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New guidelines have been developed by the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) on how to assess and manage of immune checkpoint inhibitor side effects that are often autoimmune in nature.
Checkpoint inhibitors have been developed as means to "reinvigorate an exhausted immune response" seen in cancer, says Dr. Len Calabrese of the Cleveland Clinic. (Citation source: https://buff.ly/2CQia03)
Immunotherapy with immune checkpoint inhibitors has revolutionized the treatment of many different types of cancer, making remission a realistic goal. These agents include inhbitors of cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1) pathways (ipilimumab; nivolumab pembrolizumab, and atezolizumab). The most common side effects with these drugs are rash, diarrhea, hypothyroidism and fatigue.
Unfortunately, they may also given rise to immune-related adverse events (IRAEs), manifest as autoimmune or inflammatory disorders. There have been hundreds of reports of these immune-related adverse events (irAEs), manifesting as rheumatoid arthritis, psoriatic arthritis, psoriasis, polymyalgia rheumatica, colitis, autoimmune hypophysitis, inflammatory arthritis, spondyloarthritis, Sicca syndrome, myositis, myocarditis, or rhabdomyolysis.
ASCO and NCNN convened a multidisciplinary, multi-organizational panel of experts (oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, urology, neurology, hematology, emergency medicine, nursing, trialist, and advocacy) to develop a clinical practice guideline based on a systematic literature review and informal consensus voting.
While they found 204 eligible publications on IRAEs (most of which were case series and case reports), there was a lack of high-quality evidence and thus, most of these recommendations are based on expert consensus.
- Management varies according to organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, with the exception of some neurologic, hematologic, and cardiac toxicities.
- ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert to grade 1 or less. Corticosteroids may be administered.
- Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids (prednisone 1 to 2 mg/kg/d or methylprednisolone 1 to 2 mg/kg/d).
- Corticosteroids should be tapered over the course of at least 4 to 6 weeks.
- Some refractory cases may require infliximab or other immunosuppressive therapy.
- With grade 4 toxicities, permanent discontinuation of ICPis is recommended, with the exception of endocrinopathies that have been controlled by hormone replacement.
- Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .