Table 4.

Limitations of conventional therapy in HLH.

S. No.	Recommendation	Grade of evidence	Level of agreement (%)
17.	Conventional immunochemotherapy (e.g., corticosteroids plus etoposide) is constrained by significant toxicity and limited durable efficacy in adults and complex HLH cases, supporting the need for risk-adapted and alternative therapeutic strategies beyond etoposide-based regimens.	Moderate	100% (15/15)
18.	Standard HLH therapy may be impractical or unsafe in patients with severe organ dysfunction, comorbidities, or frailty, necessitating alternative or tailored approaches.	Moderate	100% (15/15)
19.	As conventional therapy does not directly address persistent triggers, it may be insufficient in cases driven by chronic infection, malignancy, or complex immune dysregulation.	Low	93% (14/15)
20.	There is a need for targeted, risk-adapted therapies to overcome the toxicity, feasibility, and efficacy limitations of conventional treatment in HLH.	Low	100% (15/15)

Level of agreement was calculated as the proportion of respondents selecting either “agree” or “somewhat agree”.

HLH, hemophagocytic lymphohistiocytosis.