CsA Therapy Research Articles

Evaluation of adjuvant role of topical cyclosporine 1% in acute Stevens-Johnson syndrome: a randomised control trial

PurposeTo evaluate the role of topical cyclosporine A 1% (CsA) as an adjuvant therapy in patients with acute Stevens-Johnson syndrome (SJS).MethodsThis is a randomised controlled trial in which 44 patients...

Outcomes of Antithymocyte Globulin and Cyclosporine for Severe Aplastic Anemia

Background: Aplastic anemia (AA) is mediated by T cell destruction of hematopoietic stem and progenitor cells causing pancytopenia and bone marrow hypoplasia. The current standard of care for severe aplastic anemia (SAA) is hematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST) with antithymocyte globulin (ATG) plus cyclosporine (CsA) with or without eltrombopag (Epag), a thrombopoietin receptor agonist. HSCT is preferred for SAA in young adults as a curative option, but only a small proportion of patients have histocompatible siblings and mortality increases with age. The IST plus CsA combination with or without Epag has led to survival rates comparable with those observed with HSCT recipients. However, complete hematologic remission is rare with IST and there is a considerable risk of clonal complications, including PNH evolution and progression to MDS. The aim of this study was to evaluate outcomes of ATG plus CsA therapy in a large cohort of SAA patients. Methods: We retrospectively analyzed medical records of 156 patients with SAA, aged ≥2 years treated with ATG plus CsA with or without Epag at our institution between July 2000 and January 2023. Hematologic responses were evaluated at 3-, 6- and 12-months post therapy initiation. Super response (SR) was defined as hemoglobin ≥12 g/dL, platelet count ≥150x10 9/L and absolute neutrophil count (ANC) ≥1.0x10 9/L; complete response (CR) was defined as hemoglobin ≥10 g/dL, platelet count ≥100x10 9/L and ANC ≥1.0x10 9/L. Partial response (PR) was defined as not meeting the criteria for CR and SAA. Overall response encompassed SR, CR, and PR. Statistical analyses were performed with the use of Chi-squared test and Kaplan Meier method. Results: The median age at diagnosis was 52 (IQR 30-66) years, 47% were male, and 86% were Caucasian. Twenty three percent of the cohort had coexisting paroxysmal nocturnal hemoglobinuria. Most patients were treated with ATG plus CsA (92%), the remaining 8% additionally received Epag. Overall response rates were 70%, 67%, and 77% at 3-, 6- and 12-months post-treatment initiation, respectively. CR was achieved in 10%, 15%, and 18% at 3-, 6- and 12-months, respectively. SR was achieved in 16.3% of patients at 12 months, as shown in Figure 1. Patients who achieved SR were young with median age at diagnosis of 28 years, while those who achieved PR or no response had a median age of 54 and 56 years, respectively. Patients who responded to the ATG + CsA therapy had significantly higher baseline ANC (p=0.04), absolute reticulocyte count (ARC) (p<0.001) and absolute lymphocyte count (ALC) (p<0.001). Pre-treatment median values of ANC, ARC and ALC were higher for patients who achieved SR compared to the rest of responders. With a median follow up time of 4.5 years, the estimated median relapse free survival was 9.2 years (95% CI, 3.2 - not reached [NR]) (Figure 2). Of the entire cohort, 21 (13%) patients progressed to acute myeloid leukemia or myelodysplastic syndrome. At data cut off, a total of 66 patients had died; the estimated median OS was 11.6 years (95% CI, 8.4 - NR). In particular, 30 patients died within the first 12-months, 13 within 3-months of ATG initiation from treatment-related complications, 6 from pneumonia and the rest from unknown causes. Conclusion: The findings of our study demonstrate that ATG plus CsA is an effective and safe treatment option for patients with SAA, especially in the older patient population where HSCT-related toxicities can lead to high mortality. Those with higher baseline ALC, ANC and ARC were more likely to respond to therapy compared to those with lower counts. A small percentage of patients progressed to myeloid neoplasia. Mortality within the first 12-months was high, indicating the need for close monitoring to avoid treatment-related mortality.

Population Pharmacokinetics of Cyclosporine in Chinese Pediatric Patients With Acquired Aplastic Anemia.

Cyclosporine (CsA) is a component of the first-line treatment for acquired aplastic anemia (acquired AA) in pediatric patients. This study aimed to develop a population pharmacokinetic (PK) model of CsA in Chinese pediatric patients with acquired AA to inform individual dosage regimens. A total of 681 CsA whole blood concentrations and laboratory data of 157 pediatric patients with acquired AA were retrospectively collected from two hospitals in Shanghai. A nonlinear mixed-effect model approach was used to build the population PK model. Potential covariate effects of age, body weight, and biochemical measurements (renal and liver functions) on CsA PK disposition were evaluated. Model fit was assessed using the basic goodness of fit and a visual predictive check. The CsA concentration data were accurately described using a two-compartment disposition model with first-order absorption and elimination. Body weight value was implemented as a fixed allometric function on all clearance and volume of distribution parameters. Total bilirubin level was identified as a significant covariate on apparent clearance (CL/F), with a 1.07% reduction per 1 nmol/L rise in total bilirubin level. The final estimates for CL/F and central volume (Vc/F) were 29.1 L/h and 325 L, respectively, for a typical 28 kg child. Other covariates (e.g., gender, age, albumin, hemoglobin, hematocrit, serum creatinine, and concomitant medication) did not significantly affect the PK properties of CsA. This population PK model, along with a maximum a posteriori Bayesian approach, could estimate individual PK parameters in pediatric patients with acquired AA to conduct individual CsA therapy.

Levamisole Suppresses CD4+ T-Cell Proliferation and Antigen-Presenting Cell Activation in Aplastic Anemia by Regulating the JAK/STAT and TLR Signaling Pathways.

