Immunotherapy toxicity management

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Meghan Mooradian, MD Boston, MA

Grading toxicity

CTCAE

• Common Terminology Criteria for Adverse Events (CTCAE) and Common Toxicity Criteria (CTC) - Adverse event grading for clinical trials

• CTCAE 5x7" small booklet format local backup
• CTCAE 8.5x11" letter size format local backup

Diarrhea, colitis

• Grade 1: Asymptomatic; clinical or diagnostic observations only; grade 1 diarrhea <4x/day above baseline; intervention not needed
• Grade 2: Abdominal pain, mucus or blood in stool; grade 2 diarrhea frequency 4-6/day above baseline
• Grade 3: Severe abdominal pain; grade 3 diarrhea >7x/day above baseline
• Grade 4: Life threatening consequences

*GI consult is warranted in any patient who meets criteria for grade 2 diarrhea/colitis with negative infectious stool work up

Endocrinopathy

Hypophysitis:

• Grade 1: Asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated
• Grade 2: Moderate; minimal, local or noninvasive intervention indicated; limiting age appropriate instrumental ADL
• Grade 3: Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of existing hospitalization indicated; disabling; limiting self-care ADL
• Grade 4: Life-threatening consequences; urgent intervention indicated

Hypothyroid

• Grade 1: Asymptomatic; clinical or diagnostic observations only; intervention not indicated
• Grade 2: Symptomatic; thyroid replacement indicated; limiting instrumental ADL
• Grade 3: Severe or medically significant but not immediately life-threatening; hospitalization indicated
• Grade 4: Life-threatening consequences; urgent intervention indicated

Hyperthyroid

• Grade 1: Asymptomatic; clinical or diagnostic observations only; intervention not indicated
• Grade 2: Symptomatic; thyroid suppression therapy indicated; limiting instrumental ADL
• Grade 3: Severe or medically significant but not immediately life-threatening; hospitalization indicated
• Grade 4: Life-threatening consequences; urgent intervention indicated

Liver, hepatic

• Grade 1: AST, ALT > ULN - 3x ULN; total bilirubin > ULN - 1.5xULN
• Grade 2: AST, ALT > 3 - <5xULN; ULN; total bilirubin >1.5x - 3xULN
• Grade 3/4: AST, ALT > 5xULN; total bilirubin > 3xULN

Lung, pneumonitis

• Grade 1: Asymptomatic, diagnostic observation only
• Grade 2: Symptomatic, limiting instrumental ADLs; medical intervention warranted
• Grade 3: Severe symptoms; limiting ADLs; oxygen-indicated
• Grade 4: Life-threatening respiratory compromise; urgent intervention required (i.e. intubation)

Kidney, renal (Nephritis)

• Grade 1: Creatinine level increase of >0.3 mg/dl; creatinine 1.5-2x above baseline
• Grade 2: Creatinine 2-3x above baseline
• Grade 3: Creatinine >3x above baseline or greater than 4.0 mg/dl; hospitalization required
• Grade 4: Life-threatening consequences; dialysis required

Rheumatology

Arthritis

• Grade 1: Mild pain with inflammatory symptoms: erythema, or joint swelling
• Grade 2: Moderate pain associated with signs of inflammation, erythema, or joint swelling; limiting instrumental ADL
• Grade 3: Severe pain associated with signs of inflammation, erythema, or joint swelling; irreversible joint damage (e.g., erosion); disabling; limiting self-care ADL

Skin, dermatologic

Maculopapular rash: the most frequent event with checkpoint inhibitors, the fourth version of the CTCAE classification proposes:

• Grade 1: macules/papules covering < 10% the body surface area (BSA) with or without symptoms (e.g. pruritus, burning, tightness)
• Grade 2: macules/papules covering 10%–30% BSA with or without symptoms (e.g. pruritus, burning, tightness); limiting instrumental activities of daily living (ADL)
• Grade 3: macules/papules covering > 30% BSA with or without associated symptoms; limiting self-care ADL

