And Biomarker-Based Algorithm for Management of Acute Gvhd

LETTER TO THE EDITOR A proposed biology- and biomarker-based algorithm for management of acute GvHD

Bone Marrow Transplantation (2017) 52, 337–340; doi:10.1038/ manifestation (Figure 1), along with the accurate stratification of bmt.2016.289; published online 21 November 2016 these patients (Figure 2). Secondly, novel therapeutic targets are desperately needed as no treatment to date added to upfront steroids has proven beneficial. Acute GvHD remains a major cause of hematopoietic cell We propose that layering detailed information regarding the transplant (HCT)-related mortality. aGvHD represents the primary risk factors of advanced and refractory aGvHD, biological and limitation to more widespread use of allogeneic HCT as a biomarker profile, endoscopic and histological findings over potentially curative modality for patients with malignant and descriptive classical organ staging will provide a more accurate non-malignant diseases. Two main approaches may improve the risk stratification of patients with aGvHD. A more precise outcomes of patients with aGvHD: the ability to diagnose the prediction of the outcomes will lead to application of the disease in a timely manner, or even predict aGvHD prior to clinical treatment principle ‘to each according to his need’ and

Diagnosis

Symptoms of aGvHD

Diarrhea ± abdominal Skin rash Liver injury Satiety, anorexia, pain nausea and vomiting after day Yes 20 even in the absence of diarrhea, gut or liver manifestations Cholestatic Hepatitic especially with risk High pretest probability 1 factors for CMV of GvHD, skin GvHD is No present, low risk of Typical and no competing CMV1, and screening diagnosis Evidence of gut and/or After day 100 2 panel of gut infection is 6 EGD with biopsies skin GvHD and on minimal negative (Rate of false-negative immunosuppres No Yes histology is high) sion or after No Yes No 10 Yes DLI Extensive: Stage III or IV No Yes Risk for GvHD related mortality: Biopsy4 No risk of viral deep jaundice>3-4, diarrhea>>1L, 7 Yes infection, SOS Clinical extensive skin rash, albumin 8 3 Yes or DILI diagnosis drop>0.5 or albumin <1.6 g/dL No

Yes No No Skin biopsy5 Skin biopsy Clinical diagnosis is 11 can be sufﬁcient9 Liver biopsy Biopsy can be deferred deferred

Check biological proﬁle12

Serum albumin and total bilirubin Serum biomarkers: TNFR1, ST2, REG3a Fecal calprotectin & Fecal α-1 antitrypsin Absolute lymphocyte count (ALC) Endothelial markers: angiopoietin-2, circulating angiogenic factors (EGF, VEGF-A, FS, and PlGF) C-reactive protein Cytokine proﬁle

Figure 1. For caption see next page. Letter to the Editor 338

Figure 1. 1. Risk factors for CMV: seropositive recipient, mismatched or unrelated donor, T-cell depletion, alemtuzumab administration. 2. The rate of false-negative histology in upper-gut GvHD is significant. Discordance between symptoms, endoscopic findings and ‘negative’ mucosal histology for GvHD is common. When the burden of evidence favors a diagnosis of GvHD, treatment should be started.1 3. A decrease in serum albumin ⩾ 0.5 g/ dL is a useful marker of impending lower-gut GvHD.2 4. Terminal ileum should be inspected whenever possible (small bowel shows grade 4 involvement more frequently than the colon).1 Colonoscopy including inspection of terminal ileum has the highest diagnostic yield, which is not increased by additional upper EGD. The combination of recto-sigmoidoscopy and EGD including histology of the duodenum may be equivalent. 5. Skin biopsy may be dispensable because of the characteristic clinical features of aGvHD and inability to assure distinct discrimination between aGvHD and other diagnosis. Skin biopsy should be performed based on the stage (extensive rash), the clinical course of aGvHD, in cases of atypical clinical features, or attempting to exclude other diagnosis.3 Further systematic investigations of the indications and the appropriate point of time for the biopsy are required. 6. Rare cases of acute liver GvHD in the absence of skin and gut GvHD must be distinguished from drug-induced liver injury (DILI), cholangitis lenta and biliary obstruction. 7. Risk for sinusoidal obstruction syndrome: preexisting liver disease, choice of conditioningtherapy (higher doses of RT given as single dose, cyclophosphamide, busulfan, cytarabine, azathioprine, carmustine, mitomycin, dacarbazine), patient age, poor baseline performance status. 8. Risk for DILI: medications used for myeloablative conditioning (for example, cyclophosphamide, busulfan), other chemotherapy agents (for example, cytarabine, carmustine, mitomycin, 6-mercaptopurine, dacarbazine), drugs for GvHD prophylaxis (for example, cyclosporine, methotrexate) and antimicrobials (for example, amphotericin and azole antifungal agents, trimethoprim-sulfamethoxazole, ribavirin). Given the number of medications used and their sometimes unpredictable effect on liver function, it is often difficult to define the contribution of any single drug. 9. In a patient with skin and gut GvHD who is not at risk for viral infection or DILI but who develops cholestatic liver injury, a clinical diagnosis can suffice. 10. Acute hepatitis with marked elevation of serum alanine aminotransferase, usually after day 100, is most commonly seen in allograft recipients on minimal immunosuppression or after donor lymphocyte infusion (DLI).4 Immunosuppressants are usually discontinued and donor lymphocytes are infused upon relapse of leukemia, in attempt to achieve a GvL effect. Severe GvHD that develops after DLIs can lead to rapidly progressive mucosal and hepatocellular necrosis, jaundice and multi-organ failure. The prognosis is usually dismal in these cases and both GvHD and leukemia relapse will lead to death. 11. Liver biopsy is not useful for diagnosis of IL-6-caused cholestasis but may be essential when there are competing or simultaneous causes of liver injury (sinusoidal obstruction syndrome: viral hepatitis or DILI). 12. The key mechanistic and biological insights that are emerging from pre-clinical studies provide a fertile ground for translational studies. There is now an abundance of viable strategies that can be derived from these new insights not only to improve the diagnosis and risk stratification (serum albumin,2 endothelial markers,5 serum biomarkers,6,7 and absolute lymphocyte count8,9) of aGvHD, but also to provide new and effective therapeutics (cytokine inhibitors10).

