FDA Drug Safety Communication: FDA warns of serious immune system reaction with seizure and mental health medicine lamotrigine (Lamictal)

Transcription

1 藥物不良反應工作小組藥物安全警訊通告 美國食品藥物管理署 (FDA) 用藥安全資訊風險溝通 : Lamotrigine 可能引起嚴重噬血細胞淋巴組織增生症 (HLH) 的風險 摘要說明 : Lamotrigine 自 1994 年於美國核准後已上市 24 年, 主要用於治療兩歲以上癲癇病人或雙極性情感障礙 包括其學名藥在內, 統計通報至美國食品藥物管理署 (FDA) 之藥物不良反應, 已經確定有 8 名大人或小孩確定及疑似因服用 Lamotrigine 導致噬血細胞淋巴組織增生症 hemophagocytic lymphohistiocytosis (HLH), 此為罕見但嚴重的免疫過度激活反應 HLH 症狀有持續性發燒 ( 通常 >38 ), 產生血液學及器官 ( 肝 腎 肺及脾等 ) 的嚴重問題, 甚至導致住院及死亡 Lamictal (Lamotrigine) 中文仿單未有 HLH 不良反應敘述, 但是有血液及淋巴系統異常及 SJS 或 DRESS 的風險, 後者之症狀有可能會影響 HLH 的診斷結果, 尤其是在早期診斷時 醫療人員注意事項 : 1) HLH 被診斷出的時間會影響死亡率, 然而其症狀的診斷容易被 DRESS 等嚴重免疫反應混淆, 故 建議若以下症狀符合八項中的五項, 即診斷為 HLH Fever and rash Cytopenias Enlarged spleen High levels of blood ferritin Elevated levels of triglycerides or low blood levels of fibrinogen Decreased or absent Natural Killer (NK) Cell activity Elevated blood levels of CD25 showing prolonged immune cell activation Hemophagocytosis identified through bone marrow, spleen, or lymph node biopsy 2) 醫療人員應提醒病人及其照顧者若發生發燒 紅疹 右上腹疼痛或壓痛 皮膚或眼睛變黃 淋巴 結腫大 走路困難 視覺異常 癲癇發作或不正常出血等症狀與徵兆, 以上情況有可能在服用後 數周才會發生, 若有發現應儘速回診就醫 3) 醫療人員若懷疑病人因為使用藥品導致不良反應發生時, 請立即線上通報藥物不良反應及登入於 藥物過敏 / 不良反應記錄中 院內品項 : Lamictal (Lamotrigine) 50 mg/tab 樂命達錠 北醫藥物不良反應工作小組敬啟臨床藥學組呂懷恩藥師 ( 分機 8443/8444)

2 FDA warns of serious immune system reaction with seizure and mental health medicine lamotrigine (Lamictal) Safety Announcement [ ] The Food and Drug Administration (FDA) is warning that the medicine lamotrigine (Lamictal) for seizures and bipolar disorder can cause a rare but very serious reaction that excessively activates the body s infection-fighting immune system. This can cause severe inflammation throughout the body and lead to hospitalization and death, especially if the reaction is not diagnosed and treated quickly. As a result, we are requiring a new warning about this risk be added to the prescribing information in the lamotrigine drug labels.* The immune system reaction, called hemophagocytic lymphohistiocytosis (HLH), causes an uncontrolled response by the immune system. HLH typically presents as a persistent fever, usually greater than 101 F, and it can lead to severe problems with blood cells and organs throughout the body such as the liver, kidneys, and lungs. Lamotrigine is used alone or with other medicines to treat seizures in patients two years and older. It may also be used as maintenance treatment in patients with bipolar disorder to help delay the occurrence of mood episodes such as depression, mania, or hypomania. Stopping lamotrigine without first talking to a prescriber can lead to uncontrolled seizures, or new or worsening mental health problems. Lamotrigine has been approved and on the market for 24 years, and is available under the brand name Lamictal and as generics. Health care professionals should be aware that prompt recognition and early treatment is important for improving HLH outcomes and decreasing mortality. Diagnosis is often complicated because early signs and symptoms such as fever and rash are not specific. HLH may also be confused with other serious immune-related adverse reactions such as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). Evaluate patients who develop fever or rash promptly, and discontinue lamotrigine if HLH or another serious immune-related adverse reaction is suspected and an alternative etiology for the signs and symptoms cannot be established. Advise patients to seek immediate medical attention if they experience symptoms of HLH during lamotrigine treatment. A diagnosis of HLH can be established if a patient has at least five of the following eight signs or symptoms: Fever and rash Enlarged spleen Cytopenias Elevated levels of triglycerides or low blood levels of fibrinogen High levels of blood ferritin Hemophagocytosis identified through bone marrow, spleen, or lymph node biopsy Decreased or absent Natural Killer (NK) Cell activity Elevated blood levels of CD25

3 showing prolonged immune cell activation Patients or their caregivers should contact their health care professionals right away if they experience any symptom of HLH while taking lamotrigine. HLH can occur within days to weeks after starting treatment. A physical examination and specific laboratory blood tests and other evaluations are used to diagnose HLH. Signs and symptoms of HLH include but are not limited to: Fever Enlarged liver; symptoms may include pain, tenderness, or unusual swelling over the liver area in the upper right belly Swollen lymph nodes Skin rashes Yellow skin or eyes Unusual bleeding Nervous system problems, including seizures, trouble walking, difficulty seeing, or other visual disturbances Read the patient Medication Guide, which explains the benefits and risks of lamotrigine, every time you get a new prescription because the information may change. Do not stop taking lamotrigine without talking to your health care professional first as doing so can cause serious problems. In the 24 years since lamotrigine s 1994 approval, FDA identified eight cases worldwide of confirmed or suspected HLH associated with the medicine in children and adults (see Data Summary). This number includes only reports submitted to FDA ± and found in the medical literature, so there are likely additional cases about which we are unaware. We determined there was reasonable evidence that lamotrigine was the cause of HLH in these eight cases based on the timing of events and the order in which they occurred. The patients in these cases required hospitalization and received drug and other medical treatments, with one dying. We previously communicated safety information associated with lamotrigine in September 2006 (possible association between Lamictal exposure during pregnancy and oral clefts in newborns) and August 2010 (aseptic meningitis warning). Lamotrigine was also covered as part of a May 2009 safety alert concerning suicidal thoughts and behavior with the entire class of anti-seizure medicines. We urge health care professionals and patients to report side effects involving lamotrigine (Lamictal) and other medicines to the FDA MedWatch program, using the information in the Contact FDA box at the bottom of the page. *For additional drug label information, search Drugs@FDA: FDA Approved Drug Products. ±The cases were reported to the FDA Adverse Event Reporting System (FAERS). Facts about Lamotrigine (Lamictal)

4 Lamotrigine is used alone or with other medicines to treat seizures in patients two years and older. Use of lamotrigine as a single drug to treat seizures is approved only in patients 16 and older. Lamotrigine is also used as maintenance treatment in adults with bipolar disorder to help delay the occurrence of mood episodes such as depression, mania, or hypomania. In addition to HLH, lamotrigine can cause a number of other serious adverse reactions already included in the drug label such as: o Rashes, including serious rashes that may need to be treated in a hospital and may cause permanent disability or death o Serious allergic reactions that may cause problems affecting the blood, liver, and other organs o o Suicidal thoughts and actions Aseptic meningitis, a serious inflammation or swelling, of the protective membrane that covers the brain and spinal cord Less serious side effects may include dizziness, sleepiness, headache, double vision, blurred vision, nausea, vomiting, and loss of coordination. Lamotrigine is available as a tablet to be swallowed, a tablet that dissolves on the tongue (Lamictal ODT), a chewable tablet (Lamictal CD), and as an extended-release tablet (Lamictal XR). Additional Information for Patients The medicine lamotrigine (Lamictal), prescribed for seizures and bipolar disorder, has been associated with a rare but very serious reaction in which the body s immune system is excessively activated, called hemophagocytic lymphohistiocytosis (HLH). This can cause severe inflammation, or swelling, throughout the body and lead to hospitalization or death, especially if treatment is delayed. This uncontrolled, excessive immune response can lead to damage or failure of many organs and may progress to death. HLH can be caused by an underlying genetic disorder or a gene mutation, or it may be triggered by different conditions, including infections, cancer, and autoimmune diseases. In a small number of cases it can be caused by drugs, including lamotrigine. FDA is requiring a new warning about the risk of HLH to be added to the prescribing information in the lamotrigine drug labels. Do not stop taking your lamotrigine medicine without first taking to your health care professional. Stopping it suddenly can potentially cause uncontrolled seizures, or new or worsening mental health problems. Symptoms of HLH have been reported to occur within 8 to 24 days after the first dose is taken. Contact your doctor right away if you have symptoms of HLH at any time while taking lamotrigine. Seek medical attention immediately if you experience any symptoms of HLH while taking lamotrigine. Symptoms of HLH include: o Fever, usually >101 F o Enlarged liver; symptoms may include pain, tenderness, or unusual swelling over the liver area in the upper right belly o Swollen lymph nodes

5 o Skin rashes o Yellow skin or eyes o Unusual bleeding o Nervous system problems, including seizures, trouble walking, difficulty seeing or other visual disturbances Talk to your health care professional if you have questions or concerns about lamotrigine. Report side effects from lamotrigine (Lamictal) or other medicines to the FDA MedWatch program, using the information in the Contact FDA box at the bottom of this page. Additional Information for Health Care Professionals Lamotrigine (Lamictal) has been associated with a rare, but serious and life-threatening adverse reaction called hemophagocytic lymphohistiocytosis (HLH), which can lead to multi-organ failure resulting in hospitalization or death, particularly if diagnosis and treatment are delayed. Conduct a medical evaluation as soon as suspicious symptoms are reported and discontinue lamotrigine if HLH is suspected, confirming diagnosis with laboratory tests and other studies. Patients with suspected HLH should be evaluated by a hematologist. Diagnosis is often complicated because early signs and symptoms are non-specific, including fever and rash, and HLH can be confused with other serious immune-related adverse reactions such as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). FDA is requiring a new warning about the risk of HLH to be added to the prescribing information in the lamotrigine drug labels. In the eight cases FDA studied, symptoms of HLH were reported to have occurred within 8 to 24 days following treatment initiation. Tell patients about the symptoms of HLH and advise them to seek medical attention immediately if they experience these symptoms during lamotrigine treatment. A diagnosis of HLH can be established if a patient has at least five of the following eight signs or symptoms, according to the published international diagnostic criteria for HLH, known as HLH-2004 diagnostic criteria. These include: 1. Fever 2. Splenomegaly 3. Cytopenias affecting 2 of 3 lineages in the peripheral blood: a. Hemoglobin < 90 g/l (in infants < 4 weeks: hemoglobin < 100 g/l) b. Platelets < 100 x 10 9 /L c. Neutrophils < 1.0 x 10 9 /L 4. Hypertriglyceridemia and/or hypofibrinogenemia: a. Fasting triglycerides 3.0 mmol/l (i.e., 265 mg/dl) b. Fibrinogen 1.5 g/l 5. Hemophagocytosis in bone marrow or spleen or lymph nodes 6. Low or absent Natural Killer (NK) cell activity 7. Ferritin 500 µg/l 8. Soluble CD25 (i.e., soluble IL-2 receptor) 2,400 U/ml Lamotrigine may cause other serious adverse reactions such as:

6 o Serious skin rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis o Multi-organ hypersensitivity reactions and organ failure o Suicidal thoughts or actions o Aseptic meningitis Tell patients that sudden stopping of lamotrigine treatment can potentially cause uncontrolled seizures, or new or worsening mental health problems. Advise them to seek medical attention immediately if they develop any suggestive symptoms to discuss whether stopping Lamotrigine is appropriate. Encourage patients to read the patient Medication Guide they receive with their lamotrigine prescriptions, which explains its benefits and risks. Report adverse events involving lamotrigine (Lamictal) or other medicines to the FDA MedWatch program, using the information in the Contact FDA box at the bottom of this page. Data Summary We identified eight worldwide cases of confirmed or suspected hemophagocytic lymphohistiocytosis (HLH) associated with lamotrigine use in children and adults reported in the FDA Adverse Event Reporting System (FAERS) database and/or the medical literature from December 1994 through September Two cases occurred in the U.S. and six occurred abroad. Five cases had confirmed HLH, fulfilling five of the eight HLH-2004 diagnostic criteria. Three cases had suspected HLH, fulfilling four of the eight HLH-2004 diagnostic criteria. The eight cases had signs and symptoms including fever (n=8), thrombocytopenia (n=8), hyperferritinemia (n=8), hypofibrinogenemia (n=5), splenomegaly (n=3), anemia (n=3), hypertriglyceridemia (n=2), low or absent Natural Killer (NK) cells (n=1), and neutropenia (n=1). All eight cases had positive bone marrow biopsies consistent with hemophagocytosis. All cases were reported to have serious outcomes. All eight reported hospitalization, three reported other serious important medical events, two reported the outcome as being lifethreatening, and one reported death. All cases had a plausible temporal relationship with lamotrigine, occurring within 24 days of starting lamotrigine treatment. Doses ranged from 25 mg every other day to 250 mg once daily in the six cases that reported this information. In seven cases, HLH improved after treatment and discontinuation of Lamictal, and one case did not improve and had a fatal outcome. No cases reported rechallenge. Treatment reported in the eight cases included steroids (n=6), intravenous immunoglobulin (n=4), blood products (n=2), and chemotherapy (n=2). All eight cases reported concomitant medications. None of the concomitant medications are associated with HLH. References

7 1. Fukaya S, Yasuda S, Hashimoto T, et al. Clinical features of haemophagocytic syndrome in patients with systemic autoimmune diseases: analysis of 30 cases. Rheumatology Nov;47(11): Henter J, Horne A, Aricó M, et al. HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007;48: Jordan MB, Allen CE, Weitzman S et al. How I treat hemophagocytic lymphohistiocytosis. Blood 2011;118: Ramos-Casals M, Brito-Zerón P, López-Guillermo A, et al. Adult haemophagocytic syndrome. Lancet 2014; 383: Related Information Hemophagocytic Lymphohistiocytosis Seizures The Facts on Bipolar Disorder and FDA-Approved Treatments The FDA's Drug Review Process: Ensuring Drugs Are Safe and Effective Think It Through: Managing the Benefits and Risks of Medicines

8 Pediatr Blood Cancer 2007;48: REVIEW HLH-2004: Diagnostic and Therapeutic Guidelines for Hemophagocytic Lymphohistiocytosis Jan-Inge Henter, MD, PhD, 1 * AnnaCarin Horne, MD, 1 Maurizio Aricó, MD, 2 R. Maarten Egeler, MD, PhD, 3 Alexandra H. Filipovich, MD, 4 Shinsaku Imashuku, MD, 5 Stephan Ladisch, MD, 6 Ken McClain, MD, PhD, 7 David Webb, MD, 8 Jacek Winiarski, MD, PhD, 9 and Gritta Janka, MD, PhD 10 for the Histiocyte Society In HLH-94, the first prospective international treatment study for hemophagocytic lymphohistiocytosis (HLH), diagnosis was based on five criteria (fever, splenomegaly, bicytopenia, hypertriglyceridemia and/or hypofibrinogenemia, and hemophagocytosis). In HLH-2004 three additional criteria are introduced; low/absent NK-cell-activity, hyperferritinemia, and high-soluble interleukin-2-receptor levels. Altogether five of these eight criteria must be fulfilled, unless family history or molecular diagnosis is consistent with HLH. HLH-2004 chemo-immunotherapy includes etoposide, dexamethasone, cyclosporine A upfront and, in selected patients, intrathecal therapy with methotrexate and corticosteroids. Subsequent hematopoietic stem cell transplantation (HSCT) is recommended for patients with familial disease or molecular diagnosis, and patients with severe and persistent, or reactivated, disease. In order to hopefully further improve diagnosis, therapy and biological understanding, participation in HLH studies is encouraged. Pediatr Blood Cancer 2007;48: ß 2006 Wiley-Liss, Inc. Key words: diagnosis; hemophagocytic lymphohistiocytosis; survival; treatment INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a disease with major diagnostic and therapeutic difficulties. HLH comprises two different conditions that may be difficult to distinguish from one another: a primary [1] and a secondary form [2]. The primary autosomal recessive form, familial hemophagocytic lymphohistiocytosis (FHL), has an estimated incidence of around 1:50,000 live-born children [3]. FHL is a fatal disease with a median survival of less than 2 months after diagnosis if untreated, and that typically has its onset during infancy or early childhood [4]. Despite its name, family history is often negative since the disease is recessive. Importantly, the onset of FHL and bouts of the disease may be triggered by infections [5]. Secondary HLH (shlh) may develop as a result due to strong immunological activation of the immune system, which may, for example, be caused by a severe infection. shlh has been described in immunocompromised hosts in association with viral infections, virus- (infection) associated hemophagocytic syndrome (VAHS, or IAHS) [2,6]. However, most patients with shlh are not obviously immunosuppressed. shlh may also develop during malignancies (malignancy-associated hemophagocytic syndrome, MAHS); it may either be the presenting clinical picture and initially mask an underlying malignancy, or it may develop during the treatment for a known malignancy [2]. In 1991, the Histiocyte Society presented the first set of diagnostic guidelines for HLH [7], and in 1994 the first prospective international treatment protocol (HLH-94) was introduced [8]. The cumulative experiences from HLH-94 and other studies have led to the development of a ß 2006 Wiley-Liss, Inc. DOI /pbc new treatment protocol presented here, HLH-2004, which includes updated diagnostic and therapeutic guidelines from the Histiocyte Society. DIAGNOSIS OF HLH Clinical Presentation The most typical findings of HLH are fever, hepatosplenomegaly and cytopenias. Other common findings include hypertriglyceridemia, coagulopathy with hypofibrinogenemia, liver dysfunction, elevated levels of ferritin and serum 1 Childhood Cancer Research Unit, Department of Woman and Child Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; 2 Pediatric Hematology/Oncology, Ospetale dei Bambini, Palermo, Italy; 3 Department of Pediatrics IHOBA, Leiden University Medical Center, Leiden, The Netherlands; 4 Children s Hospital Medical Center, Cincinnati Ohio; 5 Department of Pediatrics, Takasago-Seibu Hospital, Japan; 6 Children s Research Institute, Washington, District of Columbia; 7 Pediatric Hematology/Oncology, Texas Children s Hospital, Houston, Texas; 8 Great Ormond Street Hospital, London, UK; 9 Department of Pediatrics, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden; 10 Department of Hematology Oncology, Children s University Hospital, Hamburg, Germany Grant sponsor: Children s Cancer Foundation of Sweden; Grant sponsor: Cancer and Allergy Foundation of Sweden; Grant sponsor: Swedish Research Council; Grant sponsor: Tobias Foundation; Grant sponsor: Märta and Gunnar V Philipson Foundation; Grant sponsor: Histiocytosis Association of America. *Correspondence to: Jan-Inge Henter, Childhood Cancer Research Unit, Karolinska Hospital Q6:05, SE Stockholm, Sweden. Jan-Inge.Henter@ki.se Received 19 February 2006; Accepted 21 July 2006

