23
Table 2. Gastrointestinal (GI) Toxicities
G1: Increase of <4 stools
per day over baseline; mild
increase in ostomy output
compared to baseline.
• Continue ICPi. Alternatively, ICPi may be held
temporarily and resumed if toxicity does not exceed
Grade 1 or resolves.
• May also include supportive care with medications
such as loperamide if infection has been ruled out
in patients with diarrhea only and not colitis-related
symptoms as a temporary measure.
• Monitor for dehydration and recommend dietary
changes.
• Patient should be closely monitored by phone or
electronic medical system for symptoms changes by
clinical providers every 3 days or more frequently if
needed until stabilized.
• May obtain gastroenterolog y consult for prolonged
G1 cases and consider endoscopy with biopsies.
G2: Increase of 4–6 stools
per day over baseline;
moderate increase in
ostomy output compared to
baseline.
• Hold ICPi at least until recovery to G1 — see last bullets.
• May also include supportive care with medications such
as loperamide if infection has been ruled out in patients
with diarrhea only and not colitis-related symptoms as a
temporary measure.
• Consider consult with gastroenterology for ≥G2.
• Administer corticosteroids, unless diarrhea is transient,
starting with initial dose of 1 mg/kg/day prednisone or
equivalent until symptoms improve to G1, and then start
taper over 4–6 weeks.
• Consider adding narrower-spectrum/more potent agents,
including anti-tumor necrosis factor (infliximab) or anti-
integrin (vedolizumab) antibody to patients whose colitis
is corticosteroid-refractory (i.e., no decrease by one grade
in 72 hours) or dependent or with high-risk endoscopic
features
*
on initial endoscopy exam.
• When symptoms improve to ≤G1, taper corticosteroids
over 4–6 weeks; may consider shorter tapers in patients
also treated with biologics.
• Endoscopic evaluation with
esophagogastroduodenoscopy/colonoscopy is highly
recommended for cases Grade ≥2 to stratify patients
for early treatment of biologics based on the endoscopic
findings.
• Resuming ICPi after symptoms improve to
