<p>Management of Immune Checkpoint Inhibitor Toxicities</p>

Abstract

Immune checkpoint inhibitors (ICIs) have radically changed the clinical outcome of several cancers with durable responses. CTLA-4 (cytotoxic T lymphocyte antigen-4), PD-1 (programmed cell death protein 1) or PDL-1 (programmed cell death ligand protein 1) represent ICIs that can be used as monotherapy or in combination with other agents. The toxicity p\rofiles of ICIs differ from the side effects of cytotoxic agents and come with new toxicities like immune-related adverse events. Typically, these toxicities occur in all organs. However, the main organs affected are the skin, digestive, hepatic, lungs, rheumatologic, and endocrine. Most of the immune toxicity that occurs is low grade but some more severe toxicities can occur that require a rapid diagnosis and appropriate treatment. The recognition of symptoms by physicians and patient is necessary to resolve them rapidly and adapt treatment to allow the toxicity to resolve.

Anti-VEGF Antibody Protects against Alveolar Exudate Leakage Caused by Vascular Hyperpermeability, Resulting in Mitigation of Pneumonitis Induced by Immunotherapy

“…Although moist rales/crackles are not very commonly manifested symptoms in the patients with immune checkpoint inhibitor-related pneumonitis, they has been listed as one of the clinical findings suspecting the onset of severe pneumonitis recommending a chest CT (21,22). Furthermore, we demonstrated that in NSCLC patients, the incidence of symptomatic pneumonitis induced by atezolizumab plus chemotherapy was lower in the group also treated with bevacizumab than in the group without bevacizumab.…”

Severe Type of Erythema Multiforme (EM major) due to Administration of Anti-PD-1 Antibody Drug

“…The majority of toxicities caused by ICIs are low in severity, but some are more serious and require multidisciplinary management of side effects. To reduce the risk of experiencing severe toxicities, gathering information on different immune toxicities has been necessary and treatment practices have needed to adapt quickly [3,5] .…”

“…When examining patients during or after administration of ICIs, it is important to keep in mind that severe mucocutaneous disorders can occur regardless of the duration of the last dose [9,10] . In addition, dermatological treatments and skin care must be tailored to the patient's condition [5,11] .…”

“…All organs can be affected by these new toxicities, although the more frequently affected organs include the skin, digestive, and endocrine organs [3,4] . The majority of toxicities caused by ICIs are low in severity, but some are more serious and require multidisciplinary management of side effects [5] . In the case of skin, a severe form of erythema multiforme, toxic epidermal necrolysis and Stevens-Johnson syndrome are very serious, and diagnosis and treatment are frequently difficult.…”

Immune Checkpoint Inhibitor-Induced Gastrointestinal Toxicity: The Opinion of a Gastroenterologist

“…However, physicians must follow several general principles when confronted with these side effects. These principles are hit fast (experienced staff must evaluate patients from the beginning; in this regard, patients are issued brochures that briefly describe ICI treatment and can be handed to any emergency physician if needed), hit early (do not hesitate to initiate immunosuppression), hit strong (will escalate rapidly if needed), and hit short (will de-escalate treatment as soon as the patient is clinically and biologically suitable) [ 14 ].…”