Management of Immune Checkpoint Inhibitor (ICI) Induced ...
19
Description

Management of Immune Checkpoint Inhibitor (ICI) Induced Cardiotoxicity
Problem - Immune checkpoint inhibitors (ICIs) are associated with cardiotoxicity.
 ✖ Cardiotoxicity with ICIs range from myocarditis and heart failure to potentially serious arrhythmias, pericarditis and vasculitis.
 ✖ Current guideline recommendations lack key prognostic factors, strategies for prevention and a data-driven suggestion for frequency of monitoring.
 ✖ The mechanisms of ICI-related cardiovascular events are not well-known.
Solution:
 ✔ With either suspicion or confirmation of ICI-associated cardiotoxicity, discontinuation of the offending agent and initiation of steroids should be initiated promptly.
 ✔ Other conditions including ischemia must be ruled out.
 ✔ Corticosteroids should be continued until resolution of symptoms and normalization of troponin, left ventricular systolic function and conduction abnormalities.
 ✔ Consider abatacept for the treatment of severe ICI myocarditis.
Severity Grading:
 G1: Mildly abnormal screening tests, no symptoms
 G2: Abnormal screening tests with mild symptoms
 G3 - Severe: Moderately abnormal screening tests (arrythmia, cardiac biomarker > upper limit of normal, significant echocardiogram findings), symptoms with 
mild activity
 G4 - Life-Threatening: Moderate to severe decompensation, hemodynamic instability, cardiac biomarker >3x upper limit of normal, requiring intravenous medications or interventions
MANAGEMENT:
G1 toxicity: 
 - Hold ICI
 - Monitor and trend electrocardiogram and cardiac biomarkers
 - Rule out other potential causes
 - Resume ICI under close monitoring if no worsening
G2-G3 toxicity:
 - Permanently discontinue ICI
 - Mild symptoms: Oral prednisone 1-2 mg/kg/day
 - Severe symptoms: Methylprednisolone intravenously 1 g/day for 3-5 days
 - Continue steroid until cardiac function returns to baseline, then taper 4-6 weeks 
G4 toxicity:
 - Permanently discontinue ICI
 - Methylprednisolone intravenously 1 g/day for 3-5 days
 - Consider initiating abatacept or other immunosuppressive therapies (antithymocyte globulin, infliximab, or mycophenolate mofetil)
 - Continue steroid until cardiac function returns to baseline, then taper 4-6 weeks
 - Initiate advanced heart failure management, including hemodynamic support with ventricular assist devices, as indicated

#Checkpoint #Inhibitor #ICI #Cardiotoxicity #cardiology #oncology #management #treatment
Contributed by

Dr. Gerald Diaz
@GeraldMD
Board Certified Internal Medicine Hospitalist, GrepMed Editor in Chief 🇵🇭 🇺🇸 - Sign up for an account to like, bookmark and upload images to contribute to our community platform. Follow us on IG:  https://www.instagram.com/grepmed/ | Twitter: https://twitter.com/grepmeded/
Medical jobs
view all

0 Comments

Related content