Sole Upfront Therapy with Beclomethasone and Budesonide for Upper Gastrointestinal Acute Graft-versus-Host Disease

• Published in: Biology of blood and marrow transplantation 2020-07, Vol.26 (7), p.1303-1311
• Main Authors: Frairia, Chiara, Nicolosi, Maura, Shapiro, Jamie, Kim, Jongphil, Betts, Brian C., Fernandez, Hugo F., Locke, Frederick L., Mishra, Asmita, Nishihori, Taiga, Ochoa-Bayona, Jose Leonel, Perez, Lia, Pidala, Joseph, Anasetti, Claudio
• Format: Article
• Language: English
• Subjects: Beclomethasone; Budesonide; Hematopoietic stem cell transplantation; Upper gastrointestinal acute GVHD
• ISSN: 1083-8791; 1523-6536
• DOI: 10.1016/j.bbmt.2020.04.023

•Upper gastro-intestinal acute GVHD may improve with sole upfront topical steroids.•Combined beclomethasone and budesonide are safe in upper gastro-intestinal GVHD.•Prospective trials should explore the advantages of topical over systemic steroids. Systemic glucocorticoids remain the standard treatment for gastrointestinal (GI) acute graft-versus-host disease (aGVHD) despite their toxicity and incomplete efficacy. Controlled trials have tested poorly absorbable steroids as adjuncts with systemic glucocorticoids, but only small case series have reported treatment with poorly absorbed beclomethasone dipropionate (BDP) and budesonide (BUD) alone. Our team has adopted the practice of administering BDP or BDP+BUD without systemic glucocorticoids as first-line therapy for isolated upper GI (UGI) aGVHD. We report results in 76 patients treated with BDP alone and in 81 patients treated with BDP+BUD, with allocation by physician choice. Almost all patients received peripheral blood stem cells (92%) from a fully HLA-matched related or unrelated donor (80%) after myeloablative conditioning (76%) for acute leukemia (49%), myelodysplastic syndrome (17%), non-Hodgkin lymphoma (14%), or another hematopoietic disorders (20%). After 28 days of treatment with BDP, 46% of the patients had a complete response (CR) and 10% had a partial response (PR); after 200 days, 61 (80%) patients were alive, 34% maintained a CR, and 3% maintained a PR, whereas 53% required additional immunosuppression (IS). After 28 days of treatment with BDP+BUD, 67% had a CR and 10% a PR; after 200 days, 74 (91%) patients were alive, 46% maintained a CR, and 2% maintained a PR, whereas 43% required additional IS. Among the entire cohort of 157 patients, 66 (42%) were treated successfully without systemic glucocorticoids. This study reports the efficacy of poorly absorbable steroids alone for patients with isolated UGI aGVHD. Prospective trials should test for the potential advantages of BDP and BUD use over systemic glucocorticoids.