ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

General guidelines for monitoring and management of new airflow obstruction after hematopoietic stem cell transplantation

General guidelines for monitoring and management of new airflow obstruction after hematopoietic stem cell transplantation
Guidelines
A. Significant new airflow obstruction with a % predicted FEV1 ≥70%
  1. Initiate inhaled glucocorticoid therapy. Add inhaled long-acting beta agonist, if patient symptomatic. Treatment should continue until either FEV1 becomes <70% (see B below) or until GVHD resolves (ie, resolution of all reversible manifestations of GVHD without exacerbation for at least 6 months after discontinuation of all systemic immunosuppressive treatment)
  2. Other immunosuppressive treatment as indicated to control GVHD in other organs
    • Treatment should continue until either FEV1 becomes <70% (see B below), or until GVHD resolves (ie, resolution of all reversible manifestation of GVHD without exacerbation for at least 12 months after discontinuation of all systemic treatments)
  3. Monitor PFTs or spirometry monthly for at least 3 months
    • If FEV1 stabilizes, obtain PFTs or spirometry every 3 months for 1 year, then continue at 6 month intervals for 1 year and at 6 to 12 month intervals thereafter
    • If FEV1 continues to decrease, go to B below
B. Significant airflow obstruction with a FEV1 <70% with/without significant airtrapping by high resolution chest CT
  1. Consider bronchoscopy to rule out an undetected infectious etiology for airflow obstruction, even if no radiographic opacity is apparent
  2. After infection has been ruled out, evaluate the patient's eligibility for clinical trial for treatment of BOS and initiate (or increase) prednisone dose to 1 mg/kg per day
    • Start standard chronic GVHD taper at 2 weeks
    • Consider continuing inhaled glucocorticoids throughout prednisone therapy
  3. If FEV1 decreases further to <70% during treatment, discuss changes of immunosuppressive treatment with transplant physician
  4. CMV monitoring in blood per standard practice
  5. Monitor PFTs or spirometry monthly for at least 3 months
    • If FEV1 stabilizes, continue PFTs or spirometry every 3 months for 1 year
    • If FEV1 continues to decrease, go to C below
C. Glucocorticoid-resistant airflow obstruction defined as progressive decline of FEV1 by ≥10% despite treatment with 1 mg/kg per day of prednisone (or similar glucocorticoids)
  1. May consider increasing the dose of prednisone to 2 mg/kg per day for a maximum of 2 weeks, followed by a taper to reach a dose of 1 mg/kg per day by 2 to 4 weeks
  2. Another treatment must be considered and discussed with the transplant team
  3. Monitor CMV in blood per standard practice
  4. Monitor PFTs monthly for at least 3 months
    • If FEV1 stabilizes, monitor PFTs every 3 months for 1 year
D. Additional considerations
  1. Consider changing prophylaxis for encapsulated bacterial infection to azithromycin 250 mg on Mondays-Wednesdays-Fridays
    • Assure patient is receiving adequate prophylaxis for Pneumocystis, varicella virus, and herpes simplex virus infections
    • Fungal prophylaxis per standard practice
  2. Monitor CMV in blood per standard practice
  3. May continue inhaled glucocorticoids throughout prednisone therapy
  4. Discontinuation of inhaled glucocorticoid treatment can be considered 12 months after treatment with prednisone has been discontinued
Before considering treatment, all potential infectious etiologies of airflow obstruction must be investigated and treated if present. Investigations that should be considered (directed by clinical symptoms), include sinus CT scan, nasal washes, sinus aspiration, high-resolution chest CT scan, sputum culture, bronchoalveolar lavage, and lung biopsy.
FEV1: forced expiratory volume in one second; GVHD: graft-versus-host disease; PFT: pulmonary function test; CT: computed tomography; CMV: cytomegalovirus.
Reproduced with permission of the American Society of Hematology, from Flowers ME, Martin PJ. How we treat chronic graft-versus-host disease. Blood 2015; 125:606; permission conveyed through Copyright Clearance Center, Inc.
Graphic 105278 Version 7.0

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