Bone Marrow Transplantation (2020) 55:641–648 https://doi.org/10.1038/s41409-019-0731-x ARTICLE Ruxolitinib in refractory acute and chronic graft-versus-host disease: a multicenter survey study Virginia Escamilla Gómez 1 Valentín García-Gutiérrez2 Lucía López Corral3 Irene García Cadenas 4 ● ● ● ● Ariadna Pérez Martínez5 Francisco J. Márquez Malaver 1 Teresa Caballero-Velázquez 1 ● ● ● Pedro A. González Sierra6 María C. Viguria Alegría7 Ingrid M. Parra Salinas8 Cristina Calderón Cabrera1 ● ● ● ● Marta González Vicent9 Nancy Rodríguez Torres1 Rocío Parody Porras10 Christelle Ferra Coll 11 ● ● ● ● Guillermo Orti12 David Valcárcel Ferreiras12 Rafael De la Cámara LLanzá 13 Paula Molés 14 ● ● ● ● Kyra Velázquez-Kennedy2 María João Mende3 Dolores Caballero Barrigón3 Estefanía Pérez3 ● ● ● ● Rodrigo Martino Bofarull4 Silvanna Saavedra Gerosa4 Jorge Sierra4 Marc Poch5 María T. Zudaire Ripa7 ● ● ● ● ● Miguel A. Díaz Pérez9 Blanca Molina Angulo9 Isabel Sánchez Ortega10 Jaime Sanz Caballer14 ● ● ● ● Juan Montoro Gómez14 Ildefonso Espigado Tocino1 José A Pérez-Simón1 On behalf of the Grupo Español ● ● ● de Trasplante Hematopoyético (GETH) Received: 21 January 2019 / Revised: 13 October 2019 / Accepted: 17 October 2019 / Published online: 7 November 2019 1234567890();,: 1234567890();,: © The Author(s) 2019. This article is published with open access Abstract Graft-versus-host disease is the main cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. First-line treatment is based on the use of high doses of corticosteroids. Unfortunately, second-line treatment for both acute and chronic graft-versus-host disease, remains a challenge. Ruxolitinib has been shown as an effective and safe treatment option for these patients. Seventy-nine patients received ruxolitinib and were evaluated in this retrospective and multicenter study. Twenty-three patients received ruxolitinib for refractory acute graft-versus-host disease after a median of 3 (range 1–5) previous lines of therapy. Overall response rate was 69.5% (16/23) which was obtained after a median of 2 weeks of treatment, and 21.7% (5/23) reached complete remission. Fifty-six patients were evaluated for refractory chronic graft-versus-host disease. The median number of previous lines of therapy was 3 (range 1–10). Overall response rate was 57.1% (32/56) with 3.5% (2/56) obtaining complete remission after a median of 4 weeks. Tapering of corticosteroids was possible in both acute (17/23, 73%) and chronic graft-versus-host disease (32/56, 57.1%) groups. Overall survival was 47% (CI: 23–67%) at 6 months for patients with aGVHD (62 vs 28% in responders vs non-responders) and 81% (CI: 63–89%) at 1 year for patients with cGVHD (83 vs 76% in responders vs non-responders). Ruxolitinib in the real life setting is an effective and safe treatment option for GVHD, with an ORR of 69.5% and 57.1% for refractory acute and chronic graft- versus-host disease, respectively, in heavily pretreated patients. Introduction Graft-versus-host disease (GVHD) is the main cause of morbidity and mortality after allogeneic hematopoietic stem These authors contributed equally: Virginia Escamilla Gómez, Valentín García-Gutiérrez, José A. Pérez-Simón cell transplantation (HSCT). Despite the use of standard prophylaxis 35–50% and 35–70% of HSCT recipients will This study has been carried out within the Grupo Español de develop acute (aGVHD) [1] and chronic GVHD (cGVHD) Trasplante Hematopoyético y Terapia Celular (GETH). [2], respectively. * Valentín García-Gutiérrez First-line systemic treatment consists of high doses of jvalentingg@gmail.com corticosteroids. Unfortunately, more than 50% of the * José A Pérez-Simón patients will not respond adequately, thus requiring second- josea.perez.simon.sspa@juntadeandalucia.es line treatment [3]. This subgroup of patients has an espe- Extended author information available on the last page of the article cially poor prognosis, with a significantly higher risk of 642 V. Escamilla Gómez et al. treatment-related mortality [4]. Until recently, there were no In addition, Novartis Inc is running two large phase III approved therapies for GVHD treatment [5]. trials of ruxolitinib vs best standard of care in steroid- Ruxolitinib is an orally administered selective Janus refractory aGVHD and cGVHD. They are open-label stu- Kinase (JAK) inhibitor approved for the treatment of dies in period of recruiting. However clinical data and myelofibrosis and polycythemia vera [6–9]. JAK inhibitors outcomes are