Combination Of Sirolimus Research Articles

Outcome of Ruxolitinib and Sirolimus in Preventing aGVHD Post to HLA Matched Hemotopietic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (HSCT) is an effective treatment for hematological malignancies. Graft-versus-host disease (GVHD) is an important cause of graft failure and death. At present, the classic prevention program of GVHD is cyclosporine and calcineurin inhibitor (CNI; i.e. tacrolimus) plus methotrexate (CTX) or mycophenolate mofetil (MMF). However, the incidence of aGVHD is about 30-50%. Furthermore, the classic preventive regimen can also inhibit the graft-versus-leukemia effective (GVL) effect while reducing aGVHD, thereby increasing the recurrence rate, slowing the immune reconstitution, increasing the opportunistic infection. Ruxolitinib is a selective JAK1/2 small molecule kinase inhibitor, which has been reported to have a significant effect on the treatment of GVHD, while retaining the GVL effect with mild side effects. Sirolimus is a macrolide antibiotic with antifungal, immunosuppressive and antitumor effects. Based on the above studies, it can be speculated that the combination of ruxolitinib and sirolimus may have the function of immune inhibition, anti-tumor, while retaining the GVL effect, reducing the recurrence rate and reducing the risk of infection. Here we report our experience of using the combination of ruxolitinib and sirolimus to prevent the occurrence of aGVHD post to HLA matched hematopoietic stem cell transplantation and analyzed the incidence and prognosis of aGVHD.1. Patients and Methods1.1 Patients: There were five patients received HSCT enrolled in this study from March 2018 to July 2018, including 2 males and 3 female with a median age 30 (range: 13-46) years old. There were three patients with acute lymphocyte leukemia (ALL; one CR and two NR patients) and two cases were acute myeloid leukemia (AML; one CR and one NR patient).1.2 Donor source: A high-resolution genotyping was applied to perform the HLA matching test. All the donors to the 5 patients were their siblings. The results are all HLA10/10. There were 3 cases indicated blood type mis-matching, 1 case with major side mis-match, and 1 case with minor side mis-match.1.3 Conditioning: Two conditioning regimens were used per disease type, repspectively. Two patients with AML were treated with: fludarabine (Flu)30mg/m2×5d(d-7~-3)+ busulfan (Bu)130mg/m2×4d(d-6~-3)+semustine200mg/m2×1d(-8d); 3 patients with ALL were treated with fludarabine(Flu)30mg/m2×5d(d-7~-3) +melphalan(Mel)50mg/m2×4d(d-6~-3) +semustine 200mg/m2×1d(-8d) .1.4 GVHD prophylaxis: the phophylaxis regimen consist of ruxolitinib and sirolimus. The ruxolitinib was give at d-6~+5 at 10mg bid, d+6~d+41 at 10mg qd, d+42~d+ 101 5mg qd, d+102~d+222 2.5mg qd. The dosage of ruxolitinib was decreased 50% when the patient's weight <25kg or combined with azole drugs; sirolimus is orally administered from day -2d to day 60. The loading dose was 3.6 mg/m2, the maintenance dose was 1.2 mg/m2, and the whole blood concentration was maintained at (10 ± 2) ng/ml.2 Results2.1 Hematopoietic Reconstitution: All 5 patients were successfully engrafted for hematopoietic reconstitution. The median time of platelet engraftment was +13d (10~14d), and the median time of neutrophil engraftment was +12d (9~12d).2.2 The incidence of GVHD: Only one of the 5 patients developed grade II liver aGVHD, and the incidence of grade II to IV aGVHD was 20.0% (1/5).2.2 Other transplant-related complications: 2 out of 5 patients developed engraftment syndrome and was relieved with small doses of glucocorticoids; 1 patient developed hemorrhagic cystitis, 3 patients developed mucositis, and 1 patient had concurrent Pulmonary fungal infection, 2 cases had cytomegalovirus infection, all the symptoms were improved through hydration, forced diuretic, voriconazole and ganciclovir administration.2.3 Prognosis: The 100-day overall survival rate (OS) was 100%. All the 5 patients were alive at our follow-up on July 10. The engrafted state was completely donor type; MRD level was negative, and the general condition was good.3 ConclusionThis experimental study shows the prevention application of the combination of ruxolitib and sirolimus post to allogeneic hematopoietic stem cell transplantation is an innovative combination of immunosuppressive therapy, which is safe and tolerable. A randomized clinical trial is underway to evaluate the efficiency of this new approach for aGVHD. DisclosuresNo relevant conflicts of interest to declare.

The Association between Transplant-Associated Thrombotic Microangiopathy and Calcineurin Inhibitor and Sirolimus Levels

