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ASH 2022: New clinical data challenge long-held assumptions
The conference starts in New Orleans on Saturday, Dec. 10, , but a sample of what is to come was given last week in a preview media briefing, moderated by Mikkael A. Sekeres, MD, from the University of Miami. Dr. Sekeres, who recently authored a book on the FDA and how it regulates drug approvals, also serves as chair of the ASH Committee on Communications.
“Feeding Our Patients Gruel”
Dr. Sekeres expressed particular excitement about a multicenter randomized trial done in Italy. It showed that patients who have neutropenia after a stem cell transplant need not be required to eat a bland diet (Abstract 169).
“We for years have been essentially feeding our patients gruel in the hospital, and these are folks who have to be hospitalized for a stem cell transplant or in my case – I’m a leukemia specialist – for acute leukemia, for 4-6 weeks. The neutropenic diet consists of the blandest food you can imagine, with nothing to really spice it up.”
He noted that a neutropenic diet is so unpalatable that family members often sneak food into patient rooms, and “for years we’ve never seen adverse outcomes in any of those folks who instead of having mashed potatoes and oatmeal ate a corned beef sandwich for dinner.”
Now, the results from this trial “actually give us license to finally allow patients to eat whatever they want,” Dr. Sekeres said.
Practice-changing data
ASH experts pointed to two more presentations that are expected to change clinical practice. These include the finding that high-dose methotrexate does not reduce the risk for central nervous system relapse in children with acute lymphoblastic leukemia and lymphoblastic lymphoma (Abstract 214).
Another new study that seems to defy conventional wisdom showed that in adults with relapsed or refractory acute myeloid leukemia, intensive chemotherapy in an effort to achieve remission before a stem cell transplant did not result in better outcomes, compared with sequential conditioning and immediate transplant (Abstract 4).
Premature aging in HL survivors
ASH President Jane N. Winter, MD, from Northwestern University, Chicago, who also spoke at the briefing, highlighted a study that followed adult survivors of pediatric Hodgkin lymphoma. This study, from St. Jude Children’s Research Hospital in Memphis and the Wilmot Cancer Institute at the University of Rochester (N.Y), found that these adult survivors are at significantly elevated risk for epigenetic age acceleration accompanied by neurocognitive deficits when compared with controls (Abstract 902).
“This is an area that is very near and dear to my heart,” she said. “Much of my career has focused on reducing the therapy to reduce the long-term consequences of treatments. Pediatricians have been very much wedded to very intensive therapies and tend to incorporate radiation more commonly in their treatment strategies for children than we do in adults.”
Dr. Winter noted that, although clinicians focus primarily on the link between mediastinal radiation and long-term adverse events such as breast cancer, “now we’re shedding a light on the neurocognitive deficits, which I think are underappreciated. Being able to screen for this impact of our treatment, and perhaps then develop strategies to deal with it or prevent it, will have very wide-ranging impact.”
Inherited thrombophilia and miscarriage
Cynthia E. Dunbar, MD, chief of the translational stem cell biology branch at the National Heart, Lung, and Blood Institute in Bethesda, Md., who also spoke at the briefing, said that one of the abstracts most important to her practice is a study concerning pregnancy. It showed that low-molecular-weight heparin did not prevent miscarriage in pregnant women with confirmed inherited thrombophilia who had two or more prior pregnancy losses, compared with standard surveillance (Abstract LBA-5).
“This is not my field at all; on the other hand, as a hematologist and a woman, that’s what my emails in the middle of the night and my panicked phone calls are often about. Once somebody has one miscarriage, especially if they feel like they’re already over 30 and the clock is ticking, there’s a huge emphasis and a huge amount of pressure on obstetricians to basically work up for everything, kind of a shotgun [approach],” she said.
Those workups may reveal genetic mutations that are associated with mild elevations in risk for clotting. As a result, some pregnant women are put on anticoagulation therapy, which can cause complications for both pregnancy and delivery. These study findings don’t solve the problem of spontaneous pregnancy loss, but they at least rule out inherited thrombophilia as a preventable cause of miscarriages, Dr. Dunbar said.
Another potentially practice-changing abstract is a study showing that, in younger adults with mantle cell lymphoma, the addition of the Bruton’s tyrosine kinase inhibitor ibrutinib (Imbruvica) to induction therapy and as maintenance with or without autologous stem cell transplant had strong efficacy and acceptable toxicity (Abstract 1).
“The results show that the ibrutinib-containing regimen without transplant is at least as good as the current standard of care with transplant.” Dr. Winter said. “Additional follow-up will be required to show definitively that an autotransplant is unnecessary if ibrutinib is included in this treatment regimen.”
A version of this article first appeared on Medscape.com.
The conference starts in New Orleans on Saturday, Dec. 10, , but a sample of what is to come was given last week in a preview media briefing, moderated by Mikkael A. Sekeres, MD, from the University of Miami. Dr. Sekeres, who recently authored a book on the FDA and how it regulates drug approvals, also serves as chair of the ASH Committee on Communications.
“Feeding Our Patients Gruel”
Dr. Sekeres expressed particular excitement about a multicenter randomized trial done in Italy. It showed that patients who have neutropenia after a stem cell transplant need not be required to eat a bland diet (Abstract 169).
“We for years have been essentially feeding our patients gruel in the hospital, and these are folks who have to be hospitalized for a stem cell transplant or in my case – I’m a leukemia specialist – for acute leukemia, for 4-6 weeks. The neutropenic diet consists of the blandest food you can imagine, with nothing to really spice it up.”
He noted that a neutropenic diet is so unpalatable that family members often sneak food into patient rooms, and “for years we’ve never seen adverse outcomes in any of those folks who instead of having mashed potatoes and oatmeal ate a corned beef sandwich for dinner.”
Now, the results from this trial “actually give us license to finally allow patients to eat whatever they want,” Dr. Sekeres said.
Practice-changing data
ASH experts pointed to two more presentations that are expected to change clinical practice. These include the finding that high-dose methotrexate does not reduce the risk for central nervous system relapse in children with acute lymphoblastic leukemia and lymphoblastic lymphoma (Abstract 214).
Another new study that seems to defy conventional wisdom showed that in adults with relapsed or refractory acute myeloid leukemia, intensive chemotherapy in an effort to achieve remission before a stem cell transplant did not result in better outcomes, compared with sequential conditioning and immediate transplant (Abstract 4).
Premature aging in HL survivors
ASH President Jane N. Winter, MD, from Northwestern University, Chicago, who also spoke at the briefing, highlighted a study that followed adult survivors of pediatric Hodgkin lymphoma. This study, from St. Jude Children’s Research Hospital in Memphis and the Wilmot Cancer Institute at the University of Rochester (N.Y), found that these adult survivors are at significantly elevated risk for epigenetic age acceleration accompanied by neurocognitive deficits when compared with controls (Abstract 902).
“This is an area that is very near and dear to my heart,” she said. “Much of my career has focused on reducing the therapy to reduce the long-term consequences of treatments. Pediatricians have been very much wedded to very intensive therapies and tend to incorporate radiation more commonly in their treatment strategies for children than we do in adults.”
Dr. Winter noted that, although clinicians focus primarily on the link between mediastinal radiation and long-term adverse events such as breast cancer, “now we’re shedding a light on the neurocognitive deficits, which I think are underappreciated. Being able to screen for this impact of our treatment, and perhaps then develop strategies to deal with it or prevent it, will have very wide-ranging impact.”
Inherited thrombophilia and miscarriage
Cynthia E. Dunbar, MD, chief of the translational stem cell biology branch at the National Heart, Lung, and Blood Institute in Bethesda, Md., who also spoke at the briefing, said that one of the abstracts most important to her practice is a study concerning pregnancy. It showed that low-molecular-weight heparin did not prevent miscarriage in pregnant women with confirmed inherited thrombophilia who had two or more prior pregnancy losses, compared with standard surveillance (Abstract LBA-5).
“This is not my field at all; on the other hand, as a hematologist and a woman, that’s what my emails in the middle of the night and my panicked phone calls are often about. Once somebody has one miscarriage, especially if they feel like they’re already over 30 and the clock is ticking, there’s a huge emphasis and a huge amount of pressure on obstetricians to basically work up for everything, kind of a shotgun [approach],” she said.
Those workups may reveal genetic mutations that are associated with mild elevations in risk for clotting. As a result, some pregnant women are put on anticoagulation therapy, which can cause complications for both pregnancy and delivery. These study findings don’t solve the problem of spontaneous pregnancy loss, but they at least rule out inherited thrombophilia as a preventable cause of miscarriages, Dr. Dunbar said.
Another potentially practice-changing abstract is a study showing that, in younger adults with mantle cell lymphoma, the addition of the Bruton’s tyrosine kinase inhibitor ibrutinib (Imbruvica) to induction therapy and as maintenance with or without autologous stem cell transplant had strong efficacy and acceptable toxicity (Abstract 1).
“The results show that the ibrutinib-containing regimen without transplant is at least as good as the current standard of care with transplant.” Dr. Winter said. “Additional follow-up will be required to show definitively that an autotransplant is unnecessary if ibrutinib is included in this treatment regimen.”
A version of this article first appeared on Medscape.com.
The conference starts in New Orleans on Saturday, Dec. 10, , but a sample of what is to come was given last week in a preview media briefing, moderated by Mikkael A. Sekeres, MD, from the University of Miami. Dr. Sekeres, who recently authored a book on the FDA and how it regulates drug approvals, also serves as chair of the ASH Committee on Communications.
“Feeding Our Patients Gruel”
Dr. Sekeres expressed particular excitement about a multicenter randomized trial done in Italy. It showed that patients who have neutropenia after a stem cell transplant need not be required to eat a bland diet (Abstract 169).
“We for years have been essentially feeding our patients gruel in the hospital, and these are folks who have to be hospitalized for a stem cell transplant or in my case – I’m a leukemia specialist – for acute leukemia, for 4-6 weeks. The neutropenic diet consists of the blandest food you can imagine, with nothing to really spice it up.”
He noted that a neutropenic diet is so unpalatable that family members often sneak food into patient rooms, and “for years we’ve never seen adverse outcomes in any of those folks who instead of having mashed potatoes and oatmeal ate a corned beef sandwich for dinner.”
Now, the results from this trial “actually give us license to finally allow patients to eat whatever they want,” Dr. Sekeres said.
Practice-changing data
ASH experts pointed to two more presentations that are expected to change clinical practice. These include the finding that high-dose methotrexate does not reduce the risk for central nervous system relapse in children with acute lymphoblastic leukemia and lymphoblastic lymphoma (Abstract 214).
Another new study that seems to defy conventional wisdom showed that in adults with relapsed or refractory acute myeloid leukemia, intensive chemotherapy in an effort to achieve remission before a stem cell transplant did not result in better outcomes, compared with sequential conditioning and immediate transplant (Abstract 4).
Premature aging in HL survivors
ASH President Jane N. Winter, MD, from Northwestern University, Chicago, who also spoke at the briefing, highlighted a study that followed adult survivors of pediatric Hodgkin lymphoma. This study, from St. Jude Children’s Research Hospital in Memphis and the Wilmot Cancer Institute at the University of Rochester (N.Y), found that these adult survivors are at significantly elevated risk for epigenetic age acceleration accompanied by neurocognitive deficits when compared with controls (Abstract 902).
“This is an area that is very near and dear to my heart,” she said. “Much of my career has focused on reducing the therapy to reduce the long-term consequences of treatments. Pediatricians have been very much wedded to very intensive therapies and tend to incorporate radiation more commonly in their treatment strategies for children than we do in adults.”
Dr. Winter noted that, although clinicians focus primarily on the link between mediastinal radiation and long-term adverse events such as breast cancer, “now we’re shedding a light on the neurocognitive deficits, which I think are underappreciated. Being able to screen for this impact of our treatment, and perhaps then develop strategies to deal with it or prevent it, will have very wide-ranging impact.”
Inherited thrombophilia and miscarriage
Cynthia E. Dunbar, MD, chief of the translational stem cell biology branch at the National Heart, Lung, and Blood Institute in Bethesda, Md., who also spoke at the briefing, said that one of the abstracts most important to her practice is a study concerning pregnancy. It showed that low-molecular-weight heparin did not prevent miscarriage in pregnant women with confirmed inherited thrombophilia who had two or more prior pregnancy losses, compared with standard surveillance (Abstract LBA-5).
“This is not my field at all; on the other hand, as a hematologist and a woman, that’s what my emails in the middle of the night and my panicked phone calls are often about. Once somebody has one miscarriage, especially if they feel like they’re already over 30 and the clock is ticking, there’s a huge emphasis and a huge amount of pressure on obstetricians to basically work up for everything, kind of a shotgun [approach],” she said.
Those workups may reveal genetic mutations that are associated with mild elevations in risk for clotting. As a result, some pregnant women are put on anticoagulation therapy, which can cause complications for both pregnancy and delivery. These study findings don’t solve the problem of spontaneous pregnancy loss, but they at least rule out inherited thrombophilia as a preventable cause of miscarriages, Dr. Dunbar said.
Another potentially practice-changing abstract is a study showing that, in younger adults with mantle cell lymphoma, the addition of the Bruton’s tyrosine kinase inhibitor ibrutinib (Imbruvica) to induction therapy and as maintenance with or without autologous stem cell transplant had strong efficacy and acceptable toxicity (Abstract 1).
“The results show that the ibrutinib-containing regimen without transplant is at least as good as the current standard of care with transplant.” Dr. Winter said. “Additional follow-up will be required to show definitively that an autotransplant is unnecessary if ibrutinib is included in this treatment regimen.”
A version of this article first appeared on Medscape.com.
FROM ASH 2022
Transplant provides no clear survival benefit in real-world MCL study
In younger patients with mantle cell lymphoma treated in U.S. community oncology settings in recent years, use of autologous transplant was not associated with improved survival, results of a large observational study show.
Autologous stem-cell transplant (ASCT) use was not linked overall survival (OS), according to the authors of the retrospective analysis of patients diagnosed with mantle cell lymphoma (MCL) between 2011 and 2021.
This lack of a clear survival benefit with use of ASCT is an “apparent contradiction” with prospective data from earlier clinical trials, authors wrote in the Journal of Clinical Oncology
However, they added, the finding is consistent with several recent registry analyses that also do not support a link between ASCT and overall survival in patients with MCL.
Although these findings are limited by the retrospective nature of the study, the results at least suggest that it is ethical to do research that doesn’t involve ASCT, study author Peter Martin, MD, said in an interview.
Furthermore, emerging data from the randomized TRIANGLE study from the European MCL Network suggest the potential for ASCT to be replaced by maintenance therapy with the Bruton's tyrosine kinase inhibitor ibrutinib, according to Dr. Martin, associate professor with Weill Cornell Medicine, New York.
“There are probably a lot of questions that will come up there, but essentially the barriers to research that do not include ASCT have been moved away, and we can go ahead and study non-ASCT (approaches) in younger patients,” Dr. Martin said.
No clear OS benefit
In current guidelines, recommended initial therapy for MCL patients younger than 65 years includes use of high-dose cytarabine-containing chemoimmunotherapy induction, followed by ASCT as consolidation, and then rituximab maintenance, Dr. Martin and coauthors say in their report.
Their primary analysis was based on the Flatiron Health database, which is derived from electronic medical records, mostly in U.S. community oncology practices, according to the report.
The researchers identified 1,274 patients under the age of 65 with a record of first-line treatment for MCL, and of those, 962 (or 76%) were considered eligible for ASCT.