not available yet. relieve symptoms related to an excess of proinflammatory With this background, we analyzed the use of ruxolitinib cytokines in these patients [10, 11]. Due to the key role of in the treatment of GVHD within the Spanish Group of JAK-STAT pathways on T cells activation, JAK inhibitors Hematopoietic Transplant and Cell Therapy (GETH) cen- may reduce GVHD by inhibiting donor T-cell expansion ters. Our data add evidence to the information available so and inflammatory cytokine production, regulatory T-cell far, on this new therapeutic strategy. (Treg) function and viability. Based on this background, Spoerl et al. [12] and Zeiser et al. [13] have reported the effectiveness of ruxolitinib to control GVHD in both mice Methods and humans. Several approaches have been evaluated as recue Study population therapy within the second-line treatment. The difficulty in grading the severity (consequence of the high hetero- Between October 2015 to July 2017, 79 patients who geneity of the manifestations) and the treatment respon- underwent an HSCT and developed GVHD resistant to ses, as well as the sequential or concomitant treatment steroids received ruxolitinib. They were evaluated in this with several immunosuppressive drugs, makes it difficult retrospective, observational, and multicenter study using to evaluate the effectiveness of any approach. In this data collected from 13 Spanish centers, including seven context, the German group [13] has published data from a pediatric patients (<14 years). Off-label treatment with retrospective study in which 95 patients with moderate- ruxolitinib and data analysis were approved by the Clinical severe GVHD refractory to steroids were treated with Research Ethics Committee of the Hospital Universitario ruxolitinib. The overall response rates (ORR) were 44/54 Ramón y Cajal, Spain. (81%) and 35/41 (85%) for aGVHD and cGVHD The median age was 51 years (range, 0–73). The most respectively, with rates of up to 46% of complete frequent underlying diseases were: acute myeloid leukemia responses (CR) in aGVHD. To assess long-term follow-up (38%), non-Hodgkin lymphoma (16.5%) and acute lym- results, they collected data in a second analysis [14] from phoblastic leukemia (15.2%). The majority of patients the same patients. Ongoing ORR was 22/54 (41%) and 10/ received reduced-intensity conditioning regimens (57%). 41 (24%) after a median follow-up of 19 and 24 months Patient baseline characteristics of the entire population are for aGVHD and cGVHD groups. The 1-year overall sur- shown in Table 1. Of note, 53% and 55% of patients with vival (OS) was 62.4% (CI: 49.4–75.4%) and 92.7% (CI: aGVHD or cGVHD, respectively, have received three or 84.7–100%), respectively. Other authors, such as Khoury more lines or prior therapy. et al. [15], reported the outcomes of 19 patients with The study was carried out in accordance with the prin- cGVHD who received salvage therapy with ruxolitinib. ciples of Declaration of Helsinki and received approval by They described early partial responses (PR) in 18 out of an independent Clinical Research Ethics Committee. Writ- 19 patients as well as a sustained steroid-sparing effect in ten informed consent for collection data was obtained and 17 out of 19 patients. signed from each patient after being treated with ruxolitinib. On May 24, 2019, the Food and Drug Administration Confidentiality of data collection was preserved following approved ruxolitinib (JAKAFI, Incyte Corporation) for local regulations (Organic Law 15/1999 of December 13, steroid-refractory aGVHD in adult and pediatric patients 12 Protection of Personal Data [LOPD]). Likewise, Law 14/ years and older [5]. Approval was based on Study INCB 2007 on Biomedical Research was respected. 18424-271 (NCT02953678), an open-label, single-arm, multicenter study of ruxolitinib that enrolled 49 patients Inclusion criteria and treatment plan with steroid-refractory aGVHD grades 2–4 (Mount Sinai Acute GVHD International Consortium criteria). Rux- Patients undergoing HSCT in GETH centers with steroid- olitinib was administered at 5 mg twice daily, and the dose refractory GVHD treated with ruxolitinib were included in could be increased to 10 mg twice daily. The trial’s primary the analysis. Refractoriness of aGVHD was defined as endpoints were day-28 ORR. The median response duration “progression within 3–5 days of starting treatment or an was 16 days (95% CI: 9, 83), and the median time from incomplete response by 7–14 