On August 14-15, the 2020 China Hematology Conference and the 14th Annual Meeting of Hematologists of the Chinese Medical Doctor Association jointly sponsored by the Chinese Medical Doctor Association and the Hematologist Branch of the Chinese Medical Doctor Association were held in Suzhou. At the meeting, Professor Xu Lanping from the Department of Hematology, Peking University People's Hospital, gave a speech on the topic of "Diagnosis and Treatment of aGVHD from the 2020 Consensus". Yimaitong organized the main contents of the report as follows.
2020 EBMT GVHD consensus update
Professor Xu gave a brief introduction to the acute graft-versus-host disease (aGVHD) treatment part of the 2020 EBMT consensus. Please see Figure 1 and Figure 2 for first-line treatment recommendations.
Figure 1
Figure 2
2020 EBMT consensus, second-line therapy is recommended for patients with hormone resistance or dependence, but there is no standard second-line therapy for aGVHD. The currently practiced prescription drugs are shown in Figure 3 (listed in alphabetical order).
Figure 3
2020 NCCN HCT guidelines update
The first-line treatment recommendations for aGVHD in the NCCN guidelines are similar to the EBMT consensus, as shown in Figure 4
Figure 4
In addition, the NCCN guidelines have also updated the definition of steroid response as follows (Figure 5).
Figure 5
aGVHD's second-line treatment is similar to the EBMT consensus. There is no clear recommendation order. They are listed in alphabetical order. The red font is consistent recommendation. As shown in Figure 6.
Figure 6
2020 China Allogeneic HSCT Expert Consensus
Expert Consensus of China Allogeneic Hematopoietic Stem Cell Transplantation for Treatment of Hematological Diseases (Ⅲ)-Acute Graft Versus Host Disease (2020 Edition), on the basis of international guidelines, including Chinese physicians in this field The main research results and clinical experience are jointly completed by 22 authoritative experts in the field. The purpose is to form a diagnosis and treatment standard suitable for China's conditions, provide guiding opinions for each transplant unit, and lay a good foundation for communication and cooperation between transplant centers Foundation. Professor Xu briefly introduced the diagnosis and treatment of aGVHD in the consensus:
01 The differential diagnosis and severity of aGVHD The diagnosis and classification of
aGVHD are mainly based on clinical manifestations. Biopsy can be performed when identification is difficult.
There are three main methods for the indexing standard: modified Glucksberg standard (most commonly used in clinical practice); MAGIC grading system (applied in recent years has a tendency to increase); IBMTR grading system.
02 The efficacy evaluation criteria and the definition of glucocorticoid-resistant aGVHD The efficacy evaluation indicators of
aGVHD include complete remission (CR), partial remission (PR), non-response (NR), disease progression (PD):
CR: aGVHD in all organs involved The performance disappeared completely;
PR: The aGVHD of all the initially involved organs improved (at least 1 grade), but did not achieve complete remission, and no other target organs aGVHD worsened;
NR: The aGVHD severity of any organ did not improve or worsen or the patient Death;
PD: aGVHD of at least 1 target organ increased (at least 1 grade), with or without improvement of aGVHD of other organs.
Among them, CR and PR are effective in treatment, and NR and PD are ineffective in treatment.
In addition, adrenal glucocorticoid-resistant aGVHD is defined as: in the evaluation of the efficacy of aGVHD, the first-line glucocorticoid is evaluated as PD within 3-5 days, 5-7 within 5-7 days as NR, or CR within 14 days. Glucocorticoid resistance and glucocorticoid dependence are failures of glucocorticoid therapy.
03 The treatment of aGVHD The first-line treatment of
aGVHD:
In principle, degree 1 aGVHD can be closely observed and treated locally. Once diagnosed, the first-line treatment of aGVHD of degree 2 and above should be started immediately. Non-blood relationship (URD) and haplotypeo) First-line treatment should be started immediately after transplantation for degree 1 aGVHD. The first-line treatment for
is methylprednisolone (MP). The recommended starting dose is 1mg/kg/d or 2mg/kg/d (intravenously divided into 2 times). At the same time, the trough concentration of cyclosporin A (CsA) is adjusted to 150 -250μg/L. If
is effective: Reduce the dose after CR, and reduce MP 10-20mg/d (or equivalent dose of other glucocorticoids) for 5-7 days in adult patients, and reduce to 10% of the initial dose in 4 weeks. In children, the dose is reduced slowly in proportion to the adult.
If hormone resistance appears: add second-line drugs and stop glucocorticoids.
If hormone dependence occurs: stop glucocorticoids after the second-line drugs take effect. Second-line treatment of
aGVHD:
, in principle, add second-line drugs to the effective concentration of CsA;
when a second-line drug is ineffective, switch to another second-line drug;
has no unified second-line drug selection process, generally follow their respective centers The principle of medication;
encourage patients to participate in clinical trials.
04 Local management of affected organs
For the skin: keep clean, apply skin protectants locally to reduce exudation
For the gastrointestinal tract:
Pay attention to gastrointestinal rest, reduce or stop oral intake, partial or full parenteral nutrition Add calories
Pay attention to the acid-base balance of water and electricity
Give empirical antibiotics when infection cannot be excluded. It is not recommended to actively use astringents for symptomatic patients with blood in the stool to strengthen blood transfusion support. For the liver: Use hepatotoxic drugs with caution
Finally, Professor Xu pointed out the diagnosis and There are still unmet needs in treatment. At this stage, prevention of aGVHD is more important than treatment, and differential diagnosis and empirical treatment are part of diagnosis and differentiation.
