Steroid Therapy for cGVHD

Treatment Approaches (Part 1)

For newly diagnosed moderate to severe cGVHD, the panel discussed:

Initial steroid dosing:

• Dr Bishop: 1 mg/kg/day for severe cases, possibly split dosing
• Dr Shaughnessy: 0.5 mg/kg/day for many cases, 1 mg/kg/day for severe lung or liver involvement
• All agree on assessing response for at least 1-2 weeks before tapering

Steroid taper considerations:

• Slow, cautious tapers, especially for cGVHD (unlike acute GVHD)
• Generally 10 mg every 1-2 weeks after stabilization, slowing at 20 mg/day
• Consider adding calcineurin inhibitor if cGVHD developed soon after prophylaxis discontinuation

For high-risk disease with relapse potential:

• Balance between GVHD control and maintaining graft-versus-leukemia effect
• Preference for local therapies when possible
• Recognition that relapse through active cGVHD is rare

Supportive care strategies include:

• Topical therapies for eyes, mouth, and skin
• UV protection and good skin/oral care
• Budesonide for gastrointestinal involvement
• Ursodiol for liver involvement
• FAM (fluticasone, azithromycin, montelukast) therapy for pulmonary involvement
• Physical therapy and rehabilitation for sclerotic and joint involvement
• Pulmonary rehabilitation for bronchiolitis obliterans syndrome