General measures—good nutrition and weight maintenance important. TPN may be necessary. IV antibiotics and antifungals often necessary in the absence of neutropenia and signs of infection may be masked by steroids. Continue cyclosporin during acute GvHD ensuring levels are not toxic.

Specific treatment should always be discussed with an experienced haemato-oncologist. Now known that mild GvHD confers a GvL effect (see p297) in the patient and mild forms of skin GvHD may require no treatment.

Overall grade

I-II Begin with prednisolone 1-2mg/kg/d PO. If response, taper dose slowly. If no response, consider progressing to high dose methyl prednisolone.

II-IV Give high dose methylprednisolone 20mg/kg/over 1h bd IV for 48h, then 5 dose by 50% every 48h.

Side effects of methylprednisolone

• Gastritis/peptic ulceration—use proton pump inhibitors rather than H2 blockers.

• Hyperglycaemia, particularly when TPN in use. May require insulin infusion.

• Hypertension may be potentiated by cyclosporin and by fluid retention—treat with diuretics and nifedipine.

• Insomnia and psychosis.

Failure of response to high dose methylprednisolone

Discuss with senior colleague. Outlook poor. Various empirical possibilities include tacrolimus, infusion of Campath or ALG.

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