Aplastic anemia (AA) is a life-threatening disease primarily caused by a metabolic disorder and an altered immune response in the bone marrow (BM) microenvironment, where cytotoxic immune cells attack resident cells and lead to hematopoietic failure. We previously reported an efficient strategy by applying cyclosporin (CSA) combined with levamisole (CSA+LMS-based regimen) in the treatment of AA, but the immunoregulatory mechanism of LMS was still unclear. Here, the therapeutic effects of LMS were examined in vivo using the BM failure murine model. Meanwhile, the proportion and related function of T cells were measured by flow cytometry in vivo and in vitro. The involved signaling pathways were screened by RNA-seq and virtual binding analysis, which were further verified by interference experiments using the specific antagonists on the targeting cells by RT-PCR in vitro. In this study, the CSA+LMS-based regimen showed a superior immune-suppressive response and higher recession rate than standard CSA therapy in the clinical retrospective study. LMS improved pancytopenia and extended the survival in an immune-mediated BM failure murine model by suppressing effector T cells and promoting regulatory T-cell expansion, which were also confirmed by in vitro experiments. By screening of binding targets, we found that JAK1/2 and TLR7 showed the highest docking score as LMS targeting molecules. In terms of the underlying molecular mechanisms, LMS could inhibit JAK/STAT and TLR7 signaling activity and downstream involved molecules. In summary, LMS treatment could inhibit T-cell activation and downregulate related molecules by the JAK/STAT and TLR signaling pathways, supporting the valuable clinical utility of LMS in the treatment of AA.

0864 Severe Central Sleep Apnea

Abstract Introduction Central sleep apnea (CSA) is a rare form of sleep disordered breathing with repeated apneic episodes with absence of associated respiratory effort. CSA due to medication is well described in literature with opiate therapy. Baclofen which is a gamma-aminobutyric acid-B agonist with muscle relaxant properties has been implicated in CSA. We present a rare case of CSA likely due to chronic baclofen use. Patient underwent a polysomnogram (PSG) while on baclofen therapy which revealed severe central sleep apnea. Patient was weaned off baclofen therapy completely and a subsequent PSG was performed which revealed resolution of the CSA. Methods 28 year old male with cerebral palsy and neurogenic bladder who presented for evaluation of snoring, chronic insomnia and non-refreshing sleep. Overnight PSG was performed for further evaluation of his sleep related complaints while on chronic baclofen therapy, which revealed severe central sleep apnea. Trial of positive airway pressure therapy for treatment of CSA and supplemental oxygen therapy were attempted during the PSG but had to be terminated due to intolerance. Echocardiography and magnetic resonance imaging of the brain were performed to rule out congestive heart failure and Chiari malformation respectively, which revealed no underlying pathology to explaining the CSA. CSA in this patient was thought to be associated with chronic baclofen therapy. Patient was weaned off baclofen with repeat PSG revealing resolution of the CSA. Results 1st diagnostic PSG - on Baclofen: 139 central apneas, 6 obstructive apneas, 3 mixed apnea, and 38 hypopneas. This study showed severe central sleep apnea. The apnea-hypopnea index (AHI) was 51.5, REM index 21.8 and supine index 51.5. Central apnea index 39.5. Respiratory events were associated with moderate oxygen desaturations. The mean oxygen saturation during the study was 92.8%, with a minimum oxygen saturation of 81%. The patient spent 2.9 minutes with an oxygen saturation equal to or less than 88% for the entire study. CPAP titration was attempted and aborted, due to patient having difficulty tolerating CPAP. Supplemental oxygen was briefly added at 0.5 LPM, which was also discontinued due to patient complaining of burning sensation in the nose. Head of the bed was elevated at several levels (20 degrees, 30 degrees and 45 degrees) which did not attenuate the respiratory events. 2nd Diagnostic PSG – patient weaned off baclofen for study – Sleep efficiency reduced at 59.4%. Sleep onset latency 7.5 minutes. REM latency 163 minutes. 100% of total sleep time in supine position Moderate snoring. The apnea-hypopnea index (AHI) was 4.2, REM index 36.5 and supine index 4.2. Respiratory events were mainly noted using REM sleep. Respiratory events were associated with moderate oxygen desaturations. The mean oxygen saturation during the study was 93.9%, with a minimum oxygen saturation of 83%. The patient spent 1.2 minutes with an oxygen saturation equal to or less than 88% for the entire study. Labs and imaging – Workup for severe central sleep apnea after first diagnostic sleep study – Echo and MRI brain, which revealed no underlying pathology explaining his central sleep apnea. Therefore, thought to be due to baclofen. Conclusion 28 year old male, concurrent and past medical history of cerebral palsy, neurogenic bladder. Presented, initially to sleep medicine clinic for complaints of insomnia, snoring, and non-refreshing sleep. Wheelchair bound. Has muscle spasticity, was on baclofen. Underwent initial sleep study, for snoring and insomnia. The initial PSG was on baclofen doses. His initial PSG – showed apnea-hypopnea index (AHI) of 51.5, REM index 21.8 and supine index 51.5, Central apnea index 39.5. Oxygen nadir – 81%. Patient had 139 central sleep apnea events. Patient had MRI and echo, which revealed no pathology to explain his severe central sleep apnea. Baclofen on his medicine list – was the concern for the driving force behind his central sleep apnea. As a result, baclofen was weaned and stopped. Repeat PSG – showed moderate snoring, overall AHI greatly improved from first study to 4.2. Respiratory events were associated with moderate oxygen desaturations. The mean oxygen saturation during the study was 93.9%, with a minimum oxygen saturation of 83%. The patient spent 1.2 minutes with an oxygen saturation equal to or less than 88% for the entire study. In closing – due to the side effect profile of baclofen leading to central sleep apnea in this case, recommend alternative therapy in place of baclofen due to severe central sleep apnea with baclofen use. Support (If Any) 1. Ghanavatian S, Derian A. Baclofen. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 15, 2021.2. Locatelli F, Formica F, Galbiati S, et al. Polysomnographic Analysis of a Pediatric Case of Baclofen-Induced Central Sleep Apnea. J Clin Sleep Med. 2019;15(2):351-354. Published 2019 Feb 15. doi:10.5664/jcsm.76443. Olivier PY, Joyeux-Faure M, Gentina T, et al. Severe Central Sleep Apnea Associated With Chronic Baclofen Therapy: A Case Series. Chest. 2016;149(5):e127-e131. doi:10.1016/j.chest.2015.10.001

