Multiple Myeloma Therapeutic agent Darzalex interfering with testing

[ElinF]

Interesting patient #2 this month.  A multiple myeloma patient who had no history had all testing positive in Gel, including the  Auto control.  Expecting a Warm auto we sent the specimen to the reference lab.  Again, they sent it further to the American red Cross.  They discovered a new medication on the med list was a medication that pretty much interfered with all blood bank testing except Immediate spin crossmatches.    Darzalex is the name of the drug.  The bulletin is below from the AABB.   So, while the patients are on this drug, our reference lab will have to perform the antibody screens for us. 

 

 

 

Association Bulletin #16-02

Date: January 15, 2016

To: AABB Members

From: Donna M. Regan, MT(ASCP)SBB—President

Miriam A. Markowitz—Chief Executive Officer

Re: Mitigating the Anti-CD38 Interference with Serologic Testing

Summary

A new class of therapeutic agents for multiple myeloma, CD38 monoclonal antibodies, can result in interference with blood bank serologic tests and thereby cause delays in issuing Red Blood Cell (RBC) units to patients receiving these agents. To minimize these delays, hospitals should set up procedures to inform the transfusion service when patients start receiving these agents. Considerations for the transfusion service, both before and after initiation of anti-CD38 therapy, are detailed below.

The AABB Clinical Transfusion Medicine Committee has developed this bulletin to provide background information and guidance to members regarding anti-CD38 interference with serologic testing. The bulletin includes recommendations for its prevention and treatment.

Association Bulletins, which are approved for distribution by the AABB Board of Directors, may include announcements of standards or requirements for accreditation, recommendations on emerging trends or best practices, and/or pertinent information. This bulletin contains information and recommendations. No new standards are proposed.

Background

CD38 monoclonal antibodies are a new treatment for multiple myeloma

CD38, an integral membrane protein that is highly expressed on myeloma cells, has been identified as an effective target antigen for monoclonal antibody therapies. In November 2015, the first therapeutic CD38 monoclonal antibody [daratumumab (Darzalex, Janssen Biotech, Horsham, PA)] was approved by the Food and Drug Administration.1 Other CD38 monoclonal antibodies are under development.

CD38 monoclonal antibodies interfere with blood bank serologic tests

CD38 is weakly expressed on red cells. Anti-CD38 binds to CD38 on reagent RBCs, causing panreactivity in vitro.2,3 Plasma samples from anti-CD38-treated patients consistently cause positive reactions in indirect antiglobulin tests (IATs), antibody detection (screening) tests, antibody identification panels, and antihuman globulin (AHG) crossmatches. Agglutination due to anti-CD38 may occur in all media (eg, saline, low ionic strength saline, polyethylene glycol),

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and with all IAT methods (eg, gel, tube, solid phase). Agglutination reactions caused by anti-CD38 are usually weak (1+), but stronger reactions (up to 4+) may be seen in solid-phase testing. However, anti-CD38 does NOT interfere with ABO/RhD typing or with immediate-spin crossmatches.

Other notes on anti-CD38 serologic interference:

 Adsorptions using either untreated or ZZAP-treated cells fail to eliminate the interference.

 Anti-CD38 variably interferes with direct antiglobulin tests (DATs) and antibody identification panel autocontrols.

 Some rare Lu(a–b–) cells are not reactive in the presence of anti-CD38, potentially giving the false impression that the patient has a Lutheran-related antibody.4,5

 Positive IATs can be observed for up to six months after anti-CD38 is discontinued.1,3

 Anti-CD38 may cause a small decrease in hemoglobin in vivo (~1 g/dL), but severe hemolysis has not been observed among treated patients.3,6

Anti-CD38 interference can cause delays in issuing RBCs

If the transfusion service is unaware that a patient has received anti-CD38, the following scenario may occur when the patient’s sample is tested:

1. ABO/RhD typing: no issues.

2. Antibody detection (screening) test: all cells positive.

3. Antibody identification panel: all cells positive (autocontrol may be negative).

4. DAT: positive or negative.

5. AHG crossmatches: positive with all RBC units tested.

6. Adsorptions: panreactivity cannot be eliminated.

This leads to delays in issuing RBCs to the patient. In some cases, the anti-CD38 interference could mask the presence of a clinically significant alloantibody.

Recommendations

To avoid problems with transfusion, hospitals should set up procedures to inform the transfusion service whenever any patient is scheduled to begin taking anti-CD38.

BEFORE a patient begins taking anti-CD38:

 A baseline type and screen should be performed.

 In addition, a baseline phenotype or genotype is recommended.

AFTER a patient begins taking anti-CD38:

 ABO/RhD typing can be performed normally.