Among ASCT-eligible patients, there was no significant association between receipt of ASCT and OS, with a hazard ratio of 0.86 (95% confidence interval, 0.63-1.18). The 3-year OS was 88% for patients receiving ASCT and similarly, 84% for those who did not, according to authors.
Likewise, there was no association between ASCT and real-world time to next treatment, an endpoint defined as time from start of first-line therapy to subsequent treatment or death, the report says.
Findings in perspective
The lack of clear survival benefit with ASCT in this and other recent observational studies may be explained in part by improvements in induction regimens, according to Timothy Fenske, MD, professor in the department of medicine at the Medical College of Wisconsin, Milwaukee.
“As our induction regimens have improved, it is very possible that the benefit for autologous transplantation will become less apparent,” Dr. Fenske said in an interview.
The discussion over ASCT in MCL is expected to evolve further in light of findings from TRIANGLE and EA4151, a randomized phase 3 trial of rituximab with or without ASCT specifically in patients with minimal residual disease (MRD)–negative MCL in first complete remission.
“If that study shows that the MRD-negative patients do not have much benefit from autologous transplantation,” Dr. Fenske said, “I think these studies will all be giving the same message – that autologous transplantation was beneficial back when induction regimens were poor (for example, CHOP without rituximab), but will have much less benefit in patients receiving modern inductions, which by and large will get more patients to be MRD negative.”
However, subgroup analyses of those TRIANGLE will be important, he added, since some patients may still benefit from ASCT, such as younger patients who remain MRD positive, or who have certain other high-risk molecular features.
Dr. Martin reported consulting or advisory roles with Janssen, BeiGene, Karyopharm Therapeutics, Kite/Gilead, Verastem, ADC Therapeutics, Bristol Myers Squibb/Celgene, Epizyme, Merck, MorphoSys, and Takeda. He reported institutional research funding from Karyopharm Therapeutics.
In younger patients with mantle cell lymphoma treated in U.S. community oncology settings in recent years, use of autologous transplant was not associated with improved survival, results of a large observational study show.
Autologous stem-cell transplant (ASCT) use was not linked overall survival (OS), according to the authors of the retrospective analysis of patients diagnosed with mantle cell lymphoma (MCL) between 2011 and 2021.
This lack of a clear survival benefit with use of ASCT is an “apparent contradiction” with prospective data from earlier clinical trials, authors wrote in the Journal of Clinical Oncology
However, they added, the finding is consistent with several recent registry analyses that also do not support a link between ASCT and overall survival in patients with MCL.
Although these findings are limited by the retrospective nature of the study, the results at least suggest that it is ethical to do research that doesn’t involve ASCT, study author Peter Martin, MD, said in an interview.
Furthermore, emerging data from the randomized TRIANGLE study from the European MCL Network suggest the potential for ASCT to be replaced by maintenance therapy with the Bruton's tyrosine kinase inhibitor ibrutinib, according to Dr. Martin, associate professor with Weill Cornell Medicine, New York.
“There are probably a lot of questions that will come up there, but essentially the barriers to research that do not include ASCT have been moved away, and we can go ahead and study non-ASCT (approaches) in younger patients,” Dr. Martin said.
No clear OS benefit
In current guidelines, recommended initial therapy for MCL patients younger than 65 years includes use of high-dose cytarabine-containing chemoimmunotherapy induction, followed by ASCT as consolidation, and then rituximab maintenance, Dr. Martin and coauthors say in their report.
Their primary analysis was based on the Flatiron Health database, which is derived from electronic medical records, mostly in U.S. community oncology practices, according to the report.
The researchers identified 1,274 patients under the age of 65 with a record of first-line treatment for MCL, and of those, 962 (or 76%) were considered eligible for ASCT.
Among ASCT-eligible patients, there was no significant association between receipt of ASCT and OS, with a hazard ratio of 0.86 (95% confidence interval, 0.63-1.18). The 3-year OS was 88% for patients receiving ASCT and similarly, 84% for those who did not, according to authors.
Likewise, there was no association between ASCT and real-world time to next treatment, an endpoint defined as time from start of first-line therapy to subsequent treatment or death, the report says.
Findings in perspective
The lack of clear survival benefit with ASCT in this and other recent observational studies may be explained in part by improvements in induction regimens, according to Timothy Fenske, MD, professor in the department of medicine at the Medical College of Wisconsin, Milwaukee.
“As our induction regimens have improved, it is very possible that the benefit for autologous transplantation will become less apparent,” Dr. Fenske said in an interview.
The discussion over ASCT in MCL is expected to evolve further in light of findings from TRIANGLE and EA4151, a randomized phase 3 trial of rituximab with or without ASCT specifically in patients with minimal residual disease (MRD)–negative MCL in first complete remission.
“If that study shows that the MRD-negative patients do not have much benefit from autologous transplantation,” Dr. Fenske said, “I think these studies will all be giving the same message – that autologous transplantation was beneficial back when induction regimens were poor (for example, CHOP without rituximab), but will have much less benefit in patients receiving modern inductions, which by and large will get more patients to be MRD negative.”
However, subgroup analyses of those TRIANGLE will be important, he added, since some patients may still benefit from ASCT, such as younger patients who remain MRD positive, or who have certain other high-risk molecular features.
Dr. Martin reported consulting or advisory roles with Janssen, BeiGene, Karyopharm Therapeutics, Kite/Gilead, Verastem, ADC Therapeutics, Bristol Myers Squibb/Celgene, Epizyme, Merck, MorphoSys, and Takeda. He reported institutional research funding from Karyopharm Therapeutics.
In younger patients with mantle cell lymphoma treated in U.S. community oncology settings in recent years, use of autologous transplant was not associated with improved survival, results of a large observational study show.
Autologous stem-cell transplant (ASCT) use was not linked overall survival (OS), according to the authors of the retrospective analysis of patients diagnosed with mantle cell lymphoma (MCL) between 2011 and 2021.
This lack of a clear survival benefit with use of ASCT is an “apparent contradiction” with prospective data from earlier clinical trials, authors wrote in the Journal of Clinical Oncology
However, they added, the finding is consistent with several recent registry analyses that also do not support a link between ASCT and overall survival in patients with MCL.
Although these findings are limited by the retrospective nature of the study, the results at least suggest that it is ethical to do research that doesn’t involve ASCT, study author Peter Martin, MD, said in an interview.
Furthermore, emerging data from the randomized TRIANGLE study from the European MCL Network suggest the potential for ASCT to be replaced by maintenance therapy with the Bruton's tyrosine kinase inhibitor ibrutinib, according to Dr. Martin, associate professor with Weill Cornell Medicine, New York.
“There are probably a lot of questions that will come up there, but essentially the barriers to research that do not include ASCT have been moved away, and we can go ahead and study non-ASCT (approaches) in younger patients,” Dr. Martin said.
No clear OS benefit
In current guidelines, recommended initial therapy for MCL patients younger than 65 years includes use of high-dose cytarabine-containing chemoimmunotherapy induction, followed by ASCT as consolidation, and then rituximab maintenance, Dr. Martin and coauthors say in their report.
Their primary analysis was based on the Flatiron Health database, which is derived from electronic medical records, mostly in U.S. community oncology practices, according to the report.
The researchers identified 1,274 patients under the age of 65 with a record of first-line treatment for MCL, and of those, 962 (or 76%) were considered eligible for ASCT.
Among ASCT-eligible patients, there was no significant association between receipt of ASCT and OS, with a hazard ratio of 0.86 (95% confidence interval, 0.63-1.18). The 3-year OS was 88% for patients receiving ASCT and similarly, 84% for those who did not, according to authors.
Likewise, there was no association between ASCT and real-world time to next treatment, an endpoint defined as time from start of first-line therapy to subsequent treatment or death, the report says.
Findings in perspective
The lack of clear survival benefit with ASCT in this and other recent observational studies may be explained in part by improvements in induction regimens, according to Timothy Fenske, MD, professor in the department of medicine at the Medical College of Wisconsin, Milwaukee.
“As our induction regimens have improved, it is very possible that the benefit for autologous transplantation will become less apparent,” Dr. Fenske said in an interview.
The discussion over ASCT in MCL is expected to evolve further in light of findings from TRIANGLE and EA4151, a randomized phase 3 trial of rituximab with or without ASCT specifically in patients with minimal residual disease (MRD)–negative MCL in first complete remission.
“If that study shows that the MRD-negative patients do not have much benefit from autologous transplantation,” Dr. Fenske said, “I think these studies will all be giving the same message – that autologous transplantation was beneficial back when induction regimens were poor (for example, CHOP without rituximab), but will have much less benefit in patients receiving modern inductions, which by and large will get more patients to be MRD negative.”
However, subgroup analyses of those TRIANGLE will be important, he added, since some patients may still benefit from ASCT, such as younger patients who remain MRD positive, or who have certain other high-risk molecular features.
Dr. Martin reported consulting or advisory roles with Janssen, BeiGene, Karyopharm Therapeutics, Kite/Gilead, Verastem, ADC Therapeutics, Bristol Myers Squibb/Celgene, Epizyme, Merck, MorphoSys, and Takeda. He reported institutional research funding from Karyopharm Therapeutics.
FROM THE JOURNAL OF CLINICAL ONCOLOGY
Blame MCL, not transplantation, for late effects?
In patients with mantle cell lymphoma, rates of respiratory disease, blood disorders, and infectious diseases do not vary according to the intensity of treatment given, the results of a large retrospective analysis suggested.
The rate of hospitalization among MCL patients was also high, but again, did not differ between ASCT and non-ASCT subgroups in the study, which included adult patients younger than age 70 with MCL who were treated in Sweden between 2000 and 2014.
Late effects independent of ASCT
These findings may have implications for clinicians tempted to avoid intensive first-line treatment including ASCT because it is “demanding” and may cause late effects, study authors wrote in a research article that appeared in Blood Advances.
In fact, the great majority of long-term health care needs in patients with MCL appear to be related to the lymphoma in itself, according to study senior author Ingrid Glimelius, MD, PhD, senior consultant and professor in oncology in the department of immunology, genetics, and pathology at Uppsala University in Sweden.
“You do have to keep your eyes open for complications like blood disorders, infections, and respiratory (disorders),” Dr. Glimelius said in an interview. “But it’s not the transplant that adds to the extra toxicity. So don’t be afraid of giving that, if you think that can prolong your patient’s remission.”
Whither transplantation?
While these data may advance the discussion over the relative safety of ASCT, she added, the paradigm is changing to ask a different question: Does the patient need a transplant, or not?
Dr. Glimelius said she was looking forward to results of TRIANGLE, a randomized, open-label, three-arm study initiated by the European MCL Network. This study compares standard first-line treatment including ASCT to the kinase inhibitor ibrutinib, which the U.S. Food and Drug Administration approved in 2013 for patients previously treated for MCL.
In the TRIANGLE study, younger patients with MCL were randomized to the standard first-line treatment, standard treatment plus ibrutinib, or ibrutinib alone.
A preliminary report on the study stated that the current standard is “not superior” to the new ibrutinib-containing regimen without ASCT, though more follow-up is needed.
Full results of the study are expected to be presented at the American Society of Hematology meeting on December 11.
“In my opinion, our data will be practice-changing,” said lead investigator Martin Dreyling, MD, PhD, professor of medicine and head of the lymphoma program at the University of Munich Hospital.
Little known about late effects
In the meantime, clinicians may be reassured by the current data from Dr. Glimelius and coauthors, which showed that late effects varied little by treatment choice.
That’s important, Dr. Glimelius said, because even as survival is improving and novel targeted drugs are taking the stage, knowledge about the late effects of MCL remains limited.
Their population-based study included all 620 patients with MCL in the Swedish Lymphoma Register who were 18-69 years of age and diagnosed between 2000 and 2014. Records were found for 620 patients, of whom 247 received high-dose chemotherapy with ASCT.
Compared with healthy individuals with no MCL, the patients with MCL had a high rate of specialist visits and hospital visits, according to the report. The MCL patients also had high risks of infections, respiratory complications, and blood disorders relative to the healthy subjects.
Lack of differences between arms
The key finding of the report, though, is the lack of significant differences in the rate of complications between the ASCT and non–ASCT-treated patients.
Relative to healthy subjects, patients undergoing ASCT and not undergoing ASCT had a higher risk of infections, with hazard ratios of 5.62 (95% confidence interval, 4.20-7.52) and 4.66 (95% CI, 3.62-5.00), respectively.
Relative risks of respiratory complications were also similar, with HRs of 4.38 and 5.26, respectively, and overlapping CIs. Likewise, the risk of blood disorders was not statistically different, with HRs of 9.84 and 5.80, respectively, but again with overlapping CIs.
Outpatient visits, inpatient visits, and bed days were likewise similar between ASCT and non-ASCT arms.
In fact, most patients died of their lymphoma, rather than a treatment complication or another cause of death, the investigators noted in their report.
Dr. Glimelius reported receiving honoraria from Janssen. Coauthors on the paper reported disclosures related to Janssen, Gilead, Celgene, Roche, Acerta. and AbbVie.
Correction, 11/21/22: The photo caption misstated Dr. Ingrid Glimelius' name.
In patients with mantle cell lymphoma, rates of respiratory disease, blood disorders, and infectious diseases do not vary according to the intensity of treatment given, the results of a large retrospective analysis suggested.
The rate of hospitalization among MCL patients was also high, but again, did not differ between ASCT and non-ASCT subgroups in the study, which included adult patients younger than age 70 with MCL who were treated in Sweden between 2000 and 2014.
Late effects independent of ASCT
These findings may have implications for clinicians tempted to avoid intensive first-line treatment including ASCT because it is “demanding” and may cause late effects, study authors wrote in a research article that appeared in Blood Advances.
In fact, the great majority of long-term health care needs in patients with MCL appear to be related to the lymphoma in itself, according to study senior author Ingrid Glimelius, MD, PhD, senior consultant and professor in oncology in the department of immunology, genetics, and pathology at Uppsala University in Sweden.
“You do have to keep your eyes open for complications like blood disorders, infections, and respiratory (disorders),” Dr. Glimelius said in an interview. “But it’s not the transplant that adds to the extra toxicity. So don’t be afraid of giving that, if you think that can prolong your patient’s remission.”
Whither transplantation?
While these data may advance the discussion over the relative safety of ASCT, she added, the paradigm is changing to ask a different question: Does the patient need a transplant, or not?
Dr. Glimelius said she was looking forward to results of TRIANGLE, a randomized, open-label, three-arm study initiated by the European MCL Network. This study compares standard first-line treatment including ASCT to the kinase inhibitor ibrutinib, which the U.S. Food and Drug Administration approved in 2013 for patients previously treated for MCL.
In the TRIANGLE study, younger patients with MCL were randomized to the standard first-line treatment, standard treatment plus ibrutinib, or ibrutinib alone.
A preliminary report on the study stated that the current standard is “not superior” to the new ibrutinib-containing regimen without ASCT, though more follow-up is needed.
Full results of the study are expected to be presented at the American Society of Hematology meeting on December 11.
“In my opinion, our data will be practice-changing,” said lead investigator Martin Dreyling, MD, PhD, professor of medicine and head of the lymphoma program at the University of Munich Hospital.
Little known about late effects
In the meantime, clinicians may be reassured by the current data from Dr. Glimelius and coauthors, which showed that late effects varied little by treatment choice.
That’s important, Dr. Glimelius said, because even as survival is improving and novel targeted drugs are taking the stage, knowledge about the late effects of MCL remains limited.
Their population-based study included all 620 patients with MCL in the Swedish Lymphoma Register who were 18-69 years of age and diagnosed between 2000 and 2014. Records were found for 620 patients, of whom 247 received high-dose chemotherapy with ASCT.
