Atorvastatin for the Prophylaxis of Acute Graft-versus-Host Disease in Patients Undergoing HLA-Matched Related Donor Allogeneic Hematopoietic Stem Cell Transplantation (allo-HCT)

Abstract

Statins possess potent immunomodulatory effects that may play a role in preventing acute GVHD (aGVHD) following allogeneic hematopoietic cell transplantation (allo-HCT). We performed a Phase II study of atorvastatin for aGVHD prophylaxis when given to allo-HCT recipients and their HLA-matched sibling donors. Atorvastatin (40mg/day) was administered to sibling donors, beginning 14 days before the anticipated start of stem cell collection. Allo-HCT recipients (n=40) received atorvastatin (40mg/day) in addition to standard aGVHD prophylaxis. The primary endpoint was cumulative incidence of grades 2-4 aGVHD at day 100. Atorvastatin was well tolerated and there were no attributable grade 3-4 toxicities in donors or their recipients. Day 100 and 180 cumulative incidences of grade 2-4 aGVHD were 30% (95% CI 17- 45%) and 40% (95% CI 25-55%), respectively. One-year cumulative incidence of chronic GVHD was 43% (95% CI 32- 69%). One year non-relapse mortality and relapse incidences were 5.5% (95% CI 0.9-16.5%) and 38% (95% CI 18- 47%), respectively. One-year progression-free survival and overall survival were 54% (95% CI 38-71%) and 82% (95% CI 69-94%). One-year GVHD-free, relapse-free survival (GRFS) was 27% (95% CI 16-47%). These results did not differ from our historical controls (N=96). While safe and tolerable, the addition of atorvastatin did not appear to provide any benefit to standard GVHD prophylaxis alone.

Recipient Immune Modulation with Atorvastatin for Acute Graft-versus-Host Disease Prophylaxis after Allogeneic Transplantation

“…In contrast to our initial report [22], the prospective trial by Efebera et al evaluating "2-pronged" atorvastatin use in matched sibling donor/recipient pairs reported a higher II to IV acute GVHD rate (30% at day +100) [34]. This difference seemed to result largely from the unusually high rates of isolated upper gastrointestinal (UGI) acute GVHD in the study by Efebera et al (where isolated UGI GVHD accounted for 42% of grade II to IV and 35% of grade I to IV acute GVHD at day +100).…”

Immune modulatory effects of statins

“…15,16 Oral atorvastatin treatment of NZB/NZW mice reduced T-cell GVHD Retrospective analysis Statin intake of the recipient correlates with lower GVHD incidence 2008 [60] GVHD Retrospective analysis Donor statin treatment is connected to reduced GVHD incidence in patients 2010 [55] GVHD Retrospective analysis. Recipient statin treatment is connected to reduced GVHD incidence in patients 2010 [56] GVHD Prospective phase II trial of atorvastatin for aGVHD prophylaxis Donor and recipient treatment with atorvastatin is effective as prophylaxis for GVHD 2013 [57] GVHD Phase II study of atorvastatin for aGVHD prophylaxis Atorvastatin did not provide any benefit to standard GVHD prophylaxis alone 2016 [59] GVHD Phase II study to evaluate the safety and efficacy of atorvastatin-based aGVHD prophylaxis Preliminary efficacy of atorvastatin for aGVHD prevention was seen 2017 [58] Abbreviations: aGVHD, acute graft-versus-host disease; CEL, contrast-enhancing lesions; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; GVHD, graft-versus-host disease; LDL-C, low-density lipoprotein cholesterol; MS, multiple sclerosis; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus. proliferation and cytokine production when the T cells were isolated from the treated mice and tested in vitro.…”

“…addition of atorvastatin to standard aGVHD prophylaxis did not provide a benefit with respect to GVHD rates. 59…”

“…In patients undergoing allogeneic haematopoietic cell transplantation, some studies showed that statin intake by the donor or host was connected to a reduced GVHD incidence . In contrast, one trial showed that the addition of atorvastatin to standard aGVHD prophylaxis did not provide a benefit with respect to GVHD rates …”

Pathogenesis of acute graft‐versus‐host disease: from intestinal microbiota alterations to donor T cell activation

“…Based on these data from the mouse model, subsequent clinical trials using statin prophylaxis in both patients/donors (Hamadani et al , ) or using treatment of donors only (Rotta et al , ) reported low GVHD rates. Conversely, one negative trial was reported where donors and patients received statins as prophylaxis leading to low rates of grade III‐IV aGVHD but unusually high rates of isolated upper intestinal tract acute GVHD (Efebera et al , ). A pharmacological approach targeting the proteasome with bortezomib was shown to reduce aGVHD in the mouse model by reducing pro‐inflammatory cytokines (Sun et al , ).…”