-Versus-Host Disease
Brief summary
Bronchiolitis Obliterans (BO) is an obstructive lung disease that can affect individuals that have undergone a lung or hematopoietic stem cell transplant. BO has been studied most extensively in lung transplant recipients, where it is considered to represent chronic lung rejection. It is the leading cause of death after lung transplant, with mortality rates up to 55 percent. In hematopoietic stem cell transplantation, BO is thought to be a manifestation of chronic graft-vs-host disease (GVHD). Up to 45 percent of patients undergoing hematopoietic stem cell transplantation at the NHLBI develop a decline in pulmonary function. Conventional therapy for patients who develop BO consists of augmentation of systemic immunosuppressants. Systemic immunosuppression has limited efficacy for BO and is associated with deleterious consequences including increased risk of infections and decreased graft-versus tumor/leukemia effects. Recently, cyclosporine inhalation solution (CIS) in solution with propylene glycol has been shown to improve overall survival and chronic rejection-free survival in lung transplant patients. These findings suggest targeted delivery of immunosuppressive therapy to the diseased organ warrants further investigation as this may minimize the morbidity associated with systemic immunosuppression. However, there currently exists limited data regarding the overall efficacy of inhaled cyclosporine to treat established BO following lung transplantation. Furthermore, inhaled cyclosporine has not been studied in the treatment of BO following hematopoietic stem cell transplantation. Here, we propose to evaluate the long-term safety and efficacy, of inhaled CIS for the treatment of BO. Enrollment will be offered to subjects who have completed the end of study (week 18 visit) for the initial protocol (Phase II Trial of CIS in lung transplant and hematopoietic stem cell transplant recipients for treatment of Bronchiolitis Obliterans) and who have shown evidence of benefit (either an improvement or stabilization) in BO/BOS with CIS treatment. Clinical parameters, including pulmonary function tests, will be measured in addition to laboratory markers of the anti-inflammatory response to CIS. Adverse events associated with extended treatment with CIS will be recorded. The primary objective is to provide long-term safety and efficacy data for the use of CIS in hematopoietic transplant patients and lung transplant patients with established BO. Secondary objectives include investigation of the inflammatory pathways that lead to chronic BO and ascertainment of the long term anti-inflammatory effects of this CSA preparation ex vivo and in vivo. Primary endpoint is the efficacy of extended use CIS for BO/BOS. Secondary endpoints include the toxicity profile (adverse events), improvement in high resolution chest CT images, results of peripheral blood and bronchoalveolar cytokine arrays to assess secondary markers of inflammation, and functional capacity measurements using a six-minute walk test.
Detailed description
Bronchiolitis Obliterans (BO) is an obstructive lung disease that can affect individuals that have undergone a lung or hematopoietic stem cell transplant. BO has been studied most extensively in lung transplant recipients, where it is considered to represent chronic lung rejection. It is the leading cause of death after lung transplant, with mortality rates up to 55 percent. In hematopoietic stem cell transplantation, BO is thought to be a manifestation of chronic graft-vs-host disease (GVHD). Up to 45 percent of patients undergoing hematopoietic stem cell transplantation at the NHLBI develop a decline in pulmonary function. Conventional therapy for patients who develop BO consists of augmentation of systemic immunosuppressants. Systemic immunosuppression has limited efficacy for BO and is associated with deleterious consequences including increased risk of infections and decreased graft-versus tumor/leukemia effects. Recently, cyclosporine inhalation solution (CIS) in solution with propylene glycol has been shown to improve overall survival and chronic rejection-free survival in lung transplant patients. These findings suggest targeted delivery of immunosuppressive therapy to the diseased organ warrants further investigation as this may minimize the morbidity associated with systemic immunosuppression. However, there currently exists limited data regarding the overall efficacy of inhaled cyclosporine to treat established BO following lung transplantation. Furthermore, inhaled cyclosporine has not been studied in the treatment of BO following hematopoietic stem cell transplantation. Here, we propose to evaluate the long-term safety and efficacy, of inhaled CIS for the treatment of BO. Enrollment will be offered to subjects who have completed the end of study (week 18 visit) for the initial protocol (Phase II Trial of CIS in lung transplant and hematopoietic stem cell transplant recipients for treatment of Bronchiolitis Obliterans) and who have shown evidence of benefit (either an improvement or stabilization) in BO/BOS with CIS treatment. Clinical parameters, including pulmonary function tests, will be measured in addition to laboratory markers of the anti-inflammatory response to CIS. Adverse events associated with extended treatment with CIS will be recorded. The primary objective is to provide long-term safety and efficacy data for the use of CIS in hematopoietic transplant patients and lung transplant patients with established BO. Secondary objectives include investigation of the inflammatory pathways that lead to chronic BO and ascertainment of the long term anti-inflammatory effects of this CSA preparation ex vivo and in vivo. Primary endpoint is the efficacy of extended use CIS for BO/BOS. Secondary endpoints include the toxicity profile (adverse events), improvement in high resolution chest CT images, results of peripheral blood and bronchoalveolar cytokine arrays to assess secondary markers of inflammation, and functional capacity measurements using a six-minute walk test.
Interventions
CIS is a sterile, clear, colorless, preservative-free solution of cyclosporine (USP) in propylene glycol developed specifically for administration by oral inhalation.
