A phase II/III randomized, multicenter trial of prednisone/sirolimus <i>versus</i> prednisone/ sirolimus/calcineurin inhibitor for the treatment of chronic graft-<i>versus</i>-host disease: BMT CTN 0801

Abstract

Initial therapy of chronic graft-<i>versus</i>-host disease is prednisone ± a calcineurin-inhibitor, but most patients respond inadequately. In a randomized, adaptive, phase II/III, multicenter trial we studied whether prednisone/sirolimus or prednisone/sirolimus/photopheresis was more effective than prednisone/sirolimus/calcineurin-inhibitor for treating chronic graft-<i>versus</i>-host disease in treatment-naïve or early inadequate responders. Primary endpoints of this study were proportions of subjects alive without relapse or secondary therapy with 6-month complete or partial response in phase II, or with 2-year complete response in phase III. The prednisone/sirolimus/photopheresis arm closed prematurely because of slow accrual and the remaining two-drug <i>versus</i> three-drug study ended in phase II due to statistical futility with 138 evaluable subjects. The two-drug and three-drug arms did not differ in rates of 6-month complete or partial response (48.6% <i>versus</i> 50.0%, <i>P</i>=0.87), or 2-year complete response (14.7% <i>versus</i> 15.5%, <i>P</i>=0.90). Serum creatinine values >1.5 times baseline were less frequent in the calcineurin-inhibitor-free arm at 2 months (1.5% <i>versus</i> 11.7%, <i>P</i>=0.025) and 6 months (7.8% <i>versus</i> 24.0%, <i>P</i>=0.016). Higher adjusted Short Form-36 Physical Component Summary and Physical Functioning scores were seen in the two-drug arm at both 2 months (<i>P</i>=0.02 and <i>P</i>=0.04, respectively) and 6 months (<i>P</i>=0.007 and <i>P</i>=0.001, respectively). Failure-free survival and overall survival rates at 2 years were similar for patients in the the two-drug and three-drug arms (48.6% <i>versus</i> 46.2%, <i>P</i>=0.78; 81.5% <i>versus</i> 74%, <i>P</i>=0.28). Based on similar long-term outcomes, prednisone/sirolimus is a therapeutic alternative to prednisone/sirolimus/calcineurin-inhibitor for chronic graft-<i>versus</i>-host disease, being easier to administer and better tolerated. <i>Clinicaltrials.gov identifier: NCT01106833.</i>