Post-Transplant Events

High-dose weekly liposomal amphotericin B antifungal prophylaxis following reduced-intensity conditioning allogeneic stem cell transplantation

Abstract

The use of high-dose corticosteroids for graft-versus-host disease (GVHD) treatment represents a major risk factor for long-term invasive fungal infections. The aim of this study was to investigate the safety and tolerance of weekly prophylactic administration of once-weekly high-dose (7.5 mg/kg) of liposomal amphotericin B (L-AmB) therapy in 21 adult patients receiving high-dose prednisone (2 mg/kg/day) for acute GVHD therapy after reduced intensity conditioning (RIC) allogeneic stem cell transplantation (allo-SCT). Patients received a median of 4 (range, 1–8) infusions of L-AmB. Seven patients (33%; 95% confidence intervals (CI), 13–53%) discontinued taking the study drug owing to study drug-related adverse events, including elevated serum creatinine (>1.5 times from baseline values; n=5), hypotension and pain (n=1), and violent chest pain and arrhythmia (n=1). The overall frequency of infusion-related reactions was 29% (n=6; 95% CI, 10–48%), but these reactions were always transient and relieved by stopping the infusion. This safety data provide support for an efficacy study of this prophylaxis strategy, because this may help further improving the outcome of RIC or nonmyeloablative allo-SCT.

Introduction

In an attempt to reduce procedure-related toxicity in elderly patients or in patients with medical comorbidities precluding the use of standard myeloablative preparative regimens before allogeneic stem cell transplantation (allo-SCT), different reduced intensity conditioning (RIC) regimens aiming to reduce the overall incidence of transplant-related mortality (TRM) and morbidity, have been investigated. Although promising results have been reported in regard to engraftment and early transplant-related toxicities, graft-versus-host disease (GVHD) and its corollary of long-term detrimental immunosuppressive therapy and opportunistic infections, remain a matter of concern.1, 2 We and others have previously shown that the use of high doses of corticosteroids for GVHD treatment represents a major risk factor for long-term infections, with invasive aspergillosis (IA) being the principal cause of infectious-related mortality,3, 4 suggesting that efforts are warranted to develop optimal antifungal preventive strategies in specific subgroups of patients after RIC allo-SCT.5, 6 The aim of this pilot study was to investigate the feasibility and tolerance of weekly prophylactic administration of a once-weekly high dose (7.5 mg/kg) of liposomal amphotericin B (L-AmB) therapy in 21 adult patients receiving high-dose corticosteroids for acute GVHD therapy after RIC allo-SCT.

Patients and methods

Study design

This study aimed at assessing the feasibility and tolerance of once-weekly high-dose L-AmB (ambisome; 7.5 mg/kg/infusion) therapy in 21 adult patients receiving high-dose prednisone (2 mg/kg/day) for acute GVHD therapy, and included in different RIC allo-SCT clinical trials at the Institut Paoli-Calmettes (Marseille, France). Written informed consent was obtained from each patient and donor. The study was performed according to institutional guidelines. Nineteen donors were histocompatibility leukocyte antigen (HLA)-A-, HLA-B- and HLA-DR-identical siblings, whereas two patients received unrelated cord blood cells. Patients were treated with a RIC before allo-SCT because of high-risk clinical or disease features that made them ineligible for our ‘standard’ myeloablative allo-SCT program.1 All patients received the preparative regimen as inpatients in private rooms with HEPA filtered air, and remained hospitalized until hematopoietic and clinical recovery.

Transplant procedures

The RIC preparative regimen included fludarabine, busulfan and antithymocyte globulin (thymoglobuline; Genzyme, Lyon, France) in 12 patients,1 and fludarabine and low-dose total-body irradiation (TBI, 2 Gy) in four patients.2 The remaining five patients received other fludarabine-based RIC preparative regimens. GVHD prophylaxis included either cyclosporine A (CsA) alone at a dose of 3 mg/kg/day by continuous intravenous infusion, and changed to twice daily oral dosing as soon as tolerated, or CsA and mycophenolate mofetil (MMF). Upon diagnosis of grade 2–4 acute GVHD, all patients were primarily treated or continued on CsA (with or without MMF) and a steroid-based regimen (prednisone or methylprednisolone 2 mg/kg/day). Tapering schedules of corticosteroids were individualized at the discretion of the attending physicians for disease status and activity of GVHD. Except for two patients who received unrelated cord blood stem cells, all other patients received G-CSF-mobilized peripheral blood stem cells.

Infection prophylaxis and supportive care

Supportive care was identical during the whole study period. Pneumocystis pneumonia prophylaxis consisted of trimethoprim-sulfamethoxazole (10 mg/kg/day trimethoprim) administered pre-transplantation and when the absolute neutrophil count (ANC) exceeded 500/μl twice weekly. As soon as ANC exceeded 500/μl, patients received daily oral amoxicillin (500 mg × 3/day) prophylaxis against encapsulated bacteria. Antibacterial prophylaxis was discontinued at time of systemic immunosuppressive therapy discontinuation. Prophylaxis against herpes simplex virus included intravenous acyclovir (250 mg × 3/day) or oral valacyclovir (500 mg × 2/day) during the first month after allo-SCT. Empiric broad-spectrum antibiotics were begun for temperatures greater than 38.5°C or clinical signs of infection. Patients did not receive systematic-specific oral digestive decontamination.5

Study drug administration and monitoring of safety and tolerance

L-AmB (ambsiome; GILEAD Sciences, Paris, France), a lyophilized liposomal preparation of amphotericin B, was reconstituted according to the manufacturer's instructions to give a 2-mg/ml solution. Drug dilutions for injection were prepared as needed with 5% dextrose. All patients received once-weekly intravenous L-AmB prophylaxis at a dose of 7.5 mg/kg as a 2-h infusion. The weekly dose of 7.5 mg/kg was chosen because of the nonlinear pharmacokinetics of L-AmB at higher doses, as well as because this dose is below the maximum tolerated dose (MTD) of L-AmB.7 Most often, L-AmB was administered on an outpatient basis. Patients were eligible for this prophylaxis schedule if they underwent RIC allo-SCT, and were receiving first-line active prednisone therapy (2 mg/kg/day) for acute GVHD. L-AmB infusions were started within 24–48 h after the beginning of corticosteroid therapy. Of note, patients should not have had any previous history, evidence or suspicion of an invasive mycosis owing to a filamentous fungus (ruled out by close clinical monitoring, and standard procedures such as chest X ray and/or CT scans, multiple antigenemia determination for aspergillosis whenever judged necessary),8 and should not have received any other concomitant antifungal prophylaxis. Also, patients were not eligible for enrolment into the study if (i) there was clinical and laboratory evidence of veno-occlusive disease, (ii) serum creatinine was > × 1.5 times the upper limit of normal for age, (iii) hypokalemia was <3.0 mEq/litre and (iv) they had a history of anaphylaxis attributed to L-AmB. Provided that adverse events did not indicate a health risk to the patient, the administration of the study drug was allowed to be continued for a total number of eight weekly infusions, fewer if the investigator judged that prophylactic L-AmB was no longer required or beneficial. In order to monitor the safety and tolerance of L-AmB infusions, patients were closely observed for side effects during the administration of study drug. The nursing staff recorded serial vital signs during and after infusion, as well as signs and symptoms of infusion-related toxicity. Pulse and blood pressure were monitored immediately before, during infusion if necessary, and at the end of the infusion. Signs, symptoms and reported side effects associated with drug infusion or occurring at any time during the study period were documented and assessed for a relationship to the study drug. Routine laboratory examinations (hemoglobin, white blood cell and platelet counts, serum creatinine, calcium, potassium, sodium and magnesium) for assessment of safety were performed at regular times before and after each infusion. Blood cultures were performed to identify the etiology of both bacterial and fungal infections. Specimens were submitted for microbial cultures according to standard methods. A diagnosis of IA was made as described previously.7, 8 Candidemia was diagnosed on the basis of positive results of blood cultures performed according to standard methods.

Statistical analysis

All patients who received at least one dose of study drug were included in the tolerance and safety analyses. This pilot study was not designed or powered to assess efficacy across the study group. Data are presented as medians, ranges, +/− standard error of mean (s.e.m.) and 95% confidence intervals (CIs).

Results

Baseline characteristics and other relevant early transplant-related events for patients included in this study are summarized in Table 1. The median age of recipients was 51 (range, 18–70) years. Seven patients had a myeloid malignancy, whereas 11 patients were diagnosed with lymphoid malignancies. The remaining three patients were treated for metastatic non-hematological malignancies. In addition to multiple lines of previous chemotherapy, 10 patients from this study had received prior autologous stem cell transplantation. A sustained ANC of more than 500/μl, was reached at a median of 19 (range, 6–28) days. Platelet engraftment occurred at a median of 10 (range, 0–28) days. All patients had acute GVHD (11 grade 2, 10 grade 3–4) occurring at a median of 42 (range, 12–84) days after allo-SCT. Patients enrolled in this study received a median of 4 (range, 1–8) infusions of L-AmB, with an actual cumulative dose ranging from 7.5 to 60 mg/kg. Study drug-related adverse events (both infusion-related events and other toxicities) are summarized in Table 2. In all 13 patients discontinued the study drug during follow-up. Six patients had to discontinue the study drug because of events not related to the study drug. Another seven patients (33%; 95% CI and 13–53%) discontinued taking the study drug owing to a study drug-related adverse event. These included elevated serum creatinine (>1.5 times from baseline values; n=5), hypotension and pain associated with infusion (n=1), and violent chest pain and arrhythmia during the first infusion (n=1). L-AmB-related liver toxicity was difficult to assess as many patients had liver involvement related to acute GVHD. However, drug-related liver toxicity was not significant as per the attending physician assessment. None of the patients who discontinued taking the study drug for elevated serum creatinine had acute renal failure, despite the fact that all 21 patients were taking concomitant CsA, and eight of them (38%) were also receiving other nephrotoxic drugs such as ganciclovir, amikacin and/or vancomycin. The five patients who had to interrupt the course of prophylactic L-AmB for increased serum creatinine (> × 1.5 baseline), did so after receiving three (n=2), 4 (n=1), 5 (n=1) and 7 (n=1) infusions of study drug. The pattern of serum creatinine (measured at base-line and 24 h after study drug infusion) in patients included this study is depicted in Figure 1. In the whole study population, the median percentage of variation of serum creatinine level between baseline and last L-AmB infusion was 15%±12. Three patients had to discontinue the study drug because of relapse or progression of primary malignancy. The study drug was discontinued by the attending physician in another three patients because of patient refusal (n=1), mild cytopenia (n=1) and hemorrhagic cystitis (n=1) related to a concomitant adenoviral infection. The latter three adverse events were not attributed to the study drug. Safety and tolerance were also monitored prospectively with particular attention to infusion-related reactions. Pre-medications were not administered per protocol for infusion-related reactions. Any adverse events with onset during or within 1 h of completion of the study drug infusion were recorded as infusion-related reactions. The overall frequency of infusion-related reactions was 29% (n=6; 95% CI and 10–48%). Infusion-related reactions were usually observed at the time of the first infusion, and included chills and tachycardia (n=1), mild abdominal pain (n=1), mild bone pain (n=1), transient hypotension (n=1), transient hypertension and diffuse pain (n=1) and a case of violent chest pain and transient arrhythmia that led to definitive study drug discontinuation. Except for this last case, symptoms of infusion-related reactions were rapidly relieved by intravenous paracetamol and by stopping the infusion. Upon resuming infusion of L-AmB, symptoms did not recur. Paracetamol was given before subsequent infusions for prevention of these infusion-related reactions in the same patients, with no recurrence of symptoms. With a median follow-up of 377 (range, 74–983) days, 13 patients are still alive. Eight patients died: five of disease progression, two of multiorgan failure, and one of refractory acute GVHD. No deaths were attributed to fungal infections: only one patient (patient no. 2004–57) who received a single infusion of study drug developed pulmonary IA 2 months after study drug discontinuation. This patient was subsequently treated with voriconazole and remained well 18 months (last follow-up) after allo-SCT.

Table 1 Patients and transplant characteristics
Table 2 High-dose L-AmB drug-related events
Figure 1
figure1

Serum creatinine levels as measured before L-AmB therapy (baseline), and 24 h after each infusion during the study period. Results are expressed as medians and s.e.m.

