Considerations in the treatment of aGvHD

In a recent publication from the American Society of Hematology Education Program,¹ Newell and Holtan discussed important factors to consider during the treatment of acute graft-versus-host disease (aGvHD), including risk-adapted treatment approaches and areas where treatment could be improved. The authors also highlighted the importance of considering the severity of patient symptoms, the possibility of alternative diagnoses and provision of supportive care before starting first-line therapy with corticosteroids. If a patient has persistent or recurring symptoms that occur after the initial treatment of aGvHD, then it is important to consider other contributors such as medication side effects, tissue damage, infections, and malabsorption, before starting second-line therapy.¹

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Conclusion

Increasing immunosuppression may not be the best second-line treatment for all patients with worsening symptoms of aGvHD. Although ruxolitinib is the only therapy approved by the U.S Food and Drug Administration (FDA) for the treatment of steroid-refractory aGvHD, it may not be suitable in all patients, especially those who already have infections, as this is a common side effect of the drug.²

To improve outcomes for patients with aGvHD, several questions need to be answered through additional clinical trials, such as:

• How can we distinguish which patients need different modes of supportive care, e.g., remediation of dysbiosis versus tissue damage?
• To achieve maximal mucosal healing, how long should adjunct repair-based therapies such as urinary-derived human chorionic gonadotropin/epidermal growth factor (uhCG/EGF) be continued?
• What other targets of aGvHD (e.g., the endothelium) should be treated?

Biomarker studies may provide an answer to some of these questions and have the potential to be used as a guide to taper immunosuppression.