Monitoring and Follow-Up of Patients with Chronic GVHD


The panel closes by reviewing the patient case once more and shares clinical pearls on the treatment of patients with GVHD.


Bonnie J. Dirr, APRN: Let’s take one last look at CB’s case. As he proceeded on in his journey…the belumosudil [Rezurock] was approved by the FDA for the use of chronic graft-vs-host disease [GVHD], and he was started on 200 mg once a day. The prescription was prescribed and he got started on his medication. Shortly following the start of his belumosudil, the patient was able to completely taper off of his remaining steroids within 1 month. He was tapered off his ruxolitinib [Jakafi] within 12 weeks, and we were able to start tapering down his tacrolimus [Prograf] dose. Within 6 months of starting belumosudil, his sclerotic features of his upper extremities and trunk completely resolved. His ocular symptoms were completely under control, and his lower extremities were starting to make marked improvement. He had restorative range of motion of his upper extremities trunk, making nice strides with bilateral lower extremities. We’ve talked quite a bit today about the multidisciplinary approach to caring for patients with both acute and chronic [GVHD]. During posttreatment for chronic [GVHD], how are these patients typically monitored?What care team members are involved? In practice, how often do you see these patients in clinic? Dr Gooptu, can you [talk] about some of these follow-up visits? How often do you see [patients], and do you continue to involve multidisciplinary teams as you move forward in monitoring patients’ [GVHD]?

Mahasweta Gooptu, MD:Typically, if a patient does not have chronic [GVHD], I’ll see them every month to every 2 months in the first year after transplant, and perhaps even less frequently in the second year. But once they have chronic [GVHD] and are on steroids or any of the other medications, as Dr Inyang pointed out, there are toxicities [that] we want to monitor [and] drug interactions we want to be mindful of. For this reason, I do see them [somewhere] between every 3 to 6 weeks to monitor both response [and] toxicity until they are on very low doses of immunosuppression. It is very much a multidisciplinary team effort. Of course, we have our nurses, our pharmacists, [and] our nurse practitioners who are the core [of our] multidisciplinary team. But depending on the organ that’s involved with chronic GVHD, we involve our colleagues who are specialized in that particular issue. For example, our medicine colleagues, our ophthalmology colleagues, dermatology, [and] we have physical therapy involved with these patients. In the patients who develop bronchiolitis obliterans, invariably, we have our pulmonary colleagues involved who comanage the patients with us. And in those patients who develop genital GVHD, such as vaginal GVHD, we involve our gynecology colleagues. It’s nice to collaborate with these different disease groups and help them to…[stay] current [on] all the advances we are seeing in this space. It’s very much a multidisciplinary effort.

Bonnie J. Dirr, APRN: Thank you for this rich information and discussion. Before we conclude, I’d like to get final thoughts on unmet needs in future perspectives and what excites you each about future therapies for [GVHD] therapy? Also, what are some of the clinical pearls you would like to offer our colleagues in the community in for the settings of their patients? Dr Inyang, I’d like to start with you.

Eno-Abasi Inyang, PharmD, BCPS, BCOP: Thanks, Bonnie. One of the biggest things I’d be interested in seeing—and I think it’s a huge unmet need [that] Dr Gooptu alluded to—was some patients having some of those harder-to-reach organs with [GVHD]. Areas such as the lung [and] the liver are typically organs that are just difficult to treat. There’s typically not a lot of data in terms of how some of these newer therapies do with these organs. That’s one of the areas where I find some of the challenges and discussing with our patients. I would love to see new trials and research in those areas. In terms of clinical pearls I would like to leave off with is—we didn’t discuss too much on drug interactions, but that is a huge thing and the bread and butter for pharmacy that we always like to talk about for these medications and patients. As Dr Gooptu alluded to, it’s really important to just make sure you’re looking at doing a full medication reconciliation with these patients, looking through their meds, looking and using databases to do drug interactions. Medications like ruxolitinib really interact with CYP3A4 inhibitors such as azoles, so that could be a limiting factor. [You should just be sure to really monitor these patients counts and labs] if you’re going to be using some of these medications with other therapies that they interact with. And I think that sometimes…is a nice option where it doesn’t have as many of those interactions. But you do have to worry about other things, such as … So that’s another one to think about when giving these medications.

Bonnie J. Dirr, APRN: Thank you. Dr Gooptu, do you have any pearls or excitement that you would like to share with our audience before we close?

Mahasweta Gooptu, MD: I’m very interested in seeing what gets established as the standard of care for prophylaxis in the ablative setting. There are some newer drugs we are very interested in, some of which involve cellular manipulation. We’ve been working on the role of minor histocompatibility antigens in acute and chronic GVHD and therapeutics surrounding it. Those are some of the areas I think are very novel—some may lead to practice changes and some may lead to a breakthrough in the way we think about the causes of GVHD, where in a fully matched donor the minor histocompatibility antigens are really instrumental in causing GVHD. There are exciting things coming down the pipeline.

Bonnie J. Dirr, APRN: Thank you, once again, to Dr Gooptu [and] Dr Inyang for their insightful discussion into our viewing audience [and] for being with us. Thank you for joining us. We hope you have found OncLive Inside the Clinic program to be useful and invaluable to the management of your patients with [GVHD]. Thank you.

Transcript is AI-generated and edited for readability.

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