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Elad S, Aljitawi O, Zadik Y. Oral Graft-Versus-Host Disease: A Pictorial Review and a Guide for Dental Practitioners. Int Dent J 2021; 71:9-20. [PMID: 33616057 PMCID: PMC9275209 DOI: 10.1111/idj.12584] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Graft-versus-host disease (GVHD) is a complication of haematopoietic stem cell transplantation (HSCT). GVHD may also develop following solid transplants or blood transfusions if white blood cells are transferred. GVHD affects multiple organs, including the oral tissues. OBJECTIVE This pictorial review provides a background of GVHD to dental practitioners, describes the most common oral manifestations of GVHD and highlights the main treatment modifications needed to deliver dental care to patients with GVHD. METHODS A narrative review enhanced with clinical photographs. RESULTS Acute GVHD may manifest in the oral mucosa; however, it often develops immediately following HSCT when routine dental treatment is postponed. Chronic GVHD may manifest in the oral mucosa, the salivary glands and the musculoskeletal compartment. It may indirectly affect the teeth and the oral flora, putting the patient at risk for infections. Importantly, GVHD poses an increased risk for oral cancer. CONCLUSION GVHD has a wide range of oral manifestations, some of which may affect dental treatment.
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Affiliation(s)
- Sharon Elad
- Division of Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA.
| | - Omar Aljitawi
- Department of Hematology and Oncology, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Yehuda Zadik
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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Jayakrishnan T, Babu M, Goodnow S, Hardman B. BUDESONIDE-INDUCED HYPEROSMOLAR HYPERGLYCEMIC STATE FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT. AACE Clin Case Rep 2020; 6:e265-e268. [PMID: 32984535 DOI: 10.4158/accr-2020-0216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/13/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Recognize a rare endocrinological side effect of a drug, budesonide, which surfaced as a result of a major procedure. METHODS We describe a patient who presented with hyperglycemic hyperosmolar state (HHS) likely as a result of the bypass of first-pass metabolism due to budesonide treatment after a transjugular intrahepatic portosystemic shunt (TIPS) procedure. RESULTS A 62-year-old female with history of combined variable immunodeficiency complicated by colitis (managed by 9 mg budesonide by mouth daily) and refractory ascites secondary to non-cirrhotic portal hypertension (status post-TIPS 3 weeks prior) presented to the hospital with HHS. Her initial insulin requirements were high but improved after discontinuation of budesonide. She was able to be transitioned to a sliding scale and discharged on metformin. When taken orally, budesonide is subject to high first-pass metabolism resulting in minimal systemic effects. Development of HHS and dramatic insulin requirements within 3 weeks of TIPS with drastic improvement following the discontinuation of budesonide leads us to postulate that this was bypassed, leading to steroid-induced diabetes. CONCLUSION The case beckons us to be mindful of procedures that alter drug metabolism and make necessary adjustments to prevent complications.
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Affiliation(s)
- Thejus Jayakrishnan
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Meera Babu
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Steven Goodnow
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Brent Hardman
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Fall-Dickson JM, Pavletic SZ, Mays JW, Schubert MM. Oral Complications of Chronic Graft-Versus-Host Disease. J Natl Cancer Inst Monogr 2020; 2019:5551350. [PMID: 31425593 DOI: 10.1093/jncimonographs/lgz007] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/15/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023] Open
Abstract
The increasing clinical indications for hematopoietic stem cell transplantation (HSCT) and improved clinical care throughout and following HSCT have led to not only long-term survival but also to an increasing incidence and prevalence of graft-versus-host disease (GVHD). Chronic GVHD (cGVHD) affects almost 50% of adult patients post-HSCT, with increasing incidence in pediatric patients as well. Oral cGVHD specifically has a reported prevalence ranging from 45% to 83% in patients who develop cGVHD and is more extensive in adult patients than in children. Oral cGVHD affects patients through clinically significant oral symptoms that may lead to significantly decreased caloric intake, oral infections, and increased health service utilization, and may thus affect overall health and survival. The most commonly used therapy for mucosal involvement of oral cGVHD is topical high-dose and ultra-high potency corticosteroids, and calcineurin inhibitors. This review of oral complications of cGVHD presents the clinical significance of oral cGVHD to HSCT survivors, our current understanding of the pathobiology of oral cGVHD and gaps in this evidence, and the global targeted interdisciplinary clinical research efforts, including the National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease. Current challenges regarding the management of oral cGVHD and strategies to advance our scientific understanding of this clinically significant chronic oral disease are presented.
