High-Dose Immunosuppression and Autologous Transplantation for Multiple Sclerosis (HALT MS) Study - Full Text View

Sponsors and Collaborators:	National Institute of Allergy and Infectious Diseases (NIAID) Immune Tolerance Network
Information provided by:	National Institute of Allergy and Infectious Diseases (NIAID)
ClinicalTrials.gov Identifier:	NCT00288626

Purpose

The purpose of this study is to determine the effectiveness of a new treatment for multiple sclerosis (MS), a serious disease in which the immune system attacks the brain and spinal cord. MS can be progressive and severe and lead to significant disability. The study treatment involves the use of high-dose chemotherapeutic drugs to suppress the immune system. The participant's own (autologous) blood-forming (hematopoietic, CD34+) stem cells are collected before the chemotherapy is given, and then transplanted back into the body following treatment. Transplantation of autologous hematopoietic stem cells is required to prevent very prolonged periods of low blood cell counts after the high-dose chemotherapy.

Condition	Intervention	Phase
Multiple Sclerosis	Drug: Granulocyte-colony stimulating factor (G-CSF) and prednisone Drug: Carmustine, etoposide, cytarabine, and melphalan (BEAM) Procedure: Autologous hematopoietic stem cell transplant	Phase II

MedlinePlus related topics: Multiple Sclerosis

Drug Information available for: Prednisone Cytarabine hydrochloride Etoposide Etoposide phosphate Granulocyte colony-stimulating factor Cytarabine Melphalan Carmustine Sarcolysin Melphalan hydrochloride

U.S. FDA Resources

Study Type:	Interventional
Study Design:	Treatment, Non-Randomized, Open Label, Uncontrolled, Single Group Assignment, Safety/Efficacy Study
Official Title:	A Phase II Study of High-Dose Immunosuppressive Therapy (HDIT) Using Carmustine, Etoposide, Cytarabine, and Melphalan (BEAM) and Thymoglobulin, and Autologous CD34+ Hematopoietic Stem Cell Transplant (HCT) for the Treatment of Poor Prognosis Multiple Sclerosis

Further study details as provided by National Institute of Allergy and Infectious Diseases (NIAID):

Primary Outcome Measures:

Time to treatment failure [ Time Frame: During the 5 years after transplant ] [ Designated as safety issue: No ]

Estimated Enrollment:	30
Study Start Date:	July 2006
Estimated Study Completion Date:	January 2015
Estimated Primary Completion Date:	September 2014 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
1: Experimental	Drug: Granulocyte-colony stimulating factor (G-CSF) and prednisone Growth factor regimen; occurs at study entry Drug: Carmustine, etoposide, cytarabine, and melphalan (BEAM) High-dose chemotherapy; occurs seven or more days following collection of autologous graft Procedure: Autologous hematopoietic stem cell transplant Occurs after growth factor regimen and collection of autologous graft

Detailed Description:

MS is a chronic autoimmune disease of the central nervous system in which myelin, the protective coat that surrounds nerve cells, is damaged or destroyed by autoimmune T cells and macrophages, leading to an eventual loss of neurologic function. In a pilot study in Europe using high-dose chemotherapy, it was observed that 18 of 19 MS patients stabilized or improved clinically, and only one patient showed a new lesion on magnetic resonance imaging (MRI) of the brain at 4.5 years after treatment. Improvement was seen in quality-of-life assessments.

In ITN033AI, high-dose chemotherapy with autologous CD34-selected hematopoietic cell transplantation will be given to confirm the results from the pilot study and to offer therapy to patients with early MS and a poor prognosis. Research studies will be performed in addition to clinical assessments to better understand the effect of the treatment on the activity of MS. High-dose chemotherapy will be used to deplete autoreactive immune cells. These regimens also deplete the bone marrow, the source of blood-forming CD34+ stem cells which causes very low blood counts. Therefore, the participant's autologous CD34+ hematopoietic stem cells will be collected before high dose immunosuppressive therapy is given and then returned as a transplant post-chemotherapy. Patients will be followed closely after the autologous transplantation since they will be at risk for infections after treatment.

At the beginning of the study, participants will undergo a number of screening and baseline procedures, including a physical exam, blood collection, MS-confirming neurology exams and questionnaires, and MRI procedures. Participants will be given prednisone and granulocyte-colony stimulating factor (G-CSF) to mobilize CD34+ hematopoietic stem cells from the bone marrow into the peripheral blood. When the peripheral blood CD34+ cell count reaches 20,000 cells/ml or greater, these cells will be collected by leukapheresis. In this process, a catheter is placed into a large blood vessel, peripheral blood is withdrawn, and a high speed sedimentation (leukapheresis) device is used to separate and retain the cells required for autologous transplantation. Other blood cells are then returned to the participant's body. In the laboratory, the CD34+ hematopoietic stem cell graft will be selected and prepared from the leukapheresis collection, and stored until needed for transplant. Seven or more days following the collection of their autologous graft, participants will be hospitalized and receive high-dose chemotherapy consisting of carmustine, etoposide, cytarabine, and melphalan (BEAM) and thymoglobulin. This is followed by transplantation of the autologous hematopoietic cell graft. Participants will remain in the hospital for observation during recovery of their peripheral blood cell counts, as described in the protocol. Participants will receive G-CSF and blood transfusions, if needed, and will be monitored for infections. Following discharge from the hospital, eight study visits will occur over sixty months (five years).

