Thalidomide treatment for chronic graft-versus-host disease .sx D. HENEY , D. R. NORFOLK , J. WHEELDON , C. C. BAILEY , I. J. LEWIS AND D. L. BARNARD .sx Departments of Paediatrics and Haematology , St James's University Hospital , Leeds , Department of Haematology , Leeds General Infirmary , Leeds .sx Received 29 August 1990 ; accepted for publication 7 January 1991 .sx Summary .sx The treatment of chronic graft-versus-host disease ( GVHD ) may present a difficult therapeutic problem .sx We used thalidomide to treat six patients with severe chronic GVHD who failed to respond to standard immunosuppressive agents .sx Four of the six patients showed a clear response to thalidomide , with the fifth patient showing a partial response .sx The best results were seen in patients with chronic cutaneous GVHD .sx Two of the patients developed neurophysiological evidence of a peripheral neuropathy , associated with clinical signs in one patient .sx Measurement of thalidomide plasma levels and pharmacokinetic curves showed a significant inter-patient variation .sx Peak plasma levels varied from 0.47 to 1.46 mu g/ml .sx Thalidomide has a role to play in the management of chronic GVHD and further studies are needed .sx The immunosuppressive properties of thalidomide have been known for over 20 years ( Hellman , 1966) .sx Although withdrawn from the market in 1961 it has remained available for research and restricted clinical use .sx In the decade that followed its withdrawal , thalidomide was shown to be an effective immunosuppressive agent for renal allotransplantation in a variety of animal models ( DeKlerk et al , 1969 ; Murphy et al , 1970) .sx This information was , however , not followed up and interest in its use in transplantation declined .sx Nevertheless thalidomide continued to be used in a variety of immunologically mediated diseases and has found a place in the management of a number of primarily mucocutaneous disorders including lepromatous leprosy , apthous stomatitis and discoid lupus erythematosus ( Barnhill & McDougall , 1982) .sx In 1986 Vogelsang reported the use of thalidomide in the treatment of acute graft-versus-host disease ( GVHD ) in a rat bone marrow transplant model .sx It was shown to be effective in the treatment and prevention of acute GVHD , and subsequent data confirmed its value in chronic GVHD ( Vogelsang et al , 1986 , 1989) .sx These experiments generated a renewed interest in thalidomide and were followed by reports of the beneficial effect of thalidomide in patients with acute and chronic GVHD ( Heney et al , 1990 ; Saurat et al , 1988 ; McCarthy et al , 1988) .sx We report on the use of thalidomide in the treatment of chronic GVHD in six patients .sx We have also modified previously described methods for the measurement of plasma levels of thalidomide and report pharmacokinetic data on our patients .sx PATIENTS AND METHODS .sx We treated six patients with thalidomide .sx Their background details are shown in Table I. All patients received HLA matched , mixed lymphocyte culture ( MLC ) compatible bone marrow transplants from either a parent or a sibling .sx They all had severe progressive chronic GVHD which had proved unresponsive to standard immunosuppressive therapy .sx Pharmacokinetics .sx Thalidomide plasma levels were measured in four patients .sx The patients were studied when they were established on thalidomide therapy .sx All patients followed the same protocol and were studied in the morning after an overnight fast .sx No solid food was allowed until 2 h after ingestion of a 100 mg thalidomide tablet .sx This was the standard thalidomide dose for each of the four patients .sx Heparinized plasma samples were obtained prior to thalidomide ingestion and hourly thereafter for a minimum of 6 h and longer where possible .sx Patient 6 declined to participate in the study , and in patient number 3 treatment was withdrawn before the study was initiated .sx Neurophysiological testing .sx All patients were examined at regular intervals for clinical evidence of a neuropathy .sx Four patients underwent neurophysiological testing which included nerve conduction studies and electromyography .sx Patient 6 declined the study and patient 4 died before being tested .sx Thalidomide assay .sx Thalidomide was extracted from plasma by solid phase extraction , using a 3 ml C18 Bond Elut cartridge ( Analytichem International) .sx Thalidomide was measured by high performance liquid chromatography ( HPLC ) ( Waters Associates ) utilizing a LiChrospher C18 5u 25 cm x 4 mm column .sx The mobile phase consisted of 20% Acetonitrile , 