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Affiliation(s)
- Jane M Fall-Dickson
- Department of Professional Nursing Practice, Georgetown University School of Nursing & Health Studies, Washington, DC
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Division of Intramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Jacqueline W Mays
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Division of Intramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Mark M Schubert
- Department of Oral Medicine, University of Washington, School of Dentistry and Seattle Cancer Care Alliance and Oral Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA
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Topical Corticosteroids a Viable Solution for Oral Graft Versus Host Disease? A Systematic Insight on Randomized Clinical Trials. ACTA ACUST UNITED AC 2020; 56:medicina56070349. [PMID: 32674447 PMCID: PMC7404764 DOI: 10.3390/medicina56070349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 11/17/2022]
Abstract
Background and Objectives: This research attempts to provide a clear view of the literature on randomized clinical trials (RCTs) concerning the efficacy of topical dexamethasone, clobetasol and budesonide in oral graft versus host disease (GVHD). Materials and Methods: An electronic search of the PubMed, Web of Science and Scopus databases was carried out for eligible RCTs. Studies were included if they had adult patients with oral GVHD treatment with topical corticosteroids, and if the RCT study was published in English. The Cochrane Risk of Bias tool was used to assess the quality of these studies. Overall, three RCTs were included (an Open, Randomized, Multicenter Trial; a Randomized Double-Blind Clinical Trial; and an Open-Label Phase II Randomized Trial). Results: The trials involved 76 patients, of which 44 patients received topical dexamethasone, 14 patients received topical clobetasol and 18 patients received topical budesonide. Topical agents were most frequently used when oral tissues were the sole site of involvement. It appears that the best overall response is present for budesonide with no difference between the four arms, followed by clobetasol, and then by dexamethasone. The limitation of the current study is mainly represented by the fact that overall response was derived in two of the studies from other parameters. Moreover, both budesonide and clobetasol were used in only one study each, while two assessed dexamethasone. Conclusions: Based on the clinical trials, all three agents seem to be effective in treating oral GVHD and had a satisfactory safety profile. There is still a need for assessing high quality RCTs to assess the efficacy of these therapies on a larger cohort.
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Efficacy and Safety of Topical Corticosteroids for Management of Oral Chronic Graft versus Host Disease. Int J Dent 2017; 2017:1908768. [PMID: 28751912 PMCID: PMC5511636 DOI: 10.1155/2017/1908768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 05/25/2017] [Indexed: 12/17/2022] Open
Abstract
Background Oral chronic graft versus host disease (cGVHD) is a major complication in transplantation community, a problem that can be addressed with topical intervention. Topical corticosteroids are the first line of treatment although the choice remains challenging as none of the available treatments is supported by strong clinical evidence. Objective This systematic review aims to determine the clinical efficacy and safety of topical corticosteroids for the management of the mucosal alterations of oral cGVHD. Data Sources Electronic search of different databases was conducted: PubMed, Cochrane library, Grey literature, WHO, and clinical trials.gov for clinical trial registration as well as hand search in the references of relevant articles up to November 2016. Data Extraction Extracted pieces of information were intervention, population, sample sizes, and outcomes. Data Synthesis Six studies were included: 2 randomized clinical trials (RCTs), 3 cohort studies, and 1 pre-post clinical trial. Results There is a limited evidence concerning clinical efficacy of topical corticosteroids. Clobetasol, dexamethasone, and budesonide were the topical corticosteroid of choice. The highest level of evidence score was given to clobetasol followed by budesonide with a lower evidence level. Conclusion All three topical corticosteroid preparations are effective for management of oral chronic GVHD with minimal easily avoided side effects.
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Zadik Y, Elad S, Shapira A, Shapira MY. Treatment of oral mucosal manifestations of chronic graft-versus-host disease: dexamethasone vs. budesonide. Expert Opin Pharmacother 2017; 18:235-242. [PMID: 28081677 DOI: 10.1080/14656566.2017.1282464] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The oral mucosa is commonly involved in chronic graft-versus-host disease (cGVHD). Oral mucosal cGVHD markedly affect individual's daily function and wellbeing. In some cases, it might become a life threating complication. Areas covered: This article describes the rationale for treatment, method of topical application in the oral cavity, evidence supporting the topical administration of dexamethasone and budesonide for oral cGVHD, and their adverse effects. Expert opinion: Evidence supports the use of topical dexamethasone and budesonide for treatment of oral cGVHD. Topical corticosteroid choice for oral cGVHD, takes into consideration the potency, bioavailability, preferred concentration, and possible adverse effects. Budesonide's pharmacological characteristics mark it as a preferable topical agent for oral cGVHD.
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Affiliation(s)
- Yehuda Zadik
- a Department of Oral Medicine, Sedation and Maxillofacial Imaging , Hadassah-Hebrew University School of Dental Medicine , Jerusalem , Israel.,b Department of Oral Medicine , The Oral and Maxillofacial Center, Medical Corps, Israel Defense Forces , Tel Hashomer , Israel
| | - Sharon Elad
- c Division of Oral Medicine, Hospital General Dentistry, Eastman Institute for Oral Health , University of Rochester Medical Center , Rochester , NY , USA.,d Wilmot Cancer Center , University of Rochester Medical Center , Rochester , NY , USA
| | - Anat Shapira
- e Pharmacy Division , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Michael Y Shapira
- f Bone Marrow Transplantation and Cancer Immunotherapy Department , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
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Albuquerque R, Khan Z, Poveda A, Higham J, Richards A, Monteiro L, Jané-Salas E, Lopez-Lopez J, Warnakulasuriya S. Management of oral Graft versus Host Disease with topical agents: A systematic review. Med Oral Patol Oral Cir Bucal 2016; 21:e72-81. [PMID: 26615510 PMCID: PMC4765756 DOI: 10.4317/medoral.20968] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/28/2015] [Indexed: 12/17/2022] Open
Abstract
Background Oral Graft-versus-Host Disease (oGvHD) is a common complication of haematopoietic stem cell transplantation. Choosing the right topical application to be used intra orally can be a challenge. Consequently, the aim of this work is to review the effectiveness and safety of topical agents currently used in the management of the inflammatory mucosal lesions encountered in oGVHD. Material and Methods We carried out electronic searches of publications up to May 2015 of the databases Pubmed, National Library of Medicine’s Medline, Embase and the Cochrane Central Register of Controlled Clinical trials to identify potentially relevant studies (keywords: “oral”, “graft”, “versus”, “host”, “disease” and “treatment”). The main inclusion criterion was the reported use of a topical agent which was not intentionally swallowed when used for the treatment of oGVHD. A 3-point grading system, described by the Swedish Council on Technology Assessment in Health Care and the Centre for Reviews and Dissemination, University of York, was used to rate the methodological quality of the papers. Results From the 902 entries identified in the search, 7 studies qualifying for inclusion were analysed. Overall, there is limited evidence with regards to the effectiveness of topical steroids for oGVHD. However, the studies showed some effect of Budesonide alone and when combined with dexamethasone. Topical tacrolimus also appears to have some effect and clobetasol propionate mouthwash had a significantly better clinical response than dexamethasone mouthwash in treating oGVHD. Conclusions As the number of clinical trials conducted is limited, there is little evidence to support the use of topical therapies to treat the inflammatory mucosal lesions found in oGVHD. High quality randomised control trials are needed in order to measure the effectiveness of any topical application for the treatment of the inflammatory mucosal lesions found in oGVHD. Key words:Oral, graft versus host disease, topical, therapy.
