Management of acute graft-versus-host disease

Current graft-versus-host disease (GVHD) prophylaxis is not uniformly successful. Since the development of GVHD has a profound impact on transplant success, treatment is required. The mainstay of therapy has been glucocorticoids (steroids), along with anti-thymocyte globulin, cyclosporine, monoclonal antibodies, and aggressive supportive care, resulting in response rates of 30-50%, dependent upon severity of the disease, type of transplant, underlying diagnosis, prophylaxis given and other factors. Dose intensification or combinations of agents may increase response rates (60-80%), however, without necessarily improving survival, due to intervening complications. Nevertheless, patients with complete responses have a higher probability of survival, and a subgroup of patients will not develop chronic GVHD. As our understanding of cell recruitment, cell interactions and cytokine networks improves, new strategies are likely to be developed. The sequential use of antibodies directed at different cell populations or cytokines, along with anti-inflammatory measures, may be helpful. Prevention of GVHD has to remain our objective; however, efforts at therapy must continue until that goal is achieved.