Discussion

This study evaluated the safety and tolerance of weekly prophylactic administration of once-weekly high dose (7.5 mg/kg) L-AmB in adult patients receiving high-dose corticosteroids for acute GVHD therapy after RIC allo-SCT. Several reasons justify our interest in this approach. We and others have previously identified higher doses of corticosteroids given for acute GVHD treatment, as a major risk factor for the likelihood of development of fungal infections.4, 5, 6 This association is not surprising given the well-known deleterious immunosuppressive effects associated with high-dose corticosteroids. Obviously this unveils the major unresolved issue of GVHD management after RIC allo-SCT, where optimal management is still poorly defined. The life-threatening nature of fungal infections warrants testing of new prophylaxis approaches. A number of options are theoretically available, but none is ideal. Prophylactic oral triazoles are limited by poor oral absorption, inter-individual variation in metabolism, and hepatic toxicity (especially in patients with acute GVHD), and leading even to reports of breakthrough infections.9, 10, 11 Though, newer oral triazoles such as voriconazole and posaconazole with better absorption profiles are currently under investigation in this setting with preliminary promising results, one could argue that conventional amphotericin B may still represent a valid prophylactic drug. However, when used prophylactically,12 it was associated with significant infusion-related toxicities, and long-term severe nephrotoxicity, that is not acceptable in allo-SCT patients already receiving nephrotoxic, but vital drugs such as CsA.13, 14 L-AmB has been already shown to cause few and very mild infusion-related reactions,15, 16 whereas allowing to achieving high plasma and tissue concentrations compared with the parent drug amphotericin B.7, 15, 17, 18, 19 Thus, the lower toxicity of L-AmB formulation allows the administration of much higher doses of active drug. Indeed, animal studies have suggested that a high dosing schedule of L-AmB may be effective in various fungal infections settings.20, 21, 22 In the human setting, Walsh et al.7 showed that the MTD of L-AmB was at least 15 mg/kg/day, and that L-AmB at dosages as high as 15 mg/kg/day, is well tolerated, and can provide effective therapy for aspergillosis and other filamentous fungal infections. Another recent study found that a once-weekly 15 mg/kg L-AmB dose given to adult patients undergoing allo-SCT achieved high, sustained tissue concentrations, similar to those achieved with conventional (1 mg/kg) daily dosing (Gubbins et al., abstract at the 44th Interscience Conference on Antimicrobial Agents and Chemotherapy, 2004). Despite some concerns about a high rate of hypokalemia,7 these data indicated that L-AmB can be given in high doses. Though one report suggested that antifungal prophylaxis with low-dose L-AmB is feasible and effective in patients undergoing intensive chemotherapy,23 we preferred the more practical weekly infusions. In our study, the relative infrequency of severe adverse infusion-related reactions is consistent with earlier observations of L-AmB.16, 24 However, one should bear in mind that all patients from this study were receiving high-dose prednisone. The current study found the development of one case of idiosyncratic reaction associated with severe substernal chest discomfort. Developing within the first 1–2 min of infusion of L-AmB, such events are not necessarily dependent upon dosage or rate of infusion.25 In all, infusion-related toxicity of L-AmB could be managed by the discontinuation of the infusion and the intravenous administration of paracetamol.

One challenging aspect of our study is the need for weekly intravenous administration of L-AmB as compared to oral antifungal prophylaxis with new triazoles such as voriconazole or posaconazole. Indeed, one major rationale for the use of the so-called RIC preparative regimens before allo-SCT is to minimize patient discomfort through limitation of hospital stay. However, the efficacy of such new oral drugs is yet to be further studied in this prophylactic setting. Thus, we reasoned that if weekly dosing of high-dose L-AmB administered on an outpatient basis, proved to be tolerable, then this would provide an acceptable prophylaxis regimen that could be administered for long periods. Although one must admit that a high loading regimen of L-AmB did not demonstrate any benefit as initial therapy for invasive filamentous fungal infections (Cornely et al., Abstract N°3222, Am Soc Hematol 2005), and though our study was not designed to prove the efficacy of this prophylactic approach, our data provide support for an efficacy study in a prophylaxis setting, because this approach may provide useful protection against fungal infections, and may help further improving the safety and outcome of RIC or nonmyeloablative allo-SCT.

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Acknowledgements

‘GILEAD Sciences’ (Paris, France; Dr L Mahi and Dr F Monchecourt) provided some support for this study, but did not participate in study design, definition or data analysis. We thank the nursing staff for providing excellent care for our patients, and the physicians of the Haematology and Oncology Departments at the Institut Paoli-Calmettes for their important study contributions and dedicated patient care. We also thank the ‘Association pour la Recherche sur le Cancer (ARC; ARECA Pole)’, the ‘Ligue Nationale contre le Cancer’, the ‘Fondation de France’, the ‘Fondation contre la Leucémie’, the ‘Agence de Biomédecine’, the ‘Association Cent pour Sang la Vie’, and the ‘Association Laurette Fuguain’ for their generous and continuous support for our clinical and basic research work. Our group is supported by several grants from the French ministry of health as part of the ‘Programme Hospitalier de Recherche Clinique (PHRC)’.

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El-Cheikh, J., Faucher, C., Fürst, S. et al. High-dose weekly liposomal amphotericin B antifungal prophylaxis following reduced-intensity conditioning allogeneic stem cell transplantation. Bone Marrow Transplant 39, 301–306 (2007). https://doi.org/10.1038/sj.bmt.1705592

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Keywords

  • liposomal amphotericin-B
  • fungal infections
  • allogeneic stem cell transplantation
  • reduced intensity conditioning
  • graft-versus-host disease

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