What is your escalation strategy for chronic GvHD?

There are now several available options for steroid resistant cGVHD. The old standbys - ECP and rituxan are useful in about 30% of patients. Ibrutinib was the first new drug to get FDA approval. Unfortunately, I don't think the real-world experience is anywhere near as good as the trial (Chin et al., PMID 34481113), it was a small study and there was undoubtedly some selection bias. The other 2 drugs are ruxolitinib and belumosudil. Rux works pretty well - in the range of 50% response rate, virtually no CR, and no lung responses. Cytopenias can be limiting, Belumosudil has a 70% response rate with CRs and activity in the lung. it is possible that rux and belu will have additive or synergistic effects but there are no data yet. They have dif...