Improving recognition and early management of immunotherapy related Diarrohea/Colitis and improving referral for specialist review

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Background

Monoclonal antibodies targeted against the immune checkpoint molecules CTLA-4 and PD-1 are increasingly being used for management of cancers. However, management of immune-related adverse events (irAEs) remains largely unknown to medical community. Although severe irAEs remain rare, they can become life-threatening if not anticipated and managed appropriately.

Aim

Improving recognition and early management of immunotherapy related Diarrhoea/Colitis and improving referral for specialist review.

Method

Patients commenced on Immunotherapy between Jan 2017 and Dec 2018 were identified from pharmacy database (OPMAS). In patients admitted with colitis were identified from discharge summaries. Data extracted from discharge summaries, ICE and inpatient notes.

Results

267 patients are commenced on Immunotherapy. 19 patients admitted with Diarrhoea/Colitis. 14 patients are on Combination Immunotherapy and 5 patients on single agent. The patients who admitted with Diarrhoea/Colitis, 100% had their blood tests, 89% had CRP,84% patients stool sent for C.Difficle,27% patients had documented grade on admission,100% started on high dose steroids and discharged on high dose tapering dose steroids and follow up arranged.8/11 (72%) patients who had G3/G4/persistent G2 were referred to GI team. 26% patients who had been commenced on combination immunotherapy has been admitted with Diarrhoea/ Colitis.

Implications

Improvement needed in documenting and assessing grade of toxicity as treatment depends on this. Referral to GI specialist should be done without delay for persistent G2/G3/G4 as there is evidence of decrease morbidity and mortality with early referrals. This project caused the awareness about high rates G3/G4 toxicity with combination immunotherapy. It lead to creation of patient leaflets and leaflets to GP to cause awareness for early recognition and treatment of toxicity to limit duration and severity of irAEs. Created Helpline action cards and Guidelines of Management of Immunotherapy adverse related event which are currently on Intranet. We would like to assess again in 2 year’s time for improvement.

https://www.gloshospitals.nhs.uk/gps/treatment-guidelines/management-immune-related-adverse-events-iraes-caused-immunotherapy