Advances in the Management of Graft Versus Host Disease - Episode 14

Supportive Care for Steroid-Refractory Chronic GVHD Treatment

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Hannah Choe, MD, leads a review of the role of supportive care and a multidisciplinary team approach to care for the treatment of steroid-refractory chronic GVHD.

Yi-Bin Chen, MD: Before we touch on closing thoughts from this session, I want to emphasize that when someone has chronic graft-vs-host disease [GVHD], we need to see them more. Sometimes they don’t realize that and we don’t realize that. Hannah, when you start steroid therapy on someone with chronic graft-vs host-disease for whatever organs are involved, are there other disciplines you get involved to see your patient? What other supportive care methods do you have for that patient?

Hannah Choe, MD: Chronic GVHD manifesting in as many organs as it does ideally needs a multidisciplinary clinic. We heavily rely on our colleagues from dermatology especially, ophthalmology very commonly, and if we can, oral pathology. There’s no way to effectively take care of a patient without having the systemic therapy that we may or may not be leading the charge on. But also, there are multidisciplinary collaborators for symptom-targeted treatments, like scleral lenses, amniotic fluid eye drops, and oral mucosal intramucosal steroid injections—things that can improve quality of life for the patient while we’re waiting for response to therapy because these small things can make it easier for them to do their job or to get back to their regular routine.

Things that we often miss that we should probably be asking our patients more often about is their genitourinary health. A lot of times we’ll have a lot of manifestations of chronic GVHD that aren’t being fully evaluated in the clinic. They may be better captured with our colleagues across disciplines, so we’re often collaborating with GI [gastrointestinal], nephrology, genitourinary, gynecology, and most commonly ophthalmology and dermatology. We absolutely can’t do excellent care without them.

Yi-Bin Chen, MD: We’ve also certainly seen that in our patients. We’ve started a sexual health program as well as support groups for our patients with chronic GVHD as well as their caregivers. These are investigational things that at some point we’ll need to find ways to make standard, because they truly help. To Nelson’s point, when we start patients on steroids, there’s probably a lot of morbidity that we don’t realize, and thus either home monitoring or physical therapy appointments to start to maintain mobility and proximal muscle strength. These are things we often forget, and we’re realizing more the burden our patients carry as they’re able to stay outpatient and continue on these other therapies.

Sophie Paczesny, MD, PhD: We’re a relatively smaller center [Medical University of South Carolina]. We have access to ECP [extracorporeal photopheresis] and subspecialty, but half the centers in the United States don’t have access to ECP. This is where an oral pill—or even an injection—is far more interesting because ECP is complex to do.

Yi-Bin Chen, MD: Yes, complex for the center and the patient. Absolutely.

Sophie Paczesny, MD, PhD: But monitoring is key, and if you have access to subspecialty, but just follow your patient.

Transcript Edited for Clarity