Multidisciplinary Approach & First-Line Treatment Options
John F. DiPersio, MD, PhD: The primary care team is usually the team that actually diagnosed, transplanted, and followed up with patients. So there’s continuity of care. That’s very important in any multidisciplinary care team. I don’t like the concept of actually doing the transplant and then handing the patient off to another set of physicians or group of people who will actually manage the complications after transplant. That’s 1 thing that’s common to most centers and really the foundation of our care here.
Surrounding us at the time that we see the patient are a number of other folks who are involved in many other aspects relating to the complications of graft-vs-host disease [GVHD]. These include financial specialists. This takes a huge toll on the finances of patients, psychologists and therapists who help patients get through the tough times, and then a number of medical staff and physicians with various types of subspecialties—such as ophthalmology, oral surgery, dermatology, cardiology, and gastroenterology—all of whom play a major role in intervening at some point in the care of the patients, whether it is endoscopies, skin biopsies, management of dry eyes, dry mouth, teeth problems. Obviously, there are also teams of physicians and staff who manage the outpatient long-term care. That’s the primary physician in that team that I mentioned initially. Also, there’s a team that is in part overlapping but in part nonoverlapping with inpatient care. If the patient is ever admitted for any complications, such as fever or infection, the inpatient team seamlessly works with the outpatient team to manage the patient. The management and decisions regarding the long-term care of the patient—every consultant, every inpatient team member, every outpatient team member—is driven by the primary physician who’s commandeering the entire team.
Management is different in every center. In our center, we have members of each team that assess GVHD at every visit. These are usually accomplished, seasoned, senior skilled nurse practitioners who formally grade both acute and chronic GVHD at every clinic visit. We use standard CIBMTR [Center for Blood and Marrow Transplant Research] criteria for grading acute and the NIH [National Institutes of Health] consensus criteria for chronic GVHD. We have data sheets that we fill out, and that’s entered into our Otter database and also into Epic Foundation System. We have a data flow for every patient every time they’re seen and their GVHD is measured.
The initial options for patients with graft-vs-host disease vary depending on the severity. For instance, patients can develop mild symptoms and manifestations of acute GVHD, such as skin rash, without any other systemic symptoms. Those patients can be managed with topical steroids. Patients who have some upper-GI [gastrointestinal]–only disease with some nausea can be managed with oral nonabsorbable steroids, beclomethasone, budesonide. High-risk patients are defined as patients who have multiorgan involvement or severe acute GVHD or have biomarkers that suggest that they’re going to have high-risk disease. That’s still somewhat debatable and not used widely. Those patients are candidates for systemic therapy.
Systemic therapy initially, for the most part, includes primarily steroids. There is debate. I wouldn’t say it’s raging debate, but there’s debate in the field about what dose of steroids to start with. If patients have severe GVHD, oftentimes patients will be treated with 2 mg/kg of methylprednisolone. If patients have much less severe GVHD, physicians will usually start at 1 mg/kg of methylprednisolone.
There’s also evidence to support the use of rapamycin in place of prednisone for patients who have low-risk disease but have GVHD, which is bothersome. Some patients can even be given a steroid-sparing approach to GVHD with the addition of rapamycin or not add steroids unless things worsen. Those are the main ways patients are initially treated for acute GVHD, which is either severe or limited.
Transcript edited for clarity.