Guidelines

• ESMO: Management of Toxicities from Immunotherapy: ESMO Clinical Practice Guidelines (2017)
• SITC: Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group
• ASCO: Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline
• Naidoo J, Page DB, Li BT, Connell LC, Schindler K, Lacouture ME, Postow MA, Wolchok JD. Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies. Ann Oncol. 2015 Dec;26(12):2375-91. link to original article correction of Figure 2 PubMed

Evaluation

Monitoring guidelines for identification of immune-related adverse events (irAEs)

• Patients should receive timely and up-to-date education about immunotherapies, their mechanism of action, and the clinical profile of possible irAEs prior to initiating therapy and throughout treatment and survivorship.
• There should be a high level of suspicion that new symptoms are treatment related.
• Recommend weekly toxicity visits for patients on combination CTLA-4/PD-1 inhibition while on therapy; every 2 or 3 week visits are reasonable for patients on single agent PD-1/PD-L1 or CTLA-4 inhibitors

Pre-treatment evaluation

• Detailed physical examination, including dermatologic assessment
• Detailed history including personal and family history of auto-immune disease
• History of bowel habits
• Baseline lab evaluation: CBC, CMP, TSH
• Consider hepatitis serologies (HBsAg, HBsAb, HBcAb, hCAb), T-spot 
• Consider baseline troponin, BNP

Endocrinopathy

• ACTH
• AM cortisol with cosyntropin stimulation test
• TSH
• FSH
• LH
• Prolactin
• Testosterone
• MRI brain in cases of suspected hypophysitis
• HgA1c, C-peptide, ests for antibodies (glutamic acid decarboxylase [GAD65], anti-insulin, anti-islet cell A, zinc transporter 8]) in cases of suspected ICI-induced T1DM
• Endocrine referral

Liver, hepatic

• Liver function tests (LFTs) or comprehensive metabolic panel (CMP)
• Hepatitis B & C serologies
• Liver/abdominal CT/MRI/ultrasound imaging

Kidney, renal

• BUN/creatinine, basic metabolic panel (BMP)
• Renal imaging (CT/MRI/ultrasound imaging)
• Total protein (spot), protein/creatinine ratio, urine sodium, urine urea, urine creatinine (for calculating FeNa and FeUrea)
• Nephrology consultation and kidney biopsy when indicated

Neurologic

• Electromyography (EMG) +/- nerve biopsy
• Muscle biopsy if myositis is suspected
• Lumbar puncture and brain MRI in evaluation of cognitive dysfunction and concern for encephalitis, meningitis and encephalopathy.

*Neurology consultation is recommended for all neurologic irAEs grade 2 and higher

Ocular

• Ophthalmology exam
• Though ophthalmologic referral is necessary in ALL cases of visual complaints, certain tests can be performed by the oncologist in the office:
  • Examination for visual acuity, which can be done using an eye chart on a smart phone with the patient wearing reading glasses for near vision or glasses for distant vision, as necessary;
  • Color vision;
  • Red reflex; pupils (equal, round, reactive), including testing for an afferent pupillary defect, which can indicate optic nerve or extensive retinal disease;
  • Penlight inspection of the anterior part of the eye.

Pancreas

• Amylase
• Lipase

Skin, dermatologic

• Complete history and physical exam, documenting % body surface area (BSA) involved ad evaluating for mucosal membrane involvement
• Rule out any other etiology of the skin problem, such as an infection, an effect of another drug, or a skin condition linked to another systemic disease or unrelated primary skin disorder.
• Basic labs: CBC, CMP
• Directed serologic studies if an autoimmune condition is suspected, such as lupus or dermatomyositis: a screening antinuclear antibody (ANA) test, SS-A/Anti-Ro, and SS-B/Anti-La if the rash is predominantly photodistributed or demonstrating photosensitivity
• Dermatology referral with skin biopsy, when indicated

