A Prospective, Multicenter Study of Closed System Extracorporeal Photopheresis for Children With Steroid-Refractory Acute Graft-Versus-Host Disease

New investigational drugs for steroid-refractory acute graft-versus-host disease: a review of the literature

INTRODUCTION

Steroid-refractory acute graft-versus-host disease (SR-aGVHD) remains a formidable obstacle in the field of allogeneic hematopoietic cell transplantation (allo-HCT), significantly contributing to patient morbidity and mortality. The current therapeutic landscape for SR-aGVHD is limited, often yielding suboptimal results, thereby emphasizing the urgent need for innovative and effective treatments.

AREAS COVERED

In light of the pivotal REACH2 trial, ruxolitinib phosphate, a Janus kinase inhibitor, has gained prominence as the standard treatment for SR-aGVHD. Nevertheless, a considerable number of patients either do not respond to or cannot tolerate this therapy. This review delves into emerging treatments for SR-aGVHD, including mesenchymal stromal cells (MSCs), fecal microbiota transplantation (FMT), CD3/CD7 blockade, neihulizumab, begelomab, tocilizumab, and vedolizumab. While some of these agents have shown encouraging results in early-phase trials, issues such as treatment-related toxicities and inconsistent responses in larger studies highlight the necessity for ongoing research.

EXPERT OPINION

Current trials exploring new agents and combination therapies offer hope for fulfilling the unmet clinical needs in SR-aGVHD, potentially leading to more effective and precise treatment strategies.

The Role of Extracorporeal Photopheresis in the Management of Graft Versus Host Disease: Narrative Review

Hematopoietic stem cell donation is a method used to treat both blood-related and non-blood-related malignancies. Graft-versus-host disease is a potentially life-threatening complication that can occur following a stem cell transplant from a donor. This happens after the transplanted grafts attack the recipient's body as foreign cells, causing significant morbidity and mortality. Clinically, this condition can be classified as acute or chronic based on onset and pathophysiology. This review aims to provide an overview of recent studies on extracorporeal photopheresis as a treatment strategy option for graft-versus-host-diseased patients. It will explain how it treats graft-versus-host disease, summarize its promising effects, and provide future recommendations for its use in treating this illness. Extracorporeal photopheresis is used to treat graft-versus-host disease by collecting and separating white blood cells from the patient. This blood is fractionated into different parts, and white blood cells undergo treatment with 8-methoxy psoralen, a photoactivable drug, before exposure to ultraviolet light A. Lastly, the cells that have been treated are reinfused into the recipient's body. It prompts the programmed cell death of lymphocytes and the engulfment of cellular debris by host antigen-presenting, leading to a subsequent rise in T regulatory cells. However, more experimental and randomized controlled studies are required to identify the best patient selection requirements, environments, and treatment regimens for graft-versus-host disease.

Extracorporeal photopheresis (ECP) improves overall survival in the treatment of steroid refractory acute graft-versus-host disease (SR aGvHD)

Steroid refractory acute graft-versus-host disease (SR aGvHD) is a major limitation of successful allogeneic hematopoietic stem cell transplantation (HSCT). Extracorporeal photopheresis (ECP) has been used to treat SR aGvHD effectively and with low treatment related toxicity. In this study, we retrospectively analyzed the outcomes of 103 Steroid Refractory aGvHD (SR aGvHD) patients to identify factors associated with improved outcomes including the use of ECP. A total of 79 patients received ECP as part of their SR aGVHD treatment compared to 24 patients who did not. Both groups had similar aGVHD grade and maximum organ stage at onset of aGVHD and treatment initiation. Patients in the group that received ECP had better OS (p = 0.01), DFS (p = 0.008), lower relapse (p = 0.05) and similar NRM compared to the group that did not receive ECP. Patients that received ECP treatment also had shorter hospital stays in the first 180 days after onset of SR aGvHD (20 vs. 38 days, p = 0.03). Multivariable analysis for OS indicated patient CMV status (CMV+ versus CMV-, HR 2.34, CI 1.16-4.69), regimen intensity (Myelo vs. non-Myeloablative, HR 0.39, CI 0.20-0.75), and the use of ECP (ECP vs. no ECP, HR 0.39, CI 0.20-0.75) were associated with OS. In summary, the use of ECP in the treatment of SR aGvHD results in improved overall survival secondary to lower relapse rates compared to other therapeutic modalities that do not incorporate ECP.