Steroid Treatment for Hypereosinophilic Syndrome

Assessment of Glucocorticoid Responsiveness and Mechanisms of Resistance in Hypereosinophilic Syndromes

Background:

- Hypereosinophilic syndrome (HES) is a disorder in which the body has too many eosinophils (a type of white blood cell). Too many eosinophils in HES can cause damage to the heart, nerves, or skin. Certain drugs can help lower eosinophil counts to prevent tissue damage. Corticosteroids, such as prednisone, are used for initial therapy in this disorder. Although most people respond to prednisone, some people develop side effects from it, or do not respond very well to treatment. Better ways of determining the dose to give could help to decide on the best therapy for HES.

Objectives:

• To determine whether a single-dose of prednisone can be used to predict which people with hypereosinophilia respond to treatment.
• To study lack of response to steroid treatment in people with HES.

Eligibility:

Inclusion criteria:

• Individuals with hypereosinophilic syndrome with high eosinophil counts.
• Individuals who are willing to have blood drawn before and after getting steroids.

Exclusion criteria:

• Individuals who are on more than 10mg of prednisone (or similar drug)
• Individuals with hypereosinophilic syndrome who are on other medications that could interfere with the study
• Women who are pregnant or breast-feeding
• Individuals who have a known gene mutation associated with chronic eosinophilic leukemia
• Children less than 18 years old who weigh less than 48kg or 106lb

Design:

• Participants will have a screening visit with a physical exam and medical history. Blood and urine samples will be collected.
• Participants will have a single dose of the steroid prednisone by mouth in the morning. Blood samples will be collected 2, 4, 24 hours after this dose.
• On the day after the steroid dose, participants will provide another blood sample in the morning.
• Participants will start to take prednisone daily when they return home. Blood samples will be collected weekly at the participant s doctor s office. The dose of prednisone will be lowered depending on the weekly eosinophil count. We will try to get each person on the lowest dose of prednisone possible that will control the disorder. Participants who do not respond or have severe side effects will be taken off prednisone. Other treatments will be considered for people who do not respond to steroids. The goal is to evaluate the response to prednisone. Our research will try to figure out why some people do not respond to steroids. Most people will complete the study within 6 to 16 weeks, depending on their response to prednisone.

Study Overview

• Status: Completed
• Conditions: Hematologic Diseases; Eosinophilia; Hypereosinophilic Syndrome; Leukocyte Disorder
• Intervention / Treatment: Drug: prednisone

Detailed Description

This study aims to develop a model to determine whether a single, oral, weight-based dose of glucocorticoid (GC) can predict clinical and biologic response to GC s over the long term in subjects with hypereosinophilic syndrome (HES). Subjects with FIP1L1/PDGFRalpha-negative HES, who are symptomatic with eosinophil count >1500/microL and receiving less than or equal to10 mg prednisone daily, will be enrolled. A single oral dose of prednisone (1 mg/kg rounded to the nearest 5mg) will be administered. Eosinophil count and various laboratory parameters will be assessed at 2 hours, 4 hours and 24 hours following prednisone administration (investigators will be blinded to the results of the eosinophil counts). The subjects will then begin GC therapy at 30 mg prednisone daily followed by a standardized taper. The lowest dose of GC at which symptoms and eosinophilia are controlled will be compared to the change in eosinophil count at 2, 4 and 24 hours post-challenge. Mechanisms and in vitro correlates of GC resistance will also be explored.

• Study Type: Interventional
• Enrollment (Actual): 26
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Maryland
    • Bethesda, Maryland, United States, 20892
      • National Institutes of Health Clinical Center, 9000 Rockville Pike

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 7 years to 100 years (ADULT, OLDER_ADULT, CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

• SUBJECT INCLUSION CRITERIA:

Subjects on Protocol #94-I-0079 will be eligible for participation in the study only if all of the following criteria apply:

1. Subjects must be 7 years of age or older to enroll
2. Subject meets diagnostic criteria for HES (AEC >1500/microL, absence of a secondary cause and signs and/or symptoms attributable to the eosinophilia)
3. AEC greater than 1500 microL obtained within 14 days prior to enrollment
4. Willingness to perform the timed steroid challenge
5. Appropriate candidate for GC treatment after challenge
6. Willingness to have samples stored for future research

SUBJECT EXCLUSION CRITERIA:

A subject will not be eligible to participate in the study if any of the following apply:

1. Receiving >10 mg prednisone or equivalent at the time of enrollment.
2. Receiving less than or equal to 10 mg of prednisone or equivalent but have not been on a fixed dose for at least 3 weeks (subjects on a current corticosteroid taper will be excluded).
3. AEC less than or equal to 1500/microl on the day of the steroid challenge
4. Use of immunomodulatory medications, (other than less than or equal to 10 mg/day prednisone) including but not limited to biologics, within the past 6 months.
5. Pregnant at the time of screening.
6. Have a known mutation in the FIP1L1-PDGFR gene.
7. Any condition that, in the opinion of the investigator, places the subject at undue risk by participating in the protocol.
8. Weight less than 48 kg (106 lbs) in subjects less than 18 years of age.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: NA
• Interventional Model: SINGLE_GROUP
• Masking: NONE

