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Blood is taken out through a machine, the white cells are treated with a light-sensitive drug and ultraviolet light, and given back. It is used for GvHD that steroids have not controlled, mainly skin and mouth, and it spares people more immunosuppression. Improvement builds over months, so it means two sessions a week for a long time.
Extracorporeal photopheresis passes blood through a continuous-flow apheresis machine, collects the mononuclear cell fraction, exposes it to 8-methoxypsoralen and ultraviolet A light, and reinfuses it. OnCo holds the drug record `methoxsalen-ecp` for the psoralen itself; this record is about what the procedure does in graft-versus-host disease.
The randomised evidence is honest and limited. A multicentre prospective phase 2 randomised study compared 12 to 24 weeks of photopheresis plus standard therapy against standard therapy alone in 95 patients with cutaneous chronic GvHD not adequately controlled by corticosteroids, 48 in the photopheresis arm and 47 in the control arm. The primary endpoint, a blinded quantitative comparison of the percentage change from baseline in Total Skin Score across 10 body regions at week 12, was not met: median improvement was 14.5 per cent with photopheresis and 8.5 per cent in the control arm, P = 0.48. Two secondary findings were positive. The proportion of patients who had at least a 50 per cent reduction in steroid dose and at least a 25 per cent decrease in Total Skin Score was 8.3 per cent with photopheresis and 0 per cent in the control arm, P = 0.04; and the non-blinded investigator assessment of skin complete or partial response favoured photopheresis, P less than 0.001. The authors' own conclusion was that the results suggest a steroid-sparing effect.
The crossover extension explains why the first trial may have measured too early. Twenty-nine control-arm patients who had progressed or not improved crossed over to a 24-week course: three treatments in week one, then twice weekly to week 12, then two treatments monthly to week 24. Twenty-five of 29 completed it. Complete or partial skin response at week 24 was seen in 9 patients, 31 per cent. The median percentage decrease in Total Skin Score was 7.9 per cent at week 12 and 25.8 per cent at week 24, so most of the improvement arrived in the second twelve weeks. A 50 per cent or greater reduction in corticosteroid dose was achieved by 17 per cent at week 12 and 33 per cent at week 24. Extracutaneous response was highest in the mouth, where 70 per cent had complete or partial resolution after week 24. The authors concluded that prolonged photopheresis appears to be necessary for optimal therapeutic effects.
What that means for a person considering it. The treatment is not fast and the evidence says so plainly: judging it at twelve weeks underestimates it, and the trials that support it are small. Against that, it adds no systemic immunosuppression, which in someone already on several immunosuppressive drugs and at risk of infection is a genuine advantage, and the steroid-sparing effect, if it is achieved, removes a drug whose own late effects, bone loss, avascular necrosis, cataract, diabetes and infection, are among the worst in this file. The practical costs are real: vascular access, two visits a week for months, and availability, since photopheresis is offered only at centres with the equipment and the trained apheresis staff.
The grade is moderate: randomised trials exist, they are small, and the primary endpoint of the main one was not met while its steroid-sparing secondary endpoint was.
Psoralen intercalates into DNA and, on absorbing ultraviolet A, cross-links it, so the treated mononuclear cells undergo apoptosis after reinfusion. The apoptotic cells are taken up by host antigen-presenting cells, which shifts them towards a tolerogenic phenotype and expands regulatory T cells, producing immune modulation rather than immune suppression. That is the mechanistic reason photopheresis does not raise infection risk the way an added immunosuppressant does, and also the reason it works slowly.
Uvadex is the drug used in photopheresis, where a patient's white cells are drawn off, treated with methoxsalen and ultraviolet light, and returned; it is approved for the skin symptoms of cutaneous T-cell lymphoma and widely used for graft-versus-host disease.
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Shares After ruxolitinib: belumosudil, axatilimab and ibrutinib in chronic GvHD, When steroids fail: ruxolitinib for steroid-refractory GvHD, Chronic GvHD organ by organ: skin, mouth, eyes, gut, liver, joints and genital tract, Chronic graft-versus-host disease and the tags rejuvenation, survivorship, transplant, gvhd.
Shares When steroids fail: ruxolitinib for steroid-refractory GvHD, Chronic GvHD organ by organ: skin, mouth, eyes, gut, liver, joints and genital tract, Chronic graft-versus-host disease, Graft-versus-host disease (GVHD) and graft-versus-leukaemia and the tags rejuvenation, survivorship, transplant, gvhd.
Shares When steroids fail: ruxolitinib for steroid-refractory GvHD, Chronic graft-versus-host disease, Graft-versus-host disease (GVHD) and graft-versus-leukaemia, After a transplant or cell therapy: what to ask for and the tags rejuvenation, survivorship, transplant, gvhd.
Shares Chronic graft-versus-host disease, Graft-versus-host disease (GVHD) and graft-versus-leukaemia, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant.
Shares Chronic graft-versus-host disease, Graft-versus-host disease (GVHD) and graft-versus-leukaemia, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant.
Shares Chronic graft-versus-host disease, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation, Survivorship and late effects are neglected and the tags rejuvenation, survivorship, transplant.
Shares Chronic GvHD organ by organ: skin, mouth, eyes, gut, liver, joints and genital tract, Chronic graft-versus-host disease, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant.
Shares Chronic GvHD organ by organ: skin, mouth, eyes, gut, liver, joints and genital tract, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation, Survivorship and late effects are neglected and the tags rejuvenation, survivorship, transplant.