Grading and risk stratiﬁcation

Standard-risk High-risk 1 organ (stage 1-3 skin or stage 1-2 GI) or 2 organs Reﬁned (stage 1-3 skin + stage 1 GI or stage 1-3 skin + stage MacMillan13 1-4 liver)14

Classical Grade II Grade I Grade III-IV Glucksberg or IBMTR

Biomarker- Low-score Moderate-score High-score based15 (TNFR1, ST2, REG3α)

Other risk factors to consider when deciding low vs high dose: mismatched unrelated16, diarrhea volume, high total bili at onset, abrupt fall in albumin≥ 0.5 g/dL, extevsive skin GvHD , ulceration & sloughing, and histology.

Therapy17

Well-designed Optimize CI Methylprednisolone or prednisone 1 Methylprednisolone 2 Well-designed phase II or III Levels. mg/kg/d (0.5 may be also acceptable)20 mg/kg/d or prednisone at 2- phase II or III trials that test Maximize Optimize CI Levels. 2.5 mg/kg/d. trials that test less intensive topical agents19 Maximize topical agents. Optimize CI Levels. novel, and Nonabsorbable steroids for GI 8- Maximize topical agents. intensiﬁed, or immunosuppr 9mg/day21 Nonabsorbable steroids for combined essive Adjunctive therapy: UDCA GI 8-9 mg/day. therapies with therapies18 Adjunctive therapy: UDCA standardized endpoints18

Figure 2. For caption see next page.