days. Refractory cGVHD was day-28 response to either death or need for new therapy for defined as “cGVHD of sustained severity during the last full aGVHD was 173 days (95% CI 66, NE). month during which the patients had received the equivalent Ruxolitinib in refractory acute and chronic graft-versus-host disease: a multicenter survey study 643 Table 1 Patient characteristics Table 1 (continued) N (%) Chronic GVHD (n = 56) N (%) Gender Skin 44 (78.5) Male 48 (60.8) Female 31 (39.2) Sclerotic changes 25 (41.1) Age Resembling lichen planus 2 (3.6) Median (range) 51 (0–73) Rash 13 (23.2) Underlying disease Hyper/hypopigmentation 3 (5.4) Acute myeloblastic leukemia 30 (38) Ichthyosis 3 (5.4) Acute lymphoblastic leukemia 12 (15.2) Myelodysplastic syndrome 11 (13.9) Oral 33 (58.9) Multiple myeloma 3 (3.8) Ocular 23 (41) Hodgkin disease 2 (2.5) Gut 16 (28.6) Non-Hodgkin disease 13 (16.5) Liver 10 (17.8) Myelofibrosis 4 (5.1) Lung 26 (45) Others 4 (5.1) Joint mobility disfunction 22 (39.4) Disease status previous HSCT CR 47 (59.5) Urinary tract 7 (12.5) PR 13 (16.5) Esophageal membrane 2 (3.6) SD 11 (13.9) Pericardial/pleural effusion 2 (3.6) Others 8 (10,1) Nephrotic syndrome 1 (1.8) Type of transplant Neuropathy 1 (1.8) Related HLA identical donor 33 (41.7) Haploidentical 7 (8.8) Microangiopathy 1 (1.8) Unrelated donor 39 (49.3) Polymyositis 3 (5.3) Conditioning regimen Previous lines of therapy Myeloablative 34 (43) 1 4 (7.1) Reduced-intensity 45 (57) 2 20 (35.7) Source 3 11 (19.6) Peripheral blood 75 (95) Bone marrow 2 (2.5) >3 21 (37.6) Umbilical cord 2 (2.5) Acute GVHD (n = 23) N (%) of prednisone 0.5 mg/kg or more per day or 1 mg/kg or Grades more every other day”. 2–4 23 (100) The severity of the disease was evaluated according to 3–4 20 (87) the International Bone Marrow Transplant Registry criteria Organs involved for aGVHD [16] and according to the international con- Skin 16 (69.6) sensus of National Institutes of Health (NIH) for cGVHD Gut 21 (95.5) [17]. Patients were scored for their best response at any time Liver 13 (59.1) after starting ruxolitinib. Treatment responses were con- Previous lines of therapy sidered when patients achieved CR or PR. Other types of 1 4 (18.2) responses were considered treatment failure. Regarding aGVHD, CR was defined as the absence of 2 7 (31.8) symptoms related to the GVHD. The PR as improvement of 3 6 (26.1) at least one category of the severity of aGVHD in one organ >3 6 (27.2) without deterioration in any other. Treatment failure was Chronic GVHD (n = 56) N (%) defined as the lack of improvement of GVHD, deterioration in any organ, appearance of new symptomatology asso- NIH score ciated with GVHD or the need to start a new treatment for Mild 0 (0) the control of the disease. Moderate 28 (50) Regarding cGVHD, response assessment was performed Severe 28 (50) following NIH criteria [18]. CR was defined as resolution of Organs involved all manifestations related to cGVHD in a specific organ; PR as improvement in score from baseline reflecting genuine clinical benefit; and treatment failure as criteria for 644 V. Escamilla Gómez et al. Table 2 Ruxolitinib responses territory. Data were collected in a specific Electronic Case Acute GVHD (n = 23) ORR CRR Report Form especially designed for the study. Overall response 16/23 (69.5) 5/23 (21.7) Statistics Response rate in grades 3–4 14/20 (70) 5/20 (25) RR by organs Results were analyzed using the Statistical Package for the Skin 11/16 (68.8) 3/16 (18.7) Social Sciences (SPSS PASW18). A p < 0.05 was con- Gut 14/21 (66.7) 4/21 (19) sidered statistically significant. OS was calculated in our Liver 9/13 (69.2) 3/13 (23) study at one year with Stata/IC 15.0 program. Given that the RR ≥ 3 lines of treatment 9/12 (75) objective of the study was merely descriptive, and therefore, And aGVHV grades 3–4 8/11 (72.7) 2/11 (18.2) there was not hypothesis to be confirmed, the sample esti- And skin involvement 8/10 (80) 2/9 (20) mation prior to the study was not necessary. And gut involvement 8/11 (72.7) 1/11 (9) And liver involvement 4/6 (66.7) 1/6 (16) Results Chronic GVHD (n = 56) ORR CRR Overall response 32/56 (57.1) 2/56 (3.5) Ruxolitinib in aGVHD RR by grades Moderate 17/28 (60.7) 1/28 (3.5) Twenty-three patients received ruxolitinib for refractory Severe 15/28 (53.5) 1/28 (3.5) aGVHD. All patients had grades 2–4 aGVHD and 20 patients (87%) had grades 3–4; the median number of RR by organs previous lines of therapy was 3 (range 1–5). ORR was Skin with sclerotic