Immunosuppressive Therapy in Large Granular Lymphocyte Leukemia-Associated Pure Red Cell Aplasia: Cyclophosphamide Responded Better Than Cyclosporine

BackgroundLarge granular lymphocyte leukemia associated pure red cell aplasia (LGLL-PRCA) accounts for a significant portion of secondary PRCA. Cyclosporine (CsA) and cyclophosphamide (CTX) are the main immunosuppressive agents used in treating LGLL-PRCA [1]. Considering the cytotoxicity of CTX, CsA may be proposed as first-line therapy [2]. However, because of the rarity of LGLL-PRCA, long-term responses and relapse rates after CsA and CTX therapy are largely unknown.Methods and resultsFrom September 2009 to December 2020, we selected 65 uniformly diagnosed LGLL-PRCA and analyzed clinical features and treatment outcomes of CsA and CTX.In the present study, 43.1% harbored neutropenia (<1.5×10 9/L) and only 1 patient had spondyloarthritis (Table 1). Besides, we found that 9.2% developed recurrent oral ulcer and 18.5% had reduced serum complemet C3 level, both of which were related to abnormal immune status.In our cohort, 44 patients received CsA therapy and 21 patients received CTX therapy. 53.8% (35/65) obtained erythroid lineage response and 26.2% (17/65) achieved complete response. CTX produced higher response rate (81.0% vs 40.9%, P=0.002) and complete response rate (47.6% vs 15.9%, P=0.007) than CsA. We further analyzed related factors influencing efficacy by Binary-Logistic multivariate regression model and found that higher response rate was mainly related to CTX therapy (P=0.02) (Table 2).We detected STAT3 and STAT5b gene in 50 cases. None of the patients had STAT5b mutation and 14 patients had STAT3 mutation. 12 of 14 mutation cases were non-elderly patients (<60 years ). For younger patients, STAT3 mutation was more frequent (85.7% vs 22.2%, P<0.01). In STAT3 mutation group, patients appeared to respond better to CTX than CsA (83.3% vs 37.5%, P=0.138).Up to the last follow-up, 11 patients treated with CsA recurred after CsA reduction or discontinuation, with a median relapse time of 10 (3~80) months after remission. Only 1 patient relpsed after the discontinuation of CTX due to neutropenia and returned to remission status after CTX retreatment. In our research, CsA had higher recurrence rate than CTX without statistical significance (25.0% vs 4.8%, P=0.104).DiscussionCsA may be proposed as first-line therapy for LGLL-PRCA [2,3]. CTX also appears to be a good treatment choice, but CTX should not be used for more than 12 months since associated toxicities and the risk for developing myelodysplastic syndromes and acute myeloid leukemia. Therefore, it is necessary to compare the efficacy of CsA or CTX in the treatment of LGLL-PRCA.Deep sequencing analyses of residuals LGLL clones reveals that CTX could eradicate LGLL clones, providing durable response, low relapse rate, whereas CsA is associated with the persistence of leukemic clones, and high frequency of relapse [4]. Our results show that the response rate of CTX is higher than CsA (P=0.02), and the probability of recurrence is relatively low (25.0% vs 4.8%, P=0.104). This is consistent with the results of previous study by Rajala [4].It was important to note that patients with STAT3 mutations are more likely to respond to MTX [5]. Our study showed that the response rate for CTX was 83.3% in patients with STAT3 mutations, which was seemingly higher than CsA (37.5%), although remained statistically insignificant (P=0.138) that might be due to small number of cases.ConclusionsThe results of the current study may reflect the real world experience of LGLL-PRCA in whom treated by CTX or CsA, may be limited by its retrospective nature, small cohorts. In preliminary conclusion, LGLL-PRCA could acquired better response to CTX than CsA. Besides, CTX may reduce relapse.

Factors Affecting Time-Varying Clearance of Cyclosporine in Adult Renal Transplant Recipients: A Population Pharmacokinetic Perspective.

The pharmacokinetic (PK) properties of cyclosporine (CsA) in renal transplant recipients are patient- and time-dependent. Knowledge of this time-related variability is necessary to maintain or achieve CsA target exposure. Here, we aimed to identify factors explaining variabilities in CsA PK properties and characterize time-varying clearance (CL/F) by performing a comprehensive analysis of CsA PK factors using population PK (popPK) modeling of long-term follow-up data from our institution. In total, 3674 whole-blood CsA concentrations from 183 patients who underwent initial renal transplantation were analyzed using nonlinear mixed-effects modeling. The effects of potential covariates were selected according to a previous study and well-accepted theoretical mechanisms. Model-informed individualized therapeutic regimens were also evaluated. A two-compartment model adequately described the data and the estimated mean CsA CL/F was 32.6Lh-1 (relative standard error: 5%). Allometrically scaled body size, hematocrit (HCT) level, CGC haplotype carrier status, and postoperative time may contribute to CsA PK variability. The CsA bioavailability in patients receiving a prednisolone dose (PD) of 80mg was 20.6% lower than that in patients receiving 20mg. A significant decrease (52.6%) in CL/F was observed as the HCT increased from 10.5% to 60.5%. The CL/F of the non-CGC haplotype carrier was 14.4% lower than that of the CGC haplotype carrier at 3months post operation. By monitoring body size, HCT, PD, and CGC haplotype, changes in CsA CL/F over time could be predicted. Such information could be used to optimize CsA therapy. CsA dose adjustments should be considered in different postoperative periods.

