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Reasons for Emergency Department Visits Related to Immune Checkpoint Inhibitor Treatment

TOP - May 2017, Vol 10, No 2 - Side-Effects Management, Side-Effects Management
Phoebe Starr

Orlando, FL—Real-world experience at the University of Texas M.D. Anderson Cancer Center, Houston, showed that the most frequent immune-related adverse events leading to emergency department visits for patients treated with immune checkpoint inhibitors were diarrhea, colitis, pneumonitis, and dermatitis.

Depending on which checkpoint inhibitor was used, the frequency of adverse effects, such as dermatitis, hypophysitis, thyroiditis, and pancreatitis, differed. Results of this single-institution study were presented at the National Comprehensive Cancer Network 22nd Annual Conference.

“Because immune checkpoint inhibitors are being used for cancer treatment more and more, healthcare professionals should be familiar with the distinct side effect profile of each of these drugs to be able to provide appropriate care,” said lead investigator Myint A. Win, MD, Internist, Department of Emergency Medicine, University of Texas M.D. Anderson Cancer Center.

The study was a retrospective review of 632 patients treated with immune checkpoint inhibitors from March 1, 2011, to February 29, 2016, at M.D. Anderson Cancer Center. Immune checkpoint inhibitors included ipilimumab (n = 186), nivolumab (n = 154), and pembrolizumab (n = 109). Of these, 179 patients were treated with combination therapy, concurrently or sequentially.

The most common adverse events leading to emergency department visits in patients who received ipilimumab were diarrhea (14.5%), colitis (7%), dermatitis (4.3%), and hypophysitis (4.3%). In the group receiving nivolumab, diarrhea (8.4%), pneumonitis (7.1%), and dermatitis (4.5%) were the leading causes of emergency department visits. In patients receiving pembrolizumab, diarrhea (6.4%), pneumonitis (4.6%), dermatitis (4.6%), and colitis (1.8%) were the most common reasons for emergency department visits. In patients receiving combination therapy, diarrhea, colitis, and dermatitis were the most common reasons.

Looking at the adverse events individually among the 3 treatment groups, the investigators found significant differences in the frequency of diarrhea (P = .007), thyroiditis (P = .008), hypophysitis (P = .016), and pancreatitis (P = .049) as reasons for emergency department visits.

All Adverse Effects

Among all patients—not just the patients who had emergency department visits—diarrhea was reported in 85.5% of the ipilimumab group, 91.6% of the nivolumab-treated group, and 93.6% of patients receiving pembrolizumab; the rate of diarrhea was 81.6% for patients receiving >1 immune checkpoint inhibitor.

Thyroiditis was reported in 98.4% of the ipilimumab group, 99.4% of the nivolumab group, 100% of the pembrolizumab group, and 95% of those receiving >1 immune checkpoint inhibitor.

Hypophysitis occurred in 95.7%, 99.4%, 100%, and 95% of patients, respectively. Pancreatitis was reported in 98.9%, 98.1%, 99.1%, and 95% of patients, respectively.

“Management of these adverse events depends on grade and severity. We take it on a case-by-case basis. If the adverse event is severe, we stop the immune checkpoint inhibitor and start steroids. If it is mild, we observe the patient,” Dr Win said.

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Last modified: May 10, 2017