Introduction: Thrombotic microangiopathy (TMA) is a known complication of allogeneic hematopoietic cell transplantation (HCT). An ongoing debate is whether TMA is caused by acute graft-versus-host disease (GVHD) or calcineurin inhibitor (CNI)/sirolimus. Previous studies have not examined the impact of CNI/sirolimus average trough levels while accounting for the confounding effect of GVHD. In the current study, we examined the association between time-varying levels of CNI/sirolimus and the onset of TMA among 2105 adult allogeneic HCT recipients.Methods: We performed a retrospective cohort analysis of allogeneic HCT recipients during 2006-2015 at Fred Hutchinson Cancer Research Center who received CNI/sirolimus for GVHD prophylaxis. TMA (outcome) was ascertained and validated as previously described (Blood 130;Suppl:666). Acute GVHD (confounder) was defined and graded according to established criteria. Consecutive CNI/sirolimus trough levels (exposure) were obtained and interval values between checks were imputed via linear interpolation. We followed patients from the time of hematopoietic cell infusion until the onset of TMA and censored patients at day 100 or >1 week of missing drug levels. To examine the association between the “type” of immunosuppressant and TMA, CNI/sirolimus exposure over time was characterized as a discrete categorical variable (tacrolimus alone, cyclosporine alone, or sirolimus + CNI). To examine the impact of the “level” of immunosuppressant on TMA, CNI/sirolimus exposure was both defined as an average of the previous 7-day trough levels (continuous variable) as well as a discrete time-above-peak variable (binary variable for tacrolimus >15 ng/mL, cyclosporine >450 ng/mL, or sirolimus >10 ng/mL). Extended Cox regression models were built to examine the time-varying association between CNI/sirolimus exposures and TMA after adjusting for GVHD.Results: In the current study, 2105 adult allogeneic HCT recipients contributed 173,171 person-days and 150 cases of TMA. The median follow-up time was 94 days and trough blood levels were checked on average 3x per week. Initial GVHD prophylaxis regimen for patients included 54% on tacrolimus (n=1135), 40% on cyclosporine (n=837), and 6% on a combination of sirolimus + CNI (n=133). Nearly no one received sirolimus alone without CNI. Eight percent of patients (n=162) had at least one switch in the immunosuppression regimen within 100 days. The median (IQR) trough levels for tacrolimus, cyclosporine, and sirolimus were 9 ng/mL (7-12), 283 ng/mL (206-372), and 5 ng/mL (4-7), respectively. Acute GVHD developed in 64% of patients including 53% grade 2 (n=1115), 9% grade 3 (n=185), 2% grade 4 (n=52).In the analysis adjusted for both discrete time-varying CNI/sirolimus exposure and GVHD, higher grades of GVHD had strong associations with TMA (Table 1: grade 2 HR 2.24, P=0.001; grade 3 HR 12.38, P<0.001; grade 4 HR 26.04, P<0.001). While cyclosporine and tacrolimus had a similar risk for TMA (HR 1.23, P=0.230), sirolimus + CNI regimen was associated with a slightly higher risk compared to CNI alone (HR 1.76, P=0.051).In the analyses of individual drug levels adjusted by GVHD, higher trough levels of tacrolimus and cyclosporine (either as a linear average level or binary time-above-peak) were not associated with an increased risk of TMA (Table 2). However, higher sirolimus trough levels were associated with an appreciable risk of TMA (HR 1.44, P=0.001 for every 1 ng/mL increase in sirolimus average trough level; HR 3.23, P=0.164 for time above 10 ng/mL).Conclusion: In allogeneic HCT patients, acute GVHD was strongly associated with the onset of TMA independent of ongoing exposures of CNI/sirolimus. We did not find an association between CNI recipients (tacrolimus versus cyclosporine) or CNI levels and the risk of TMA. However, when combined with CNI, higher sirolimus trough levels were linearly associated with a higher risk for TMA. Limitations in this observational study include the inability to adjust for concomitant medications and conditions that might have altered drug levels and inability to adjust for target drug levels since recognized risk factors might have led clinicians to target higher drug levels due to higher risks of GVHD. These findings suggest that prevention and treatment of GVHD and avoidance of high sirolimus levels will decrease the risk of TMA. DisclosuresLee:Amgen: Consultancy, Research Funding; Mallinckrodt: Honoraria; Incyte: Consultancy; Pfizer: Consultancy; Onyx: Research Funding; Kadmon: Research Funding; Takeda: Research Funding. Garcia:Pfizer: Consultancy; Portola: Research Funding; Shingoi: Consultancy; Retham Technologies LLC: Consultancy; Janssen: Consultancy, Research Funding; Bristol Meyers Squibb: Consultancy; Daiichi Sankyo: Research Funding; Incyte: Research Funding; Boehringer Ingelheim: Consultancy.

Clinical Outcomes One Year and Beyond After Combination Sirolimus-Eluting Endothelial Progenitor Cell Capture Stenting During Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction.

Primary percutaneous coronary intervention (PCI) during acute ST-segment elevation myocardial infarction (STEMI) represents a thrombotic milieu and is associated with delayed healing after stenting. The pro-healing combination sirolimus eluting endothelial progenitor cell (EPC) capture stents encourage early endothelialization after stenting and may be beneficial in the STEMI population. We aim to evaluate the clinical outcomes one year and beyond for patients with STEMI who received the combination sirolimus eluting EPC capture stents during primary PCI. All STEMI patients implanted with combination sirolimus eluting EPC capture stents during primary PCI from November 2013 to December 2016 were enrolled. The primary outcome was target lesion failure (TLF) at in-hospital, one-month, one-year and beyond one year. A total of 260 consecutive STEMI patients (283 lesions) were implanted with 313 combination sirolimus eluting EPC capture stents during primary PCI. Mean age was 56.1 ± 11.2 years and 88.8% were male. One in ten patients (10.9%) had cardiogenic shock on presentation, 7.3% needed mechanical ventilation and 7.7% had intra-aortic balloon pump inserted. A total of 97.9% of lesions achieve final TIMI 3 flow. Device success was seen in all patients. At extended follow up period (median 23.4 months), the clinical outcomes were TLF 8.8%, major adverse cardiovascular events 10.8%, cardiac mortality 4.2%, target vessel myocardial infarction 3.4%, target lesion revascularization 3.8%, and definite stent thrombosis 1.9%. This study demonstrated acceptable clinical outcomes for an all-comers STEMI patients undergoing primary PCI with the use of combination sirolimus eluting EPC cell capture stents.

Combinatorial Therapeutic Discovery Using Perturbational Gene-Expression Signatures

Cancer is a complex disease that relies on both oncogenic mutations and non-mutated genes for survival, thereafter coined as oncogene and non-oncogene addictions. The need for more effective combination therapies to overcome drug resistance in oncology has been increasingly recognized, but the identification of potentially synergistic drugs at scale remains challenging. Here we propose a geneexpression- based approach, which uses the recurrent perturbation–transcript regulatory relationships inferred from a large compendium of chemical and genetic perturbation experiments across multiple cell lines, to engender a testable hypothesis for combination therapies. These transcript-level recurrences were distinct from known compound–protein target counterparts, reproducible in external datasets, and correlated with small-molecule sensitivity. Using this new approach, we predicted synergistic drug pairs for cancer, including most frequently the combinations of a topoisomerase inhibitor and an mTOR or PI3K inhibitor. We also experimentally confirmed the synergistic effects of one combination of CD-437 (a retinoid) and sirolimus (an mTOR inhibitor) and the other combination of narciclasine (a protein synthesis inhibitor) and purvalanol A (a CDK inhibitor) in two breast and two lung cancer cell lines. Our results corroborate a gene-expression-based strategy for combinatorial drug screening as a way to target non-mutated genes in complex diseases.

A Phase II Trial of Sirolimus with Standard Induction Chemotherapy in Patients with De Novo Acute Myeloid Leukemia

Abstract Background: The initial treatment of FLT3 wild type acute myeloid leukemia (AML) has not significantly changed since induction therapy with Ara-C and anthracyclines was first developed. Preclinical data suggests constitutive activation of the AKT3/mammalian target of rapamycin (mTOR) pathway may play a role in pathogenesis of this disease in a subset of AML patients. Previous data from our group has shown that the presence of phosphorylated ribosomal S6 (pS6) in AML blasts as detected by flow cytometry may predict response to the combination of sirolimus and induction chemotherapy. Here we report the clinical and pharmacodynamics results of a phase II study of the combination of these drugs. Methods: Subjects had newly diagnosed AML based on WHO criteria. Subjects received oral sirolimus starting on day 1 (12 mg loading dose) then 4 mg daily on days 2-10 with idarubicin 12mg/m2 days 4-7 and cytarabine 100mg/m2 days 4-10. Clinical response was assessed at hematologic recovery or by day 42 using IWG for response. Samples for pharmacodynamic studies of blasts were drawn prior to treatment with sirolimus on day 1, and then again prior to dosing of idarubicin and cytarabine on day 4. Assessment of pS6 on gated blasts, a biomarker of mTORC1 activation, was assessed by flow cytometry using previously described methods. Results: 55 patients enrolled on this trial received sirolimus with an average age of 58 years. Toxicity was similar to published 7+3 data and prolonged aplasia without recovery was not observed. Twenty-nine patients (53%) had high risk cytogenetic or molecular mutations, 15 (27%) had intermediate risk disease, and 11 (20%) patients had lower risk disease. As a whole, 35 patients (64%) entered into CR or CRp, 1 had a PR, 17 (27%) were non-responders. Two (4%) patients (ages 64 and 71) died during induction. Thirteen (45%) patients with high risk disease had a CR or CRp, 14 (48%) were non-responders, and 2 died in induction. Of the 15 subjects with intermediate risk disease, 11 (79%) patients had a CR or CRp, 1 had a partial response, and 3 were non-responders. All low risk patients had a CR, and 9 of 11 are alive and in remission at the time of censoring of data with a median time on study of 674 days. One patient with low risk disease subsequently relapsed, went to stem cell transplant, and is currently in CR. Two patients with low risk disease refused to proceed with standard of care consolidation; of these, 1 is alive and in remission 946 days from study entry, and 1 died in relapse. Fifteen patients (27%) subsequently underwent allogeneic stem cell transplantation in CR, and 8 (53%) are still alive an average of 358 days after transplant. Thirty-seven of 55 patients had adequate samples for pharmacodynamic analysis. Surprisingly, all patients demonstrated activation of ribosomal S6 prior to therapy in contrast to 67% positivity seen in previous studies that focused on patients with relapsed AML. mTORC1 was inhibited greater than 40% in 28/37 (76%) of patients. Inhibition did not correlate with either overall survival or age of patients. Conclusions: Sirolimus and 7+3 is a well-tolerated regimen. mTORC1 appears to be activated in almost all patients at the time of diagnosis of AML as assessed by flow cytometric assessment of ribosomal S6. Inhibition of mTORC1 did not correlate with response, suggesting that AML cells may have redundant signaling pathways that regulate chemosensitivity when mTORC1 is inhibited. Given the large percentage of samples with mTORC1 activation in this upfront AML study, future research into dual mTORC inhibitors may prove valuable. Disclosures Carroll: Astellas Pharmaceuticals: Research Funding; Incyte Pharmaceuticals: Research Funding. Porcu: Innate Pharma: Research Funding; Kura: Research Funding; Miragen: Research Funding; Kiowa: Research Funding; Galderma: Research Funding; Tetralogic: Research Funding; Cell Medica: Research Funding; Celgene: Research Funding. Perl: Arog Pharmaceuticals: Consultancy; Novartis: Other: Advisory Board; Pfizer: Other: Advisory Board; Seattle Genetics: Other: Advisory board; Asana Biosciences: Other: Scientific advisory board; Astellas: Consultancy; Daiichi Sankyo: Consultancy; Actinium Pharmaceuticals: Other: Scientific Advisory Board.