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Affiliation(s)
- Rui Albuquerque
- Oral Medicine Department, Birmingham Dental Hospital/School of Dentistry, University of Birmingham, Birmingham B4 6NN, UK,
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Van Schandevyl G, Bauters T. Formulation of budesonide mouthwash for the treatment of oral chronic graft-versus-host disease. J Oncol Pharm Pract 2014; 22:82-5. [PMID: 25411262 DOI: 10.1177/1078155214560654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Oral involvement is (very) common in chronic graft-versus-host disease and can cause discomfort and impairment of oral function. Budesonide, a highly potent corticosteroid with low systemic activity, can be used as a topical treatment for oral chronic graft-versus-host disease. We describe the development of a formulation of budesonide and sodium bicarbonate for use as mouthwash in patients with oral chronic graft-versus-host disease.
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Affiliation(s)
- Guy Van Schandevyl
- Department of Hematology and Oncology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles (ULB), Belgium
| | - Tiene Bauters
- Department of Pharmacy, Ghent University Hospital, Belgium
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Noce CW, Gomes A, Shcaira V, Corrêa MEP, Moreira MCR, Silva Júnior A, Gonçalves LS, Garnica M, Maiolino A, Torres SR. Randomized Double-Blind Clinical Trial Comparing Clobetasol and Dexamethasone for the Topical Treatment of Symptomatic Oral Chronic Graft-Versus-Host Disease. Biol Blood Marrow Transplant 2014; 20:1163-8. [DOI: 10.1016/j.bbmt.2014.04.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 04/07/2014] [Indexed: 01/12/2023]
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Affiliation(s)
- Sandra Regina Torres
- Faculdade de Odontologia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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11
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Zadik Y, Nakdimon I, Meyerowitz C, Shapira MY, Elad S. Topical budesonide for severe oral chronic graft-versus-host disease. Am J Health Syst Pharm 2014; 71:181-2. [DOI: 10.2146/ajhp130520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Yehuda Zadik
- Department of Oral Medicine Hebrew University–Hadassah School of Dental Medicine Jerusalem Israel
| | - Idan Nakdimon
- Israeli Air Force Aero Medical Center Tel Hashomer Israel
| | - Cyril Meyerowitz
- Eastman Institute for Oral Health University of Rochester Medical Center Rochester, NY
| | - Michael Y. Shapira
- Department of Bone Marrow Transplantation and Cancer Immunotherapy Hadassah Hebrew University Medical Center Jerusalem
| | - Sharon Elad
- Division of Oral Medicine Eastman Institute for Oral Health University of Rochester Medical Center
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12
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Park AR, La HO, Cho BS, Kim SJ, Lee BK, Rhie JY, Gwak HS. Comparison of budesonide and dexamethasone for local treatment of oral chronic graft-versus-host disease. Am J Health Syst Pharm 2013; 70:1383-91. [DOI: 10.2146/ajhp120567] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Ae Ryoung Park
- Department of Pharmacy, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
| | - Hyen Oh La
- Department of Pharmacology, College of Medicine, Catholic University of Korea, and Director, Department of Pharmacy, Seoul St. Mary’s Hospital
| | - Byung Sik Cho
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, College of Medicine, Catholic University of Korea
| | - Soon Joo Kim
- Department of Pharmacy, Seoul St. Mary’s Hospital
| | - Byung Koo Lee
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul
| | - Jeong Yeon Rhie
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul
| | - Hye Sun Gwak
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul
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Abstract
Chronic graft-versus-host disease (cGVHD) is a major complication of allogeneic hematopoietic cell transplantation that is associated with a diminished quality of life. The oral cavity is frequently affected, with a wide variety of signs and symptoms that can result in significant short- and long-term complications ranging from mucosal sensitivity and limited oral intake to secondary malignancy and early death. This article provides a comprehensive approach to the diagnosis and clinical management of patients with oral cGVHD, with particular attention to differential diagnosis, control of symptoms, and prevention of and screening for secondary complications. The clinical considerations and recommendations presented are intended to be practical and relevant for all clinicians involved in the care of patients with oral cGVHD, with the ultimate goal of improving care and outcomes.