9 Diagnosis and Treatment of HLH 125 transaminases, and neurological symptoms that may be associated with a spinal fluid hyperproteinemia and a moderate pleocytosis [1,4,9,10]. Other, less common, initial clinical findings include lymphadenopathy, skin rash, jaundice, and edema. Spontaneous partial remissions are observed [11]. The onset of the primary (genetic) form is typically during early infancy but presentation in adolescents and adults have also been reported [12]. Histopathological findings include a widespread accumulation of lymphocytes and mature macrophages, sometimes with hemophagocytosis, affecting especially the spleen, lymph nodes (if enlarged), the bone marrow, the liver, and the cerebral spinal fluid (CSF) [13]. In the liver, a histological picture similar to chronic persistent hepatitis is commonly found [7,13]. Other frequent abnormal laboratory findings in HLH are low natural killer (NK) cell activity [14 18], and a hypercytokinemia, in particular elevated soluble interleukin- 2 receptor (sil-2r) levels (scd25) [18,19] in serum and in the CSF [19,20]. Importantly, it is still often difficult to distinguish between the familial and secondary forms of HLH despite advances regarding molecular diagnosis. Infection-associated forms of HLH may subside spontaneously, but may also be associated with increased mortality [2]. Furthermore, proving an acute infection at onset of symptoms is not of major diagnostic or therapeutic assistance, since not only shlh but also FHL often feature a triggering infectious agent [5]. Differential Diagnoses Many conditions can lead to the clinical picture of HLH, including malignancies (leukemia, lymphoma, other solid tumors), infections (viral, bacterial or parasitic), and rheumatoid disorders. In addition, there are diseases which develop a true HLH episode during their clinical course, such as X-linked lymphoproliferative syndrome (XLP), and Chédiak Higashi and Griscelli (type 2) syndromes [2,7,21 24]. Some differential diagnoses are Langerhans cell histiocytosis (that may be complicated by HLH), lysinuric protein intolerance [25], severe combined immunodeficiency [26], DiGeorge syndrome, and Omenn s syndrome [27]. Viral infections, especially Epstein Barr virus (EBV), may trigger primary as well as secondary forms of HLH [2]. Patients with severe shlh due to EBV infections can be treated with this protocol [28]. It is possible that patients presently considered to have shlh may have some, as yet unknown, subtle, inborn immune defect. Macrophage activation syndrome (MAS), a serious complication of systemic rheumatoid arthritis and other childhood systemic inflammatory disorders, is thought to be caused by excessive activation and proliferation of T lymphocytes and macrophages. It is also a complication of autoimmune diseases in adults. The recognition that MAS belongs to the secondary or reactive hemophagocytic Pediatr Blood Cancer DOI /pbc syndromes has led to a proposal to rename it according to the contemporary classification of histiocytic disorders [29]. Moreover, and in the same way as in HLH, it has been shown that in addition to corticosteroids, cyclosporin A (CSA) is also effective in patients with MAS [30]. Diagnostic Guidelines Guidelines In 1991, diagnostic guidelines for HLH were presented by the Histiocyte Society, based on common clinical, laboratory and histopathological findings [7]. However, HLH may also have an atypical and insidious course in some patients in whom all criteria are not always fulfilled [7]. Moreover, a number of patients may develop one or more of the diagnostic criteria late during the course of the disease [7,31]. With these concerns in mind and an extended knowledge on clinical and laboratory findings [10,18,19], the diagnostic guidelines have now been revised [32,33]. Guidelines The five criteria in the 1991 guidelines are still relevant: 1/fever, 2/splenomegaly, 3/cytopenias affecting at least two of three lineages in the peripheral blood, 4/hypertriglyceridemia and/or hypofibrinogenemia, and 5/hemophagocytosis in bone marrow, spleen, or lymph nodes [7]. In addition, three additional criteria have been introduced: 6/low or absent NK-cell activity, 7/hyperferritinemia, and 8/high levels of sil-2r (Table I). Altogether five of the eight criteria must be fulfilled, but patients with a molecular diagnosis consistent with HLH do not necessarily need to fulfill the diagnostic criteria [32,33]. NK-cell activity is typically low or absent in HLH, and most perforin deficient patients have abnormal NK-cell activity [15 18,34]. Data on ferritin, an important diagnostic parameter [10], were available in 31 of 48 eligible children with familial disease (defined as having an affected sibling), registered in HLH-94 between July 1994 and June 2002, and 26/31 had a ferritin level above 500 mg/l (sensitivity 0.84). Soluble IL-2r (scd25) also appears to be a valuable serum parameter in the diagnosis of HLH (sensitivity 0.93) [19,32,33]. Molecular Diagnosis FHL has, in some patients, been shown to be associated with decreased apoptosis triggering [35]. Subsequently, it was shown that one of the underlying gene defect involves mutations in the gene encoding perforin (PRF), which account for 20 40% of all affected FHL families and up to 50% in a cohort of North American families [36 38]. Perforin, which is co-localized with granzyme B in granules of cytotoxic cells, is secreted from cytotoxic T lymphocytes and NK cells upon conjugation between effector and target cells. In the presence of calcium it is able to insert (perforate) into the membrane of the target cell, where it polymerizes to form a cell death-inducing pore (reviewed in Reference [39]). It has been suggested that pore formation may lead to

