Treatment of gastrointestinal acute graft-versus-host disease

Therapy of acute graft-versus-host disease (GVHD) aims to selectively alter the graft-host interactions to foster antitumor effect and minimize antihost effects. The immunosuppression produced by the various therapies ranges from broad, nonselective effects to relatively narrow targeted impact. Despite advances in understanding the pathophysiology of GVHD, newer agents with more selective effects have not yet produced therapeutic advances. The newer targeted agents continue to produce a degree of immunosuppression in which infection and relapse of malignancy are all too common. High-dose systemic steroids remain, as they have for two decades, the initial treatment of choice. Patients failing to respond to steroids continue to represent a challenge, as no second-line therapy is clearly superior to the others. However, some of the new agents appear to be particularly effective in certain organs involved with acute GVHD. For those patients with steroid-refractory GVHD involving primarily the gut, we favor infliximab with concomitant antifungal therapy. For those with primarily skin or liver disease, we favor extracorporeal photochemotherapy.