Hematopoietic stem progenitor cells lacking HLA differ from those lacking GPI-anchored proteins in the hierarchical stage and sensitivity to immune attack in patients with acquired aplastic anemia.

To characterize glycosylphosphatidylinositol-anchored protein-deficient (GPI[-]) and HLA-class I allele-lacking (HLA[-]) hematopoietic stem progenitor cells (HSPCs) in acquired aplastic anemia (AA), we studied the peripheral blood (PB) of 56 AA patients in remission who possessed both (n = 13, Group A) or either GPI(-) (n = 34, Group B) and HLA(-) (n = 9, Group C) cell populations. Seventy-seven percent (10/13) of Group A had HLA(-) cells in all lineages of PB cells, including platelets, while only 23% (3/13) had GPI(-) cells in all lineages, and the median percentage of HLA(-) granulocytes in the total granulocytes (21.2%) was significantly higher than that of GPI(-) granulocytes (0.28%, P < 0.05). The greater lineage diversity in HLA(-) cells than in GPI(-) cells was also seen when Group B and Group C were compared. Longitudinal studies of seven patients in Group A showed a gradual decrease in the percentage of HLA(-) granulocytes, with a reciprocal increase in the GPI(-) granulocytes in four patients responding to cyclosporine (CsA) and an increase in the HLA(-) granulocytes with a stable or declining GPI(-) granulocytes in three patients in sustained remission off CsA therapy. These findings suggest that HLA(-) HSPCs differ from GPI(-) HSPCs in the hierarchical stage and sensitivity to immune attack in AA.

Role of combined immunomodulator therapy in severe steroid intolerant vernal keratoconjunctivitis

To describe the role of combined topical cyclosporine (CsA) 0.1% and tacrolimus 0.03% in cases with severe steroid intolerant vernal keratoconjunctivitis (VKC). Medical records of patients with acute exacerbation of VKC and steroid intolerance referred from glaucoma to cornea clinic were reviewed from March 2017 to December 2018. Eleven patients (22 eyes), (nine with steroid-induced glaucoma, two with steroid-induced cataract and glaucoma) were found. All were started on topical CsA 0.1% QID. Due to suboptimal response at 2 weeks, topical tacrolimus 0.03% BD was also included. The mean total subjective score at presentation was 13 ± 1.4, which reduced to 11.2 ± 1.3 at 2 weeks of topical CsA therapy and further reduced to 5 ± 0 at 2 weeks of combination therapy (p < 0.001). The mean total objective score at presentation was 9.4 ± 1.4 that reduced to 8.0 ± 1.3 at 2 weeks of topical CsA therapy and further reduced to 4.3 ± 1.6 at 2 weeks of combination therapy (p < 0.001). Similar results were obtained in a sub-group analysis including the worse eye or right eye of the cases only. The absolute change in the total subjective and objective score was much more with combination therapy. Photophobia and conjunctival hyperemia resolved within 4 weeks of combined therapy. No recurrence was observed till 6 months follow-up. Combined use of cyclosporine and tacrolimus may lead to rapid resolution of symptoms and reduced recurrence rate in cases with severe VKC where steroid has to be avoided.

Role of Multidrug Resistance Proteins in Nonresponders to Immunomodulatory Therapy for Noninfectious Uveitis.

PurposeNearly a third to half of patients with noninfectious uveitis (NIU) fail to achieve control with immunomodulatory therapy (IMT). Multidrug resistance (MDR) proteins are transmembrane proteins that allow efflux of intracellular drugs, leading to drug resistance. The aim of our study was to compare MDR protein function in blood CD4+ cells between responders and nonresponders to IMT.MethodsWe included NIU patients on IMT for ≥6 months and corticosteroid dose ≤10 mg/d. Nonresponders to treatment were those with worsening (two or more steps) of inflammation in the past 3 months on full-dose immunosuppressive therapy. MDR function was assessed by Rhodamine-123 dye retention in blood CD4+ cells. Three nonresponders were treated with adjunctive oral cyclosporine A (CSA, MDR inhibitor) therapy for 2 months and reevaluated.ResultsFourteen NIU patients were recruited. Most (n = 8) had Vogt-Koyanagi-Harada disease. These included nine nonresponders and five responders to IMT. Nonresponders produced significantly higher MDR function and proinflammatory cytokines (interferon γ, tumor necrosis factor α, interleukin 17, and Granulocyte Macrophage Colony Stimulating Factor (GM-CSF)) than responders. In vitro CSA treatment of CD4+ cells inhibited MDR expression and proinflammatory cytokine production while increasing Foxp3. Finally, adjunctive oral CSA therapy led to improvement in clinical inflammatory scores with a concurrent decrease in MDR function and proinflammatory cytokine secretion.ConclusionsMDR function is significantly higher in CD4+ T cells of nonresponders to IMT. Adjunctive CSA therapy may decrease MDR function and allow improvement in treatment response to IMT.Translational RelevanceOur study highlights the need for MDR inhibition strategies in NIU patients not responding to IMT for improving the efficacy of anti-inflammatory therapy.

