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Happy New Year!
I hope you all had a wonderful holiday season.
Kathy Adams will be our presenter for our January session.
I know we all appreciate her offering to lead this month.
This month’s topic continues our December discussion of management of treatment adverse events.
We will be discussing management of adverse events related to checkpoint inhibitors.
Here are the articles for this month:
A review of serious adverse effects under treatment with checkpoint inhibitors
Checkpoint Inhibitors Common immune-related adverse events and their managementI look forward to reading your thoughts on this topic.
Kathy Adam’s initial post:
1) What was the knowledge gained from the article?
I knew there was effects on the lungs and skin from checkpoint inhibitors, but I did not know it could affect the gastrointestinal tract, liver, heart, Neuro, and endocrine glands and even cause autoimmune side-effects like Guillain-Barre syndrome. You always think that it is the saver one. There are so many side effects I was not aware of. It made me more aware of symptoms I may not have otherwise related to the patient’s therapy. Knowing all the side effects will now make me more focused and escalate appropriately. Early detection seems to be the key as well as using corticosteroids or immunosuppressants to manage symptoms. Again, both articles mention that collaboration among healthcare providers will provide the best outcomes for patients. Also, it is mentioned that regular patient monitoring is critical to identifying early symptoms and minimize complications, which I believe we all know but every healthcare facility is stretched thin.
2) Will the research/information in this article change or influence your practice? If so, how?
Being more aware of all the different side effects will allow me to be more aware for earlier detection of adverse effects. After reading these articles I can educate patients about potential side effects enabling them to recognize symptoms early to seek medical treatment sooner.
3) What other questions does the articles raise about current practice?
Are patients being adequately informed about the risks of irAEs and taught to recognize symptoms early? Are there protocols in place for early detection and management of irAEs? Is there effective communication and coordination among oncologists, primary care providers, and specialist to manage IrAEs? Are there systems in place to monitor the long-term effects of checkpoint inhibitors and the potential chronic disease of some irAEs?
4) Do you agree/disagree with the conclusions of the author, why? I would have to agree with the conclusions as both articles advocate for monitoring and patient education, which are critical to improving safety and outcomes in immunotherapy. I have always been a strong patient advocate. I also feel the articles align with current guidelines.My name is Amber and I work in the CARE clinic at West Campus. I also work with one of the cardio-oncologists and palliative care physicians.
1. What was the knowledge gained from this article?
It was interesting to learn that 27% of patients receiving ipilimumab experience a serious adverse effects such as diarrhea, colitis, hypophystitis. Patients receiving combination ipi/nivo have an increase to 55% of adverse effects that are Grade 3 or 4 in severity. Neuro side effects are rare, but can be severe if they occur. It was interesting to read that patients can also develop hypo and/or hyperthyroidism, diabetes, colitis, and hepatitis.2. Will the research/information in the article change or influence your practice?
Cardiotoxicity is being documented with checkpoint inhibitors. These patients are treated with steroids and symptom manangement. It is important to monitor patients with pre-existing cardiac conditions and should be evaluated if cardiac symptoms start. Working in a cardio onc clinic, this will be something we will have to be monitoring for patients receiving checkpoint inhibitors.3. What other questions does the article raise about current practice?
Pneumonitis and pulmonary side effects can occur up to 19 months after treatment is finished. Once toxicity has occurred, patients remain susceptible for symptom recurrence-even if checkpoint inhibitors have been discontinued. Refractory immune related adverse events occur when patients are responsive to steroids and/or tapering of steroids. Patients may need additional testing and/or other immunosuppressants. I am curious about what patient education the patients receive prior to receiving checkpoint inhibitors. I think it would be important to tell patients to contact the office of early symptoms. I know there is a rheumatologist, Dr. Meara, who will see patients who have checkpoint inhibitor side effects who may need high dose steroids or aren’t responsive to steroids.Hi everyone, My name is Trish Strickland and I am an after-hours nurse at the James. Thanks to my work-buddy Kathy for leading this journal club this month. We see a lot of patients receiving check point inhibitors sometimes independently and sometimes in combination with chemotherapy and radiation. The more we know about this type of treatment, the better we can triage the patients on them.
1. What was the knowledge gained from the article? Immunotherapy and checkpoint inhibitors are becoming more and more available for cancer patients and are used in conjunction with chemotherapy or in place of. The side effects of checkpoint inhibitors effect health tissues while they are working on the cancer to.
2. Will the research/information in this article change or influence your practice? If so, how? It reinforces the need to become as familiar with the side effects of check point inhibitors as we are with the side effects of chemotherapy as well. Rashes are always difficult to triage on the After-hours line, even when the patient sends pictures. The variety and ranging severity caused by check point inhibitors is a little overwhelming. Thankfully, OSU has the mychart pictures that we can have the attending or on-call review just to see if this is something critical that needs addressed immediately or if this is something that can be addressed the following morning.
