Howell, M., Lee, R., Bowyer, S., Fusi, A., & Lorigan, P. (2015). Optimal management of immune-related toxicities associated with checkpoint inhibitors in lung cancer. Lung Cancer, 88, 117–123. 

DOI Link

Purpose & Patient Population

PURPOSE: To provide recommendations on the management of immune-related toxicities from checkpoint inhibitors
 
TYPES OF PATIENTS ADDRESSED: Treatment with checkpoint inhibitors

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Expert opinion

PROCESS OF DEVELOPMENT: Review article
 
DATABASES USED: None
 
INCLUSION CRITERIA: None
 
EXCLUSION CRITERIA: None

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment

Results Provided in the Reference

Briefly reviews the management of diarrhea related to checkpoint inhibitor adverse reactions.

Guidelines & Recommendations

Brief review of available literature: Holding therapy is appropriate based on grade of toxicity. Management of toxicities is based on grade. Provide supportive therapy based on type and grade of toxicity. Steroids are commonly used and are route-based on grade/severity. Taper steroids over four weeks appropriately to avoid rebound toxicity.  
 
Diarrhea: Grade 1–2: Antidiarrheal medications; supportive care, such as hydration and electrolyte replacement orally. Grade 2: Manage diarrhea lasting more than five days with prednisolone 0.5 mg/kg or equivalent with dose adjusted to meet patient needs; consider colonoscopy. Grade 3–4: IV steroids (1–2 mg/kg daily methylprednisolone or equivalent). After grade 1 diarrhea is achieved, taper slowly over four weeks to avoid rebound diarrhea. Steroid refractory diarrhea: Use infliximab except in patients with sepsis or bowel perforation. All patients with colitis need stool cultures.  
 
Skin: Grade 1–2: Topical medications, such as emollients, 1% hydrocortisone cream, or similar steroid cream and antihistamines. Grade 3–4: Referral to dermatology for evaluation and 1–2 mg/kg/day prednisolone or equivalent. After resolution of grade 3 skin reactions to grade 1, taper steroids.
 
Pneumonitis: Grade 1: Monitor. Grade 2: Hold therapy and start 1 mg/kg/day prednisolone or equivalent. Consider hospitalization and pulmonary physician consult. With recurrence, stop checkpoint inhibitor therapy. Grade 3–4: Hospitalization required, pulmonary physician consult required, and IV high dose steroids 2–4 mg/kg/day methylprednisolone or equivalent. If persistent bronchoscopy with biopsy, infliximab may be considered, although evidence is limited.

Limitations

Brief literature review of common checkpoint inhibitor adverse and serious adverse events. No evidence quality review was provided.

Nursing Implications

Patient education is crucial to the early reporting of adverse events that develop in patients after treatment with checkpoint inhibitors. Closely monitor patients with evidence of adverse events. Hospitalization and aggressive patient support may be required for serious adverse events.