Treating VOD: Standard-of-Care Approach


Mitchell Cairo, MD, shares his standard-of-care approach to treating VOD and the role of defibrotide, the only FDA-approved drug for VOD.

This is a synopsis of an Insights series featuring Mitchell S. Cairo, MD, of New York Medical College, and Sergio Giralt, MD, of Memorial Sloan Kettering Cancer Center.

Dr. Giralt noted his center uses ursodeoxycholic acid for VOD prophylaxis, as recommended by British and American transplant societies. However, he asked Dr. Cairo to discuss current standard of care treatment for patients developing VOD.

Dr. Cairo responded supporting vital organ function is critical and cannot be overlooked before detailing specific VOD therapy. This includes meticulous fluid and electrolyte management, diuresis to control fluid overload, maintaining blood pressure and treating encephalopathy, respiratory failure, renal failure, or heart failure as needed with modalities like hemodialysis, continuous veno-venous hemofiltration, portal shunts, mechanical ventilation, and vasopressors. Patience is essential as patients improve minimally at first. Defibrotide is the only FDA-approved VOD therapy for patients with renal or pulmonary dysfunction. Earlier administration substantially improves survival and complete response rates.

Dr. Giralt concurred, emphasizing careful fluid/electrolyte management, rule-out of infection, adequate platelet monitoring if considering defibrotide, and avoiding outdated therapies like heparin or tissue plasminogen activator. He advocated starting defibrotide in high-risk patients early, even with subtle signs like exertional hypoxemia with weight gain and ascites, rather than waiting for multiorgan failure. Defibrotide has anticoagulant, profibrinolytic, anti-inflammatory and endothelial stabilizing effects, so earlier administration capitalizes on multiple mechanisms. With defibrotide's mild anticoagulation/fibrinolysis, the platelet count should be over 10,000-20,000 depending on comorbidities, with no concomitant systemic anticoagulation/thrombolytics. The earlier defibrotide is initiated, the higher likelihood of response.

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

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