1. Immunosuppression in Bone Marrow Transplant Nwogoh Benedict Department of Haematology/Blood Transfusion, Federal Medical Centre, Owerri BBMT Conference, Benin, July 15 - 27, 2013

2. Objectives  Summarize the principles for use of immunosuppression in allogeneic stem cell transplant (SCT)  Compare and contrast commonly used medications used for immunosuppression  Describe monitoring parameters and common adverse effects associated with immunosuppression

3. Introduction  HSCT is a process of reconstituting the haemopoietic and immunological system of a recipient using previously harvested stem cells from same individual or a donor HSC.  Allogeneic HSCT involves a complex immunological interplay between donor and recipient immune systems with potentials of both beneficial and serious life threatening complications

4. Introduction  Appropriate manipulation of this complexity is necessary for a successful transplant.  Immunosuppresion is a important modality of moderating this immunological interaction to ensure a successful HSCT.

5. Immune System  Innate Immunity Physical Barriers Secretions with microbiocidal activity Phagocytes  Adaptive/Specific Immunity Humoral Cellular: B, T and Plasma cells

6. Cells of the Immune System

7. Antigen  Major HLA Ags Class I HLA A, B, C Class II HLA DP, DQ, DR Class III  Minor HLA Ags  Non HLA Ags

8. http://www.rikenresearch.riken.jp/eng/frontline/5028

9. Use of Immunosuppression  Immunosuppression is used in allogeneic stem cell transplant to: Prevention of rejection Prophylaxis for graft versus host disease (GVHD) Treatment of GVHD

10. Prevention of rejection  Rejection is a consequence of host versus graft reaction.  Immunosuppresants are incuperated into the conditioning regimen to prevent rejection.  Eradicates host T-cells to allow acceptance of donor cells  Commonly used agents include ATG, Alemtuzimab and Cyclophosphamide.

11. Prophylaxis for graft versus host disease (GVHD)  Pre- & post-transplant medications  Suppresses donor T-cells to minimize recognition of host cells as foreign  Post transplant could be Ex-vivo manipulation of the graft to deplete it of T cells (TCD) In-vivo

12. Treatment of GVHD  The first line agent is usually steroids (methylprednisolone 1-2mg/kg)  A calcineurine inhibitor (Cyclosporine) may be used in combination.  Second line agent may be indicated when first line fails.  First line agent is adjudged to have failed when : Features are progressive after 3 days of steroid therapy Failure to respond after 14 days of therapy

13. Pathophysiology of GVHD Ferrara, et al. Lancet 2009;373:1550-61.

14. Medications used for immunosuppression ClassDrug Immune globulinAntithymocyte globulin (ATG) - Equine ATG: Atgam  - Rabbit ATG: Thymoglobulin  Monoclonal antibodyAlemtuzumab - Campath  Calcineurin InhibitorsTacrolimus - Prograf  Cyclosporine - Non-modified: SandIMMUNE  - Modified: Gengraf  or Neoral  Antifolate antimetaboliteMethotrexate ImmunosuppressantMycophenolate mofetil - CellCept  CorticosteroidsMethylprednisolone Prednisone mTOR inhibitorSirolimus - Rapamune 

15. Alemtuzumab  Anti CD52 monoclonal antibody  CD52 expressed on: B and T lymphocytes Monocytes Macrophages NK cells Dendritic cells www.nature.com/reviews/drugdisc

16. Alemtuzumab Adverse Effects  Infusion related reactions Chills, dyspnea, fevers, hypotension, rigors  May be fatal Premedicate with acetaminophen, diphenhydramine, ± corticosteroid  Hypersensitivity reactions  Cytokine release syndrome  Opportunistic infections Requires anti-infective prophylaxis

17. Antithymocyte Globulin (ATG) Mohty. Leukemia.2007, 21:1387-94.

18. Antithymocyte Globulin  Polyclonal antibodies active against T cells  Administration Infuse over at least 6 hours Premedicate with acetaminophen, corticosteroids, and an antihistamine Rabbit ATG (Thymoglobulin®) and equine ATG (Atgam ®) are NOT interchangeable

19. Antithymocyte Globulin  Adverse effects Infusion-related reactions  Fever, chills, headache Hypersensitivity reactions Cytokine release syndrome Increased risk of infections Serum sickness

20. Calcineurin inhibitors http://www.nature.com/nrneph/journal/v2/n12/fig_tab/ncpneph0343_F2.html

21. Calcineurin Inhibitors  Inhibit T cell activation by suppressing production of IL-2  IV Administration Non-PVC tubing Continuous infusion over 24 hours  IV:PO conversion = ~1:3  Therapeutic Drug Monitoring (TDM) PO: trough levels (30 min prior to dose)

22. Calcineurin Inhibitors: Adverse Effects  Nephrotoxicity  Hypertension  Hyperglycemia  Hypercholesterolemia  Hypomagnesemia  Hyperkalemia  HUS/TTP  CNS toxicity Tremor Posterior reversible encephalopathy syndrome (PRES)