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Dignan FL, Scarisbrick JJ, Cornish J, Clark A, Amrolia P, Jackson G, Mahendra P, Taylor PC, Shah P, Lightman S, Fortune F, Kibbler C, Andreyev J, Albanese A, Hadzic N, Potter MN, Shaw BE. Organ-specific management and supportive care in chronic graft-versus-host disease. Br J Haematol 2012; 158:62-78. [DOI: 10.1111/j.1365-2141.2012.09131.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
| | | | | | - Andrew Clark
- Bone Marrow Transplant Unit; Beatson Oncology Centre; Gartnavel Hospital; Glasgow
| | - Persis Amrolia
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital; London
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle
| | - Prem Mahendra
- Department of Haematology; University Hospital Birmingham; Birmingham
| | - Peter C. Taylor
- Department of Haematology; Rotherham General Hospital; Rotherham
| | - Pallav Shah
- Department of Respiratory Medicine; Royal Brompton Hospital; London
| | - Sue Lightman
- University College London/Institute of Opthalmology; Moorfields Eye Hospital; London
| | - Farida Fortune
- Department of Oral Medicine; Barts and the London NHS Trust; London
| | | | - Jervoise Andreyev
- Department of Medicine; The Royal Marsden NHS Foundation Trust; London
| | | | - Nedim Hadzic
- Paediatric Liver Service & Institute of Liver Studies; King's College Hospital; London
| | - Michael N. Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London
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Kida A, McDonald GB. Gastrointestinal, Hepatobiliary, Pancreatic, and Iron-Related Diseases in Long-Term Survivors of Allogeneic Hematopoietic Cell Transplantation. Semin Hematol 2012; 49:43-58. [DOI: 10.1053/j.seminhematol.2011.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Elad S, Zeevi I, Finke J, Koldehoff M, Schwerdtfeger R, Wolff D, Mohrbacher R, Levitt M, Greinwald R, Shapira MY. Improvement in Oral Chronic Graft-versus-Host Disease with the Administration of Effervescent Tablets of Topical Budesonide—An Open, Randomized, Multicenter Study. Biol Blood Marrow Transplant 2012; 18:134-40. [DOI: 10.1016/j.bbmt.2011.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 06/01/2011] [Indexed: 10/18/2022]
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Meier JKH, Wolff D, Pavletic S, Greinix H, Gosau M, Bertz H, Lee SJ, Lawitschka A, Elad S. Oral chronic graft-versus-host disease: report from the International Consensus Conference on clinical practice in cGVHD. Clin Oral Investig 2010; 15:127-39. [PMID: 20859645 DOI: 10.1007/s00784-010-0450-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Accepted: 07/26/2010] [Indexed: 01/12/2023]
Abstract
Chronic graft-versus-host disease (cGVHD) is a multi-organ disease that occurs post-hematopoietic stem cell transplantation, with the mouth being one of the most frequently affected organs. In 2009, the German-Austrian-Swiss working party on bone marrow and blood stem cell transplantation held a consensus conference to define clinical management of cGVHD. The consensus conference aimed to summarize the literature on diagnosis and topical treatment options for oral cGVHD and to provide recommendations for clinical practice, including routine dental and oral care as well as monitoring for secondary malignancies and bisphophonate-induced osteonecrosis of the jaw.
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Affiliation(s)
- Johannes K-H Meier
- Department of Cranio-Maxillo-Facial Surgery, University of Regensburg, Regensburg, Germany
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Wolff D, Gerbitz A, Ayuk F, Kiani A, Hildebrandt GC, Vogelsang GB, Elad S, Lawitschka A, Socie G, Pavletic SZ, Holler E, Greinix H. Consensus conference on clinical practice in chronic graft-versus-host disease (GVHD): first-line and topical treatment of chronic GVHD. Biol Blood Marrow Transplant 2010; 16:1611-28. [PMID: 20601036 DOI: 10.1016/j.bbmt.2010.06.015] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation is still associated with significant morbidity and mortality. First-line treatment of cGVHD is based on steroids of 1 mg/kg/day of prednisone. The role of calcineurin inhibitors remains controversial, especially in patients with low risk for mortality (normal platelets counts), whereas patients with low platelets at diagnosis and/or high risk for steroid toxicity may be treated upfront with the combination of prednisone and a calcineurin inhibitor. Additional systemic immunosuppressive agents, like thalidomide, mycophenolic acid, and azathioprine, failed to improve treatment results in the primary treatment of cGVHD and are in part associated with higher morbidity, and in the case of azathioprine, with higher mortality. Despite advances in diagnosis of cGVHD as well as supportive care, half of the patients fail to achieve a long-lasting response to first-line treatment, and infectious morbidity continues to be significant. Therefore, immunomodulatory interventions with low infectious morbidity and mortality such as photopheresis need urgent evaluation in clinical trials. Beside systemic immunosuppression, the use of topical immunosuppressive interventions may improve local response rates and may be used as the only treatment in mild localized organ manifestations of cGVHD.
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Affiliation(s)
- Daniel Wolff
- Department of Hematology and Clinical Oncology, University of Regensburg, F.J. Strauss Allee 11, Regensburg, Germany.