Compared with healthy individuals with no MCL, the patients with MCL had a high rate of specialist visits and hospital visits, according to the report. The MCL patients also had high risks of infections, respiratory complications, and blood disorders relative to the healthy subjects.
Lack of differences between arms
The key finding of the report, though, is the lack of significant differences in the rate of complications between the ASCT and non–ASCT-treated patients.
Relative to healthy subjects, patients undergoing ASCT and not undergoing ASCT had a higher risk of infections, with hazard ratios of 5.62 (95% confidence interval, 4.20-7.52) and 4.66 (95% CI, 3.62-5.00), respectively.
Relative risks of respiratory complications were also similar, with HRs of 4.38 and 5.26, respectively, and overlapping CIs. Likewise, the risk of blood disorders was not statistically different, with HRs of 9.84 and 5.80, respectively, but again with overlapping CIs.
Outpatient visits, inpatient visits, and bed days were likewise similar between ASCT and non-ASCT arms.
In fact, most patients died of their lymphoma, rather than a treatment complication or another cause of death, the investigators noted in their report.
Dr. Glimelius reported receiving honoraria from Janssen. Coauthors on the paper reported disclosures related to Janssen, Gilead, Celgene, Roche, Acerta. and AbbVie.
Correction, 11/21/22: The photo caption misstated Dr. Ingrid Glimelius' name.
In patients with mantle cell lymphoma, rates of respiratory disease, blood disorders, and infectious diseases do not vary according to the intensity of treatment given, the results of a large retrospective analysis suggested.
The rate of hospitalization among MCL patients was also high, but again, did not differ between ASCT and non-ASCT subgroups in the study, which included adult patients younger than age 70 with MCL who were treated in Sweden between 2000 and 2014.
Late effects independent of ASCT
These findings may have implications for clinicians tempted to avoid intensive first-line treatment including ASCT because it is “demanding” and may cause late effects, study authors wrote in a research article that appeared in Blood Advances.
In fact, the great majority of long-term health care needs in patients with MCL appear to be related to the lymphoma in itself, according to study senior author Ingrid Glimelius, MD, PhD, senior consultant and professor in oncology in the department of immunology, genetics, and pathology at Uppsala University in Sweden.
“You do have to keep your eyes open for complications like blood disorders, infections, and respiratory (disorders),” Dr. Glimelius said in an interview. “But it’s not the transplant that adds to the extra toxicity. So don’t be afraid of giving that, if you think that can prolong your patient’s remission.”
Whither transplantation?
While these data may advance the discussion over the relative safety of ASCT, she added, the paradigm is changing to ask a different question: Does the patient need a transplant, or not?
Dr. Glimelius said she was looking forward to results of TRIANGLE, a randomized, open-label, three-arm study initiated by the European MCL Network. This study compares standard first-line treatment including ASCT to the kinase inhibitor ibrutinib, which the U.S. Food and Drug Administration approved in 2013 for patients previously treated for MCL.
In the TRIANGLE study, younger patients with MCL were randomized to the standard first-line treatment, standard treatment plus ibrutinib, or ibrutinib alone.
A preliminary report on the study stated that the current standard is “not superior” to the new ibrutinib-containing regimen without ASCT, though more follow-up is needed.
Full results of the study are expected to be presented at the American Society of Hematology meeting on December 11.
“In my opinion, our data will be practice-changing,” said lead investigator Martin Dreyling, MD, PhD, professor of medicine and head of the lymphoma program at the University of Munich Hospital.
Little known about late effects
In the meantime, clinicians may be reassured by the current data from Dr. Glimelius and coauthors, which showed that late effects varied little by treatment choice.
That’s important, Dr. Glimelius said, because even as survival is improving and novel targeted drugs are taking the stage, knowledge about the late effects of MCL remains limited.
Their population-based study included all 620 patients with MCL in the Swedish Lymphoma Register who were 18-69 years of age and diagnosed between 2000 and 2014. Records were found for 620 patients, of whom 247 received high-dose chemotherapy with ASCT.
Compared with healthy individuals with no MCL, the patients with MCL had a high rate of specialist visits and hospital visits, according to the report. The MCL patients also had high risks of infections, respiratory complications, and blood disorders relative to the healthy subjects.
Lack of differences between arms
The key finding of the report, though, is the lack of significant differences in the rate of complications between the ASCT and non–ASCT-treated patients.
Relative to healthy subjects, patients undergoing ASCT and not undergoing ASCT had a higher risk of infections, with hazard ratios of 5.62 (95% confidence interval, 4.20-7.52) and 4.66 (95% CI, 3.62-5.00), respectively.
Relative risks of respiratory complications were also similar, with HRs of 4.38 and 5.26, respectively, and overlapping CIs. Likewise, the risk of blood disorders was not statistically different, with HRs of 9.84 and 5.80, respectively, but again with overlapping CIs.
Outpatient visits, inpatient visits, and bed days were likewise similar between ASCT and non-ASCT arms.
In fact, most patients died of their lymphoma, rather than a treatment complication or another cause of death, the investigators noted in their report.
Dr. Glimelius reported receiving honoraria from Janssen. Coauthors on the paper reported disclosures related to Janssen, Gilead, Celgene, Roche, Acerta. and AbbVie.
Correction, 11/21/22: The photo caption misstated Dr. Ingrid Glimelius' name.
FROM BLOOD ADVANCES
Balanced crystalloid fluids surpass saline for kidney transplant
ORLANDO – Using a low-chloride, balanced crystalloid solution for all intravenous fluids received by patients who received a deceased donor kidney transplant resulted in significantly fewer episodes of delayed graft function, compared with patients who received saline as their IV fluids, in a new multicenter trial with 807 randomized and evaluable patients called BEST-Fluids.
“The findings suggest that balanced crystalloids should be the standard-of-care IV fluid in deceased donor kidney transplantations,” Michael G. Collins, MBChB, PhD, said at the annual meeting of the American Society of Nephrology.
“Balanced crystalloids are cheap, readily available worldwide, and this simple change in kidney transplant practice can easily be implemented in global practice ... almost immediately,” said Dr. Collins, a nephrologist at Royal Adelaide Hospital, Australia.
A 1-L bag of balanced crystalloid fluid is more expensive; however, it has a U.S. retail cost of about $2-$5 per bag, compared with about $1 per bag of saline fluid, Dr. Collins added.
Various other commentators had mixed views. Some agreed with Dr. Collins and said the switch could be made immediately, although one researcher wanted to see more trials. Another wondered why balanced crystalloid fluid hadn’t seemed to provide benefit in studies in acute kidney injury.
Treating 10 patients prevents one delayed graft function
The incidence of delayed graft function, defined as the need for dialysis during the 7 days following transplantation, occurred in 30.0% of 404 patients who received balanced crystalloid fluids (Plasma-Lyte 148) and in 39.7% of 403 patients who received saline starting at the time of randomization (prior to surgery) until 48 hours post-surgery, Dr. Collins reported.
This translated into a significant, adjusted relative risk reduction of 26% and a number needed to treat of 10 to result in one avoided episode of delayed graft function.
Preventing delayed graft function is important because it is a “major complication” of deceased donor kidney transplantation that usually occurs in about 30%-50% of people who receive these organs, Dr. Collins explained. Incident delayed graft function leads to higher hospitalization costs because of a prolonged need for dialysis and extended hospital days, as well as increased risk for long-term graft failure and death.
A secondary outcome – the number of dialysis sessions required during the 28 days following transplantation – was 406 sessions among those who received balanced crystalloid fluids and 596 sessions among the controls who received saline, a significant adjusted relative decrease of 30%.
Freedom from need for dialysis by 12 weeks after surgery increased by a significant 10% among those treated with balanced crystalloid fluids, compared with controls. The balanced crystalloid fluids were also significantly linked with an average 1-L increase in urine output during the first 2 days after transplantation, compared with controls.
Chloride is the culprit
“I think this is driven by the harmful effects of saline,” which is currently the standard fluid that kidney transplant patients receive worldwide, said Dr. Collins. Specifically, he cited the chloride content of saline – which contains 0.9% sodium chloride – as the culprit by causing reduced kidney perfusion.
“Some data suggest that saline may be harmful because of chloride acidosis producing vasoconstriction and increasing ischemia,” commented Karen A. Griffin, MD, chief of the renal section at the Edward Hines, Jr. VA Medical Center, Hines, Illinois. But Dr. Griffin said she’d like to see further study of balanced crystalloid fluids in this setting before she’d be comfortable using it routinely as a replacement for saline.
However, Pascale H. Lane, MD, a pediatric nephrologist with Oklahoma University Health, Oklahoma City, predicted that based on these results, “I think it will be rapidly embraced” by U.S. clinicians. Dr. Lane expressed concern about the availability of an adequate supply of balanced crystalloid fluid, but Dr. Collins said he did not believe supply would be an issue based on current availability.
This was “a beautiful study, very well done, with nice results, and a very easy switch to balanced crystalloid fluids without harm,” commented Richard Lafayette, MD, a nephrologist and professor of medicine at Stanford (Calif.) University.
Success attributed to early treatment
But Dr. Lafayette also wondered, “Why should this work for transplant patients when it did not work for patients who develop acute kidney injury in the ICU?” And he found it hard to understand how the impact of the balanced crystalloid fluid could manifest so quickly, with a change in urine output during the first day following surgery.
Dr. Collins attributed the rapid effects and overall success to the early initiation of balanced crystalloid fluids before the transplant occurred.
The BEST-Fluids trial ran at 16 centers in Australia and New Zealand and enrolled patients from January 2018 to August 2020. It enrolled adults and children scheduled to receive a deceased donor kidney, excluding those who weighed less than 20 kg and those who received multiple organs.
Enrolled patients averaged about 55 years old, about 63% were men, and their average duration on dialysis prior to surgery was about 30 months. The study randomized 808 patients who received their transplanted kidney, with 807 included in the efficacy analysis. Patients in each of the two groups showed very close balance for all reported parameters of patient and donor characteristics. During the period of randomized fluid treatment, patients in the balanced crystalloid group received an average of just over 8 L of fluid, while those in the control group received an average of just over 7 L.
During follow-up, serious adverse events were rare and balanced, with three in the balanced crystalloid group and four among controls.
The only significant difference in adverse events was the rate of ICU admissions that required ventilation, which occurred in one patient in the balanced crystalloid group and 12 controls.
BEST-Fluids received balanced crystalloid and saline solutions at no charge from Baxter Healthcare, which markets Plasma-Lyte 148. The study received no other commercial funding. Dr. Collins, Dr. Griffin, and Dr. Lane have reported no relevant financial relationships. Dr. Lafayette has received personal fees and grants from Alexion, Aurinia, Calliditas, Omeros, Pfizer, Roche, Travere, and Vera and has been an advisor to Akahest and Equillium.
A version of this article first appeared on Medscape.com.
ORLANDO – Using a low-chloride, balanced crystalloid solution for all intravenous fluids received by patients who received a deceased donor kidney transplant resulted in significantly fewer episodes of delayed graft function, compared with patients who received saline as their IV fluids, in a new multicenter trial with 807 randomized and evaluable patients called BEST-Fluids.
“The findings suggest that balanced crystalloids should be the standard-of-care IV fluid in deceased donor kidney transplantations,” Michael G. Collins, MBChB, PhD, said at the annual meeting of the American Society of Nephrology.
“Balanced crystalloids are cheap, readily available worldwide, and this simple change in kidney transplant practice can easily be implemented in global practice ... almost immediately,” said Dr. Collins, a nephrologist at Royal Adelaide Hospital, Australia.
A 1-L bag of balanced crystalloid fluid is more expensive; however, it has a U.S. retail cost of about $2-$5 per bag, compared with about $1 per bag of saline fluid, Dr. Collins added.
Various other commentators had mixed views. Some agreed with Dr. Collins and said the switch could be made immediately, although one researcher wanted to see more trials. Another wondered why balanced crystalloid fluid hadn’t seemed to provide benefit in studies in acute kidney injury.
Treating 10 patients prevents one delayed graft function
The incidence of delayed graft function, defined as the need for dialysis during the 7 days following transplantation, occurred in 30.0% of 404 patients who received balanced crystalloid fluids (Plasma-Lyte 148) and in 39.7% of 403 patients who received saline starting at the time of randomization (prior to surgery) until 48 hours post-surgery, Dr. Collins reported.
This translated into a significant, adjusted relative risk reduction of 26% and a number needed to treat of 10 to result in one avoided episode of delayed graft function.
Preventing delayed graft function is important because it is a “major complication” of deceased donor kidney transplantation that usually occurs in about 30%-50% of people who receive these organs, Dr. Collins explained. Incident delayed graft function leads to higher hospitalization costs because of a prolonged need for dialysis and extended hospital days, as well as increased risk for long-term graft failure and death.
A secondary outcome – the number of dialysis sessions required during the 28 days following transplantation – was 406 sessions among those who received balanced crystalloid fluids and 596 sessions among the controls who received saline, a significant adjusted relative decrease of 30%.
Freedom from need for dialysis by 12 weeks after surgery increased by a significant 10% among those treated with balanced crystalloid fluids, compared with controls. The balanced crystalloid fluids were also significantly linked with an average 1-L increase in urine output during the first 2 days after transplantation, compared with controls.
Chloride is the culprit
“I think this is driven by the harmful effects of saline,” which is currently the standard fluid that kidney transplant patients receive worldwide, said Dr. Collins. Specifically, he cited the chloride content of saline – which contains 0.9% sodium chloride – as the culprit by causing reduced kidney perfusion.
“Some data suggest that saline may be harmful because of chloride acidosis producing vasoconstriction and increasing ischemia,” commented Karen A. Griffin, MD, chief of the renal section at the Edward Hines, Jr. VA Medical Center, Hines, Illinois. But Dr. Griffin said she’d like to see further study of balanced crystalloid fluids in this setting before she’d be comfortable using it routinely as a replacement for saline.
However, Pascale H. Lane, MD, a pediatric nephrologist with Oklahoma University Health, Oklahoma City, predicted that based on these results, “I think it will be rapidly embraced” by U.S. clinicians. Dr. Lane expressed concern about the availability of an adequate supply of balanced crystalloid fluid, but Dr. Collins said he did not believe supply would be an issue based on current availability.
This was “a beautiful study, very well done, with nice results, and a very easy switch to balanced crystalloid fluids without harm,” commented Richard Lafayette, MD, a nephrologist and professor of medicine at Stanford (Calif.) University.
Success attributed to early treatment
But Dr. Lafayette also wondered, “Why should this work for transplant patients when it did not work for patients who develop acute kidney injury in the ICU?” And he found it hard to understand how the impact of the balanced crystalloid fluid could manifest so quickly, with a change in urine output during the first day following surgery.
Dr. Collins attributed the rapid effects and overall success to the early initiation of balanced crystalloid fluids before the transplant occurred.
The BEST-Fluids trial ran at 16 centers in Australia and New Zealand and enrolled patients from January 2018 to August 2020. It enrolled adults and children scheduled to receive a deceased donor kidney, excluding those who weighed less than 20 kg and those who received multiple organs.
Enrolled patients averaged about 55 years old, about 63% were men, and their average duration on dialysis prior to surgery was about 30 months. The study randomized 808 patients who received their transplanted kidney, with 807 included in the efficacy analysis. Patients in each of the two groups showed very close balance for all reported parameters of patient and donor characteristics. During the period of randomized fluid treatment, patients in the balanced crystalloid group received an average of just over 8 L of fluid, while those in the control group received an average of just over 7 L.
During follow-up, serious adverse events were rare and balanced, with three in the balanced crystalloid group and four among controls.
