Linardou, H., & Gogas, H. (2016). Toxicity management of immunotherapy for patients with metastatic melanoma. Annals of Translational Medicine, 4, 272.
DOI Link
Purpose & Patient Population
PURPOSE: To review the side effects of checkpoint inhibitors and their management
TYPES OF PATIENTS ADDRESSED: Adult patients with melanoma receiving checkpoint inhibitor therapy
Type of Resource/Evidence-Based Process
RESOURCE TYPE: Expert opinion
Phase of Care and Clinical Applications
PHASE OF CARE: Active antitumor treatment
Guidelines & Recommendations
Skin: Rash reported in about 20% of patients in clinical trials. Suggests topical and/or oral steroid treatment for persistent or recurring grade 2 rash. Antihistamines suggested for pruritis. IV high-dose steroids (methylprednisolone 1–2 mg/kg/day) followed by oral steroids on improvement tapered over four weeks
Diarrhea: Most studies report diarrhea in at least 30% commonly presenting at about five weeks. Grade 1: Loperamide, antidiarrheal diet, hydration
Grade 2: Oral budesonide or other moderate corticosteroid, tapered over 30 days.
Grade 3: High-dose IV steroids (e.g., methylprednisolone 1–2 mg/kg/day) tapering for at least one month. If no improvement occurs within one week, use anti-TNF inhibitors, remicade, or infliximab.
Limitations
Expert opinion level only. The evidence is derived only from initial drug clinical trials.
Nursing Implications
Limited research evidence regarding interventions to prevent and manage side effects of immunotherapies exists, and most relies on corticosteroid treatment with increased dosing according to the severity of the side effects. Nurses need to be aware that diarrhea, in particular, with immunotherapy can lead to severe colitis, which can be life-threatening and require surgical removal of the colon. Patients need to be taught to report side effects promptly, and patients need to be monitored closely for these adverse events, with prompt intervention.