Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy

Published online ahead of print November 1, 2021, DOI: 10.1200/JCO21.01440 

Bryan J. Schneider, Jarushka Naidoo, Bianca D. Santomasso, Christina Lacchetti, Sherry Adkins, Milan Anadkat, Michael B. Atkins, Kelly J. Brassil, Jeffrey M. Caterino, Ian Chau, Marianne J. Davies, Marc S. Ernstoff, Leslie Fecher, Monalisa Ghosh, Ishmael Jaiyesimi, Jennifer S. Mammen, Aung Naing, Loretta J. Nastoupil, Tanyanika Phillips, Laura D. Porter, Cristina A. Reichner, Carole Seigel, Jung-Min Song, Alexander Spira, Maria Suarez-Almazor, Umang Swami, John A. Thompson, Praveen Vikas, Yinghong Wang, Jeffrey S. Weber, Pauline Funchain, and Kathryn Bollin. 

Purpose

To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitor (ICPi) therapy.

Methods

A multidisciplinary panel of medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to update the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 through 2021.

Results

A total of 175 studies met the eligibility criteria of the systematic review and were pertinent to the development of the recommendations. Because of the paucity of high-quality evidence, recommendations are based on expert consensus.

Recommendations

Recommendations for specific organ system–based toxicity diagnosis and management are presented. While management varies according to the organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, except for some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert # grade 1. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids. Corticosteroids should be tapered over the course of at least 4-6 weeks. Some refractory cases may require other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement.

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