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19
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Elad S, Zeevi I, Or R, Resnick IB, Dray L, Shapira MY. Validation of The National Institutes of Health (NIH) Scale for Oral Chronic Graft-versus-Host Disease (cGVHD). Biol Blood Marrow Transplant 2010; 16:62-9. [DOI: 10.1016/j.bbmt.2009.08.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 08/27/2009] [Indexed: 12/12/2022]
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20
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Dilger K, Halter J, Bertz H, Lopez-Lazaro L, Gratwohl A, Finke J. Pharmacokinetics and pharmacodynamic action of budesonide after buccal administration in healthy subjects and patients with oral chronic graft-versus-host disease. Biol Blood Marrow Transplant 2009; 15:336-43. [PMID: 19203724 DOI: 10.1016/j.bbmt.2008.12.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Accepted: 12/01/2008] [Indexed: 12/21/2022]
Abstract
Buccal administration of budesonide (mouthwash) may be effective as a topical add-on therapy in patients with oral chronic graft-versus-host disease (cGVHD). Safety of approved oral budesonide is based on high intestinal and hepatic extraction by cytochrome P450 3A (CYP3A) enzymes. The purpose of this study was to evaluate the presystemic extraction and pharmacodynamic action of buccal budesonide. Oral budesonide (3 mg) was taken as reference to which various single and multiple dose regimens of buccal budesonide were compared. Budesonide and the 2 main CYP3A-dependent metabolites (6beta-hydroxybudesonide, 16alpha-hydroxyprednisolone) were analyzed in blood and urine along with the drug's effect on endogenous cortisol in 12 healthy subjects and 7 patients with oral cGVHD. We assessed CYP3A-dependent metabolites in both healthy subjects and patients after buccal budesonide. Whereas systemic exposure to budesonide was markedly lower in healthy subjects after the mouthwash compared to oral dosing (mean relative bioavailability 18%-36%), the systemic concentrations thereafter in patients were as high as those after the identical dose of oral budesonide. Reduced buccal CYP3A activity (lower inactivation of budesonide) in patients contributed to this remarkable difference. Endogenous cortisol was suppressed in some patients during 1 week of continuous treatment with buccal budesonide (3 x 3 mg per day). We are the first to report the biotransformation of budesonide via CYP3A enzymes after buccal drug administration. Only 2% of a buccal dose of budesonide achieves systemic circulation in healthy individuals; that fraction is 10% in patients with oral cGVHD, probably because of alterations in drug uptake and metabolization.
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Nagler R, Barness-Hadar L, Lieba M, Nagler A. Salivary Antioxidant Capacity in Graft versus Host Disease. Cancer Invest 2009; 24:269-77. [PMID: 16809154 DOI: 10.1080/07357900600634013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Stem cell transplantation (SCT)-related salivary gland injury and dysfunction result in local and systemic manifestations that may be long lasting and are associated with a high rate of morbidity and increased risk of infection. The salivary antioxidant system may have a major protective role. We, therefore, assessed salivary antioxidant capacity and function in 30 patients who had undergone SCT: 18 males and 12 females whose median age was 36 years (range: 7-58). Salivary gland function was assessed by sialometric and biochemistry means, which included measuring total protein, secretory IgA (SIgA) and the antioxidants peroxidase, uric acid (UA), and total antioxidant status (TAS) in the collected saliva. In patients who developed graft versus host disease (GVHD), we observed a significant decrease of the salivary flow rate, from 0.74 +/- 0.14 ml/minute to 0.19 +/- 0.08 ml/min, pre- and post-SCT, respectively (p < 0.01) with no recovery. In contrast, in patients who underwent autologous or allogeneic SCT and did not develop GVHD, salivary flow rates returned to normal 3-5 months posttransplantation. GVHD also resulted in a concomitant reduction of the salivary protein content and the salivary antioxidant capacity. The TAS levels in the saliva of the GVHD patients were found to be significantly reduced, to about one-third of the base-line value (P < 0.02). The concomitant reduction in salivary flow rate, protein content, and antioxidant capacity may well explain the GVHD-induced oral and gastrointestinal tract (GIT) mucositis, as the saliva constantly swallowed into the GIT losses its usual antioxidant protective roles. In conclusion, our findings may point at a possible new mechanism for the pathogenesis of oral and intestinal mucositis in pre-GVHD patients. Therapy with artificial saliva and free radical scavengers and/or antioxidants (administered either systemically or via oral rinses) thus, may be of clinical relevance.
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Affiliation(s)
- Rafael Nagler
- Oral and Maxillofacial Surgical Department, Oral Biochemistry Laboratory and Salivary Clinic, Rambam Medical Center, Faculty of Medicine, Technion Institute, Haifa, Israel.
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22
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Ibrahim RB, Abidi MH, Cronin SM, Lum LG, Al-Kadhimi Z, Ratanatharathorn V, Uberti JP. Nonabsorbable corticosteroids use in the treatment of gastrointestinal graft-versus-host disease. Biol Blood Marrow Transplant 2009; 15:395-405. [PMID: 19285626 DOI: 10.1016/j.bbmt.2008.12.487] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 12/04/2008] [Indexed: 02/05/2023]
Abstract
For over a decade, nonabsorbable corticosteroids have been employed in the treatment of gastrointestinal graft-versus-host-disease (GVHD) in hematopoietic stem cell transplant (HSCT), as monotherapy or in combination with systemic corticosteroids. The majority of the evidence showing a favorable outcome consisted of case series, small phase II trials and a large randomized phase III trial. The 2 most commonly studied molecules were oral budesonide and beclomethasone diproprionate. Although these reports hint at some benefit with the local treatment strategy, their methodologic inconsistencies preclude meaningful adoption to everyday clinical practice. This review evaluates the current evidence of nonabsorbable corticosteroids in HSCT and sets forth recommendations for future trials with these agents.
