Time to Change Our Practice: Experience in the Treatment of Steroid Refractory Graft Versus Host Disease in a Universitary Hospital in Chile

• Published in: Blood 2019-11, Vol.134 (Supplement_1), p.5683-5683
• Main Authors: Triantafilo, Nicolas, Maldonado, Mauricio Sarmiento, Palacios, Felipe, Campbell, James, Sandoval, Vicente, Rojas, Andres, Veronica, Jara, Katherine, Soto, Arellano, Silvana, Lorca, Carla, Pizarro, Isabel, Rivera, Elizabeth, Galleguillos, Mauricio, Rodriguez, Isabel, Bertin, Pablo, Ocqueteau, Mauricio, Pereira, Jaime
• Format: Article
• Language: English
• ISSN: 0006-4971; 1528-0020
• DOI: 10.1182/blood-2019-131737

Introduction Steroids refractory (SR) acute (a) or chronic (c) graft versus host disease (GVHD) carries morbidity and lethality. Treatment algorithms varies widely among institutions meaning that the most effective treatment is not yet established. Extracorporeal photopheresis (ExP) and Ruxolitinib have shown in retrospective studies a hopeful efficacy in the treatment of this disease. Moreover, prolonged corticoid or immunosuppressant drugs are associated with opportunistic infection and mortality. Consequently our GVHD algorithm consider 7 days of high dose steroids before moving on to the second line treatments mentioned above to avoid prolonged infectious risk. Because of quick availability and reported benefit, without adding more immunosuppression, we have prefered ExP over other treatments. However this apparent advantages are contrasted with its great cost, as each session exceeds $US 2000. Ruxolitinib in the other hand, is less expensive, but since it is only administered orally, doubts regarding its absorption frequently appear in situations of intestinal GVHD. Hence we used Ruxolitinib as third line therapy after ExP. To know real outcomes of our patients we analyzed all patients with SR-GVHD of our adult hematopoietic transplantation program. Methodology Since 1993 we prospectively performed a registry of all transplanted patients. For this analysis we reviewed all allogeneic transplantated patients and data of those who developed SR-GVHD was extracted. In 2013, ExP was available in our center and was included in our algorithm. SR-GVHD was defined as patients that did not respond despite 5-7 of high dose steroids. As some patients suffer from aGVHD and cGVHD we analyse them separately for global response purpose. Considering that some events can affect more than one organ, when less than 3 organs were affected, we also analyse responses to each one of them separately. When 3 or more organs were affected we consider it as multisystemic affectation Results Until 2013 150 allogeneic transplants were performed; of those, 14 patients (9%) developed SR-GVHD, with 90% mortality. Unsuccessful treatmens included ATG, high doses of methylprednisolone, etanercept, and cyclosporine adjustment. Since 2013 we performed 135 allogeneic transplants and 20 patients (14,8%) developed SR-GVHD. Twelve patients presented with SR-aGVHD, 5 patients with SR-cGVHD and 4 patients with acute and chronic SR-GVHD in different time. For analysis of global response, then, we