Management

General organ agnostic recommendations

The following are general recommendations that should be followed irrespective of affected organs. For organ-specific management,

Per the ASCO guidelines, clinicians should manage toxicities as follows:

• In general, ICI therapy should be continued with close monitoring for grade 1 toxicities, with the exception of some neurologic, hematologic, and cardiac toxicities.
• Hold ICI for most grade 2 toxicities and consider resuming when symptoms and/or laboratory values revert to grade 1 or less.
  • Corticosteroids (initial dose of 0.5 to 1 mg/kg/day of prednisone or equivalent) may be administered.
• Hold ICI for grade 3 toxicities and initiate high-dose corticosteroids prednisone 1 to 2 mg/kg/day or methylprednisolone IV 1 to 2 mg/kg/day).
  • Corticosteroids should be tapered over the course of at least 4 to 6 weeks. If symptoms do not improve with 48 to 72 hours of high-dose corticosteroid, should consider additional immune modulatory agents (such as infliximab for ICI-induced colitis)
• When symptoms and/or laboratory values revert to grade 1 or less, re-challenging with ICIs may be offered; however, caution is advised, especially in those patients with early-onset irAEs.
  • Dose adjustments are not recommended.
• In general, grade 4 toxicities warrant permanent discontinuation of ICI with the exception of endocrinopathies that have been controlled by hormone replacement.

Infusion Reaction

Grade 1: Mild transient reaction

MGMT: Infusion rate may be decreased or infusion temporarily interrupted until resolution of the event

Grade 2: Therapy or infusion interruption indicated but responds promptly to symptomatic treatment (see below)

MGMT: Acute: Antihistamines, NSAIDS, potential use of IV corticosteroids; Consider ppx mgmt: anti-histamines (i.e. Allegra the night prior and morning of infusion);

** Consider reduced the rate of infusion upon re-initiation or subsequent infusion

Grade 3: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae

MGMT: Acute: Antihistamines, NSAIDS, IV corticosteroids; Ppx mgmt: anti-histamines (i.e. Allegra the night prior and morning of infusion) ;

** Reduce rate of infusion upon re-initiation or subsequent infusion

Consider referral to allergist

Grade 4: Life-threatening consequences; urgent intervention indicated

MGMT: Acute: Antihistamines, NSAIDS, IV corticosteroids; likely permanent discontinue ICI

Skin, dermatologic

Pruritus: a frequent event with checkpoint inhibitors, often can be treated supportively with topicals, anti-histamines with continuation of ICI

·      Topical lotions/emollients – menthol containing hydrate skin and provide pruritus relief in mild cases (i.e. Gold Bond)

·      Topical steroids (clobestasol propionate, betasmethasone dipropionate)

·      Oral anti-histamines: cetirizine/loratidine daily, hydroxyzine

·      If intense, limiting quality of life: oral corticosteroid – prednisone 0.5-1mg/kg/day tapered over 1-2 weeks; and dermatology referral

Maculopapular rash: the most frequent event with checkpoint inhibitors, the fourth version of the CTCAE classification proposes:

• Grade 1: macules/papules covering < 10% the body surface area (BSA) with or without symptoms (e.g. pruritus, burning, tightness);

MGMT: avoid skin irritants; topical steroids, anti-histamines; continue ICI;

• Grade 2: macules/papules covering 10%–30% BSA with or without symptoms (e.g. pruritus, burning, tightness); limiting instrumental activities of daily living (ADL);

MGMT: avoid skin irritants; topical steroids, anti-histamines +/- oral agents if needed; continue ICI;

Non-urgent dermatology referral; consider skin biopsy

• Grade 3: macules/papules covering > 30% BSA with or without associated symptoms; limiting self-care ADL;