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Affiliation(s)
- Rami B Ibrahim
- Karmanos Cancer Institute and Wayne State University, Detroit, Michigan 48201, USA.
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23
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Imanguli MM, Alevizos I, Brown R, Pavletic SZ, Atkinson JC. Oral graft-versus-host disease. Oral Dis 2008; 14:396-412. [PMID: 18593456 DOI: 10.1111/j.1601-0825.2008.01448.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Graft-versus-host disease (GVHD) is a leading cause of morbidity and mortality in patients receiving hematopoietic cell transplant. It is estimated that 40-70% of engrafted patients surviving the initial transplant eventually develop chronic GVHD (cGVHD), which can persist for months to years and require long-term management from multiple disciplines. This review describes the oral component of this transplant complication. DESIGN The search related to GVHD patho-biology, salivary gland disease after hematopoietic cell transplant and treatments for oral GVHD encompassed literature from 1966 through 2008. Searches were limited to the MEDLINE/PubMed database and English language literature in peer-reviewed journals. RESULTS Our understanding of the patho-biology of oral cGVHD is based on studies of other affected tissues. It is difficult to determine the prevalence and incidence of salivary gland disease after transplant because there is no universally accepted case definition. In general, clinical trials for treatment of oral cGVHD have been too small to make strong recommendations for use in clinical practice. CONCLUSIONS Larger well-designed clinical studies are needed to understand the patho-biology of oral cGVHD and determine best treatments for this disease.
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Affiliation(s)
- M M Imanguli
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
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24
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Enteral budesonide in treatment for mild and moderate gastrointestinal chronic GVHD. Bone Marrow Transplant 2008; 42:541-6. [PMID: 18641680 DOI: 10.1038/bmt.2008.209] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Budesonide (BUD) is a steroid with a low bioavailability, which has been used for the treatment of oral manifestations of chronic GVHD (cGVHD). We retrospectively evaluated the efficacy of BUD in the treatment of gastrointestinal cGVHD. Thirteen patients (median age 47 years) receiving BUD for the treatment of cGVHD after allogeneic hematopoietic SCT for hematological malignancies were evaluated for response. Five patients had isolated gastrointestinal cGVHD and 8 patients had mild multiorgan involvement including gastrointestinal manifestations. Six patients received CYA at the time of onset of cGVHD, which was continued during treatment with BUD. Treatment consisted of BUD, with an initial daily dose of 3 x 3 mg orally. Complete resolution of cGVHD was achieved in seven patients, and one patient achieved partial remission of cGVHD. One patient achieved complete resolution of gastrointestinal cGVHD, while systemic manifestations of cGVHD remained stable. Four patients progressed on BUD. Owing to the predominantly local effect, relapse of symptoms of cGVHD after withdrawal of immunosuppression (n=3) as well as progression of GVHD at other sites (n=3) has been observed. BUD represents a treatment option in mild-to-moderate cGVHD, which is well tolerated and associated with a high response rate in gastrointestinal cGVHD.
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25
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Budesonide for local therapy of complex oral mucosal immune-mediated inflammatory diseases: case reports. ACTA ACUST UNITED AC 2008; 106:e11-7. [DOI: 10.1016/j.tripleo.2008.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 02/14/2008] [Accepted: 02/20/2008] [Indexed: 11/17/2022]
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Abstract
Hematopoietic cell transplantation is used to treat malignancies, hematologic and immune deficiency states, marrow failure syndromes, and autoimmune diseases. Graft-versus-host disease (GVHD) is a clinical syndrome seen following allogeneic transplantation where donorderived immunocompetent T cells and inflammatory responses attack host tissues. GVHD can cause significant morbidity and even result in mortality. The oral cavity is a frequently involved site with clinical changes resembling autoimmune collagen vascular diseases. Recognition, diagnosis, and monitoring of oral GVHD can help with diagnosis and grading of GVHD and judging responses to therapy. Topical and local management of symptomatic oral GVHD can reduce oral symptoms that can interfere with oral function and quality of life, and can reduce the need for more intensive immunosuppressive systemic therapies.
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Affiliation(s)
- Mark M Schubert
- Oral Medicine Service, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA 98109, USA.
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27
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da Fonseca MA, Murdoch-Kinch CA. Severe gingival recession and early loss of teeth in a child with chronic graft versus host disease: a case report. SPECIAL CARE IN DENTISTRY 2007; 27:59-63. [PMID: 17539221 DOI: 10.1111/j.1754-4505.2007.tb00329.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Graft versus host disease (GVHD) occurs after a hematopoietic stem cell transplantation (HSCT) when the donor's immune system rejects the recipient's body, leading to significant morbidity and mortality. Increased numbers of chronic GVHD (c-GVHD) patients are likely to be seen by dental professionals because of the advances made in transplantation. The oral cavity may be the primary or the only site of c-GVHD and may have persistent lesions after resolution has occurred in other areas. Approximately 80% of patients with extensive c-GVHD present some type of oral involvement, including xerostomia, oral pain and lesions. Dental and oral care can be challenging for these patients. This paper discusses the manifestations and treatment of oral c-GVHD and presents the case history of a 15-month-old girl who developed severe oral GVHD with an unusual periodontal presentation and early loss of primary teeth.