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
OTHER: Steroid Challenge; A single oral dose of prednisone (1 mg/kg rounded to the nearest 5mg) was administered to all participants. The following day, participant began glucocorticoid therapy of prednisone 30 mg oral daily for one week followed by a standardized taper until a minimally effective dose was achieved or participant tapered to prednisone 5 mg oral daily.	Drug: prednisone; Glucocorticoids (GC) are considered the first- line therapy for hypereosinophilic syndrome.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean Percent Change in Eosinophil Count After Glucocorticoid Challenge	Response to glucocorticoid challenge as assessed by the percentage of the eosinophil count 24 hours post-glucocorticoid challenge relative to the Baseline AEC for each participant. Measure Description (%): Percent of baseline AEC is defined as the Absolute Eosinophil Count at 24 hours divided by the Absolute Eosinophil Count at Baseline *100.	24 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Participants With Glucocorticoid Responsiveness - IHES Variant	Participants with idiopathic hypereosinophilic syndromes (IHES) that achieved glucocorticoid responsiveness, suboptimal responsiveness, or without response.	Baseline (Day 1)
Participants With Glucocorticoid Responsiveness - LHES Variant	Participants with lymphoid hypereosinophilic syndromes (LHES) that achieved glucocorticoid responsiveness, suboptimal responsiveness, or without response.	Baseline (Day 1)
Participants With Glucocorticoid Responsiveness - MHES Variant	Participants with myeloid hypereosinophilic syndromes (MHES) that achieved glucocorticoid responsiveness, suboptimal responsiveness, or without response.	Baseline (Day 1)
Participants With Glucocorticoid Responsiveness - Overlap HES Subtypes	Participants with overlap hypereosinophilic syndromes that achieved glucocorticoid responsiveness, suboptimal responsiveness, or without response.	Baseline (Day 1)
Mean Baseline IgE Level	Mean baseline immunoglobulin E (IgE) level in participants prior to initiation of glucocorticoid	Baseline (Day 1)
Mean Baseline Absolute Eosinophil Count	Mean baseline absolute eosinophil count in participants prior to initiation of glucocorticoids	Baseline (Day 1)
Participants With Glucocorticoid Responsiveness - Cardiac Involvement	Cardiac involvement in participants with hypereosinophilic syndromes (HES)	Baseline (Day 1)
Participants With Glucocorticoid Responsiveness - Pulmonary Involvement	Pulmonary involvement in participants with hypereosinophilic syndromes (HES)	Baseline (Day 1)

Collaborators and Investigators

• Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

Publications and helpful links

General Publications

• Ogbogu PU, Bochner BS, Butterfield JH, Gleich GJ, Huss-Marp J, Kahn JE, Leiferman KM, Nutman TB, Pfab F, Ring J, Rothenberg ME, Roufosse F, Sajous MH, Sheikh J, Simon D, Simon HU, Stein ML, Wardlaw A, Weller PF, Klion AD. Hypereosinophilic syndrome: a multicenter, retrospective analysis of clinical characteristics and response to therapy. J Allergy Clin Immunol. 2009 Dec;124(6):1319-25.e3. doi: 10.1016/j.jaci.2009.09.022.
• Prin L, Lefebvre P, Gruart V, Capron M, Storme L, Formstecher P, Loiseau S, Capron A. Heterogeneity of human eosinophil glucocorticoid receptor expression in hypereosinophilic patients: absence of detectable receptor correlates with resistance to corticotherapy. Clin Exp Immunol. 1989 Dec;78(3):383-9.
• Hamilos DL, Leung DY, Muro S, Kahn AM, Hamilos SS, Thawley SE, Hamid QA. GRbeta expression in nasal polyp inflammatory cells and its relationship to the anti-inflammatory effects of intranasal fluticasone. J Allergy Clin Immunol. 2001 Jul;108(1):59-68. doi: 10.1067/mai.2001.116428.
• Stokes K, Yoon P, Makiya M, Gebreegziabher M, Holland-Thomas N, Ware J, Wetzler L, Khoury P, Klion AD. Mechanisms of glucocorticoid resistance in hypereosinophilic syndromes. Clin Exp Allergy. 2019 Dec;49(12):1598-1604. doi: 10.1111/cea.13509. Epub 2019 Oct 27.

Helpful Links

• NIH Clinical Center Detailed Web Page

Study record dates

Study Major Dates

• Study Start (ACTUAL): February 16, 2012
• Primary Completion (ACTUAL): December 10, 2020
• Study Completion (ACTUAL): December 10, 2020

Study Registration Dates

• First Submitted: February 1, 2012
• First Submitted That Met QC Criteria: February 1, 2012
• First Posted (ESTIMATE): February 2, 2012

Study Record Updates

• Last Update Posted (ACTUAL): February 15, 2022
• Last Update Submitted That Met QC Criteria: January 26, 2022
• Last Verified: February 22, 2021

More Information

Terms related to this study

• Keywords: Hypereosinophilic Syndrome; HES; Therapy; Hypereosinophilia; Corticosteroids
• Additional Relevant MeSH Terms: Pathologic Processes; Disease; Syndrome; Hematologic Diseases; Eosinophilia; Hypereosinophilic Syndrome; Leukocyte Disorders; Physiological Effects of Drugs; Anti-Inflammatory Agents; Antineoplastic Agents; Glucocorticoids; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Antineoplastic Agents, Hormonal; Prednisone
• Other Study ID Numbers: 120026; 12-I-0026

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No