Distinct Escape Mechanisms of HLA Class I Allele-Lacking Hematopoietic Stem Progenitor Cells (HSPCs) from GPI-Deficient HSPCs in Acquired Aplastic Anemia

[Background] In cases of immune-mediated bone marrow (BM) failure, such as acquired aplastic anemia (AA) and AA/PNH, aberrant hematopoietic stem progenitor cells (HSPCs) that acquire resistance to immune attack are thought to survive and support hematopoiesis in convalescent patients. Two representative progenies of such "escape" HSPC clones are HLA class I allele-lacking (HLA[-]) leukocytes and glycosylphosphatidylinositol-anchored protein-deficient (GPI[-]) cells. The mechanism underlying the immune selection of HLA(-) HSPCs is the failure of cytotoxic T lymphocyte (CTL) to recognize target antigens that are presented by particular HLA class I alleles of HSPCs. However, the mechanisms underlying the immune selection of GPI(-) HSPCs remain unclear. In addition, whether or not immune pressure that persists after immunosuppressive therapy (IST) contributes to the development and maintenance of clonal hematopoiesis by HLA(-) or GPI(-) HSPCs that are often seen in patients in long-term remission is also unknown. Phenotypical analyses of HSPCs that can be obtained from peripheral blood (PB) of AA patients who possess HLA(-) or GPI(-) leukocytes may provide a hint to elucidate these unsolved issues. [Objectives/Methods] We analyzed PB lineage-CD45dimCD34+CD38+ HSPCs of 15 AA patients who had 1%-99% HLA-A2(-) or HLA-A24(-) granulocytes (Gs) using flow cytometry (FCM). PB samples from 1 patient with severe AA were obtained before IST while the other 14 patients were in remission at the time of sampling; 10 were on cyclosporin (CsA) and eltrombopag (EPAG) (n=1), CsA and anabolic steroids (n=3), CyA (n=4), anabolic steroids (n=1) and EPAG alone (n=1); and 4 were free of therapy. We also determined the percentages of HLA(-) cells in different CD34+ subsets of BM, including HSCs (CD38-CD90+CD45RA-), MPPs, CMPs, GMPs, MEPs and CLPs for patients whose BM cells were available. Six AA/PNH patients whose GPI(-) Gs were 4-99% of the total Gs were subjected to the same PB HSPC analysis. For a separate group of seven AA patients who responded to CsA and had both HLA(-) and GPI(-) G populations, the percentages of each population were serially determined over one to 12 years. [Results] FCM identified 0.01%-0.4% (median 0.01%) CD45dimCD34+CD38+ HSPCs in the mononuclear cell population of the 15 AA patients, values that were significantly lower than those of seven healthy volunteers (0.19-0.78%, median 0.58%, P&lt;0.05). In 4 of the 9 patients on treatment and in 4 patients who had been free of therapy, the percentages of HLA(-) cells in HSPCs were similar to those of Gs (1%/1%, 1%/1%, 14%/15% and 100%/98% in the 4 treated patients; 16%/11% in the untreated patient; 13%/13%, 95%/95%, 99%/99% and 99%/99% in the 4 patients in remission after therapy). BM subsets including HSCs of 2 patients whose Gs and PB HSPCs lacked HLA-A2 almost completely, were 99% negative for HLA-A2. In contrast, in the remaining 6 patients, the percentages of HLA(-) cells in HSPCs were markedly lower than those in Gs (0%/25%, 2%/7%, 4%/65%, 6%/77% [Case 1], 9%/75% and 10%/39% [Case 2]), suggesting the persistence of CTL attack against HPCs or more differentiated myeloid cells (Figure 1). In contrast to HLA(-) PB HSPCs, there was no discordance in the percentage of GPI(-) cells between PB Gs and HSPCs (4%/4%, 49%/50%, 94%/100%, 96%/96%, 96%/99% and 99%/92%) in all 6 AA/PNH patients including 3 responding to CsA. Lastly, serial changes in the percentage of PB HLA(-) and GPI(-) Gs during CsA therapy were compared in seven patients who possessed both aberrant cells. In 4 patients who were responding to CsA, the HLA(-) G percentage gradually decreased in 3 and remained stable in the remaining one, while the GPI(-) G percentage reciprocally increased in 3 and remained stable in one. In contrast, in 3 patients who obtained sustained remission after CsA therapy, the HLA(-) G percentage increased after cessation of CsA. The GPI(-) G percentages decreased in 1 and remained unchanged in 2 (Figure 2). [Conclusions] Immune selection that favors the survival of HLA(-) HSPCs or HPCs takes place even in AA patients who have been in remission for many years after successful IST and may contribute to clonal hematopoiesis by HLA(-) HSPCs. Given no signs of selection at the HSPC stage and the reciprocal increases in the percentage of GPI(-) Gs in AA/PNH patients responding to CsA therapy, the proliferation of GPI(-) HSPCs may not be affected by immune pressure in convalescent patients. Disclosures Yoroidaka: Ono Pharmaceutical: Honoraria. Nakao:Ono Pharmaceutical: Honoraria; Chugai Pharmaceutical Co.,Ltd: Honoraria; Takeda Pharmaceutical Company Limited: Honoraria; Celgene: Honoraria; Novartis Pharma K.K: Honoraria; SynBio Pharmaceuticals: Consultancy; Daiichi-Sankyo Company, Limited: Honoraria; Janssen Pharmaceutical K.K.: Honoraria; Bristol-Myers Squibb: Honoraria; Ohtsuka Pharmaceutical: Honoraria; Alaxion Pharmaceuticals: Honoraria; Kyowa Kirin: Honoraria.

Premature cyclosporine cessation and TBI-containing conditioning regimen increase the risk of acute GvHD in children undergoing unrelated donor hematopoietic stem cell transplantation.

