Evaluation of Corticosteroids for Engraftment Syndrome (ES) Prophylaxis in Patients Undergoing Autologous Hematopoietic Cell Transplantation (AHCT) with High-Dose Melphalan (MEL)

Abstract

Background ES is a potential complication following AHCT. First-line treatment typically involves corticosteroids (CS). In 2002, due to historically high ES incidence resulting in prolonged hospitalizations requiring CS treatment, our institution adopted the practice of administering prophylactic CS in patients undergoing AHCT. Due to lack of contemporary evidence supporting ES prophylaxis as well as potential intolerance of prophylactic CS noted in our patient population, a pilot was instituted to remove prophylactic CS from MEL conditioning regimen for multiple myeloma (MM) or amyloidosis. Objectives The primary objective was to evaluate the impact of prophylactic CS on the incidence of ES. Secondary objectives included hospital length of stay (LOS), duration of intravenous (IV) opioid administration during hospitalization, and incidence of infection, fever, or 30-day readmission due to any cause. Methods Beginning December 2016, CS for ES prophylaxis were removed from our standard of care in patients receiving MEL. Prior to this pilot, patients received methylprednisolone 40 mg IV daily from day +5 to day +15 or hospital discharge (whichever occurred sooner). We retrospectively reviewed the charts of patients receiving MEL from June 1 to December 15 of 2016 (CS group) and December 16, 2016 to June 30, 2017 (CS-free group). ES was defined as noninfectious fever >38°C and new documented rash at the time of engraftment (between day +7 to +11). Results A total of 76 patients were reviewed (CS group, n = 40; CS-free group, n = 36). Baseline characteristics were similar between groups in terms of median age (63 vs. 63 years, p = .65), sex (62.5% vs. 56% male, p = .54), and median CD34+ cell dose (6.36 vs. 6.43 × 106 cells/kg, p = .75). There was no difference in the incidence of documented ES between the CS and CS-free groups (2.5% vs. 0%, p = 1.00). There were no significant differences in median hospital LOS (14 vs. 14 days, p = .67), incidence of infection (17.5% vs. 22.2%, p = .61), incidence of fever (25% vs. 25%, p = .81), and 30-day readmission rate (17.5% vs. 11.1%, p = .43) in CS vs. CS-free groups, respectively. Patients in the CS group received significantly more days of IV opioid administration (median 4.5 vs. 4.0, p = .01). A greater proportion of patients received treatment with CS for suspected ES in the CS-free group compared to the CS group (8.3% vs. 2.5%, p = .34), possibly due to the strict conditions required for our definition of ES or the preemptive use of CS. Conclusions These results suggest a low overall incidence of ES in MM or amyloidosis patients undergoing AHCT using MEL. The use of prophylactic CS did not have a significant impact on incidence of ES which could be attributed to the pre-specified definition of ES. A preemptive strategy of using CS in patients with suspected ES may be sufficient in ameliorating symptoms associated with this syndrome.