3
Key Recommendations
The following are general recommendations that should be followed
irrespective of affected organs. For organ-specific and systemic toxicities
management, please see Tables 1–11.
It is recommended that clinicians manage toxicities as follows:
➤ Patient and family caregivers should receive timely and up-to-date
education about immunotherapies, their mechanism of action, and
the clinical profile of possible irAEs before initiating therapy and
throughout treatment and survivorship.
➤ There should be a high level of suspicion that new symptoms are
treatment-related.
➤ In general, ICPi therapy should be continued with close monitoring
for Grade 1 toxicities, except for some neurologic, hematologic, and
cardiac toxicities.
➤ Consider holding ICPis for most Grade 2 toxicities and resume
when symptoms and/or lab values revert ≤ Grade 1. Corticosteroids
(initial dose of 0.5–1 mg/kg/day of prednisone or equivalent) may be
administered.
➤ Hold ICPis for Grade 3 toxicities and initiate high dose corticosteroids
(prednisone 1–2 mg/kg/day or equivalent). Corticosteroids should
be tapered over the course of at least 4–6 weeks. If symptoms do not
improve with 48–72 hours of high dose steroid, infliximab may be
offered for some toxicities.
➤ When symptoms and/or lab values revert ≤ Grade 1, rechallenging
with ICPis may be offered, however, caution is advised especially
in those patients with early-onset irAEs. Dose adjustments are not
recommended. Rechallenge with PD-1/PD-L1 monotherapy may be
offered in patients with toxicity from combined therapy with a CTLA-4
antagonist once recovered to ≤ Grade 1.
➤ In general, Grade 4 toxicities warrant permanent discontinuation
of ICPis, except for endocrinopathies that have been controlled by
hormone replacement.
All recommendations in this guideline are consensus based with benefits outweighing
harms.
