28
Treatment
Table 3. Lung Toxicities
G3: Severe symptoms;
Hospitalization required:
Involves all lung lobes or
>50% of lung parenchyma;
limiting self-care ADL; oxygen
indicated.
• Permanently discontinue ICPi.
• Empiric antibiotics may be considered.
• Methylprednisolone IV 1–2 mg/kg/day.
• If no improvement after 48 hours, may add
immunosuppressive agent. Options include
infliximab or mycophenolate mofetil IV or IVIG or
cyclophosphamide (See Table A2 for dosing ). Taper
corticosteroids over 4–6 weeks
*
• Pulmonary and infectious disease consults if
necessary.
• May consider bronchoscopy with BAL +/-
transbronchial biopsy if patient can tolerate.
G4: Life-threatening
respiratory compromise;
urgent intervention indicated
(intubation)
Footnotes:
*
Subset of patients may develop chronic pneumonitis and may require longer taper. Chronic
pneumonitis is a described phenomenon where the incidence is not known, but <2%.
(cont'd)
Table 4. Endocrine Toxicities
4.1 Thyroid
4.1.1 Primary Hypothyroidism
Workup/Evaluation:
• TSH, with the option of also including FT4, can be checked every 4–6 weeks as part
of routine clinical monitoring for asymptomatic patients on ICPi therapy.
• TSH and FT4 should be used for case detection in symptomatic patients.
• Low TSH with a low FT4 is consistent with central hypothyroidism. Evaluate as per
hypophysitis (see section 4.3).
• Commonly develops after thyrotoxicosis phase of thyroiditis (see section 4.1.2).
Grading Management
G1: TSH >4.5 and <10
mIU/L and asymptomatic
• Should continue ICPi with monitoring of TSH
(option for FT4) every 4–6 weeks as part of routine
care.
