How are immunotherapy adverse effects managed in patients with non–small cell lung cancer (NSCLC)?

Updated: Jul 15, 2021
  • Author: Winston W Tan, MD, FACP; Chief Editor: Nagla Abdel Karim, MD, PhD  more...
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Answer

Treatment of immunotherapy-related toxicity depends on its severity and the organ system involved. Corticosteroid therapy is indicated for most symptomatic toxicity. Holding immunotherapy may be indicated. [209]

National Comprehensive Cancer Network (NCCN) guidelines include the following recommendations on initiation of corticosteroid therapy for specific immunotherapy-related toxicities [209] :

  • Maculopapular rash – Severe (grade 3-4); prednisone 0.5–1 mg/kg/day
  • Pruritus – Severe (grade 3); prednisone/methylprednisolone 0.5–1 mg/kg/day
  • Bullous dermatitis – Moderate (grade 2); prednisone/methylprednisolone 0.5–1 mg/kg/day
  • Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) – Severe (grade 3) or life-threatening (grade 4); prednisone/methylprednisolone 1–2 mg/kg/day
  • Diarrhea/colitis – Moderate (grade 2); prednisone/methylprednisolone 1 mg/kg/day
  • Transaminitis without elevated bilirubin – If moderate (grade 2; 3-5 times the upper limit of normal [UNL]), consider prednisone 0.5–1 mg/kg/day; if severe (grade 3; > 5-20 x ULN), initiate prednisone 1–2 mg/kg/day
  • Transaminitis > grade 1 with bilirubin >1.5 x ULN (unless Gilbert syndrome) – Prednisone/methylprednisolone 2 mg/kg/day
  • Acute pancreatitis – Moderate (grade 2); prednisone/methylprednisolone 0.5–1 mg/kg/day
  • Primary adrenal insufficiency – Steroid replacement with hydrocortisone 20 mg in AM, 10 mg in PM, then slowly titrating doses down according to symptoms,  or  prednisone 7.5 mg or 10 mg starting dose, then reduce to 5 mg daily as appropriate,  and fludrocortisone can be started 0.1 mg every other day; then titrated up or down based on blood pressure, symptoms, lower-extremity edema, and labs
  • Pneumonitis – Moderate (grade 2); prednisone/methylprednisolone 1–2 mg/kg/day
  • Elevated serum creatinine/acute renal failure – Moderate (grade 2; creatinine 2–3x above baseline); start prednisone 0.5–1 mg/kg/day if other causes are ruled out
  • Anterior uveitis or episcleritis – Grade 2; treatment guided by ophthalmology to include ophthalmic and systemic prednisone/methylprednisolone
  • Myasthenia gravis – Moderate (grade 2), consider low-dose oral prednisone 20 mg daily, increase by 5 mg every 3–5 days to a target dose of 1 mg/kg/day but not more than 100 mg daily (steroid taper based on symptom improvement); severe (grade 3-4), methylprednisolone 1–2 mg/kg/day (steroid taper based on symptom improvement)
  • Peripheral neuropathy – Moderate (grade 2); Initial observation or initiate prednisone 0.5–1 mg/kg orally (if progressing from mild); if progression occurs, initiate methylprednisolone 2–4 mg/kg/day and consider Guillain-Barré syndrome
  • Encephalitis – Trial of methylprednisolone 1–2 mg/kg/day; if severe or progressing symptoms or oligoclonal bands present, consider pulse steroids, methylprednisolone 1 g IV daily for 3–5 days plus IVIG
  • Transverse myelitis –  Methylprednisolone pulse dosing 1 g/day for 3–5 days
  • Cardiovascular (myocarditis,  pericarditis, arrhythmias, impaired ventricular function) – Severe (grade 3) or life-threatening (grade 4); consider methylprednisolone pulse dosing 1 g/day for 3–5 days
  • Inflammatory arthritis - Mild; if nonsteroidal anti-inflammatory drugs (NSAIDs) ineffective, consider low-dose prednisone 10–20 mg daily x 4 weeks; if not improving, treat as moderate; moderate, prednisone 0.5 mg/kg/day x 4–6 weeks; if no improvement, treat as severe; severe, prednisone/methylprednisolone 1 mg/kg/day
  • Myalgias or myositis – Moderate, severe, or life-threatening; prednisone 1–2 mg/kg/day

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