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