Circulating Biomarkers From the Phase 1 Trial of Sirolimus and Autophagy Inhibition for Patients With Lymphangioleiomyomatosis

We have previously conducted the Sirolimus and Autophagy Inhibition in LAM (SAIL) trial, a phase 1 dose-escalation study of the combination of sirolimus and hydroxychloroquine in patients with lymphangioleiomyomatosis (LAM). The goal of the present study was to analyze sera from the SAIL trial to identify novel biomarkers that could shed light into disease pathogenesis and response to therapy. We used the DiscoveryMAP platform from Rules Based Medicine to simultaneously measure 279 analytes in sera collected at each visit from subjects enrolled in the SAIL trial. We used longitudinal regression and pathway analysis to examine analyte rate of change and corresponding effect on lung function and to identify networks and potential nodes of interest. A total of 222 analytes were included in the analysis. We identified 32 analytes that changed over the treatment period of the study. Pathway analysis revealed enrichment in cytokine-receptor interaction and mechanistic/mammalian target of rapamycin-related pathways, in addition to seemingly unrelated processes such as rheumatoid arthritis. Search Tool for the Retrieval of Interacting Genes/Proteins analysis identified two hubs centered around acetyl-CoA carboxylase alpha and beta and coagulation factor II. In addition, we identified vascular endothelial growth factor receptor-3 and CCL21 as molecules significantly associated with changes in FEV1 during the study period. We performed a large-scale analyte study in sera of women with LAM and identified potential markers that could be linked to disease pathogenesis, lung injury, and therapeutic response. These data will enable future investigation into the specific roles of these molecules in LAM. ClinicalTrials.gov; No. NCT01687179; URL: www.clinicaltrials.gov).

A Single Center Experience with Post Transplant Tuberculosis in a Developing Country

Background Tuberculosis (TB) is endemic in India. Our transplant center performs over 250 renal transplants a year and TB is a significant morbidity in the post transplant period. This retrospective review of follow up data provides an idea of the disease burden and its treatment in the post transplant population at our center. Methods A retrospective review of follow up data from Jan 2004 to Dec 2016 was undertaken to identify those patients who either tested positive for acid fast bacilli (AFB) or were treated with anti tubercular therapy (ATT) for at least 6 months were identified and details of their presentation, immunusuppression and ATT were noted. Additional information on associated infections and outcomes were also noted. Results Out of data reveiwed for 2600 patients 89 (M:F 75:14) fulfilled our criteria for identifying patients with TB. The mean age at presentation was 35.21 +- 9.78 yrs and the mean time post transplant was 25.58 +- 32.32 months. Sixteen patients had received induction immunosuppression with anti-thymocyte globulin (n=8), belatacept (n=1), basiliximab (n=6) or dacluzimab (n=1). Fifty eight patients had received ATT with a fluoroquinolone substituting rifampicin for financial contraints and 10 patients had taken rifampicin based ATT while ATT data was unavailable for 21 patients. Patients were either on tacrolimus (n=67) cyclosprin (n=15) or sirolimus (n=1) in combination with either azathioprine (n=10) or mycophenolate (n=68). Associated infections were UTI (n=10), bacterial pneumonias (n=6), cancidiasis (n=5), aspergillosis (n=1), herpesviridae infections (n=7) and viral hepatitis (n=14). There were only two deaths due to tuberculosis out of 55 deaths directly attributable to infections in the follow up group. Conclusion Tuberculosis is a significant disease in the post transplant population in developing nations and treatment with non rifampicin based ATT should be studied and its role defined.

Molecular Guided Therapy Provides Sustained Clinical Response in Refractory Choroid Plexus Carcinoma

Choroid plexus carcinomas (CPCs) are rare, aggressive pediatric brain tumors with no established curative therapy for relapsed disease, and poor survival rates. TP53 Mutation or dysfunction correlates with poor or no survival outcome in CPCs. Here, we report the case of a 4 month-old female who presented with disseminated CPC. After initial response to tumor resection and adjuvant-chemotherapy, the tumor recurred and metastasized with no response to aggressive relapse therapy suggesting genetic predisposition. This patient was then enrolled to a Molecular Guided Therapy Clinical Trial. Genomic profiling of patient tumor and normal sample identified a TP53 germline mutation with loss of heterozygosity, somatic mutations including IDH2, and aberrant activation of biological pathways. The mutations were not targetable for therapy. However, targeting the altered biological pathways (mTOR, PDGFRB, FGF2, HDAC) guided identification of possibly beneficial treatment with a combination of sirolimus, thalidomide, sunitinib, and vorinostat. This therapy led to 92% reduction in tumor size with no serious adverse events, excellent quality of life and long term survival.

Abstract 1644: Combination of MT-3724 with sirolimus reduces anti-drug antibody response and prolongs drug exposure

