ALBERT

Description: Introduction: Allogeneic stem cell transplantation (SCT) is the best form of therapy for a young patient (〈 50 years) with severe aplastic anaemia. In developing countries, there is a big time interval between diagnosis and SCT leading to increased transfusions and increased risk of infections, both of which adversely affects transplant outcome. This retrospective analysis is aimed at studying the outcomes of SCT among Indian patients with aplastic anaemia. Methodology: The Indian Stem cell transplant registry (ISCTR) is a group of transplant physicians representing about 30 active transplant centres in India. This retrospective analysis was done on data reported on 634 patients by 20 centres who reported outcomes of SCT for aplastic anaemia. Data was collected from individual medical records and databases. Analysis was done using SPSS software version 16.0 Results: Six hundred and thirty four patients [445 males and 189 females] with a median age of 21 years (range: 2 - 65) underwent allogeneic SCT between 1990 and March 2015. There were 209 children (age 〈 15 years). The median time from diagnosis to SCT was 5 months (range: 1 - 120) while the median number of transfusions was 20 (range: 1 - 150). All donors were HLA identical sibling or family donors; matched unrelated and haplo-identical donor transplants were excluded from this analysis. Conditioning regimen was Cyclophosphamide based (Cy/ Cy+ ATG/ Cy+ TBI/TLI) in 78 patients (12.3%) while majority received Fludarabine with Cyclophosphamide (n = 481; 75.8%) and 75 received other conditioning regimens (Flu/TBI, Flu/Bu, Bu/Cy etc). Graft source was bone marrow [BM] in 124 (19.5%) and peripheral blood stem cells in 510 patients (80.5%). Graft versus host disease (GVHD) prophylaxis predominantly consisted of Cyclosporine and methotrexate in 543 patients (85.6%). Engraftment was seen in 572 patients (90.4%) while 19 (2.9%) had primary graft failure and 43 (6.7%) expired prior to engraftment due to infection or bleeding. The median time to neutrophil engraftment was 13 days (range: 8 - 21) while platelet engraftment occurred at 13 days (range: 5 - 37). Grade II - IV acute GVHD occurred in 29.3% while grade III-IV was seen in 14.1%. Chronic GVHD was seen in 41% of evaluable patients which was limited in most patients. At a median follow up of 43 months (range: 1 - 264), 431 patients are alive. The 5 yr OS for the entire group is 66.3 + 2.0%. The OS was higher in children compared to adults (73.4 + 3.3% vs 62.8 + 2.5%; p = 0.006), better for Flu/Cy compared to Cy based conditioning (69.8 + 2.2% vs 57.8 + 5.6%; p = 0.002) and better for PBSC compared to BM (68.9 + 2.2% vs 56.1 + 4.8%; p = 0.020). There has been significant improvement in outcomes over the past 15 years [3 yr OS of 41.9 + 1.3% for 1984-1995, 40.9 + 1.2% for 1996-2000, 70.6 + 5.0% for 2001 -2005, 70.3 + 3.1% for 2006-2010 and 68.8 + 3.0% from 2011 onwards]. Conclusion: Outcomes of patients with aplastic anaemia are improving and patients have a 70% chance of getting cured with a HLA identical sibling donor transplant. The use of PBSC as graft source is not associated with inferior outcomes. Disclosures No relevant conflicts of interest to declare.

