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Antithymocyte globulins for use in blood and marrow transplant (BMT)

Clinical safety note
Antithymocyte globulins are NOT directly interchangeable

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Class and mode of action

Antithymocyte globulins (ATG) are polyclonal purified horse or rabbit antibodies against human lymphocytes that deplete the number of T lymphocytes.

Formulations

There are three commercially available formulations of antithymocyte globulin, as listed in the table below. The appropriate dosing of all three formulations is different, as protein compositions and concentrations vary depending on the source of the ATG used. Clinicians should therefore ensure that the dose prescribed is appropriate for the ATG product being administered.

Brand name Source Premedication Serum sickness Test dose Filter required
ATGAM® Horse Yes Yes Yes Yes
Thymoglobuline® Rabbit Yes Yes No Yes
ATG-Fresenius S® Rabbit Yes No* No No

*With shorter treatment periods of 7 days or less the incidence of serum sickness is low. With single high-dose therapy of ATG-Fresenius S® serum sickness has not been observed.r

Contraindications

  • hypersensitivity to the active substance (i.e. rabbit proteins (Thymoglobuline®), equine gamma globulin preparations (ATGAM®)) or to any product excipients
  • active acute or chronic infections, which would contraindicate any additional immunosuppression.

Precautions

  • anaphylaxis
  • severe or unremitting thrombocytopenia
  • severe or unremitting leukopenia
  • increased risk of CMV and EBV infection 
  • increased risk of post-transplant lymphoproliferative disease (PTLD) 

Storage 

  • Generally, reconstituted solutions should be stored between 2-8 degrees for no more than 24 hours. Local institution policies may differ. 

Incompatibilities 

Venous access 

Where possible the preference is for ATG to be given via a central venous access device into a large vein to reduce the incidence of phlebitis and thrombosis. 

Premedication:

Administer suggested premedication (alternative antihistamines or corticosteroids may be administered):

  • paracetamol 1000 mg PO
  • promethazine 12.5 to 25 mg IV
  • methylprednisolone 1 to 2 mg/kg IV.

If a patient has a hypersensitivity reaction - stop the infusion and have the patient reviewed immediately by a medical officer. A systemic reaction such as a generalised rash, tachycardia, dyspnoea, hypotension, or anaphylaxis precludes any additional administration of ATGAM®.

Note: It is the consensus of the eviQ BMT Reference Committee that the following doses are utilised.

Formulation Dose Day to be administered Administration (via IV infusion)
ATGAM ®

10 mg/kg (sibling)

20, 30 or 40 mg/kg (unrelated)

 -5, -4, -3, -2 and -1*
  • over 4 to 6 hours
  • IV giving set with 0.2 to 1.0 micron in-line filter must be used for ATGAM ® (to remove any precipitate)
  • monitor blood pressure, pulse, temperature and respiratory rate every 30 minutes for the first hour, then hourly until 3 to 4 hours after the completion of the infusion
  • flush with 100 mL of sodium chloride 0.9%
Thymoglobuline® 0.5 mg/kg -3
  • over 6 hours initially
  • 0.22 micron in-line filter recommended for administration (to remove any precipitate)
  • baseline observations prior to infusion
  • if well tolerated the rate may be increased for subsequent infusions but the total dose should not be infused over less than 4 hours
  • infusions reactions are common
  • monitor blood pressure, pulse, temperature and respiratory rate every 30 minutes for the first hour, then hourly until 3 to 4 hours after the completion of the infusion
  • if hypotension or dyspnoea occurs, stop infusion and consult medical staff (rarely reported in the literature)
  • when symptoms completely subside restart the infusion at a slower rate
2 mg/kg -2
2 mg/kg -1
ATG-Fresenius S ®

10 mg/kg (sibling)

20 mg/kg (unrelated)

 -1
  • over ~ 2 to 4 hours
  • first 30 minutes to be infused at a slower rate
  • baseline observations prior to infusion
  • monitor blood pressure, pulse, temperature and respiratory rate every 30 minutes for the first hour, then hourly until 3 to 4 hours after the completion of the infusion
  • if hypotension or dyspnoea occurs, stop infusion and consult medical staff (rarely reported in the literature)

* The optimal dosing schedule of ATGAM® varies widely in the literature. Variables such as age, stem cell source, donor type and the planned conditioning protocol make it difficult to delineate the optimal dose.

