Treatment Goals for a Patient With Chronic GVHD


The group discusses treatment goals and patient education for chronic GVHD.


Yi-Bin Chen, MD: Catherine, you see this patient in clinic, so they have early scleroderma, about 18% BSA [body surface area]. You had talked a bit about topical therapies in the past, but I think maybe you want to offer this patient systemic therapy at this point. What do you think?

Catherine J. Lee, MD, MS: No, I completely agree. If this patient presented to me in my clinic, I would start prednisone at this time.Try to see if we can control it early and improve symptoms.

Yi-Bin Chen, MD: And Colleen, when you talk to a patient now, you know when we have these discussions, many of them are a bit, shall we say, not happy that they have to now start treatment for something else thinking they were entering a phase of recovery. What expectations do you set for this patient now going forward once you start therapy for chronic GVHD [graft-versus-host disease]?

Colleen Danielson, NP: I think, you know, I agree with you. Patients are discouraged when this comes up at this timing. I think we need to talk about the details of graft-versus-host disease. What they’re experiencing now. Why we need to be starting systemic therapy versus, you know, trying a topical based on how they’re presenting in clinic. But we need to talk about the things that they need to watch for with starting systemic therapy with prednisone. We need to be monitoring their blood sugar and their blood pressure and those sorts of things. I think in terms of setting expectations and educating them on what to be watching for, we certainly want to know about progression. If they’re seeing this 18% total body surface area progressing beyond the topical, or, sorry, excuse me, the systemic steroids that we’re starting, they need to be reporting that to us so we know. And then it’s also educating about these other things, like Dr Cutler was mentioning. Patients often aren’t going to tell us about these other involvement of their eyes or their mouth or other things. So it’s educating on progression or new sites of disease that we need to know about.

Yi-Bin Chen, MD: Corey, what are your treatment goals here?

Corey S. Cutler, MD, MPH, FRCPC: I think we have to be very clear with what the treatment goals are with the patient. I think a lot of patients will expect to start a drug or a therapy and be better in 3 or 4 days. I think couching expectations is important. The main thing I would think about in a patient like this is preventing progression and disability and minimizing side effects from the therapies that we’re going to provide. I get very worried with sclerosis. It’s often very difficult to control. But I think we also have to tell the patient that it is possible that the best outcome might be that the sclerosis simply doesn’t get worse, but it might not actually get better. There are some therapeutics that might be able to do that, but sclerosis is difficult to treat and difficult to reverse. I think the expectation that we’re hoping to make sure that things don’t get any worse is really top line here.

Yi-Bin Chen, MD: I agree. I think going through the years, you know, I think I’ve understood the importance of education and setting expectations in that way, so patients understand [and] so patients’ goals are aligned with your goals. I think that’s essential to success.

Transcript edited for clarity.

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