Inside the Clinic: Graft-versus-Host Disease Best Practices - Episode 12
Zachariah DeFilipp, MD: One thing that stands out to me in the treatment of patients with acute graft-versus-host [GvHD] disease, is that their treatment is truly a team effort. Therefore, establishing a team approach within the institution so that not only physicians but also NPs [nurse practitioners], nurses, social workers, dieticians, and case managers are all included is essential. This allows for good communication about the progress of patients and helps ensure that all the aspects of their complicated care are addressed.
Another take-home point from our institution is that it is essential to encourage patients to participate in clinical trials. Clinical trials remain immensely important to our field. While the FDA approval of ruxolitinib is a huge step in the treatment of patients with acute graft-versus-host disease, there’s still much to be developed and learned so that we can continue to improve the treatment landscape for our patients.
Yi-Bin Chen, MD: In the management of acute graft-versus-host disease, one thing I’ve gathered over the last few years in treating patients and also participating on a national level in trials, is that it is really helpful to have a team-based approach and have an infrastructure for graft-versus-host disease. Many cases of graft-versus-host disease are not a major life-threatening event. But building an infrastructure around that to collect samples, to determine eligibility for trials, and to have a team-based approach where everyone is buying in and motivated to help the cause here will help your center participate on a national level and ultimately help us improve outcomes by developing new drugs but also figuring out how to design trials for this population.
We’ve got a long history of trials that have failed in acute graft-versus-host disease, and there are many reasons for that, and it’s on us to figure out the systems to improve that. I think that enrollment on a clinical trial still is our number 1 priority. Even with progress made with ruxolitinib being approved, I think there’s still so much more room we have to improve. There are still huge unmet needs not only in the treatment but the prevention of acute graft-versus-host disease. We want to not have to treat steroid-refractory disease, that’s our goal, because if patients have steroid-refractory disease, it means they’ve already suffered a ton to get there to begin with. And the toxicity they’re going to have along the road to recovery is definitely not trivial.
As we alluded to before, the clinical presentation of graft-versus-host disease or the symptoms of ongoing graft-versus-host disease, they’re not specific. I think we owe it to all of us to continue to think whether there are other etiologies for the patient’s symptoms because concluding that someone is steroid refractory will lead you down a pathway where they might really not be. We are still primitive in how we figure this out. Using crude clinical symptoms is not the way we need to be doing this, and so developing the ability to diagnose graft-versus-host disease by assays that are much more biologically based or accurate has to be a priority. And constant reassessment of your patient right now, including serial endoscopies to figure out if they’re improving, is certainly the right way to go for a subset of patients instead of measuring diarrhea output. Those things are, I think, important in figuring out how we go forward here.
Corey Cutler, MD: In terms of management of acute graft-versus-host disease, this needs to be a team approach. We are very collaborative at our center. We involve our dermatologists early on for management of skin disease. We involve our gastroenterology and nutrition teams very early on for management of GI [gastrointestinal] involvement, and similarly our hepatology colleagues when there’s an issue with hepatic GvHD. Patients need to be patient. Responses, particularly for visceral organ can take 1 to 2 weeks for us to see responses.
One of the strongest things I try to tell my colleagues is to not jump the gun and add layers upon layers of immunosuppressive therapy too early. Patients who are progressing early and who have early signs of steroid refractoriness, those patients do need escalated therapy. But for individuals with GI or hepatic involvement, I often try to wait 7 to 10 to sometimes even 14 days before escalating therapy while waiting for a response. One has to remember that if one starts with a denuded gastrointestinal epithelial layer, it does take time for these things to recover. In the absence of a real urgency, I encourage people to move a little bit slower while waiting for primary therapy such as steroids to take effect.
Transcript Edited for Clarity