Skin testing

Although there is controversy regarding the role of skin testing for ATGAM® and practise between units differs, we strongly advocate for skin testing due to its ability to guide initial infusion ratesr. As skin testing has not been demonstrated to be predictive of severe allergic reactions, many units do not perform skin testing prior to administration of ATGAM®. Where skin testing is done the following practise is recommended:

No premedication to be administered prior to skin test.

Use an epicutaneous (prick) testing with undiluted ATG. If the patient does not show a wheal ten minutes after pricking, proceed to:

  • Intradermal testing with 0.02 mL of a 1:1000 v/v (volume/volume) saline dilution of ATG on the inner aspect of one forearm, with a separate saline control injection of similar volume on the other arm
  • Read the result at ten minutes
  • A wheal at the ATG site greater than or equal to 3 mm larger in diameter than that at the saline control site (or a positive prick test) suggests clinical sensitivity and an increased possibility of a systemic allergic reaction should the drug be used intravenously
  • A severe reaction or anaphylaxis is a contraindication to proceeding with treatment. However, the predictive nature of the skin test is not clinically proven. Allergic reactions such as anaphylaxis have occurred in patients whose skin test is negative. In the presence of a locally positive skin test to ATGAM®, serious consideration to alternative forms of therapy should be given.

Immune-mediated reactions:

Anaphylaxis, infusion associated reactions (IAR), cytokine release syndrome and serum sickness (see below) are rare but potentially fatal reactions which have been reported. Reactions such as flushing, rash, erythema, oedema, dyspnoea with or without bronchospasm and cough are commonly observed during and after the administration.Cytokine release related symptoms include: fever, chills, headache, nausea, vomiting, tachycardia and circulatory changes. These reactions usually respond well to treatment.

Management

Prophylactic medication may be administered to alleviate these symptoms. Reduction in infusion rates may minimise the incidence of reactions. The occurrence of anaphylaxis/anaphylactic shock requires immediate termination of the infusion and medical treatment.

Serum sickness:

An immune-complex mediated reaction, may occur in patients after treatment with antithymocyte globulin (ATG). Serum sickness presents with significant morbidity but is usually self-limiting or resolves rapidly with corticosteroid treatment. Symptoms usually develop 7 to 21 days after the start of treatment with ATG. However, some patients may develop symptoms in 1 to 3 days if they have previously been exposed to ATG. 

Management

Prophylaxis with corticosteroids may reduce the frequency of this reaction. If serum sickness does develop:

  • high dose corticosteroids may be prescribed as treatment for severe cases
  • antihistamines and corticosteroid creams or ointments may relieve the discomfort of itching and rash.

Infection:

Infections, reactivation of infections such as cytomegalovirus (CMV) and sepsis have been reported after ATG administration. There is increased risk of infection especially when ATG is given in combination with immunosuppressive agents.

Management

Close monitoring of patient and appropriate anti-infective prophylaxis are recommended. Appropriate anti-infective therapy should be given if infection occurs.

Haematological effects:

Thrombocytopenia and leukopenia are common and transient adverse effects. Anaemia is commonly observed after administration of ATG-Fresenius S and fulminant haemolysis has been reported rarely with ATGAM administration for which transfusion of erythrocytes may be required. Platelet and white cell counts generally return to normal without interrupting therapy and with transfusions.

Management

Monitor blood counts prior to and throughout ATG therapy. Dose reductions may be required for concomitant immunosuppressive and/or ATG therapy.

Malignancy:

Malignancies including, but not limited to post-transplant lymphoproliferative disease (PTLD) and other lymphomas as well as solid tumours have been rarely reported with Thymoglobuline® and ATG-Fresenius S®. These adverse events were always associated with a combination of multiple immunosuppressive agents.

Management

Close monitoring of patient throughout and after the completion of treatment is recommended.

Vaccinations 

Live vaccinations should not be administered to patients being treated with ATGAM® for the duration of their therapy and for 6 months after treatment with ATGAM®. Patients should be advised that other vaccinations might be less efficacious. 

Live vaccines are contraindicated in immunocompetent persons and cancer patients receiving immunosuppressive therapy and/or those who have poorly controlled malignant disease. 

Management

Refer to the recommended schedule of vaccination for immunocompromised persons, as outlined in the Australian Immunisation Handbook 10th edition (updated 2018).

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Bibliography

ATGAM ® (anti-thymocyte globulin [equine]) Product Information. May 2018. Pfizer Australia Pty Ltd
Thymoglobuline ® (anti-thymocyte globulin [rabbit], rATG) Product Information. Aug 2019. Genzyme Australaisa Pty Ltd
Admiraal, R., S. Nierkens, M. A. de Witte, et al. 2017. "Association between anti-thymocyte globulin exposure and survival outcomes in adult unrelated haemopoietic cell transplantation: a multicentre, retrospective, pharmacodynamic cohort analysis." Lancet Haematol 4(4):e183-e191.

