Calcineurin Inhibitors Replacement by Ruxolitinib as Graft-versus-Host Disease Prophylaxis for Patients after Allogeneic Stem Cell Transplantation

Abstract

Graft-versus-host disease (GVHD) is a common complication of allogeneic stem cell transplantation (allo-SCT) that carries a high mortality. Although calcineurin inhibitors (CNIs) have been widely used in GVHD prophylaxis, the incidence of acute GVHD (aGVHD) remains at roughly 30% to 50%. Moreover, some allo-SCT recipients cannot tolerate CNI. Thus, improved GVHD prevention methods are needed. Our study aimed to determine the prophylactic value of ruxolitinib for GVHD in CNI-intolerant patients after allo-SCT. Between September 2017 and March 2019, 10 patients with hematopoietic malignancies after allo-SCT who were intolerant to CNI at our center were enrolled in this study. The regimens were based on a myeloablative busulfan and cyclophosphamide regimen. Antithymocyte globulin was administered to patients with an HLA-haploidentical related donor (HRD) at a dosage of 6 mg/kg. All received ruxolitinib to replace CNI as GVHD prophylaxis. Ruxolitinib was initiated at 5 to 10 mg twice daily until 2 to 3 months post-transplantation and then tapered gradually, and in the absence of GVHD, discontinued by day +180. Eight patients had acute leukemia, 1 patient had myeloproliferative neoplasm, and 1 patient had natural killer T cell (NK/T) lymphoma. The donor type was a matched sibling donor in 3 patients and an HLA-haploidentical related donor (HRD) in 7 patients. All patients received CNI plus short-course of methotrexate as GVHD prophylaxis, but showed intolerance to CNI within 45 days post-transplantation. After ruxolitinib replacement, only 1 patient (10%) developed grade II skin aGVHD within 100 days, and only 1 patient developed severe aGVHD after 100 days. Two patients developed moderate/severe chronic GVHD (cGVHD) after tapering or stopping ruxolitinib, resulting in a 1-year cumulative incidence of moderate/severe cGVHD of 21.4%. Cytomegalovirus (CMV) reactivation occurred in 4 patients (40%), and Epstein-Barr virus (EBV) reactivation occurred in 3 patients (30%). None of the patients developed CMV disease or EBV post-transplantation lymphoproliferative disorder. After a median follow-up of 11 months (range, 2 to 15.5 months), 2 patients (20%) relapsed and 7 (70%) were alive, of whom 6 (60%) were negative for minimal residual disease and 4 were off immunosuppressant therapy. The prophylactic application of ruxolitinib for CNI-intolerant patients after allo-SCT appears to be safe and effective in preventing GVHD, but this awaits further study in larger cohorts.