The only significant difference in adverse events was the rate of ICU admissions that required ventilation, which occurred in one patient in the balanced crystalloid group and 12 controls.
BEST-Fluids received balanced crystalloid and saline solutions at no charge from Baxter Healthcare, which markets Plasma-Lyte 148. The study received no other commercial funding. Dr. Collins, Dr. Griffin, and Dr. Lane have reported no relevant financial relationships. Dr. Lafayette has received personal fees and grants from Alexion, Aurinia, Calliditas, Omeros, Pfizer, Roche, Travere, and Vera and has been an advisor to Akahest and Equillium.
A version of this article first appeared on Medscape.com.
ORLANDO – Using a low-chloride, balanced crystalloid solution for all intravenous fluids received by patients who received a deceased donor kidney transplant resulted in significantly fewer episodes of delayed graft function, compared with patients who received saline as their IV fluids, in a new multicenter trial with 807 randomized and evaluable patients called BEST-Fluids.
“The findings suggest that balanced crystalloids should be the standard-of-care IV fluid in deceased donor kidney transplantations,” Michael G. Collins, MBChB, PhD, said at the annual meeting of the American Society of Nephrology.
“Balanced crystalloids are cheap, readily available worldwide, and this simple change in kidney transplant practice can easily be implemented in global practice ... almost immediately,” said Dr. Collins, a nephrologist at Royal Adelaide Hospital, Australia.
A 1-L bag of balanced crystalloid fluid is more expensive; however, it has a U.S. retail cost of about $2-$5 per bag, compared with about $1 per bag of saline fluid, Dr. Collins added.
Various other commentators had mixed views. Some agreed with Dr. Collins and said the switch could be made immediately, although one researcher wanted to see more trials. Another wondered why balanced crystalloid fluid hadn’t seemed to provide benefit in studies in acute kidney injury.
Treating 10 patients prevents one delayed graft function
The incidence of delayed graft function, defined as the need for dialysis during the 7 days following transplantation, occurred in 30.0% of 404 patients who received balanced crystalloid fluids (Plasma-Lyte 148) and in 39.7% of 403 patients who received saline starting at the time of randomization (prior to surgery) until 48 hours post-surgery, Dr. Collins reported.
This translated into a significant, adjusted relative risk reduction of 26% and a number needed to treat of 10 to result in one avoided episode of delayed graft function.
Preventing delayed graft function is important because it is a “major complication” of deceased donor kidney transplantation that usually occurs in about 30%-50% of people who receive these organs, Dr. Collins explained. Incident delayed graft function leads to higher hospitalization costs because of a prolonged need for dialysis and extended hospital days, as well as increased risk for long-term graft failure and death.
A secondary outcome – the number of dialysis sessions required during the 28 days following transplantation – was 406 sessions among those who received balanced crystalloid fluids and 596 sessions among the controls who received saline, a significant adjusted relative decrease of 30%.
Freedom from need for dialysis by 12 weeks after surgery increased by a significant 10% among those treated with balanced crystalloid fluids, compared with controls. The balanced crystalloid fluids were also significantly linked with an average 1-L increase in urine output during the first 2 days after transplantation, compared with controls.
Chloride is the culprit
“I think this is driven by the harmful effects of saline,” which is currently the standard fluid that kidney transplant patients receive worldwide, said Dr. Collins. Specifically, he cited the chloride content of saline – which contains 0.9% sodium chloride – as the culprit by causing reduced kidney perfusion.
“Some data suggest that saline may be harmful because of chloride acidosis producing vasoconstriction and increasing ischemia,” commented Karen A. Griffin, MD, chief of the renal section at the Edward Hines, Jr. VA Medical Center, Hines, Illinois. But Dr. Griffin said she’d like to see further study of balanced crystalloid fluids in this setting before she’d be comfortable using it routinely as a replacement for saline.
However, Pascale H. Lane, MD, a pediatric nephrologist with Oklahoma University Health, Oklahoma City, predicted that based on these results, “I think it will be rapidly embraced” by U.S. clinicians. Dr. Lane expressed concern about the availability of an adequate supply of balanced crystalloid fluid, but Dr. Collins said he did not believe supply would be an issue based on current availability.
This was “a beautiful study, very well done, with nice results, and a very easy switch to balanced crystalloid fluids without harm,” commented Richard Lafayette, MD, a nephrologist and professor of medicine at Stanford (Calif.) University.
Success attributed to early treatment
But Dr. Lafayette also wondered, “Why should this work for transplant patients when it did not work for patients who develop acute kidney injury in the ICU?” And he found it hard to understand how the impact of the balanced crystalloid fluid could manifest so quickly, with a change in urine output during the first day following surgery.
Dr. Collins attributed the rapid effects and overall success to the early initiation of balanced crystalloid fluids before the transplant occurred.
The BEST-Fluids trial ran at 16 centers in Australia and New Zealand and enrolled patients from January 2018 to August 2020. It enrolled adults and children scheduled to receive a deceased donor kidney, excluding those who weighed less than 20 kg and those who received multiple organs.
Enrolled patients averaged about 55 years old, about 63% were men, and their average duration on dialysis prior to surgery was about 30 months. The study randomized 808 patients who received their transplanted kidney, with 807 included in the efficacy analysis. Patients in each of the two groups showed very close balance for all reported parameters of patient and donor characteristics. During the period of randomized fluid treatment, patients in the balanced crystalloid group received an average of just over 8 L of fluid, while those in the control group received an average of just over 7 L.
During follow-up, serious adverse events were rare and balanced, with three in the balanced crystalloid group and four among controls.
The only significant difference in adverse events was the rate of ICU admissions that required ventilation, which occurred in one patient in the balanced crystalloid group and 12 controls.
BEST-Fluids received balanced crystalloid and saline solutions at no charge from Baxter Healthcare, which markets Plasma-Lyte 148. The study received no other commercial funding. Dr. Collins, Dr. Griffin, and Dr. Lane have reported no relevant financial relationships. Dr. Lafayette has received personal fees and grants from Alexion, Aurinia, Calliditas, Omeros, Pfizer, Roche, Travere, and Vera and has been an advisor to Akahest and Equillium.
A version of this article first appeared on Medscape.com.
AT KIDNEY WEEK 2022
Living donor liver transplants on rise for most urgent need
Living donor liver transplants (LDLT) for recipients with the most urgent need for a liver transplant in the next 3 months – a model for end-stage liver disease (MELD) score of 25 or higher – have become more frequent during the past decade, according to new findings presented at the annual meeting of the American Association for the Study of Liver Diseases.
Among LDLT recipients, researchers found comparable patient and graft survival at low and high MELD scores. But among patients with high MELD scores, researchers found lower adjusted graft survival and a higher transplant rate among those with living donors, compared with recipients of deceased donor liver transplantation (DDLT).
The findings suggest certain advantages of LDLT over DDLT may be lost in the high-MELD setting in terms of graft survival, said Benjamin Rosenthal, MD, an internal medicine resident focused on transplant hepatology at the Hospital of the University of Pennsylvania, Philadelphia.
“Historically, in the United States especially, living donor liver transplantation has been offered to patients with low or moderate MELD,” he said. “The outcomes of LDLT at high MELD are currently unknown.”
Previous data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) found that LDLT offered a survival benefit versus remaining on the wait list, independent of MELD score, he said. A recent study also has demonstrated a survival benefit across MELD scores of 11-26, but findings for MELD scores of 25 and higher have been mixed.
Trends and outcomes in LDLT at high MELD scores
Dr. Rosenthal and colleagues conducted a retrospective cohort study of adult LDLT recipients from 2010 to 2021 using data from the Organ Procurement and Transplantation Network (OPTN), the U.S. donation and transplantation system.
In baseline characteristics among LDLT transplant recipients, there weren’t significant differences in age, sex, race, and ethnicity for MELD scores below 25 or at 25 and higher. There also weren’t significant differences in donor age, relationship, use of nondirected grafts, or percentage of right and left lobe donors for LDLT recipients. However, recipients with high MELD scores had more nonalcoholic steatohepatitis (29.5% versus 24.6%) and alcohol-assisted cirrhosis (21.6% versus 14.3%).
The research team evaluated graft survival among LDLT recipients by MELD below 25 and at 25 or higher. They also compared posttransplant patient and graft survival between LDLT and DDLT recipients with a MELD of 25 or higher. They excluded transplant candidates on the wait list for Status 1/1A, redo transplant, or multiorgan transplant.
Among the 3,590 patients who had LDLT between 2010 and 2021, 342 patients (9.5%) had a MELD of 25 or higher at transplant. There was some progression during the waiting period, Dr. Rosenthal noted, with a median listing MELD score of 19 among those who had a MELD of 25 or higher at transplant and 21 among those who had a MELD of 30 or higher at transplant.
For LDLT recipients with MELD scores above or below 25, researchers found no significant differences in adjusted patient survival or adjusted graft survival.
Then the team compared outcomes of LDLT and DDLT in high-MELD recipients. Among the 67,279-patient DDLT comparator group, 27,552 patients (41%) had a MELD of 25 or higher at transplant.
In terms of LDLT versus DDLT, unadjusted and adjusted patient survival were no different for patients with MELD of 25 or higher. In addition, unadjusted graft survival was no different.
However, adjusted graft survival was worse for LDLT recipients with high MELD scores. In addition, the retransplant rate was higher in LDLT recipients, at 5.7% versus 2.4%.
The reason why graft survival may be worse remains unclear, Dr. Rosenthal said. One hypothesis is that a low graft-to-recipient weight ratio in LDLT can cause small-for-size syndrome. However, these ratios were not available from OPTN.
“Further studies should be done to see what the benefit is, with graft-to-recipient weight ratios included,” he said. “The differences between DDLT and LDLT in this setting should be further explored as well.”
The research team also described temporal and transplant center trends for LDLT by MELD group. For temporal trends, they expanded the study period from 2002-2021.
The found a marked U.S. increase in the percentage of LDLT with a MELD of 25 or higher, particularly in the last decade and especially in the last 5 years. But the percentage of LDLT with high MELD remains lower than 15%, even in recent years, Dr. Rosenthal noted.
Across transplant centers, there was a trend toward centers with increasing LDLT volume having a greater proportion of LDLT recipients with a MELD of 25 or higher. At the 19.6% of centers performing 10 or fewer LDLT during the study period, none of the LDLT recipients had a MELD of 25 or higher, Dr. Rosenthal said.
The authors didn’t report a funding source. The authors declared no relevant disclosures.
Living donor liver transplants (LDLT) for recipients with the most urgent need for a liver transplant in the next 3 months – a model for end-stage liver disease (MELD) score of 25 or higher – have become more frequent during the past decade, according to new findings presented at the annual meeting of the American Association for the Study of Liver Diseases.
Among LDLT recipients, researchers found comparable patient and graft survival at low and high MELD scores. But among patients with high MELD scores, researchers found lower adjusted graft survival and a higher transplant rate among those with living donors, compared with recipients of deceased donor liver transplantation (DDLT).
The findings suggest certain advantages of LDLT over DDLT may be lost in the high-MELD setting in terms of graft survival, said Benjamin Rosenthal, MD, an internal medicine resident focused on transplant hepatology at the Hospital of the University of Pennsylvania, Philadelphia.
“Historically, in the United States especially, living donor liver transplantation has been offered to patients with low or moderate MELD,” he said. “The outcomes of LDLT at high MELD are currently unknown.”
Previous data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) found that LDLT offered a survival benefit versus remaining on the wait list, independent of MELD score, he said. A recent study also has demonstrated a survival benefit across MELD scores of 11-26, but findings for MELD scores of 25 and higher have been mixed.
Trends and outcomes in LDLT at high MELD scores
Dr. Rosenthal and colleagues conducted a retrospective cohort study of adult LDLT recipients from 2010 to 2021 using data from the Organ Procurement and Transplantation Network (OPTN), the U.S. donation and transplantation system.
In baseline characteristics among LDLT transplant recipients, there weren’t significant differences in age, sex, race, and ethnicity for MELD scores below 25 or at 25 and higher. There also weren’t significant differences in donor age, relationship, use of nondirected grafts, or percentage of right and left lobe donors for LDLT recipients. However, recipients with high MELD scores had more nonalcoholic steatohepatitis (29.5% versus 24.6%) and alcohol-assisted cirrhosis (21.6% versus 14.3%).
The research team evaluated graft survival among LDLT recipients by MELD below 25 and at 25 or higher. They also compared posttransplant patient and graft survival between LDLT and DDLT recipients with a MELD of 25 or higher. They excluded transplant candidates on the wait list for Status 1/1A, redo transplant, or multiorgan transplant.
Among the 3,590 patients who had LDLT between 2010 and 2021, 342 patients (9.5%) had a MELD of 25 or higher at transplant. There was some progression during the waiting period, Dr. Rosenthal noted, with a median listing MELD score of 19 among those who had a MELD of 25 or higher at transplant and 21 among those who had a MELD of 30 or higher at transplant.
For LDLT recipients with MELD scores above or below 25, researchers found no significant differences in adjusted patient survival or adjusted graft survival.
Then the team compared outcomes of LDLT and DDLT in high-MELD recipients. Among the 67,279-patient DDLT comparator group, 27,552 patients (41%) had a MELD of 25 or higher at transplant.
In terms of LDLT versus DDLT, unadjusted and adjusted patient survival were no different for patients with MELD of 25 or higher. In addition, unadjusted graft survival was no different.
However, adjusted graft survival was worse for LDLT recipients with high MELD scores. In addition, the retransplant rate was higher in LDLT recipients, at 5.7% versus 2.4%.
The reason why graft survival may be worse remains unclear, Dr. Rosenthal said. One hypothesis is that a low graft-to-recipient weight ratio in LDLT can cause small-for-size syndrome. However, these ratios were not available from OPTN.
“Further studies should be done to see what the benefit is, with graft-to-recipient weight ratios included,” he said. “The differences between DDLT and LDLT in this setting should be further explored as well.”
The research team also described temporal and transplant center trends for LDLT by MELD group. For temporal trends, they expanded the study period from 2002-2021.
The found a marked U.S. increase in the percentage of LDLT with a MELD of 25 or higher, particularly in the last decade and especially in the last 5 years. But the percentage of LDLT with high MELD remains lower than 15%, even in recent years, Dr. Rosenthal noted.
Across transplant centers, there was a trend toward centers with increasing LDLT volume having a greater proportion of LDLT recipients with a MELD of 25 or higher. At the 19.6% of centers performing 10 or fewer LDLT during the study period, none of the LDLT recipients had a MELD of 25 or higher, Dr. Rosenthal said.
The authors didn’t report a funding source. The authors declared no relevant disclosures.
Living donor liver transplants (LDLT) for recipients with the most urgent need for a liver transplant in the next 3 months – a model for end-stage liver disease (MELD) score of 25 or higher – have become more frequent during the past decade, according to new findings presented at the annual meeting of the American Association for the Study of Liver Diseases.
Among LDLT recipients, researchers found comparable patient and graft survival at low and high MELD scores. But among patients with high MELD scores, researchers found lower adjusted graft survival and a higher transplant rate among those with living donors, compared with recipients of deceased donor liver transplantation (DDLT).
The findings suggest certain advantages of LDLT over DDLT may be lost in the high-MELD setting in terms of graft survival, said Benjamin Rosenthal, MD, an internal medicine resident focused on transplant hepatology at the Hospital of the University of Pennsylvania, Philadelphia.
“Historically, in the United States especially, living donor liver transplantation has been offered to patients with low or moderate MELD,” he said. “The outcomes of LDLT at high MELD are currently unknown.”
