Inside the Clinic: Acute Graft-versus-Host Disease - Episode 4

Approaching Acute Graft-Vs-Host Disease

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Yi-Bin A. Chen, MD: As you’ve heard, there is a spectrum of severity of acute graft-vs-host disease [GVHD], and I think it’s helpful to illustrate to you what patients go through from 1 end of the spectrum to the other. We’re going to illustrate 2 cases. The first case is a patient who we’re seeing as an outpatient after their initial hospitalization for transplant. They show up with a new skin rash. Our impression is that it’s acute graft-vs-host disease. They don’t have any gastrointestinal [GI] involvement, and their liver tests are fine. They’re mostly feeling well, still recovering from transplant.

For this patient, if the skin rash is greater than 50% of their body surface area, we might prescribe them oral steroids as an outpatient. And for the majority of these patients, we would expect that they would have a relatively good outcome. If they’re young and healthy and don’t have comorbidities that are affected much by the steroids, we hope they would have a relatively uneventful course as their rash resolves and we’re able to lower the steroids.

However, it is a completely different journey and experience for a patient who develops severe graft-vs-host disease, most commonly characterized by lower gastrointestinal involvement. As you heard from Colleen, this is staged or measured by the volume of diarrhea they have, often exceeding 2, 3, 4, or even 5 L in a 24-hour period. This patient requires inpatient hospitalization. Colleen has actually had the privilege of caring for patients both in the inpatient and outpatient settings. Colleen, would you describe what a patient who has gastrointestinal GVHD goes through?

Colleen M. Danielson, NP: Sure, Yi-Bin. The patient experience is tough, and it’s very different from what you’re talking about, where we can manage someone as an outpatient. With the type of gastrointestinal graft-vs-host disease that falls into the severe category, putting out a lot of diarrhea, these patients have to be hospitalized. And when we think about that hospitalization and the length of stay, we’re talking about weeks to maybe a month or 2. For patients, this is a big diagnosis. They’re coming off a long hospitalization with their transplant. When we think about the things we need to do, the first step is really, diagnostically: What do we do to work this patient up?

We may be suspecting that graft-vs-host disease is the cause of their diarrhea. However, these patients are also very immunocompromised from their transplant alone. We first will rule out infections and make sure that’s not a contributing factor here. We will also consult our GI colleagues for the patient to undergo a flexible sigmoidoscopy for biopsies to be taken. While that’s happening, we also, as you mentioned, typically start standard-of-care therapy, which will be high-dose steroids for the patient.

In addition, bowel rest is a big mainstay of treating this patient—helping them recover and for the inflammation in their bowel to calm down. That means they’re made NPO [nothing by mouth]. They can’t have anything to eat or drink. All their medications need to be converted from oral agents to intravenous medications. We also need to think about their nutrition. Most often, these patients are put on TPN [total parenteral nutrition] to provide them nutrition while they’re not eating and drinking.

When we think about all these things, there are a lot of complications that can happen not only from the graft-vs-host disease itself. We think about the therapies that we’re giving, such as the high-dose steroids. Patients deal with malnutrition, as we talked about, and their albumin is often low. They can get edema. They have issues with potential falls in the hospital, overall deconditioning. And then there is the whole psychosocial piece and emotional piece of what they’re going through. Really, to care for these patients, it involves a multidisciplinary care team. We think about all the people who are involved, who really give these patients the best care they deserve. This involves nursing, physical therapy, social work, and nutrition, all to really help the patient get through what they’re dealing with in another hospitalization. It’s a big journey. I think about how much social work plays into the patient experience and what these patients and their families have gone through. It really can be a long hospitalization for them.

Yi-Bin A. Chen, MD: Thanks, Colleen. As you can see, for each patient who suffers from 1 of these admissions from this complication, it really hits the entire care team. Certainly, the patient and the patient’s family really go through a huge ordeal here, and it really illustrates for us how much progress we have to make and why we’re committed to this research. That’s why at Massachusetts General Hospital we often will have multiple clinical trials open to try to improve the treatment of graft-vs-host disease. It’s an interesting dynamic when a patient is diagnosed. Colleen, you see a lot of patients when they first show up in the outpatient clinic with the initial, perhaps suspicion of acute graft-vs-host disease. Can you describe what happens at that point when you see that patient?

Colleen M. Danielson, NP: Sure, Yi-Bin. When we first see someone in the clinic and we’re concerned about graft-vs-host disease, the first step is really obviously talking to the patient, evaluating the patient, and then we think a lot about clinical trials. There’s standard of therapy, but we have so many clinical trials that are available to our patients. It usually involves reviewing what clinical trials are available with the attending physician that we work with. That also then involves the next step of contacting our research team for them to evaluate what trials this patient may be eligible for. If a patient is eligible for a potential trial, it then involves talking to the patient and their family about what the trial is and what that would mean for them, explaining the rationale of the trial. And then if the patient does want to enroll on the clinical trial, enrolling them and getting that started is really kind of the big step. But involving our research team early on is really important.

Yi-Bin A. Chen, MD: We should mention that it is gratifying to see how much research is going on in acute graft-vs-host disease these days. I’ll say that when I first started doing this, which was only about 12 years ago, graft-vs-host disease research was, shall we say, not very common. It was difficult to find any trials. These days, as you can see now when a patient presents, many centers will have multiple trials that patients are able to participate in. However, it does involve a team-based approach, time, and talking to the patient and their family and explaining the rationale behind the trial. But it’s only through these trials that we’re able to make progress.

Transcript Edited for Clarity