Description: A toxicity reduced conditioning regimen containing Treosulfan (Treo), fludarabine (Flu), thiotepa for high risk Thal Major (TM) has been used since 2009 at our centre that has significantly improved transplant outcomes of these patients compared to the historical cohort of patients receiving busulfan/ cyclophosphamide based myeloablative regimen (Mathews et al, 2013). Limited knowledge is available on the pharmacokinetics (PK), pharmacogenetics (PG) and pharmacodynamics of fludarabine and treosulfan, especially in non-malignant hematological disorders like TM. We describe here the PK of Flu and Treo in patients with TM undergoing HSCT, the factors influencing the inter-individual variability in PK and the role of these factors on HSCT outcome. Seventy one patients diagnosed with TM undergoing HSCT with Flu/Treo based conditioning regimen between January 2012 and January 2015 were included (Table: Patient demographics). Selected functional polymorphisms in the NT5E, DCK, hENT1 and GST genes that are involved in fludarabine or treosulfan metabolism were screened. All patients received Flu 40mg/m2/day x 4 days as an 1hr infusion on days 1 and 4 and Treo as 14g/m2/day x 3 days at the rate 5g/hr. Plasma was separated from the peripheral blood collected at predetermined time points after the infusion of Flu and Treo PK analysis. Plasma Flu was analyzed using a LC-MS/MS method and the concentration was expressed as mMole/ml while Treo was analyzed using a HPLC-RI method and concentration was expressed as mg/L. Flu and Treo PK was estimated using nonlinear mixed effects modeling via Monolix 4.3.3. The covariates tested for both PK were: age, sex, body weight, BSA, ferritin, and polymorphisms in NT5E, hENT1, dCK and GST genes. The PK parameters AUC, CL, V and k were estimated on day 1 for Treo and on day 1 and day 4 for Flu (Table). The influence of Flu and Treo PK and PG on graft rejection, early transplant related mortality (TRM) & chimerism status was estimated using logistic regression analysis. Wide inter-individual variation in Flu and Treo PK was noted (7 and 9 fold Vs 5 and 8 fold respectively for Day 1 & 4 Flu AUC & Cl; 33 & 31 fold variation in Treo AUC and Cl) (Table). Flu CL was significantly higher on day 4 compared to day1 (Figure A). The variation in Flu PK was explained by genetic variants in NT5E and dCK. Patients having variant genotype for the SNPs in NT5E (rs2295890) and dCK (rs11544786) showed significantly lower plasma Flu clearance compared to those with wild type genotype (p=0.006 & p=0.05 respectively) (Figure B). This is consistent with our previous report in patients with aplastic anemia undergoing HSCT (Mohanan et al. 2014; Blood: 124 (21)). None of the genetic variants in the GST genes explained the variation in Treo PK. Day21 mortality was seen in 6/71 patients (8.5%) and graft rejection in 3/66 evaluable patients (4.5%). Analysis of the influence of PK and PG variables on transplant outcome showed significantly high first dose Flu AUC to be associated with D21 mortality upon Univariate analysis (median 42.5, range 32.1-63.7 compared to 31.8, range 15.2-111 mMole*h/mL, in those with and without TRM respectively; p=0.043); none of these parameters were significantly associated with graft rejection or mixed chimerism. There was no association between Treo PK parameters and graft rejection or TRM. The influence of Flu and Treo PK on regimen related toxicity is yet to be evaluated. The lack of the influence of PK on transplant outcome could be due to lower incidence of rejection and TRM in this cohort. Further analysis in a larger cohort of patients will be done once we enroll more patients for PK analysis. Our results demonstrate that Flu PK is influenced by genetic variants in NT5E and dCK, the enzymes involved in Flu biotransformation. The relationship between high-plasma Flu exposure and TRM and given the fact that multiple factors influence TRM, we can extrapolate that the plasma Flu AUC may be a surrogate marker of overall preparative regimen intensity as reported previously (Long-Boyle et al, Bone Marrow Transplant, 2011). The lack of association of genetic variants in GST genes in explaining the inter-patient variability in treosulfan exposure suggests the involvement of other drug metabolizing genes on treosulfan PK. We are currently evaluating the role of genetic variants in a large panel of drug metabolizing genes on explaining this inter-individual variability in Treo PK. Disclosures No relevant conflicts of interest to declare.

