Klair, J.S., Girotra, M., Hutchins, L.F., Caradine, K.D., Aduli, F., & Garcia-Saenz-de-Sicilia, M. (2016). Ipilimumab-induced gastrointestinal toxicities: A management algorithm. Digestive Diseases and Sciences, 61, 2132–2139. 

DOI Link

Purpose & Patient Population

PURPOSE: To provide awareness to gastroenterologists regarding the wide spectrum of gastrointestinal toxicity of ipilimumab
 
TYPES OF PATIENTS ADDRESSED: Patients with recurrent or malignant melanoma

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Expert opinion

INCLUSION CRITERIA: Ipilimumab, colitis, perforation, metastatic melanoma

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment 
 
APPLICATIONS: Elder care

Results Provided in the Reference

The authors developed an algorithm for caring for patients who develop diarrhea with ipilimumab treatment. Three case studies were outlined. In one study, a patient developed autoimmune colitis after an infectious diarrhea workup was negative, was treated with high-dose glucocorticoids, and improved. Another patient presented with bloody diarrhea, leukocytosis, negative stool cultures, and negative C-difficile. A colonoscopy showed severe active colitis with ulcerations that were inflammatory based on biopsy and pathology. The patient was treated with infliximab and improved. The third patient presented with nausea/vomiting, and diarrhea for one week, had negative stool and C-difficile cultures, no leukocytosis, and a normal erythrocyte sedimentation rate. Autoimmune colitis was noted on a sigmoidoscopy. The patient improved with glucocorticoids.

Guidelines & Recommendations

1. Infectious diarrhea workup with onset of diarrhea during ipilimumab with consideration that diarrhea is ipilimumab induced until proven otherwise
 
2. Grade 1–2 diarrhea: Hold ipilumumab and manage symptoms with hydration, electrolyte replacement, and antidiarrheals. If the patient improves, consider restarting ipilimumab. If not, start a steroid taper. If symptoms persist on steroids, consider lower endoscopy.
 
3. Grade 3–4 diarrhea: Admit patient to hospital and consider ICU. Serial abdominal exams and surgical consult should take place for possible acute abdomen or perforation. Perform symptom management of diarrhea. Use antibiotics if suspicious of sepsis/perforation. Urgent lower endoscopy. Use high-dose IV steroids followed by oral steroid taper over six to eight weeks. Follow up three days after steroid induction. If symptoms havenot improved, start infliximab. Permanently stop ipilimumab.

Limitations

Case study of three patients, each with a different presentation. Two of the patients were octogenarians, and both developed more severe symptoms than the third patient, who was 51 years. Patient comorbidities were not identified.

Nursing Implications

Nurses need to carefully assess gastrointestinal symptoms in patients receiving ipilimumab to minimize complications.