Abstract Molecular Templates is developing engineered toxin bodies (ETBs), potent recombinant immunotoxins that combine the specificity of an antibody fragment with the powerful direct cytotoxicity of the Shiga-like toxin A subunit. ETBs can induce their own internalization, route through the cell in a predictable manner, enzymatically and irreversibly destroy ribosomes to shutdown protein synthesis and induce apoptosis of tumor cells. This mechanism of action is distinct from that of other therapeutics, making ETBs an attractive treatment for patients who have become resistant to chemotherapy and other treatment modalities. MT-3724 is Molecular Templates’ first-generation ETB targeting CD20, a surface receptor that is highly expressed on malignant B cells in hematological malignancies. Pre-clinical and clinical studies have shown promising results for non-Hodgkin’s lymphoma cell lines and patients; however anti-drug antibodies are formed in experimental animals and patients after repeat dosing. Sirolimus (rapamycin) is a macrolide compound approved to prevent organ rejection and in LAM, and has been used in tolerization protocols with replacement enzymes. In pre-clinical studies, we have co-administered sirolimus in combination with MT-3724 in rodents as well as in a non-human primate model in order to reduce the anti-drug antibody response to MT-3724. These studies demonstrated that the combination of sirolimus with MT-3724 decreased anti-drug antibody response, prolonged serum exposure of MT-3724, and improved B-cell depletion as compared to MT-3724 alone. Molecular Template’s ETB technology has resulted in potent and targeted therapeutic agents that have a unique mechanism of action in the field of oncology. Our first-generation, CD20-targeted therapeutic, MT-3724, has promising clinical results in the refractory setting for non-Hodgkin’s lymphoma. The combination of sirolimus with MT-3724 is an attractive and feasible regimen which will be further explored in clinical studies. Citation Format: Jack P. Higgins, Garrett L. Robinson, Sangeetha Rajagopalan, Brigitte Brieschke, Jensing Liu, Erin K. Willert. Combination of MT-3724 with sirolimus reduces anti-drug antibody response and prolongs drug exposure [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1644. doi:10.1158/1538-7445.AM2017-1644

Acute Rejection after Pediatric Intestinal Transplantation

Background: Rejection is a major threat to the survival of intestinal allografts. As immunosuppression regimens have improved, the incidence of acute rejection has decreased significantly. The aim of our study is to report incidence and outcomes of acute rejection (AR) in pediatric intestinal transplantation at our center over the last decade. Methods: All pediatric intestinal transplants performed at our program between 2003–2016 were reviewed. Parameters analyzed included patient demographics, incidence, timing, severity, treatment and outcome of AR. Overall patient and graft survival was also analyzed. Results: The records of 111 pediatric intestinal transplants (n = 40, 36% isolated small bowel (SB), n = 49,45% liver-bowel (LB) and n = 22, 18% multivisceral) performed between 2003–2016 were analyzed; 61 (55%) male, median age 2 years (range 0.5 - 18). The most common indication for transplant was short gut secondary to gastroschisis (27, 24%) and necrotizing enterocolitis (19, 17%). Immunosuppression consisted of a combination of tacrolimus, mycophenolate mofetil, sirolimus and steroids. The overall incidence of AR was 34% after a median interval of 250 days (range 14–3,037) from transplant. The incidence of AR was 35% (14/40) in SB, 35% (17/49) in LB and 27% (6/22) in MV. The severity of acute rejection was classified as grade 1 in 34%, grade 2 in 20%, and grade 3 in 46%. The incidence of AR during 2003–2007 was 58% (22/38) with a median time to rejection of 296 days. The incidence of AR during 2008–2011 was 26% (9/35) with a median time to rejection of 362 days. The incidence of AR during 2012–2016 was 16% (6/38) with a median time to rejection of 21 days. Since 2003, the overall patient and graft survival was 81% and 77%, respectively, with patient and graft survival at 1-year reaching 89% and 87%. Conclusions: According to our experience over a thirteen-year time period, the incidence of acute rejection has decreased over time and current survival rates have improved significantly compared to the early era.

Sirolimus, Post–Transplant Cyclophosphamide, and CTLA4-Ig Maintain Stable Mixed Chimerism In a Mismatched Murine Model

Abstract Hematopoietic stem cell transplantation (HSCT) is the only curative option for patients with sickle cell disease (SCD). We sought to extend our haploidentical HSCT regimen with nonmyeloablative conditioning. The objective of our study was to assess the ability of the immunosuppressive agent CTLA4-Ig to induce mixed chimerism in the haploidentical HSCT setting when combined with sirolimus, post-transplant cyclophosphamide (PT-Cy), or both. We used a mismatched mouse model with BALB/c donors and C57BL/6 recipients. Recipient mice received 200 cGy TBI on day of the transplant and were conditioned with or without sirolimus, PT-Cy, and/or CTLA4-Ig. Our data show that when CTLA4-Ig alone or CTLA4-Ig/PT-Cy are given, donor cells are not detected. However, mixed chimerism is maintained in mice who received either sirolimus/PT-Cy or sirolimus/PT-Cy given together with CTLA4-Ig over 60 days. Additionally our data indicate a significant increase in recovery of donor cells within CD8 T-cell, CD19 B-cell, and CD11b myeloid cell populations in groups conditioned with sirolimus/PT-Cy, or sirolimus/PT-Cy/CTLA4-Ig as compared to groups conditioned with CTLA4-Ig (p=0.003; p=0.002; p=0.049) alone or CTLA4-Ig/PT-Cy (p=0.001; p&amp;lt;0.0001; p=0.001) at 30 days, respectively. These data demonstrate that sirolimus in combination with PT-Cy and CTLA4-Ig is synergistic in an MHC-mismatched mouse model. The novel tri-drug group establishes mixed chimerism while conditioning with CTLA4-Ig alone or CTLA4-Ig/PT-Cy does not. The data also identify induction of stable mixed chimerism in specific cellular subpopulations within the sirolimus/PT-Cy and sirolimus/PT-Cy/CTLA4-Ig groups, indicating that these cells may play an important role in HCST.

