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Case study | 51-year-old with chronic GvHD with no improvement after a week on prednisone
By Alice Hyde
Featured
First-line therapy for patients with graft-versus-host disease (GvHD) is treatment with steroids; however, ~50% of patients do not respond to initial treatment.1 To explore how to approach these patients, we spoke to Arnon Nagler, who has provided his opinion on how to treat a particular patient with chronic GvHD who was not responding to prednisone.
Case study
The initial characteristics of the patient in question are presented in Figure 1.
Figure 1. Patient characteristics and treatment history
Allo-HSCT, allogeneic hematopoietic stem cell transplant; AML, acute myeloid leukemia; GvHD, graft-versus host disease; MTX, methotrexate; TAC, tacrolimus.
5-month follow-up post-transplant
- On examination, the patient had a maculopapular rash across both upper limbs and chest and oral lesions suggestive of lichen planus (Figure 2).
- The patient reported symptoms began 3−4 months post allogeneic hematopoietic stem cell transplant (allo-HSCT) and was unsuccessful in managing with over-the-counter solutions.
- During the visit, the patient noticeably rubbed their eyes a lot. He said his eyes have been feeling dry but not so much as to affect his daily activities.
- According to the National Institute of Health global severity score of chronic GvHD,2 a diagnosis of moderate chronic GvHD was confirmed (based on skin score, 2; mouth score, 1)
Figure 2. Affected area of the maculopapular rash and oral lesions
Initial treatment for chronic GvHD
Figure 3. Administered therapy and outcome
Question for expert
Expert Opinion
In summary
The patient is young and has developed moderate chronic GvHD with skin mucosal and ophthalmic involvement early post-allo-HSCT (5 months) during tapering of post-transplant immunosuppression. The patient has now failed to respond to 1 mg/kg steroid treatment alongside increased tacrolimus dosing (back to therapeutic levels).
Patient next steps
Figure 4. Treatment plan
GI, gastrointestinal; PR, partial response.
- Kasikis S, Etra A, Levine JE. Current and emerging targeted therapies for acute graft-versus-host disease. 2021;35(1):19-33. DOI: 10.1007/s40259-020-00454-7
- Jagasia MH, Greinix HT, Arora M, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. The 2014 Diagnosis and Staging Working Group report. Biol Blood Marrow Transplant. 2015;21(3):389-401. DOI: 1016/j.bbmt.2014.12.001
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