25
Table 2. Gastrointestinal (GI) Toxicities
2.2 Hepatitis
Workup/Evaluation:
• Monitor patient for abnormal liver blood tests: AST, ALT, and bilirubin prior to
each infusion and/or consider weekly if Grade 1 LFT elevations. No treatment is
recommended for Grade 1 LFT abnormality.
• Review medications and supplements that may cause hepatotoxicity and rule out
abnormal liver enzymes from development or progression of liver metastases.
• Liver biopsy should be considered if the patient is steroid refractory or if concern for
other differential diagnoses that would alter medical management.
For Grade ≥2:
• Work up for other causes of elevated liver enzymes (e.g., viral hepatitis, alcohol history,
iron studies, thromboembolic event, or potential liver metastasis from primary
malignancy) by doing blood work and imaging (ultrasound and cross-sectional
imaging ). If suspicion for primary autoimmune hepatitis is high, can consider
antinuclear antibody (ANA)/ASMA/antineutrophil cytoplasmic antibodies (ANCA).
If patients with elevated ALKP alone, GGT should be tested. For isolated elevation of
transaminases, consider checking creatine kinase for other etiologies.
Grading Management
G1: Asymptomatic (AST
or ALT > upper limit of
normal (ULN) to 3.0×
ULN and/or total bilirubin
>ULN to 1.5× ULN).
• Continue ICPi with close monitoring ; consider
alternate etiologies.
• Consider monitoring labs 1 to 2 times weekly.
• Manage with supportive care for symptom control.
G2: Asymptomatic (AST
or ALT >3.0 to ≤5×ULN
and/or total bilirubin >1.5
to ≤3× ULN).
• Hold ICPi temporarily.
• Patients should be advised to stop unnecessary
medications and any known hepatotoxic drugs.
Temporarily hold other potentially hepatotoxic
oncologic agents.
• For Grade 2 hepatic toxicity, may administer steroid
(0.5–1 mg/kg day prednisone) or equivalent if no
improvement is seen after 3–5 days.
• Increase frequency of monitoring to every 3 days.
• If inadequate improvement after 3 days, consider
adding mycophenolate mofetil.
• May initiate steroid taper when symptoms improve
to ≤G1 and may resume ICPi treatment when steroid
≤10 mg/day. Taper over at least 1 month.
• Consider hepatolog y consult for G2 and above.
• May resume if recover to ≤G1 on prednisone ≤10 mg/
day.
(cont'd)