During these visits, participants will undergo blood and urine collection, MRI studies, leukapheresis, and MS neurology exams and will complete questionnaires.

Eligibility

Ages Eligible for Study:	18 Years to 60 Years
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

Diagnosis of relapsing-remitting or progressive-relapsing multiple sclerosis for less than 15 years using McDonald Criteria. More information on this criterion can be found in the protocol.
Score between 3.0 and 5.5 on the Expanded Disability Status Scale (EDSS)
T2 abnormalities on brain MRI consistent with MS
Two or more relapses in 18 months time on interferon (IFN), glatiramer acetate (GA), natalizumab or cytotoxic therapy with EDSS increase of 1.0 or greater for participants with EDSS at screening of 3.0 to 3.5 (0.5 or greater for participants with EDSS at screening of 4.0 to 5.5) sustained at least 4 weeks after at least one of these relapses OR one relapse on IFN, GA, natalizumab or cytotoxic therapy with EDSS increase of 1.5 or greater (1.0 for subjects with EDSS at screening of 5.5) sustained at least 4 weeks, together with MRI changes consistent with poor prognosis. More information on this criterion can be found in the protocol.
On IFN or GA for at least 6 months before the relapses occur that are counted to satisfy previous inclusion criterion OR have received adequate doses of natalizumab or cytotoxic therapy on a treatment schedule before the relapses occur that are counted to satisfy previous inclusion criterion.
Approval by an MS Review Panel to participate in the study. More information on this criterion can be found in the protocol.
In good clinical condition with adequate organ function and without coexisting medical problems that would increase the risk to the participant
Willing to use acceptable methods of contraception
Willing and able to comply with all study requirements
Willing to accept and comprehend irreversible sterility as side effect of therapy

Exclusion Criteria:

Primary progressive MS
Secondary progressive MS without relapses (i.e., progression without exacerbations or relapses) for 12 or more months
Neuromyelitis optica, a disease similar to MS
Initiation of new immunosuppressant treatment after the participant becomes eligible for the protocol or continuance of immunosuppressant drugs after the participant is screened for the protocol. Treatment with IFN, GA, or corticosteroids is permitted after the participant becomes eligible for the protocol.
Lapse of greater than 6 months between the time a participant is eligible for the protocol and initiation of protocol treatment except when judged acceptable by the MS Review Panel
Prior treatment with investigational immunosuppressive agents within 3 months of study eligibility
Positive baseline plasma and CSF testing for JC virus or a brain MRI that has changes consistent with a diagnosis of progressive multifocal encephalopathy (PML).
History of cytopenia consistent with the diagnosis of myelodysplastic syndrome (MDS)
Active hepatitis B or C infection, cirrhosis, or HIV infection
Uncontrolled diabetes mellitus
Uncontrolled viral, fungal, or bacterial infection. Patients with asymptomatic bacteriuria are not excluded.
Any illness that would jeopardize the ability to tolerate aggressive chemotherapy
Prior history of malignancy, except localized basal cell or squamous skin cancer. Other malignancies for which the subject is judged cured by the administered therapy will be considered on an individual basis.
Hypersensitivity to mouse, rabbit, or Escherichia coli-derived proteins or to iron compounds/medications
Metallic objects implanted in the body that would affect MRI exams
Psychiatric illness, mental deficiency, or cognitive dysfunction
Pregnancy

Contacts and Locations

Please refer to this study by its ClinicalTrials.gov identifier: NCT00288626

Locations

United States, Ohio
Ohio State University School of Medicine	Recruiting
Columbus, Ohio, United States, 43210
Contact: Lisa Hafer 614-293-7877 hafer.15@osu.edu
Principal Investigator: Michael K. Racke, MD
Principal Investigator: Steven M. Devine, MD
United States, Texas
M.D. Anderson Cancer Center; Transplant site, please contact Baylor College of Medicine	Recruiting
Houston, Texas, United States, 77230-1402
Contact: Uday Popat, MD 713-745-3055 upopat@mdanderson.org
Principal Investigator: Uday Popat, MD
Baylor College of Medicine	Recruiting
Houston, Texas, United States, 77030
Contact: Semahat Eiswirth, RN 713-798-6059 sparilti@bcm.edu
Contact: George J. Hutton, MD 713-798-8170 ghutton@bcm.tmc.edu
Principal Investigator: George J. Hutton, MD
United States, Washington
Fred Hutchinson Cancer Research Center	Recruiting
Seattle, Washington, United States, 98109-1024
Contact: Bernie McLaughlin, RN 206-667-4916 bmclaugh@fhcrc.org
Principal Investigator: James Bowen, MD
Principal Investigator: Richard Nash, MD
Principal Investigator: George H. Kraft, MD