Description: Background Studies have shown that the incidence of inhibitor development varies between FVIII concentrates, with some suggesting that recombinant FVIII (rFVIII) concentrates produced in hamster cell lines pose a greater risk of inhibitor development than plasma-derived (pd) von Willebrand factor (VWF)-containing FVIII (pdFVIII/VWF) products. In the SIPPET study, the cumulative incidence of high-titer inhibitorswith hamster-cell derived rFVIII products was 28.4% vs 18.6% for pdFVIII/VWF (Peyvandi F et al. N Engl J Med 2016; 374:2054-2064). These studies did not include new generation rFVIII products produced in human cell lines. Nuwiq® (Human-cl rFVIII) is the first and only new-generation rFVIII produced in human cells without chemical modification or protein fusion. The pharmacokinetics, efficacy and safety of Nuwiq® have been examined in previously treated patients (PTPs) with severe hemophilia A, and no inhibitors have been reported in 201 PTPs. The immunogenicity, efficacy and safety of Nuwiq® in previously untreated patients (PUPs) with severe hemophilia A is currently being assessed in the ongoing NuProtect study. Methods The NuProtect study was initiated in 2013 and is being conducted in 17 countries and 38 centers worldwide. One hundred evaluable (110 enrolled) male PUPs of all ages and ethnicities are being studied for 100 exposure days (EDs) or a maximum study participation of 5 years. The patients were to have received no treatment with FVIII concentrates or other blood products containing FVIII prior to study entry. The primary objective of the NuProtect study is to assess the immunogenicity of Nuwiq® by determining inhibitor activity (≥0.6 BU) using the Nijmegen modified Bethesda assay in a central laboratory. Intensive screening for inhibitors is scheduled every 3-4 EDs until 20 EDs, then every 10-12 EDs until 100 EDs, and every 3 months until study completion. Secondary endpoints include assessment of hemostatic efficacy in prophylaxis, in the treatment of bleeds and in surgical prophylaxis, as well as safety and tolerability. All patients undergo F8 gene mutation analysis. Results Data from 85 treated PUPs have been included in the first pre-planned interim analysis (May 2016) of which 66 PUPs had ≥20 EDs (by which time the majority of inhibitors are likely to have arisen). The median age at first treatment was 13 months (range: 3-135). Of the 59 patients with available F8 gene mutation analysis, 1 (1.7%) had no identifiable mutation, 44 (74.6%) had mutations conferring a high risk of inhibitor development and 47 (81.0%) had null mutations. Data analysis in May 2016 showed that only 8 of the 66 PUPs treated with Nuwiq® for ≥20 EDs had developed a high-titer inhibitor after a median of 11.5 EDs (range 6-24). Five of the 66 PUPs developed a low-titer inhibitor, 4 (80%) of which were transient. Only 2 patients developed an inhibitor (1 high-titer) after 20 EDs. The cumulative incidence of high-titer inhibitors in PUPs treated with Nuwiq® is 12.8% (95% CI: 4.49-21.15) (Figure 1). The cumulative incidence of low-titer inhibitors was 8.4% (95% CI: 1.28-15.59) and of all inhibitors was 20.8% (95% CI: 10.68-30.95). No patient developed an inhibitor after 25 EDs. The incidence has remained consistent since the start of the study in 2013. Twelve of 13 patients who developed inhibitors had the causative F8 gene mutation detected, all of which were null, and all but one were high-risk. Conclusions PUPs treated with Nuwiq® for ≥20 EDs had 12.8% cumulative incidence of high-titer inhibitorsat the time of interim analysis (8 of 66 PUPs) despite the fact that 81% of patients had gene mutations known to be associated with increased inhibitor risk (e.g. null mutations). These interim data support the low rate of inhibitor development in PUPs treated with Nuwiq® - a human-cell derived (not chemically modified or protein fused) recombinant FVIII. Final data from the NuProtect study are expected in 2018 and will provide further insights into the development of inhibitors in PUPs with severe hemophilia A. Figure 1. Cumulative incidence of inhibitor development Figure 1. Cumulative incidence of inhibitor