Patients suspected to have pneumonitis should be evaluated for symptoms, which may include new or worsening cough, shortness of breath, and chest pain. Radiographic imaging may reveal ground-glass opacities, reticular opacities, and bronchiectasis.


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Clinicians should administer corticosteroids at an initial dose of 1 to 2 mg/kg per day prednisone equivalents (followed by a taper) for grade 2 or greater pneumonitis. In addition to monitoring for clinical improvement of pneumonitis, clinicians should monitor for changes in blood pressure, electrolytes, blood glucose, and mental status, as well as for signs and symptoms of infection while patients are receiving corticosteroid therapy.

For patients receiving pembrolizumab, treatment should be withheld for grade 2 pneumonitis, and permanently discontinued for grade 3, grade 4, or recurrent grade 2 pneumonitis. For nivolumab-treated patients, clinicians should withhold nivolumab until resolution for grade 2 pneumonitis, and permanently discontinue treatment for grade 3 or 4 pneumonitis.

Authors of letter published in The New England Journal of Medicine describe 3 patient cases in which the onset of pneumonitis occurred at 7.4 to 24.3 months following the initiation of PD-1 inhibitor therapy.4

One patient, whose case of autoimmune pneumonitis was described in the correspondence, resolved after 2 weeks of glucocorticoid treatment. The patient resumed treatment with nivolumab.

Another patient’s condition improved over the course of 10 weeks; the third died 4 weeks after the diagnosis of pneumonitis.                       

Reference

  1. Keytruda (pembrolizumab) [prescribing information]. Whitehouse Station, NJ: Merck & Co., Inc.; 2016. https://www.merck.com/product/usa/pi_circulars/k/keytruda/keytruda_pi.pdf. Updated August 20, 2016. Accessed August 2016.
  2. Opdivo (nivolumab) [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; 2016. http://packageinserts.bms.com/pi/pi_opdivo.pdf. Updated May 2016. Accessed August 2016.
  3. Nishino M, Giobbie-Hurder A, Hatabu H, Ramaiya NH, Hodi FS. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advance cancer. JAMA Oncol. 2016 Aug 18. doi: 10.1001/jamaoncol.2016.2453 [Epub ahead of print]
  4. Nishino M, Sholl LM, Hodi FS, Hatabu H, Ramaiya NH. Anti-PD-1-related pneumonitis during cancer immunotherapy. N Engl J Med. 2015;373(3):288-90. doi: 10.1056/NEJMc1505197