Figure 2. 13. MacMillan refined score uses standard GvHD organ staging categories, with ‘high-risk GvHD (HR-GvHD)’ differentiated from ‘standard-risk GvHD: SR-GvHD’ by number of organs involved and severity of symptoms. Failure to achieve a complete response to prednisone after initial therapy for 28 days was seen in 73% and 52% of patients with high-risk GvHD and standard-risk GvHD, respectively. This suggests that a significant number of patients classified as standard risk had their risk treatment failure at 28 days underestimated, and buried in the classification ‘high-risk’ are patients who are incurable by any means.11 A free web-based program to easily determine the GvHD risk group for a given patient using this refined risk score is available at: http://z.umn.edu/MNAcuteGVHDRiskScore. Incorporating biomarkers into the available clinical scores may improve the predictive and risk-stratification power of these scores. 14. 1% of patients present with stage 1-4 liver disease alone and should be deemed as HR-GvHD as their outcomes are universally poor. However, 3% of patients who present with stage 1-3 skin plus stage 1-4 liver have favorable outcomes and should be considered standard-risk GVHD. This discrepancy cannot be fully explained.11 15. Incorporating the clinical characteristics and risk factors with biomarker scores (such as Ann Arbor score) will improve the predictive power of these scores and their treatment algorithms.6,7 16. Patients who receive a graft from a HLA-matched or mismatched URD are less likely to respond than those who received either a related donor or an umbilical cord blood graft. 17. There are few reports of randomized controlled trials of the management of aGvHD and patients should be included in trial protocols whenever possible. Second- and third-line options are likely to be determined based on the effects of any previous treatment, consideration of potential toxicity, interaction with other agents, availability of treatments, financial considerations, and individual patient and physician preferences. 18. Outcomes are poor for patients with HR-GvHD treated with steroids alone, and these patients should be considered for enrollment in clinical trials testing new approaches for treatment of acute GvHD. Conversely, those with standard-risk GVHD should be considered for studies using therapeutic approaches designed to limit risks of treatment toxicity or risks of chronic GvHD. 19. The management of grade 1 disease should include topical therapy and optimizing the levels of calcineurin inhibitors without the need for additional systemic immunosuppression. Dermatology supervision is advised when using potent steroids on the face. If more than 50 g of very potent steroid is used per week, sufficient steroid may be absorbed through the skin, resulting in adrenal gland suppression or Cushingoid features. In resistant grade I aGvHD, topical tacrolimus may also be useful although this is not a licensed indication in USA. 20. Acute GvHD of the upper GI tract is more responsive to lower-dose systemic corticosteroids and topical steroid therapy. A reasonable initial approach to treatment of acute GvHD of the upper GI tract is methylprednisolone or prednisone at 1 mg/kg/day. 21. Oral beclomethasone should not be administered if a gastrointestinal infection, such as CMV colitis, is suspected. Beclomethasone dipropionate BDP emulsion at 1 mg 4 times per day plus enteric-coated budesonide at 3 mg twice daily can be used. Oral BDP 8 mg/d for 28 days as the sole initial therapy resulted in complete remission in some patients with lower-risk GvHD in some studies, but responses sometimes took 1 to 3 weeks to be achieved.13

Response evaluation22

No response in 5-7 days Unable to tolerate the side effects of adequate Complete or partial response Or doses of systemic steroids Progressive symptoms after 72 h

Steroid resistant

Taper as soon as manifestations Obtain histologic proof of aGvHD if show major improvement23 not done at onset of symptoms Steroid intolerant Taper prednisone by 0.2 mg/kg/d every 3-5 days and slower when prednisone dose < 20-30 mg/d New-onset or worsening jaundice or GI bleeding Recurrence of aGvHD during steroid taper and before reaching 50% of initial High mortality almost Screen for clinical starting dose 100% trial for refractory disease24 Consider goals of care Steroid Not available discussion and hospice Add second line & dependent 25 care taper steroids

ECP26 Anti-TNF Abs mTOR inhibitors Ruxolitinib MMF ATG29-30 Cytokines and cytokines inhibitors28 Skin+ Liver> GI27 GI> skin-liver sirolimus Antagonists tested in trials: Potential therapies: (Phase I/II ± III) Twice weekly for minimum Etanercept (0.4 mg/kg Use in caution when 5-10 mg PO BID. Can be used if Monitor for - TNF: - IL-13: lebrikizumab, tralokinumab of 8 weeks (grade III-IV may sub twice weekly for 8 combined with CI or Side effects: cytopenia MMF was not used anaphylaxis and serum TNF-aR2: etanercept - IL-17: benefit from 3 treatments w). azoles. and CMV reactivation. for GvHD sickness. IL -17A mAb: secukinumab, weekly for first 4 weeks) Infliximab Monitor for HUS and The loss of GVL activity prophylaxis. Weekly PCR for EBV, TNF-a binding mAb: infliximab Taper steroids starting week No apparent increase in HLD. is a major concern. Consider risk: adenovirus, and CMV - IL -1Ra: anakinra ixekizumab, perakizumab 2 of ECP on weekly basis infections compared to Monitor levels twice benefit carefully for 6 months after last - IL-2: IL -17RA mAb: brodalumab (aim at 50% first 4 w and steroids alone. weekly (target: 3-12 when GI GvHD. dose or absolute IL -2: aldesleukin IL -17A/TNF: ABT122 50% second 4 w) in steroids ng/mL and <10 when lymphocytes>300 IL -2Ra/anti-CD25: basiliximab, daclizumab - IL -22: fezakinumab dependent and faster in combined with CI) - IL -6R: Tocilizumab - IL -12p40/23 mAb: ustekinumab steroid refractory. - IL -23p 19: guselkumab, tildrakizumab

Monitor weekly No response Progressive disease Assess after 8 weeks Consider another second-line agent No response Consider third-line agent Complete Partial Lower GI response response with receiving still response <25 mg requiring> to ECP Mesenchymal Alemtuzumab30 Pentostatin30 Methotrexate prednisone 25 mg prednisone stem cells GI + liver

