Graft Versus Host Disease Treatment & Management

Acute GVHD

• Primary prophylaxis

  • The criterion standard for prophylaxis is CSP A for 6 months and short course MTX in T-cell–replete allogeneic HCT. CSP levels should be kept above 200 ng/mL.
  • Substitution of tacrolimus for CSP A is frequently used, especially in unrelated-donor transplantation, because it may improve the control of GVHD, though not survival. The addition of prednisone to the prophylactic regimen also reduces the incidence of GVHD but does not change overall survival.^[28]
  • Antithymocyte globulin (ATG) given before HCT significantly reduces the risk of grade III or IV acute GVHD and extensive chronic GVHD, but it does not alter survival, possibly because of the increased risk of infection.^[29] Ex-vivo depletion of T-cells has also been tried (in the 1980s), but transplantation-related mortality was not reduced compared to standard treatments in patients receiving HLA-matched grafts.
  • Other agents that have been studied for GVHD prophylaxis include combinations with or substitutions by other agents such as mycophenolate mofetil,^[30] sirolimus,^[18] pentostatin, Campath-1H,^[31] keratinocyte growth factor (KGF), and suberoylanilide hydroxamic acid (SAHA).
  • Extracorporeal photopheresis (ECP) is an immunomodulatory procedure that collects lymphocytes and mixes them with 8-methoxypsoralen (which intercalates into the DNA of the lymphocytes), rendering them susceptible to ultraviolet light radiation effects that cause apoptosis. The lymphocytes are then returned to the patient. ECP has been used as part of a conditioning regimen together with pentostatin and total body irradiation with very promising results.^[12]
• Primary therapy

  • For skin GVHD of stage I or II, observation or a trial of topical corticosteroids (eg, triamcinolone 0.1%) may be used.
  • Begin systemic treatment in patients with grade II-IV acute GVHD. Treatment consists of continuing the original immunosuppressive prophylaxis (CSP A or tacrolimus [FK506]) and adding methylprednisolone. Doses have been in the range of 1-60 mg/kg, but the most common starting dose is 2 mg/kg/d given in 2 divided doses. Median time to resolution of acute GVHD is 30-42 days. In patients who respond to initial therapy, short-term tapering treatment with prednisone to a cumulative dose of 2000 mg/m² is effective and expected to minimize steroid-related complications.
  • Other therapies are ATG, CSP alone, mycophenolate mofetil, daclizumab, anti–IL-2 receptor, anti-CD5–specific immunotoxin, and a pan T-cell ricin A-chain immunotoxin (XomaZyme). These agents can be used alone or in combination. No data from well-conducted controlled trials have shown the superiority of 1 over any other.
  • Novel therapies like the addition of ex vivo cultured mesenchymal cells derived from unrelated donors to conventional steroid therapy showed initial response rates of 90%, although 31% of patients required a second-line agent to control the disease.^[32]
• Secondary therapy

  • Failure of initial therapy is defined as the progression of acute GVHD after 3 days, no change after 7 days, or incomplete response after 14 days of treatment with methylprednisolone. Secondary therapy is usually initiated in steroid-refractory cases.
  • ATG or multiple pulses of methylprednisolone (at doses higher than those used in initial therapy) have a response rate of about 40%.
  • Mycophenolate mofetil (MMF) at 2 g daily, when added to the steroid regimen, caused an overall response rate of 62%.^[30]
  • Muromomab-CD3 (Orthoclone OKT3) monoclonal antibody has shown some benefit, but it is associated with a 24% incidence of Epstein-Barr–associated lymphoproliferative syndrome.
  • Humanized anti-Tac antibody to the IL-2 receptor showed a 40% clinical response rate in clinical trials. IL-1 receptor or IL-1 receptor antagonists have yielded response rates of 57-63% in pilot trials. Monoclonal antibodies against the efferent arm of GVHD, such as those for tumor necrosis factor–alpha (TNF-alpha), have produced responses. Partial responses are reported, but in all cases GVHD returned after treatment was discontinued.
  • Psoralen and ultraviolet A irradiation (PUVA) may be beneficial for cutaneous lesions of GVHD and may improve survival in some patients with steroid-resistant GVHD. ECP, in a phase II study, achieved a 60% response in steroid-refractory GVHD 3 months following the initiation of treatment. More responders were observed in patients with skin involvement only than in patients with liver or gut involvement.^[33]
  • Approximately 12% of patients with GVHD resistant to CSP may respond to a conversion to tacrolimus. In patients who develop CSP-related neurotoxicity, therapy can be switched and maintained with tacrolimus, which stabilizes and resolves neurologic abnormalities.
• Other therapies