3. What other questions does the article raise about current practice? Nurses need to be aware of the side effects of the checkpoint inhibitors since they are being used more frequently. The endocrinology side effects were surprising to me so I wonder if I had missed subtle signs in the past that may be caused by these treatments. What else do I need to screen for in the after-hours capacity and what is safe to have addressed by the clinic during office hours?
4. Do you agree/disagree with the conclusions of the author, why? I agree that since they are being used more in cancer care, the nursing needs to know what the side effects can be and educate the patient to be able to report symptoms should they occur.
Kathy: I was surprised to see such a severe side effect at Guilian Barre as well, the rashes are so widespread and are always challenging as well. Even the rare (but serious) Neuro side effects should be on our radar because we would be able to pick those out and get the patient’s triaged quickly if they called in. And I thought that it was crazy to think that the pneumonitis’s could happen so far after the treatment that you may not even be thinking about the checkpoint inhibitors if they have moved onto another treatment since then.
Amber: I always have thought that the patients were getting the “easy” treatment when they were on a checkpoint inhibitor vs chemotherapy too. Not so much, they have quite a bit of side effects as well. It almost feels that they should just stay on steroids for the treatments instead of waiting for all the side effects to happen.
Thanks for hosting Kathy! My name is Jeff, and I am one of the outpatient float pool nurses.
1. What was the knowledge gained from the article?
When we give checkpoint inhibitors (or immunotherapies) we don’t think so much about the cardiac effects- we think of the other -itises (pneumonitis/ colitis mainly) and dermatologic side effects. We often overlook the myocarditis side of it since it is less common (and not even listed in the figures/ tables. I was surprised to see the serious adverse events more than double when combining nivo and ipi. The first article also talks about the neurological side effects that were reported; again, we don’t often hear of them being this bad but moreso just slight neuropathy. The 2nd article figure 1- was actually very beneficial with the percentage break down of how common each side effect is from specific drugs.2. Will the research/information in this article change or influence your practice? If so how? These articles will have me be more alert regarding myocarditis/ neurotoxicity/ and endocrinopathies for our patients. The most common side effects we are already looking out for and asking questions on our ECOG assessments but the lesser side effects we are not asking specifically about. I feel it should also be the physician/ mid-level responsibility to go into a thorough cardiac background or even get cardiac clearance before starting these drugs.
3. What other questions does the article raise about current practice? Shortly after covid- there was a run of immunotherapy patients reacting like other chemotherapies- was this caused by true allergies or caused by other immune drugs patient had received? Would atropine or similar drug be considered to help with the gastrointestinal side effects (it works with irinotecan so maybe with immunotherapies as well)? Is there a better way to assess these patients for the -itises (since so many of them are exhibiting these at baseline or during treatment- especially thoracic patients with the shortness of breath/ cough)?
4. Do you agree/disagree with the conclusions of the author, why? I do agree with both authors in that we need to be watching for all the less common side effects in addition to the common ones we ask about in our ECOG assessments. As I stated earlier, I think it comes down to physicians and mid-level providers to do a better job of obtaining cardiac cleared or at least cardiac history and include it in their notes or H/P.
Amber- do you happen to know if Dr Meara is a referral to see these patients who react to checkpoint inhibitors?
Happy New Year! I am glad that we are able to start the year off early with journal club!
1. What was the knowledge gained from the articles?
I too did not realize the broad amount of adverse immune related reactions patients experience while taking the checkpoint inhibitors. I had some knowledge of the cardio toxicity and GI symptoms, but not some of the others listed, especially the neurological. I had some experience while working in surgical oncology with breast cancer patients mainly with the GI issues, especially diarrhea. I would say that many patients really tried to keep going with the regimen, but when they had to stop, sometimes felt as a failure.2. Will the research from the articles change my practice?
I now work in endoscopy and don’t come in contact with many patients that are taking these medications. I have had a few patients come through though that are taking some of these medications but have not encountered any of them experiencing these symptoms.3. What other questions do the articles raise?
I wonder if a better questionnaire is out there to use for these patients for assessment of these symptoms. In the past, I feel as though patients can ignore subtle symptoms that turn in to becoming work and unless asked directly it doesn’t come to their mind.4. Do I agree/disagree with the conclusions of the articles?
I do agree with the authors of these articles. Assessment of patients taking these medications should be very thorough to aid them in being successful with the regimen they are on.Jeff-For Dr. Meara, she does see patients who react to checkpoint inhibitors, especially if they aren’t responding to steroids. Or if they can’t be weaned off steroids. She is a rheumatologist and does need to have a referral placed for patients to see her.