23. Calcineurin Inhibitors: Drug Interactions  Many others CYP3A4 inducers and inhibitors Anti- fungals AntibioticsGI AgentsAnti- convulsants Others FluconazoleMetronidazoleMetoclopramidePhenytoinProtease inhibitors VoriconazoleErythromycinCimetidinePhenobarbitalSirolimus PosaconazoleClarithromycinLansoprazoleCarbamazepineSt. John’s wort KetoconazoleRifampinGrapefruit juice

24. Calcineurin Inhibitors: Cyclosporine  Dosing 3 mg/kg CIVI over 24 hours (initial) 5-6 mg/kg PO every 12 hours (initial) Modified ≠ non-modified May mix oral solution with orange juice  TDM 150-350 ng/ml  Adverse effects Hirsutism/hypertrichosis Gingival hyperplasia

25. Methotrexate  Mechanism of action Induces apoptosis of activated lymphocytes Blocks dihydrofolate reductase to inhibit purine synthesis  Dosing 5-15 mg/m2 IVP on D+1, 3, 6, 11 +/- leucovorin rescue  Adverse effects Mucositis Myelosuppression Hepatotoxicity

27. Mycophenolate mofetil  Mechanism of action Inhibits lymphocyte proliferation by blocking purine synthesis  Dosing 1000 mg PO/IV every 12 hours  Drug interactions Calcium & magnesium  Adverse effects Nausea, vomiting, diarrhea Myelosuppression

29. Corticosteroids  Mechanism of action Affect number & function of B-cells & T-cells  Dosing Systemic  Methylprednisolone or prednisone 0.5-2 mg/kg IV/PO daily  Taper when applicable Topical  Budesonide-SR 3 mg PO every 8-12 hours (gut GVHD)  Triamcinolone cream 0.1% to body +/- hydrocortisone 1% to face (skin GVHD)

30. Corticosteroid Adverse Effects  Short term Hyperglycemia Mood disturbance, psychosis Insomnia Hypertension Fluid retention Skin atrophy Gastric ulcers  Long term Adrenal suppression Moon facies Weight gain Osteoporosis Buffalo hump Cataracts Myopathy Infections

31. Sirolimus  Mechanism of action Inhibits proliferation of lymphocytes by blocking m-TOR  Dosing 12 mg PO x 1 then 4 mg PO once daily  Therapeutic Drug Monitoring (TDM) 3-12 ng/ml Trough levels (30 min prior to dose)

32. http://www.nature.com/nrneph/journal/v2/n12/fig_tab/ncpneph0343_F2.html

33. Sirolimus  Drug interactions Similar to calcineurin inhibitors (CYP 3A4)  Adverse effects Hyperlipidemia Myelosuppression Pneumonitis Thrombotic microangiopathy

34. Additional Immunosuppressants: Treatment for GVHD  TNF α blockers Etanercept, infliximab  Pentostatin  Alefacept  Many drugs under investigation for treatment of acute and chronic GVHD

35. Infection Prevention  Use appropriate anti-infective prophylaxis throughout immunosuppressive therapy Pneumocystis carinii pneumonia Fungal infections Viral infections

36. Summary  Immunosuppression is utilized in allogeneic SCT to prevent rejection and GVHD, and for the treatment of GVHD  Infectious complications are common, making appropriate anti-infective prophylaxis important

37. Date Conditioning Doses Route Immunsuppr. 10mg/kg Isolation Heparin CsA 200mg/d MMF i.v. 1200 mg/ m2 Acyclor 1500 mg/ m2 Gut decontamination Tue 16.07.2013Catheter -7Wed 17.07.2013 -6Thu 18.07.2013Fludarabine40 mg/m 2 IV.ATGAM 500mg -5Fri 19.07.2013Fludarabine Busulphan 40 mg/m 2 4mg/kg/d IV PO ATGAM 500mg -4Sat 20.07.2013Fludarabine Busulphan 40 mg/m 2 4mg/kg/d IV PO ATGAM 500 mg -3Sun 21.07.2013Fludarabine Busulphan 40 mg/m 2 4mg/kg/d IV PO -2Mon 22.07.2013Fludarabine Busulphan 20 mg/m 2 4mg/kg/d IV PO Tue 23.07.2013Rest day 0Wed 24.07.2013BMT +1Thu 25.07.2013 +2Fri 26.07.2013 +3Sat 27.07.2013 Stem Cell Unit, Dept of Haematology, Blood Transfusion and Stem Cell Transplantation. Physician:Bazuaye G. N 05.07.2013 Patient: Matthew Ebenezer, DOB: 23.11.1997Diagnosis: Sickle Cell Anaemia Donor: Matthew Naomi (MSD), Genotype: AA Conditioning: Flu 180 mg/m 2, Bu 16mg/kg, ATG (ATGAM) 1500mg total dose over 3days, CSA 5mg/kg/day. (analog EBMT 2005 Sykora und Sauer et al.) Weight. 48 kg, Height 175 cm, BSA 1.53 m 2 PROTOCOL

38. References  Ashley Newland. Notes on Immunosuppression in Bone Marrow Transplant.  Eliane Gluckman. Choice of the donor according toHLA typing and stem cell source. In EBMT HSCT handbook 6th Edition  Jane Appley. Graft versus host disease. In EBMT HSCT handbook 6th Edition

39. Thank You!