1. 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 Oct 5;377(14): doi: /NEJMoa Epub 2017 Sep 11. Overall Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma. Larkin et al.
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; .  October 17, 2017.
See Reference #2
See Reference #1