Study of Baricitinib, a JAK1/2 Inhibitor, in Chronic Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation

Sponsor

National Cancer Institute (NCI) (NIH)

Overall Status

Active, not recruiting

CT.gov ID

NCT02759731

Collaborator

(none)

Enrollment

Location

Arms

78.9

Anticipated Duration (Months)

0.3

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Background:

Chronic graft versus host disease (cGVHD) can affect people who had a hematopoietic stem cell transplant using donor cells. It is often fatal. It is usually treated with high doses of steroids. But that helps only about half the people in the long term. Researchers want to see if a drug called baricitinib can help people with cGVHD that has not responded to therapy. The drug inhibits the proteins involved in communication in the immune system. These proteins may play a role in cGVHD and other inflammatory diseases.

Objectives:

To test the safety and effectiveness of baricitinib in people with cGVHD that has not responded to therapy.

Eligibility:

Adults 18 and older with cGVHD that has not responded to therapy.

Design:

Participants will be screened with a medical history, physical exam, and blood and urine tests. They will have lung and heart tests and chest scans.

Baseline visit: Participants will have:

Medical history

Physical exam

Blood tests

Tests for infectious diseases

Skin, eye, and teeth evaluations

Rehabilitation and occupational medicine evaluations

Photos of any lesions

Gynecology evaluation (females)

The study will occur in 28-day cycles. Participants will take the study drug by mouth every day for 3 cycles. Some will take it for 3 or 6 more cycles.

Participants will have a few visits during each cycle. They will repeat some previous tests. They may also have scans and questionnaires.

Participants will have a visit when they stop taking the drug and another 3 months later. They will repeat a few study tests. They will have follow-up calls for 2 years.

Condition or Disease	Intervention/Treatment	Phase
Chronic Graft vs Host Disease Chronic Graft-Versus-Host Disease	Drug: Baricitinib	Phase 1/Phase 2

Detailed Description

Background:
Chronic graft-versus-host disease (cGVHD) is the leading cause of non-relapse morbidity and mortality in persons after allogeneic hematopoietic stem cell transplantation (SCT).
Approximately 50% of patients with cGVHD have disease refractory to systemic corticosteroids; currently, there is no standard second-line therapy.
The JAK-STAT pathway relays the signaling function of several inflammatory cytokines that have a role in GVHD (IFN-gamma, IL-2, IL-6, IL-12).
Murine models have demonstrated activity of JAK inhibitors in graft-versus-host disease.
Baricitinib is a potent and selective inhibitor of JAK1 and JAK2 that has demonstrated anti-inflammatory effects and a good safety profile in patients with rheumatoid arthritis, but has not been evaluated in GVHD.
Objectives:
To determine the safety and tolerability of baricitinib in patients with cGVHD that is refractory to steroids
To determine the efficacy of baricitinib in patients with cGVHD that is refractory to steroids
Eligibility:
Inclusion:
Age greater than or equal to 18 years
Moderate or severe cGVHD per NIH consensus criteria
Karnofsky performance status greater than or equal to 50%
cGVHD that did not respond to high-dose corticosteroids (prednisone at 1.0 mg/kg/day for at least 1 week or prednisone at 0.5 mg/kg/day or 1 mg/kg every other day for at least 4 weeks), or second-line therapy (any)
Receiving stable or tapering doses of systemic therapy in the preceding 4 weeks if taking systemic therapy for cGVHD
Exclusion:
Neutrophils <1.0x10^{9/L, platelets <50X10}9/L, creatinine greater than or equal to 1.5 times the upper limit of normal or estimated creatinine clearance <50mL/min/1.73m^2 (Cockroft-Gault formula), serum aspartate aminotransferase or alanine aminotransferase concentration >3x ULN or total bilirubin greater than or equal to 1.5x ULN
Progressive malignancy, uncontrolled infection or any major organ dysfunction as defined by the protocol
Design:
This is a Phase 1/2 trial to determine the safety and efficacy of baricitinib in patients with cGVHD that is refractory to steroids.
Patients will initially be treated with baricitinib at 2mg daily for 12 weeks. If the response at 12 weeks is a CR and there has not been a DLT, the dose will be remain at 2mg daily for an additional 12 weeks, with the primary response assessment at 24 weeks of total treatment. If the response is a PR or stable disease, the dose will be increased to 4mg daily for an additional 12 weeks, with the primary response assessment at 24 weeks of total treatment. If there is progression of disease at any time within the first 12 weeks, the dose can be increased to 4mg daily at that time, and patients will continue for a total of 24 weeks of treatment. Patients will have the option to continue baricitinib for an additional 6 months as tolerated if they have stable or responding disease.
The co-primary endpoint of safety will be determined by rate, severity, and duration of adverse events based on CTCAE v4 criteria. Assessment for DLTs will occur every 2 weeks during the first 4 weeks of each dose level. Safety monitoring will occur every 4 weeks thereafter.
The co-primary endpoint of efficacy will be defined as rate of overall response at 24 weeks per NIH consensus criteria (CR or PR).
Peripheral blood samples will be collected prior to treatment, at 2 weeks, at 12 weeks and every 12 weeks thereafter to evaluate cytokine and cellular profiles, STAT phosphorylation, candidate chronic GVHD biomarkers. Pharmacokinetic studies will also be performed at each dose level.
In an initial futility analysis, if 0 of the first 7 patients enrolled in cohort 1 have responded at 12 weeks, then a 2nd cohort of patients will be accrued to start treatment at the higher dose (4mg daily). Otherwise, if 1 or more of the first 7 patients respond in cohort 1, then 21 evaluable patients will be treated in cohort

