COMPLICATIONS OF IMMUNOTHERAPY IN THE HOSPITALIZED PATIENT Vivek Batra MD, Emma Weaver MD Division of Medical Oncology, Thomas Jefferson University, Philadelphia COMPLICATIONS AND SIDE EFFECTS OF IMMUNOTHERAPY WHY IS IMMUNOTHERAPY IMPORTANT INTRODUCTION Last 20 years, immunotherapy such as cytokine, cancer vaccines, immune checkpoint inhibition, adoptive T-cell transfer Direct cytotoxic chemotherapy vs. Immunotherapy Immunotherapy stimulates patient’s immune system Effective immunotherapies achieve durable disease control and survival in melanoma, even in advanced disease Ipilimumab (Yervoy) (Anti-cytotoxic T Lymphocyte Associated Antigen 4 Antibody) Anti–Programmed Death 1 Protein Antibodies Pembrolizumab (Keytruda) a humanized anti–PD-1 IgG4 monoclonal antibody, was approved by the FDA in 2014 for metastatic melanoma patients with disease progression following ipilimumab (and BRAF inhibitor therapy if BRAFV600 mutation positive) Nivolumab (Opdivo) is another human anti–PD-1 IgG4 monoclonal antibody.  Which tumors? Melanoma, non-small cell lung cancer, renal cell carcinoma, bladder cancer Antibody binds to CD 20: Rituximab, since 1997 Durvalumab: human immunoglobulin G1 kappa (IgG1κ) monoclonal antibody that blocks the interaction of programmed cell death ligand 1 (PD-L1) with the PD-1 and CD80. Approved for locally advanced or metastatic urothelial carcinoma Atezolizumab , bladder cancer, failed phase 3 trial   See Reference #3 TREATMENT PARADIGM See Reference #3 Stop the drug Admit to hospital, can be life threatening Steroids, 1 month taper Dose dependent on severity PCP prophylaxis, adrenal suppression, hyperglycemia, volume overload, gastric ulcer Co-management with oncologist is essential REFERENCES N Engl J Med. 2017 Oct 5;377(14):1345-1356. doi: 10.1056/NEJMoa1709684. Epub 2017 Sep 11. Overall Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma. Larkin et al. http://www.pharmaceutical-journal.com/news-and-analysis/feature/immune-checkpoint-inhibitors-bring-new-hope-to-cancer-patients/20067127.article Reynolds K, Ananthakrishnan A, Dougan M, Bardia A. Immune-Related Adverse Events (irAEs) in Cancer Patients. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB. eds. Principles and Practice of Hospital Medicine, 2e New York, NY: McGraw-Hill; . http://proxy.library.upenn.edu:2447/content.aspx?bookid=1872&sectionid=146984610. Accessed October 17, 2017. See Reference #2 See Reference #1