GvHD Prophylaxis

For AFM conditioning: Cyclosporin starts at 3 mg/kg/d IV in divided doses on day –1 to +3. Levels are checked on day +4 and Mondays and Thursdays thereafter to maintain a level between 200 to 300 mcg/L for four weeks and then 100 to 200 mcg/L up to day +90. In the absence of GVHD, cyclosporin is tapered from 3 months post transplant. Proceed as outlined in the Flowchart for Post RIC SCT Management.

For Flu-TBI: Mycophenolate mofetil is added (30 mg/kg/day in two divided doses), day 0 to day +27. If a non-haematological toxicity of mycophenolate occurs, the dose can be adjusted. For G I toxicity, reduce the dose by 20%, and a further 20% if toxicity persists. Make no dose adjustment for haematological toxicity unless severe neutropenia develops after day +21 (ANC <0.1 X 10⁹/L for >5 days).

In general, immunosuppression is tapered more rapidly for patients with high risk disease and no GvHD. With lower risk disease, immunosuppression at full dose may continue until day +90 before tailing off at approximately 10% every 5 days. Aim to have stopped cyclosporin by day 180.

The dose of these drugs will be adjusted by the Consultant/Transplant Registrar supervising the patient and will reflect a number of factors. These include drug toxicity. Levels of cyclosporin need close monitoring. MMF toxicity if it occurs is likely to affect the GI tract. The presence or absence of GvHD will also influence post SCT management, see Clinical Features and Grading of Severity of GvHD. The underlying disease activity if any is also relevant.

See Criteria for Disease Progression and Definition of Patient Risk Categories.

Switching from IV to oral cyclosporin

To switch from IV to oral cyclosporin, double the intravenous dose and round it to the nearest 25 mg. Check cyclosporin blood levels 3 to 4 days later.

Note: cyclosporin is subject to large variations in absorption and interacts with many medications which may affect the result of the conversion. If the patient's medications are not stable, consider contacting the haematology pharmacist for advice.


About this Canterbury DHB document (8888):
Document Owner:	Andrew Butler (see Who's Who)
Last Reviewed:	December 2016
Next Review:	December 2018
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
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