development Disclosures Liesner: CSL Behring: Consultancy, Honoraria, Research Funding; Biogen: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; SOBI: Consultancy, Honoraria, Research Funding, Speakers Bureau; Octapharma: Consultancy, Honoraria, Research Funding, Speakers Bureau; BPL: Consultancy, Honoraria, Research Funding; Bayer: Consultancy, Honoraria, Speakers Bureau; Cangene: Research Funding; Baxalta Innovations GmbH, now a part of Shire: Consultancy, Honoraria, Research Funding; Grifols: Consultancy, Honoraria. Altisent:Baxalta: Consultancy, Research Funding; Bayer: Consultancy, Research Funding; Novo Nordisk: Consultancy, Research Funding; Grifols: Consultancy; Pfizer: Consultancy, Research Funding; CSL Behring: Consultancy, Research Funding; Octapharma: Consultancy. Belletrutti:Shire Pharmaceuticals (formerly Baxalta): Membership on an entity's Board of Directors or advisory committees, Other: Travel support, Research Funding; Bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Octapharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel support, Research Funding; NovoNordisk: Other: Travel support. Borel-Derlon:LFB: Other: Reference expert and national coordinator for VWD; Shire - Baxalta: Research Funding; Octapharma: Research Funding; NovoNordisk: Other: Expert for scientific committee. Ducore:CSL Behring: Membership on an entity's Board of Directors or advisory committees; Biogen: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; LFB: Membership on an entity's Board of Directors or advisory committees; Octapharama: Membership on an entity's Board of Directors or advisory committees; Baxalta (Shire): Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees. Sigaud:Shire - Baxalta: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Description: Pharmacokinetic (PK)-targeted dose adjustment of oral Bu has been shown to minimize the toxicity and treatment related mortality following hematopoietic stem cell transplantation (HSCT). Intravenous busulfan (IV Bu) based myeloablative conditioning regimen has significantly reduced the inter-patient variability, ease of administration and reduced toxicities compared to oral Bu. However due to challenges in availability and cost of original formulation (Busulfex, Otsuka Pharmaceuticals) has resulted in the increased use of generic versions of the drug worldwide. Also, in many parts of the world, regulatory approval for generic drugs is obtained only with bioequivalence studies without a clinical trial or PK data. From June 2010 to December 2014, our center has used generic IV busulfan Bucelon™ (Celon Labs, Hyderabad, India) with routine therapeutic drug monitoring and dose adjustment. Since January 2015, Buslera™ (Biem Pharmaceuticals, Ankara, Turkey), a newer generic IV busulfan formulation, is being used in patients undergoing HSCT in our centre due to non-availability of Bucelon™. We prospectively analyzed the PK of IV Buslera™ and compared the systemic exposure and targeted dose adjustment pattern with our experience with Bucelon™. Eighteen patients underwent HSCT with IV Buslera™ based conditioning regimen between January and July 2015. Twelve patients received once daily Bu dose (Q24H; 40mg/m2/day x 4 days) and 6 received every 6 hour dosing (Q6H; 0.8mg/kg/dose x 4 days). In the historical cohort, 135 patients (30 Q6H and 105 Q24H) received Bucelon™ (Mohanan et al, Blood 2013; 122:3280). Demographics of the patients in both groups are depicted in the Table. Blood samples were collected at predetermined time points on day 1 and 3 & busulfan plasma concentrations analyzed using previously published method (Desire et al, 2013). Further doses of busulfan were adjusted to achieve target busulfan AUC (4500-5500 mmoles*min for Q24H and 900-1350 mmoles*min for Q6H). In patients receiving Q24H IV Buslera, the median busulfan AUC on day 1 was 6516 mMoles*min (3908-14064 mMoles*min). The Buslera dose was reduced in 8 patients (median dose reduction 13%; range: 7-18%), increased in one (9%) and 3 patients did not require any dose adjustment. In patients receiving Q6H IV Bu, the AUC on day 1 was 784 mMoles*min (446-960 mMoles*min). Five out of 6 patients required a moderate increase in dose (median dose increase 5%; range: 5-8%) and one did not require any dose adjustment. This data is strikingly different when compared to the historical cohort of patients receiving IV Bucelon™ where 60% patients receiving Q24h dose required dose increase, while with Buslera™ only 9% of patients needed dose increase (p

