Around the Practice: Chronic GVHD Treatment Advances - Episode 10
A panel of experts shares key insights into the role of photopheresis when patients with GVHD progress following initial treatment and emphasize its potential for patients with high skin involvement.
John F. DiPersio, MD, PhD: What about photopheresis, and then I want to ask you about other investigational agents. Obviously, clinical trials are the mainstay in these populations of patients for which we have limited options, but what about photopheresis as a standard of care? Does it work and when do you use it? Hannah?
Hannah Choe, MD: Photopheresis is a great option that I particularly like to utilize when I have a patient who has a history of infections. Like Pashna was just mentioning, using a multimodality approach is great. It’s just that we have to balance that with the risk of infections and broad immunosuppression. Electrophoresis is great as an option for that. The problem with it is that it’s a slow response, at least 12 to 15 weeks before you start to see your response. But I particularly employ it for skin involvement. Thus, this for the difficult scleroderma cases, ECP [extracorporeal photopheresis], and probably in clinical practice in combination with other therapies as well.
John F. DiPersio, MD, PhD: Great. Pashna?
Pashna N. Munshi, MD: I agree. Photopheresis has been around for 30, 40 years now, with CTCL [cutaneous T-cell lymphoma] and other aspects, then came to chronic GVHD graft-vs-host disease] use. And hence, I think it works best in the lower grades of chronic GvHD, particularly sclerodermas skin involvement. It’s steroid sparing and infection sparing, it does cause a bit of anemia because the patient is on the machine and blood is cycling through a machine and outside of the body. But the patients have to be committed to coming in twice a week or every week for the first few months of that induction phase, and then you have to maintain them chronically on it. And I’ve done that on many of my patients, but then they also have to get port in place, etc. Thus, you have to talk to your patients about what you anticipate is going to be best for them. I am a believer in photopheresis. I think it does work in the right setting.
John F. DiPersio, MD, PhD: Now, in the old days, when we didn’t have all these drugs available, we would go to photopheresis more often, and now I think it’s sort of the last resort. And we do use it primarily, most of us, in patients who have sclerodermatous changes that don’t respond to other treatments. I do think it works in a subset of patients. It can be quite dramatic too. I’m pretty impressed that some people can get a lot better, and actually the kinds of responses on occasion you see with photopheresis are above and beyond what you usually see with other drugs. Thus, it is for some patients quite remarkable, those patients who have mostly sclerodermas and subcutaneous chronic GvHD with lots of skin thickening.
Transcript edited for clarity.