Managing chronic graft-versus-host disease (CGVHD) after allogeneic hematopoietic stem cell transplantation requires subtle clinical judgment, especially in patients with advanced multi-organ involvement. In this interview, PharmacyTimes® will discuss with Gianni Scappaticci, Pharmad and BCOP, a clinical pharmacist specialist in bone marrow transplantation and cell therapy at Michigan Medicine in Northville, Michigan. (T-AML) Complete remission 1 (CR1) Late blood stem cell (PBSC) haplotype transplantation.
scappaticci discusses the factors that lead to the potential use of ruxolitinib (Jakafi; Incyte Corporation) and Belumosudil (Rezurock; Kadmon Pharmaceuticals) individually or in combination.
Pharmacy Time: When reviewing cases of a 61-year-old female patient diagnosed with T-AML on CR1 and received a haplocin PBSC allograft, how do you approach this patient's coordinated therapy while considering evidence-based best practices?
Gianni Scappaticci, Pharmd, BCOP: In this particular case, this was about 34 days after implantation when the skin grade II acute GVHD was first developed in a 61-year-old woman. This was treated with 2 mg oral prednisone per day, and topical steroids were eventually resolved. After implanting day plus 128, she developed moderate CGVHD, including grade II and skin in the mouth. This was Grade I. This was also treated with topical corticosteroids that had partial reactions with 1 mg oral prednisone per day. By day 205, her CGVHD had progressed and severe, with altered sclerosity, mouth, grade II, and skin grade II with joints, which was grade I. So now we are looking for the best treatment to treat her steroid-resistant CGVHD.
Blood smear analysis. Image credit: ©Johannes -Stock.adobe.com
So, initially, my thoughts in this case are causal relationships of our kind of ruxolitinib almost always in steroid-resistant cGVHD. It's certainly an option and the patient doesn't have a lab for the patient, but I think the patient can withstand 5 mg [twice a day (BID)] Or a 10 mg bid for ruxolitinib. Therefore, you can start lower and taper to increase the dosage. However, patients have some unique properties using CGVHD, which involves changes in sclerosity due to the skin. In previous treatments, she was treated with both topical and oral steroids. Therefore, they can be considered as two different lines of treatment. So perhaps another approach would be to activate anti-fibrotic agents in this setting, or to start a combination of Belumosudil and ruxolitinib together. With CGVHD progressing so quickly, having drugs that may not function very quickly in this situation seems to be an option. Personally, I think I would agree to starting Belumosudil and Ruxolitinib together in this setting to stop the progression of CGVHD and treat more acute symptoms currently in progress.
