Journal List > J Rheum Dis > v.26(4) > 1137066

Jeung, Oh, and Kim: Immune-related Adverse Events: Overview and Management Strategies for the Use of Immune Checkpoint Inhibitors

Abstract

Recent studies on T cell immunology have been instrumental in developing therapies to overcome cancer immune escape, and immune checkpoint inhibitors have emerged as one of the most promising therapeutic tools in advanced cancer patients. Immune checkpoint inhibitors (ICPIs) are monoclonal antibodies that modulate the effects of immune checkpoints. These include cytotoxic T lymphocyte antigen 4 and programmed cell death protein 1, which are co-inhibitory signals responsible for immune suppression. Despite their clinical benefits, ICPIs behave as general immune activators, exerting to several toxic effects called immune-related adverse events attributed to organ-specific inflammation. Here, we review ICPI toxicities, highlighting the importance of their early identification and proper management.

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Table 1.
General management guideline of immune-related adverse events
Severity CTCAE grade Type of patient care Use of steroid Use of additional immunosuppressive agents Continuation of next cycle immunotherapy Other medication
1 Outpatient Generally, not necessary Not recommended Continue Not recommended
2 Outpatient Topical steroids or oral steroids: Prednisone 0.5∼1 mg/kg/d Not recommended Suspend temporarily: outside skin or endocrine disorders, where immunotherapy can be maintained Not recommended
3∼4 Consider hospitalization according to the specific case IV or oral steroids; prednisone or methylprednisolone 1∼2 mg/kg/d for 48∼72 hours, then reduce to 1 mg/kg/d; course of generally 2∼4 weeks; steroids must be reduced gradually over a period of at least 1 month Considered administration of infliximab (5 mg/Kg) and eventually repeat after 14 days; Consider mycophenolate mofetil (500 mg every 12 h) Skipping a dose of immunotherapy or discontinuing the immunotherapy can be considered, depending on the benefit/risk ratio of each given situation; If grade 4 toxicity occurs, discontinue permanently r If a dose equivalent to 20 mg of prednisone is administered for over 4 weeks, consider prophylaxis for pneumocystis infections with trimethoprim/ sulfamethoxazole (80+40 mg/d or 160/800 mg TIW)

CTCAE: common terminology criteria for adverse events, TIW: 3 times a week.

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