Front Line Ibrutinib Without Corticosteroids for Newly Diagnosed Chronic Graft-versus-Host Disease

A Study of Front Line Ibrutinib Without Corticosteroids for Newly Diagnosed Chronic Graft-versus-Host Disease

Background:

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 ibruntinib 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 drug s 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.

Study Overview

• Status: Recruiting
• Conditions: Chronic GVHD
• Intervention / Treatment: Drug: Ibrutinib

Detailed Description

Background:

• 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 Bruton s 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 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.

• Study Type: Interventional
• Enrollment (Estimated): 40
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Steven Z Pavletic, M.D.; Phone Number: (240) 760-6174; Email: sp326h@nih.gov

Study Locations

• United States
  • Maryland
    • Bethesda, Maryland, United States, 20892
      • Recruiting
      • National Institutes of Health Clinical Center
      • Contact: For more information at the NIH Clinical Center contact National Cancer Institute Referral Office; Phone Number: 888-624-1937
  • Missouri
    • Saint Louis, Missouri, United States, 63110
      • Recruiting
      • Washington University, School of Medicine
      • Contact: Iskra Pusic; Phone Number: 314-286-2508; Email: iskrapusic@wustl.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

• INCLUSION CRITERIA:

  1. Newly diagnosed moderate or severe chronic Graft versus Host Disease (GvHD) (according to the 2014 NIH Consensus Criteria, requiring systemic immunosuppression
  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 ULN
     • AST and 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 lesds 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:

1. Relapsed or progressive malignant disease (other than minimal residual disease)

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention; Determine response rate via continuous daily dose by mouth to determine efficacy	Drug: Ibrutinib; 140 mg capsules for a dose of 420 mg daily for up to 12 months.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
To evaluate the efficacy of ibrutinib as a first-line treatment for persons with newly diagnosed chronic graft-versus-host disease (GvHD) by measuring the overall response rate	measuring the overall response rate (complete response [CR] + partial response [PR]) according to the 2014 NIH Consensus Criteria.	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
To evaluate safety of ibrutinib for newly diagnosed chronic GvHD	Safety of the agent will be assessed by determining the grade of adverse events	6 months
To evaluate failure-free survival (FFS)	Time to event endpoints such as failure free survival will be determined using a Kaplan-Meier curve.	6 months
To evaluate 24 months post-treatment follow-up for survival	Survival will be determined using a Kaplan-Meier curve at 24 months.	6 months

Collaborators and Investigators

• Sponsor: National Cancer Institute (NCI)
• Investigators: Principal Investigator: Steven Z Pavletic, M.D., National Cancer Institute (NCI)

Publications and helpful links

Helpful Links

• NIH Clinical Center Detailed Web Page

Study record dates

Study Major Dates

• Study Start (Actual): May 10, 2021
• Primary Completion (Estimated): June 24, 2024
• Study Completion (Estimated): June 28, 2026

Study Registration Dates

• First Submitted: March 3, 2020
• First Submitted That Met QC Criteria: March 3, 2020
• First Posted (Actual): March 4, 2020

Study Record Updates

• Last Update Posted (Actual): February 23, 2024
• Last Update Submitted That Met QC Criteria: February 22, 2024
• Last Verified: February 21, 2024

More Information

Terms related to this study

• Keywords: Hematologic Malignancies; Immunosuppressive Therapy; Kinase Inhibitors; steroid pulses; alloHSCT
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Immune System Diseases; Lung Diseases; Bronchial Diseases; Lung Diseases, Obstructive; Bronchitis; Bronchiolitis Obliterans; Bronchiolitis; Organizing Pneumonia; Graft vs Host Disease; Bronchiolitis Obliterans Syndrome
• Other Study ID Numbers: 200058; 20-C-0058

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: .All IPD recorded in the medical record will be shared with intramural investigators upon request. @@@@@@All collected IPD will be shared with collaborators under the terms of collaborative agreements.
• IPD Sharing Time Frame: Clinical data available during the study and indefinitely.
• IPD Sharing Access Criteria: Clinical data will be made available via subscription to BTRIS and with the permission of the study PI.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF

Drug and device information, study documents

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