Immunotherapy-related side effects can occur at any time and can affect any organ. These irAEs, are unique and require specialised approach, therefore early referral to the cancer team and other specialists are critical.
When detected early and correctly treated, IRAE’s are reversible, however, they can become severe and life-threatening if inappropriately treated or underestimated. Treatment is often with high dose corticosteroids and requires specialist consultation.
When problems occur, it is important to identify which ones constitute an emergency requiring resuscitation and hospital admission, and which can be initially managed at home. If the patient is managed at home, it is useful to schedule a review for the patient in 2 to 3 days to ensure that the problem has resolved. Close and careful monitoring are required as mild irAEs can worsen rapidly.
If the patient is managed initially at home, cancer team should be alerted within 24 hours for further investigation and management.
Rapid Assessment and Access Toolkit Resources are available to assist in identifying and prioritising the presenting problems:
Rapid Assessment & Access Toolkit
Triage Tool
Telephone triage log sheet
The side effects listed below are not a complete list of all possible side effects for this treatment.
Skin problems |
Skin problems such as rash, pruritis and vitiligo are common. Rare and sometimes fatal cases of Steven-Johnson syndrome and toxic epidermal necrolysis have also been reported.
- Encourage sun protection and avoid irritants
- If mild (grade 1), topical application of an emollient and/or topical corticosteroids
- Inform cancer team for further investigation and dermatology review
- Manage symptoms as per usual practice e.g. antihistamines for itch
(Link to grading description)
- For further information see Management of immune-related adverse effects
|
Gastrointestinal toxicity |
Colitis, diarrhoea or more bowel movements than usual; blood or mucous in stools; dark, tarry, sticky stools; abdominal pain or tenderness.
Diarrhoea is common and may be associated with enterocolitis, which requires urgent attention.
- Initial symptomatic management with fluid resuscitation and loperamide
- Early referral to the cancer team for further investigation and management
- Grade 2 or above are managed in similar way to acute ulcerative colitis requiring urgent hospital admission
(Link to grading description)
- For further information see Management of immune-related adverse effects
|
Other immune-related adverse events |
Other irAEs include: hepatitis, pneumonitis, endocrine toxicity, and renal toxicity.
For all irAEs, mild symptoms may initially be managed similarly to how they are managed outside of cancer, however referral to the cancer team is paramount as irAEs can escalate quickly, and further investigations and management often require specialist input.
It is also important to note that irAEs can manifest with general symptoms (e.g. headache, fever, fatigue), and relationship to immunotherapy may not be obvious. Therefore the patient needs to be educated on the importance of reporting of any new symptoms. (See section Preventing problems)
|
Fever |
Unlike conventional chemotherapy, myelosuppression is relatively uncommon. However, neutropenic sepsis is a life-threatening toxicity and if suspected, should be treated as a MEDICAL EMERGENCY. Patients can deteriorate rapidly and die within hours. Neutropenic patients do not mount a normal immunological response to infection. As such, it is important to treat any symptoms with suspicion and urgent referral to the hospital is required. Prompt action reduces the risk of death from neutropenic sepsis.
|
Nausea and vomiting |
Nausea and vomiting are uncommon with immunotherapies and prophylactic antiemetics are rarely prescribed upfront.
If the patient experiences nausea and/or vomiting:
- investigate other symptoms that may suggest endocrine involvement e.g. significant weight loss, excessive fatigue, thirst, polyuria. If suspected, contact cancer team for prompt referral for endocrine review.
- ensure fluid resuscitation
- if mild, consider metoclopramide 10 mg orally three times a day (maximum 30 mg/24 hours, up to 5 days); regular around the clock administration rather than as required dosing may be more effective. Inform cancer team within 24 hours.
- if moderate to severe, seek immediate advice from cancer team for investigation and management
|