  • ABX-CBL is an immunoglobulin (Ig) M (IgM) murine monoclonal antibody that recognizes CD147 and initiates killing by means of complement-mediated lysis. ABX-CBL induced complete responses in 13 of 26 subjects with corticosteroid-refractory GVHD.^[34]
  • Visilizumab is a humanized anti-CD3 monoclonal antibody with a mutated IgG2 isotype and selective apoptotic activity in activated T cells. It has produced promising responses in many patients, but posttransplantational lymphoproliferative disease is a problem.
  • Daclizumab, a humanized anti-interleukin-2 receptor alpha chain antibody, was associated with a worse 100-day and 1-year survival than a control arm because of increased relapse and infection.
  • Infliximab is a genetically constructed IgG1 murine-human chimeric monoclonal antibody that binds the soluble subunit and the membrane-bound precursor of TNF-alpha. It causes a high response rate, but opportunistic infections (especially noncandidal invasive fungal infections) result in a high mortality rate.
  • Etanercept, a soluble dimeric TNF-α receptor 2 that can be given as a subcutaneous injection competes for TNF-α binding, thus rendering it inactive. Higher response rates are seen with etanercept plus steroids (82%) versus steroids alone (66%) as primary therapy for acute GVHD.^{[35, 36]}
  • Denileukin diftitox is a recombinant protein composed of IL-2 fused to diphtheria toxin and has selective toxicity against activated lymphocytes. In studies, it elicited a 50% complete and 21% partial response in corticosteroid-refractory GVHD.^[37] Hepatic transaminase elevation was the dose-limiting toxicity.
  • Pentostatin at 1.5 mg/m² produced a complete and partial response rate of 64% and 14%, respectively, and was also effective in patients who were retreated at progression.

Chronic GVHD

• Primary therapy

  • Recognizing and treating chronic GVHD early, before disability ensues, is critical. Used alone, prednisone 1 mg/kg every other day decreases treatment-related mortality rates (21% vs 40%) compared with prednisone combined with azathioprine, which is associated with a survival rate of 61% in patients with standard-risk chronic GVHD (no thrombocytopenia).
  • The addition of CSP 6 mg given every 12 hours every other day in patients at high risk for GVHD with thrombocytopenia may improve survival rates from 26% to 52%. It may also improve functional performance to near-normal in long-term survivors by significantly decreasing the incidence of disabling scleroderma. However, infections are a frequent cause of morbidity and mortality in patients with high-risk chronic GVHD.
  • The addition of tacrolimus to steroids was associated with a high response rate of 72% but led to a high chronic GVHD-related mortality (34%) and a significant need for salvage therapy (47%).
  • Thalidomide has been reported as effective primary treatment for chronic GVHD because of its TNF-modulating effect. The 3-year survival rate is about 48%, with a diminished incidence of infection in long-term survivors.
• Secondary therapy