MGMT: avoid skin irritants; if mild – moderation systemic steroids 0.5-1mg/kg prednisone daily for 3 days then taper off; if more severe wean consider IV methylpred (1-2mg/kg) and slower taper over 2-4 weeks; can consider re-trial of ICI depending on severity of rash and dermatology recommendation;

Dermatology referral with biopsy

Hypophysitis

Hypophysitis
Grade	CTCAE Description*	Management
1	Asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated	• Hold ICI if ≥ grade 2 irAE until work up is completed and appropriate hormone replacement is started • If central adrenal insufficiency: start physiologic steroid replacement: Hydrocortisone ~10 mg/m2 (HC 15 mg am, 5 mg at 3 pm) ○ Periodic assessment (e.g., every 3 months in the first year, every 6 months thereafter): clinical monitoring and repeat hormone levels (am cortisol and ACTH and/or low dose cosyntropin stimulation test) to assess recovery • If central hypothyroidism: start thyroid hormone (levothyroxine 1mcg/kg) ○ Repeat thyroid function testing 6–8 weeks after initiation of thyroid hormone and then periodically (e.g., every 3 months in the first year and every 6 months thereafter) to assess recovery • If central hypogonadism, repeat hormone levels in 2–3 months and consider testosterone in men or HRT in women if appropriate for cancer type For severe/life-threatening symptoms such as adrenal crisis, severe headache, visual field deficiency: • Hospitalize as appropriate. • High dose corticosteroid (prednisone 1 mg/kg/day) (or equivalent dose of methylprednisolone) in the acute phase, followed by taper over 1 month. • Adrenal crisis should be managed per standard guidelines. • If central hypothyroidism, replace thyroid hormone (see above) after corticosteroids have been initiated
2	Moderate; minimal, local or noninvasive intervention indicated; limiting age- appropriate instrumental ADL
3	Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of existing hospitalization indicated; disabling; limiting self-care ADL
4	Life-threatening consequences; urgent intervention indicated

Hypothyroidism

Hypothyroidism
Grade	CTCAE Description	Management
1	Asymptomatic; clinical or diagnostic observations only; intervention not indicated	• Hold ICI for ≥grade 3 irAEs • ICI can be continued after resolution of symptoms to grade 2 or better. • Start standard thyroid replacement therapy: initial dose can be the full dose (1.6 mcg/kg) in young, healthy patients, but a reduced dose of 25 -50mcg should be initiated in elderly patients with known cardiovascular disease. • Repeat TSH and free T4 testing after 6–8 weeks and adjust thyroid hormone dose accordingly. If TSH is above reference range, increase thyroid hormone dose by 12.5 mcg to 25 mcg • After identification of the appropriate maintenance dose, further evaluation is required every year, or sooner if patient’s status changes • After identification of the appropriate maintenance dose, further evaluation is required every year, or sooner if patient’s status changes
2	Symptomatic; thyroid replacement indicated; limiting instrumental ADL
3	Severe symptoms; limiting self-care ADL; hospitalization indicated
4	Life-threatening consequences; urgent intervention indicated

Hyperthyroidism

Hyperthyroidism
Grade	CTCAE Description	Management
1	Asymptomatic; clinical or diagnostic observations only; intervention not indicated	• Hold ICI for ≥ grade 3 irAEs • Standard therapy for hyperthyroidism should be followed • Thyroiditis is self-limiting and has 2 phases: ○ In the hyperthyroid phase, patients may benefit from beta blockers if symptomatic (e.g., atenolol 25–50 mg daily, titrate for HR < 90 if BP allows). Monitor closely with regular symptom evaluation and free T4 testing every 2 weeks. ○ Introduce thyroid hormones (see hypothyroidism management) if the patient becomes hypothyroid (low free T4/T3, even if TSH is not elevated). • Graves’ disease should be treated per standard guidelines.
2	Symptomatic; thyroid suppression therapy indicated; limiting instrumental ADL
3	Severe symptoms; limiting self-care ADL; hospitalization indicated
4	Life-threatening consequences; urgent intervention indicated