Acute graft-versus-host disease (aGvHD) is a potentially fatal complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Identifying its risk factors would enable the proper prophylaxis and management, which may significantly improve the general outcome of children treated with HSCT. The aim of this single-center, retrospective cohort study was to assess the potential risk factors for grades II-IV of aGvHD in children after the 1st allo-HSCT from an unrelated donor (UD), performed as a result of an underlying malignant disease. From among patients who received HSCT in our center in the years 2004-2015, 237 were included in the study cohort. All the patients received standard aGvHD prophylaxis consisting of cyclosporine (CsA) and a short course of methotrexate (MTX). Various clinical and epidemiological features, the transplant proceedings, graft composition, conditioning regimens, as well as the duration and coherence of aGvHD prophylaxis were analyzed as potential risk factors for aGvHD. The incidence of II-IV aGvHD in the study cohort was 58.6%. The median time of the diagnosis of aGvHD was 18 days post-HSCT. In the multivariate analysis, risk factors significantly associated with grades II-IV of aGvHD were: myeloablative conditioning regimen containing total body irradiation (TBI-MAC) (RR (relative risk): 1.69; p = 0.03), premature termination of CsA administration due to its toxicity (RR: 1.99; p = 0.0003) and HSCT performed before the year 2009 (RR: 1.97; p = 0.0001). Donor and recipient age, donor-recipient sex mismatch, stem cell source, risk of disease, and amount of infused CD34+ cells seem to be insignificant as risk factors for aGvHD. The overall survival (OS) of patients with aGvHD was noticeably worse that in those who were aGvHD-free: 60.8% vs 74.1% (p = 0.08). The conditioning regimen and the proper aGvHD prophylaxis, including continuous CsA administration, have a major impact on aGvHD occurrence. According to our results, the termination of CsA therapy should be carefully considered, and avoided if possible.

Ameliorated and antioxidant effects of Fucoidan against cyclosporine A-induced kidney injury in rats

BackgroundCyclosporine A (CsA) is an immunosuppression agent used frequently in fields of organs transplantation and autoimmune diseases. However, CsA-induced kidney injury is a major clinical problem associated with CsA therapy in which the conceivable accountable mechanism is oxidative stress (OS). The present study evaluated the protective and ameliorated effects of fucoidan (FU) as an antioxidant and an anti-inflammatory agent against CsA-induced kidney injury.MethodsMale rats were randomly divided into three groups. The first group was served as a control group that administered olive oil orally and normal saline subcutaneously, the second group (CA) was treated with CsA orally, and the third group (CA + FU) was treated with CsA orally in concomitant with FU subcutaneously. Experimental animals were sacrificed 20 days following the treatment period and serum samples were analyzed for creatinine test. The homogenate of renal tissues was prepared for OS assessment. Light and ultrastructure microscopic kidney sections were prepared for histopathological examination.ResultsTreatment of rats with CsA alone produced a significant increase in the levels of creatinine, nitric oxide (NO), and malondialdehyde (MDA), as well as the activities of superoxide dismutase (SOD), catalase (CAT), and glucose 6 phosphate dehydrogenase (G6PD), whereas the level of glutathione reduced (GSH) was decreased. Some histopathological changes of the kidney tissue including tubular epithelial hypertrophy, vacuolizations, necrotic glomerulus cell, capillaries network shrinking, vascular congestion, interstitial infiltration, loss of apical microvilli, and deteriorated mitochondria were observed in CA group. Concomitant FU administration with CsA enhanced renal function, as indicated by the low level of creatinine. Moreover, FU ameliorated the oxidative status in kidney tissue as well as it provided histological protection against CsA-induced kidney injury.ConclusionFU can develop a protective mechanism against kidney injury induced by CsA that mediated by OS.

PF707 INCIDENCE AND OUTCOMES OF REFRACTORY IMMUNE THROMBOCYTOPENIC PURPURA IN CHILDREN; A SINGLE INSTITUTION EXPERIENCE

Background:The treatment of refractory immune thrombocytopenic purpura (ITP) in children is challenging. Although various medical approaches have been used to treat refractory ITP, few data are available on the long‐term incidence of outcomes in children with refractory ITP.Aims:In this study, we aimed to reveal the outcomes of 87 children with ITP in our institution during the last 19 years.Methods:We retrospectively reviewed the clinical data of children who were newly diagnosed with ITP from April 1998 to March 2017 at the Nihon University Itabashi Hospital. Patients aged below 16 years were included in this study. Patients with follow‐up duration of less than 3 months were excluded. In this study, refractory ITP was defined as a platelet count of &lt;50 × 109 /L, which did not respond to intravenous immunoglobulin (IVIG) and prednisolone (PSL). The definition of the treatment response was as follows: complete response (CR) or partial response (PR), platelet count sustaining more than 100 × 109/L or between 50 and 100 × 109/L at 6 months after change in the treatment approach, respectively. Since 2009, we have introduced cyclosporine (CSA) for refractory ITP; we have diagnosed refractory ITP as refractory thrombocytopenia, which is a subtype of refractory cytopenia of childhood, and then we have used CSA for such patients. In this study, we compared the incidence of CR plus PR in refractory ITP at 3 years after diagnosis in the 1998–2008 group and in the 2009–2017 group. This retrospective study was approved by the institutional review board.Results:A total of 87 children with ITP were identified (50 males and 37 females): 42 children (48%) in the 1998–2008 group and 45 children (52%) in the 2009–2017 group. There were 9 patients (21%) with refractory ITP in the 1998–2008 group and 8 patients (18%) in the 2009–2017 group. Treatment chart in 17 patients with refractory ITP are shown in Figure 1. We changed the diagnosis of ITP to refractory thrombocytopenia in the all patients with refractory ITP in the 2009–2017 group, and initiated treatment with CSA. CSA was started at a dose of 4–6 mg/kg/day (per oral), and the trough level was adjusted between 100 and 150 ng/ml. Two patients achieved CR by CSA therapy alone at 16 and 119 days after starting CSA therapy, respectively. One patient achieved PR with the addition of PSL. Five patients did not respond to CSA therapy alone and then received IVIG at the CSA trough level of more than 100 ng/ml. With this approach, 4 patients achieved CR at a median time of 21 days (range, 13–38) after starting CSA therapy. Overall, 7 out of the 8 patients with refractory ITP in the 2009–2017 group maintained CR plus PR at 3 years after diagnosis. No severe CSA‐associated adverse event was seen in any patients. In contrast, only 2 out of 9 patients with refractory ITP in the 1998–2008 group achieved CR spontaneously (without additional treatment) at 3 years after diagnosis. Moreover, 2 patients obtained CR after splenectomy, and the other 5 patients remained with thrombocytopenia.Summary/Conclusion:CSA with or without IVIG therapy was effective in most cases (88%) of childhood refractory thrombocytopenia. These findings indicate that childhood thrombocytopenia is partially mediated by T cells. Although splenectomy was a conventional treatment for refractory ITP, it surely increases the long‐term risks of venous and arterial thrombosis as well as sepsis from Streptococcus pneumoniae. Therefore, CSA with or without IVIG therapy is feasible in children with refractory ITP to avoid splenectomy.image