changes 14/25 (56) 0/25 (0) 69.5% (16/23) which was obtained after a median of Lung 16/26 (61.5) 2/26 (7) 2 weeks of treatment (range: 0.5–4 weeks), and 21.7% (5/ Gut 9/16 (56.3) 2/16 (12) 23) reached CR. Median follow-up was 78 days (range: RR ≥3 lines of treatment 17/32 (53.1) 2/32 (6.3) 4–913). The median dose of ruxolitinib was 20 mg/day And moderate plus severe 17/32 (53.1) 2/32 (6.3) divided in two doses. Remarkably, we found no differences cGVHD in treatment responses depending on the organs involved And skin involvement with sclerotic 8/15 (53.3) 0/15 (0) (Table 2). More specifically, 66.7% of patients with gas- changes trointestinal GVHD did respond, 19% obtaining CR. The And lung involvement 10/14 (71.4) 2/14 (14.2) use of ruxolitinib allowed to taper steroids doses in 17/23 of And gut involvement 7/10 (70) 2/10 (20) patients (73.7%). Globally, overall survival at 6 months was 47% (CI: 23–67%) (Fig. 1a). Overall survival (OS) at 6 months in responders vs non-responders was 62% vs progression defined in NIH consensus. Discontinuation of 28%, respectively (Fig. 1b). ruxolitinib due to toxicity was not considered treatment failure. Histologic GVHD grading was performed on the Ruxolitinib in cGVHD basis of histopathology according to a published staging system for histology and clinical grading according to cri- Fifty-six patients were evaluated for refractory cGVHD. All teria for aGVHD or cGVHD [19]. patients had moderate (28/57, 50%) to severe (28/57, 50%) cGVHD. The median number of previous lines of therapy Study design was 3 (range 1–10). ORR was 57.1% (32/56) with 3.5% (2/56) obtaining CR which was obtained at a median of This is a retrospective, observational and multicenter study. 4 weeks of treatment (range: 1–24 weeks). Median follow- Safety and efficacy data were analyzed in patients who have up was 181 days (range: 15–560). The median dose admi- already been treated with ruxolitinib in the clinical practice nistrated was 20 mg daily divided in two doses. Again, no under a compassionate use. The study did not imply a differences were found upon analyzing response rate by change in the therapeutic action or additional tests. The organs involved. Remarkably, ORR in patients with information source was patient´s clinical history in all cases. sclerotic changes was 56%, for those with lung involvement The study was performed within the hospital setting, with 61.5% and for those with gut involvement 56.3%. the participation of Departments of Hematology belonging Responses for lung involvement were evaluated according to the Spanish Group of Hematopoietic Transplant and Cell to NIH scoring/staging/response assessment as part of Therapy (GETH) distributed throughout the national standard clinical practice. Thirty-two patients (59.2%) could Ruxolitinib in refractory acute and chronic graft-versus-host disease: a multicenter survey study 645 a OVERALL SURVIVAL IN ACUTE GVHD a OVERALL SURVIVAL IN CHRONIC GVHD 1.00 1.00 0.75 0.75 Overall survival Overall survival 0.50 0.50 0.25 0.25 0.00 0.00 0 200 400 600 800 1000 0 200 400 600 Time after start of ruxolitinib (days) Time after start of ruxolitinib (days) Number at risk Number at risk 23 9 5 1 1 0 56 27 12 0 b OVERALL SURVIVAL IN ACUTE GVHD b OVERALL SURVIVAL IN CHRONIC GVHD 1.00 1.00 0.75 Overall survival 0.75 Overall survival 0.50 0.50 0.25 0.25 0.00 0.00 0 200 400 600 800 1000 0 200 400 600 Time after start of ruxolitinib (days) Time after start of ruxolitinib (days) Number at risk Number at risk Responders 16 8 4 1 1 0 Responders 32 14 6 0 Non-responders 7 1 1 0 0 0 Non-responders 24 13 6 0 Responders Non-responders Responders Non-responders Fig. 1 a Overall survival among patients with acute GVHD. b Overall Fig. 2 a Overall survival among patients with chronic GVHD. b Overall survival in responders vs non-responder acute GVHD patients survival in responders vs non-responder chronic GVHD patients taper the doses of steroids. OS at 1 year was 81% (IC: copies. Those patients with confirmed reactivation received 63–89) (Fig. 2a). OS at 1 year in responders vs non- valgancyclovir (foscarnet in case of severy neutropenia) responders was 83% vs 76%, respectively (Fig. 2b). according to current recommendations. Overall, 26 patients (32.9%) interrupted ruxolitinib due Toxicities, relapse, and mortality to: lack of response (14), cytopenias (three patients had thrombocytopenia, three anemia, three had both); infections Cytomegalovirus (CMV) reactivation was observed both in (1); and other causes (2). aGVHD and chronic subgroups of patients while on treat- Regarding drug-related toxicities, only three patients ment with ruxolitinib. Regarding aGVHD, CMV reactiva- discontinued ruxolitinib (Table 3). Causes for discontinua- tion occurred in 12/23 (52.2%) patients, while in the tion in these patients were fungal infection, thrombocyto- cGVHD subgroup, it was observed in 11/56 (19.6%) penia, and hepatic impairment. For 16 patients, it was patients. Nevertheless, when we analyzed CMV reactivation sufficient with temporary suspension or dose reduction. before ruxolitinib treatment was started, the incidence was Relapse of the underlying malignancy was only observed similar or even higher: among patients with aGVHD: 12/23 in one non ruxolitinib-responsive patient. (52.2%); and among patients with cGHVD: 15/56 (26%), Globally, 18 patients (22.8%) died: 10/23 patients indicating that ruxolitinib may not exert a significant (43.5%) within the aGVHD and 8/56 patients (14.3%) increase in the risk of CMV reactivation. Monitoring by within the cGVHD subgroup. Causes of death were: plasma CMV PCR was performed in all recipients and infections (10), refractory GVHD (6) and other causes (2). CMV reactivations were treated according to clinical prac- We also analyzed bilirubin, alkaline phosphatase, creati- tice. Since these data were retrospectively collected in dif- nine and LHD levels before ruxolitinib was started. How- ferent centers, there was not a uniform algorithm. Globally, ever, we did not find any biomarkers that could predict it was defined as 2 confirmed PCR CMV tested above 600 treatment responses. Median bilirubin, alkaline phosphatase, 646 V. Escamilla Gómez et al. Table 3 Toxicities, adverse events, and malignancy relapse to assess ORR is a limitation and could be considered a flaw Toxicities and adverse events N = 26/79 (32.9%) in the methodology. Nevertheless, taking into account the median time to best response for aGVHD by day 14 and Infections 4 (5) considering that late responses occurred up to day 27, our Fungal infection 2 data does well represent the ORR occurring by day +28, Bacterial/viral infection 2 which is currently considered the gold standard regarding Cytopenia 14 (17.7) the timing for aGVHD evaluation. Anemia 3 The German group [13] has reported data from a retro- Leukopenia 2 spective study in which 95 patients with moderate-severe Thrombocytopenia 5 GVHD refractory to steroids were treated with ruxolitinib. Combinations 4 The ORR were 81% (44/54) and 85% (35/41) for aGVHD Others 8 (10.1) and cGVHD respectively, with rates of up to 46% (25/54) Renal impairment 3 of CR in aGVHD and 7.3% (3/41) in cGVHD. OS rates at Hepatic impairment 3 6 months were 79% and 97%, respectively. Tapering of Hypertension 1 corticosteroids was possible in both aGVHD (17/23, 73%) Edema 1 and cGVHD (32/56, 57.1%) groups. In the current study, Action the median number of prior lines of treatment was 3 (1–5) Dose reduction 14 (17.7) among patients with aGVHD, and 3 (1–10) for patients with Temporary suspension 2 (2.5) cGVHD. Accordingly, the response rates previously Discontinuation 3 (3.7) described were obtained in heavily pretreated patients, both No actions/Others 7 (8.8) in the current study as well as in the study by Zeiser et al., Malignancy relapse 1 (1.2) although ORR and CR rates were higher in the German study. Ongoing prospective randomized trials are required to confirm these data, although in both studies, the response rate is remarkable as compared with other approaches [22– creatinine, and LHD levels were 1.5 mg, 117 U/L, 1 mg/dl, 32] and, furthermore, the toxicity profile was manageable in and 289 U/L respectively. this fragile population. The study led by Khoury et al. [15], reported outcomes of 19 patients with steroid-resistant cGVHD who received Discussion salvage ruxolitnib therapy. In their analysis they described early PR in 18 out of 19 patients. Of importance, they The development of novel approaches for the treatment of remark the reduction to physiologic doses or discontinua- relapsed or refractory GVHD is an unmet medical need. In tion of prednisone in ~90% of patients. the current study, ORR among patients with aGVHD was Recently, Incyte Corporation has announced positive 69.5% (16/23) with 21.7% (5/23) patients obtaining CR. results from its ongoing pivotal Phase 2 REACH1 trial for Among patients with refractory cGVHD, ORR was 57.1% aGVHD. The study showed an ORR of 55% (n = 