This phase II study evaluates whether early treatment with mycophenolate mofetil (MMF) plus prednisone improves liver inflammation caused by immune checkpoint inhibitors. The study includes patients who develop moderate to severe immune-related hepatitis after receiving PD-(L)1 or CTLA-4-based cancer therapy. The main goal is to determine how many patients experience improvement in liver function within 30 days while successfully tapering steroids. Safety and treatment-related side effects will also be monitored.
This is a phase II, interventional clinical trial evaluating the efficacy and safety of combination immunosuppression with mycophenolate mofetil (MMF) plus prednisone for the treatment of grade 2-3 immune-related adverse event (irAE) hepatitis associated with immune checkpoint inhibitor therapy (PD-(L)1 and/or Cytotoxic T-lymphocyte associated protein 4 (CTLA-4) inhibitors). Eligible patients are those with laboratory-defined grade 2-3 hepatitis and a clinical diagnosis consistent with irAE hepatitis. When feasible, liver biopsy is obtained within 120 hours of diagnosis to confirm the diagnosis and evaluate alternative causes of liver injury; however, biopsy is not required in patients where the procedure is deemed unsafe (e.g., due to coagulopathy or ascites). Treatment initiation must occur within 72 hours of diagnosis. In select patients where clinically appropriate, immunosuppressive therapy may be delayed up to 48 hours to allow for diagnostic evaluation, including biopsy and viral testing. Patients in whom an alternative cause of liver injury is considered more likely (e.g., tumor involvement) or whose liver function improves to grade 1 or lower without intervention will not receive protocol-directed treatment and will instead enter an observational follow-up cohort. Patients with grade 4 hepatitis at presentation are excluded due to safety concerns with the study's treatment approach. All treated patients receive combination therapy consisting of fixed-dose MMF and physician-directed prednisone. Prednisone tapering is guided by suggested protocols but ultimately determined by the treating physician. Dose modification guidelines are provided for MMF. The primary endpoint is treatment response at 30 days from irAE hepatitis diagnosis, defined as improvement to grade 0-1 hepatitis with successful steroid taper to ≤20 mg prednisone equivalent daily. The primary analysis will be conducted on an intention-to-treat basis. The study uses a Simon two-stage design to evaluate efficacy. The null hypothesis assumes a response rate of ≤60%, while the alternative hypothesis assumes a response rate of ≥80%. Stage I includes 11 evaluable patients, and Stage II includes 20 patients, with interim futility analyses conducted at each stage. Early safety monitoring includes toxicity assessment in the first 8 patients. A steering committee will regularly review safety data to monitor for patient harm. Treatment failure is defined as lack of response at 30 days or death attributable to irAE, severe infection, or treatment-related toxicity. Death due to underlying cancer progression is not considered treatment failure. This study aims to determine whether early combination immunosuppression can improve outcomes in patients with immune-mediated hepatitis while maintaining an acceptable safety profile.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
31
MMF dosing is 1000 mg orally twice daily, and dosing for individual patients will be managed based on toxicity monitoring rules. The addition of alternative agents for treatment of irAEs will be at the treating Oncologist/Hematologist's discretion. Patients for whom prednisone is held may resume those agents at treating Oncologist/Hematologist's discretion, while rules for MMF re-challenge are stipulated. At the end of the 30-day primary study period, patients may continue one or both agents as deemed appropriate by the treating physician.
Fox Chase Cancer Center
Philadelphia, Pennsylvania, United States
RECRUITINGResponse rate of immunotherapy (IO)-related hepatitis to MMF and prednisone
The response rate of IO-related hepatitis to MMF and prednisone defined as achievement of corticosteroid (CS) dose of ≤ 20 mg prednisone with improvement to G1 or better as protocol defined at day 30 following treatment initiation
Time frame: 30 days
Frequency of bacterial, viral, or fungal infection requiring systemic treatment
The frequency of bacterial, viral, or fungal infection requiring systemic treatment within 90 days of initiation of MMF plus prednisone
Time frame: 90 days
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