10 126 Henter et al. TABLE I. Revised Diagnostic Guidelines for HLH The diagnosis HLH can be established if one of either 1 or 2 below is fulfilled (1) A molecular diagnosis consistent with HLH (2) Diagnostic criteria for HLH fulfilled (five out of the eight criteria below) (A) Initial diagnostic criteria (to be evaluated in all patients with HLH) Fever Splenomegaly Cytopenias (affecting 2 of 3 lineages in the peripheral blood): Hemoglobin <90 g/l (in infants <4 weeks: hemoglobin <100 g/l) Platelets < /L Neutrophils < /L Hypertriglyceridemia and/or hypofibrinogenemia: Fasting triglycerides 3.0 mmol/l (i.e., 265 mg/dl) Fibrinogen 1.5 g/l Hemophagocytosis in bone marrow or spleen or lymph nodes No evidence of malignancy (B) New diagnostic criteria Low or absent NK-cell activity (according to local laboratory reference) Ferritin 500 mg/l Soluble CD25 (i.e., soluble IL-2 receptor) 2,400 U/ml Comments: (1) If hemophagocytic activity is not proven at the time of presentation, further search for hemophagocytic activity is encouraged. If the bone marrow specimen is not conclusive, material may be obtained from other organs. Serial marrow aspirates over time may also be helpful. (2) The following findings may provide strong supportive evidence for the diagnosis: (a) spinal fluid pleocytosis (mononuclear cells) and/ or elevated spinal fluid protein, (b) histological picture in the liver resembling chronic persistent hepatitis (biopsy). (3) Other abnormal clinical and laboratory findings consistent with the diagnosis are: cerebromeningeal symptoms, lymph node enlargement, jaundice, edema, skin rash. Hepatic enzyme abnormalities, hypoproteinemia, hyponatremia, VLDL ", HDL #. destruction of target cells by allowing the entry of granzymes, which trigger apoptosis. However, perforin concentrations which are lower than necessary for pore formation, together with granzyme B, may induce targeted cell death. Recent studies suggest that entry of granzyme B into target cells can also occur in a perforin-independent manner, but granzyme alone is not sufficient to induce toxicity [39]. In 2003, it was shown that mutations in the gene UNC13D (17q25) also cause FHL [40]. The encoded protein, Munc 13-4, is essential for the priming step of cytolytic granule secretion preceding vesicle membrane fusion and a deficiency results in defective cytolytic granule exocytosis. A third gene defect associated with FHL (STX11 on chromosome 6q24) was recently identified encoding a protein, syntaxin 11, which is postulated to play a role in intracellular trafficking, although its precise function is not known [41]. Mutations in UNC13D and STX11 affect up to 20 and 10% of FHL patients in various series, respectively [42,43]. Pediatr Blood Cancer DOI /pbc In XLP, 60 70% of patients have mutations in the gene SAP (SLAM-associated protein), also termed SH2-DIA (SH2-domain containing gene 1A) or DSHP. This gene, located at Xq25, regulates a protein involved in signal transduction in Tand NK cells. In T cells, the protein binds to the Signaling Lymphocyte Activation Molecule (SLAM, known as CDw150) and in NK cells it binds to 2B4, an NKcell-activating receptor [21]. Chédiak Higashi syndrome is linked to the LYST-gene (lyzosomal trafficking regulator gene, 1q42), and Griscelli syndrome type 2 is linked to mutations in RAB27a, a key effector of cytotoxic granule exocytosis [24]. TREATMENT OF HLH Therapeutic Background The first major achievement in the treatment of HLH came when the use of the epipodophyllotoxin derivatives etoposide, and later teniposide, in combination with steroids were shown to induce prolonged symptomatic resolution [44 46]. The immunosuppressive drugs CSA and antithymocyte globulin (ATG) are also effective in FHL [47]. In HLH-94, etoposide and dexamethasone were combined with CSA [8,48]. Cerebral involvement may cause severe and irreversible damage [43,49,50]. In children with HLH, CNS disease at diagnosis often resolves with systemic therapy. Therefore, systemic therapy including dexamethasone, which penetrates the blood-brain barrier better than prednisolone, was first line therapy in HLH-94, and also in cases of CNS involvement. Intrathecal methotrexate was added after 2 weeks in children with progressive neurological symptoms or if an abnormal CSF had not improved. However, although chemo-immunotherapy is effective in prolonging survival, in some patients more than 5 years after onset [11], it has not been possible to ultimately cure any child with FHL with chemo-immunotherapy alone. It was therefore a major therapeutic advance when allogeneic hematopoietic stem cell transplantation (HSCT) was shown to provide cure for FHL [51 53]. In HLH-94, the estimated 3-year probability of survival overall in HLH-94 at a median follow-up of 3.1 years was 55% (95% confidence interval 9%) (9%) (n ¼ 113) [48]. In children with an affected sibling, that is familial disease, the 3-year probability of survival was 51% for eligible patients recruited during the 4-year period, July 1994 June 1998 [48]. Proposed Revision of HLH-94 Protocol Since the pre-hsct therapy was successful in allowing as many as 80% of the patients with verified familial disease, that is with an affected sibling, to survive to HSCT, the revised protocol was based on the achievements made by HLH-94 [48]. In addition, minor revisions are included, as presented below.