Sponsors
National Heart, Lung, and Blood Institute (NHLBI)
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
10 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
* INCLUSION CRITERIA: 1. Completed the End of Study visit (week 19) on the initial protocol (Phase II Trial of Cyclosporine Inhalation Solution (CIS) in Lung Transplant and Hematopoietic Stem Cell Transplant Recipients for Treatment of Bronchiolitis Obliterans) in the preceding 12 weeks 2. Patients have shown evidence for a clinical benefit to CIS as evidenced by one or more of the following: * Improvement in pulmonary function defined by a 10 percent or more increase in the FEV1 at week 18, confirmed with repeat PFTs at least 1 week apart. * In patients with progressive disease at study entry on the initial protocol (Phase II Trial of Cyclosporine Inhalation Solution (CIS) in Lung Transplant and Hematopoietic Stem Cell Transplant Recipients for Treatment of Bronchiolitis Obliterans), stabilization in pulmonary function, defined as less than a 10 percent improvement in FEV1 or less than 10 percent decline in FEV1 at week 18, confirmed with repeat PFTs at least 1 week apart. * In patients with stable disease (active BOS stable by FEV1 criteria) at study entry on the initial protocol (Phase II Trial of Cyclosporine Inhalation Solution (CIS) in Lung Transplant and Hematopoietic Stem Cell Transplant Recipients for Treatment of Bronchiolitis Obliterans), stabilization in pulmonary function, defined as less than a 10 percent improvement in their FEV1 or less than 10 percent decline in FEV1, and a decrease in the dose of one or more systemic immunosuppressants by at least 20 percent (sustained for 3 weeks, excluding adjustments made for target drug levels). \* The criteria for study entry on this extension protocol are not the same as the criteria for response on the primary protocol to allow for entry of patients on this extension protocol, which is deriving some clinical benefit, but have not met the full response criteria as defined in the primary protocol.
Exclusion criteria
1. More than a 12 week gap in study drug administration (CIS) 2. Evidence of uncontrolled, pulmonary infection 3. ECOG performance status greater than or equal to 3 4. Patient pregnant or breast feeding or not willing to continue the use of an approved method of birth control 5. Life expectancy less than 18 weeks 6. History of hypersensitivity reaction to propylene glycol 7. Documented allergy or intolerance to CIS 8. History of untreated coronary insufficiency, severe cardiac arrhythmias, and/or uncontrolled hypertension. 9. Serum creatinine greater than 2.5 mg/dl 10. Inability to comprehend the investigational nature of the study and provide informed consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Improvement in Lung Function - Increase in FEV1 | 6 Months | Continued improvement in lung function as defined by 10% or more increase in FEV1 |
| Disease Stablization - Decrease in FEV1 or Less Than 10% Increase in FEV1 | 6 Months | Stabilization in Pulmonary Function Test (PFT) as defined by less than 10% increase in FEV1 or less than 10% decline in FEV1 |
| Disease Progression - Decrease in FEV1 or Additional/Increase in Immunosuppressive Therapies | 6 Months | Disease progression as defined by a 20% or more decline in FEV1, or those who require an increase in immunosuppressive therapies by at least 25% or the addition of new immunosuppressive therapies. |
Countries
United States
Participant flow
Recruitment details
The lung transplant arm was closed during the study due to lack of subject enrollment
Participants by arm
| Arm | Count |
|---|---|
| Inhaled Cyclosporine in HSCT Participants Hemopoietic Stem Cell transplant (HSCT) subjects with Bronchiolitis Obliterans Syndrome (BOS) received cyclosporine inhalation solution (CIS) at maximum tolerated dose not exceeding 300 mg administered three times per week | 7 |
| Total | 7 |
Baseline characteristics
| Characteristic | Inhaled Cyclosporine in HSCT Participants |
|---|---|
| Age, Categorical <=18 years | 1 Participants |
| Age, Categorical >=65 years | 0 Participants |
| Age, Categorical Between 18 and 65 years | 6 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 7 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 1 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) White | 6 Participants |
| Sex: Female, Male Female | 4 Participants |
| Sex: Female, Male Male | 3 Participants |
| Status of Pulmonary Disease at Initial Enrollment Progressive Pulmonary Disease (Declining FEV1) | 3 Participants |
| Status of Pulmonary Disease at Initial Enrollment Stable Pulmonary Disease (Stable FEV1) | 4 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 1 / 7 |
| other Total, other adverse events | 7 / 7 |
| serious Total, serious adverse events | 1 / 7 |
Outcome results
Primary
Disease Progression - Decrease in FEV1 or Additional/Increase in Immunosuppressive Therapies
Disease progression as defined by a 20% or more decline in FEV1, or those who require an increase in immunosuppressive therapies by at least 25% or the addition of new immunosuppressive therapies.
Time frame: 6 Months
Population: Inhaled Cyclosporine in hematopoietic stem cell transplant (HSCT) participants
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Inhaled Cyclosporine in HSCT Participants | Disease Progression - Decrease in FEV1 or Additional/Increase in Immunosuppressive Therapies | 0 Participants |
Primary
Disease Stablization - Decrease in FEV1 or Less Than 10% Increase in FEV1
Stabilization in Pulmonary Function Test (PFT) as defined by less than 10% increase in FEV1 or less than 10% decline in FEV1
Time frame: 6 Months
Population: Inhaled Cyclosporine in hematopoietic stem cell transplant (HSCT) participants
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Inhaled Cyclosporine in HSCT Participants | Disease Stablization - Decrease in FEV1 or Less Than 10% Increase in FEV1 | 7 Participants |
Primary
Improvement in Lung Function - Increase in FEV1
Continued improvement in lung function as defined by 10% or more increase in FEV1
Time frame: 6 Months
Population: Inhaled Cyclosporine in hematopoietic stem cell transplant (HSCT) participants
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Inhaled Cyclosporine in HSCT Participants | Improvement in Lung Function - Increase in FEV1 | 0 Participants |