P053 TARGETED RELEASE ORAL CYCLOSPORINE FORMULATION AS A POTENTIAL NEW THERAPY FOR ULCERATIVE COLITIS

Ulcerative colitis (UC) is a chronic inflammatory disease of the colonic mucosa. Infliximab has long been a standard therapy for moderate to severe UC. IV followed by oral cyclosporine (CsA) has demonstrated similar safety and efficacy to infliximab for the treatment of acute UC; however, prolonged use for the maintenance of remission is limited due to concerns about side effects of systemically available CsA. There remains a need for an oral CsA therapy that controls UC disease activity while minimizing systemic exposure. ST-0529 is a novel, orally administrated, solubilized CsA formulation designed to optimize the delivery of drug to colonic tissue while minimizing systemic absorption. To characterize the whole blood pharmacokinetics of ST-0529 following single and multiple oral doses (ODs), and compare to the pharmacokinetic profile following CsA IV infusion in healthy male subjects. To establish CsA colonic mucosa concentrations following single or twice-daily (BID) ODs and various dosage regimens of ST-0529 for seven days, comparing them to CsA continuous IV infusion. In Stage 1, a total of 24 eligible healthy male subjects received either 2 mg/kg/day of IV CsA over two consecutive 12-hour infusions (per protocol) and a once- or a twice-daily ODs of 75 mg ST-0529 for seven days. The protocol allowed to conduct further investigations with alternative ST-0529 doses and dose frequencies after review of Stage 1 data. Following this review, eight subjects recruited to Stage 2 received 37.5mg ST-0529 once-daily orally for seven days. A further eight subjects recruited to Stage 3 received 150mg ST-0529 BID ODs for seven days. Single dose systemic exposure to CsA was considerably lower (~5%) following treatment with ST-0529 ranging from 37.5 mg to 300 mg daily for seven days compared with 24-hour continuous IV 2 mg/kg/day infusion. All ST-0529 dosage groups tested achieved colon tissue concentrations comparable to or above that attained during IV CsA administration with the 75 mg BID and 150 mg BID groups sustaining the minimum tissue concentrations achieved following IV infusion and being substantially higher than that achieved by 37.5 mg OD and 75 mg OD groups. A total of 26 subjects (54.2%) reported treatment-emergent adverse events (TEAEs) during the study. All were mild or moderate; there were no severe TEAEs reported. The study demonstrated ST-0529 achieved similar or higher colonic tissue concentrations than continuous IV CsA infusion with substantially lower systemic exposure. These data suggest that ST-0529 may provide similar or enhanced efficacy to IV or oral CsA formulations with an improved tolerance profile and thus support further development as a treatment for the induction and maintenance of remission in UC. Mean CsA concentrations and AEs Mean CsA concentrations and AEs

Reactivation of Hepatitis B Virus Infection in Aplastic Anemia Patients Receiving Immunosuppressive Therapy

▪Objective: The aim of this study was to assess the risk of HBV reactivation in HBsAg-positive or negative, HBcAb-positive patients with aplastic anemia (AA) receiving immunosuppressive therapy.Methods: We analyzed clinical data of 60 AA patients with HBV infection out of 201 cases. Entecavir or lamivudine therapy was initiated if HBV reactivation was encountered, or used as antiviral prophylaxis regimen for HBsAg-positive patients.Result: Among 60 AA patients, 12 were chronically infected and 48 were previously exposed. There was no difference in clinical features in AA patients with or without HBV infection. The prevalence of non-severe AA (NSAA) progressed to severe AA (SAA) was similar in two groups (35.6% vs 42.7%, p=1.0). In NSAA group, the response rate to CsA, to ATG and CsA, and progression to SAA were similar in patients with or without HBV infection (35.7% vs 35.3%, p>0.05; 42.8% vs 58.8%, p= 1.0; 35.5% vs 42.7%, p= 0.414). In SAA group, patients with or without HBV infection responded to ATG and CsA therapy similarly (83.33% vs 59.0%, p = 0.252). HBV reactivation was occurred in all 5 HBsAg positive patients without any antiviral therapy, while no HBV reactivation happened in other 7 patients received antiviral therapy. Disease course (RR=1.012, p=0.036) and absolute reticulocyte count (RR=11.556, P=0.025) were the risk factors for HBV reactivation by univariate analysis. Logistic regression indicated that HBsAg positivity without preventive therapy was the only strong factor for HBV reactivation.Conclusion: Antiviral prophylaxis is recommended for HBsAg-positive patients with AA who will receive IST because of high rate of HBV reactivation. HBV infection has no influence on the clinic course of AA, and antiviral therapy does not affect the efficacy of IST. DisclosuresNo relevant conflicts of interest to declare.

