- This topic has 29 replies, 14 voices, and was last updated 7 months, 2 weeks ago by
.
-
Posts
-
Hello! My name is Patti and I work with Kathy and Trish in the clinical call center department.
What was the knowledge gained from the article?
Immune checkpoint blocking antibodies are an exciting line of therapy that are being used to treat several types of cancers. I’m seeing more patients on these therapies in my current role. The autoimmune side-effects have been at times very challenging for the providers to treat. The regimens that are combination of immunotherapies have a higher risk of auto-immune side effects. The side-effects can affect all organ systems I find that to be unique.
Will the research/information in this article change or influence your practice? If so how?
I’m currently a triage nurse here at the James so this information is very applicable to my work. I think in the cases where patients are needing to utilize the emergency services of their local hospital some local providers might not be familiar with these drugs and the potential side effects. Empowering the patient to educated local providers and encouraging the collaboration of James providers with local providers.
What other questions does the article raise about current practice?
Side effects can occur months after completion as others have said that makes this very difficult to catch. Treatment Algorithms are always helpful tools when caring for complicated patients.
Do you agree/disagree with the conclusions of the author, why?
It was mentioned that some might be under reporting adverse side effects which can be detrimental to the health of our patients.Hi everyone, I’m Sarah and I work in the outpatient James float pool as a nurse. Thanks for picking such interesting articles Kathy!
1) What was the knowledge gained from the article?
As a nurse who administers immunotherapy on a regular basis, I did not realize cardiotoxicities were as common as they are. I frequently educate patients on colitis, pneumonitis, dermatitis, and hepatitis, but often just touch on cardiac side effects that are extreme, such as chest pain, heart racing, or something that would warrant an ED visit. It was shocking to see multiple, larger studies are now reporting frequent cardiac events such as myocarditis, pericarditis, and heart block. I am more aware of the broad range of immune-related AEs that can occur after reading this article and will use this information to better assess and educate my patients.
2) Will the research/information in this article change or influence your practice?
Absolutely! As stated above, I was unaware of the high percentages of life-threatening immune-related AEs after hearing “immunotherapy is so much better tolerated than chemotherapy” by countless people. Although, I do feel chemo and immunotherapy are totally different ballgames, this article has made me realize immunotherapy has its long list of toxicities that us as nurses need to be vigilant about when assessing patient’s who are receiving it. We (doctor, mid-level provider, nurses) also need to be aware of patient history and use that knowledge to determine the risks of more severe immune-related AES.
3) What other questions does the articles raise about current practice?
I was thinking about the severe/life-threatening AEs and wonder if there are ways to predict who might have them based on previous immunotherapy exposure, comorbidities, treatment with chemo/immunotherapy combinations, etc. and if they could be monitored more closely or sent to a specialist to manage steroid use, refractory symptoms, and close follow-up? It can be an itis clinic =)
4) Do you agree/disagree with the conclusions of the author, why?
I do agree with the conclusion of the articles and think early detection, thorough assessment by experienced providers, and management is key to keep immunotherapy a gold-standard in cancer treatment!
Hi Patti,
Working at the James I forget that smaller, local ED staff to not have the knowledge or experience to diagnose or manage immune-related AEs and so many of our patients are visiting them. I do think it starts with extensive patient/family education and then encouraging patients to notify the team of immunotherapy use. I would also encourage patient’s to advocate for a transfer to the James for more personalized cancer care and treatment of irAEs. Thanks for your insight!
Hi Amber,
Thanks for sharing! Have you noticed an increased in referrals to the cardio-onc clinic related to immune related AEs? I bet now that more information is coming out regarding cardiotoxicities, there could be more patients visiting your clinic. Is echo considered the gold-standard to diagnose cardiotoxicities?
Hi Jeff,
You mentioned using atropine for those that experience diarrhea. Atropine works as a competitive antagonist at anticholinergic receptors. I’ve seen it used with Sacituzumab and irinotecan because they have the potential of causing cholinergic syndrome. I’m not sure if that’s the same mechanism as check point inhibitors.Amber, I didn’t realize,” Once toxicity has occurred, patients remain susceptible for symptom recurrence-even if checkpoint inhibitors have been discontinued.”
Amber, it seems like Check-point inhibitor patient can start with mild side effects and they could rapidly become worse.
Definitely presents different then antineoplastics.This is Greg Goodman, an outpatient JCRU RN.
What was the knowledge gained from the article?
Don’t give anyone ipilimumab. Sentences like “new-onset paraplegia 5 months after complete remission on ipilimumab therapy” make me wonder if ipi should even be used. It seems most of the worst side-effects were due to ipi. Other than that, there are a dizzying number of potential side-effects that seem impossible to remember, although the list on page 47 and the chart on page 48 of Gordon, et al (2017) is helpful.
Will the research/information in this article change or influence your practice? If so how?
I think we need to do a better job of establishing baseline symptoms and habits before the patient begins treatment. Both articles emphasis early identification and treatment of AE’s. Gordon, et al (2017) even state “Managing colitis should begin before the patient experiences any symptoms” by establishing the baseline bowel habits of patients.
What other questions does the article raise about current practice?
The extensive list of possible side-effects of immunotherapy, with the many and vague presenting symptoms, vast range of time for side-effects to appear, and complexity in diagnosis and follow-up make it clear that we need better, faster methods to diagnose and treat side-effects. Many patients present with symptoms at baseline, and most have underlying diagnoses that increase their risk for side-effects. It sounds almost like we would have to pause treatment and investigate symptoms in between every dose.
Do you agree/disagree with the conclusions of the author, why?
Yes, we are very important in identifying these toxicities early and educating patients, but it seems a very daunting task given the variety of possible symptoms.