 For antibody detection (screening) and identification, dithiothreitol (DTT)-treated cells can be used to eliminate the interference.2,7

o Because DTT treatment destroys Kell antigens, K-negative units should be provided unless the patient is known to be K-positive.

o Antibodies against other DTT-sensitive blood group antigens (anti-k, anti-Yta, anti-Doa/Dob, etc) will not be detectable when the antibody screen with DTT-

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treated cells is performed; such antibodies are encountered infrequently, however.

Crossmatch

 For patients with a negative antibody screen using DTT-treated cells, an electronic or immediate-spin crossmatch with ABO/RhD-compatible, K-matched units may be performed.

 For patients with known alloantibodies, phenotypically or genotypically matched RBC units may be provided.6,8

o As some typing antisera require the use of AHG, phenotyping should be performed before the patient receives anti-CD38.

o Genotyping can be performed either before or after the patient receives anti-CD38.

o AHG crossmatches with phenotypically or genotypically matched units will still be incompatible.

o Some clinically significant antibodies may be missed with the use of uncrossmatched phenotypically or genotypically matched units, although this will occur infrequently.

 Alternatively, an AHG crossmatch may be performed using DTT-treated donor cells.

 If an emergency transfusion is required, uncrossmatched ABO/RhD-compatible RBCs may be given per local blood bank practices.

Future/alternative approaches to mitigating the anti-CD38 interference

It is possible to neutralize anti-CD38 in plasma and eliminate the interference using either recombinant soluble human CD38 or daratumumab idiotype antibody.2,3 Neither reagent is widely available at this time, and additional validation would be needed. In principle, soluble CD38 could be used to neutralize any anti-CD38, while different idiotype antibodies would be needed to neutralize different CD38 therapeutic antibodies. Finally, antigen-typed cord cells have been used for the antibody screen as an alternative to DTT-treated cells.9

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References

1. Darzalex package insert. Horsham, PA: Janssen Biotech, 2015. [Available at: http://www.darzalex.com/shared/product/darzalex/darzalex-prescribing-information.pdf (accessed January 7, 2016).]

2. Chapuy CI, Nicholson RT, Aguad MD, et al. Resolving the daratumumab interference with blood compatibility testing. Transfusion 2015;55(6pt2):1545-54.

3. Oostendorp M, Lammerts van Bueren JJ, Doshi P, et al. When blood transfusion medicine becomes complicated due to interference by monoclonal antibody therapy. Transfusion 2015;55(6pt2):1555-62.

4. Velliquette RW, Shakarian G, Jhang J, et al. Daratumumab-derived anti-CD38 can be easily Mistaken for clinically significant antibodies to Lutheran antigens or to Knops antigens (abstract). Transfusion 2015;55(3S):26A.

5. Aye T, Arndt PA, Leger RM, et al. Myeloma patients receiving daratumumab (anti-CD38) can appear to have an antibody with Lutheran-related specificity (abstract). Transfusion 2015;55(3S):28A.

6. Chari A, Satta T, Tayal A, et al. (2015, December) Outcomes and management of red blood cell transfusions in multiple myeloma patients treated with daratumumab (oral and poster abstract presented Monday, December 7, 2015, 6:00 PM-8:00 PM at 57th Annual American Society of Hematology meeting). Blood 2015;26(Suppl):Abstract 3571.

7. Chapuy CI, Aguad MD, Nicholson RT, et al. International validation of a dithiothreitol (DTT)-based method to resolve the daratumumab interference with blood compatibility testing (oral and poster abstract presented Monday, December 7, 2015, 6:00 PM-8:00 PM at 57th Annual American Society of Hematology meeting). Blood 2015;126(Suppl):Abstract 3567.

8. Hannon JL, Caruk B, Clarke G. Serological findings related to treatment with a human monoclonal antibody (daratumumab) in patients with advanced plasma cell myeloma (abstract). Transfusion 2014;54(2S):162A.

9. Schmidt AE, Kirkley S, Patel N, et al. An alternative method to dithiothreitol treatment for antibody screening in patients receiving daratumumab (abstract). Transfusion 2015;55(3S):2292-3.

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[Teristella]

Yes, we have been seeing this too. There are a couple of threads on this. Trying to get pre-treatment samples on patients who will be going on this drug has not been fun.

[AMcCord]

We've been trying to work with the Oncology practices on this one. I'm hoping we'll get a crack at the patient pre-treatment - we'll see!

[DPruden]

This is a fun drug (I really need a sarcastic font!).  We have added a order into the HIS order sets for multiple myeloma diagnoses to include a molecular genotype before the drug is initiated.  Hopefully, that will help!

[Liz0316]

We are developing a protocol, where by we get a baseline sample on the patient, have molecular genotyping done and once the drug is started, we will be testing with DTT and issuing K- red cells. I'll keep watch on the thread and try to keep up with our progress on the protocol.