Previous data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) found that LDLT offered a survival benefit versus remaining on the wait list, independent of MELD score, he said. A recent study also has demonstrated a survival benefit across MELD scores of 11-26, but findings for MELD scores of 25 and higher have been mixed.
Trends and outcomes in LDLT at high MELD scores
Dr. Rosenthal and colleagues conducted a retrospective cohort study of adult LDLT recipients from 2010 to 2021 using data from the Organ Procurement and Transplantation Network (OPTN), the U.S. donation and transplantation system.
In baseline characteristics among LDLT transplant recipients, there weren’t significant differences in age, sex, race, and ethnicity for MELD scores below 25 or at 25 and higher. There also weren’t significant differences in donor age, relationship, use of nondirected grafts, or percentage of right and left lobe donors for LDLT recipients. However, recipients with high MELD scores had more nonalcoholic steatohepatitis (29.5% versus 24.6%) and alcohol-assisted cirrhosis (21.6% versus 14.3%).
The research team evaluated graft survival among LDLT recipients by MELD below 25 and at 25 or higher. They also compared posttransplant patient and graft survival between LDLT and DDLT recipients with a MELD of 25 or higher. They excluded transplant candidates on the wait list for Status 1/1A, redo transplant, or multiorgan transplant.
Among the 3,590 patients who had LDLT between 2010 and 2021, 342 patients (9.5%) had a MELD of 25 or higher at transplant. There was some progression during the waiting period, Dr. Rosenthal noted, with a median listing MELD score of 19 among those who had a MELD of 25 or higher at transplant and 21 among those who had a MELD of 30 or higher at transplant.
For LDLT recipients with MELD scores above or below 25, researchers found no significant differences in adjusted patient survival or adjusted graft survival.
Then the team compared outcomes of LDLT and DDLT in high-MELD recipients. Among the 67,279-patient DDLT comparator group, 27,552 patients (41%) had a MELD of 25 or higher at transplant.
In terms of LDLT versus DDLT, unadjusted and adjusted patient survival were no different for patients with MELD of 25 or higher. In addition, unadjusted graft survival was no different.
However, adjusted graft survival was worse for LDLT recipients with high MELD scores. In addition, the retransplant rate was higher in LDLT recipients, at 5.7% versus 2.4%.
The reason why graft survival may be worse remains unclear, Dr. Rosenthal said. One hypothesis is that a low graft-to-recipient weight ratio in LDLT can cause small-for-size syndrome. However, these ratios were not available from OPTN.
“Further studies should be done to see what the benefit is, with graft-to-recipient weight ratios included,” he said. “The differences between DDLT and LDLT in this setting should be further explored as well.”
The research team also described temporal and transplant center trends for LDLT by MELD group. For temporal trends, they expanded the study period from 2002-2021.
The found a marked U.S. increase in the percentage of LDLT with a MELD of 25 or higher, particularly in the last decade and especially in the last 5 years. But the percentage of LDLT with high MELD remains lower than 15%, even in recent years, Dr. Rosenthal noted.
Across transplant centers, there was a trend toward centers with increasing LDLT volume having a greater proportion of LDLT recipients with a MELD of 25 or higher. At the 19.6% of centers performing 10 or fewer LDLT during the study period, none of the LDLT recipients had a MELD of 25 or higher, Dr. Rosenthal said.
The authors didn’t report a funding source. The authors declared no relevant disclosures.
FROM THE LIVER MEETING
Real-world evidence seen for metal stents in biliary strictures
A real-world analysis in the United Kingdom found that a fully covered metal stent is safe and effective at controlling anastomotic strictures (AS) following liver transplants.
Biliary AS occurs in an estimated 5%-32% of patients following a liver transplant. Generally, these have been managed by insertion of side-by-side plastic stents to remodel the stricture, but this often required multiple procedures to resolve the problem. More recently, transpapillary fully covered self-expanding metallic stents (FCSEMSs) have been introduced and they appear to perform equivalently to their plastic counterparts while requiring fewer procedures.
The new study “is yet another large experience demonstrating that use of fully covered metal stents for treating anastomotic biliary strictures is highly effective and also cost-effective because you really decrease the number of ERCPs [endoscopic retrograde cholangiopancreatographies] that are required to treat an anastomotic stricture,” said Vladimir Kushnir, MD, who was asked to comment on the study, which was published in Therapeutic Advances in Gastroenterology.
The researchers analyzed retrospective data from 162 consecutive patients who underwent ERCP with intraductal self-expanding metal stent (IDSEMS) insertion at nine tertiary centers. The procedures employed the Kaffes (Taewoong Niti-S) biliary covered stent, which is not available in the United States. Unlike conventional FCSEMSs, the device does not have to traverse the papilla. It is also shorter and includes an antimigration waist and removal wires that may reduce the risk of silent migration. Small case series suggested efficacy in the treatment of post–liver transplant AS.
There were 176 episodes of stent insertion among the 162 included patients; 62% of patients were male, and the median age at transplant was 54 years. Etiologies included hepatocellular carcinoma (22%), alcohol-related liver disease (18%), and nonalcoholic fatty liver disease (12%). The median time to development of a stricture was 24.9 weeks. Among all patients, 35% had previously received stents; 75% of those were plastic stents.
Overall, 10% of patients experienced stricture recurrence at a median interval of 19 weeks following stent removal. Median stent emplacement was 15 weeks, and 81% of patients had a resolution of their strictures.
Dr. Kushnir, from Washington University in St. Louis, highlighted the differences between the stent used in the study and those currently available in the United States. “This type of stent is a self-expanding metal stent that’s covered, but what’s different about it is that it’s designed to go completely within the bile duct, whereas a traditional fully covered metal stent traverses the major duodenal papilla.”
Despite those differences, he believes that the study can inform current practice in the United States. “In situations where you’re faced with a question of whether or not you leave multiple plastic stents in, or you put a full metal stent in that’s going to be fully within the bile duct, I think this data does provide some reassurance. If you’re using one of the traditional stents that we have in the United States and putting it fully within the bile duct, you do need to be prepared to have a little bit of a harder time removing the stent when the time comes for the removal procedure, which could require cholangioscopy. But this does provide some evidence to back up the practice of using fully covered metal stents fully within the bile duct to remediate anastomotic strictures that may be just a little too high up to treat traditionally with a stent that remains transpapillary,” said Dr. Kushnir.
The study also suggests an avenue for further research. “What’s also interesting about this study is that they only left the stents in for 3 months. In most clinical trials, where we’ve used fully covered metal stents for treating anastomotic biliary strictures, you leave the stent in from anywhere from 6 to 12 months. So with only 3 months dwell time they were able to get pretty impressive results, at least in the short term, in a retrospective study, so it does raise the question of should we be evaluating shorter dwell times for stents in treating anastomotic strictures when we’re using a fully covered metal stent that’s a larger diameter?” said Dr. Kushnir.
The authors noted some limitations, such as the retrospective design, small sample size, and lack of control group. They also noted that the multicenter design may have introduced heterogeneity in patient management and follow-up.
“In conclusion, IDSEMS appear to be safe and highly efficacious in the management of [post–liver transplant] AS,” concluded the authors. “Long-term outcomes appear good with low rates of AS recurrence.”
The authors declare no conflicts of interest. Dr. Kushnir is a consultant for ConMed and Boston Scientific.
A real-world analysis in the United Kingdom found that a fully covered metal stent is safe and effective at controlling anastomotic strictures (AS) following liver transplants.
Biliary AS occurs in an estimated 5%-32% of patients following a liver transplant. Generally, these have been managed by insertion of side-by-side plastic stents to remodel the stricture, but this often required multiple procedures to resolve the problem. More recently, transpapillary fully covered self-expanding metallic stents (FCSEMSs) have been introduced and they appear to perform equivalently to their plastic counterparts while requiring fewer procedures.
The new study “is yet another large experience demonstrating that use of fully covered metal stents for treating anastomotic biliary strictures is highly effective and also cost-effective because you really decrease the number of ERCPs [endoscopic retrograde cholangiopancreatographies] that are required to treat an anastomotic stricture,” said Vladimir Kushnir, MD, who was asked to comment on the study, which was published in Therapeutic Advances in Gastroenterology.
The researchers analyzed retrospective data from 162 consecutive patients who underwent ERCP with intraductal self-expanding metal stent (IDSEMS) insertion at nine tertiary centers. The procedures employed the Kaffes (Taewoong Niti-S) biliary covered stent, which is not available in the United States. Unlike conventional FCSEMSs, the device does not have to traverse the papilla. It is also shorter and includes an antimigration waist and removal wires that may reduce the risk of silent migration. Small case series suggested efficacy in the treatment of post–liver transplant AS.
There were 176 episodes of stent insertion among the 162 included patients; 62% of patients were male, and the median age at transplant was 54 years. Etiologies included hepatocellular carcinoma (22%), alcohol-related liver disease (18%), and nonalcoholic fatty liver disease (12%). The median time to development of a stricture was 24.9 weeks. Among all patients, 35% had previously received stents; 75% of those were plastic stents.
Overall, 10% of patients experienced stricture recurrence at a median interval of 19 weeks following stent removal. Median stent emplacement was 15 weeks, and 81% of patients had a resolution of their strictures.
Dr. Kushnir, from Washington University in St. Louis, highlighted the differences between the stent used in the study and those currently available in the United States. “This type of stent is a self-expanding metal stent that’s covered, but what’s different about it is that it’s designed to go completely within the bile duct, whereas a traditional fully covered metal stent traverses the major duodenal papilla.”
Despite those differences, he believes that the study can inform current practice in the United States. “In situations where you’re faced with a question of whether or not you leave multiple plastic stents in, or you put a full metal stent in that’s going to be fully within the bile duct, I think this data does provide some reassurance. If you’re using one of the traditional stents that we have in the United States and putting it fully within the bile duct, you do need to be prepared to have a little bit of a harder time removing the stent when the time comes for the removal procedure, which could require cholangioscopy. But this does provide some evidence to back up the practice of using fully covered metal stents fully within the bile duct to remediate anastomotic strictures that may be just a little too high up to treat traditionally with a stent that remains transpapillary,” said Dr. Kushnir.
The study also suggests an avenue for further research. “What’s also interesting about this study is that they only left the stents in for 3 months. In most clinical trials, where we’ve used fully covered metal stents for treating anastomotic biliary strictures, you leave the stent in from anywhere from 6 to 12 months. So with only 3 months dwell time they were able to get pretty impressive results, at least in the short term, in a retrospective study, so it does raise the question of should we be evaluating shorter dwell times for stents in treating anastomotic strictures when we’re using a fully covered metal stent that’s a larger diameter?” said Dr. Kushnir.
The authors noted some limitations, such as the retrospective design, small sample size, and lack of control group. They also noted that the multicenter design may have introduced heterogeneity in patient management and follow-up.
“In conclusion, IDSEMS appear to be safe and highly efficacious in the management of [post–liver transplant] AS,” concluded the authors. “Long-term outcomes appear good with low rates of AS recurrence.”
The authors declare no conflicts of interest. Dr. Kushnir is a consultant for ConMed and Boston Scientific.
A real-world analysis in the United Kingdom found that a fully covered metal stent is safe and effective at controlling anastomotic strictures (AS) following liver transplants.
Biliary AS occurs in an estimated 5%-32% of patients following a liver transplant. Generally, these have been managed by insertion of side-by-side plastic stents to remodel the stricture, but this often required multiple procedures to resolve the problem. More recently, transpapillary fully covered self-expanding metallic stents (FCSEMSs) have been introduced and they appear to perform equivalently to their plastic counterparts while requiring fewer procedures.
The new study “is yet another large experience demonstrating that use of fully covered metal stents for treating anastomotic biliary strictures is highly effective and also cost-effective because you really decrease the number of ERCPs [endoscopic retrograde cholangiopancreatographies] that are required to treat an anastomotic stricture,” said Vladimir Kushnir, MD, who was asked to comment on the study, which was published in Therapeutic Advances in Gastroenterology.
The researchers analyzed retrospective data from 162 consecutive patients who underwent ERCP with intraductal self-expanding metal stent (IDSEMS) insertion at nine tertiary centers. The procedures employed the Kaffes (Taewoong Niti-S) biliary covered stent, which is not available in the United States. Unlike conventional FCSEMSs, the device does not have to traverse the papilla. It is also shorter and includes an antimigration waist and removal wires that may reduce the risk of silent migration. Small case series suggested efficacy in the treatment of post–liver transplant AS.
There were 176 episodes of stent insertion among the 162 included patients; 62% of patients were male, and the median age at transplant was 54 years. Etiologies included hepatocellular carcinoma (22%), alcohol-related liver disease (18%), and nonalcoholic fatty liver disease (12%). The median time to development of a stricture was 24.9 weeks. Among all patients, 35% had previously received stents; 75% of those were plastic stents.
Overall, 10% of patients experienced stricture recurrence at a median interval of 19 weeks following stent removal. Median stent emplacement was 15 weeks, and 81% of patients had a resolution of their strictures.
Dr. Kushnir, from Washington University in St. Louis, highlighted the differences between the stent used in the study and those currently available in the United States. “This type of stent is a self-expanding metal stent that’s covered, but what’s different about it is that it’s designed to go completely within the bile duct, whereas a traditional fully covered metal stent traverses the major duodenal papilla.”
Despite those differences, he believes that the study can inform current practice in the United States. “In situations where you’re faced with a question of whether or not you leave multiple plastic stents in, or you put a full metal stent in that’s going to be fully within the bile duct, I think this data does provide some reassurance. If you’re using one of the traditional stents that we have in the United States and putting it fully within the bile duct, you do need to be prepared to have a little bit of a harder time removing the stent when the time comes for the removal procedure, which could require cholangioscopy. But this does provide some evidence to back up the practice of using fully covered metal stents fully within the bile duct to remediate anastomotic strictures that may be just a little too high up to treat traditionally with a stent that remains transpapillary,” said Dr. Kushnir.
The study also suggests an avenue for further research. “What’s also interesting about this study is that they only left the stents in for 3 months. In most clinical trials, where we’ve used fully covered metal stents for treating anastomotic biliary strictures, you leave the stent in from anywhere from 6 to 12 months. So with only 3 months dwell time they were able to get pretty impressive results, at least in the short term, in a retrospective study, so it does raise the question of should we be evaluating shorter dwell times for stents in treating anastomotic strictures when we’re using a fully covered metal stent that’s a larger diameter?” said Dr. Kushnir.
The authors noted some limitations, such as the retrospective design, small sample size, and lack of control group. They also noted that the multicenter design may have introduced heterogeneity in patient management and follow-up.
“In conclusion, IDSEMS appear to be safe and highly efficacious in the management of [post–liver transplant] AS,” concluded the authors. “Long-term outcomes appear good with low rates of AS recurrence.”
The authors declare no conflicts of interest. Dr. Kushnir is a consultant for ConMed and Boston Scientific.
FROM THERAPEUTIC ADVANCES IN GASTROENTEROLOGY
Bias and other barriers to HSCT access
For example, at the June 5 plenary session of the American Society of Clinical Oncology, Paul Richardson, MD, presented results of the DETERMINATION trial. More than 40,000 attendees heard his message that, in patients with newly diagnosed multiple myeloma (MM), up-front high-dose melphalan with autologous hematopoietic stem cell transplant (HSCT) support is associated with a significantly longer median progression-free survival of 67 months, compared with 46 months for patients randomized to delayed transplantation. The 5-year overall survival is similar for both arms.