Sponsors and Collaborators

National Institute of Allergy and Infectious Diseases (NIAID)

Immune Tolerance Network

Investigators

Study Chair:	Richard A. Nash, MD	Fred Hutchinson Cancer Research Center, Clinical Research Division, University of Washington
Study Chair:	James D. Bowen, MD	Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington
Study Chair:	George H. Kraft, MD	Departments of Neurology and Rehabilitation Medicine, University of Washington
Study Chair:	George J. Hutton, MD	The Maxine Messinger Multiple Sclerosis Clinic, The Methodist Hospital, Baylor College of Medicine
Study Chair:	Uday Popat, MD	Department of Blood and Marrow Transplantation, University of Texas, M.D. Anderson Cancer Center
Study Chair:	Michael K. Racke, MD	Department of Neurology, Ohio State University Medical Center
Study Chair:	Steven M. Devine, MD	Department of Hematology and Oncology, Ohio State University Medical Center

More Information

Additional Information:

Click here for the Immune Tolerance Network Web site This link exits the ClinicalTrials.gov site

Publications:

Fassas A, Nash R. Stem cell transplantation for autoimmune disorders. Multiple sclerosis. Best Pract Res Clin Haematol. 2004 Jun;17(2):247-62. Review.

Muraro PA, Douek DC. Renewing the T cell repertoire to arrest autoimmune aggression. Trends Immunol. 2006 Jan 4; [Epub ahead of print]

Muraro PA, Douek DC, Packer A, Chung K, Guenaga FJ, Cassiani-Ingoni R, Campbell C, Memon S, Nagle JW, Hakim FT, Gress RE, McFarland HF, Burt RK, Martin R. Thymic output generates a new and diverse TCR repertoire after autologous stem cell transplantation in multiple sclerosis patients. J Exp Med. 2005 Mar 7;201(5):805-16. Epub 2005 Feb 28.

Saccardi R, Mancardi GL, Solari A, Bosi A, Bruzzi P, Di Bartolomeo P, Donelli A, Filippi M, Guerrasio A, Gualandi F, La Nasa G, Murialdo A, Pagliai F, Papineschi F, Scappini B, Marmont AM. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005 Mar 15;105(6):2601-7. Epub 2004 Nov 16.

Tyndall A, Saccardi R. Haematopoietic stem cell transplantation in the treatment of severe autoimmune disease: results from phase I/II studies, prospective randomized trials and future directions. Clin Exp Immunol. 2005 Jul;141(1):1-9. Review.

Mancardi G, Saccardi R. Autologous haematopoietic stem-cell transplantation in multiple sclerosis. Lancet Neurol. 2008 Jul;7(7):626-36. Review.

Responsible Party:	DAIT/NIAID ( Associate Director, Clinical Research Program )
Study ID Numbers:	DAIT ITN033AI, DAIT SCMS2
Study First Received:	February 7, 2006
Last Updated:	March 3, 2009
ClinicalTrials.gov Identifier:	NCT00288626 History of Changes
Health Authority:	United States: Food and Drug Administration

Keywords provided by National Institute of Allergy and Infectious Diseases (NIAID):

Hematopoietic Stem Cell Transplantation
Immunosuppressive Agents

Study placed in the following topic categories:

Antimetabolites
Prednisone
Melphalan
Autoimmune Diseases
Immunologic Factors
Demyelinating Diseases
Carmustine
Sclerosis
Antiviral Agents
Immunosuppressive Agents

Etoposide phosphate
Multiple Sclerosis
Demyelinating Autoimmune Diseases, CNS
Mitogens
Antineoplastic Agents, Alkylating
Antineoplastic Agents, Phytogenic
Alkylating Agents
Etoposide
Autoimmune Diseases of the Nervous System
Cytarabine

Additional relevant MeSH terms:

Antimetabolites
Melphalan
Anti-Infective Agents
Antimetabolites, Antineoplastic
Molecular Mechanisms of Pharmacological Action
Immunologic Factors
Antineoplastic Agents
Physiological Effects of Drugs
Pathologic Processes
Multiple Sclerosis
Therapeutic Uses
Etoposide
Alkylating Agents
Cytarabine

Autoimmune Diseases of the Nervous System
Autoimmune Diseases
Immune System Diseases
Demyelinating Diseases
Carmustine
Nervous System Diseases
Sclerosis
Immunosuppressive Agents
Antiviral Agents
Pharmacologic Actions
Myeloablative Agonists
Demyelinating Autoimmune Diseases, CNS
Antineoplastic Agents, Alkylating
Antineoplastic Agents, Phytogenic

ClinicalTrials.gov processed this record on May 07, 2009