Clinical Management of Acute Graft-Versus-Host Disease: An Evidence-Based Review from the ASTCT Committee on Practice Guidelines

Acute graft-versus-host disease (GVHD) is a well-established complication of allogeneic hematopoietic cell transplantation. Although the incidence of severe acute GVHD is decreasing with advances in prophylactic approaches, many clinical questions remain. Herein, acute GVHD diagnosis, grading, and treatment are reviewed and critically evaluated. Specific criteria were used for searching the published literature, grading the quality and strength of evidence, and grading the strength of recommendations. A panel of experts developed consensus recommendations for the clinical management of acute GVHD, providing guidance on behalf of the American Society for Transplantation and Cellular Therapy. Key recommendations include: 1) The MAGIC grading scheme is supported as the consensus grading scheme for acute GVHD; 2) Clinical tools and non-invasive blood-based biomarkers can aid in risk stratification of patients with newly diagnosed acute GVHD; 3) Corticosteroids remain the recommended first-line systemic therapy for acute GVHD, despite innovative approaches to improve front-line treatment; 4) Ruxolitinib is supported as the second-line therapy standard, while acknowledging remestemcel-L-rknd is a recognized alternative standard for pediatric patients. Finally, no consensus treatment exists for third-line therapy. Ongoing and future studies will seek to improve upon the current treatment paradigm through risk-adapted strategies. Innovative investigative approaches will be needed to address the unmet needs in acute GVHD.