39/71) at (32/56) with 3.5% (2/56) obtaining CR. It is worth men- day 28, and the best ORR at any time was 73% (n = 52/71), tioning that, in the current study, the response rate reached thus corroborating our findings. The most common treat- 56% for cGVHD with skin involvement and sclerotic fea- ment adverse events described were anemia (61%), throm- tures, which is promising considering the limited ther- bocytopenia (61%), and neutropenia (56%). apeutic options for these patients [20]. Similarly, lung In the current study, the safety profile was satisfactory, involvement is one of the most severe features of cGVHD. with the most frequent side effects consisting of cytopenias We observed a response rate of 61% among these patients. and CMV reactivation. According to our data, CMV reac- Other studies using extracorporeal photopheresis have tivation was observed in both aGVHD (52.2%) and chronic observed a response rate in the range of 33–63% [21]. In (19.6%) GVHD during the treatment. However, the analysis addition, considering that ruxolitinib is administrated orally, of CMV reactivation before starting ruxolitinib was even there might be some concerns regarding its absorption and higher, suggesting that treatment with ruxolitinib might not biodistribution. Noteworthy, ORR reached 67 and 56% increase the risk of CMV reactivation as suggested in other among patients with gastrointestinal aGVHD and cGVHD, studies. Therefore, CMV copy numbers should be mon- respectively. Considering the retrospective nature of the itored as a standard procedure according to current guide- study, we did not set a specific time point post ruxolitinib lines for clinical practice in this heavily pretreated group of for GVHD assessment, but we based our analysis on the patients in order to administer preemptive treatment if time of best response. The lack of a standardized time point required, not just because of an increased risk of Ruxolitinib in refractory acute and chronic graft-versus-host disease: a multicenter survey study 647 reactivation related to the drug but because of patients References characteristics. Concerning other toxicities related to the treatment, we 1. Jacobsohn DA, Vogelsang GB. Acute graft versus host disease. Orphanet J Rare Dis. 2007;2:35. found cytopenias as the most frequent event. It is known 2. Socié G, Ritz J. Current issues in chronic graft-versus-host dis- that JAK–STAT pathways are essential for cytokine- ease. Blood. 2014;124:374–84. mediated hematopoiesis [12]; that is the reason why 3. Martin P, Rizzo JD, Wingard JR, Ballen K, Curtin PT, Cutler C, thrombocytopenia and anemia are one of the major adverse et al. First- and second- line systemic treatment of acute graft- versus-host disease: recommendations of the American Society of effects of ruxolitinib that have been observed in other stu- Blood and Marrow Transplantation. Biol Blood Marrow Trans- dies in myelofibrosis. In our study, only three patients dis- plant. 2012;18:1150–63. continued ruxolitinib due to drug-related toxicities, 4. Westin JR, Saliba RM, De Lima M, Alousi A, Hosing C, Qazil- indicating that the drug shows an excellent toxicity profile. bash MH, et al. Steroid-refractory acute GVHD: predictors and outcomes. Adv Hematol. 2011;2011:601953–601953. It is also worth mentioning that a higher immuno- 5. Jaglowski SM, Blazar BR. How ibrutinib, a B-cell malignancy suppression might lead to a potential increased risk of drug, became an FDA-approved second-line therapy for steroid- relapse of the underlying malignancy [33]. In our study, we resistant chronic GVHD. Blood Adv. 2018;2:2012–9. did not observe any relapse among ruxolitinib-responsive 6. Harrison C, Kiladjian JJ, Al-Ali HK, Gisslinger H, Waltzman R, Stalbovskaya V, et al. JAK inhibition with ruxolitinib versus best patients. The only relapse observed in our series was seen in available therapy for myelofibrosis. NEnglJMed. 2012;366: a patient who did not respond to ruxolitinib. Overall, the 787–98. frequency of relapse was very low (1.2%) in comparison 7. Greenfield G, McPherson S, Mills K, McMullin MF. The rux- with other studies using other immunosuppressive drugs. olitinib effect: understanding how molecular pathogenesis and epigenetic dysregulation impact therapeutic efficacy in myelo- In summary, ruxolitinib in the real life setting has been proliferative neoplasms. J Transl Med. 2018;16(Dec):360. shown as an effective and safe treatment option for GVHD 8. Harrison CN, Mead AJ, Panchal A, Fox S, Yap C, Gbandi E, et al. patients, with an ORR of 69.5% and 57.1% for refractory Ruxolitinib vs best available therapy for ET intolerant or resistant aGVHD and cGVHD, respectively, among heavily pre- to hydroxycarbamide. Blood. 