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ASH 2017: Abatacept Nearly Eliminates Severe Acute GVHD After Hematopoietic Stem Cell Transplant

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Key Points

  • At 100 days post-transplant, the cumulative incidence of grade III to IV acute graft-vs-host disease (GVHD) occurred in 3% of patients receiving abatacept compared to 32% receiving calcineurin inhibitor and methotrexate (CNI/MTX) and 22% receiving CNI/MTX plus antithymocyte globulin (+ATG).
  • Patients receiving abatacept had intact immune reconstitution; significant improvement in transplantation-related mortality; no major uncontrolled infection; and no increase in disease relapse.
  • Significant survival advantages for the abatacept group were demonstrated at 1-year post-transplant. Overall survival improved to 85% (vs 57% in CNI/MTX and 68% in +ATG controls); 79% of patients experienced disease-free survival (vs 50% in CNI/MTX and 63% in +ATG controls).

Results from a phase II clinical trial presented by Kean et al at the 59th American Society of Hematology (ASH) Annual Meeting (Abstract 212) show that the drug abatacept (Orencia) nearly eliminated life-threatening severe acute graft-versus-host disease (GVHD) in patients receiving hematopoietic stem cell transplants.

When added to the standard drug regimen used to prevent GVHD, abatacept reduced the occurrence of acute, grade III–IV GVHD from 32% to 3% in pediatric and adult patients who underwent mismatched unrelated donor stem cell transplants to treat advanced cancer and other blood disorders. As a result, patients receiving the post-transplant regimen with abatacept experienced improved disease-free and overall survival compared to those who did not.

Acute GVHD is a complication that can arise after stem cell transplantation. GVHD occurs when the donated T cells launch a vigorous attack on a patient's organs, including the skin, liver, kidneys, lung, and the gastrointestinal tract. For patients receiving cells from an unrelated donor, the rate of mild-to-severe forms of acute GVHD can reach as high as 80%, with up to half of patients dying from the most severe forms.

“Given the serious threat of graft-vs-host disease, new approaches to make stem cell transplants safer for patients remain a critical unmet need,” said Leslie Kean, MD, PhD, the trial's principal investigator and Associate Director of the Ben Towne Center for Childhood Cancer Research at Seattle Children's. “To see such striking results in patients at extremely high risk for graft-vs-host disease is incredibly encouraging.”

More on Abatacept

Dr. Kean first became interested in using abatacept to prevent GVHD based on the immunotherapy drug's success in treating patients with rheumatoid arthritis. In rheumatoid arthritis, abatacept inhibits T-cell activation and prevents the chain of events that lead to debilitating joint inflammation.

Similarly, feasibility studies conducted by Dr. Kean found that abatacept blocks the activation of certain T cells after transplant. In their models, abatacept reduced the proliferation and activation of effector T cells, which incite GVHD when they become overactive as the patient's immune system starts to rebuild itself from the donor stem cells.

“Preventing graft-vs-host disease and relapse after transplant requires a difficult balance of eliminating the bad, overactive effector T-cells, without suppressing the good, regulatory T-cells,” said Dr. Kean, who is also Associate Professor of Pediatrics at the University of Washington School of Medicine and a member of the Fred Hutchinson Cancer Research Center.

Study Findings

The multicenter data presented included two patient cohorts who were enrolled across 18 sites. In the cohort of patients who received transplants from mismatched unrelated donors, all 43 patients received four doses of abatacept with a calcineurin inhibitor and methotrexate. To serve as the control, researchers looked at data from a national database of matched patients receiving two commonly used regimens to prevent GVHD—a calcineurin inhibitor and methotrexate (CNI/MTX) or a calcineurin inhibitor and methotrexate plus antithymocyte globulin (+ATG).  

At 100 days post-transplant, the cumulative incidence of grade III to IV acute GVHD occurred in 3% of patients receiving abatacept compared to 32% receiving CNI/MTX and 22% receiving +ATG. Patients receiving abatacept had intact immune reconstitution; significant improvement in transplantation-related mortality; no major uncontrolled infection; and no increase in disease relapse. Significant survival advantages for the abatacept group were demonstrated at 1-year post-transplant. Overall survival improved to 85% (vs 57% in CNI/MTX and 68% in +ATG controls); 79% of patients experienced disease-free survival (vs 50% in CNI/MTX and 63% in +ATG controls).

The second cohort of 140 patients with human leukocyte antigen­–matched unrelated donor transplants completed enrollment in November 2017, with data expected from this randomized double-blind arm of the study in the next 6 months.

“As a transplant physician, it's beyond heartbreaking to witness a patient develop severe acute graft-vs-host disease after having their leukemia cured through bone marrow transplant,” said Dr. Kean. “To have a therapy at our disposal that safely targets just the T cells causing graft-vs-host disease would represent a major step forward in stem cell transplantation. It not only offers new hope that we can prevent graft-vs-host disease upfront, but that we can also significantly improve outcomes for patients requiring high-risk transplants.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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