The Changing Landscape of Chronic Graft vs. Host Disease - Episode 7

Management of Chronic GvHD

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Experts in hematology/oncology review factors to consider when approaching the management of chronic graft-versus-host disease.

John DiPersio, MD, PhD: The issues with chronic GvHD [graft-versus-host disease] are two things that I’m aware of that limit the incidence of chronic GvHD. Taking the T cells out, which causes lots of problems, we don’t do that. Although limited T-cell depletion and alpha-beta depletion and things like this have been used in children and adults with some success. And that’s reduced the rates of chronic GvHD and early intervention with posttransplant Cytoxan [cyclophosphamide] and antithymocyte globulin. Those are also effective. But how about the management of chronic GvHD, Mike? What’s your approach with patients who come in and have developed signs and symptoms and chronic GvHD?

Michael Bishop, MD: Multiple factors go into that. I always like to think, chronic graft-versus-host disease, it’s a far more muddied entity than those patients with clinical acute graft-versus-host disease. From several perspectives, what organs are involved? What is the severity of those organs? What are the complications that happen in regard in the posttransplant setting? All of a sudden, they had acute graft-versus-host disease and they develop a fungal infection, or they were on steroids and got avascular necrosis. Those issues will come into play of what agents I’m going to choose. Is the patient still on a calcineurin inhibitor? Then you and I would know that generally those patients, they’re beyond 3 months, and they’ve gone home, and they’re trying to resume some resemblance of a normal life again. And all of a sudden, we’re saying, well, now we need to start you on this new therapy.

And, just as you said, we need to nip it in the bud as quick as possible because this is going to likely be a problem that you’re going to have for several months to years. It can intend to include other organs eventually. And how do we come up with the strategy and tactics to try to have a person have a quality of life, keep them alive, and not have them have another complication and prevent a recurrence of another complication, be that fungal infection or, most importantly, and the reason they probably went to transplant, is to make sure their disease doesn’t come back. Although, if they’ve developed graft-versus-host disease, that’s the one good thing that we can think about. If they have chronic graft-versus-host disease, the probability of their leukemia and their lymphoma coming back drops down dramatically.

That’s how I get my global picture. And for localized skin, again eyes, mouth, and skin are the three most common we’ll see in chronic graft-versus-host disease, I will try to avoid systemic therapy if possible. As soon as I see a patient needs systemic therapy, when I see such as lung, kidney, or liver involvement, then I know I’m going to have to use systemic therapy. But I will try to limit it to maintain quality of life and to try to limit the toxicities of steroids. That’s my general approach.

John DiPersio, MD, PhD: Yes. I agree. And one of the things is I’ve always been impressed of how little steroids do, too, for these patients with chronic GvHD.

Transcript Edited for Clarity