Intestinal GVHD
Conditions
Brief summary
Therapy of severe intestinal graft-versus-host disease (GVHD) despite the introduction of novel target agents is associated with worse outcome compared to the other forms. Response to steroids is observed only in about 10% of patients. The most promising approaches are JAK inhibition and fecal microbiota transplantation. In this pilot study we evaluate this combination treatment in the first line.
Detailed description
Acute intestinal GVHD grade III-IV after allogeneic stem cell transplantation the form with low effectiveness of corticosteroids. Despite high response rate to systemic immunosupressive agents, long term survival in this group is poor due to recurrent septic episodes and gut colonization with multidrug resistant bacteria. Fecal microbiota transplantation (FMT) from a healthy allogeneic donor, allows to restore numerous local and systemic microbiota functions, including immunomodulation and thus to reduce/stop the manifestations of GVHD. The therapeutic mechanism of action of FMT is based on competition for nutrients between obligate and pathologic bacterial strains, direct growth inhibition of the pathological pathogens, host immune system modulation, especially T-reg homeostasis, through interaction with the normal microbiota.In this pilot trial we combine FMT with ruxolitinib and steroids, one of the most effective option for refractory GVHD.
Interventions
BIOLOGICALallogeneic fecal microbiota
Single dose of capsules with fecal transplant (capsules for adults - 400-815mg, for adolescents - 280-500mg, for children - 160-320mg) - 2 capsules/kg body weight, divided in two consecutive days Additional supportive therapy after FMT include omeprazole 40mg po, inulin 1gr x 4 times a day po, metoclopramide 40mg po.
DRUGRuxolitinib
Ruxolitinib starting dose 10 mg bid. In case of grade 4 hematological toxicity dose can be reduced by 25-75%.
DRUGMethylprednisone
Methylprednisone starting dose 0.5 mg/kg bid IV or oral, with subsequent tapper by 0.1 mg/kg every 5 days.
Sponsors
St. Petersburg State Pavlov Medical University
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Age 5-70 years * Histologically confirmed gastrointestinal acute GVHD * Grade III-IV gastrointestinal GVHD based on 2016 MAGIC criteria * Ability for oral drug intake * Signed informed consent
Exclusion criteria
* Requirement for oxigen and/or vasopressor support * Respiratory distress \>grade I * Severe organ dysfunction: AST or ALT \>5 upper normal limits, bilirubin \>1.5 upper normal limits, creatinine \>2 upper normal limits,creatinine clearance \< 60 mL/min * Ongoing fluconazole therapy * Any malignancy requiring systemic therapy at the time of enrollment * Mixed chimerism at last evaluation * Uncontrolled bacterial or fungal infection at the time of enrollment * Requirement for vasopressor support at the time of enrollment * Karnofsky index \<30% * Severe concurrent illness that can interfere with study procedures * Somatic or psychiatric disorder making the patient unable to sign informed consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Overall survival | 365 days | Time from treatment initiation to death or end of follow up |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of Adverse Events based on CTC AE 5.0 | 100 days | Based on CTC AE 5.0 |
| Infectious complications | 100 days | Cumulative incidence of bacterial, viral and fungal infections |
| Overal response rate | 100 days | Evaluated with 2009 consensus criteria and 2016 severity grading on days +7,+28, +56, +100 |
| Time to ruxolitinib discontinuation | 365 days | Time from treatment initiation to ruxolitinib cessation without GVHD flare |
| Time to systemic immunosuppression discontinuation | 365 days | Time from treatment initiation to cessation of all systemic immunosupression without GVHD flare |
| Time to steroid discontinuation | 100 days | Time from treatment initiation to steroid cessation without GVHD flare |
Countries
Russia
Outcome results
None listed