Liz

 

[tbostock]

11 hours ago, Liz0316 said:

We are developing a protocol, where by we get a baseline sample on the patient, have molecular genotyping done and once the drug is started, we will be testing with DTT and issuing K- red cells. I'll keep watch on the thread and try to keep up with our progress on the protocol.

Liz

 

Hey Liz.  I want to bring DTT in.  I'm having a hard time finding a source for it; is there any vendor that sells it already pre-mixed, or do you have to get the PBS and powdered DTT?

[ElinF]

So question then...We have our patient typed and screened.  He has not received blood in 3 months  or has been pregnant (obviously).  How long can we extend his original crossmatch/antibody ID specimen that we had send to the Red Cross and was found negative.   How long can we honor that antibody screen.  Can we redraw just for the Immediate spin crossmatch if he were need to be transfused in the upcoming weeks?   It has already been probably a month, and he is holding strong.  but I was just curious what everyone's policies were.  Ours really doesn't give a long date.  We have never had this come up. 

 

 

[John Eggington]

How long would you extend the crossmatch/antibody screen for a patient that didn't have antibodies, hadn't, been transfused in the last 3 months, wasn't pregnant, etc.? I suppose this is about how reliable a 'history' you have!

[ElinF]

36 minutes ago, John Eggington said:

How long would you extend the crossmatch/antibody screen for a patient that didn't have antibodies, hadn't, been transfused in the last 3 months, wasn't pregnant, etc.? I suppose this is about how reliable a 'history' you have!

I am wondering what the timeframe is at other facilities  We have never had to extend anything longer than a week.  We are a smaller hospital and we don't do many surgeries requiring blood.   

Other places on this website say 30 days.  We are getting to the 30 day mark, so I am sure he will be rescreened, but having had no transfusions, I was wondering how long we could extend. 

[StevenB]

Technically, if the patient had not been transfused/pregnant within the three months PRIOR TO that last work-up, then that last work-up stands.  Without any stimulus, there is no reason for new antibody development.

I agree with John though; I'd really like to know that I could rely on the patient accurately giving you their "history".

And sure enough, "Standards" is of little help.  It states, paraphrasing, that pretransfusion testing shall include testing for unexpected antibodies.  Well, under your scenario, that is a "pretransfusion" test regardless of the time frame. However, if the patient had been transfused or pregnant prior to that last work-up, even if that sample was antibody negative, a new sample should be tested... you won't find that particular scenario though in Standards.  It's timeline is transfused or pregnant within 3 months of your pretransfusion testing on the sample you just had drawn.

I've noticed though that hospitals impose upon themselves rather strict standards when it comes to how long pretransfusion testing is good for.  In today's world, that's probably not a bad thing.

[catchmenow51]

On Friday, February 26, 2016 at 8:25 AM, tbostock said:

Hey Liz.  I want to bring DTT in.  I'm having a hard time finding a source for it; is there any vendor that sells it already pre-mixed, or do you have to get the PBS and powdered DTT?

Terri, to my knowledge PSB and powdered DTT are the only options at this time. There is buzz in the reagent community about manufacturing this reconstituted for resale. Sigma Aldrich does sell the powder form. You can go on their website and find the info or contact one of their engineers. They are very helpful.

[ElinF]

On 2/29/2016 at 3:58 PM, StevenB said:

Technically, if the patient had not been transfused/pregnant within the three months PRIOR TO that last work-up, then that last work-up stands.  Without any stimulus, there is no reason for new antibody development.

I agree with John though; I'd really like to know that I could rely on the patient accurately giving you their "history".

And sure enough, "Standards" is of little help.  It states, paraphrasing, that pretransfusion testing shall include testing for unexpected antibodies.  Well, under your scenario, that is a "pretransfusion" test regardless of the time frame. However, if the patient had been transfused or pregnant prior to that last work-up, even if that sample was antibody negative, a new sample should be tested... you won't find that particular scenario though in Standards.  It's timeline is transfused or pregnant within 3 months of your pretransfusion testing on the sample you just had drawn.

I've noticed though that hospitals impose upon themselves rather strict standards when it comes to how long pretransfusion testing is good for.  In today's world, that's probably not a bad thing.

Thank you for your reply.  This makes sense to me.  Better to be safe since he has had prior transfusions even if it was 3 years ago.  When he comes back in we will re-screen him and then once he is transfused he will be treated normally, we will just have to send his sample to the ARC for the special tesing.  

[Liz0316]

Sorry it took me so long to get back, I've been a bit ill. Anyway, I think I can only get it powdered and have to make it, I haven't ordered it yet. I'll check on the manuf. tomorrow and get back to you. I have instructions . 

