Management of Immune-Related Adverse Events

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Side effects with immunotherapy are different from, and in most cases of PD-1 inhibition, better than chemotherapy.
Side effects with immunotherapy are different from, and in most cases of PD-1 inhibition, better than chemotherapy.

MIAMI – Side effects with immunotherapy are different from, and in most cases of PD-1 inhibition, better than chemotherapy, according to a presentation at the 14th International Kidney Cancer Symposium 2015 (IKCS 2015).1

There are a number of immune checkpoint-blocking antibodies approved for the treatment of cancer, including ipilimumab, pembrolizumab, and nivolumab; however, they are often associated with immune-related adverse events.

 “These are side effects that can affect any organ,” said Michael A. Postow, MD, of the Memorial Sloan Kettering Cancer Center in New York, NY. “Median time to onset for treatment-related select adverse events range from 5 weeks for skin adverse events and 15 weeks for renal adverse events.”

A mild checkpoint inhibitor rash can be treated with topical triamcinolone, while more significant rashes may require oral steroids. Hydroxyzine may also help with managing itching.

For patients experiencing diarrhea or colitis, management depends on how many stools that patient has per day.  For stools less than 4 times baseline, clinicians can recommend loperamide or budesonide.

For stools less than 7 times baseline can be managed with prednisone at a dose of 1 mg/kg, and patients with stools greater than 7 times baseline or refractory to oral steroids should be hospitalized to receive methylprednisolone 1-2 mg/kg with consideration for infliximab treatment if continued diarrhea.

Endocrinopathies can also occur in these patients. Permanent levothyroxine and hydrocortisone, typically given 20 mg in the morning and 10 mg in the evening, may be required as hormone replacement.

“Clinicians should be aware of the possibility of adrenal crisis with stressful situations like surgery or infection,” Dr. Postow noted.

RELATED: Should Checkpoint Inhibitors Precede IL-2 as Initial Therapy for mRCC

Another problematic issue is pneumonitis, which has resulted in treatment-related fatalities in early studies. Mild symptoms can be managed with 2 mg/kg of prednisone with a consideration for hospitalization, while severe symptoms or hypoxia can be managed with 2-4 mg/kg of methylprednisolone, bronchoscopy, and infliximab.

“With nivolumab, resolution rates for the majority of grade 3-4 adverse events were 50% to 100%, and 85% to 100% when nivolumab was combined with ipilimumab,” Dr. Postow said.


  1. Postow MA. Management of immune-related adverse events [Oral presentation at 14th International Kidney Cancer Symposium].

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