Inferior Outcomes with Cyclosporine and Mycophenolate Mofetil after Myeloablative Allogeneic Hematopoietic Cell Transplantation

Betty K. Hamilton, Ying Liu, Michael T. Hemmer, Navneet Majhail, Olle Ringden, Dennis Kim, Luciano Costa, Robert Stuart, Amin Alousi, Joseph A. Pidala, Daniel R. Couriel, Mahmoud Aljurf, Joseph H. Antin, Christopher Bredeson, Jean Yves Cahn, Mitchell Cairo, Sung Won Choi, Christopher Dandoy, Robert Peter Gale, Usama GergisPeiman Hematti, Yoshihiro Inamoto, Rammurti T. Kamble, Margaret MacMillan, David I. Marks, Eneida Nemecek, Taiga Nishihori, Ayman Saad, Bipin N. Savani, Jeff Schriber, Sachiko Seo, Gérard Socié, Takanori Teshima, Leo F. Verdonck, Edmund K. Waller, Mona Wirk, Stephen R. Spellman, Mukta Arora, Saurabh Chhabra

Research output: Contribution to journalArticlepeer-review

1 Scopus citations

Abstract

Combination therapy with a calcineurin inhibitor (CNI), such as cyclosporine (CSA) or tacrolimus (Tac), and methotrexate (MTX) or mycophenolate mofetil (MMF) is a widely used approach to graft-versus-host disease (GVHD) prevention. Data on the comparative effectiveness of MMF compared with MTX are limited and conflicting, however. We analyzed data from the Center for International Blood and Marrow Transplant Research for adult patients undergoing first myeloablative hematopoietic cell transplantation (HCT) from an HLA-identical matched related donor (MRD; n = 3979) or matched unrelated donor (URD; n = 4163) using CSA+MMF, CSA+MTX, Tac+MMF, or Tac+MTX for GVHD prevention between 2000 and 2013. Within the MRD cohort, 2252 patients received CSA+MTX, 1391 received Tac+MTX, 114 received CSA+MMF, and 222 received Tac+MMF. Recipients of CSA+MMF had a higher incidence of acute GVHD grade II-IV (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.24 to 2.20; P < .001) and grade III-IV (HR, 1.92; 95% CI, 1.31 to 2.83; P < .001) compared with Tac+MTX. The use of CSA+MMF was also associated with inferior overall survival (OS) (HR, 2.31; 95% CI, 1.73 to 3.09; P < .001) due to higher transplantation-related mortality (TRM) (HR, 4.03; 95% CI, 2.61 to 6.23; P < .001) compared with Tac+MTX. Within the URD cohort, 974 patients received CSA+MTX, 2697 received Tac+MTX, 68 received CSA+MMF, and 424 received Tac+MMF. CSA+MMF was again significantly associated with a higher incidence of grade III-IV acute GVHD (HR, 2.31; 95% CI, 1.57 to 3.42; P <0001), worse OS (HR, 2.36; 95% CI, 1.67 to 3.35; P < .001), and higher TRM (HR, 3.09; 95% CI, 2.00 to 4.77; P < .001), compared with Tac+MTX and other regimens. Thus, this large retrospective comparison of MMF versus MTX in combination with CSA or Tac demonstrates significantly worse GVHD and survival outcomes with CSA+MMF compared with Tac+MTX.

Original languageEnglish (US)
Pages (from-to)1744-1755
Number of pages12
JournalBiology of Blood and Marrow Transplantation
Volume25
Issue number9
DOIs
StatePublished - Sep 2019

Keywords

  • Allogeneic hematopoietic cell transplantation
  • Graft-versus-host disease
  • Methotrexate
  • Mycophenolate mofetil
  • Myeloablative

ASJC Scopus subject areas

  • Hematology
  • Transplantation

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