While I and many of my colleagues in the field of transplantation used this data to strongly encourage MM patients to undergo HSCT as consolidation of their initial remission, others – including many investigators on the DETERMINATION trial – reached a starkly different conclusion. They suggested that delaying transplant was a valid option, since no survival benefit was observed.
Bias, when defined as a prejudice in favor of or against a specific treatment on the part of physicians and patients, has not been carefully studied in the realm of cellular therapies. However, physician and patient perceptions or misperceptions about the value or toxicity of a specific therapy are probably major drivers of whether a patient is referred for and accepts a particular form of treatment. In my specialization, that would mean either a stem cell transplant or other forms of cell therapy.
As with other medical procedures, in my field there are significant disparities in the use of transplantation among patients of different racial, ethnic, and age groups. Rates of both auto- and allo-HSCT are significantly higher for Whites than for African Americans. Hispanic patients have the lowest rates of utilization of auto-HSCT. Patients over the age of 60 have an eightfold risk of nonreferral to an HSCT center. Obviously, these nonreferrals reduce access to HSCT for older patients, particularly if they are seen at nonacademic centers.
One must question whether these disparities are caused by the physicians not believing in the value of transplantation, or simply not understanding its value? Or do they just lack the time to refer patients to a transplant center?
Socioeconomic factors, insurance status, age, and psychosocial characteristics all impact access to HSCT, yet some older patients with fewer economic resources and less insurance coverage still undergo the procedure. Is that because their physicians spent time educating these patients about the potential value of this treatment? Is it because the physicians went the extra mile to get these patients access to HSCT?
Physician preference also plays a significant role in whether a patient receives an allo-HSCT for acute myeloid leukemia and myelodysplastic syndrome. In a large survey of hematologists and oncologists performed by Pidala and colleagues, half of those surveyed agreed with the statement: “I feel the risk (morbidity and mortality) after HSCT is very high.” Most indicated that they “feel outcomes of unrelated donor HCT are much worse than matched sibling HCT.”
More importantly, more than one-third of those surveyed agreed that, “because of the high risks of allogeneic HSCT, I refer only after failure of conventional chemotherapy.” They voiced this opinion despite the fact that mortality rates after HSCT have been reduced significantly. With modern techniques, outcomes of unrelated donors are as good as with sibling donor transplants, and national guidelines strongly recommend that patients get referred before they become refractory to chemotherapy.
What can we do about this problem? Obviously, physician and provider education is important, but primary care physicians and general oncologists are already bombarded daily with new information. Relatively rare conditions like those we treat simply may not get their attention.
Personally, I think one of the most effective ways to overcome bias among physicians would be to target patients through a direct advertising campaign and public service announcements. Only by getting the attention of patients can they be directed to current, accurate information.
This solution could reduce the impact of physician biases or misperceptions and provide patients with greater access to lifesaving cell therapies.
Dr. Giralt is deputy division head of the division of hematologic malignancies at Memorial Sloan Kettering Cancer Center in New York.
For example, at the June 5 plenary session of the American Society of Clinical Oncology, Paul Richardson, MD, presented results of the DETERMINATION trial. More than 40,000 attendees heard his message that, in patients with newly diagnosed multiple myeloma (MM), up-front high-dose melphalan with autologous hematopoietic stem cell transplant (HSCT) support is associated with a significantly longer median progression-free survival of 67 months, compared with 46 months for patients randomized to delayed transplantation. The 5-year overall survival is similar for both arms.
While I and many of my colleagues in the field of transplantation used this data to strongly encourage MM patients to undergo HSCT as consolidation of their initial remission, others – including many investigators on the DETERMINATION trial – reached a starkly different conclusion. They suggested that delaying transplant was a valid option, since no survival benefit was observed.
Bias, when defined as a prejudice in favor of or against a specific treatment on the part of physicians and patients, has not been carefully studied in the realm of cellular therapies. However, physician and patient perceptions or misperceptions about the value or toxicity of a specific therapy are probably major drivers of whether a patient is referred for and accepts a particular form of treatment. In my specialization, that would mean either a stem cell transplant or other forms of cell therapy.
As with other medical procedures, in my field there are significant disparities in the use of transplantation among patients of different racial, ethnic, and age groups. Rates of both auto- and allo-HSCT are significantly higher for Whites than for African Americans. Hispanic patients have the lowest rates of utilization of auto-HSCT. Patients over the age of 60 have an eightfold risk of nonreferral to an HSCT center. Obviously, these nonreferrals reduce access to HSCT for older patients, particularly if they are seen at nonacademic centers.
One must question whether these disparities are caused by the physicians not believing in the value of transplantation, or simply not understanding its value? Or do they just lack the time to refer patients to a transplant center?
Socioeconomic factors, insurance status, age, and psychosocial characteristics all impact access to HSCT, yet some older patients with fewer economic resources and less insurance coverage still undergo the procedure. Is that because their physicians spent time educating these patients about the potential value of this treatment? Is it because the physicians went the extra mile to get these patients access to HSCT?
Physician preference also plays a significant role in whether a patient receives an allo-HSCT for acute myeloid leukemia and myelodysplastic syndrome. In a large survey of hematologists and oncologists performed by Pidala and colleagues, half of those surveyed agreed with the statement: “I feel the risk (morbidity and mortality) after HSCT is very high.” Most indicated that they “feel outcomes of unrelated donor HCT are much worse than matched sibling HCT.”
More importantly, more than one-third of those surveyed agreed that, “because of the high risks of allogeneic HSCT, I refer only after failure of conventional chemotherapy.” They voiced this opinion despite the fact that mortality rates after HSCT have been reduced significantly. With modern techniques, outcomes of unrelated donors are as good as with sibling donor transplants, and national guidelines strongly recommend that patients get referred before they become refractory to chemotherapy.
What can we do about this problem? Obviously, physician and provider education is important, but primary care physicians and general oncologists are already bombarded daily with new information. Relatively rare conditions like those we treat simply may not get their attention.
Personally, I think one of the most effective ways to overcome bias among physicians would be to target patients through a direct advertising campaign and public service announcements. Only by getting the attention of patients can they be directed to current, accurate information.
This solution could reduce the impact of physician biases or misperceptions and provide patients with greater access to lifesaving cell therapies.
Dr. Giralt is deputy division head of the division of hematologic malignancies at Memorial Sloan Kettering Cancer Center in New York.
For example, at the June 5 plenary session of the American Society of Clinical Oncology, Paul Richardson, MD, presented results of the DETERMINATION trial. More than 40,000 attendees heard his message that, in patients with newly diagnosed multiple myeloma (MM), up-front high-dose melphalan with autologous hematopoietic stem cell transplant (HSCT) support is associated with a significantly longer median progression-free survival of 67 months, compared with 46 months for patients randomized to delayed transplantation. The 5-year overall survival is similar for both arms.
While I and many of my colleagues in the field of transplantation used this data to strongly encourage MM patients to undergo HSCT as consolidation of their initial remission, others – including many investigators on the DETERMINATION trial – reached a starkly different conclusion. They suggested that delaying transplant was a valid option, since no survival benefit was observed.
Bias, when defined as a prejudice in favor of or against a specific treatment on the part of physicians and patients, has not been carefully studied in the realm of cellular therapies. However, physician and patient perceptions or misperceptions about the value or toxicity of a specific therapy are probably major drivers of whether a patient is referred for and accepts a particular form of treatment. In my specialization, that would mean either a stem cell transplant or other forms of cell therapy.
As with other medical procedures, in my field there are significant disparities in the use of transplantation among patients of different racial, ethnic, and age groups. Rates of both auto- and allo-HSCT are significantly higher for Whites than for African Americans. Hispanic patients have the lowest rates of utilization of auto-HSCT. Patients over the age of 60 have an eightfold risk of nonreferral to an HSCT center. Obviously, these nonreferrals reduce access to HSCT for older patients, particularly if they are seen at nonacademic centers.
One must question whether these disparities are caused by the physicians not believing in the value of transplantation, or simply not understanding its value? Or do they just lack the time to refer patients to a transplant center?
Socioeconomic factors, insurance status, age, and psychosocial characteristics all impact access to HSCT, yet some older patients with fewer economic resources and less insurance coverage still undergo the procedure. Is that because their physicians spent time educating these patients about the potential value of this treatment? Is it because the physicians went the extra mile to get these patients access to HSCT?
Physician preference also plays a significant role in whether a patient receives an allo-HSCT for acute myeloid leukemia and myelodysplastic syndrome. In a large survey of hematologists and oncologists performed by Pidala and colleagues, half of those surveyed agreed with the statement: “I feel the risk (morbidity and mortality) after HSCT is very high.” Most indicated that they “feel outcomes of unrelated donor HCT are much worse than matched sibling HCT.”
More importantly, more than one-third of those surveyed agreed that, “because of the high risks of allogeneic HSCT, I refer only after failure of conventional chemotherapy.” They voiced this opinion despite the fact that mortality rates after HSCT have been reduced significantly. With modern techniques, outcomes of unrelated donors are as good as with sibling donor transplants, and national guidelines strongly recommend that patients get referred before they become refractory to chemotherapy.
What can we do about this problem? Obviously, physician and provider education is important, but primary care physicians and general oncologists are already bombarded daily with new information. Relatively rare conditions like those we treat simply may not get their attention.
Personally, I think one of the most effective ways to overcome bias among physicians would be to target patients through a direct advertising campaign and public service announcements. Only by getting the attention of patients can they be directed to current, accurate information.
This solution could reduce the impact of physician biases or misperceptions and provide patients with greater access to lifesaving cell therapies.
Dr. Giralt is deputy division head of the division of hematologic malignancies at Memorial Sloan Kettering Cancer Center in New York.
First drug therapy approved for childhood GVHD
Specifically, the indication is for pediatric patients with cGVHD who have already been treated with one or more lines of systemic therapy. The manufacturers have also launched a new oral suspension formulation, in addition to capsules and tablets, which were already available.
Ibrutinib is already approved for use in adults with cGVHD.
The drug is also approved for use in several blood cancers, including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenström’s macroglobulinemia. All these approvals are for adult patients.
This is the first pediatric indication for the product and is “incredibly meaningful,” said Gauri Sunkersett, DO, associate medical director at AbbVie, which markets the drug together with Jansen. “As a pediatric oncologist, when my patients describe the physical pain they experience from simply hugging their parents, due to their cGVHD, the importance of researching alternative treatment options in this patient population is further validated.”
These children have already been through a lot, having been diagnosed with a leukemia or lymphoma and then undergoing chemotherapy and/or radiotherapy for a stem cell transplant. Just over half (52%-65%) of children who receive allogeneic transplants go on to develop cGVHD, in which the donor bone marrow or stem cells attack the recipient.
“Imagine going through a transplant and then being told you have a moderate to severe chronic disease that can sometimes also be life-threatening,” commented Paul A. Carpenter, MD, attending physician at Seattle Children’s Hospital. “If these children were between 1 and 12 and didn’t respond to steroid treatment, we didn’t have any rigorously studied treatment options – until now.”
The new indication was approved by the U.S. Food and Drug Administration on the basis of results from the iMAGINE trial, for which Dr. Carpenter was a principal investigator.
The phase 1/2 iMAGINE trial was an open-label, multicenter, single-arm trial conducted with 47 patients (mean age, 13 years; range, 1-19 years) with relapsed/refractory cGVHD who had received at least one prior systemic therapy. Ibrutinib was given at a dose of 420 mg orally once daily to patients aged 12 and older and at a dose of 240 mg/m2 orally once daily to patients who were younger than 12 years.
The overall response rate through week 25 was 60% (confidence interval, 95%, 44%-74%). The median duration of response was 5.3 months (95% CI, 2.8-8.8).
The safety profile was consistent with the established profile for ibrutinib. Observed adverse events in pediatric patients were consistent with those observed in adult patients with moderate to severe cGVHD, the companies noted.
The FDA noted that the most common (≥ 20%) adverse reactions, including laboratory abnormalities, were anemia, musculoskeletal pain, pyrexia, diarrhea, pneumonia, abdominal pain, stomatitis, thrombocytopenia, and headache.
Full prescribing information for ibrutinib is available here.
A version of this article first appeared on Medscape.com.
Specifically, the indication is for pediatric patients with cGVHD who have already been treated with one or more lines of systemic therapy. The manufacturers have also launched a new oral suspension formulation, in addition to capsules and tablets, which were already available.
Ibrutinib is already approved for use in adults with cGVHD.
The drug is also approved for use in several blood cancers, including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenström’s macroglobulinemia. All these approvals are for adult patients.
This is the first pediatric indication for the product and is “incredibly meaningful,” said Gauri Sunkersett, DO, associate medical director at AbbVie, which markets the drug together with Jansen. “As a pediatric oncologist, when my patients describe the physical pain they experience from simply hugging their parents, due to their cGVHD, the importance of researching alternative treatment options in this patient population is further validated.”
These children have already been through a lot, having been diagnosed with a leukemia or lymphoma and then undergoing chemotherapy and/or radiotherapy for a stem cell transplant. Just over half (52%-65%) of children who receive allogeneic transplants go on to develop cGVHD, in which the donor bone marrow or stem cells attack the recipient.
“Imagine going through a transplant and then being told you have a moderate to severe chronic disease that can sometimes also be life-threatening,” commented Paul A. Carpenter, MD, attending physician at Seattle Children’s Hospital. “If these children were between 1 and 12 and didn’t respond to steroid treatment, we didn’t have any rigorously studied treatment options – until now.”
The new indication was approved by the U.S. Food and Drug Administration on the basis of results from the iMAGINE trial, for which Dr. Carpenter was a principal investigator.
The phase 1/2 iMAGINE trial was an open-label, multicenter, single-arm trial conducted with 47 patients (mean age, 13 years; range, 1-19 years) with relapsed/refractory cGVHD who had received at least one prior systemic therapy. Ibrutinib was given at a dose of 420 mg orally once daily to patients aged 12 and older and at a dose of 240 mg/m2 orally once daily to patients who were younger than 12 years.
The overall response rate through week 25 was 60% (confidence interval, 95%, 44%-74%). The median duration of response was 5.3 months (95% CI, 2.8-8.8).
The safety profile was consistent with the established profile for ibrutinib. Observed adverse events in pediatric patients were consistent with those observed in adult patients with moderate to severe cGVHD, the companies noted.
The FDA noted that the most common (≥ 20%) adverse reactions, including laboratory abnormalities, were anemia, musculoskeletal pain, pyrexia, diarrhea, pneumonia, abdominal pain, stomatitis, thrombocytopenia, and headache.
Full prescribing information for ibrutinib is available here.
A version of this article first appeared on Medscape.com.
Specifically, the indication is for pediatric patients with cGVHD who have already been treated with one or more lines of systemic therapy. The manufacturers have also launched a new oral suspension formulation, in addition to capsules and tablets, which were already available.
Ibrutinib is already approved for use in adults with cGVHD.
The drug is also approved for use in several blood cancers, including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenström’s macroglobulinemia. All these approvals are for adult patients.
This is the first pediatric indication for the product and is “incredibly meaningful,” said Gauri Sunkersett, DO, associate medical director at AbbVie, which markets the drug together with Jansen. “As a pediatric oncologist, when my patients describe the physical pain they experience from simply hugging their parents, due to their cGVHD, the importance of researching alternative treatment options in this patient population is further validated.”
These children have already been through a lot, having been diagnosed with a leukemia or lymphoma and then undergoing chemotherapy and/or radiotherapy for a stem cell transplant. Just over half (52%-65%) of children who receive allogeneic transplants go on to develop cGVHD, in which the donor bone marrow or stem cells attack the recipient.
