Basic evaluation |
(1) When was the treatment with checkpoint inhibitor started and how many doses has the patient already received? |
(2) Which is/are the leading symptom/s and when did it/they start? |
(3) Which grading definition(s) according to NCI CTCAE is fulfilled? |
(4) Rule out important differential diagnosis: pre-existing autoimmune condition, complication of underlying malignancy, infection |
(5) What is the patient’s prognosis due to malignancy? |
Initial management |
(1) ICU monitoring, venous/arterial access, fluid load, vasopressors and oxygen supplementation, ultrasound, and/or CT scan as indicated |
(2) Check common laboratory tests: hematology, chemistry (including renal and liver function tests), coagulation, endocrine function, microbial and viral infections, autoantibodies (e.g., ANA, AMA, SMA, LKM1, pANCA, TPOAb, TRAb, TGAb) |
(3) If diagnosis of IRAEs is established, initiate steroid therapy at 1–2 mg/kg of body weight OR, if patient is already on steroids, consider increase of dose (up to 5 mg/kg or equivalent) |
(4) Involve organ specialists: gastroenterology, endocrinology, and neurology, surgery (if perforation or ileus is suspected) |
Advanced support |
(1) If symptoms do not improve after 5–7 days, discuss additional immunosuppressive intervention (mycophenolate mofetil, tacrolimus) |
(2) Consider endoscopy and colonic biopsies for patients with diarrhea/colitis, or liver biopsy in selected cases |
(3) Evaluate specific recommendations for organ dysfunction: -Hormone replacement in endocrine disorders -Infliximab in severe colitis |
(4) In responding events slowly taper steroids over 4 weeks; discuss duration of alternative immunosuppression (if needed) with organ specialist |
(5) Checkpoint inhibition should be discontinued definitively after grade 3/4 IRAEs |