Similarly, if the second cohort is used, and if 0 of the 7 patients enrolled in this second cohort have responded at 12 weeks, then no further patients will be accrued. Otherwise, if 1 or more of the first 7 patients respond in cohort 2, then 21 evaluable patients will be treated in cohort 2.

A total of 21 evaluable patients will be enrolled in either cohort 1 or 2 as appropriate, in order to have 80% power to detect a response rate consistent with 30% and ruling out 10%, with a one-sided significance level of 0.10 for the cohort. As an early stopping rule for safety, if 2/3 or greater patients at any given dose level experiences a dose limiting toxicity requiring dose reduction or discontinuation, that dose will not be subsequently used and no further dose escalation will take place.

Study Design

Study Type:

Interventional

Actual Enrollment :

24 participants

Allocation:

Non-Randomized

Intervention Model:

Sequential Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

A Phase 1/2 Study of Baricitinib, a JAK1/2 Inhibitor, in Chronic Graft-Versus-Host Disease (cGVHD) After Allogeneic Hematopoietic Stem Cell Transplantation (SCT)

Actual Study Start Date :

Nov 1, 2016

Anticipated Primary Completion Date :

Jan 1, 2023

Anticipated Study Completion Date :

Jun 1, 2023

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Arm 1 Baricitinib starting at a dose of 2mg daily for 12 weeks. If the response at 12 weeks is a CR and there has not been a DLT, the dose will be remain at 2mg daily for an additional 12 weeks. If there has been a DLT within the first 4 weeks, the dose will be decreased to 1mg daily, and will continue at this dose as tolerated. If there has been DLT at this dose (1 mg), patients will be taken off treatment.	Drug: Baricitinib Cycle=28 days: Baricitinib: 1mg-4mg PO QD
Experimental: Arm 2 If the response is a PR or stable disease (from cohort 1), the dose will be increased to 4mg daily for an additional 12 weeks. If there has been a DLT within the first 4 weeks will have a dose reduction back to 2mg daily. For patients who experience cGVHD progression at any time within the first 12 weeks on 2mg daily, the dose can be increased to 4mg daily until 24 weeks.	Drug: Baricitinib Cycle=28 days: Baricitinib: 1mg-4mg PO QD

Arm

Intervention/Treatment

Experimental: Arm 1

Baricitinib starting at a dose of 2mg daily for 12 weeks. If the response at 12 weeks is a CR and there has not been a DLT, the dose will be remain at 2mg daily for an additional 12 weeks. If there has been a DLT within the first 4 weeks, the dose will be decreased to 1mg daily, and will continue at this dose as tolerated. If there has been DLT at this dose (1 mg), patients will be taken off treatment.

