Insights From: Yi-Bin A. Chen, MD, Massachusetts General Hospital; Zachariah M. DeFilipp, MD, Massachusetts General Hospital; Colleen M. Danielson, NP, Massachusetts General Hospital
Yi-Bin A. Chen, MD: Standard treatment of acute graft-versus-host disease hasn’t changed in the last couple of decades, and that’s driven a lot of the research that we’re doing now. Zack, can you describe what our standard approach is for dosing of steroids for patients with acute graft-versus-host disease and where that is?
Zachariah M. DeFilipp, MD: Sure. For patients who don’t respond to topical therapy or for patients who have more severe involvement of graft-versus-host disease at the time of diagnosis, the standard of care is systemic corticosteroids. There’s actually not much data published about the ideal starting dose for corticosteroid therapy in patients with acute graft-versus-host disease, but the majority of the data suggest that a dose of more than 2 mg/kg per day probably adds no benefit. Thus, the consensus guidelines from the American Society of Transplantation and Cellular Therapy recommend that the starting dose for graft-versus-host disease therapy be somewhere between 1 and 2 mg/kg per day.
In our practice, our starting dose depends on disease-related factors and patient-related factors. So for patients who have more severe organ involvement that includes the lower GI [gastrointestinal] tract or the liver, we often start at the higher dose of 2 mg/kg per day. But in certain cases, in older patients or in patients who have isolated skin involvement, we may start at the lower dose of 1 mg/kg. The question then becomes, what’s the best way to taper these steroids? That really depends, once again, on how the patient is responding to therapy, but also on whether the patient is experiencing toxicities from the steroids. Especially in our patient population, which is often older, we see a lot of steroid-related toxicities that may include hyperglycemia, hypertension, insomnia, and weight gain. Over time, patients can even experience adrenal insufficiency.
So we typically taper our steroids about once a week with the goal that if a patient is having a good response, we can get that dose of steroids down to around 0.25 mg/kg over approximately the first month of treatment. After that, the additional taper of the steroids, the timing, and the dose reductions really depend, once again, on whether the patient remains with a good response to steroids or whether they’re having a flare, and also whether they’ve experienced any of the previously mentioned toxicities.