Available for 10 mg subcutaneously or IV 1.5 mg/m2 per day for 3 d. Possible beneﬁt from compassionate use in daily for 5 days Myelosupressive: Reduce low dose MTX Stop ECP Continue Taper to 2-weekly pediatric population. Serious cytopenia with very dose by 50% if ANC<1000 combined with low ECP until cycles then Great potential. No high rate of viral activation: and discontinue if dose steroids. no further monthly before signiﬁcant adverse weekly PCR for EBV, ANC<500. adenovirus, and CMV for 6 response stopping ECP effects. No increased Very high rate of viral months after last dose or and stop risk of infections. activation: weekly PCR for absolute lymphocytes>300. Randomized phase III EBV, adenovirus, and CMV Add PCP and HSV for 6 months after last dose ongoing. prophylaxis or absolute lymphocytes>300.

Figure 3. For caption see next page.

Figure 3. 22. Patients with aGvHD should be assessed daily for evidence of disease-related complications (for example, infection) and symptoms (for example, pruritus, diarrhea). A more formal assessment should be undertaken on day 5 and 7 after the initiation of therapy. At this time, the severity (grade) of acute GvHD is determined by the degree of involvement of the skin, liver and gastrointestinal tract. Patients who demonstrate progression of disease by 72 h or nonresponse by days 5-7 are considered to have glucocorticoid resistance. It is at the physician’s discretion whether to wait for a longer interval time (for example, 14 days) in non-responsive grade II patients before considering second-line agents. 23. One prospective randomized trial compared a short versus long prednisolone taper. Patients in the long taper group achieved resolution of aGvHD after a median of 30 days of therapy compared to 42 days in the short taper group. There was no difference in survival, incidence of chronic GvHD or steroid-related complications between the two groups.12 24. Often there is no better therapy to offer a patient than enrollment onto a well-designed, scientifically valid, peer-reviewed clinical trial. 25. Defining with certainty the futility of further therapy is impossible, but knowing that there were no survivors among adult patients with severe gut GvHD who were unresponsive to prednisone, jaundiced, with gastrointestinal bleeding leads to goals of care discussion and hospice care.14 These risk factors may also be used to formulate eligibility criteria and to stratify patients for enrollment in investigational studies testing new approaches for treating severe GI GvHD. 26. Unlike other second-line therapies, extracorporeal photophoresis (ECP) is not immunosuppressive and has no reported drug interactions. ECP may also be a valuable treatment in immunosuppressed patients unable to tolerate systemic steroids or other immunosuppressive second-line agents. Importantly, ECP does not have a negative impact on the graft-versus-malignancy effect of the transplant. 27. Although anecdotal evidence suggests that some immune suppressive regimens for treatment of liver GvHD result in resolution more frequently than other regimens (pulse cyclophosphamide, extracorporeal photopheresis, switching from one calcineurin inhibitor to another or sirolimus), data from controlled trials are lacking. 28. Encouraging results seen in preclinical studies attempting to translate the current knowledge about the role of cytokines in aGvHD to the clinic. However, early-phase clinical trials have either not progressed into phase III studies, or effects have not been robust within this context (for example, IL-1 and TNF inhibition). Despite these difficulties in directly translating laboratory observations to the clinic, cytokine therapy for GvHD remains fertile ground for new and effective therapeutics, because a number of agents that augment or antagonize cytokine pathways are already available, having been explored and validated in other autoimmune and inflammatory disease settings. 29. ATG is prepared by injecting cellular preparations into animals (horses or rabbits). The process of generating ATG from horses suffers more lot-to-lot and animal-to-animal variations. Therefore, the pharmacokinetics and efficacy of horse ATG are difficult to determine and doses of horse ATG vary widely. Interestingly, it has been noted that lymphopenia is more protracted after treatment with rabbit ATG compared to horse ATG (much lower numbers of regulatory Tcells).15 30. When agents that cause profound depression of T-cell function (that is, anti-thymocyte globulin, alemtuzumab, daclizumab, pentostatin) are administered, strategies for intensified surveillance and prophylaxis for opportunistic infections must be implemented when possible. For example, CMV-seropositive patients require increased monitoring for CMV reactivation, and the threshold for starting treatment with ganciclovir or foscarnet should be low. Long-term prophylaxis with mold-active antifungal agents should be administered. Since profound T-cell suppression increases the risk of EBV-lymphoproliferative disorders, adenovirus and human herpes virus 6 infections, the viral loads should be monitored during administration of second-line treatment for acute GvHD until the number of T cells in the blood has begun to recover.

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