Acute and Chronic Graft Versus Host Disease (GVHD) Management in the Eastern Mediterranean Region: Result of the Worldwide Network for Blood & Marrow Transplantation (WBMT) Global GvHD Survey.

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Introduction Despite the approval of multiple therapies for acute and chronic GVHD over the past few years, it continues to be an area of need, particularly in cases of refractory GVHD where options remain limited. Objective To understand the current practices of GVHD management in the Eastern Mediterranean (EM) Region. Methodology As part of the WBMT global GVHD survey, a 46-item questionnaire was distributed electronically to the hematopoietic cell transplantation (HCT) programs in the EM region between December 2022 and June 2023. The questionnaire addressed different aspects of acute and chronic GVHD management and supportive care. Results The survey was completed by 30 programs in 26 different institutions. Responses were from 11 countries, with ten centers participating from Saudi Arabia. Additionally, we received three responses from centers in Pakistan and Egypt, two from Iran, Algeria, Lebanon, Jordan, Oman, and Morocco, and one from Tunisia and Kuwait. Regarding acute GVHD (aGVHD) management, the most commonly reported initial reported prednisone dose was 1 mg/kg/day for grade IIa and 2 mg/kg/day for grade IIb. Most programs report continuing immunosuppressive therapy along with prednisone or reintroducing it if GVHD develops after its cessation. Ruxolitinib was the most frequently identified medication as a possible second-line treatment by 83% of the programs. This was followed by calcineurin inhibitors (47%), high-dose steroids (>2 mg/kg, 43%), MMF (40%), and ECP (40%). The frequencies were similar across disease-specific GvHD. Two (7%) programs reported the inclusion of steroid-refractory aGVHD patients in clinical trials, and 30% reported having no standard operating procedure (SOP). For chronic GVHD (cGVHD) management, systemic steroids are used for initial management of mild cGVHD not accessible by topical treatment and moderate/severe disease with a most commonly used initial dose of 0.5-1 and >1 mg/kg/day, respectively. Twenty-one (70%) programs use another agent in addition to steroids in patients who develop moderate/severe cGVHD patients while off immunosuppressive therapy. For steroid-refractory cGVHD, most programs selected multiple options in the second line setting, with the most frequently selected options being ruxolitinib (80%), calcineurin inhibitors (67%), MMF (53%), imatinib (53%), ECP (50%), rituximab (47%) and ibrutinib (40%). No program has reported the use of belumosudil. Three (10%) centers reported including steroid-refractory cGVHD patients in clinical trials, and 13 centers (43%) reported having no SOP for their management. Additionally, only 6 (20%) programs reported having a multi-disciplinary cGVHD team. Conclusion Although most practices in the EM region align with current guidelines, our results highlight the need to increase access to clinical trials and multi-disciplinary supporting teams.

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