Submitted December 6, 2006
Accepted January 11, 2007
How I Treat Refractory Acute GVHD
H Joachim Deeg*
Fred Hutchinson Cancer Research Center and University of Washington School of Medicine, Seattle, WA, United States
* Corresponding author; email: jdeeg{at}fhcrc.org.
Graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT) is associated with considerable morbidity and mortality, particularly in patients who do not respond to primary therapy, which usually consists of glucocorticoids (steroids). Approaches to therapy of acute GVHD refractory to "standard" doses of steroids have ranged from increasing the dose of steroids to the addition of polyclonal or monoclonal antibodies, the use of immunotoxins, additional immunosuppressive/chemotherapeutic interventions, phototherapy and other means. While many pilot studies have yielded encouraging response rates, in most of these studies long-term survival was not improved in comparison to that seen with the use of steroids alone. A major reason for failure has been the high rate of infections, including invasive fungal, bacterial and viral infections. It is difficult to conduct controlled prospective trials in the setting of steroid-refractory GVHD, and a custom-tailored therapy dependent upon the time after HCT, specific organ manifestations of GVHD and severity is appropriate. All patients being treated for GVHD should also receive intensive prophylaxis against infectious complications.