BACKGROUND: Anti-thymocyte globulin (ATG) is used to prevent graft-versus-host disease (GvHD) after allogeneic haemopoietic cell transplantation (HCT). However, ATG can also cause delayed immune reconstitution of T cells, negatively affecting survival. We studied the relation between exposure to ATG and clinical outcomes in adult patients with acute leukaemia and myelodysplastic syndrome. METHODS: We did a retrospective, pharmacokinetic-pharmacodynamic analysis of data from patients with acute lymphoid leukaemia, acute myeloid leukaemia, or myelodysplastic syndrome receiving their first T-cell repleted allogeneic peripheral blood stem cell HCT with ATG (thymoglobulin) as part of non-myeloablative conditioning from March 1, 2004, to June 1, 2015. Patients received a cumulative intravenous dose of 8 mg/kg divided over 4 days, starting on day -8 before HCT. Active ATG concentrations were measured using a validated bioassay and pharmacokinetic exposure measures (maximum concentration, concentration at time of infusion of the graft, time to reach a concentration of 1 arbitary unit [AU] per day/mL, area under the curve [AUC], and the AUC before and after HCT) were calculated with a validated population pharmacokinetic model. The main outcome of interest was 5-year overall survival, defined as days to death from any cause or last follow-up. Other outcomes were relapse-related mortality, non-relapse mortality, event-free survival, acute and chronic GvHD, and assessment of current and optimum dosing. We used Cox proportional hazard models and Fine-Gray competing risk models for the analyses. FINDINGS: 146 patients were included. ATG exposure after HCT was shown to be the best predictor for 5-year overall survival. Optimum exposure after transplantation was determined to be 60-95 AU per day/mL. Estimated 5-year overall survival in the group who had optimum exposure (69%, 95% CI 55-86) was significantly higher than in the group who had below optimum exposure (32%, 20-51, p=0.00037; hazard ratio [HR] 2.41, 95% CI 1.15-5.06, p=0.020) and above optimum exposure (48%, 37-62, p=0.030; HR 2.11, 95% CI 1.04-4.27, p=0.038). Patients in the optimum exposure group had a greater chance of event-free survival than those in the below optimum exposure group (HR 2.54, 95% CI 1.29-5.00, p=0.007; HR for the above optimum group: 1.83, 0.97-3.47, p=0.063). Above-optimum exposure led to higher relapse-related mortality compared with optimum exposure (HR 2.66, 95% CI 1.12-6.31; p=0.027). Below optimum exposure increased non-relapse mortality compared with optimum exposure (HR 4.36, 95% CI 1.60-11.88; p=0.0040), grade 3-4 acute GvHD (3.09, 1.12-8.53; p=0.029), but not chronic GvHD (2.38, 0.93-6.08; p=0.070). Modelled dosing based on absolute lymphocyte counts led to higher optimum target attainment than did weight-based dosing. INTERPRETATION: Exposure to ATG affects survival after HCT in adults, stressing the importance of optimum ATG dosing. Individualised dosing of ATG, based on lymphocyte counts rather than bodyweight, might improve survival chances after HCT.

Baron, F., M. Mohty, D. Blaise, et al. 2017. "Anti-thymocyte globulin as graft-versus-host disease prevention in the setting of allogeneic peripheral blood stem cell transplantation: a review from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation." Haematologica 102(2):224-234.

Allogeneic hematopoietic stem cell transplantation is increasingly used as treatment for patients with life-threatening blood diseases. Its curative potential is largely based on immune-mediated graft-versus-leukemia effects caused by donor T cells contained in the graft. Unfortunately, donor T cells are also the cause of graft-versus-host disease. The vast majority of human leukocyte antigen-matched allogeneic hematopoietic stem cell transplants are nowadays carried out with peripheral blood stem cells as the stem cell source. In comparison with bone marrows, peripheral blood stem cells contain more hematopoietic stem/progenitor cells but also one log more T cells. Consequently, the use of peripheral blood stem cells instead of bone marrow has been associated with faster hematologic recovery and a lower risk of relapse in patients with advanced disease, but also with a higher incidence of chronic graft-versus-host disease. These observations have been the basis for several studies aimed at assessing the impact of immunoregulation with anti-thymocyte globulin on transplantation outcomes in patients given human leukocyte antigen-matched peripheral blood stem cells from related or unrelated donors. After a brief introduction on anti-thymocyte globulin, this article reviews recent studies assessing the impact of anti-thymocyte globulin on transplantation outcomes in patients given peripheral blood stem cells from human leukocyte antigen-matched related or unrelated donors as well as in recipients of grafts from human leukocyte antigen haploidentical donors.

