Variation in management of immune suppression after allogeneic hematopoietic cell transplantation

Abstract

Practice variation in transplant physician management of immune suppression (IS) after allogeneic hematopoietic cell transplantation (HCT) is anticipated to have important consequences, but has not been characterized to date. We conducted a national survey of transplant physician members of the American Society for Blood and Marrow Transplantation to discern variation in IS management, characterize the burden of graft-versus-host disease (GVHD) emerging in the setting of IS taper, and describe the proportion of HCT recipients who successfully discontinue IS by 2 and 5 years post-HCT. There was marked heterogeneity in IS discontinuation practice, with variation in initiation of taper, sequence of agents tapered, frequency of changes, and strategy utilized. Twenty-five percent reported no consistent strategy in their usual practice. Confidence in therapeutic decision making was limited. The majority indicated that they could not predict who would develop GVHD on taper of IS, and reported a resultant burden of both acute and chronic GVHD (aGVHD, cGVHD) emerging or recurring in the setting of IS taper. HCT physicians projected rates of IS discontinuation that increased from 2 to 5 years post-HCT, and differed significantly according to donor relation and stem cell source utilized. 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 data argue for more rigorous study of IS management post-HCT so that evidence-based practice guidelines can be developed.

Figure 1

Frequency histogram of reported day post-HCT for initiation of immune suppression taper.

Figure 2

Frequency distribution of estimated rates of recurrent aGVHD following IS taper. PBSCT = ablative conditioning, peripheral blood stem cells; BMT = ablative conditioning, bone marrow; MUD = ablative conditioning, unrelated donor peripheral blood stem cells; RIC = reduced-intensity conditioning, peripheral blood stem cells; post-resolved GVHD = recurrent aGVHD in setting of IS taper following prior successfully treated episode of aGVHD (P <.05 for comparisons between each group, with exception of the comparison of myeloablative PBSCT and RIC PBSCT).

Figure 3

Estimated recurrent cGVHD in the setting of IS taper following successful control of a prior episode of cGVHD.

Figure 4

Frequency distribution of estimated rate of IS discontinuation at 2 years after HCT according to clinical vignette. MRD = matched related donor; MUD = matched unrelated donor; MAC = myeloablative conditioning; RIC = reduced-intensity conditioning; PBSC = peripheral blood stem cells; BM = bone marrow stem cells. The proportions off IS are compared between each of these clinical vignettes by Bowker's test with P <.05 for each, except the comparison of MRD/MAC/PBSC and MRD/RIC/PBSC vignettes, where P = NS.

Figure 5

Frequency distribution of estimated rate of IS discontinuation at 5 years after HCT according to clinical vignette. MRD = matched related donor; MUD = matched unrelated donor; MAC = myeloablative conditioning; RIC = reduced-intensity conditioning; PBSC = peripheral blood stem cells; BM = bone marrow stem cells. The proportions off IS are compared between each of these clinical vignettes by Bowker's test with P <.05 for each, except the comparison of MRD/MAC/PBSC and MRD/RIC/PBSC vignettes, where P = NS.