Supportive Care

For a detailed review of supportive care and discussion of organ-specific recommendations see BCSH guidelines (Dignan, F. L., et al. (2012). "Diagnosis and management of acute graft-versus-host disease." Br J Haematol 158(1): 62-78).

General aspects of supportive care include infection prophylaxis and it is important to start this/continue it while acute GvHD and/or its treatment continues. This includes:

Prophylaxis for PCP (co-trimoxazole 480 mg PO daily).
Bacterial infections (penicillin 250-500 mg BD).
Viral infections (valaciclovir 500 mg once daily or valaciclovir 500 mg BD according to serological status).
Fungal infections (posaconazole tablets 300 mg once daily).
CMV reactivation (continue/recommence weekly PCR testing).
EBV reactivation (continue/recommence fortnightly PCR testing).

Skin

Cotrimoxazole is photosensitising and cyclosporine causes UV-related skin damage and predisposes to squamous cell carcinoma. Advise all patients to cover up and use a sunscreen. Sunscreen is available on prescription – use the script for Marine Blue sunblock.

Patients with symptomatic photosensitive skin eruptions can be treated with soap substitutes and topical steroids. These are available on prescription – use the script for photosensitive dermatitis.

Emollients should be used for symptom control in all patients with skin GvHD.

Topical steroids, e.g. hydrocortisone 1% cream applied twice daily are recommended as part of 1st line therapy of acute GvHD.

Patients with grade II-IV cutaneous GvHD should be referred to Dermatology.

Gastro-intestinal

It is common to have multiple causes at the same time for GI symptoms. Therefore if empirical treatment is not effective other causes should be considered, e.g. bile acid reflux (nausea), small bowel bacterial overgrowth (nausea, reflux, bloating), strictures (nausea, vomiting, anorexia).

In suspected GI GvHD it is common practice to add modified release budesonide 3 mg caps BD or TDS. See Hockenbery et al, A randomized, placebo-controlled trial of oral beclometasone dipropionate as a prednisone-sparing therapy for gastrointestinal graft-versus-host disease. Blood 2007;109:4557-4563.

When other causes of diarrhoea have been excluded, patients with GI GvHD may respond to loperamide, codeine or octreotide.

Maintenance of Adequate Nutritional Status

It is crucial to maintain good nutrition while acute GvHD is brought under control. The gut may need to be rested and the patient be kept nil by mouth.

Enteral nutrition is always preferred to parenteral nutrition.

Enteral feeding is likely to be more effective if started before mucositis develops.

Patients receiving parenteral nutrition should have, in addition to routine daily bloods, twice weekly phosphate, magnesium, bicarbonate and monthly selenium, copper and zinc.

Supplemental B12, D and E may be required if TPN is prolonged.

See:

Nutrition for full details of oral and parental nutrition in this situation.

The GvHD progression diet.


About this Canterbury DHB document (9075):
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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Topic Code: 9075