  • Steroid-refractory chronic GVHD has been treated with azathioprine, alternating CSP/prednisone, or thalidomide, with approximately similar survival rates. Clofazimine, an antileprosy agent, has also been effective in treating cutaneous and oral lesions of chronic GVHD and may be useful as a steroid-sparing agent because its adverse effects and infections appear to be minimal.
  • MMF is now the most commonly used agent used to treat steroid-refractory chronic GVHD. Responses of 90% and 75% in first and second line settings are seen when MMF is added to standard tacrolimus, cyclosporine, and/or prednisone treatments. MMF does not seem to increase the rate of infections or relapse.^[30]
  • PUVA therapy plays a role in patients with refractory cutaneous chronic GVHD. In 1 study, it resulted in a 78% response rate and improvement in a few extracutaneous sites.
  • Extracorporeal photopheresis, a modification of PUVA treatment, has also shown benefit, with best responses in the skin (59%), liver (71%), eye (67%), and oral mucosa (77%).^[33]
  • The anti-CD20 monoclonal antibody rituximab produced a clinical response rate of 70% mainly for musculoskeletal and cutaneous chronic GVHD. These responses were durable through 1 year after initiation of therapy and allowed a 75% reduction in steroid doses.^[38]
  • Pentostatin at a dose of 4 mg/m² IV every 2 weeks for 6 months produced 50% response rates in patients with chronic GVHD who failed 2 prior immunosuppressive regimens. Aggressive infection prophylaxis was necessary with steroid tapering, antibiotics, antifungals, and antiviral agents.
  • Low-dose (100-cGy) total lymphoid irradiation to thoracoabdominal areas can lead to partial or complete improvement in some patients.
  • Imatinib has shown an overall response rate of 79% at 6 months for patients with refractory GVHD with fibrotic features where antibodies activating the platelet-derived growth factor receptor pathway have been reported.^[39]
• Other supportive care

  • Pain control with analgesics for patients with painful mouth sores allows for oral intake. Oral beclomethasone may improve oral intake, nausea, and diarrhea without causing systemic or local toxicity.
  • Octreotide can control secretory diarrhea in enteric GVHD.
  • Antiviral prophylaxis (eg, for herpes simplex, cytomegalovirus [CMV]) can prevent oropharyngeal infection and interstitial pneumonia in patients with refractory GVHD.
  • Antifungal agents (eg, new triazoles, liposomal amphotericin B) may be useful for preventing and treating serious mycotic infections. Posaconazole is approved for prophylaxis against invasive aspergillosis in patients undergoing treatment for GVHD.^[40]
  • Retinoic acid is used for ocular sicca syndrome, and pilocarpine (Salagen), for oral sicca manifestations.
  • Clonazepam is used to treat neuromuscular manifestations (eg, muscular aches, cramping, carpal spasm).
  • Ursodeoxycholic acid treatment for abnormalities in liver function can result in improvement of hepatic chronic GVHD; it can reduce elevated bilirubin levels by as much as 30%.
  • Patients receiving chronic corticosteroid therapy are at risk for osteoporosis and fractures. For female patients, estrogen replacement, calcium supplements, and antiosteoporosis agents (eg, Fosamax, calcitonin) should be considered.
  • Patients with stage IV skin GVHD are best treated in the burn unit, where the staff should pay meticulous attention to skin and wound care, nutrition, and infection control.

Surgical consultations are required mainly for the insertion of central venous access devices, such as Infuse-A-Port devices and pheresis catheters.

• In patients with severe dermal involvement of chronic GVHD, burn care speeds reepithelialization and closure of the portals of infection.
• Plastic surgery may be necessary for skin allografting from the marrow donor in certain severe cases of dermal involvement due to chronic GVHD.
• Patients with eye manifestations of chronic GVHD require ophthalmologic examination, follow-up, and treatment.

• Institute gut rest and hyperalimentation for patients with acute GVHD and severe diarrhea.
• Patients should slowly advance to a bland diet or to the bananas, rice cereal, applesauce, and toast (BRAT) diet as tolerated.

Encourage patients who are receiving corticosteroid therapy to maintain an active lifestyle and to participate in a mild-to-moderate exercise program.