80% water plus 750 mu l of 30% HCL per litre .sx The flow rate was 1 ml/min and detection was at 230 nm .sx Acetophenetidin was used as an internal standard .sx table&caption .sx Standards were prepared by adding purified thalidomide ( Grunenthal GmbH ) to drug-free plasma .sx Thalidomide concentrations were calculated by comparing the peak height ratio of thalidomide and internal standard in study plasma samples with those from the calibration curve .sx The analytical recovery of thalidomide from plasma was 92% at 1 mu g/ml .sx Using the above chromatographic conditions , thalidomide and internal standard were well separated with approximate retention times of 12 and 17 min respectively ( see Fig 1) .sx The limit of detectibility was 0.1 mu g/ml .sx All solvents were supplied by Rathburn Chemicals , Walkerburn , Scotland .sx The thalidomide standard was kindly donated by Grunenthal GmbH , Germany .sx The thalidomide tablets were supplied by Champion Farmaceutica Ltd , S a-tilde o Paulo , Brazil .sx All other reagents came from Sigma Chemicals , Poole , U.K. RESULTS .sx Clinical response .sx The dosage of thalidomide and the clinical repsonse is shown in Table II .sx Patient 1 developed disabling chronic GVHD with extensive scleroderma which necessitated his attending a school for the physically handicapped .sx Thalidomide 200 mg daily was introduced but immediately caused significant somnolence .sx The dose was reduced to 100 mg daily , with no further somnolence , and a rapid clinical response over several weeks .sx The improvement has been sustained over a 24 month period allowing him to partake in normal activities , with the discontinuation of his azathioprine and a reduction in his prednisolone from 15 mg to 5 mg alternate days .sx Patient 2 also developed severe sclerodermatous chronic GVHD with marked pain and joint contractures .sx His mobility was greatly impaired and he had difficulty attending school .sx A clear improvement of both skin texture and mobility was noted within 6 weeks of starting thalidomide .sx There was a continued improvement over a 24-month period allowing him to complete his schooling and obtain full-time employment .sx His prednisolone was discontinued .sx At 24 months , neurophysiological testing revealed a moderately severe sensorimotor neuropathy , although he had no clinical signs or symptoms .sx The thalidomide was tailed off with no deterioration of his chronic GVHD .sx figure&caption .sx Patient 3 had severe multi-system chronic GVHD .sx She experienced moderate drowsiness when started on thalidomide 100 mg b.d. , and the dose was reduced to 100 mg nightly .sx A marked improvement in her cutaneous GVHD was evident within 8 weeks , and this continued over a 12-month period .sx Her azathioprine was discontinued and prednisolone reduced from 7.5 mg to 5 mg daily .sx She continued to have intercurrent respiratory infections but these were easily controlled .sx After 12 months of therapy she presented with numbness of both feet with clinical and neurophysiological evidence of a peripheral neuropathy .sx Thalidomide was discontinued and was followed immediately by a relapse of her cutaneous GVHD , with thickening and tightening of her skin .sx Her parasthesiae continued to worsen over a 3-month period but subsequently settled and 12 months later she has no clinical evidence of peripheral neuropathy .sx Her GVHD also stabilized .sx table&caption .sx Patient 4 developed severe mucocutaneous chronic GVHD with erythema and desquamation of her skin , dystrophic nails and oral ulceration and lichen planus .sx Thalidomide therapy was associated with an improvement in both her skin and oral mucosa .sx Her nais fell out shorty after starting thalidomide but thereafter started to grow again .sx Thalidomide therapy was continued for 6 months .sx During this time her azathioprine was discontinued and prednisolone reduced from 10 mg to 5 mg daily .sx Cyclosporine was maintained at 100 mg b.d. She then presented with a varicella zoster pneumonitis which proved rapidly fatal despite appropriate therapy .sx Patient 5 developed multisystem chronic GVHD with recurrent respiratory infections , sclerodermatous skin changes , vaginal stenosis , sicca syndrome and hepatic GVHD .sx She was started on thalidomide 200 mg nightly but this was associated with undue drowsiness and the dose was reduced to 100 mg nightly .sx There was a gradual improvement in her oral mucosa and also her skin which remained dry but otherwise stable .sx Problems with vaginal stenosis and respiratory infections persisted .sx Her azathioprine was discontinued