Immunotherapy-related adverse effects: how to identify and treat them in the emergency department
When patients with cancer present to the emergency department with therapy-related symptoms, it’s crucial to ascertain at the outset whether the treatment is with chemotherapy or immunotherapy so that the appropriate symptom treatment can be initiated as early as possible. In this interview, Dr David Henry and Dr Maura Sammon discuss some of the most common immunotherapy-related side effects – lung, gastrointestinal, rash, and endocrine-related problems – and Dr Sammon describes in detail how physicians in the ED would triage and treat the patient. However, the overarching takeaway is the importance of communication: first, between the oncologist and patient, so that the patient is aware of these nuances in advance of an emergency, and second, between the ED physician and the treating oncologist soon after the patient has presented and undergone an initial assessment.
Dr Henry is the Editor-in-Chief of The Journal of Community and Supportive Oncology (www.jcso-online.com).This is an edited version of the interview podcast.
LISTEN TO THE INTERVIEW here.
Correspondence
David H Henry, MD; David.Henry@uphs.upenn.edu
Disclosures
Dr Sammon and Dr Henry report no disclosures/conflicts of interest.
Citation JCSO 2018;16(4):e216-e220
©2018 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0408
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DR HENRY That’s very well put and always difficult, because there are so many causes of rash. That takes me to an area that has always been difficult for me, which is therapy-related endocrine problems. It’s interesting to note that these drugs can cause endocrine problems. I’ve heard you speak about the pituitary affecting vision, as well as thyroid or adrenal issues. Let’s start with how you’d approach vision difficulty in a patient on these drugs.
DR SAMMON The endocrinopathies that you can get with these checkpoint inhibitors really have a myriad of symptoms. Your patient may present saying that they’re feeling tired, that they’re feeling weak, or they may have a headache. If your patient is having actual pituitary enlargement, they can present with headaches, visual field defects, or cranial nerve defects. The reason for those symptoms is that the pituitary sits in the cavernous sinus, and you have various cranial nerves passing through that area as well as the optic chiasm just above the pituitary gland (Figure 3).1 Your patient may present with a bitemporal hemianopia. Or with diplopia. You are going to want to very quickly get either a CT scan or an MRI to find out if that is what’s going on (Figure 4).1 These folks need to be treated aggressively as well.
DR HENRY You’ll get your CT scan or your MRI and rule out an enlargement or a change to the visual field. I haven’t seen this yet, but certainly exciting when you see it to treat it. Would you get the radialis brevis involved, steroids involved? How would you manage that?
DR SAMMON It’s interesting, because you do want to use corticosteroids. One of the questions here is, which corticosteroid do you want to use? If you’re talking about someone who may have adrenal insufficiency, you may want to be able to do a stimulation test. In these patients, you may want to choose using dexamethasone, because you can still do the corticotropin stimulation test. However, if your patient is in frank shock because of what you think is an adrenal crisis, you’re going to want to use hydrocortisone. If a patient is truly hypotensive and unstable, the testing is at that point less important than the treatment.
DR HENRY Very interesting. We have covered what I would consider the major aspects of these fascinating drugs. We haven’t covered all of what they do when they work well, which hopefully we’re seeing more and more often, but we have covered very well what can happen when things go wrong in side effects. Anything else that you would like to add from the ED perspective or other side effects worth mentioning?
DR SAMMON The thing that I would most like to share with the oncology office is the importance of communicating with your patients that, when they’re on these drugs, they need to tell emergency physicians that they’re on immunotherapy, not chemotherapy. It might be helpful to give these patients a card stating that they’re on immunotherapy, not chemotherapy, and outlining some of the side effects that ED physicians should be looking out for in these patients.
DR HENRY That’s a great point. I’ve seen that some of the manufacturers have little cheat cards that the patient can carry naming the drug and the side effects, because not all ED doctors are aware of the side effects of these drugs.
DR SAMMON Absolutely. We love those cards.
DR HENRY Yes. I’ve also given some to the ED doctors at Pennsylvania Hospital, and they love it. I think we’ve covered everything in quite a bit of detail. Thank you, Dr Sammon, for sharing this information from the frontlines of the ED.