“Imagine going through a transplant and then being told you have a moderate to severe chronic disease that can sometimes also be life-threatening,” commented Paul A. Carpenter, MD, attending physician at Seattle Children’s Hospital. “If these children were between 1 and 12 and didn’t respond to steroid treatment, we didn’t have any rigorously studied treatment options – until now.”
The new indication was approved by the U.S. Food and Drug Administration on the basis of results from the iMAGINE trial, for which Dr. Carpenter was a principal investigator.
The phase 1/2 iMAGINE trial was an open-label, multicenter, single-arm trial conducted with 47 patients (mean age, 13 years; range, 1-19 years) with relapsed/refractory cGVHD who had received at least one prior systemic therapy. Ibrutinib was given at a dose of 420 mg orally once daily to patients aged 12 and older and at a dose of 240 mg/m2 orally once daily to patients who were younger than 12 years.
The overall response rate through week 25 was 60% (confidence interval, 95%, 44%-74%). The median duration of response was 5.3 months (95% CI, 2.8-8.8).
The safety profile was consistent with the established profile for ibrutinib. Observed adverse events in pediatric patients were consistent with those observed in adult patients with moderate to severe cGVHD, the companies noted.
The FDA noted that the most common (≥ 20%) adverse reactions, including laboratory abnormalities, were anemia, musculoskeletal pain, pyrexia, diarrhea, pneumonia, abdominal pain, stomatitis, thrombocytopenia, and headache.
Full prescribing information for ibrutinib is available here.
A version of this article first appeared on Medscape.com.
Fewer transplants for MM with quadruplet therapy?
“It is not a big leap of faith to imagine that, in the near future, with the availability of quadruplets and T-cell therapies, the role of high-dose melphalan and autologous stem cell transplant will be diminished,” said Dickran Kazandjian, MD, and Ola Landgren, MD, PhD, of the myeloma division, Sylvester Comprehensive Cancer Center, University of Miami.
They commented in a editorial in JAMA Oncology, prompted by a paper describing new results with a novel quadruple combination of therapies. These treatments included the monoclonal antibody elotuzumab (Empliciti) added onto the established backbone of carfilzomib (Kyprolis), lenalidomide (Revlimid), and dexamethasone (known as KRd).
“Regardless of what the future holds for elotuzumab-based combinations, it is clear that the new treatment paradigm of newly diagnosed MM will incorporate antibody-based quadruplet regimens,” the editorialists commented.
“Novel immunotherapies are here to stay,” they added, “as they are already transforming the lives of patients with multiple MM and bringing a bright horizon to the treatment landscape.”
Study details
The trial of the novel quadruplet regimen was a multicenter, single-arm, phase 2 study that involved 46 patients with newly diagnosed multiple myeloma, explain first author Benjamin A. Derman, MD, of the University of Chicago Medical Center, and colleagues.
These patients had a median age of 62; more than two-thirds were male (72%) and White (70%). About half (48%) had high-risk cytogenetic abnormalities.
All patients were treated with 12 cycles of the quadruple therapy Elo-KRd regimen. They underwent bone marrow assessment of measurable residual disease (MRD; with 10-5 sensitivity) after cycle 8 and cycle 12.
“An MRD-adapted treatment approach is rational because it may identify which patients can be administered shorter courses of intensive therapy without compromising efficacy,” the authors explained.
Patients who had MRD negativity at both time points did not receive further Elo-KRd, while patients who converted from MRD positivity to negativity in between cycles 8 and 12 received 6 additional cycles of Elo-KRd. Those who remained MRD positive or converted to positivity after 12 cycles received an additional 12 cycles of Elo-KRd.
Following Elo-KRd treatment, all patients transitioned to triple therapy with Elo-Rd (with no carfilzomib), for indefinite maintenance therapy or until disease progression.
For the primary endpoint, the rate of stringent complete response and/or MRD-negativity after cycle 8 was 58% (26 of 45), meeting the predefined definition of efficacy.
Importantly, 26% of patients converted from MRD positivity after cycle 8 to negativity at a later time point, while 50% of patients reached 1-year sustained MRD negativity.
Overall, the estimated 3-year, progression-free survival was 72%, and the rate was 92% for patients with MRD-negativity at cycle 8. The overall survival rate was 78%.
The most common grade 3 or 4 adverse events were lung and nonpulmonary infections (13% and 11%, respectively), and one patient had a grade 5 MI. Three patients discontinued the treatment because of intolerance.
“An MRD-adapted design using elotuzumab and weekly KRd without autologous stem cell transplantation showed a high rate of stringent complete response (sCR) and/or MRD-negativity and durable responses,” the authors wrote.
“This approach provides support for further evaluation of MRD-guided de-escalation of therapy to decrease treatment exposure while sustaining deep responses.”
To better assess the difference of the therapy versus treatment including stem cell transplantation, a phase 3, randomized trial is currently underway to compare the Elo-KRd regimen against KRd with autologous stem cell transplant in newly diagnosed MM.
“If Elo-KRd proves superior, a randomized comparison of Elo versus anti-CD38 mAb-based quadruplets would help determine the optimal combination of therapies in the frontline setting,” the authors noted.
Randomized trial anticipated to clarify benefit
In their editorial, Dr. Kazandjian and Dr. Landgren agreed with the authors that the role of elotuzumab needs to be better clarified in a randomized trial setting.
Elotuzumab received FDA approval in 2015 based on results from the ELOQUENT-2 study, which showed improved progression-free survival and overall survival with the addition of elotuzumab to lenalidomide and dexamethasone in patients with multiple myeloma who have previously received one to three other therapies.
However, the editorialists pointed out that recently published results from the randomized ELOQUENT-1 trial of lenalidomide and dexamethasone with and without elotuzumab showed the addition of elotuzumab was not associated with a statistically significant difference in progression-free survival.
The editorialists also pointed out that, in the setting of newly diagnosed multiple myeloma, another recent, similarly designed study found that the backbone regimen of carfilzomib, lenalidomide, and dexamethasone – on its own – was also associated with a favorable MRD-negative rate of 62%.
In addition, several studies involving novel quadruple treatments with the monoclonal antibody daratumumab (Darzalex) instead of elotuzumab, have also shown benefit in newly diagnosed multiple myeloma, resulting in high rates of MRD negativity.
Collectively, the findings bode well for the quadruple regimens in the treatment of MM, the editorialists emphasized.
“Importantly, with the rate of deep remissions observed with antibody-based quadruplet therapies, one may question the role of using early high-dose melphalan and autologous stem cell transplant in every patient, especially in those who have achieved MRD negativity with the quadruplet alone,” they added.
The study was sponsored in part by Amgen, Bristol-Myers Squibb, and the Multiple Myeloma Research Consortium. Dr. Derman reported advisory board fees from Sanofi, Janssen, and COTA Healthcare; honoraria from PleXus Communications and MJH Life Sciences. Dr. Kazandjian declares receiving advisory board or consulting fees from Bristol-Myers Squibb, Sanofi, and Arcellx outside the submitted work. Dr. Landgren has received grant support from numerous organizations and pharmaceutical companies. Dr. Landgren has also received honoraria for scientific talks/participated in advisory boards for Adaptive Biotech, Amgen, Binding Site, Bristol-Myers Squibb, Celgene, Cellectis, Glenmark, Janssen, Juno, and Pfizer, and served on independent data monitoring committees for international randomized trials by Takeda, Merck, Janssen, and Theradex.
A version of this article first appeared on Medscape.com.
“It is not a big leap of faith to imagine that, in the near future, with the availability of quadruplets and T-cell therapies, the role of high-dose melphalan and autologous stem cell transplant will be diminished,” said Dickran Kazandjian, MD, and Ola Landgren, MD, PhD, of the myeloma division, Sylvester Comprehensive Cancer Center, University of Miami.
They commented in a editorial in JAMA Oncology, prompted by a paper describing new results with a novel quadruple combination of therapies. These treatments included the monoclonal antibody elotuzumab (Empliciti) added onto the established backbone of carfilzomib (Kyprolis), lenalidomide (Revlimid), and dexamethasone (known as KRd).
“Regardless of what the future holds for elotuzumab-based combinations, it is clear that the new treatment paradigm of newly diagnosed MM will incorporate antibody-based quadruplet regimens,” the editorialists commented.
“Novel immunotherapies are here to stay,” they added, “as they are already transforming the lives of patients with multiple MM and bringing a bright horizon to the treatment landscape.”
Study details
The trial of the novel quadruplet regimen was a multicenter, single-arm, phase 2 study that involved 46 patients with newly diagnosed multiple myeloma, explain first author Benjamin A. Derman, MD, of the University of Chicago Medical Center, and colleagues.
These patients had a median age of 62; more than two-thirds were male (72%) and White (70%). About half (48%) had high-risk cytogenetic abnormalities.
All patients were treated with 12 cycles of the quadruple therapy Elo-KRd regimen. They underwent bone marrow assessment of measurable residual disease (MRD; with 10-5 sensitivity) after cycle 8 and cycle 12.
“An MRD-adapted treatment approach is rational because it may identify which patients can be administered shorter courses of intensive therapy without compromising efficacy,” the authors explained.
Patients who had MRD negativity at both time points did not receive further Elo-KRd, while patients who converted from MRD positivity to negativity in between cycles 8 and 12 received 6 additional cycles of Elo-KRd. Those who remained MRD positive or converted to positivity after 12 cycles received an additional 12 cycles of Elo-KRd.
Following Elo-KRd treatment, all patients transitioned to triple therapy with Elo-Rd (with no carfilzomib), for indefinite maintenance therapy or until disease progression.
For the primary endpoint, the rate of stringent complete response and/or MRD-negativity after cycle 8 was 58% (26 of 45), meeting the predefined definition of efficacy.
Importantly, 26% of patients converted from MRD positivity after cycle 8 to negativity at a later time point, while 50% of patients reached 1-year sustained MRD negativity.
Overall, the estimated 3-year, progression-free survival was 72%, and the rate was 92% for patients with MRD-negativity at cycle 8. The overall survival rate was 78%.
The most common grade 3 or 4 adverse events were lung and nonpulmonary infections (13% and 11%, respectively), and one patient had a grade 5 MI. Three patients discontinued the treatment because of intolerance.
“An MRD-adapted design using elotuzumab and weekly KRd without autologous stem cell transplantation showed a high rate of stringent complete response (sCR) and/or MRD-negativity and durable responses,” the authors wrote.
“This approach provides support for further evaluation of MRD-guided de-escalation of therapy to decrease treatment exposure while sustaining deep responses.”
To better assess the difference of the therapy versus treatment including stem cell transplantation, a phase 3, randomized trial is currently underway to compare the Elo-KRd regimen against KRd with autologous stem cell transplant in newly diagnosed MM.
“If Elo-KRd proves superior, a randomized comparison of Elo versus anti-CD38 mAb-based quadruplets would help determine the optimal combination of therapies in the frontline setting,” the authors noted.
Randomized trial anticipated to clarify benefit
In their editorial, Dr. Kazandjian and Dr. Landgren agreed with the authors that the role of elotuzumab needs to be better clarified in a randomized trial setting.
Elotuzumab received FDA approval in 2015 based on results from the ELOQUENT-2 study, which showed improved progression-free survival and overall survival with the addition of elotuzumab to lenalidomide and dexamethasone in patients with multiple myeloma who have previously received one to three other therapies.
However, the editorialists pointed out that recently published results from the randomized ELOQUENT-1 trial of lenalidomide and dexamethasone with and without elotuzumab showed the addition of elotuzumab was not associated with a statistically significant difference in progression-free survival.
The editorialists also pointed out that, in the setting of newly diagnosed multiple myeloma, another recent, similarly designed study found that the backbone regimen of carfilzomib, lenalidomide, and dexamethasone – on its own – was also associated with a favorable MRD-negative rate of 62%.
In addition, several studies involving novel quadruple treatments with the monoclonal antibody daratumumab (Darzalex) instead of elotuzumab, have also shown benefit in newly diagnosed multiple myeloma, resulting in high rates of MRD negativity.
Collectively, the findings bode well for the quadruple regimens in the treatment of MM, the editorialists emphasized.
“Importantly, with the rate of deep remissions observed with antibody-based quadruplet therapies, one may question the role of using early high-dose melphalan and autologous stem cell transplant in every patient, especially in those who have achieved MRD negativity with the quadruplet alone,” they added.
The study was sponsored in part by Amgen, Bristol-Myers Squibb, and the Multiple Myeloma Research Consortium. Dr. Derman reported advisory board fees from Sanofi, Janssen, and COTA Healthcare; honoraria from PleXus Communications and MJH Life Sciences. Dr. Kazandjian declares receiving advisory board or consulting fees from Bristol-Myers Squibb, Sanofi, and Arcellx outside the submitted work. Dr. Landgren has received grant support from numerous organizations and pharmaceutical companies. Dr. Landgren has also received honoraria for scientific talks/participated in advisory boards for Adaptive Biotech, Amgen, Binding Site, Bristol-Myers Squibb, Celgene, Cellectis, Glenmark, Janssen, Juno, and Pfizer, and served on independent data monitoring committees for international randomized trials by Takeda, Merck, Janssen, and Theradex.
A version of this article first appeared on Medscape.com.
“It is not a big leap of faith to imagine that, in the near future, with the availability of quadruplets and T-cell therapies, the role of high-dose melphalan and autologous stem cell transplant will be diminished,” said Dickran Kazandjian, MD, and Ola Landgren, MD, PhD, of the myeloma division, Sylvester Comprehensive Cancer Center, University of Miami.
They commented in a editorial in JAMA Oncology, prompted by a paper describing new results with a novel quadruple combination of therapies. These treatments included the monoclonal antibody elotuzumab (Empliciti) added onto the established backbone of carfilzomib (Kyprolis), lenalidomide (Revlimid), and dexamethasone (known as KRd).
“Regardless of what the future holds for elotuzumab-based combinations, it is clear that the new treatment paradigm of newly diagnosed MM will incorporate antibody-based quadruplet regimens,” the editorialists commented.
“Novel immunotherapies are here to stay,” they added, “as they are already transforming the lives of patients with multiple MM and bringing a bright horizon to the treatment landscape.”
Study details
The trial of the novel quadruplet regimen was a multicenter, single-arm, phase 2 study that involved 46 patients with newly diagnosed multiple myeloma, explain first author Benjamin A. Derman, MD, of the University of Chicago Medical Center, and colleagues.
These patients had a median age of 62; more than two-thirds were male (72%) and White (70%). About half (48%) had high-risk cytogenetic abnormalities.
All patients were treated with 12 cycles of the quadruple therapy Elo-KRd regimen. They underwent bone marrow assessment of measurable residual disease (MRD; with 10-5 sensitivity) after cycle 8 and cycle 12.
“An MRD-adapted treatment approach is rational because it may identify which patients can be administered shorter courses of intensive therapy without compromising efficacy,” the authors explained.
Patients who had MRD negativity at both time points did not receive further Elo-KRd, while patients who converted from MRD positivity to negativity in between cycles 8 and 12 received 6 additional cycles of Elo-KRd. Those who remained MRD positive or converted to positivity after 12 cycles received an additional 12 cycles of Elo-KRd.
Following Elo-KRd treatment, all patients transitioned to triple therapy with Elo-Rd (with no carfilzomib), for indefinite maintenance therapy or until disease progression.
For the primary endpoint, the rate of stringent complete response and/or MRD-negativity after cycle 8 was 58% (26 of 45), meeting the predefined definition of efficacy.
Importantly, 26% of patients converted from MRD positivity after cycle 8 to negativity at a later time point, while 50% of patients reached 1-year sustained MRD negativity.