11 Diagnosis and Treatment of HLH 127 Initial therapy (weeks 1 8). Not surprisingly in a disease characterized by severe cytopenias and an immunodeficiency, dose modifications in HLH-94 were common. In particular, the doses of VP-16 were decreased in a substantial number of the patients. For dexamethasone, the amount administered was often increased during the induction phase. During the first 4 years of HLH-94, six patients were reported to have died during the first month of treatment and six more during the second month of treatment. It was sometimes difficult to clarify whether death was caused by the disease or by its treatment, in particular in case of infections associated with neutropenia. However, most deaths were considered to be due to the HLH disease by the reporting physicians. Because of the data cited above, it was proposed that treatment intensity be increased during the first 2 months of therapy with a drug that does not induce myelotoxicity. As a result, in HLH-2004 CSA is initiated upfront instead of after 8 weeks. Continuation therapy. Of the six children who died during weeks 9 24 on the HLH-94 protocol, all were reported as death due to HLH disease, and at least three of these children had CNS-involvement. We considered including CSF analysis every fourth week in all children (at least for cells and protein, and cytospin in case of CSF pleocytosis) in order to detect early reactivation in the CNS. As a minimum, it is recommended to perform CSF analysis at the time of systemic reactivation or new onset or reactivation of neurological symptoms. Brain MRI is also recommended at diagnosis in these situations. Intrathecal therapy. With available HLH-94 data, it has not yet been possible to determine whether intrathecal therapy, in addition to the systemic HLH-94 therapy, is beneficial or not. Systemic therapy, as provided in HLH-94, will in most patients reduce CNS disease activity. It cannot be ruled out that intrathecal therapy may have additional beneficial effects, at least in some patients, but potential side-effects also have to be considered [46,48,54,55]. Intrathecal therapy is recommended for patients with signs of persistent active CNS disease and in cases of CNS reactivation. As in HLH-94, up to four intrathecal doses are recommended weeks 3 6, if the neurological symptoms are progressive during the first 2 weeks or if an abnormal CSF at onset has not improved after 2 weeks. With the potential beneficial effect of systemic corticosteroids in mind, it is now suggested to add corticosteroids to the intrathecal therapy. Hematopoietic cell transplantation. The estimated overall 3-year probability of survival after HSCT for HLH- 94 patients recruited during the period was 64% (CI ¼ 10%) (n ¼ 86); 71 18% with matched related donors (n ¼ 24), 70 16% with matched unrelated donors (n ¼ 33), 50 24% with family haploidentical donors (n ¼ 16), and 54 27% with mismatched unrelated donors (n ¼ 13) [56]. The HLH-94 results also suggest that some degree of disease activity at the time for transplantation Pediatr Blood Cancer DOI /pbc should not automatically preclude HSCT [56]. The recommended dosages for chemotherapy used in the preparative regimen and the graft-versus-host-disease (GVHD) prophylaxis have been modified slightly in the HLH-2004 protocol to reflect more recent HSCT experience. HLH-2004 Study Design The HLH-2004 protocol is designed for the patients with HLH, with or without evidence of familial or genetic disease, regardless of suspected or documented viral infections. The Japanese experience has demonstrated that patients with EBV infection and a clinical picture of HLH have a significant advantage when treated according to this approach [57]. Initial therapy (weeks 1 8) is based on etoposide, dexamethasone, and CSA; only selected patients will receive intrathecal therapy with methotrexate and prednisolone. For a general overview of the patient treatments options in HLH-2004, see Figure 1. In patients without a known family history who achieve complete resolution of the disease after 8 weeks of therapy, treatment is stopped in order to avoid HSCT in a child that may have shlh. All children with familial disease or with a diagnosis verified by genetic testing, as well as children with a non-familial disease that is severe and persistent, or reactivated, are recommended to receive continuation therapy with etoposide, dexamethasone, and CSA. HSCT should be performed as early as possible, when an acceptable donor is available. Patients less than 18 years of age at onset of therapy who fulfil the diagnostic criteria of HLH, and who have not received prior cytotoxic or CSA treatment for HLH, are eligible to be enrolled. Patients with HLH aged 18 years or more and patients who do not fulfil the diagnostic criteria will be studied separately. Similarly, patients with XLP, Chediak Higashi syndrome, Griscelli syndrome type 2, as well as patients with MAS secondary to known rheumatoid diseases, may be registered and will be studied separately. Initial therapy. The initial therapy covers the first 8 weeks of treatment (Fig. 2). The complete protocol is available for request at Maximal initial supportive care is suggested, and appropriate broad-spectrum antibiotics (until culture results) are made available. The supportive therapy includes prophylactic cotrimoxazole, an oral antimycotic during the initial therapy, consideration of antiviral therapy in patients with ongoing viral infections, and IvIG (0.5 g/kg IV) once every 4 weeks (during the initial and continuation therapy). Gastroprotection with ranitidine or some other gastroprotective agent is also suggested. If there is clinical evidence after 2 weeks of progressive neurological symptoms or if an abnormal CSF (cell count and protein) has not improved, 4 weekly intrathecal injections are recommended [46,48,54]. Continuation therapy. Patients without a family history of HLH and without genetic evidence of the disease are

12 128 Henter et al. Fig. 1. Flow-sheet of treatment options for children with hemophagocytic lymphohistiocytosis in HLH If there is a treatable infection it should be treated but be aware that this may not be sufficient and the patient may need HLH-treatment in addition. If HLH is persistent or recurring consider that the patient may have an undiagnosed inherited disease. HLH may also develop secondary to a number of other diseases as malignancies, rheumatic diseases, and metabolic disorders, requiring a different treatment. Start therapy if the patient has a genetically verified disease, a familial form of HLH, or if the disease is severe, persistent, or recurrent. (HSCT ¼ hematopoietic stem cell transplantation.) recommended to start continuation therapy if the disease is active after the initial therapy. Increasing disease activity may make it necessary to intensify the treatment in some children (see below). Reactivation therapy. FHL is characterized by frequent reactivations, or even more or less continuous disease activity. In particular, reactivation of the disease is common as therapeutic intensity is reduced, such as during the later part of the initial therapy. Accordingly, a reactivation will commonly respond to an intensification of the initial therapy. Reactivations may also occur following immune response triggering, such as infections and vaccinations. In cases of reactivation, broad-spectrum antibiotics, antiviral therapy, and antifungal therapy should also be considered as supportive or therapeutic measures. If the patient develops a reactivation, intensification of therapy is recommended, such as to restart from week 2, in which case the initial therapy may be less than 8 weeks, and then continue with modified continuation therapy. Intrathecal therapy is recommended in cases of CNS-reactivation [46,48,54]. HSCT has high priority. Salvage therapy. The HLH-2004 protocol does not include a salvage protocol. We want to mention an alternative approach of inducing remission, with a regimen including a treatment with steroids, CSA, and ATG [47]. However, in our experience ATG usually fails in patients that are nonresponders. It is therefore suggested that salvage therapy is discussed with the local sub-center. Note that early after HSCT, the immunodysregulation may induce a shlh picture, which may be related to engraftment but delayed Fig. 2. Schematic treatment overview of the HLH-2004 protocol. For information on whether to start continuation therapy and perform stem-cell transplantation, see text and Figure 1. The complete protocol is available for request at (VP-16 ¼ etoposide, I.T. therapy ¼ intrathecal methotrexate and corticosteroids, HSCT ¼ hematopoietic stem cell transplantation.) Pediatr Blood Cancer DOI /pbc

