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Caution: inotuzumab before transplant (veno-occlusive disease)
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.
VOD occurred in 22% of INO-VATE patients who proceeded to transplant; risk rises with >2 cycles, dual-alkylator conditioning, and prior hepatic injury. Guidance: limit to 2 cycles pre-transplant, avoid busulfan-thiotepa, consider defibrotide prophylaxis.
Rationale
Calicheamicin damages hepatic sinusoidal endothelium, which is then further injured by conditioning chemotherapy.
Evidence
INO-VATE safety data; label boxed warning.