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Maintenance Therapies for Hodgkin and Non-Hodgkin Lymphomas After Autologous Transplantation: A Consensus Project of ASBMT, CIBMTR, and the Lymphoma Working Party of EBMT
Kanate, A. S., Kumar, A., Dreger, P., Dreyling, M., Le Gouill, S., Corradini, P., Bredeson, C., Fenske, T. S., Smith, S. M., Sureda, A., et al
JAMA oncology. 2019
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Abstract
Importance: Maintenance therapies are often considered as a therapeutic strategy in patients with lymphoma following autologous hematopoietic cell transplantation (auto-HCT) to mitigate the risk of disease relapse. With an evolving therapeutic landscape, where novel drugs are moving earlier in therapy lines, evidence relevant to contemporary practice is increasingly limited. The American Society for Blood and Marrow Transplantation (ASBMT), Center for International Blood and Marrow Transplant Research (CIBMTR), and European Society for Blood and Marrow Transplantation (EBMT) jointly convened an expert panel with diverse expertise and geographical representation to formulate consensus recommendations regarding the use of maintenance and/or consolidation therapies after auto-HCT in patients with lymphoma. Observations: The RAND-modified Delphi method was used to generate consensus statements where at least 75% vote in favor of a recommendation was considered as consensus. The process included 3 online surveys moderated by an independent methodological expert to ensure anonymity and an in-person meeting. The panel recommended restricting the histologic categories covered in this project to Hodgkin lymphoma (HL), mantle cell lymphoma (MCL), diffuse large B-cell lymphoma (DLBCL), and follicular lymphoma. On completion of the voting process, the panel generated 22 consensus statements regarding post auto-HCT maintenance and/or consolidation therapies. The grade A recommendations included endorsement of: (1) brentuximab vedotin (BV) maintenance and/or consolidation in BV-naive high-risk HL, (2) rituximab maintenance in MCL undergoing auto-HCT after first-line therapy, (3) rituximab maintenance in rituximab-naive FL, and (4) No post auto-HCT maintenance was recommended in DLBCL. The panel also developed consensus statements for important real-world clinical scenarios, where randomized data are lacking to guide clinical practice. Conclusions and Relevance: In the absence of contemporary evidence-based data, the panel found RAND-modified Delphi methodology effective in providing a rigorous framework for developing consensus recommendations for post auto-HCT maintenance and/or consolidation therapies in lymphoma.
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Low-Dose Acyclovir Prophylaxis for Varicella zoster Reactivation in Autologous Hematopoietic Cell Transplantation Recipients
Fei, N., Shah, N., Cumpston, A., Wen, S., Ross, K. G., Craig, M., Kanate, A. S.
Clinical hematology international. 2019;1(2):101-104
Abstract
Varicella zoster virus (VZV) reactivation after autologous hematopoietic cell transplantation (auto-HCT) may be observed in a quarter of patients. Currently, prophylactic use of acyclovir 800 mg twice daily or valacyclovir 500 mg twice daily is recommended for prophylaxis against VZV reactivation for at least one-year post-HCT, with continued use recommended in immunosuppressed recipients. Acyclovir dosing regimens vary between institutions despite the noted recommendations. In this single-center, retrospective study, recipients of auto-HCT who received at least one year of low-dose antiviral prophylaxis defined as the equivalent of acyclovir 400 mg orally twice daily or valacyclovir 500 mg daily were included. The primary objective of this study was to assess the incidence of VZV reactivation with low-dose acyclovir/valacyclovir prophylaxis in autograft recipients. One hundred and eighty patients undergoing auto-HCT between April 2008 and March 2015 were included. Patients received low-dose acyclovir, for a median duration of 55.5 months (range 12-100). There were no occurrences of VZV reactivation while patients were on these drugs. However, 2 patients (1.1%) had VZV reactivation after discontinuation of therapy, occurring 18.8 and 14 months from transplant and 6.7 and 2 months after stopping prophylaxis, respectively. Our retrospective analysis found low-dose antiviral prophylaxis with oral acyclovir 400 mg twice daily or valacyclovir 500 mg daily to be effective in preventing VZV reactivation in auto-HCT recipients.