although prednisolone 10 mg daily and cyclosporine 50 mg b.d. was maintained .sx Thalidomide therapy was continued for 18 months .sx While on thalidomide she developed pre-malignant vaginal changes necessitating a hysterectomy and vaginectomy , and also pre-malignant changes of her peri-anal skin .sx She then presented with lymphadenopathy of her neck and a diagnosis of stage IA nodular sclerosing Hodgkins disease was made for which she is receiving local radiotherapy .sx Patient 6 developed chronic respiratory GVHD with both restrictive and obstructive lung disease .sx He also had sicca syndrome and oral lichen planus .sx There was no response to thalidomide therapy over a 15-month period and the thalidomide has been discontinued .sx No side effects were noted .sx Neurophysiological testing .sx Patient 2 had ill-formed , low amplitude , sensory action potentials of both upper and lower limbs .sx Motor conduction responses were also of low amplitude with conductive delay .sx The electromyogram ( EMG ) showed mild denervative changes .sx These findings confirm a moderately severe axonal neuropathy with sensory and motor symptoms .sx Patient 3 had low amplitude sensory and motor action potentials , consistent with a mild generalized sensorimotor neuropathy .sx Patients 1 and 5 had no evidence of a neuropathy .sx Thalidomide pharmacokinetics .sx Thalidomide plasma levels of four patients are shown in Fig 2 .sx Base line levels varied between 0.26 and 0.50 mu g/ml , with Cmax ( peak levels ) varying from 0.47 to 1.46 mu g/ml .sx The rate , extent and duration of the rise of thalidomide levels following ingestion also varied .sx Peak to trough ratios were 2.9 , 2.1 , 2.0 and 1.4 for patients 1 , 2 , 4 and 5 respectively .sx Thus patient 5 had only a minimal rise while patients 1 and 4 had a more pronounced rise .sx In general there was a gradual return to base line levels at approximately 6-8 h. figure&caption .sx DISCUSSION Four of the six patients showed a clear response to thalidomide .sx The best responses were seen in those patients with chronic cutaneous GVHD .sx Patients 1 , 2 and 3 all showed a marked improvement in skin texture and mobility .sx Oral mucocutaneous symptoms also improved , most noticeably in patients 3 and 4 .sx The poorest reponses were seen in patients with multi-system disease , in particular where there was a combination of active respiratory and mucocutaneous disease .sx However , thalidomide may still be of value in this situation , as the cutaneous GVHD appeared to stabilize in patient 5 , and there are reports in the literature of respiratory disease responding to thalidomide ( McCarthy et al , 1988) .sx In three patients an improvement was noted within 6-8 weeks of starting therapy .sx The improvement usually continued over a period of months .sx In all cases the improvement was sustained and there was no evidence of recurrence while on thalidomide .sx In patient 3 thalidomide was discontinued abruptly because of peripheral neuropathy and a recurrence of symptoms was noted immediately .sx In patient 2 thalidomide was discontiuned gradually with no relapse of symptoms .sx Thalidomide has a number of early side effects which are seldom severe and are reversible when treatment is interrupted ( Grosshans & Illy , 1984) .sx They include drowsiness , dizziness , headaches , constipation , nausea , dryness of mouth and skin , erythematous skin eruptions and oedema .sx Less common side effects include allergic vasculitis and thrombocytopenic purpura .sx Three of our patients experienced drowsiness at a dose of 200 mg daily and necessitated a reduction of the dose .sx No other early side effects were noted .sx Apart from the well-known teratogenic effects , the most important side effect is the occurrence of polyneuropathies .sx Attention was first drawn to the neurotoxic effects of thalidomide by Florence ( 1960) .sx These patients had used thalidomide as a sedative in varying dosages from 50 to 600 mg at night and usually for prolonged periods from 6 months to years .sx In affected subjects sensory symptoms predominated with parasthesia of hands and feet , pallor and coldness of fingers and toes and muscular cramps of the extremities .sx The overall incidence of neuropathy remains difficult to assess .sx The manufacturers originally suggested an incidence of 0.5% in patients who had taken the drug for 2 months or more .sx Recent reports , however , suggest the incidence may be much higher , in the order of 25% or more , especially if neurophysiological tests are performed ( Clemmensen et al , 1984 ; Hess et al , 1986) .sx