PURPOSE: To describe the recommendations for the management of immune-related adverse events and usual kinetics of tumor response
TYPES OF PATIENTS ADDRESSED: Adults receiving ipilimumab
Skin (rash pruritis): Occurrence of any grade is reported in 47%–68% of patients. For grade 1–2 pruritis, use topical corticosteroids and antipruritics. For persistent grade 2 or grade 3 pruritis, withhold dose and oral steroids. For grade 4, permanently discontinue immune therapy.
Diarrhea: Occurrence of any grade is reported in 31%–46% of patients. For grade 1, use loperamide and a colitis diet. For persistent grade 2 or higher, order stool, etc., examinations and give diphenoxylate hydrochloridek and atropine sulfate (lomotil) and budesonide daily. An endoscopy should be conducted to rule out colitis. For grade 3–4 or blood in stools, IV steroids should be initiated and treatment should be discontinued. If this treatment does not resolve symptoms, treatment with infliximab 5 mg/kg once every two weeks is suggested. Prophylactic use of budesonide is not recommended and not shown to be effective.
Peripheral neuropathy: Low occurrence exists, but transient neuropathies have been reported. With persistent grade 2, withhold a dose. For persistent or worsening neuropathy, try treatment with oral steroids. For severe grade 3–4, ipilimumab should be permanently discontinued and systemic steroids tapered over 30 days.
The authors point out that tumor regression may not be evidenced for a long period of time, and median time to complete response was 30 months.
Nurses need to educate patients that it may take a long time to see a tumor response from treatment, and also that adverse events can occur a relatively long time after treatment. Patients need to know to promptly report events that occur weeks and months after treatment and that ongoing patient follow-up to assess for and manage any adverse events is critical. In most cases, management of treatment-related symptoms involves the administration of systemic corticosteroids for persistent or severe symptoms.