Description: Introduction: The use of fecal surveillance cultures in predicting bacteremia in patients undergoing intensive chemotherapy and stem cell transplant is an unsettled issue (Neshar et al. Transpl. Infect Dis. 2015). With the increasing incidence of multi-drug resistant (MDR) organisms and high mortality rates with these infections, we sought to describe the spectrum of MDR identified in fecal surveillance, and re-visit the use of fecal surveillance in predicting infection with MDR organisms post-allogeneic stem cell transplant (allo-SCT). Methods: We analyzed data from all patients who underwent allogeneic stem cell transplant during a 2 year period (2014-2015). Patients with MDR strains of bacteria (defined in this study as defined as Vancomycin resistant enterococcus (VRE), Extended spectrum Beta-Lactamases (ESBL) and Carbapenem resistant enterobacteriacea (CRE)) in fecal surveillance were compared with patients who did not have MDR in fecal surveillance cultures. Baseline characteristics and post allo-SCT outcomes including MDR blood culture positivity, severe sepsis and 100-day transplant related mortality (TRM) were compared. Multivariate analysis using logistic regression model was used to determine independent predictors of outcome. Results: A total of 313 allogeneic stem cell transplants were performed in 299 patients, of which data on pre-transplant fecal surveillance cultures were available in 232 transplants. The incidence of MDR isolates in fecal surveillance cultures was 56% (134/232, with E.Coli 118, Klebsiella 33 and Enterococcus 13). Of these, 129 were ESBL alone (78.6%), 17 were CRE alone (10.3%), 10 were ESBL + CRE (6%), 6 (3.6%) were VRE alone. More than one drug resistant organism was isolated in fecal surveillance in 31 patients. The incidence of any MDR positivity in post-transplant blood cultures in all patients was 13.8% (32/232), with 9.4% CRE, 2.6% ESBL, and 1.7% VRE. Thirty-one patients had severe sepsis without any MDR organism isolated on blood culture, but of these 3 had CRE in sputum, 2 had Colistin resistant Acetinobacter (sputum), 2 had candidemia, 3 had NF-GNB and one had Enterococcus. Baseline characteristics between patients who were positive and negative for MDR in fecal surveillance were similar in relation in relation to age (p=0.058), diagnosis (0.133), type of transplant - matched family/MUD/Haplo (p=0.610), stem cell source (0.370), grade 3-4 GVHD (0.834). There was a significantly higher subsequent blood MDR positivity (any MDR) (p=0.012), 100-day mortality (p=0.012) and poor outcome (severe sepsis or 100 day mortality) (p=0.006) in patients who had MDR detected in fecal surveillance cultures. However, of the 25 patients who had MDR isolated in both fecal surveillance culture as well as subsequent blood cultures, only 9 patients had the same organism and susceptibility pattern in both. Factors influencing 100-day mortality included patient's age (p=0.001), MDR positivity in blood (p=0.0001), MDR in fecal surveillance (p=0.01), use of an alternate (Haplo/MUD/family) donor (p=0.0001), GVHD grade 3-4 (p=0.000) and severe sepsis (p=0.000). On multivariate analysis, only patient's age (p=0.015), alternate donor (0.009), severe sepsis (p=0.000) and grade 3-4 GVHD (p=0.001) retained significance in predicting 100-day mortality. Conclusion: Multidrug resistant organisms are frequently seen on fecal surveillance in the pre-transplant setting. MDR in fecal surveillance is associated with a higher incidence of MDR positive blood cultures but not with the same organism, and on univariate analysis is associated with higher incidence of 100 day mortality. Newer strategies to reduce bacteremia and mortality in this group of high risk patients need to be considered. Disclosures No relevant conflicts of interest to declare.