Sequencing Therapies in Steroid-Refractory Chronic GVHD


Dr Yi-Bin Chen discusses the indications of ibrutinib, ruxolitinib, and belumosudil in steroid-refractory chronic graft-vs-host disease and shares his approach to selecting the optimal therapy for patients.

Matt Fowler: Can you briefly touch on the indications that each of these are approved on and get into maybe the age requirements or previous lines of therapy?

Yi-Bin Chen, MD: There are subtle differences in the approval labels for each of these 3 agents for steroid-refractory chronic graft-vs-host disease. Ibrutinib [Imbruvica] is only approved for adults who have failed 1 or more lines of therapy for chronic graft-vs-host disease [GVHD]. Belumosudil [Rezurock] is approved for patients 12 years and older, but it was only studied in patients who had failed at least 2 lines of therapy. It’s approved really for third-line therapy in chronic graft-vs-host disease. Ruxolitinib [Jakafi] is approved for patients 12 years and older as well, having failed at least 1 line of therapy. That’s how they’re all approved right now. We haven’t seen any data for them to be used in combination, though many of us are doing that. We also don’t know how long to use these agents for, and also how to stop them if they’re not working. All of these things bear future study.

Matt Fowler: With these 3 options, which regimens do you use the most in patients with steroid-refractory disease? Really, what factors go into influencing the treatment choice for patients?

Yi-Bin Chen, MD: I’m often asked, with these new agents, how do I sequence them in our patients? After steroids, if their patients are steroid-refractory, steroid-dependent, or need another agent for different reasons, our standard right now is ruxolitinib. It’s been that way even before approval because of how well tolerated ruxolitinib was and how well it was working. I would guess at least three-quarters of the patients I’ve started on ruxolitinib for chronic GVHD have had some kind of benefit. I tend to use that first. If that is not efficacious, or it works yet we need something else, then I generally have a discussion with the patient around belumosudil, photophoresis, or any clinical trials that we may have open. There’s a lot of discussion around those options and what makes the most sense for patients depending on their clinical manifestations, how enthusiastic they may be for certain clinical trials we have open, how OK they are to tolerate the logistics of doing photophoresis as a therapy itself. All those things go into play to figure out what we should use for third-line therapy.

Transcript Edited for Clarity

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