How is graft vs host disease (GVHD) minimized and managed?

How is graft versus host disease minimized and managed?

Depending on the type of transplant you get, how we try to minimize the risk for graft versus host disease is going to be different. With some types of transplants where we take out the cells that we think cause GvHD, we don't give any immunosuppressive medicines and just let that immune system recover, organically in the body. Immunosuppressive medicines are drugs that weaken the immune system to prevent it from attacking healthy tissues and organs. With all other types of transplants, we give some combination of immunosuppressive medicines. For some of them, they go home on one immunosuppressive medicine, and other times they'll go on more than one immunosuppressive medicine. But we do all this to minimize the risk for this graft versus host disease. And over time, as we see that the body and the immune system are playing nicely together, we try to take the brakes off and let that immune system fully wake up and hopefully not see any of this graft versus host disease. The earlier form of graft versus host disease, we call acute graft versus host disease, can occur anywhere from when the blood counts are first coming up through six months, sometimes even later after transplant. And this tends to be red rashes that come and stay, diarrhea, loss of appetite, severe nausea or frequent vomiting. And this is typically after recovery from the chemotherapy of the transplant that we worry more about these things. The treatment for this acute form of graft versus host disease at first line is high dose steroids. And high dose steroids have all sorts of issues with them. They can disrupt sleep. They can cause a lot of hunger. They can cause moodiness. They put us at higher risk for infection. They can affect our blood sugars and our blood pressures. And roughly two thirds of patients will have a response to these, be able to come off the steroids and later be able to come off their other immunosuppression. When we see the chronic graft versus host disease arise, this is one that tends to happen more slow and be a much longer process. So instead of starting them on as high of a dose of steroids, we start them on a lower dose of steroids. But it has to go over a much longer period of time, and many patients will get transitioned or have additional medicines added on as a way of trying to get these steroids off because we don't like long term steroid exposure. Chronic graft versus host disease can cause all sorts of different types of skin rash. It's one of the ones that we worry about most. We call sclerodermas chronic graft versus host, where the skin can thicken and scar, or sometimes sock down to the body and make it hard for things to move. It's very worrisome, but relatively infrequent. It can cause dry eyes, dry mouth and sores in the mouth, and cause food to get stuck when we're swallowing because of tightening of the esophagus. It can cause irritation to the liver or the intestinal tract and also cause diarrhea, constipation, or bloating and gas. It can cause limitations in mobility, even if the skin looks normal, because of tightening of the joints, because of the immune system attacking the joints. All of these are things that we can see as well as a progressive, either restrictive or obstructive pattern of damage to the lungs. So either like an emphysema type picture, or pulmonary fibrosis type picture, and either of these things can be extremely worrisome. This is part of why patients who are able to do pulmonary function tests, and we get both at baseline before transplant and check frequently after transplant, typically every 3 to 6 months, to look for any early signs that we can see before patients have symptoms. Because lung chronic graft versus host disease can be extremely dangerous and can be life threatening. And we want to find that early so we can reverse it as quickly as possible. So these are the things that we worry about. I think the most worrisome parts of chronic GvHD, if they occur, are that scleroderma is scarring of the skin or progressive kind of graft versus host use of the lungs. But on top of that, dry eyes, dry mouth and everything else that we can see with chronic graft versus host disease are some of the biggest things that contribute to long term impairments on quality of life and being able to get fully immersive back into normal life for patients, which is why we're so vigilant and watching for them.