Table 1. Manifestations, Evaluation, and Management of Multimorbidity Associated With Chronic Graft-Versus-Host Disease and its Treatment.

System	Manifestations	Evaluation/Monitoring	Management
Cardiovascular	Insulin resistance, post-transplant diabetes mellitus Dyslipidemia Accelerated atherosclerosis	Lipid profile Fasting blood sugar and A1c measurement	Cardio-oncology referral Endocrinology referral Consideration of lipid-lowering therapies Nutrition and exercise therapy
Bone	Osteopenia and osteoporosis Fragility fracture Osteonecrosis of the jaw (ONJ) Avascular necrosis (AVN) of bone	Vitamin D level Dual-energy x-ray absorptiometry imaging Magnetic resonance imaging if concerned for ONJ and AVN of bone	Weight bearing and resistance exercise Calcium and vitamin D supplementation Bisphosphonate therapy Endocrinology referral for advanced osteoporosis Orthopedics referral for AVN of bone for arthroplasty
Endocrine	Adrenal insufficiency Symptomatic hypothyroidism Premature gonadal failure Women: Premature menopause, hypoestrogenism, vulvovaginal atrophy Men: Symptoms of low testosterone, erectile dysfunction	Thyroid function testing Measurement of hormones in hypothalamic-pituitary-adrenal axis	Endocrinology referral Hormone replacement therapy Stress dose steroids when acutely ill
Sexual Health	Women: vulvovaginal lesions, vulvar pain, vaginal dryness, dyspareunia, post-coital bleeding, decreased fertility Men: balanoposthitis, lichen sclerosis-like changes, phimosis, urethral meatal stenosis, Peyronie’s disease, erectile dysfunction, decreased fertility	Gynecological exam and potential biopsy to rule out superimposed or secondary cause in women Urological exam	Reproductive endocrinology referral Gynecology referral Urology referral Topical steroids and calcineurin inhibitors Topical estrogen for women
Ocular Health	Keratoconjunctivitis sicca: dry eyes, burning, photosensitivity, foreign body sensation Conjunctivitis, conjunctival fibrosis Corneal ulceration or perforation Glaucoma Cataracts	Ophthalmologic evaluation: slit lamp exam, corneal fluorescein staining, Schirmer’s test, tonometry	Ophthalmology referral Artificial tears Topical steroids and calcineurin inhibitors Scleral lenses Phacoemulsification for cataracts Glaucoma therapy
Pulmonary	Obstructive lung disease: bronchiolitis obliterans syndrome Cough, wheezing, dyspnea Hypoxemia and respiratory failure Opportunistic pulmonary infections, bronchiectasis	Pulmonary function testing High resolution chest computed tomography Bronchoscopy	Pulmonary rehabilitation Fluticasone, azithromycin, montelukast Inhaled bronchodilators Prophylactic antimicrobials