A phase Ib trial of continuous once-daily oral afatinib plus sirolimus in patients with epidermal growth factor receptor mutation-positive non-small cell lung cancer and/or disease progression following prior erlotinib or gefitinib

ObjectivesDysregulation of the downstream PI3K/AKT/mTOR signaling pathway is a proposed mechanism of resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs). We investigated safety and antitumor activity of afatinib plus sirolimus as a potential combination to reverse acquired resistance to EGFR-TKIs in a phase IB trial in patients with EGFR mutation-positive non-small-cell lung cancer (EGFR mut NSCLC) and/or disease progression following prior erlotinib/gefitinib. Materials and methodsPatients with EGFR mut NSCLC and/or disease progression following at least prior erlotinib/gefitinib were included in the trial. The primary endpoint was incidence of dose-limiting toxicities (DLT) to determine the maximum tolerated dose (MTD). Four initial dose cohorts were proposed to evaluate DLTs. Other endpoints included tumor response, safety, progression-free survival (PFS) and pharmacokinetics. ResultsThirty-nine patients received afatinib and sirolimus. Additional dose cohorts were added since the second cohort (afatinib 40mg/day and sirolimus 5mg/day) was considered to have excessive toxicity. All patients experienced adverse events (AE) [grade 3: 66.7%; serious AE: 56.4%]. The most frequent AEs were diarrhea (94.9%), mucosal inflammation (64.1%), asthenia (53.8%) and rash (53.8%). Discontinuations and dose reduction due to AEs occurred in 23.1% and 25.6% of patients. MTD was determined as afatinib 30mg and sirolimus 1mg. Responses were observed in 5 patients (12.8%) [2 (5.1%) with confirmed partial response (PR); 3 (7.7%) with unconfirmed PR], and stable disease in 18 patients (46.2%). Four of the 5 responses were at doses above MTD. PFS at 6 months was estimated in 33.3% (median PFS 3.4 months). Pharmacokinetic parameters of afatinib and sirolimus were similar after single administration or in combination. ConclusionThe combination of afatinib and sirolimus showed lower responses than expected. Together with increased AEs and poor tolerability, this precludes clinical use and further clinical development of this combination. No pharmacokinetic interactions were observed. ClinicalTrials.gov IdentifierNCT00993499.

Sirolimus and Autophagy Inhibition in Lymphangioleiomyomatosis: Results of a Phase I Clinical Trial

Animal and cellular studies support the importance of autophagy inhibition in lymphangioleiomyomatosis (LAM). In a cohort of subjects with LAM, we tested the hypothesis that treatment with sirolimus and hydroxychloroquine (an autophagy inhibitor) at two different dose levels is safe and well tolerated. Secondary end points included changes in lung function. This 48-week, two-center phase I trial evaluated the safety of escalating oral hydroxychloroquine doses (100-200mg) given twice a day in combination with sirolimus to eligible patients≥ 18 years old with LAM. Subjects received combination therapy for 24weeks followed by an observation phase without taking study drugs for an additional 24weeks. Fourteen patients provided written informed consent. Thirteen were treated in cohorts of three patients each with escalating hydroxychloroquine doses (200 and 400mg) and an extension phase at the 400-mg dose. The most common adverse events were mucositis, headache, and diarrhea. No drug-related serious adverse events were reported. Secondary end points showed improvement in lung function at 24weeks, with a decrease in lung function at the 48-week time point. When the higher dose of hydroxychloroquine was analyzed separately, FEV1 and FVC remained stable at 48weeks, but the 6-min walk distance showed a decrease toward baseline. The combination of sirolimus and hydroxychloroquine is well tolerated, with no dose-limiting adverse events observed at 200mg twice a day. Potential effects on lung function should be explored in larger trials. ClinicalTrials.gov; No.: NCT01687179; URL: www.clinicaltrials.gov.

Sirolimus Combination with Tacrolimus in Kidney Transplant Recipients at High Immunological Risk: Observational Results 3 Years after Transplantation

Sirolimus Combination with Tacrolimus in Kidney Transplant Recipients at High Immunological Risk: Observational Results 3 Years after Transplantation

BLOCKADE OF EPIDERMAL GROWTH FACTOR RECEPTOR, CYCLOXYGENASE-2 (COX-2) AND MAMMALIAN TARGET OF RAPAMYCIN (M-TOR) IN ANIMAL MODEL OF LUNG CANCER

To explore the effectiveness and possible toxicity of the use of epidermal growth factor receptor inhibitor (EGFR Inhibitor), Celecoxib (COX2 inhibitor) and Sirolimus (m-TOR inhibitor) as single agents and drug combinations for the treatment of lung cancer in an experimental model. Lung cancer was induced in Balb-C mice by intraperitoneal injection urethane. Mice were treated with water (control) , Erlotinib (E) (50 mg/kg), Celecoxib (X) (50 mg/kg), Sirolimus (R) (2 mg/kg) given alone and in the following doublet and triplet combinations in the same dosages for 7 days. The number of pulmonary nodules in the combined treatment was significantly inhibited compared with control (p=0.010); E (p=0.028), EX (p=0.010), ERX (p=0.040) showed a smaller number of statistically significant nodules. Regarding coat changes we observe statistically significant differences among groups (p&lt;0.001) where ERX and ER had a higher occurrence of this change. There was a higher incidence of skin rashes in groups: E (p&lt;0.001), ER (p&lt;0.0001), and ERX (p&lt;0.001). Regarding weight we identify weight loss in the ERX (p=0.025). The combination of EGFR inhibitor, COX-2 inhibitor and m-TOR inhibitor had anti-tumor activity in experimental lung cancer. The combination of Celecoxib treatment with Erlotinib is a suggestion for decrease of dermatological events in patients. The combination of EGFR inhibitor and Sirolimus does not decrease the number of lung nodules and potentiates adverse events.

Sirolimus and metformin synergistically inhibit hepatocellular carcinoma cell proliferation and improve long-term survival in patients with HCC related to hepatitis B virus induced cirrhosis after liver transplantation.

