Considerations for Steroid Therapy in cGVHD: Optimizing Patient Care

Clinical Case Continued (Part 2)

In the clinical case, prednisone at 0.5 mg/kg/day was initiated with a 6-week taper. The patient initially improved but experienced progression during tapering. Steroids were increased again, but another taper was unsuccessful, leading to diagnosis of steroid-refractory cGVHD.

For management of steroid-induced complications, the panel emphasized:

• Internal medicine principles for managing diabetes, hypertension
• Involvement of specialists (endocrinology, cardiology, primary care)
• Attention to bone health to prevent osteoporosis

For infection prophylaxis in cGVHD patients on immunosuppression:

• All provide varicella zoster virus prophylaxis, especially at ≥0.5 mg/kg steroids
• Fungal prophylaxis for prolonged steroid use
• Pneumocystis jirovecii pneumonia (PJP) prophylaxis (Bactrim can cover both PJP and encapsulated organisms)
• Some centers also provide prophylaxis against encapsulated organisms
• Awareness of functional asplenia and T/B cell dysfunction in these patients

For vaccinations:

• Nonstandardized approaches across centers
• Generally continue flu and COVID-19 vaccines
• Some hold nonessential vaccines until prednisone <20 mg/day
• Avoid live vaccines until off immunosuppression
• Shingrix typically delayed until 8 months off immunosuppression