Referral for Photopheresis in Graft-Versus-Host Disease
Referral for photopheresis in graft-versus-host disease
Extracorporeal photopheresis (ECP) is usually carried out in specialist photopheresis centres and patients are often referred for treatment from outlying hospitals or by general practitioners/ community doctors. It is important that referring doctors have a good knowledge of appropriate criteria for referring patients with graft-versus-host disease (GVHD) for photopheresis, and yet there is very little information in the literature that referring doctors can base their decisions on.
During a recent ‘Leaders of Photopheresis’ meeting on the treatment of GVHD with photopheresis, experts in GVHD and ECP were able to provide some guidance on referring patients for photopheresis therapy.
Photopheresis referral for acute graft-versus-host disease
When asked about the referral of acute graft-versus-host disease (aGVHD) patients for photopheresis, Professor James Ferrara of the University of Michigan Blood and Marrow Transplant Program cited aGVHD patients who are at high risk as being appropriate candidates for photopheresis.*41 Professor Ferrara explained that this would typically be, ‘someone who is older, who has an unrelated donor, or whose GVHD comes on early – does not respond well within a week of initiation of high-dose steroids and other therapies’.*41
According to Professor Ferrara, other candidates for photopheresis treatment include aGVHD patients whose aGVHD flares up while their steroid therapy is being tapered, or patients with infections prior to transplant.*41
Photopheresis referral for chronic graft-versus-host disease
When asked about the referral of chronic graft-versus-host disease (cGVHD) patients for photopheresis, Dr Daniel R Couriel (who works with Professor James Ferrara at the University of Michigan Blood and Marrow Transplant Program) talked about the traditionally accepted criteria for the referral of cGVHD patients for ECP.*41 According to Dr Couriel, these include patients with moderately severe too severe cGVHD (as defined by the NIH consensus); patients with cGVHD of the skin – particularly patients with sclerodermal rather than lichenoid forms; also, mucosal, dry eye, dry mouth, lichenoid changes in the mouth, vaginal, lung and liver GVHD.*41
Dr Julia Scarisbrick from St Thomas’ Hospital, London identified patients with cutaneous, mucous membrane or hepatic cGVHD as people that she would focus on for ECP referral.*41 Dr Scarisbrick also commented that, for ECP referral, patients should have ‘all of the following: having had a transplant, with proven GVHD, extensive GVHD as defined by the Seattle group, and who are either steroid-dependent or steroid-refractory’.*41
Dr Peter Taylor who is Director of the Photopheresis Unit at Rotherham Foundation Trust added that, in his experience, many patients are referred for ECP because they have problems being weaned off steroids, and that the steroid sparing effect of photopheresis is very significant in treating these patients.*41
*The views expressed here do not necessarily reflect the views of Johnson & Johnson Medical Limited.