2017;130:1889–97. 9. Verstovsek S, Mesa RA, Gotlib J, Levy RS, Gupta V, DiPersio JF, treated patients. It is therefore a reasonable alternative to et al. A double-blind, placebo-controlled trial of ruxolitinib for consider for the treatment of steroid-refractory aGVHD and myelofibrosis. N Engl J Med. 2012;366:799–807. cGVHD. Its effectiveness has been shown both in the 10. Takanori T. JAK inhibitors: a home run for GVHD patients? improvement of GVHD as well as in the probability to spare Blood. 2014;123:3691–3. 11. Choi J, Cooper ML, Alahmari B, Ritchey J, Collins L, Holt M, the doses of steroids. et al. Pharmacologic blockade of JAK1/JAK2 reduces GvHD and preserves the graft-versus-leukemia effect. PLoS ONE. 2014;9: Acknowledgements This study has been performed in collaboration e109799. Boussiotis VA, ed. with the Spanish Group of Hematopoietic Transplant and Cell Therapy 12. Spoerl S, Mathew NR, Bscheider M, Schmitt-Graeff A, Chen S, (GETH). To the CIBERONC (CB16/12/00480). Mueller T, et al. Activity of therapeutic JAK 1/2 blockade in graft- versus-host disease. Blood. 2014;123:3832–42. Compliance with ethical standards 13. Zeiser R, Burchert A, Lengerke C, Verbeek M, Maas-Bauer K, Metzelder SK, et al. Ruxolitinib in corticosteroid-refractory graft- versus-host disease after allogeneic stem cell transplantation: a Conflict of interest Valentín García-Gutiérrez: Novartis: consultancy, multicenter survey. Leukemia. 2015;29:2062–8. honoraria and research funding José Antonio Përez-Simón: con- 14. Zeiser R, Burchert A, Lengerke, Verbeek M, Maas-Bauer K, sultancy, research funding and/or honoraria from Novartis, Jassen, Metzelder S, et al. Long-term follow-up of patients with Jazz, Takeda, Celgene and Roche. Other authors declare that they have corticosteroid-refractory graft-versus-host disease treated with no conflict of interest. ruxolitinib. Blood 2016;128:4561. 15. Khoury HJ, Langston AA, Kota VK, Wilkinson JA, Pusic I, Jil- Publisher’s note Springer Nature remains neutral with regard to lella A, et al. Ruxolitinib: a steroid sparing agent in chronic graft- jurisdictional claims in published maps and institutional affiliations. versus-host disease. Bone Marrow Transplant. 2018;53:826–31. 16. Przepiorka D, Weisdorf D, Martin P, Klingemann HG, Beatty P, Open Access This article is licensed under a Creative Commons Hows J, et al. 1994 Consensus Conference on Acute GVHD Attribution 4.0 International License, which permits use, sharing, Grading. Bone Marrow Transplant. 1995;15:825–8. adaptation, distribution and reproduction in any medium or format, as 17. Greinix HildegardT, et al. Diagnosis and staging of chronic graft- long as you give appropriate credit to the original author(s) and the versus-host disease in the clinical practice. Biol Blood Marrow source, provide a link to the Creative Commons license, and indicate if Transplant. 2011;17:167–75. changes were made. The images or other third party material in this 18. Lee, Stephanie J, Wolff D, Kitko C, Koreth J, Inamoto Y, et al. article are included in the article’s Creative Commons license, unless Measuring Therapeutic Response in Chronic Graft-versus-Host indicated otherwise in a credit line to the material. If material is not Disease. National Institutes of Health Consensus Development included in the article’s Creative Commons license and your intended Project on criteria for clinical trials in chronic graft-versus-host use is not permitted by statutory regulation or exceeds the permitted disease: IV. the 2014 response Criteria Working Group. Biol use, you will need to obtain permission directly from the copyright Blood Marrow Transplant. 2015;21:984–99. holder. To view a copy of this license, visit http://creativecommons. 19. Shulman HM, Kleiner D, Lee SJ, Morton T, Pavletic SZ, Farmer org/licenses/by/4.0/. E, et al. Histopathologic diagnosis of chronic graft-versus-host- 648 V. Escamilla Gómez et al. disease: National Institutes of HealthConsensus Development 27. Furlong T, Martin P, Flowers ME, Carnevale-Schianca F, Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Yatscoff R, Chauncey T, et al. Therapy with mycophenolate Disease: II. Pathology Working Group Report. Biol Blood Mar- mofetil for refractory acute and chronic GVHD. Bone Marrow row Transplant. 