Monitoring Patients Receiving Steroids for Chronic GVHD
Erin Kopp, NP, emphasizes the importance of identifying patient response to steroids, establishing steroid dependence, and using a systematic tapering regimen for effective management of chronic graft-vs-host disease.
Nelson Chao, MD, MBA: Here we have this patient on steroids, responding. So now what? Do we keep it on indefinitely? Do we start tapering now that he's responded? Do we wait? What would you do at City of Hope?
Erin Kopp, NP: I would say we have a lot of faculty, so there are a lot of choices. But what I teach people, and what I try to stick to, is the concept that we're looking for: is it a partial response, a complete response? And having all that identified, and then really trying an appropriate taper. So, having a taper regimen and having interaction with the patient each time we're tapering, and in between tapers. Looking at what it means to be steroid dependent. That's one thing as well. It's identified and outlined in NCCN. If you can't taper below 0.25 mg/kg per day, and there are two unsuccessful attempts that are separated by at least eight weeks, then we know that they're steroid-dependent. So, using that as a guideline, I would tell the patient we are not going to drop this quickly. And so, we all know that it's effective, and we see the efficacy; we can drop by whatever percentage it is that your institution uses, with close follow-up. And then, bringing it back up, and over that eight weeks if we can't get them off, then are you introducing a second line? Often, it's the approach we do first. If we're able to get them under control with steroids and we can taper them effectively, which I've seen, then that is what we will do, depending on where they are in the continuum, what the symptoms are, etc. But I think establishing whether this patient is steroid-dependent is something that we can't overlook. When we are not comfortable with GvHD, people throw a lot of things in the pot at one time, and then you don't know which ingredient is destroying the recipe. So, if you're doing steroids and five other second-line agents, which I think we've all seen, especially if it's somebody who is not as familiar, you don't know which is effective, and you don't know if the steroids are being effective. Once you initiate a second-line agent, then there are guidelines to that too: Ruxolitinib is an example. It gives clear guidelines—if you're giving Rux and you're giving steroids, this is when you start to taper the Rux, and this is when you can start to taper the steroid.
Nelson Chao, MD, MBA: I think what you said in the beginning is probably the truest statement, which is, with a lot of physicians, there are a lot of recipes. Graft vs. Host Disease is unfortunate in many ways. Let's move on.
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