Kekre, N., Y. Zhang, M. J. Zhang, et al. 2017. "Effect of antithymocyte globulin source on outcomes of bone marrow transplantation for severe aplastic anemia." Haematologica 102(7):1291-1298.

For treatment of severe aplastic anemia, immunosuppressive therapy with horse antithymocyte globulin results in superior response and survival compared with rabbit antithymocyte globulin. This relative benefit may be different in the setting of transplantation as rabbit antithymocyte globulin results in more profound immunosuppression. We analyzed 833 severe aplastic anemia transplants between 2008 and 2013 using human leukocyte antigen (HLA)-matched siblings (n=546) or unrelated donors (n=287) who received antithymocyte globulin as part of their conditioning regimen and bone marrow graft. There were no differences in hematopoietic recovery by type of antithymocyte globulin. Among recipients of HLA-matched sibling transplants, day 100 incidence of acute (17% versus 6%, P<0.001) and chronic (20% versus 9%, P<0.001) graft-versus-host disease were higher with horse compared to rabbit antithymocyte globulin. There were no differences in 3-year overall survival, 87% and 92%, P=0.76, respectively. Among recipients of unrelated donor transplants, acute graft-versus-host disease was also higher with horse compared to rabbit antithymocyte globulin (42% versus 23%, P<0.001) but not chronic graft-versus-host disease (38% versus 32%, P=0.35). Survival was lower with horse antithymocyte globulin after unrelated donor transplantation, 75% versus 83%, P=0.02. These data support the use of rabbit antithymocyte globulin for bone marrow transplant conditioning for severe aplastic anemia.

Bacigalupo, A. 2017. "How I treat acquired aplastic anemia." Blood 129(11):1428-1436.

Acquired severe aplastic anemia (SAA) is a rare hematologic disease associated with significant morbidity and mortality. Immune destruction of hemopoietic stem cells plays an important role in pathogenesis, as shown by successful treatment with immunosuppressive agents, leading to transfusion independence or complete recovery of peripheral blood counts in a proportion of patients. Growth factors can be combined with immunosuppressive therapy (IST) and may improve response rates, as recently shown with thrombopoietin analogs. Anabolic steroids may still play a role in combination with IST. The problem with IST is failure to respond and the development of late clonal disorders. Bone marrow transplantation (BMT) is the other therapeutic option: a matched sibling donor remains the best choice. For patients lacking a matched family donor, unrelated donors can be readily found, although mostly for patients of Caucasian origin. Other BMT options include unrelated cord blood or mismatched family donors. Acute and chronic graft-versus-host disease remain important complications of BMT. Patient age is a strong predictor of outcome for both IST and BMT, and must be considered when designing therapeutic strategies. Early diagnosis and treatment, as well as long-term monitoring, remain crucial steps for successful treatment of SAA.

Ruggeri, A., Y. Sun, M. Labopin, et al. 2017. "Post-transplant cyclophosphamide versus anti-thymocyte globulin as graft- versus-host disease prophylaxis in haploidentical transplant." Haematologica 102(2):401-410.