Immunosuppressive agents used postoperatively after liver transplantation (LT) for hepatocellular carcinoma (HCC) favor recurrence and metastasis. Therefore, new effective immunosuppressants are needed. This retrospective study assessed combined sirolimus and metformin on survival of HCC patients after LT. In 2001-2013, 133 HCC patients with LT were divided into four groups: sirolimus and metformin combination (Sir+Met), sirolimus monotherapy (Sir), other immunosuppressants in diabetes mellitus (DM) patients without metformin (No Sir with DM), and other immunosuppressants in patients without DM (No Sir without DM). Kaplan-Meier and Log-rank tests were used to assess survival. Cell proliferation and tumor xenograft assays were performed to disclose the mechanisms underlying the sirolimus and metformin effects. The Sir+Met group showed significantly prolonged survival compared to the other groups. The most significant cytotoxicity was seen in the Sir+Met group, with significantly decreased levels of phosphorylated PI3K, AKT, AMPK, mTOR, 4EBP1 and S6K, compared with the other groups. In agreement, Sir+Met had the highest suppressive effect on tumor growth among all groups (P<0.01). In summary, Sir+Met treatment significantly prolonged survival, likely by suppressing cell proliferation. Therefore, this combination could represent a potential routine-regimen for patients post LT.

Effectiveness and safety of conversion therapy with the combination of sirolimus with low dose cyclosporine in renal transplantation recipients: a five-year clinical observation

To assess the effectiveness and safety of the conversion therapy from traditional cyclosporine (CsA) triple immunosuppression therapy to sirolimus (SRL) combined with low dose CsA and prednisone (Pred) in renal transplantation recipients in a five-year follow-up period. A prospective, open-label non-randomized study was performed with 46 renal allograft recipients who visited Tongji Hospital regularly for follow-up visits between January 2007 and May 2011 and were taking CsA+ mycophenolate mofetil (MMF)+ Pred. Conversion therapy to SRL+ low dose CsA+ Pred was initiated after renal transplantation. The recipients were allocated to 2 groups according to their renal function and proteinuria before the conversion: active conversion group [n=27, serum creatinine (SCr) ≤ 140 μmol/L with no or minimal proteinuria] and passive conversion group [n=19, SCr>140 μmol/L with less than moderate proteinuria]. After conversion, dosages of SRL and CsA were adjusted for trough levels of 5-7 μg/L and 20-60 μg/L, respectively. SCr and urine protein were compared before and after the conversion in five-year follow-up. Incidence of acute rejection, renal graft survival and SRL-related adverse effects of the immunosuppressive regimen were also observed. After conversion, an average 63% dose reduction of CsA was achieved in all the patients. In the active conversion group, the mean SCr level was (110±19) μmol/L at the time of conversion. Eight patients in this group withdrew from the study during the follow-up period for the following reasons: arthralgia (1 case), deteriorated proteinuria (2 cases), chronic diarrhea (2 cases), mild or suspicious acute rejection (2 cases), and recurrent fever (1 case). The rest patients (19/27) with a mean follow-up time of 5 years had a stable SCr level [(103±12) μmol/L] and a 100% 5-year graft survival. In the passive conversion group, the mean SCr level was (205±45) μmol/L at the time of conversion. There were 4 patients quitting the study, 2 for deteriorated proteinuria and 2 for lost to follow-up. Chronic allograft failure developed in 10 patients in this group 1-50 months after conversion, while the remaining 5 patients had a stable SCr during the 5-year follow-up period [(218 ±46) μmol/L before conversion vs (205±73) μmol/L 5 years after conversion]. The overall 5-year graft survival after the conversion therapy in the passive conversion group was 33.3%, significantly lower than that of the active conversion group (P<0.001). Acute rejection was observed in 2 cases in the active conversion group, while not observed in the passive conversion group. None of the patients developed leukopenia, thrombocytopenia, oral ulcer, or pneumonia in the follow-up. The combination therapy of SRL and low dose of CsA is overall a safe and effective maintenance immunosuppressive regimen, but it is important to initiate at an appropriate stage. More favourable long-term benefits may be obtained from the conversion therapy in patients with normal or only slightly impaired renal graft function. It may offer an option of individualized immunosuppressive therapy after renal transplantation.

Phase I study of safety and tolerability of sunitinib in combination with sirolimus in patients with refractory solid malignancies and determination of VEGF (VEGF-A) and soluble VEGF-R2 (sVEGFR2) in plasma

Sirolimus, an oral mTOR inhibitor, may complement the anti-angiogenic and anti-tumor activity of sunitinib, an oral small molecule inhibitor of multiple receptor tyrosine kinases, by vertical disruption of vascular epithelial growth factor receptor (VEGFR) signaling, by reducing the compensatory production of VEGF in sunitinib-treated patients and also by directly inhibiting tumor cell proliferation. We conducted this phase 1 study to investigate the maximum tolerated dose (MTD) for this combination of sunitinib and sirolimus in humans. Sunitinib was given at 50mg daily×28 every 6weeks. The first cohort received sunitinib alone for cycle 1 (50mg daily for 2weeks followed by 2weeks off) and received sunitinib at standard dose 50mg daily for 4weeks followed by 2weeks off in combination with sirolimus 4mg weekly; this dose and schedule were further investigated in second cohort. The third cohort received decreased dose of sunitinib at 37.5mg daily for 4weeks followed by 2weeks off in combination with sirolimus at 4mg weekly. Sirolimus dose was escalated to 8mg weekly in fourth cohort. Eighteen patients with ECOG PS of 0 or 1 were enrolled, median age 57years (range 24-76), M:F ratio: 11:7. Median number of prior treatments is 2 (range 0-5); six patients had no prior systemic therapy. Half of patients from the first two cohorts required dose reduction or early discontinuation of treatment; therefore, sunitinib dose was decreased to 37.5mg daily in third and fourth cohort. In third and fourth cohort, one-third of patients required dose modification during cycle 1 or cycle 2. Multiple patients had significant toxicities including fatigue and hand-foot syndrome. One patient developed interstitial pneumonitis, and one patient died suddenly on day 8 due to progressive disease. There were six patients who tolerated four or more cycles. Among these six patients, two patients with renal cell carcinoma (RCC) achieved partial response; one subsequently underwent surgical resection of residual renal mass and lymph node dissection and achieved complete response afterward. One with metastatic melanoma also achieved complete response after metastatectomy. There was no apparent pharmacokinetic interaction between sunitinib and sirolimus. 4mg weekly sirolimus did not reduce the sunitinib-induced circulating VEGF production but stimulated more VEGF production through some unknown compensatory mechanism. Toxicity precluded dose escalation of weekly sirolimus in combination with a standard sunitinib dose/schedule. These results suggest caution when combining targeted agents lacking specificity for tumor signaling or vasculature.