Overall, the estimated 3-year, progression-free survival was 72%, and the rate was 92% for patients with MRD-negativity at cycle 8. The overall survival rate was 78%.
The most common grade 3 or 4 adverse events were lung and nonpulmonary infections (13% and 11%, respectively), and one patient had a grade 5 MI. Three patients discontinued the treatment because of intolerance.
“An MRD-adapted design using elotuzumab and weekly KRd without autologous stem cell transplantation showed a high rate of stringent complete response (sCR) and/or MRD-negativity and durable responses,” the authors wrote.
“This approach provides support for further evaluation of MRD-guided de-escalation of therapy to decrease treatment exposure while sustaining deep responses.”
To better assess the difference of the therapy versus treatment including stem cell transplantation, a phase 3, randomized trial is currently underway to compare the Elo-KRd regimen against KRd with autologous stem cell transplant in newly diagnosed MM.
“If Elo-KRd proves superior, a randomized comparison of Elo versus anti-CD38 mAb-based quadruplets would help determine the optimal combination of therapies in the frontline setting,” the authors noted.
Randomized trial anticipated to clarify benefit
In their editorial, Dr. Kazandjian and Dr. Landgren agreed with the authors that the role of elotuzumab needs to be better clarified in a randomized trial setting.
Elotuzumab received FDA approval in 2015 based on results from the ELOQUENT-2 study, which showed improved progression-free survival and overall survival with the addition of elotuzumab to lenalidomide and dexamethasone in patients with multiple myeloma who have previously received one to three other therapies.
However, the editorialists pointed out that recently published results from the randomized ELOQUENT-1 trial of lenalidomide and dexamethasone with and without elotuzumab showed the addition of elotuzumab was not associated with a statistically significant difference in progression-free survival.
The editorialists also pointed out that, in the setting of newly diagnosed multiple myeloma, another recent, similarly designed study found that the backbone regimen of carfilzomib, lenalidomide, and dexamethasone – on its own – was also associated with a favorable MRD-negative rate of 62%.
In addition, several studies involving novel quadruple treatments with the monoclonal antibody daratumumab (Darzalex) instead of elotuzumab, have also shown benefit in newly diagnosed multiple myeloma, resulting in high rates of MRD negativity.
Collectively, the findings bode well for the quadruple regimens in the treatment of MM, the editorialists emphasized.
“Importantly, with the rate of deep remissions observed with antibody-based quadruplet therapies, one may question the role of using early high-dose melphalan and autologous stem cell transplant in every patient, especially in those who have achieved MRD negativity with the quadruplet alone,” they added.
The study was sponsored in part by Amgen, Bristol-Myers Squibb, and the Multiple Myeloma Research Consortium. Dr. Derman reported advisory board fees from Sanofi, Janssen, and COTA Healthcare; honoraria from PleXus Communications and MJH Life Sciences. Dr. Kazandjian declares receiving advisory board or consulting fees from Bristol-Myers Squibb, Sanofi, and Arcellx outside the submitted work. Dr. Landgren has received grant support from numerous organizations and pharmaceutical companies. Dr. Landgren has also received honoraria for scientific talks/participated in advisory boards for Adaptive Biotech, Amgen, Binding Site, Bristol-Myers Squibb, Celgene, Cellectis, Glenmark, Janssen, Juno, and Pfizer, and served on independent data monitoring committees for international randomized trials by Takeda, Merck, Janssen, and Theradex.
A version of this article first appeared on Medscape.com.
FROM JAMA ONCOLOGY
Evusheld for COVID-19: Lifesaving and free, but still few takers
Evusheld (AstraZeneca), a medication used to prevent SARS-CoV-2 infection in patients at high risk, has problems: Namely, that supplies of the potentially lifesaving drug outweigh demand.
At least 7 million people who are immunocompromised could benefit from it, as could many others who are undergoing cancer treatment, have received a transplant, or who are allergic to the COVID-19 vaccines. The medication has laboratory-produced antibodies against SARS-CoV-2 and helps the body protect itself. It can slash the chances of becoming infected by 77%, according to the U.S. Food and Drug Administration.
And it’s free to eligible patients (although there may be an out-of-pocket administrative fee in some cases).
To meet demand, the Biden administration secured 1.7 million doses of the medicine, which was granted emergency use authorization by the FDA in December 2021. As of July 25, however, 793,348 doses have been ordered by the administration sites, and only 398,181 doses have been reported as used, a spokesperson for the Department of Health & Human Services tells this news organization.
Each week, a certain amount of doses from the 1.7 million dose stockpile is made available to state and territorial health departments. States have not been asking for their full allotment, the spokesperson said July 28.
Now, HHS and AstraZeneca have taken a number of steps to increase awareness of the medication and access to it.
- On July 27, HHS announced that individual providers and smaller sites of care that don’t currently receive Evusheld through the federal distribution process via the HHS Health Partner Order Portal can now order up to three patient courses of the medicine. These can be
- Health care providers can use the HHS’s COVID-19 Therapeutics Locator to find Evusheld in their area.
- AstraZeneca has launched a new website with educational materials and says it is working closely with patient and professional groups to inform patients and health care providers.
- A direct-to-consumer ad launched on June 22 and will run in the United States online and on TV (Yahoo, Fox, CBS Sports, MSN, ESPN) and be amplified on social and digital channels through year’s end, an AstraZeneca spokesperson said in an interview.
- AstraZeneca set up a toll-free number for providers: 1-833-EVUSHLD.
Evusheld includes two monoclonal antibodies, tixagevimab and cilgavimab. The medication is given as two consecutive intramuscular injections during a single visit to a doctor’s office, infusion center, or other health care facility. The antibodies bind to the SARS-CoV-2 spike protein and prevent the virus from getting into human cells and infecting them. It’s authorized for use in children and adults aged 12 years and older who weigh at least 88 pounds.
Studies have found that the medication decreases the risk of getting COVID-19 for up to 6 months after it is given. The FDA recommends repeat dosing every 6 months with the doses of 300 mg of each monoclonal antibody. In clinical trials, Evusheld reduced the incidence of COVID-19 symptomatic illness by 77%, compared with placebo.
Physicians monitor patients for an hour after administering Evusheld for allergic reactions. Other possible side effects include cardiac events, but they are not common.
Doctors and patients weigh in
Physicians – and patients – from the United States to the United Kingdom and beyond are questioning why the medication is underused while lauding the recent efforts to expand access and increase awareness.
The U.S. federal government may have underestimated the amount of communication needed to increase awareness of the medication and its applications, said infectious disease specialist William Schaffner, MD, professor of preventive medicine at Vanderbilt University School of Medicine, Nashville, Tenn.
“HHS hasn’t made a major educational effort to promote it,” he said in an interview.
Many physicians who need to know about it, such as transplant doctors and rheumatologists, are outside the typical public health communications loop, he said.
Eric Topol, MD, director of the Scripps Research Transational Institute and editor-in-chief of Medscape, has taken to social media to bemoan the lack of awareness.
Another infectious disease expert agrees. “In my experience, the awareness of Evusheld is low amongst many patients as well as many providers,” said Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security, Baltimore.
“Initially, there were scarce supplies of the drug, and certain hospital systems tiered eligibility based on degrees of immunosuppression, and only the most immunosuppressed were proactively approached for treatment.”
“Also, many community hospitals never initially ordered Evusheld – they may have been crowded out by academic centers who treat many more immunosuppressed patients and may not currently see it as a priority,” Dr. Adalja said in an interview. “As such, many immunosuppressed patients would have to seek treatment at academic medical centers, where the drug is more likely to be available.”
A version of this article first appeared on Medscape.com.
Evusheld (AstraZeneca), a medication used to prevent SARS-CoV-2 infection in patients at high risk, has problems: Namely, that supplies of the potentially lifesaving drug outweigh demand.
At least 7 million people who are immunocompromised could benefit from it, as could many others who are undergoing cancer treatment, have received a transplant, or who are allergic to the COVID-19 vaccines. The medication has laboratory-produced antibodies against SARS-CoV-2 and helps the body protect itself. It can slash the chances of becoming infected by 77%, according to the U.S. Food and Drug Administration.
And it’s free to eligible patients (although there may be an out-of-pocket administrative fee in some cases).
To meet demand, the Biden administration secured 1.7 million doses of the medicine, which was granted emergency use authorization by the FDA in December 2021. As of July 25, however, 793,348 doses have been ordered by the administration sites, and only 398,181 doses have been reported as used, a spokesperson for the Department of Health & Human Services tells this news organization.
Each week, a certain amount of doses from the 1.7 million dose stockpile is made available to state and territorial health departments. States have not been asking for their full allotment, the spokesperson said July 28.
Now, HHS and AstraZeneca have taken a number of steps to increase awareness of the medication and access to it.
- On July 27, HHS announced that individual providers and smaller sites of care that don’t currently receive Evusheld through the federal distribution process via the HHS Health Partner Order Portal can now order up to three patient courses of the medicine. These can be
- Health care providers can use the HHS’s COVID-19 Therapeutics Locator to find Evusheld in their area.
- AstraZeneca has launched a new website with educational materials and says it is working closely with patient and professional groups to inform patients and health care providers.
- A direct-to-consumer ad launched on June 22 and will run in the United States online and on TV (Yahoo, Fox, CBS Sports, MSN, ESPN) and be amplified on social and digital channels through year’s end, an AstraZeneca spokesperson said in an interview.
- AstraZeneca set up a toll-free number for providers: 1-833-EVUSHLD.
Evusheld includes two monoclonal antibodies, tixagevimab and cilgavimab. The medication is given as two consecutive intramuscular injections during a single visit to a doctor’s office, infusion center, or other health care facility. The antibodies bind to the SARS-CoV-2 spike protein and prevent the virus from getting into human cells and infecting them. It’s authorized for use in children and adults aged 12 years and older who weigh at least 88 pounds.
Studies have found that the medication decreases the risk of getting COVID-19 for up to 6 months after it is given. The FDA recommends repeat dosing every 6 months with the doses of 300 mg of each monoclonal antibody. In clinical trials, Evusheld reduced the incidence of COVID-19 symptomatic illness by 77%, compared with placebo.
Physicians monitor patients for an hour after administering Evusheld for allergic reactions. Other possible side effects include cardiac events, but they are not common.
Doctors and patients weigh in
Physicians – and patients – from the United States to the United Kingdom and beyond are questioning why the medication is underused while lauding the recent efforts to expand access and increase awareness.
The U.S. federal government may have underestimated the amount of communication needed to increase awareness of the medication and its applications, said infectious disease specialist William Schaffner, MD, professor of preventive medicine at Vanderbilt University School of Medicine, Nashville, Tenn.
“HHS hasn’t made a major educational effort to promote it,” he said in an interview.
Many physicians who need to know about it, such as transplant doctors and rheumatologists, are outside the typical public health communications loop, he said.
Eric Topol, MD, director of the Scripps Research Transational Institute and editor-in-chief of Medscape, has taken to social media to bemoan the lack of awareness.
Another infectious disease expert agrees. “In my experience, the awareness of Evusheld is low amongst many patients as well as many providers,” said Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security, Baltimore.
“Initially, there were scarce supplies of the drug, and certain hospital systems tiered eligibility based on degrees of immunosuppression, and only the most immunosuppressed were proactively approached for treatment.”
“Also, many community hospitals never initially ordered Evusheld – they may have been crowded out by academic centers who treat many more immunosuppressed patients and may not currently see it as a priority,” Dr. Adalja said in an interview. “As such, many immunosuppressed patients would have to seek treatment at academic medical centers, where the drug is more likely to be available.”
A version of this article first appeared on Medscape.com.
Evusheld (AstraZeneca), a medication used to prevent SARS-CoV-2 infection in patients at high risk, has problems: Namely, that supplies of the potentially lifesaving drug outweigh demand.
At least 7 million people who are immunocompromised could benefit from it, as could many others who are undergoing cancer treatment, have received a transplant, or who are allergic to the COVID-19 vaccines. The medication has laboratory-produced antibodies against SARS-CoV-2 and helps the body protect itself. It can slash the chances of becoming infected by 77%, according to the U.S. Food and Drug Administration.
And it’s free to eligible patients (although there may be an out-of-pocket administrative fee in some cases).
To meet demand, the Biden administration secured 1.7 million doses of the medicine, which was granted emergency use authorization by the FDA in December 2021. As of July 25, however, 793,348 doses have been ordered by the administration sites, and only 398,181 doses have been reported as used, a spokesperson for the Department of Health & Human Services tells this news organization.
Each week, a certain amount of doses from the 1.7 million dose stockpile is made available to state and territorial health departments. States have not been asking for their full allotment, the spokesperson said July 28.
Now, HHS and AstraZeneca have taken a number of steps to increase awareness of the medication and access to it.
- On July 27, HHS announced that individual providers and smaller sites of care that don’t currently receive Evusheld through the federal distribution process via the HHS Health Partner Order Portal can now order up to three patient courses of the medicine. These can be
- Health care providers can use the HHS’s COVID-19 Therapeutics Locator to find Evusheld in their area.
- AstraZeneca has launched a new website with educational materials and says it is working closely with patient and professional groups to inform patients and health care providers.
- A direct-to-consumer ad launched on June 22 and will run in the United States online and on TV (Yahoo, Fox, CBS Sports, MSN, ESPN) and be amplified on social and digital channels through year’s end, an AstraZeneca spokesperson said in an interview.
- AstraZeneca set up a toll-free number for providers: 1-833-EVUSHLD.
Evusheld includes two monoclonal antibodies, tixagevimab and cilgavimab. The medication is given as two consecutive intramuscular injections during a single visit to a doctor’s office, infusion center, or other health care facility. The antibodies bind to the SARS-CoV-2 spike protein and prevent the virus from getting into human cells and infecting them. It’s authorized for use in children and adults aged 12 years and older who weigh at least 88 pounds.
Studies have found that the medication decreases the risk of getting COVID-19 for up to 6 months after it is given. The FDA recommends repeat dosing every 6 months with the doses of 300 mg of each monoclonal antibody. In clinical trials, Evusheld reduced the incidence of COVID-19 symptomatic illness by 77%, compared with placebo.
Physicians monitor patients for an hour after administering Evusheld for allergic reactions. Other possible side effects include cardiac events, but they are not common.
Doctors and patients weigh in
Physicians – and patients – from the United States to the United Kingdom and beyond are questioning why the medication is underused while lauding the recent efforts to expand access and increase awareness.
The U.S. federal government may have underestimated the amount of communication needed to increase awareness of the medication and its applications, said infectious disease specialist William Schaffner, MD, professor of preventive medicine at Vanderbilt University School of Medicine, Nashville, Tenn.
“HHS hasn’t made a major educational effort to promote it,” he said in an interview.
Many physicians who need to know about it, such as transplant doctors and rheumatologists, are outside the typical public health communications loop, he said.
Eric Topol, MD, director of the Scripps Research Transational Institute and editor-in-chief of Medscape, has taken to social media to bemoan the lack of awareness.
Another infectious disease expert agrees. “In my experience, the awareness of Evusheld is low amongst many patients as well as many providers,” said Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security, Baltimore.
“Initially, there were scarce supplies of the drug, and certain hospital systems tiered eligibility based on degrees of immunosuppression, and only the most immunosuppressed were proactively approached for treatment.”
“Also, many community hospitals never initially ordered Evusheld – they may have been crowded out by academic centers who treat many more immunosuppressed patients and may not currently see it as a priority,” Dr. Adalja said in an interview. “As such, many immunosuppressed patients would have to seek treatment at academic medical centers, where the drug is more likely to be available.”
A version of this article first appeared on Medscape.com.