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Affiliation(s)
- Marcio A da Fonseca
- Section of Pediatric Dentistry, The Ohio State University College of Dentistry/Columbus Children's Hospital, Columbus, Ohio, USA.
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28
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Epstein JB, Elad S, Eliav E, Jurevic R, Benoliel R. Orofacial pain in cancer: part II--clinical perspectives and management. J Dent Res 2007; 86:506-18. [PMID: 17525349 DOI: 10.1177/154405910708600605] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.
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Affiliation(s)
- J B Epstein
- Department of Oral Medicine and Diagnostic Sciences, MC-838, College of Dentistry, 801 S. Paulina St., Chicago, IL 60612, USA.
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Albert MH, Becker B, Schuster FR, Klein B, Binder V, Adam K, Nienhoff C, Führer M, Borkhardt A. Oral graft vs. host disease in children--treatment with topical tacrolimus ointment. Pediatr Transplant 2007; 11:306-11. [PMID: 17430488 DOI: 10.1111/j.1399-3046.2006.00666.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Oral chronic graft vs. host disease (GVHD) frequently presents in patients with sclerotic features of skin GVHD and is often associated with considerable limitations of oral food intake and decreased quality of life. Systemic tacrolimus is efficacious for prophylaxis and treatment of acute and chronic GVHD and topical tacrolimus has shown activity in chronic GVHD skin lesions. We therefore initiated a pilot study to investigate the safety and efficacy of topical tacrolimus ointment in children with oral GVHD. Six patients suffering from oral GVHD (five chronic and one acute) were included in the study. Tacrolimus ointment 0.1% was applied twice daily using sterile gauze. The only side-effects observed were a slight burning discomfort after the first application in one patient and after food intake in another patient. Tacrolimus was absorbed systemically in four of six patients. Of six patients, we observed a complete response in two, a very good partial response (VGPR) in two, and a PR in two patients, respectively. We conclude that topical application of tacrolimus ointment holds promise as a safe and efficacious treatment for oral GVHD in children. The Food and Drug Administration has recently issued a health advisory about a potential cancer risk associated with topical tacrolimus treatment of the skin; therefore, its benefits should be weighed against its potential risks and diligent long-term follow-up should be carried out especially in children.
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Affiliation(s)
- Michael H Albert
- Department of Pediatric Hematology/Oncology, Dr von Haunersches Kinderspital, Ludwig Maximilians University, Munich, Germany.
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30
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Sari I, Altuntas F, Kocyigit I, Sisman Y, Eser B, Unal A, Fen T, Ferahbas A, Ozturk A, Unal A, Cetin M. The effect of budesonide mouthwash on oral chronic graft versus host disease. Am J Hematol 2007; 82:349-56. [PMID: 17109390 DOI: 10.1002/ajh.20814] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Oral chronic graft versus host disease (cGVHD) is common and a major cause of morbidity and loss of quality of life in long term survivors. Cyclosporine with prednisone remains the first line therapy for oral manifestations of cGVHD. However, even with routine administration of systemic agents, many patients with oral manifestations of cGVHD do not have resolution of their disease and may benefit from incorporation of local therapy. Budesonide is a highly potent steroid which has minimal systemic side effects and being used for oral cGVHD. We designed a retrospective study to compare treatment results of patients with oral cGVHD who received topical budesonide in addition to systemic therapy that consists of combined prednisone and cyclosporine (Group A, n = 12), with the treatment results of patients who were administered the same systemic therapy alone (Group B, n = 11) to determine whether budesonide mouthwash had any advantage on response rates. Three mg topical budesonide/10 ml saline was used 3-4 times a day for up to 6 months in group A. Diagnosis, clinical staging, and treatment response scoring for cGVHD were performed according to National Institutes of Health (NIH) consensus criteria. At the baseline examination, there were no statistically significant differences in terms of median oral cGVHD examination scores between two groups. After treatment, there was statistically significant decrease in median oral cGVHD examination scores compared to baseline (P < 0.001 and 0.021), and significant differences were found between two groups (P < 0.032). Overall response rate was 83% and 36% for group A and B, respectively (P = 0.036). However, no statistically significant differences were found between median pain scores of two groups before and after treatment (P = 0.740 and P = 0.091). No major systemic side effects and oral candidiasis were observed in two groups of patients. We concluded that topical budesonide might be added to systemic therapy to obtain better response rates in patients with oral cGHVD.
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Affiliation(s)
- Ismail Sari
- Department of Hematology, Faculty of Medicine, M.K. Dedeman Oncology Hospital, Erciyes University, Cappadoccia Transplant Center, Kayseri, Turkey.
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31
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Al-Hashimi I, Schifter M, Lockhart PB, Wray D, Brennan M, Migliorati CA, Axéll T, Bruce AJ, Carpenter W, Eisenberg E, Epstein JB, Holmstrup P, Jontell M, Lozada-Nur F, Nair R, Silverman B, Thongprasom K, Thornhill M, Warnakulasuriya S, van der Waal I. Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations. ACTA ACUST UNITED AC 2007; 103 Suppl:S25.e1-12. [PMID: 17261375 DOI: 10.1016/j.tripleo.2006.11.001] [Citation(s) in RCA: 213] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 11/03/2006] [Indexed: 01/06/2023]
Abstract
Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.
