Frontline Steroid Treatment for Acute GVHD

Transcript:

Bonnie J. Dirr, APRN: As we reflect on CB’s [patient case study] case, we do see that he had grade 2 skin acute GVHD [graft-vs-host disease]. Dr Gooptu, describe to us your approach to corticosteroids as a frontline treatment agent for patients with acute graft-vs-host disease. What is the typical dosing that you start with?

Mahasweta Gooptu, MD: Despite quite dramatic advances in the treatment of GVHD, corticosteroids remains our mainstay for frontline therapy for patients who need systemic treatment. If I see a patient who has less than 25% of body surface area involvement with just skin GVHD, we could get away with topical steroids. However, when it’s more than 25% of body surface area, then we are unlikely to achieve real resolution with just topical steroids. In that situation, we use systemic steroids. The typical dose that we use is somewhere between 1 [and] 2 mg/kg. Two mg/kg would really be a very standard dose and is a large dose in some patients, like our patient, who was on the obese side. We will sometimes titrate the dose based on those factors, since high-dose corticosteroids have toxicity. In his case, we kind of split the difference and did 1.5 mg/kg, which was still a high dose of corticosteroids because of his BMI [body mass index]. For gut GVHD, I always use 2 mg/kg as the starting dose because that has been shown to be more effective in clinical trials. Similarly for liver GVHD, I would start with 2 mg/kg, but obviously as soon as we can, we start tapering the steroids—mindful of those toxicities.

Bonnie J. Dirr, APRN: Dr Inyang, I know when any new therapy is often initiated, you play a vital role with education for patients and families. What common adverse effects do you educate your patients to be aware of with the initiation of corticosteroid use? And can you talk to us a bit more about how you work with your patients in education in terms of mitigating some of the adverse effects associated with corticosteroids?

Eno-Abasi Inyang, PharmD, BCPS, BCOP: Well, certainly, it’s a good question. Usually I like to educate patients on some of the short-term as well as potential long-term adverse effects with steroids. For some of the short-term adverse effects that could occur with steroid use, things like upset stomach [are] something I love to counsel patients on, as well as difficulty sleeping, such as insomnia, restlessness, mood changes or behavioral changes.…agitation, increased sweating, fluid retention. Usually sometimes swelling in the hands, the face, ankles, or feet. Then particularly for diabetic patients, [I] definitely like to educate them on the potential of increased blood sugar. Some of the longer-term adverse effects with prolonged usage I like to educate patients on [are] things like weight gain. This can be associated sometimes with increased appetite, as well. Decreased bone density and increased risk of fractures and then thinning [of] the skin and hair. For the mitigation strategies for some of these, some of the recommendations I love to give are [the following]. When you’re taking steroids, try to take them in the morning. This can help decrease the wakefulness or insomnia later in the evening. Taking steroids with food can help with the stomach upset, as well as maybe an antacid or histamine-2 blocker can help decrease stomach acid. I think proton pump inhibitors [are] another option. I usually educate patients to have a discussion with their care team before recommending it, just in case there are any drug interactions with any of the other medications. Then bone mineral density testing is something I usually like to have a conversation with the team [about] if patients are going to be on steroids for a long period of time.

Transcript is AI-generated and edited for clarity and readability.