(768) - Proliferation Signal Inhibitors Prevent Donor-Specific Antibody Production in Sensitized Patients after Heart Transplantation

Everolimus and sirolimus are proliferation signal inhibitors (PSI) reported to decrease incidence and progression of transplant coronary artery disease, incidence of cardiac rejection, and development of de novo circulating antibodies (Abs) in the 1st year after heart transplant (Htx). Donor-specific Abs (DSA) appear to be a main factor associated with poor outcome in sensitized patients post-Htx. It is not established whether PSIs affect development of DSA in sensitized patients after Htx. Between 2010 and 2014, we evaluated 78 Htx patients (pts) with circulating Abs after Htx. Several were switched from mycophenolate mofetil (MMF) to PSI including everolimus (n=19) or sirolimus (n=11) in combination with a calcineurin inhibitor (CNI). Pts with pre-existing DSA were excluded. Pts were divided into 2 groups: maintenance of MMF use ≥1-year (Group A), and PSI use ≥ 1-year (Group B). Maintenance MMF group was matched to the switch-to-PSI group for time from Htx. Assessment of circulating Abs, including development of de novo DSA at 12 months after initiation of PSI was performed. In addition, 1-year subsequent survival and freedom from subsequent DSA development, cellular rejection, antibody-mediated rejection (AMR) were recorded. Reduction of PRA over 1 year was recorded for both groups. The PSI group compared to the MMF group had significantly greater freedom from de novo DSA development over the course of 1 year (see table). There was no significant difference between study groups in 1-year subsequent survival and 1-year subsequent freedom from cellular rejection and AMR. There was no significant difference with treatment of PSIs for subsequent 12-month Class I Abs levels %PRA (38 ± 37 vs. 33 ± 34, P=0.58) or Class II Abs levels %PRA (19 ± 29 vs. 20 ± 28, p=0.81). The use of PSIs in sensitized Htx pts appears to lower de novo development of subsequent DSA compared to maintenance MMF. Further study is warranted with a larger population.Tabled 1EndpointsGroup A Mycophenolate ≥ 1-Year (N=48)Group B PSI ≥ 1-Year (N=30)P-Value1-Year Subsequent Survival after PSI or MMF Initiation100.0%100.0%1.0001-Year Subsequent Freedom from De Novo Antibody Development after PSI or MMF Initiation86.9%100.0%0.0421-Year Subsequent Freedom from Any Treated Rejection93.8%96.7%0.5721-Year Subsequent Freedom from Acute Cellular Rejection97.9%96.7%0.7431-Year Subsequent Freedom from Antibody-Mediated Rejection97.9%93.2%0.3061-Year Subsequent Freedom from Biopsy Negative Rejection97.9%100.0%0.429 Open table in a new tab

Effect of stents coated with a combination of sirolimus and alpha-lipoic acid in a porcine coronary restenosis model

The aim of this study was to evaluate antiproliferative sirolimus- and antioxidative alpha-lipoic acid (ALA)-eluting stents using biodegradable polymer [poly-L-lactic acid (PLA)] in a porcine coronary overstretch restenosis model. Forty coronary arteries of 20 pigs were randomized into four groups in which the coronary arteries had a bare metal stent (BMS, n = 10), ALA-eluting stent with PLA (AES, n = 10), sirolimus-eluting stent with PLA (SES, n = 10), or sirolimus- and ALA-eluting stent with PLA (SAS, n = 10). A histopathological analysis was performed 28 days after the stenting. The ALA and sirolimus released slowly over 30 days. There were no significant differences between groups in the injury or inflammation score; however, there were significant differences in the percent area of stenosis (56.2 ± 11.78% in BMS vs. 51.5 ± 12.20% in AES vs. 34.7 ± 7.23% in SES vs. 28.7 ± 7.30% in SAS, P < 0.0001) and fibrin score [1.0 (range 1.0-1.0) in BMS vs. 1.0 (range 1.0-1.0) in AES vs. 2.0 (range 2.0-2.0) in SES vs. 2.0 (range 2.0-2.0) in SAS, P < 0.0001] between the four groups. The percent area of stenosis based on micro-computed tomography corresponded with the restenosis rates based on histopathological stenosis in different proportions in the four groups (54.8 ± 7.88% in BMS vs. 50.4 ± 14.87% in AES vs. 34.5 ± 7.22% in SES vs. 28.9 ± 7.22% in SAS, P < 0.05). SAS showed a better neointimal inhibitory effect than BMS, AES, and SES at 1 month after stenting in a porcine coronary restenosis model. Therefore, SAS with PLA can be a useful drug combination for coronary stent coating to suppress neointimal hyperplasia.