NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Immune checkpoint inhibitors : A new class of cancer medicine – Management of suspected adverse events

Immune checkpoint inhibitors are a relatively new class of cancer medicine. They can only be prescribed by cancer specialists, however, GP’s and non-cancer specialists should have an awareness of their unique spectrum of side effects and the need for urgent referral.

What are Immune checkpoint inhibitors?
Immune checkpoint inhibitors (or ‘immuno-oncology medicines’) represent a significant breakthrough in cancer care. In some cases this has resulted in complete and durable remissions in patients with disease previously considered incurable. Since 2011, several new drugs in this class have been licensed and approved for use in NHS Scotland, including ipilimumab, nivolumab and pembrolizumab. These medicines are all given by intravenous infusion and work by stimulating the immune system to fight cancer. Immune checkpoint inhibitors are currently licensed for several cancers including non-small cell lung cancer, melanoma and renal cancer.
Although these medicines can only be prescribed by cancer specialists it is considered good practice to record all cancer medicines in the electronic GP medicine records. For further information see Medicines Update May 2017.

What are the possible side effects?
These medicines are generally well tolerated and not associated with the typical side effects associated with conventional cytotoxic chemotherapy. However, they can result in significant immune related adverse events (IrAEs) in a small number of patients. These IrAEs may develop during or several months after the last treatment. IrAEs can affect any organ system, however, the most common IrAEs include:

  • pneumonitis 
  • colitis 
  • hepatitis 
  • nephritis or renal dysfunction 
  • endocrinopathies
  • rash 

The incidence of IrAEs is higher in patients receiving combination therapy compared with single agent treatment.

What should I do if I suspect my patient may have an IrAE?
If you suspect your patient has an immune related adverse effect you should discuss this urgently with a member of their cancer care team either via the Cancer Treatment Helpline (0141 301 7990) or via the on-call registrar at the Beatson.

Cancer services should issue patients with an alert card and contact details for the Cancer Treatment Helpline. In addition, patients should be given a letter for their GP outlining the possible side effects to their new treatment. Patients are encouraged to report (via the helpline) any suspected adverse reactions early.

Early identification of IrAEs and timely intervention are essential to minimise the risk of severe toxicity and able treatment to be continued.

Remember to also report suspected adverse drug reactions via Yellow Card scheme.

How are immune-related adverse events managed?
The management of suspected IrAEs is complex and requires specialist advice.
The majority will improve or resolve with appropriate management, including interruptions of treatment and administration of corticosteroids and/or supportive care. For many IrAEs the mainstay of treatment is corticosteroid therapy. Corticosteroids suppress the immune stimulating effect of checkpoint inhibitors and for this reason should NOT be prescribed in these patients for any other reason e.g. appetite stimulation. Long term hormone replacement therapy may be necessary in cases of irreversible immune-related endocrinopathies.

Where can I get more information?
The West of Scotland Cancer Network (WOSCaN) Guidelines for Management of Immune-related Adverse Events have recently been issued. These guidelines are available on the WOSCAN intranet site and on the GGC Clinical Guidelines directory on StaffNet. However, due to the complexity of these adverse effects, these guidelines are primarily intended for clinicians in the hospital setting. They may however be of interest for background information.
An immunotherapy multi-disciplinary learning event is being held in Glasgow on 24th November. Event details can be found here. The webpage states the event is by invitation only, however this event is suitable for healthcare professionals including non cancer specialists. To register, email joanne.reid@ggc.scot.nhs.uk directly.
The Royal College of physicians are also hosting a conference ‘Changing face of cancer – what the general physician needs to know’ on 2 February 2018. Details can be found here.

 

Published 27/10/17