Trish- I understand what you’re saying about keeping patients on steroids while on innumotherapies for symptom management but often times the treatments must be held or delayed if a patient is on steroids because it reduces the efficacy of the checkpoint inhibitors. The treatment plan even states that if patient is on steroids to delay treatment.
Hello everyone, my name is Stephanie Hsu and I work in the clinical trial units.
The knowledge that I gained from these articles is that I was unaware of the timeline of adverse side effects for immunotherapy. It was interesting to learn that typically half the patients receiving ipilimumab will have a dermatologic reaction just before the second dose. I also was unfamiliar with the possible side effects on the patient’s thyroid, joints, and ocular impacts of checkpoint inhibitors.
So many times we have used steroids as our intervention medication of choice, but to learn that patients could be refractory and continue to have symptoms is alarming. I am also concerned for all our diabetic patients and the complexity of checkpoint inhibitors with steroid interventions.What other questions does the article raise about current practice? I question how often we are making sure patients are being seen by an optometrist/ophthalmologist and if they are getting the proper assessments before and throughout their treatments. I have to admit many times when patients tell me they are “achy” I assume it’s due to advanced age as normal complaints, but knowing immunotherapy could be the reason that caused joint inflammation makes managing and assessing patients more challenging. The same for many of the side effects that checkpoint inhibitors can have. How many times have we dismissed some side effects being attributed to age, disease, and as their baseline assessment?
Do you agree/disagree with the conclusions of the author, why? I do agree that it is vital to properly manage patients’ side effects by continually assessing and intervention with early recognition of symptoms. Also, communication is vital with patients and the treating team.
Kathy,
Thank you for leading this month’s journal club.
It is overwhelming to see all the systems and side effects from checkpoint inhibitors. It almost makes you wonder if the benefits outweigh all the adverse effects.
I agree, collaboration, closely monitoring, and patient education is vital for patient safety.Jeff,
I agree, the treating team should get cardiac clearance before starting these checkpoint inhibitors and there should be better assessment tools to monitor cardiac side effects. It’s an interesting thought about using atropine or another similar drug to help with the gastrointestinal side effects. If it’s not currently being used and if so, if it’s therapeutic.Trish,
I can’t imagine how difficult it must be trying to triage a rash. I suppose it’s helpful if they can submit a photo.Amber I did not know that pulmonary side effects can occur up to 19 months after treatment is finished, I must have missed that. But I do believe we all need more education on the new treatments as well as patients. I like that we have a journal club that helps educates us. We all come from different backgrounds and all the input that we add helps a lot in understanding the new meds and side effects. Thank you so much for your input. thank you for giving us a contact for patients. (I know there is a rheumatologist, Dr. Meara, who will see patients who have checkpoint inhibitor side effects who may need high dose steroids or aren’t responsive to steroids)
Trish, I agree that patients and staff caring for the patients on these new medications need to be better educated. I also agree that as a triage RN we do have to us a lot of instinct. I had a pt that ended up with a stroke from a check point inhibitor. They never said anything about neuro status changes just concerned with arm being swollen and molded. But something just seemed off so I had them call 911. Luckily they did and pt went straight to surgery for infarction.
Kathy- I too was surprised at how many systems can experience adverse effects and wonder if more education should be spent on this with the nurses to help recognize patients with symptoms and possible earlier interventions being provided. One downfall though is that some symptoms may not present until many months later, making the patient less likely to think it could have been from their previous treatments.
Trish- I can only imagine the number of triage calls you must work through with many of these patients. I agree with Stephanie that thankfully there is the photo options now via mychart to help give patients advice on how to handle their adverse effects without making them come into clinic immediately, of course as long as not an emergent symptom.
Hello my name is Kelly. I am a nurse in CTU.
1. I learned from the article “Checkpoint Inhibitors Common immune-related…” the timing of when to expect each toxicity to commonly occur during the treatment stages. I.E. Colitis is about 7 weeks after initiating treatment where derm toxicities can occur as early as week 3 and that the treatment is almost always going to involve a steroid.
2. These articles are definitely a good reminder to always have these toxicities in the back of your mind when doing patient’s assessments and if any are suspected to work closely with the team.
3. A question I wondered while reading about the cardiological side effects was what/if any are the limiting pre existing conditions that would not allow a patient to start a checkpoint inhibitor?
4. I agree very much that the key for successful management is good communication between the patient and treating team.
Trish-I agree with you, that this form of treatment is dubbed as the “easier” and I truly do feel like for the most part they are tolerated. We see a lot of Nivo and Pembro, and those really do seem tolerated in terms of patients being on multiple cycles. But I guess this is just another good reminder to always keep assessing for toxcities.
Jeff- I wonder if there is some kind of cardiac clearance that we just aren’t aware of esp if they have a history of cardiac issues?
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