Graft-versus-host disease (GVHD)

Graft-versus-host-disease (GVHD) can happen after an allogeneic stem cell transplant. An allogeneic transplant uses stem cells from someone else (a donor) instead of your own stem cells. The stem cells from the donor develop into a new immune system that will identify and destroy cancer cells. But it can also attack your healthy cells and cause damage to tissues and organs.

Some people who have an allogeneic transplant never get GVHD. The closer the donor’s stem cells match yours, the less likely it is that you will develop GVHD. Those who do get it will have acute GVHD or chronic GVHD or both. GVHD can be mild to very severe.

Acute GVHD usually happens in the first 100 days after an allogeneic stem cell transplant. It often affects the skin, liver and intestines but may affect other organs too.

GVHD is more likely to happen if the donor is not related to you or isn’t a close match, or if you haven’t taken the drugs that suppress the immune system after your transplant.

Acute GVHD is graded based on the severity of the symptoms:

• grade 1 – mild symptoms
• grade 2 – moderate symptoms
• grade 3 – severe symptoms
• grade 4 – very severe symptoms

Symptoms of acute GVHD include:

• burning and redness of the skin on the palms of the hands or soles of the feet
• rashes that can spread over the entire body
• blisters and peeling skin
• diarrhea, loss of appetite, cramping or abdominal pain, nausea and vomiting
• enlarged liver, liver tenderness, abnormal liver enzymes or liver failure
• jaundice

Chronic GVHD usually starts 100 or more days after an allogeneic stem cell transplant. It can last a few months or a lifetime. Chronic GVHD can happen right after you have had acute GVHD or after a time with no symptoms. It can also develop if you haven’t had acute GVHD.

Chronic GVHD can affect almost any part of the body. It can be mild to severe and cause different problems, depending on the organs affected. In some cases, chronic GVHD can permanently damage an organ.

Symptoms of chronic GVHD include:

• skin problems such as dryness, rash, itching, peeling, darkening, hard texture and feeling tight
• dry eyes that may have a burning or gritty feeling
• a dry mouth with or without mouth ulcers
• diarrhea, loss of appetite, stomach cramps, vomiting
• pain in muscles and joints
• infections
• weight loss
• difficulty breathing

To help prevent GVHD, doctors may remove some of the immune cells that cause GVHD before the stem cell transplant (called T-cell depletion). You may need to take drugs that suppress the immune system to prevent or treat GVHD. You may take these drugs for months or years after an allogeneic transplant.

The healthcare team will check you for early signs of GVHD. Tell your healthcare team if you have any symptoms.

The main drug combination given to prevent GVHD or decrease its severity is cyclosporine (Neoral) and methotrexate. Alternating cyclosporine and prednisone every other day is a common treatment.

Other drugs used in combination or alone include:

• tacrolimus
• mycophenolate
• sirolimus (Rapamune)
• thalidomide (Thalomid)
• azathioprine
• pentostatin (deoxycoformycin, Nipent)
• infliximab
• dacluzimab
• ibrutinib (Imbruvica) – for refractory chronic GVHD

Antibiotics, antifungal and antiviral drugs may be given to reduce the risk of infection while GVHD is being treated with drugs to suppress the immune system. The suppressed immune system puts you at a high risk for developing many infections. Eye drops, such as artificial tears, can be used for dry eyes. And you should protect yourself from the sun’s UV rays.