P556 Cyclosporine in acute severe steroid-refractory ulcerative colitis: Short-and long-term outcomes

Intravenous cyclosporine (CSA) therapy followed by oral cyclosporine therapy has been shown to be effective in steroid-refractory ulcerative colitis (UC) reducing the need for urgent colectomy. However, the long-term benefits of cyclosporine remain questionable. The aim of this study is to evaluate the short- and long-term efficacy of CSA in patients with acute severe UC refractory to corticosteroids. We conducted a retrospective study icluding all patients admitted in our department for acute severe UC refractory to corticosteroids, treated with intravenous CSA and then oral CSA between January 2007 and December 2016. A total of 76 patients with severe steroid-refractory ulcerative colitis were treated with intravenous CSA (2 mg/kg/day), for a mean period of 7.8 days [7–10 days]. Forty-six patients (68, 7%) responded to intravenous CSA and avoided colectomy during hospitalisation. Twenty-one (45, 65%) were males and 25 (54, 34%) were females with a mean age of 32, 78 years [14–61 years]. Subsequently the patients were started on oral cyclosporine (4 mg/kg/day) and followed for a mean of 37months (6 months–10 years). All patients received azathioprine (AZA) for maintaining remission after response to CSA therapy. During follow-up, 22 patients (47, 8%) treated with AZA developed new attacks with a mean time of 15, 6 months [2–48 months]. Anti-TNF therapy was prescribed to five relapsing patients, while nine patients (19, 56%) required colectomy for new severe attack of UC. At the end of the follow-up, clinical-remission was maintained in 24 cases (52, 2%). Our study shows that Cyclosporine therapy is an effective treatment for acute severe steroid-refractory UC in the short term. Although long remission was maintained in more than half of the patients, colectomy rate after response to CSA remain relatively high in the longer term (20% in our study).

P750 Predictors of quick remission after cyclosporine A therapy in Paediatric ulcerative colitis

Cyclosporin A is a second-line drug in ulcerative colitis that failed to respond to intravenous glucocorticoids according to ECCO/ESPGHAN consensus . Up-to-date CsA induced mucosal healing (Mayo 0 score) is the only factor predicting the lack of course deterioration in the future. The aim of the study was to investigate a presence of factors contributing to positive CsA therapy outcome. It is a retrospective, single center study. We describe a clinical characteristic of 59 children (33 females, 26 males), mean age of 13.7 years, mean disease duration 32 months, who underwent CsA treatment in the course of UC in years 2005–2015. The primary endpoint was clinical remission (defined as PUCAI<10) or clinical response (defined as decrease in PUCAI scoring for at least 20 points) at Day 8. Response/remission at Day 8 was achieved in 43 out of 59 (81%) and 31 out of 59 (58%) patients, respectively. Clinical (PUCAI score), laboratory (CsA concentration), endoscopic (disease extension and severity) and demographic (age, age of onset, disease duration) data were used as independent variables in analysis of discrimination between: group with clinical response vs. no response and group with clinical remission vs. no remission. PUCAI score, UC duration and Mayo score create the model which predict clinical remission at Day 8 with sensitivity 0.8 and specificity 0.66. No model was established to discriminate between groups with clinical response vs. no response. PUCAI score, UC duration and Mayo score contribute to response for induction therapy with CsA in children with UC.

Pustular psoriasis – Clinical study in a tertiary care center

Background: Pustular psoriasis is an uncommon form of psoriasis consisting of sheets of pustules on erythematous background. Treatment depends on the extent of involvement, severity, and underlying risk factors. Objectives: To study the clinical profile of pustular psoriasis, to identify triggering factors, and to study the response to treatment. Materials and Methods: A prospective clinical and therapeutic study of patients with pustular psoriasis attending DVL department over a period of 2 years. Diagnosis was made based on clinical and histopathological findings. Fourteen patients were admitted, investigated, and treated appropriately. Results: Nine were females and five were males. The mean age of the patients was 30 years. The duration of disease was 1–3 weeks. Among 14 cases of generalized pustular psoriasis, 10 were of acute type, 3 were pregnancy-related, and 1 childhood onset. In pregnancy group, all the patients were managed with systemic steroids till delivery followed by methotrexate (Mtx) and cyclosporine (CsA) during postpartum period in two patients, respectively. Eight patients were managed with short course of steroids and Mtx followed by Mtx alone. One patient with tuberculosis spine was managed with CsA and antituberculous therapy. Highly active retroviral therapy and acitretin (50 mg) were given in a retroviral-positive patient. One patient with recurrent episodes improved with antibiotics only. In our study, steroids were followed by maintenance therapy with Mtx/CsA and acitretin accordingly. CsA was given during crisis followed by maintenance with acitretin. Two patients on Mtx and one on CsA therapy with frequent flares were shifted to acitretin. Acitretin showed good response in patients who had frequent flares while on Mtx and CsA. In our study, response with acitretin, Mtx, and CsA was 100%, 57.1%, and 50%, respectively. Limitations: Only small number of patients. Conclusion: All patients were generalized type and showed good remission except one who succumbed to death due to septicemia.

Infusional Therapies, Continuous Dopaminergic Stimulation, and Nonmotor Symptoms.

Pump-based Parkinson (PD) therapies, including subcutaneous apomorphine infusion (CSA) and levodopa-carbidopa intestinal gel (LCIG), presently constitute the most effective pharmacological treatments available for advanced PD. These therapies are based on a more constant delivery of the dopaminergic drug resulting in a more continuous dopaminergic stimulation and a more stable treatment effect. This can be detected as reduction of time in off, reduction of dyskinesia frequency and severity, as well as increase of time in on without troublesome dyskinesias. A number of open-label studies now suggest that also the nonmotor PD symptomatology can improve under CSA and LCIG therapy. The most consistent improvements are seen concerning sleep, mood, and apathy, gastrointestinal symptoms, and urological symptoms. But also cardiovascular symptoms, perception, attention, and sexual function might show beneficial effects when moving from conventional therapies to pump treatment. Further there might be negative influences on some parts of the nonmotor symptomatology through side effects of CSA and LCIG therapy. In this chapter, we review the present knowledge about these aspects of the pump-based therapies. This information might be valuable when deciding on advanced therapy for individual patients.