Work

Variation in Management of Immune Suppression After Allogeneic Hematopoietic Cell Transplantation: Results of a National Survey of Asbmt Transplant Physicians

Year: 2011

Type: article

Abstract: Practice variation in immune suppression (IS) liberation after allogeneic hematopoietic cell transplantation (HCT) is anticipated to have important consequences, but has not been characterized to date. We conducted a survey of transplant physician members of the American Society for Blood and Marrow Transplantation to discern variation in IS management and attitudes toward this practice, characterize the burden of GVHD in the setting of IS taper, and to describe the proportion of HCT recipients who successfully liberate from IS by 2 and 5 years. From 1,100 eligible physicians, 225 (21%) completed the electronic survey. Practice varied according to reported time of initiation of IS taper post-HCT, sequence of agents tapered, frequency of changes, and strategy utilized; 25% reported no consistent strategy. In the presence of post-HCT relapse, 71% of respondents recommended stopping all IS agents, and 50% utilized donor lymphocyte infusion. Confidence in therapeutic decision making was limited: Most reported no consistent practice guidelines, 41% reported that their current IS liberation strategy is not adequate, and 26% reported being either uncomfortable or very uncomfortable with making decisions on IS management. The majority indicated that they could not predict who would develop GVHD on taper of IS, and reported a resultant burden of GVHD emerging or recurring in the setting of IS taper. In the setting of recurrent GVHD following IS taper, therapeutic approaches differed: 44% resumed the original IS agents; 73% started 1-2mg/kg of steroids; and 16% both started 1-2mg/kg steroids and added an additional systemic IS agent. The potential adverse consequence of GVHD emerging or recurring in the setting of IS taper was highlighted by HCT physicians' self-report of the proportion of these cases that are not successfully treated to resolution. Projected rates of IS liberation increased from 2 to 5 years post-HCT, and differed significantly according to donor relation and stem cell source utilized (p < 0.05). The marked variation in practice, burden of GVHD emerging in the setting of IS taper, and limited confidence in therapeutic decision making all highlight shortcomings in an essential component of HCT physicians' scope of practice. These findings argue for both more rigorous study of IS liberation post-HCT and development of evidence-based practice guidelines.

Source: Transplantation and Cellular Therapy

DOI: 10.1016/j.bbmt.2010.12.261

Authors: J. Pidala, S.J. Lee, G. Quinn, H. Jim, J. Kim, C. Anasetti

Institutions: Moffitt Cancer Center, Fred Hutch Cancer Center

Language: English

Topic: Hematopoietic Stem Cell Transplantation

Subfield: Hematology

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: hybrid

Estimated APC paid: $3,650