‘Real-life’ report on the management of chronic GvHD in the Gruppo Italiano Trapianto Midollo Osseo (GITMO)

Abstract

Several guidelines have been published about management of chronic GvHD (cGvHD), but the clinical practice still remains demanding. The Gruppo Italiano Trapianto di Midollo Osseo (GITMO) has planned a prospective observational study on cGvHD, supported by a dedicated software, including the updated recommendations. In view of this study, two surveys have been conducted, focusing the management of cGvHD and ancillary therapy in cGvHD, to address the current 'real life' situation. The two surveys were sent to all 57 GITMO centers, performing allografting in Italy; the response rate was 57% and 66% of the interviewed centers, respectively. The first survey showed a great disparity especially regarding steroid-refractory cGvHD, although extracorporeal photo-apheresis resulted as the most indicated treatment in this setting. Another challenging issue was the strategy for tapering steroid: our survey showed a great variance, and this disagreement could be a real bias in evaluating outcomes in prospective studies. As for the second survey, the results suggest that the ancillary treatments are not standardized in many centers. All responding centers reported a strong need to standardize management of cGvHD and to participate in prospective trials. Before starting observational and/or interventional studies, a detailed knowledge of current practice should be encouraged.

Changes in Immunosuppressive Treatment of Chronic Graft-versus-Host Disease: Comparison of 2 Surveys within Allogeneic Hematopoietic Stem Cell Transplant Centers in Germany, Austria, and Switzerland

“…Interestingly, low platelets at diagnosis of cGVHD are still considered as a high-risk feature because more centers apply a combination of CS and CNI compared with a "normal platelet" scenario [10]. Overall, the results are in line with a survey and guidelines provided by the European Society for Blood and Marrow Transplantation for treatment of cGVHD [22,23] and by a recent survey by the Italian transplant group [24] and a review by Martin et al [8] indicating a broad consensus on the initial treatment of cGVHD.…”

“…An area of uncertainty remains the speed of taper of CS after response to cGVHD as documented by the 2009 survey, which is in line with results from a recent survey from the Italian transplant group and is most likely due to lack of controlled trials comparing different CS taper schedules in cGVHD [24]. The same applies to the various target drug levels of mTORi and CNI that have been studied in acute GVHD but to a lesser extend in cGVHD.…”

“…Both surveys document major variations in practice in second-line treatment that has been already shown by a survey of the Italian transplant group [24], with ECP being the most frequently applied treatment option. Moreover, the 2018 survey also demonstrates that new treatment options like ibrutinib [33] are used after failure of first-line treatment, and even published retrospective analyses influence clinical practice as documented by the increasing use of RUX in the treatment of cGVHD [34].…”

Rational use of chronic graft-versus-host treatment alternatives: A systematic review

“…It has been determined that studies have been carried out on various agents for the treatment of the disease, but randomized controlled studies are quite limited [10,15,23,35,39,52,57]. Most of the studies are observational studies or retrospective studies with a small number of cases [62][63][64]. In the content of these studies and/or medical congress presentations, the agents used in the treatment of cGVHD are discussed, but according to the available information, a clear interpretation cannot be made about which agent should be used at which stage of the treatment.…”

The clinical landscape of chronic graft‐versus‐host disease management in 2021

“…23 Patients whose disease becomes steroid-dependent also represent an important clinical challenge, for which one workingdefinition includes uncontrollable cGVHD flares with prednisone taper below 0Á25 mg/kg/day seen in at least two separate taper attempts (with at least eight weeks in between each). 24 However, notably, this definition varies widely in real-world clinical practice 25 and requires further data-driven updates and standardization. 23 If no response to front-line therapy is seen within 8-12 weeks, or progression of disease occurs within 4 weeks, additional second-line treatments are needed, as discussed below.…”