Hepatitis, Drug-Induced
Conditions
Keywords
Hepatitis, Immunotherapy, Cancer, Adverse events, Immune checkpoint inhibitors, Steroid-refractory, Steroid-dependent
Brief summary
This clinical trial is to clarify and investigate the patterns of immune-related hepatitis and the optimal treatment choice for patients who are steroid-dependent. The project aims to prospectively characterize the various histopathological, biochemical, and phenotypical liver injury patterns induced by immune checkpoint inhibitors and the treatment responses to corticosteroids. Furthermore, the effect of adding a second-line immunosuppressive drug, either MMF in steroid-refractory or steroid-dependent cases will be explored and compared.
Detailed description
The number of patients treated with immune checkpoint inhibitors (ICI) is expanding worldwide due to an increasing number of indications, including additional types of cancer, combination of ICI with other antineoplastic therapies and have recently moved into the adjuvant setting. According to clinical trial material, almost all patients in ICI treatment will eventually develop any grade of an adverse event, here, estimated in up to 90 percent of treated patients. Around 10-30 percent of ICI-treated patients will show signs of liver injury related to ICI treatment and will be diagnosed with immune-related hepatitis. The treatment hereof should include observation and medium-dose steroids in low-grade asymptomatic patients (grade ≤ 2 ir-hepatitis) and high-dose steroids in higher grades according to the current European and American guidelines. However, up to 25 percent of patients with ir-hepatitis may not respond properly to steroids due to primary resistance or relapse during tapering. These patients should be offered a second-line immunosuppressive treatment. The present recommendation for patients with steroid-dependent ir-hepatitis is based on the case series and includes immunosuppressive treatment with mycophenolate mofetil (MMF). To date, no evidence exists for which second-line treatment to choose. However, in the clinic, the initiation of MMF may be delayed, meanwhile, patients are typically treated with an increased dose of steroids. In some cases, an increased dose of steroids with prolonged tapering can be sufficient. We want to explore if increased doses of steroids or adding MMF is the best strategy for relapse of hepatitis. In addition, patients with signs of biliary or mixed liver injury may benefit from adding ursodeoxycholic acid (UDCA).
Interventions
DRUGMycophenolate Mofetil
Day 1: MMF 500 mg twice a day Day 2: MMF 1000 mg twice a day
DRUGSolu-Medrol
2 mg/kg/day
DRUGUrsodeoxycholic acid
Patients with mixed or cholestatic liver injury pattern will also be administrated peroral UDCA according to weight
Shift from solu-medrol IV to peroral prednisolon. A tapering plan will be performed.
Sponsors
Inge Marie Svane
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
The aim is to enroll around 40 patients in Cohort A for prospectively characterize the various patterns of liver injury histopathologically, biochemically, and phenotypically that are induced by ICI, and the response to treatment (steroids and MMF). Cohort B: 20 patients who experienced a relapse of ir-hepatitis (grade ≥2) during prednisolone tapering or within one month after ended tapering will be randomized to either 100% dose of current steroid dose or restart of steroid 0.5-1 mg/kg versus adding MMF (if the patient received prednisolone the tapering plan hereof is continued, prednisolone up to 25 mg can be added if clinical indicated). Treatment efficacy is evaluated after seven days, if sufficient response the patients continued treatment, in case of insufficient response a cross-over will be performed
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Cohort A: \- Abnormal liver parameters equal to ≥ grade 3 ir-hepatitis defined as; AST/ALT/ALP \>5 x ULN, INR ≥ 2.5 x ULN, or bilirubin \> 3.0 x ULN Cohort B: \- Patients who recur during or within one months of prednisolone tapering of ≥2 ir-hepatitis equal to AST/ALT ≥3 x ULN, ALP ≥2.5 x ULN, INR ≥ 1.5 x ULN, or bilirubin ≥ 3.0 x ULN Cohort A and Cohort B * Histologically confirmed solid cancer * Treatment with cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) or Programmed Cell Death-1 (PD-1)/Programmed Cell Death Ligand-1 (PD-L1) inhibitor or a combination of CTLA-4 plus PD-1 inhibitors within 6 months * Age: ≥ 18 years * Women of childbearing potential: Negative serum pregnancy test and must use effective contraception. This applies from screening and until 6 months after treatment. Birth control pills, spiral, depot injection with gestagen, subdermal implantation, hormonal vaginal ring and transdermal depot patch are all considered effective contraceptives * Men with female partner of childbearing potential must use effective contraception from screening and until 6 months after treatment. Effective contraceptives are as described above for the female partner. In addition, documented vasectomy and sterility or double barrier contraception are considered effective contraceptives * Signed statement of consent after receiving oral and written study information * Willingness to participate in the planned treatment and follow-up and capable of handling toxicities.
Exclusion criteria
* Concomitant chemotherapy treatment or tyrosine kinases or angiogenesis inhibitors * Concomitant immunosuppressive medication except prednisolone * Patients with hepatocellular carcinoma * Known hypersensitivity to one of the active drugs or excipients * Uncontrolled infection * Acute viral hepatitis * Any medical condition that will interfere with patient compliance or safety * Simultaneous treatment with other experimental drugs or other anticancer drugs * Pregnant or breastfeeding females * Phenylketonuria
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Treatment-assessed hepatitis response rates | Through study completion, an average of 5 years | Treatment-assessed hepatitis response rates with steroids and steroids plus either mycophenolate mofetil or tacrolimus |
| Time to response or downgrading of liver injury in days | Until completion of the study, an average of 5 years | Time to response or downgrading of liver injury in patients with ≥grade 3 ir-hepatitis measured as; Days to ≥20 percent reduction in liver specific transaminases (ALT/AST) or bilirubin Days to shift to peroral prednisolone and discharge |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Time to downgrading of hepatotoxicity assessed by CTCAE v5.0 | Through study completion, an average of 5 years | Time to downgrading of hepatotoxicity from grade 4 to grade 3, to grade 2 and to grade 1, respectively, assessed by CTCAE v5.0 |
| Description of histopathological changes in liver tissue | Until completion of the study, an average of 5 years | Number of patients with hepatocellular, cholestatic and mixed liver injury respectively, assessed by histological findings of predominant injury to hepatocytes, bile ducts or combined. |
| Cumulated doses of corticosteroids and MMF respectively | Until completion of the study, an average of 5 years | Cumulated doses of corticosteroids and MMF respectively, during the study period of 6 months |
| Cancer progression free survival at 6 months | Until completion of the study, an average of 5 years | Cancer progression free survival at 6 months |
| Overall survival rates at 6 months | Until completion of the study, an average of 5 years | Overall survival rates at 6 months |
| Incidence of abnormal laboratory test results | Until completion of the study, an average of 5 years | Incidence of abnormal laboratory test results in blood |
| Relapse rate of immune related hepatitis ≥2 during tapering plan | Through study completion, an average of 5 years | Percent of patients with relapse to grade ≥2 hepatitis during steroid or during steroid plus either mycophenolate mofetil or tacrolimus tapering. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Blood biomarkers | Until completion of the study, an average of 5 years | Correlation of the baseline immune markers, genomics and other biomarkers in blood |
| Description of changes in the fecal microbiome | Until completion of the study, an average of 5 years | Description of changes in the fecal microbiome and characterization of the prevalence of specific bacteria e.g. Faecalibacterium and Firmicutes |
Countries
Denmark
Contacts
Primary ContactInge Marie Svane, M.D. Professor
Backup ContactRikke B Holmstrøm, M.D
Outcome results
None listed