Liz

[Liz0316]

I've ordered the DTT from Bio-Rad.

catalog # 161-0611 - from the Life Sciences division . 1-800-879-2289

LSG.ORDERS.US@BIO-RAD.COM

I hope that helps.

Liz

 

[noelrbrown]

Hemo bioscience is going to be launching ready for use DTT in the next 2-3 weeks.  We plan on pushing it through our email list and will update our web site with product codes.

[Mabel Adams]

I've heard that some places are extending specimen dating out a week between DTT workups even if the patient is transfused.  I plan to do it every 3 days on those recently transfused and only ask for pathologist approval to deviate if there are extenuating circumstances.  Most of these patients are regulars for OP transfusion but they could end up in a car wreck etc. and need multiple surgeries in a short time frame.

I have connected with the oncology pharmacists at our Cancer Clinic to help us flag patients before they start on the drug.  They are finding that the first infusion is so long and pretty prone to infusion reactions that they are admitting the patients to give the drug.  One guy ended up on a respirator for a few days from his reaction.  This means I need to have IP pharmacists know to tell us also.

[Jane12]

We started with two patients and within a month we have six patients now going through DARA treatment. Our Transfusion pathologist coordinates with Oncologists at our facility so that we have a baseline phenotyping and genotyping( if required) before the DARA treatment. When on DARA, we send the specimen to Reference lab for work up and TAT is 24 hours for the results. Therefore, we transfuse the patient within that 72 hours timeframe before the specimen expires. Last weekend, when I was working, one of the patients was in crisis and ended up in ER with critically low H & H. The physician requested immediate transfusion. There was no time to send the specimen to the Ref lab for workup & we released Phenotypically crossmatched ( AHG XM ) blood for transfusion. Our Lead made up a Binder for the DARA patients so that all shifts are aware of these patients.

[SMILLER]

We are currently dealing with our first DARA patient.  She came in with a broken femur.  We are giving her phenotypically-matched RBCs, and so far have extended her specimen out date to 14 days.  We are just doing an IS crossmatch for these.

According to one of our oncologists, DARA is a treatment option that is only used after other treatments for MM are exhausted, and indeed, our current patient is very ill.  We are hoping that these cases do not show up to often.  Unfortunately, as someone else has pointed out, patients on DARA can have rather severe side-effects, and MM patients are prone to pancytopenia and broken bones.

Scott

[Winter]

Last weekend, when I was working, one of the patients was in crisis and ended up in ER with critically low H & H. The physician requested immediate transfusion. There was no time to send the specimen to the Ref lab for workup & we released Phenotypically crossmatched ( AHG XM ) blood for transfusion. Our Lead made up a Binder for the DARA patients so that all shifts are aware of these patients. 

Jane12, what were the reactions in the AHG XM? Did you have DTT treated plasma?

[SMILLER]

By the way.  The instructions I have seen for using DTT to inactivate RBCs for antibody testing for DARA patients are not real in-depth.

For one, we would like to know how stable DTT-treated cells are.  If we do want to start doing this, I am guessing it is an immediate use process once the reagent cells are treated.  Are there any other issues we should know about if we have to commit to doing DTT treatments?

Thanks, Scott

[exlimey]

Winter - in the case of DARA patients, the DTT is use to treat (panel or screening) cells rather than the serum.

SMILLER - do you enzyme-treat your own cells ? If so, have you determined their stability ?

Edited April 11, 2016 by exlimey

[Barb Thompson]

Does anyone know how long after treatment has started before the interference shows up?  Are all patients on darzalex affected? I had a patient come in the day after her first dose. Her screen was positive in gel. I sent it to reference and they called it a cold and suggested doing a prewarmed screen and crossmatch.  Any thoughts on this?

 

thanks,

Barbara

[John Eggington]

On high dose therapy I would have thought it would be detectable very soon after therapy started (immediately?), but working in a reference lab we're rarely that close, in time, to the start of therapy. It could be mistaken for a warm autoantibody or an antibody to a high frequency antigen but, in my experience, it would seem unlikely it could be mistaken for a 'cold' antibody.

[Mabel Adams]

We have a patient who got his first dose on 3/17/16 but who had a negative antibody screen on 3/31 and 4/13.  On 4/26 he now has a pos screen in gel and a saline tube screen is about 1+ at 37 but barely positive at AHG.  We have sent the sample out for DTT workup.  With his frequent transfusions we may want to get some DTT so we can do the workup ourselves.

[CMCDCHI]

We are working with our HIS team to get pharmacy orders for DARA to print in the blood bank as well as a "heads up" that there is a new patient on the drug.  So far, oncology has been great about communicating with us.