What are the key clinical considerations for the use of ECP in steroid-refractory GvHD?

The GvHD Hub was pleased to speak with Daniel Wolff, University Hospital Regensburg, Regensburg, DE. We asked, What are the key clinical considerations for the use of ECP in SR-GvHD?​​ 

In this interview, Wolff discusses factors guiding the use of extracorporeal photopheresis (ECP) in steroid-refractory graft-versus-host disease (SR-GvHD). Treatment decisions should account for patient- and disease-related factors, including cytopenias, risk of infection or malignant relapse, and organ involvement, alongside practical considerations, such as venous access, treatment frequency, and the commitment required for long-term therapy. 

Key points 

• ECP is an immunomodulatory, leukapheresis-based procedure used as a second-line or later treatment option for SR-GvHD.¹  
• Ruxolitinib, a Janus kinase 1/2 inhibitor, is an established second-line therapy for SR-GvHD. ECP may be considered in combination with ruxolitinib in selected patients, including those with an inadequate response to ruxolitinib monotherapy or a need to reduce corticosteroid exposure, particularly children and older adults.^2–4 
• ECP may be a valuable therapeutic option in specific clinical settings, particularly for patients with: 
  • An elevated risk of infections, as ECP does not cause generalized immunosuppression.^5–8 
  • Cytopenia, which may limit the use of pharmacological treatments such as ruxolitinib.^9–11 
  • A high risk of malignant relapse, as ECP appears to preserve the graft-versus-leukemia effect.^8,12 
  • Challenges with treatment adherence, as treatment is administered intravenously in a supervised clinical setting.¹³  
• Although ECP can be used across different manifestations of GvHD, it has shown particular benefit in cutaneous GvHD, while alternative treatments, such as ruxolitinib or mesenchymal stromal cells, may be considered in patients with severe intestinal GvHD.^8,14–16 
• Various practical and logistical factors should be considered prior to initiating ECP:  
  • Adequate venous access is essential for the safe and effective delivery of ECP, and peripheral venous access is preferred where feasible. If peripheral access is inadequate, central venous access may be required, which carries additional risks and complications.^8,17 
  • ECP is time intensive and requires long-term patient commitment, so proximity to the treatment center should be considered.⁸ 
• Overall, Wolff highlights that the decision to use ECP should be individualized, balancing patient- and disease-related factors, treatment goals, and the practical requirements of long-term therapy.  

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