13 Diagnosis and Treatment of HLH 129 lymphocyte recovery, necessitating reinstitution of some form of HLH therapy [56]. Stopping therapy. Stopping therapy is only recommended in children with complete resolution of the disease. Close follow-up is warranted, including evaluation for fevers, hepatosplenomegaly, neurological abnormalities, anemia, thrombocytopenia, neutropenia, as well as elevation of ferritin, serum transaminases, and scd25. Hematopoietic Cell Transplantation The choice of the donor rests with the treating physician. If an HLA-identical relative is not available, a matched unrelated donor is recommended. The risk of a sibling carrying the disease must be considered. If a genetic marker (such as for PRF, UNC13D, orstx11) is not available, NK-cell activity can be considered as a surrogate marker of immune dysfunction, although healthy siblings may also have persistently decreased NK-cell activity [16]. If there is no matched donor available, use of a partially mismatched donor is sought. Outcome in the HLH-94 study with regard to various donors has been presented [57]. Results with mismatched donors are improving [52,53,56,58,59]. If no other donor is available, HSCT with a haplo-identical family donor is suggested. The use of peripheral blood or cord blood HSCT may be considered, at the discretion of the physician. Preparative regimen and GVHD prophylaxis. The preparative regimen for HSCT and the GVHD prophylaxis rests with the transplantation unit, but a suggested regimen is provided. It proposes including etoposide, in addition to busulfan and cyclophosphamide, in the conditioning regimen, in accordance with previous experiences [48,53]. The dosages suggested are outlined in the complete protocol, available for request at The marrow infusion is preferably made with nucleated cells/kg, and non-t-cell-depleted. In haploidentical and antigen mismatched unrelated transplants, T-celldepletion may need to be considered. Since there is evidence that donor T cells and NK cells are instrumental in curing HLH, use of T-cell-depletion should be carefully weighted. The GHVD prohylaxis for unmanipulated T-cell replete grafts is based on CSA and a short course of methotrexate, and methotrexate may be substituted by mycophenolate mofetil. Additional treatment for unrelated donor transplants include ATG [53]. Reduced intensity conditioning. There are limited data available on reduced intensity conditioning in HLH [59]. It is not yet possible to make definitive suggestions regarding the preference for such regimens in HLH. BIOLOGICAL STUDIES HLH-94 had a number of associated biological studies, including analyses of NK-cell and T-cell cytotoxicity, Pediatr Blood Cancer DOI /pbc preparation of DNA for genetic analyses, as well as EBVassociated studies. These studies have all been successful and they have improved diagnostics and therapy, and increased the biological understanding of the disease as well as of normal human immune modulation. Recent studies have shown that the disease is associated with decreased apoptosis triggering [35,39]. This causes the defect in the NK and T-cell cytotoxicity that has been recognized for long [15,16], with three causative gene defects known today; PRF [9], UNC13D [40], and STX11 [41]. It is possible to identify a cohort of individuals with PRF gene mutations by the use of flow cytometry for the perforin protein [17]. Moreover, it has also recently been shown that the cytotoxicity defect can be grouped in four subtypes [18], and that group 3 patients will most likely need a HSCT in order to survive [34]. The biological studies in HLH-2004 address these recent novel findings. The goals are to: (1) gather biological material in order to identify additional genetic defects; (2) study the correlation of genetic mutations and associated flow cytometry results; (3) study genotype phenotype associations; (4) and study the biological and clinical significance of cytotoxic subgroups. It is therefore recommended that study patients be analyzed for genetic mutations, by flow cytometry, and for NK and T-cell cytotoxicity. CONCLUSION Survival for patients with HLH has improved dramatically during the last decades as has the understanding of the underlying biological mechanisms. The HLH-94 treatment protocol has been widely accepted, and patients from 29 countries have been registered in the database. Based on the cumulative experiences from HLH-94 and other studies, a new treatment protocol, HLH-2004, has been developed which includes diagnostic and therapeutic guidelines. In order to attempt to further improve diagnosis, therapy and biological understanding, participation in HLH clinical trials is encouraged. REFERENCES 1. Henter J-I, Arico M, Elinder G, et al. Familial hemophagocytic lymphohistiocytosis (primary HLH). Hematol Oncol Clin North Am 1998;12: Janka G, Elinder G, Imashuku S, et al. Infection- and malignancyassociated hemophagocytic syndromes: Secondary hemophagocytic lymphohistiocytosis. Hematol Oncol Clin North Am 1998;12: Henter J-I, Söder O, Öst Å, et al. Incidence and clinical features of familial hemophagocytic lymphohistiocytosis in Sweden. Acta Paediatr Scand 1991;80: Janka GE. Familial hemophagocytic lymphohistiocytosis. Eur J Pediatr 1983;140: Henter J-I, Ehrnst A, Andersson J, et al. Familial hemophagocytic lymphohistiocytosis and viral infections. Acta Paediatr 1993;82:

