The Expanding Field of GVHD - Episode 10
An overview of the frontline treatment armamentarium for patients diagnosed with chronic graft versus host disease.
Corey Cutler, MD, MPH, FRCPC: You’ve made a diagnosis of chronic GVHD [graft-vs-host disease]. Yi-Bin, tell us about initial therapies, options, systemic vs local therapy, and the role of steroids?
Yi-Bin Chen, MD: Going back to what Linda said, the most commonly involved organs are your eyes, your mouth, and your skin. For the eyes and the mouth, we tend to maximize topical therapies or localized therapies that work closely with our ophthalmology colleagues in terms of local eyedrops, as well as comprehensive exams of the cornea, tier production, and so forth. The mouth certainly maximizes the use of oral rinses and works with oral medicines [given by] colleagues as well. We also emphasize the importance of good dental health for all our patients because of the decrease in saliva and the natural dry mouth that occurs with this whole process, especially if you get chronic graft-vs-host disease. In terms of the skin, we use topical steroids and other topical agents as well. In terms of topical tacrolimus, hopefully at some point we’ll be able to use topical ruxolitinib as well, which was just approved for eczema, and treat as much as we can.
At some point, multiple organ involvement, larger surface area involvement of the skin, or other visceral involvement mandates the use of systemic therapy. Unfortunately, as Corey mentioned for the standard treatment of acute graft-vs-host disease, the standard first-line systemic treatment for chronic graft-vs-host disease is steroids. The dosage is a little lower than acute [GVHD], somewhere between 0.5 to 1 mg/kg per day to start. For patients, unfortunately it’s tough. It’s tough to add back steroids at that dosage to patients at that point. Depending on the situation, many of our patients have had prior acute [GVHD] and have had a long course of steroids, and they’re getting down to very low doses when the chronic [GVHD] develops because prior acute [GVHD] is 1 of the biggest risk factors for developing chronic graft-vs-host disease.
Patients experience the morbidities of steroid use in chronic [GVHD]. The steroid course is unfortunately really long term. A recent study from the chronic GVHD Consortium looked at patients who started systemic steroids for chronic graft-vs-host disease and then followed them for a couple of years. [The studies] showed that a sobering one-third of patients were able to get off those steroids in the long run. Once we start steroids, that has led to us to reframe expectations for patients. As Linda mentioned, we need to think about chronic graft-vs-host disease as a chronic autoimmune disease in some ways, and the need for long-term immunosuppression, as well as monitoring for comorbidities.
Corey Cutler, MD, MPH, FRCPC: That’s all definitely true. The turning moment in chronic GVHD has been that we’ve now got 3 agents that are approved in the second-line setting and beyond. Because of the availability of most of those agents, most of us have become very accustomed to starting these second-line agents a little earlier. In that context, we’re making a real effort to wean our patients off their corticosteroids, particularly when they’re not actually working.
Transcript edited for clarity.