Inside the Clinic: Graft-versus-Host Disease Best Practices - Episode 6
Corey Cutler, MD: As a team we really prioritize clinical trials at our center. At the Dana Farber, we have a uniform approach to clinical trials. We always have a trial available for prevention of acute GVHD, and we almost always have a trial available for the therapy of acute GVHD. Sometimes those trials are for primary therapy, sometimes they’re for organ-specific primary therapy, and sometimes they’re for steroid-resistant or steroid-refractory disease. We really try to present every patient the opportunity to participate in a clinical trial, either for prevention or the treatment of GVHD. It’s really the way we’re going to move this field forward.
Zachariah DeFilipp, MD: We see great variability in patients’ response to initial therapy with steroids. Some patients have steroid responsive disease which we see symptoms resolve in a short period of time with treatment. And other patients have steroid resistant or refractory disease in which their treatment course is prolonged.
In regards to supportive care, patients with severe acute graft-vs-host disease, especially those cases affecting the lower GI [gastrointestinal] tract, require extensive supportive care during their hospitalization. Patients often require parenteral nutrition, as they are on bowel rest.
Patients work with physical therapy in order to prevent deconditioning. And we know that having severe GVHD can take an emotional toll on patients and their families. So, having the support of social work is essential.
Yi-Bin Chen, MD: I think expectations for treatment and supportive care for patients is really important. I think patients, despite all the counseling we try and do prior to transplant, don’t have a good idea of what graft-vs-host disease is or can do. I mean how can they? It’s such a big unknown. And so, I think at the beginning, in terms of the severity of the graft-vs-host disease, are we going to use mostly local treatments, such as skin creams, or do we have to give systemic treatments? Unfortunately, systemic treatments right now still revolve around high doses of corticosteroids, and they take a toll. Our main supportive care counseling involves the management of toxicities and preparing patients for such.
I think discussing with patients how long they’re going to be on steroids is important. Preparing them for the duration of hospitalization especially if they have lower GI [gastrointestinal] disease is important, talking to their families as well. I think talking to them about nutrition and infection. Steroids take a huge toll on proximal muscle weakness. Patients will develop swelling, as well as the appearance to their bodies and body image. Then for a lot of patients who start steroids, they develop secondary diabetes and discussing it with the patient that it may happen and the treatment that is needed for that complication is really important also.
Transcript Edited for Clarity