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I had a chance to review these in a bit more detail since this last post. I do think once you get into the guidelines, the “guidance” offered is a bit more specific, however a bit cumbersome to follow. I think the one thing that I would say is maybe “lacking” is I would have liked to have seen a section on how to work up specific complaints. All of the pathways are after you have a diagnosis. For example, fatigue- would have been nice to have a “consider XYZ in the differential”. I’m curious what others thoughts are.
We have not used vendolizumab a lot, but have been able to get it paid for in a handful of patients. Our GI docs have been very instrumental in this process.
Update: We just got an email here yesterday that all non-investigational infusion times for nivolumab will be going to the 30 minute infusions.
I have not had a chance to review these in detail, but plan to do so as well very soon. I’m a little bit concerned about the “blanket” statements of treating based on the grade only. I’m not sure that we’ve come much further then what the drug companies provided as overall guidance early on and that concerns me for folks in the community who are not used to treating a great number of patients. I agree our care step pathways offer a more in depth set of guidelines for nurses.
In response to #1- I would say the approval has increased our volume more in terms of new patients coming for second opinions and I’m not quite sure why. I don’t know if it is because the community is uncomfortable recommending this or patients aren’t wanting to get treatment so they come hoping we won’t recommend anything. I would say I’ve noticed a small increase in the volume of returns as we put more patients on adjuvant nivolumab.
In response to #2- We are currently not recommending adjuvant BRAF/MEK.
Currently we are not using flip dose Ipi/Nivo (“ipi lite” as we like to refer to it) off clinical trial. Thank you all for the responses, we are still working on infusion times here and this is very helpful.
Great question. In my practice many years ago in the first days of Ipi clinical trials, we too kind of did the “phone a friend” in whatever sub-specialty we needed at the time. Since that time when Ipi got FDA approved we actually set up a formal “network” of sub-specialists that had in interest in this. Since they obviously can’t see all the patients with toxicity on their own as they have their regular practices to contend with, they have done many trainings with a core group of people in their department so that they are up to speed, etc on irAE’s.
In terms of managing patients with pre-existing autoimmune conditions, we are very similar to Krista in that it depends on the condition. Sometimes this is difficult though as patients may be being managed in their community for their condition. And as such we are unable to get them in for an appointment with a subspecialist here (high demand), because their condition is stable and they won’t be offering any “value-added” to the patient. In that case we will usually connect with their specialist on the outside and/or do an e-consult.
Thank you everyone! I too discuss with my patients that sound scientific evidence is really lacking in this arena and glad to hear others are discussing the same.
Interesting conversation. We have been trying to do multimodality therapy with our ocular patients (i.e SBRT, ablation) in combo with ICI therapy. We’ve had a bit more success with this manner then just ICI alone.
In terms of our mucosal patients, we seem to have had better results from dual ICI therapy in this group, although to a lower extent than we see in the cutaneous population.
From my experience I would proceed with additional imaging, to rule out increased edema, radiation necrosis, and/or additional disease. The usual culprit I see is increased edema, s/p radiation coinciding with the start of ICI’s. Alternatively, you could just restart some very low dose dex (i.e 1-2 mg BID) and see if his symptoms resolve spontaneously. If so, then a really slow taper would be in order.
This is a great question. In my practice I continue to refer patients to their PCP for these type of issues. I discuss with patients that primary care and health maintenance guidelines are continually changing and that their PCP is the expert in this field just as we are in oncology.
I would completely agree. Just recently had a patient who recurred in the lymph nodes underwent surgical resection and now will start adjuvant nivolumab. Had to have a very difficult discussion about discontinuation of breast feeding as well as future fertility as she really would like to have more children. Not a conversation that came easily.
I believe in the patients for whom this is applicable this will be an important discussion upfront and included in the pretreatment teaching as with any other expected side effect.
That is a very interesting question. I think this would be a difficult situation and I would want to reserve this treatment for a setting where other therapies have failed. I would not absolutely rule it out.
Hi Virginia, Agree the vedolizumab would have been ideal and we’ve done this in several patients. Have you tried to appeal to the company via a patient assistance program? We were able to get this paid for via this route for one patient. Additionally we had one patient that ended up having some really uncommon sort of pathogen and we were able treat with antibiotics and she had significant improvement and was able to wean off the steroids.
Really the only time I have seen this is with patients on high-dose steroids. But definitely something to keep in mind.