2006;12(Jan):31–47. Transplant. 2009;44:739–48. 20. Hurabielle C, Sicre de Fontbrune F, Moins‐Teisserenc, Robin M, 28. Bacigalupo A, Deeg J, Caballero D, Gualandi F, Raiola AN, Jachiet M,Coman, et al. Efficacy and tolerance of ruxolitinib in Varaldo R, et al. Treatment of patients with steroid refractory refractory sclerodermatous chronic graft‐versus‐host disease. Br J acute graft vs host disease (SR-GvHD): a matched paired analysis Dermatol. 2017;177:e206–e208. of anti-CD26 (begelomab) compared to Other Treatment. Blood 21. Benden C. Haughton m, Leonard S, Huber LC. Therapy options 2016;128:671. for chronic lung allograft dysfunction–bronchiolitis obliterans 29. Chen X, Wang C, Yin J, Xu J, Wei J, Zhang Y. Efficacy of syndrome following first-line immunosuppressive strategies: a mesenchymal stem cell therapy for steroid-refractory acute graft- systematic review. J Heart Lung Transplant. 2017;9:921–33. versus-host disease following allogeneic hematopoietic stem cell 22. Koreth J, Matsuoka K, Kim HT, McDonough SM, Bindra B, transplantation: a systematic review and meta-analysis. PLoS Alyea EP, et al. Interleukin-2 and regulatory T cells in graft- ONE. 2015;10:e0136991. versus-host disease. N Engl J Med. 2011;365:2055–66. 30. Miklos D, Cutler CS, Arora M, Waller EK, Jagasia M, Pusic I, 23. Cutler C, Miklos D, Kim HT, Treister N, Woo SB, Bienfang D, et al. Ibrutinib for chronic graft-versus-host disease after failure of et al. Rituximab for steroid-refractory chronic graft-versus-host prior therapy. Blood. 2017;130:2243–50. disease. Blood. 2006;108:756–62. 31. Greinix HT, Worel N, Just U, Knobler R. Extracorporeal photo- 24. Benito AI, Furlong T, Martin PJ, Anasetti C, Appelbaum FR, Doney pheresis in acute and chronic graft-versus-host disease. Transfus K, et al. Sirolimus (rapamycin) for the treatment of steroid-refractory Apher Sci. 2014;50:349–57. acute graft-versus-host disease. Transplantation. 2001;72:924–1929. 32. Hannani D. Extracorporeal photopheresis: tolerogenic or immu- 25. Ghez D, Rubio MT, Maillard N, Suarez F, Chandesris MO, nogenic cell death? beyond current dogma. Front Immunol. Delarue R, et al. Rapamycin for refractory acute graft-versus-host 2015;6:349. disease. Transplantation. 2009;88:1081–7. 33. Heine A, Held SA, Daecke SN, Wallner S, Yajnanarayana 26. Hoda D, Pidala J, Salgado-Vila N, Kim J, Perkins J, Bookout R, SP, Kurts C, et al. The JAK-inhibitor ruxolitinib impairs dendritic et al. Sirolimus for treatment of steroid-refractory acute graft- cell function in vitro and in vivo. Blood. 2013;122:1192–202. versus-host disease. Bone Marrow Transplant 2010;45:1347–51. Affiliations Virginia Escamilla Gómez 1 Valentín García-Gutiérrez2 Lucía López Corral3 Irene García Cadenas 4 ● ● ● ● Ariadna Pérez Martínez5 Francisco J. Márquez Malaver 1 Teresa Caballero-Velázquez 1 ● ● ● Pedro A. González Sierra6 María C. Viguria Alegría7 Ingrid M. Parra Salinas8 Cristina Calderón Cabrera1 ● ● ● ● Marta González Vicent9 Nancy Rodríguez Torres1 Rocío Parody Porras10 Christelle Ferra Coll 11 ● ● ● ● Guillermo Orti12 David Valcárcel Ferreiras12 Rafael De la Cámara LLanzá 13 Paula Molés 14 ● ● ● ● Kyra Velázquez-Kennedy2 María João Mende3 Dolores Caballero Barrigón3 Estefanía Pérez3 ● ● ● ● Rodrigo Martino Bofarull4 Silvanna Saavedra Gerosa4 Jorge Sierra4 Marc Poch5 María T. Zudaire Ripa7 ● ● ● ● ● Miguel A. Díaz Pérez9 Blanca Molina Angulo9 Isabel Sánchez Ortega10 Jaime Sanz Caballer14 ● ● ● ● Juan Montoro Gómez14 Ildefonso Espigado Tocino1 José A Pérez-Simón1 On behalf of the Grupo Español ● ● ● de Trasplante Hematopoyético (GETH) 1 Department of Hematology of the University Hospital Virgen del 7 Hospital of Navarra, Navarra, Spain Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/ 8 12/00480), Universidad de Sevilla, Seville, Spain University Hospital Miguel Servet, Zaragoza, Spain 2 9 Department of Hematology, University Hospital Ramon y Cajal, Hospital Niño Jesús, Madrid, Spain IRYCIS, Madrid, Spain 10 Instituto Catalá de Oncología Hospitalet, Barcelona, Spain 3 Complejo Asistencial Universitario de Salamanca-IBSAL, Centro 11 de Investigación del Cáncer-IBMCC, Salamanca, Spain Instituto Catalá de Oncología Germans Trias, Badalona, Spain 12 4 Hospital Santa Creu I Sant Pau, Barcelona, Spain University Hospital Vall d´Hebron, Barcelona, Spain 13 5 Clinic University Hospital of Valencia, Valencia, Spain Hospital La Princesa, Madrid, Spain 14 6 University Hospital, Granada, Spain Hospital La Fe, Valencia, Spain