# Caution: inotuzumab before transplant (veno-occlusive disease)

Source: https://onco.cc/pairings/inotuzumab-then-transplant-caution/  
OnCo record `inotuzumab-then-transplant-caution` (Pairing). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

The CD22 ADC is an excellent bridge to transplant, but too many cycles or the wrong conditioning can cause severe liver damage after the transplant.

## Summary

This caution pairing concerns inotuzumab ozogamicin, the CD22 antibody-drug conjugate, used as a bridge to allogeneic stem cell transplantation in acute lymphoblastic leukaemia. Its calicheamicin payload damages the hepatic sinusoidal endothelium, which is then further injured by conditioning chemotherapy, and the result can be severe veno-occlusive disease after transplant. In INO-VATE a substantial fraction of patients who proceeded to transplant developed veno-occlusive disease, and the risk rises with more than two cycles of inotuzumab, dual-alkylator conditioning and prior hepatic injury; the label carries a boxed warning. Current guidance is to limit inotuzumab to two cycles before transplant, avoid busulfan-thiotepa conditioning, and consider defibrotide prophylaxis.

## Fields

- Kind: Pairing
- Last checked: 2026-09-07
- Pairs: Inotuzumab ozogamicin + Allogeneic stem cell transplantation
- Type: caution
- Rationale: Calicheamicin damages hepatic sinusoidal endothelium, which is then further injured by conditioning chemotherapy.
- Evidence: INO-VATE safety data; label boxed warning.

## Sources

- INO-VATE: inotuzumab ozogamicin, a CD22 antibody-drug conjugate, versus chemotherapy for relapsed adult B-cell ALL (New England Journal of Medicine 2016): https://doi.org/10.1056/NEJMoa1509277

## Connected records

- cancers: [Acute lymphoblastic leukaemia](https://onco.cc/cancers/all-leukemia/)
- technologies: [Allogeneic stem cell transplantation](https://onco.cc/technologies/allogeneic-hsct/)
- drugs: [Inotuzumab ozogamicin](https://onco.cc/drugs/inotuzumab-ozogamicin/)
- key papers: [INO-VATE: inotuzumab ozogamicin, a CD22 antibody-drug conjugate, versus chemotherapy for relapsed adult B-cell ALL](https://onco.cc/key-papers/paper-ino-vate-inotuzumab-all-nejm-2016/)

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