I agree with many of the comments: the possibility of delayed reactions symptoms causes some concern. Many patients see providers with less frequency once they complete treatment, and follow-up clinic visits are focused on disease surveillance. We do not usually perform a full symptom assessment when they are not on treatment. Perhaps we should or we risk missing some of these late reactions. It’s almost as if patients need to carry a card or something to that lists the immunotherapy they were treated with and the number to their oncologist to give to any other non-oncology providers they see from family doctor to local emergency department. This will alert other facilities that these patients are not like the other “normal” patients that present with the same symptoms.
Kathy (good to hear from you again!) and Trish- your jobs seem even more important now that we know there are so many potential side-effects and they can occur so long after treatment completes. You two are the primary contact for many of our patients and managing side-effects (such as rash like you mention) over the phone must be very challenging. Thank you for the work you do in assisting our patients!
Hi, my name is Jennifer Clark, I work in the Clinical Treatment Unit. Thanks for leading the discussion Kathy.
What was the knowledge gained from the article?
We frequently administer checkpoint inhibitors in combination with an investigational drug and we assess the patient every visit for the more common inflammatory issues of pneumonitis, colitis and hepatitis. I did not realize that thyroid issues could arise from immunotherapy as well as ocular issues. I also did not realize there could be such a delayed onset of an adverse reaction.Will the research/information in this article change or influence your practice? If so how?
I will ask more detailed questions on a patient’s assessment regarding symptoms if they are on checkpoint inhibitors, and be more aware of the possibility of adverse reactions happening at any time. Sometimes the complaints are so vague and tolerable, we could overlook an issue.What other questions does the article raise about current practice? I wonder if there is any thought to having routine cardiac testing or ophthalmologic exams done in patients who are receiving multiple cycles of check point inhibitors, or if that would be done only if an issue arises.
Do you agree/disagree with the conclusions of the author, why? I agree that recognizing an adverse reaction early is important. Patient education is key, stressing the importance of reporting any symptoms and a thorough assessment of the patient by the nurse and treating team.
Stephanie, I think I undervalue joint pain in patients. I also think of it as a normal part of aging, when it actually can be due to the treatment.
Jeff, I will also pay more attention to lesser known “itises”- watch for trends in labs, etc.
Hi, my name is Jessica Junge. I am an outpatient clinic nurse at The James at New Albany.
1. What was the knowledge gained from the article?
The articles highlight the serious side effects of immune checkpoint inhibitors, which treat cancer and other diseases. These side effects can affect various organs (like the heart, brain, and lungs) and may be life-threatening, but early detection and treatment can usually manage them successfully.2. Will the research/information in this article change or influence your practice? If so, how?
Yes, it will influence practice by stressing the need for careful monitoring of patients using these drugs. The focus on early identification of side effects and immediate intervention will likely lead to more proactive monitoring and quicker response if adverse reactions occur.3. What other questions does the article raise about current practice?
The article raises questions like:
– How can we predict which patients will have serious side effects?
– Are we managing rare but severe side effects like heart or brain issues effectively?4. Do you agree/disagree with the conclusions of the author, why?
I agree with the author’s conclusions. The need for early detection, prompt treatment, and better communication between patients and healthcare providers is crucial. However, I think there’s room to explore more standardized protocols for handling these side effects to improve consistency in patient care.Hi Jennifer! I completely agree that early detection is crucial, and patient education is a big part of that. Ensuring patients know the importance of reporting even small symptoms will go a long way in preventing complications. I love that you’re planning to ask more detailed questions during assessments. Those subtle symptoms are often the key to catching issues early, so being extra thorough will make a big difference.
Hi Sarah! I agree with your take on the article’s conclusion—early detection and thorough assessment are key. It’s great that you’re now more aware of the potential for severe immune-related side effects with immunotherapy. Your idea of using patient history to assess risk and being proactive in patient assessments will definitely improve care and help catch issues early.
What was the knowledge gained from the article?
In the article “Checkpoint Inhibitors; Common immune related adverse events and their management”, Figure 1 was very insightful. It helps to know the percentages of side effects in different CPIs. For example, atezolizumab has very low incidence endocrinopathies, and actually seeing the Pembrolizumab stats on endocrinopathies was also surprising. I would have thought they would have been much higher. It seems like the majority of our Pembrolizumab patient’s are on levothyroxine. I am very aware of the dermatological toxicities, I feel like we see those in the majority of patient’s on a CPI, or at least our patient’s are complaining of itching with or without the presence of a rash. I thought the over all percentages seemed low to me.Will the research/information in this article change or influence your practice? If so how?
Reading these articles was a really good refresher and reminder of the seriousness of CPIs side effects. As an oncology infusion RN, sometimes we can get so busy and think “oh its just a pembro/ immunotherapy”. We need to slow down and really evaluate patient’s on CPIs so we can catch AEs before they become life threatening. WE are often the professionals at the bedside evaluating the patient’s labs and toxicity assessment. We have a vital role to keep these patients safe and not blow off minor complaints. We really need to be assessing them closely.What other questions does the article raise about current practice?
Why are patient’s not screened closer and receiving cardiac clearance prior to starting a check point inhibitor? If a patient is on CPI, should they be followed by a cardiologist through treatment and for 1 year after completion for evaluation and early intervention treatment in the event of a cardiac AE? Seeing Figure 1 and looking over the prevalence of toxicities and the percentages I had a thought, I am wondering if it were broken down by disease line would we see any differences in the percentages? Is this even a factor?Jen I agree that patient complaints can be vague and hard to evaluate. I think I would be a great idea, esp for patient’s going on CPI maintenance, sometimes for up to 1.5 years, to be followed by a cardiologist and ophthalmologist. Lets be proactive and not reactive!
- You must be logged in to reply to this topic.