Etanercept plus topical corticosteroids as initial therapy for grade one acute graft-versus-host disease after allogeneic hematopoietic cell transplantation

Clinical diagnosis of grade 1 acute graft-versus-host disease (GVHD) marks the beginning of a potentially progressive and fatal course of GVHD after hematopoietic stem cell transplantation (HSCT). However, interventional studies to treat early GVHD are lacking. We conducted a single-arm prospective phase II trial to test the hypothesis that treatment of newly diagnosed grade 1 acute GVHD with etanercept and topical corticosteroids would reduce progression to grade 2 to 4 within 28days. Study patients (n=34) had a median age of 51years (range, 10 to 67years) and had undergone unrelated (n=22) or related (n=12) donor HSCT. Study patients were treated with etanercept (4mg/kg, maximum 25mg/dose) twice weekly for 4 to 8weeks. Ten of 34 patients (29%) progressed to grade 2 to 4 acute GVHD within 28days. The cumulative incidence of grade 2 to 4 and grade 3 to 4 acute GVHD at 1year was 41% and 3%, respectively. Nonrelapse mortality was 19% and overall survival was 63% at 2years. Among a contemporaneous control cohort of patients who were diagnosed with grade 1 acute GVHD and treated with topical corticosteroids but not etanercept during the study period, 12 of 28 patients (43%) progressed to grade 2 to 4 GVHD within 28days, with a 1-year incidence of grade 2 to 4 GVHD and grade 3 to 4 GVHD of 61% (41% versus 61%, P=08) and 18% (3% versus 18%, P=05), respectively. Patients treated with etanercept also experienced less increase in GVHD plasma biomarkers suppression of tumorigenicity 2 (P=06) and regenerating islet-derived 3-alpha (P=01) 28days after grade 1 acute GVHD diagnosis compared with contemporaneous control patients. This study was terminated early because of poor accrual. Future prospective studies are needed to identify patients with grade 1 acute GVHD at risk of swift progression to more severe GVHD and to establish consensus for the treatment of grade 1 acute GVHD. This trial is registered with ClinicalTrials.gov, number NCT00726375.