Assessing Symptoms of Chronic GVHD in Patients

EP: 1.Clinical Scenario: A 53-Year-Old Man With Chronic GVHD

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EP: 2.Assessing Symptoms of Chronic GVHD in Patients

EP: 3.Importance of Early Diagnosis and Treatment of GVHD

EP: 4.Frontline Treatment Options for Chronic GVHD

EP: 5.Monitoring Patients Receiving Steroids for Chronic GVHD

EP: 6.Second-Line Treatment Options for Steroid-Refractory Chronic GVHD

EP: 7.Clinical Scenario: A 52-Year-Old Woman With Chronic GVHD

EP: 8.Tapering Approaches for Patients With Steroid-Refractory Chronic GVHD

EP: 9.The Future of GVHD Treatment

EP: 10.Selecting and Sequencing Ruxolitinib, Other Treatments in Chronic GVHD

Nelson Chao, MD, MBA: Erin, when you look at this patient, is this patient mild, moderate, or severe? How would you grade this patient?

Erin Kopp, NP: Well, thank you for asking that question. When I first started in this field, I thought, "Oh my gosh, this is severe graft versus host disease." There wasn't a common language that people were utilizing. That's where the NIH consensus grading comes in. At our institution, if the patient is inpatient, we complete a graft versus host disease flow sheet every Wednesday. We have the guidelines next to us, enabling us to say, "Let's look at what the FEV1 is and what's involved. There's 15% of the BSA." I'm looking at the case study as we talk. To see what it is so we have a common language. If I'm talking to my physician colleagues, and I say, "Right now this patient is really at a grade two," we're all speaking the same language. If it goes to a grade three, we know what that means versus a grade one. I'm noting skin changes with hyperpigmentation. About a third of each arm shows lichen planus and superficial sclerotic features.

Catherine Lee, MD, MS: I agree. There has been incredible movement in the chronic graft versus host disease field. We've developed a language we can all understand and use. This is important for deciding the severity or grading of chronic graft versus host disease. At the Hutch, we rely on the NIH consensus criteria. We also use flow sheets at every visit to document organ severity. It's interesting; we also still use Rodnan skin scoring to assess skin changes longitudinally, particularly for patients with sclerotic features. The NIH criteria are foundational, but they have limitations. They're a great initial assessment tool but don't always correlate with patient symptoms. For example, we might see a patient responding to therapy based on symptoms but not see that objectively on exam. The Lee chronic GvHD symptoms scale score can help differentiate between symptom responses and objective physical exam findings.

Nelson Chao, MD, MBA: Absolutely. Hana?

Hana Safah, MD: Beautiful presentation by both of my colleagues. With this patient, I go by the higher score of that organ because of superficial sclerosis. I would classify him as having moderate chronic GvHD. I design my treatment accordingly and speak to my patients about my expectations. There are challenges and limitations with the NIH scoring system, including its lack of validation for pediatric patients and rare organ involvement like kidneys.

Nelson Chao, MD, MBA: Those are important points. One problem is that if someone loses tear duct function, that never heals, and the GvH score will never change. Performance status needs to be included because it makes a big difference.

Erin Kopp, NP: And Dr. Chao, when you asked about this patient and grading or staging GvHD, the language is important. Acute and chronic GvHD have different grading systems. Some people use the terms interchangeably, but they are not. The NIH criteria help with this. There's also the issue of extra-organ presentations, which aren't well accounted for in the NIH criteria but are crucial for treatment decisions. Finally, seeing changes in sclerotic features can take a long time, affecting both provider and patient perceptions of disease progression. Multiple facets to GvHD exist, making it challenging to document and identify clinical improvement.