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Affiliation(s)
- Ibtisam Al-Hashimi
- Salivary Dysfunction Clinic, Baylor College of Dentistry, Houston, TX, USA
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32
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Imanguli MM, Pavletic SZ, Guadagnini JP, Brahim JS, Atkinson JC. Chronic graft versus host disease of oral mucosa: Review of available therapies. ACTA ACUST UNITED AC 2006; 101:175-83. [PMID: 16448918 DOI: 10.1016/j.tripleo.2005.08.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Revised: 08/03/2005] [Accepted: 08/19/2005] [Indexed: 12/16/2022]
Abstract
The use of hematopoetic stem cell transplantation (HSCT) has greatly expanded in the recent years for many neoplastic and hematological disorders. Chronic graft versus host disease (cGVHD) is a major complication of allogeneic HSCT and a major cause of morbidity and mortality. Oral mucosal involvement is frequent in cGVHD and contributes significantly to the overall burden of the condition. Oral medicine professionals should be familiar with various treatment options for oral cGVHD. This review discusses treatment modalities available for the management of oral mucosal manifestations of cGVHD. Available evidence for efficacy and safety of various systemic and topical agents, including corticosteroids, calcineurin antagonists, mycophenolate mofetil, and extracorporeal photopheresis, is reviewed.
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Affiliation(s)
- Matin M Imanguli
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
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Fricain JC, Sibaud V, Hafian H, Deminière C, Taiëb A, Boiron JM. Les manifestations buccales de la réaction du greffon contre l’hôte. Ann Dermatol Venereol 2005; 132:1017-25. [PMID: 16446654 DOI: 10.1016/s0151-9638(05)79574-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J-C Fricain
- Pôle d'Odontologie et Santé Buccale, CHU, Hôpital Pellegrin, place Amélie Raba Léon, 33000 Bordeaux.
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34
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Iyer RV, Hahn T, Roy HN, Battiwalla M, Cooper M, Anderson B, Paplham P, Brown K, Bambach B, Segal BH, McCarthy PL. Long-Term Use of Oral Beclomethasone Dipropionate for the Treatment of Gastrointestinal Graft-versus-Host Disease. Biol Blood Marrow Transplant 2005; 11:587-92. [PMID: 16041308 DOI: 10.1016/j.bbmt.2005.04.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Treatment of severe acute and chronic gastrointestinal (GI) graft-versus-host disease (GVHD) with prolonged high-dose systemic corticosteroids has limited success and considerable toxicity. Beclomethasone dipropionate (BDP) is a potent topically active steroid. We treated 15 patients with acute (n = 2) or chronic (n = 13) GI GVHD refractory to systemic corticosteroids with 28-day courses of oral BDP (2 mg 4 times daily). Response was measured by the change in GI score (sum of 6 GI symptoms) as well as the ability to taper or discontinue systemic corticosteroids. Nine (60%) of 15 evaluable patients responded to BDP, including 3 complete responses (a GI score of 0 or 1 and discontinuation of systemic corticosteroids). Attempts to taper calcineurin inhibitor during BDP therapy were unsuccessful. The 2 patients with acute GVHD had no response to BDP. Responders received a median of 3 cycles (range, 1-20), compared with 1 cycle (range, 1-5) in nonresponders. Suppression of the hypothalamic-adrenal axis was seen in 2 of the 5 patients tested, but neither demonstrated clinically significant symptoms. We conclude that BDP is safe and effective for long-term treatment of chronic GI GVHD. Multiple courses may be necessary to achieve or maintain response in some patients, and prolonged BDP therapy is a feasible alternative to prolonged systemic corticosteroids.
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Affiliation(s)
- Renuka V Iyer
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
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35
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Abstract
Hematopoietic stem cell transplant (SCT) is considered standard therapy for a variety of malignant and nonmalignant diseases. Graft-versus-host disease (GVHD) still represents today a major complication of hematopoietic SCT. Two types of GVHD have traditionally been recognized on the basis of the time of onset following transplantation, distinct pathobiological pathways, and different clinical presentations. The acute form commonly breaks out 2 to 6 weeks after transplantation, affecting up to 60% of patients receiving allogeneic transplants from HLA identical donors. Transfer of immunocompetent donor T cells contained in the graft may undergo alloreactivity against recipient cells because of major or minor histocompatibility antigens disparities between the donor and the immunosuppressed host. Target specificity in acute GVHD involves preferential injury to epithelial surfaces of the skin and mucous membranes, biliary ducts of the liver, and crypts of the intestinal tract. Chronic GVHD affects approximately 30% to 80% of patients surviving 6 months or longer after stem cell transplantation and is the leading cause of nonrelapse deaths occurring more than 2 years after transplantation. Chronic GVHD is a multiorgan syndrome with clinical features suggesting some autoimmune diseases, and possibly both alloreactive and autoreactive T cell clones are involved in its pathophysiology. Although GVHD may convey beneficial graft-versus-leukemia/lymphoma effects, it also entails a significant risk of morbidity and mortality. Patients with mild GVHD need only minimal, if any, immunosuppressive treatment, whereas prognosis of patients with extensive disease or resistant to standard immunosuppressive treatment may be dismal. Early recognition of GVHD followed by prompt therapeutic intervention may prevent the progression to higher-grade disease and improve the outcome for patients receiving hematopoietic SCT.
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Affiliation(s)
- Erich Vargas-Díez
- Department of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain.
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