Drug: Baricitinib

Cycle=28 days: Baricitinib: 1mg-4mg PO QD

Experimental: Arm 2

If the response is a PR or stable disease (from cohort 1), the dose will be increased to 4mg daily for an additional 12 weeks. If there has been a DLT within the first 4 weeks will have a dose reduction back to 2mg daily. For patients who experience cGVHD progression at any time within the first 12 weeks on 2mg daily, the dose can be increased to 4mg daily until 24 weeks.

Drug: Baricitinib

Cycle=28 days: Baricitinib: 1mg-4mg PO QD

Outcome Measures

Primary Outcome Measures

To evaluate the safety of baricitinib [every 2 weeks during the first 4 weeks of each dose level then every 4 weeks.]
Safety
To evaluate the efficacy of baricitinib [24 weeks]
Efficacy

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years to 99 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

-INCLUSION CRITERIA:

Moderate or severe cGVHD (after allogeneic hematopoietic stem cell transplantation) diagnosed and staged per NIH criteria. Responses to JAK inhibitors have not been restricted to specific organs, so any organ involvement is eligible.
Age greater than or equal to 18 years of age. Because inadequate dosing or adverse event data are currently available on the use of baricitinib in patients <18 years of age, children are excluded from this study.
Karnofsky performance score >50%
Chronic GVHD that did not respond to high-dose corticosteroids (prednisone at 1.0 mg/kg/day for at least 1 week or prednisone at 0.5 mg/kg/day or 1 mg/kg every other day for at least 4 weeks), or second-line therapy (any).
If patient is taking systemic therapy for cGVHD at the time of enrollment, they must be on a stable or tapering doses in the preceding 4 weeks.
Patients must have normal organ and marrow function as defined below:

absolute neutrophil count greater than or equal to 1,000/mcL

absolute lymphocyte count greater than or equal to 500/mcL

platelets greater than or equal to 50,000/mcL

hemoglobin greater than or equal to 9 g/dL

total bilirubin less than or equal to 1.5 X institutional upper limit of normal, unless there is a known history of Gilbert s disease

AST(SGOT)/ALT(SGPT) less than or equal to 3 X institutional upper limit of normal

Creatinine < 1.5 times the upper limit of normal, or:

creatinine clearance greater than or equal to 50 mL/min/1.73 m^2. Creatinine clearance should be calculated per institutional standard.

Primary malignancy for which the patient received transplant has been stable for 3 months prior to enrollment on study.
The effects of baricitinib on human fetal development are unknown. Women of child-bearing potential and men must agree to use 2 effective forms of contraception (hormonal or barrier method of birth control; abstinence) for the duration of study participation and for at least 7 days after study drug exposure. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, or if a man s partner becomes pregnant or suspects she is pregnant while he is participating in this study, she or he should inform their treating physician immediately.
Ability of subject to understand and the willingness to sign a written informed consent document.

EXCLUSION CRITERIA:

Systemic immune suppression or systemic therapy for cGVHD started within preceding 4 weeks.
Hypersensitivity to JAK inhibitors.
Any serious medical condition within the previous 4 weeks which places the subject at an unacceptable risk if he or she were to participate in the study or confounds the ability to interpret data from the study, including, but not limited to, symptomatic congestive heart failure, unstable angina pectoris, uncontrolled cardiac arrhythmias, acute kidney injury, or psychiatric illness/social situations that would limit compliance with study requirements.
Uncontrolled infection, including active HIV-1, Hepatitis B (HBV) and/or Hepatitis C (HCV) infection (positive HBV or HCV viral load in the setting of positive HBV core antibody or surface antibody or HCV antibody). History of HBV or HCV is allowed if there is no uncontrolled viral infection. Because the study agent may impact response to infections, patients with any active viral infection are excluded.
Recurrent or progressive malignancy requiring anticancer treatment.
Other cancer except that for which the transplant was done <2 years before study entry, except non-melanoma skin cancer or carcinoma in situ of the uterine cervix or breast.
Patients who are receiving any other investigational agents.
NIH lung score 3.
Pregnant women are excluded from this study because the teratogenic effects of baricitinib are unknown. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with baricitinib, breastfeeding should be discontinued if the mother is treated with this agent.