To evaluate the spectrum, incidence and management of irAEs from checkpoint immunotherapy admitted to a tertiary referral hospital.
Patients (pts) admitted with irAEs between June 2015 and July 2017 were prospectively identified. Data retrospectively collected included toxicity, treatment, length of stay (LoS), resource utilisation, discharge disposition and patient outcomes.
Over two years, 60 pts had 82 admissions with irAEs. 90% of pts had melanoma. At the time of presentation 60% were receiving Ipilimumab (combination/monotherapy); 37% anti-PD-1 monotherapy; 3% were no longer on treatment. Most admissions (76%) were via the Emergency Department (ED). Of the 82 admissions, 24% had two or more concurrent irAEs. The most common irAEs were colitis (46%), hepatitis (21%), pneumonitis (16%), hypophysitis (11%). Mean LoS was 7.5days (0.29 – 60.3 days). In 93% of cases consultation with another specialist team was indicated; additional investigative procedures were performed in 51% including flexi-sigmoidoscopy or bronchoscopy. Management with steroids occurred in almost all pts (96%); 16/38 pts with colitis received Infliximab (five had >2 doses); six pts received further immunosuppressive agents including mycophenolate (n=6) and anti-thymocyte globulin (n=2); three pts required colectomy. Mean time to discharge post high cost treatment was 5.9 days. Discharge disposition was home for 93%; there were two deaths from treatment refractory toxicity (pneumonitis; Stevens-Johnson Syndrome). Of the 60 pts, 22 (37%) continued to receive immunotherapy; 39 (65%) have ongoing partial (n=19) or complete (n=20) disease response.
Checkpoint immunotherapy improves outcomes and is now standard treatment for many cancers. These agents bring a new and varied toxicity profile that provides challenges for health resources and requires a multi-disciplinary approach. High-cost immunosuppressive agents instituted early may decrease LoS and provide a cost benefit. Improved management strategies need to be identified which should include education of ED staff and engagement of other specialities.