14 130 Henter et al. 6. Risdall RJ, McKenna RW, Nesbit ME, et al. Virus-associated hemophagocytic syndrome. A benign histiocytic proliferation distinct from malignant histiocytosis. Cancer 1979;44: Henter J-I, Elinder G, Öst Å, the FHL Study Group of the Histiocyte Society. Diagnostic guidelines for hemophagocytic lymphohistiocytosis. Semin Oncol 1991;18: Henter J-I, Arico M, Egeler M, et al. HLH-94: A treatment protocol for hemophagocytic lymphohistiocytosis. Med Pediatr Oncol 1997;28: Arico M, Janka G, Fischer A, et al. Hemophagocytic lymphohistiocytosis: Diagnosis, treatment and prognostic factors. Report of 122 children from the international registry. Leukemia 1996;10: Esumi N, Ikushima S, Todo S, et al. Hyperferritinemia in malignant histiocytosis, virus-associated hemophagocytic syndrome and familial hemophagocytic lymphohistiocytosis. Acta Paediatr Scand 1989;78: Henter J-I, Elinder G. Familial hemophagocytic lymphohistiocytosis. Clinical review based on the findings in seven children. Acta Paediatr Scand 1991;80: Clementi R, Emmi L, Maccario R, et al. Adult onset and atypical presentation of hemophagocytic lymphohistiocytosis in siblings carrying PRF1 mutations. Blood 2002;100: Favara B. Hemophagocytic lymphohistiocytosis: A hemophagocytic syndrome. Semin Diagn Pathol 1992;9: Ladisch S, Poplack DG, Holiman B, et al. Immunodeficiency in familial erythrophagocytic lymphohistiocytosis. Lancet 1978;1: Perez N, Virelizier J, Arenzana-Seisdedos F, et al. Impaired natural killer cell activity in lymphohistiocytosis syndrome. J Pediatr 1984;104: Sullivan KE, Delaat CA, Douglas SD, et al. Defective natural killer cell function in patients with hemophagocytic lymphohistiocytosis and in first degree relatives. Pediatr Res 1998;44: Kogawa K, Lee SM, Villanueva J, et al. Perforin expression in cytotoxic lymphocytes from patients with hemophagocytic lymphohistiocytosis and their family members. Blood 2002;99: Schneider EM, Lorenz I, Müller-Rosenberger M, et al. Hemophagocytic lymphohistiocytosis (HLH) is associated with deficiencies of cellular cytolysis but normal expression of transcripts relevant to killer cell induced apoptosis. Blood 2002;100: Komp DM, McNamara J, Buckley P. Elevated soluble interleukin-2 receptor in childhood hemophagocytic histiocytic syndromes. Blood 1989;73: Henter J-I, Elinder G, Söder O, et al. Hypercytokinemia in familial hemophagocytic lymphohistiocytosis. Blood 1991;78: Nichols KE. X-linked lymphoproliferative disease: Genetics and biochemistry. Rev Immunogenet 2000;2: Arico M, Imashuku S, Clementi R, et al. Hemophagocytic lymphohistiocytosis due to germline mutations in SH2D1A, the X-linked lymphoproliferative disease gene. Blood 2001;97: Ward DM, Shiflett SL, Kaplan J. Chediak Higashi syndrome: A clinical and molecular view of a rare lysosomal storage disorder. Curr Mol Med 2002;2: Bizario JC, Feldmann J, Castro FA, et al. Griscelli syndrome: Characterization of a new mutation and rescue of T-cytotoxic activity by retroviral transfer of RAB27A gene. J Clin Immunol 2004;24: Duval M, Fenneteau O, Doireau V, et al. Intermittent hemophagocytic lymphohistiocytosis is a regular feature of lysinuric protein intolerance. J Pediatr 1999;134: Schmid I, Reiter K, Schuster F, et al. Allogeneic bone marrow transplantation for active Epstein Barr virus-related lymphoproliferative disease and hemophagocytic lymphohistiocytosis in an infant with severe combined immunodeficiency syndrome. Bone Marrow Transplant 2002;29: Aleman K, Noordzij JG, de Groot R, et al. Reviewing Omenn syndrome. Eur J Pediatr 2001;160: Imashuku S, Hibi S, Ohara T, et al. Effective control of Epstein Barr virus-related hemophagocytic lymphohistiocytosis with immunochemotherapy. Blood 1999;93: Ramanan AV, Baildam EM. Macrophage activation syndrome is hemophagocytic lymphohistiocytosis need for the right terminology. J Rheumatol 2002;29: Stephan JL, Kone-Paut I, Galambrun C, et al. Reactive haemophagocytic syndrome in children with inflammatory disorders. A retrospective study of 24 patients. Rheumatology (Oxford) 2001; 40: Henter J-I, Elinder G. Cerebromeningeal hemophagocytic lymphohistiocytosis. Lancet 1992;339: Janka GE, Schenider EM. Modern management of children with haemophagocytic lymphohistiocytosis. Br J Haematol 2004;124: Henter J-I, Tondini C, Pritchard J. Histiocytic syndromes. Crit Rev Oncol Hematol 2004;50: Horne AC, Zheng C, Lorenz I, et al. Subtyping of natural killer cell cytotoxicity deficiencies in hemophagocytic lymphohistocytosis provides therapeutic guidance. Br J Haematol 2005;129: Fadeel B, Orrenius S, Henter J-I. Induction of apoptosis and caspase activation in cells obtained from familial haemophagocytic lymphohistiocytosis patients. Br J Haematol 1999;106: Stepp SE, Dufourcq-Lagelouse R, Le Deist F, et al. Perforin gene defects in familial hemophagocytic lymphohistiocytosis. Science 1999;286: Ericson KG, Fadeel B, Nilsson-Ardnor S, et al. Spectrum of perforin gene mutations in familial hemophagocytic lymphohistiocytosis. Am J Hum Genet 2001;68: Molleran Lee S, Villanueva J, Sumegi J, et al. Characterisation of diverse PRF1 mutations leading to decreased natural killer cell activity in North American families with haemophagocytic lymphohistiocytosis. J Med Genet 2004;41: Fadeel B, Orrenius S, Henter J-I. Familial hemophagocytic lymphohistiocytosis: Too little cell death may seriously damage your health. Leuk Lymphoma 2001;42: Feldmann J, Callebaut I, Raposo G, et al. Munc13-4 is essential for cytolytic granules fusion and is mutated in a form of familial hemophagocytic lymphohistiocytosis (FHL3). Cell 2003;115: Zur Stadt U, Schmidt S, Kasper B, et al. Linkage of familial hemophagocytic lymphohistiocytosis (FHL) type-4 to chromosome 6q24 and identification of mutations in syntaxin 11. Hum Mol Genet 2005;14: Zur Stadt U, Beutel K, Kolberg S, et al. Mutation spectrum in children with primary hemophagocytic lymphohistiocytosis: Molecular and functional analyses of PRF1, UNC13D, STX11, and RAB27A. Hum Mutat 2006;27: Rudd E, Ericson KG, Zheng CY, et al. Spectrum and clinical implications of syntaxin 11 gene mutations in familial hemophagocytic lymphohistiocytosis: Association with disease-free remissions and hematopoietic malignancies. J Med Genet 2006;43:e Ambruso DR, Hays T, Zwartjes WJ, et al. Successful treatment of lymphohistiocytic reticulosis with phagocytosis with epipodophyllotoxin VP Cancer 1980;45: Pediatr Blood Cancer DOI /pbc