PURPOSE: Review the incidence and management of immune-related adverse events associated with immune checkpoint inhibitors
TYPES OF PATIENTS ADDRESSED: Adults receiving treatment via immune checkpoint blockade
RESOURCE TYPE: Expert opinion
PROCESS OF DEVELOPMENT: Review of clinical trials results and clinical experience
This review emphasizes the importance of early recognition of adverse effects and judicious use of immunosuppression in management, and points to the need to provide appropriate antibiotic prophylaxis with the prolonged use of immunosuppression.
Dermatologic events: Reports that the time frame for more severe skin effect occurrence ranged from 3.1–17.3 weeks after initiating treatment. For grade 1, use topical steroids. For grade 2, withhold treatment and consider systemic steroids if no improvement is observed within one week of topicals and if the rash involves more than 30% of body surface area. For 10%–30% body surface involvement, symptomatic therapy is withheld and systemic steroids are considered. For grade 3–4, permanently discontinue immune therapy treatment and systemic corticosteroids and refer patient to a dermatologist.
Diarrhea: May occur about six weeks into treatment. For grade 1 (less than four stools above baseline), initiate stool testing, oral hydration, a bland diet, and monitoring. Recommends against symptomatic treatment to avoid masking more severe symptoms. For grade 2, initiate stool testing, withhold immune therapy, and order an endoscopic evaluation to check for colitis. For grade 3–4, permanently discontinue treatment, admit to hospital, and call for a gastroenterology evaluation. Use systemic steroids only if the patient is clinically unstable or if indicated from a stool and gastrointestinal evaluation.
Dyspnea: Median time to presentation reported was five months. New cough or dyspnea warrants evaluation. For grade 2, use oral or IV corticosteroids 1 mg/kg/day. For grade 3–4, use high-dose steroids and consider immunosuppressive therapy.
Currently, limited evidence regarding the effects of interventions for adverse events with immunotherapy exists, and current information is based on initial clinical trial results and personal clinical experience.
Nurses need to be aware of the myriad adverse effects that can occur with immunotherapies, and recognize that many of them can occur long after treatment has concluded. This means that patient teaching and ongoing follow-up to assess for these effects are crucial. Current sources point to the importance of early detection and interventions for the management of adverse effects to prevent more severe negative patient outcomes. As opposed to some other sources, these authors recommend against “knee jerk” implementation of systemic corticosteroids for diarrhea because such treatment may mask the development of severe colitis.