Severe graft-versus-host disease is a major barrier for non-T-cell-depleted haploidentical stem cell transplantation. There is no consensus on the optimal graft-versus-host disease prophylaxis. This study compared the two most commonly used graft-versus-host disease prophylaxis regimens (post-transplant cyclophosphamide-based vs. the anti-thymocyte globulin-based) in adults with acute myeloid leukemia reported to the European Society for Blood and Bone Marrow Transplantation. A total of 308 patients were analyzed; 193 received post-transplant cyclophosphamide-based regimen and 115 anti-thymocyte globulin-based regimen as anti-graft-versus-host disease prophylaxis. The post-transplant cyclophosphamide-based regimen was more likely to be associated to bone marrow as graft source (60% vs. 40%; P=0.01). Patients in the post-transplant cyclophosphamide-based regimen group had significantly less grade 3-4 acute graft-versus-host disease than those in the anti-thymocyte globulin-based group (5% vs. 12%, respectively; P=0.01), comparable to chronic graft-versus-host disease. Multivariate analysis showed that non-relapse mortality was lower in the post-transplant cyclophosphamide-based regimen group [22% vs. 30%, Hazard ratio (HR) 1.77(95%CI: 1.09-2.86); P=0.02] with no difference in relapse incidence. Patients receiving post-transplant cyclophosphamide-based regimen had better graft-versus-host disease-free, relapse-free survival [HR 1.45 (95%CI: 1.04-2.02); P=0.03] and leukemia-free survival [HR 1.48 (95%CI: 1.03-2.12); P=0.03] than those in the anti-thymocyte globulin-based group. In the multivariate analysis, there was also a trend for a higher overall survival [HR 1.43 (95%CI: 0.98-2.09); P=0.06] for post-transplant cyclophosphamide-based regimen versus the anti-thymocyte globulin-based group. Notably, center experience was also associated with non-relapse mortality and graft-versus-host disease-free, relapse-free survival. Haplo-SCT using a post-transplant cyclophosphamide-based regimen can achieve better leukemia-free survival and graft-versus-host disease-free, relapse-free survival, lower incidence of graft-versus-host disease and non-relapse mortality as compared to anti-thymocyte globulin-based graft-versus-host disease prophylaxis in patients with acute myeloid leukemia.

Killick, S. B., N. Bown, J. Cavenagh, et al. 2016. "Guidelines for the diagnosis and management of adult aplastic anaemia." Br J Haematol 172(2):187-207.
Atta, E. H., D. C. de Oliveira, L. F. Bouzas, et al. 2014. "Less graft-versus-host disease after rabbit antithymocyte globulin conditioning in unrelated bone marrow transplantation for leukemia and myelodysplasia: comparison with matched related bone marrow transplantation." PLoS One 9(9):e107155.

One of the major drawbacks for unrelated donor (UD) bone marrow transplantation (BMT) is graft-versus-host disease (GVHD). Despite results from randomized trials, antithymocyte globulin (ATG) is not routinely included for GVHD prophylaxis in UD BMT by many centers. One of ways to demonstrate the usefulness of rabbit ATG in UD BMT is to evaluate how its results approximate to those observed in matched related (MRD) BMT. Therefore, we compared the outcomes between UD BMT with rabbit ATG (Thymoglobulin) for GVHD prophylaxis (n = 25) and MRD BMT (n = 91) for leukemia and myelodysplasia. All but one patient received a myeloablative conditioning regimen. Grades II-IV acute GVHD were similar (39.5% vs. 36%, p = 0.83); however, MRD BMT recipients developed more moderate-severe chronic GVHD (36.5% vs. 8.6%, p = 0.01) and GVHD-related deaths (32.5% vs. 5.6%, p = 0.04). UD BMT independently protected against chronic GVHD (hazard ratio 0.23, p = 0.04). The 6-month transplant-related mortality, 1-year relapse incidence, and 5-year survival rates were similar between patients with non-advanced disease in the MRD and UD BMT groups, 13.8% vs. 16.6% (p = 0.50), 20.8% vs. 16.6% (p = 0.37), and 57% vs. 50% (p = 0.67), respectively. Stable full donor chimerism was equally achieved (71.3% vs. 71.4%, p = 1). Incorporation of rabbit ATG in UD BMT promotes less GVHD, without jeopardizing chimerism evolution, and may attain similar survival outcomes as MRD BMT for leukemia and myelodysplasia especially in patients without advanced disease.

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Version 4

Date Summary of changes
19/05/2011 Developed and reviewed at HPCT Reference Committee meeting
06/06/2011 Approved and published on eviQ
24/10/2011 Removed the 4 mg/kg (if mismatched unrelated) option from the Day -1 Thymoglobuline as per consensus from HPCT Reference Committee meeting
09/07/2015 Transferred to new format and reviewed
- references to HPCT calculator removed
- adverse effects section added

31/05/2017

Transferred to new eviQ website. Version number change to V.3
22/09/2017 

Clinical resource reviewed at the BMT Reference Committee meeting with the following changes made: 

  •  information regarding storage, incompatabilities, venous access and vaccinations added 
  • references updated   
  • version number changed to V.4.    
22/07/2019 Link to Australian Immunisation handbook updated to June 2018 (site page history)

This document reflects what is currently regarded as safe practice. While every effort has been made to ensure the accuracy of the content at the time of publication, the Cancer Institute NSW does not accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceuticals and/or medical products as examples does not imply endorsement of any of these products. Use is subject to eviQ’s disclaimer available at www.eviQ.org.au

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14 Dec 2019