Tips for Treating Immuno-Oncology Patients in the Emergency Department
Sarah McCullough, MD, FACEP
North Dakota ACEP Chapter Secretary/Treasurer
So many “abs” so much to know…where do I begin?
Immunotherapy is being used to treat multiple conditions including cancer, multiple sclerosis, migraine headaches, and multiple autoimmune diseases. Not all immunotherapy is the same. There are currently at least 7 FDA approved immunotherapy oncology drugs being used. (Opdivo-nivolumab, Keytruda- pembrolizumab, Libtayo-cemiplimab-rwlc, Tecentriq-atezolizumab, Bavencio- avelumab, Imfinzi-durvalumab, and Yervoy-ipilimumab). They are known as checkpoint inhibitors. They block either PD-1, PD-L1, or CTLA-4 proteins. These proteins are present on cells and they prevent an immune response to the tumor cells. When they are blocked, the T cell (immune system) is activated and the tumor is attacked. The activated immune system can affect any area in the body causing immune related adverse effects (irAEs). The more common effects are pulmonary, dermatologic, gastrointestinal, and endocrine related. IrAEs can occur any time during or after treatment is completed. It is possible to develop an irAEs a year after treatment or perhaps even longer. The medications have only been used for a limited time and the period for developing adverse effects is undetermined. So, at this point it is best to assume that irAEs could occur for the remainder of one’s life.
The severity of irAEs ranges from Grade 1, asymptomatic with only lab changes, to grade 3/4 and refractory which are severe and may result in death. Treatment for irAEs above grade 1 is to discontinue immunotherapy and give steroids, methylprednisolone 0.5-2mg/kg/day. For refractory cases, additional immunosuppression with inflixamab (Remicade), mycophenolate (CellCept), cyclosporin, or immunoglobulin may be needed. The difficulty is that the presentation of irAEs can be the same presentation as for all the other medical problems that we see in the emergency department, including, infections, pulmonary embolism, diabetes, cardiac disease, etc. It is most important to realize that irAEs are in the differential and that in addition to our usual work up and treatment, steroids need to be considered in these cases as they may be lifesaving treatment.
Everybody that receives these medications is given a card-just like a pacemaker card. They should carry the Immunotherapy Wallet Card with them at all times. It provides the name of the medication, cancer diagnosis, start date of treatment, and other cancer medications being given. The oncology provider and contact information as well as irAEs are listed. Be sure to ask for the card. Always contact the patient’s oncology provider to discuss the presentation and treatment for immuno-oncology patient.
(excerpted from PeerView.com activity “Best Practices for Recognizing and Managing Immune-Related Adverse Events in the Emergency Department: Become Aware, Stay Alert, Change Your Practice, & Keep Patient’s With Cancer Safe.”)
|
