Third Line Treatment in Chronic GVHD

Opinion
Video

Drs Yi-Bin Chen, Corey Cutler, Hannah Choe, and Mitchell Horwitz discuss a complex chronic GVHD case post-allogeneic transplant. The panel explores third-line options, including belumosudil, ibrutinib, photopheresis, and clinical trials, emphasizing shared decision-making and the need for well-designed trials in guiding treatment decisions.

This is a video synopsis of a discussion involving Dr Yi-Bin Chen, Director of the Transplant and Cell Therapy Program at Massachusetts General Hospital and Professor of Medicine at Harvard Medical School; Dr Corey Cutler, Director of the Stem Cell Transplant Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School; Dr Mitchell Horwitz, Professor of Medicine and Director of the Adult Blood and Marrow Transplant Program at Duke University, and Dr Hannah Choe, Assistant Professor and Director of the Graft-versus-Host-Disease (GVHD) program at Ohio State University.

The panelists discuss a clinical scenario where a patient, 4 to 5 months post-allogeneic transplant for AML [acute myeloid leukemia], presents with chronic GVHD involving skin, eyes, and mucosa. After initiating ruxolitinib as a second-line therapy, the patient shows a partial response with persistent symptoms, prompting a discussion on third-line options.

Dr Chen and the panel explore potential treatments, including belumosudil, ibrutinib, photopheresis, and clinical trials. Dr Corey Cutler emphasizes shared decision-making, considering the patient's goals and response to previous therapies. In the absence of a good clinical trial, he suggests substituting belumosudil for ruxolitinib in a scenario with minimal response. The discussion touches on the challenges of transitioning between agents and the need for carefully designed clinical trials.

Dr Hannah Choe introduces Extracorporeal Photopheresis (ECP) as an option, particularly for skin-related chronic GVHD, emphasizing its therapeutic benefits. Dr Chen highlights the anecdotal use of combination therapy with ruxolitinib and belumosudil, acknowledging the need for formal data on safety and efficacy.

The panel addresses the complexities of steroid use in chronic GVHD, expressing reluctance due to associated comorbidities and the desire to minimize prolonged steroid exposure. Dr Cutler notes the uncertainty in distinguishing which therapeutic maneuvers contribute to improvement.

Dr Mitchell Horwitz seeks insights from Dr Chen regarding the consideration of higher steroid doses to assess refractoriness. Dr Chen discusses the challenges of judging inflammatory manifestations and expresses his aversion to prolonged steroid use in the elderly population.

The panel concludes with reflections on the evolving landscape of chronic GVHD therapies, emphasizing the importance of carefully designed clinical trials to guide treatment decisions.

Video synopsis is AI-generated and reviewed by OncLive® editorial staff.

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