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I agree with your statement, Krista…..there is certainly no one-size-fits-all approach to managing IMAEs. Some AEs definitely warrant longer courses of steroids than others. For example, rashes usually respond very quickly to steroids, and in my experience, wouldn’t warrant 6 weeks of steroids. And, you’re right on par with the endocrinopathies that don’t warrant interruption at all.
I can recall one similar case – patient didn’t respond to steroids or Cellcept. Viral work-up negative. All other hepatotoxic drugs discontinued (statins, acetaminophen, etc). It unfortunately wasn’t a happy ending for this patient – dealing with it went on for a year. We even referred to a hepatologist. However, this is the ONLY case that I can recall. It’s a reminder that these drugs, though seemingly benign, can still be very toxic and detrimental in a few select cases. Sending him for a biopsy was very appropriate – keep us posted on the outcome.
True – the side effects are a separate issue. It will be interesting to see which oncologists prefer in the BRAF mutant population. The good news is that we at least have options beyond interferon!!
This is such a challenging issue. We had a patient on adjuvant ipi who developed hypophysitis. She has been off treatment for almost a year, and she would now like to conceive. This is definitely unchartered territory for us, her OB and her Reproductive Endocrinologist. Beyond the hypophysitis, we know that the immune system plays a pivotal role in pregnancy and that there are checkpoints involved (PD-1/PDL-1 being one of them) to prevent the mom’s immune system from attacking the fetus. If a patient is having a durable response to immunotherapy, is the mom’s immune system, in that case, going to be too upregulated to sustain a pregnancy?…….There are certainly lots of unknowns in this realm.
On that note, I will say that if you use mycophenolate (CellCept), it can take several days to get a PA since it is an oral therapy. We have run into some occasional issues with this.
I receive this question a lot. We certainly don’t recommend it on the front-end, but if patients wish to take them, we allow it.
We are still administering ipilimumab over 90 min and nivolumab over 60 min. However, I believe that we are in the process of changing the infusion time for nivolumab to 30 minutes across the institution.
Xerostomia (from Sjogren’s as an immune adverse event) can certainly set people up for decay and other dental issues.