Canterbury DHB

Context

Initial Management of Acute GvHD

In This Section

Steroid tapering

What dose of steroid?

When to start 2nd line treatment

Management of steroid-refractory acute GvHD

Which 2nd line treatment to choose

Further reading

Steroid tapering

What dose of steroid?

There is debate and uncertainty about the optimal dose of glucocorticoids for acute GvHD.

When to start 2nd line treatment

2nd line therapy should be started earlier for more severe GvHD.

The following is intended as a guide only:

Management of steroid-refractory acute GvHD

There are no uniform criteria of SR-GvHD but generally accepted definitions are:

The management of patients with grade II-IV GvHD unresponsive to prednisone 1 mg/kg PO daily is difficult, and guidelines appropriate for all patients in this situation cannot be given. The outcome for these patients is poor with a mortality rate of approximately 70%.

The best management will now reflect the:

Consultation within the Haematology Department, other Christchurch specialists and overseas experts may all be required.

Treatments to consider

Which 2nd line treatment to choose

Choice of 2nd line should take into account effects of previous therapy, toxicity, and interaction with other drugs, convenience, expense, and familiarity. No treatment has been shown either to be better than another or detrimental.

Note: The agents in bold type are available in New Zealand.

Further reading

Alousi, A. M., et al. (2009). "Etanercept, mycophenolate, denileukin, or pentostatin plus corticosteroids for acute graft-versus-host disease: a randomized phase 2 trial from the Blood and Marrow Transplant Clinical Trials Network." Blood 114(3): 511-517.

Dignan, F. L., et al. (2012). "Diagnosis and management of acute graft-versus-host disease." Br J Haematol 158(1): 30-45.

Dignan, F. L., et al. (2012). "Organ-specific management and supportive care in chronic graft-versus-host disease." Br J Haematol 158(1): 62-78.

Levine et al, Etanercept plus methylprednisolone as initial therapy for acute graft-versus-host disease. Blood 2008;111;4;2470-2475.

MacMillan, M. L., D. J. Weisdorf, S. M. Davies, T. E. DeFor, L. J. Burns, N. K. Ramsay, J. E. Wagner and B. R. Blazar (2002). "Early antithymocyte globulin therapy improves survival in patients with steroid-resistant acute graft-versus-host disease." Biol Blood Marrow Transplant 8(1): 40-46.

Martin, P. J., J. D. Rizzo, J. R. Wingard, K. Ballen, P. T. Curtin, C. Cutler, M. R. Litzow, Y. Nieto, B. N. Savani, J. R. Schriber, P. J. Shaughnessy, D. A. Wall and P. A. Carpenter (2012). "First- and Second-Line Systemic Treatment of Acute Graft-versus-Host Disease: Recommendations of the American Society of Blood and Marrow Transplantation." Biol Blood Marrow Transplant 18(8): 1150-1163.

About this Canterbury DHB document (9073):

Document Owner:

Andrew Butler (see Who's Who)

Issue Date:

December 2016

Next Review:

December 2018

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 9073