February 5, 2018 at 3:20 am #4663Expert NurseKathleen Madden
Just a curiosity related to ICI irAE’s
1.How you refer patients to organ specific specialists to GI, Endocrine, opthamology, etc..
Do you have an ICI specialist referral base or network?
2.If patients have a pre-existing medical issue such as hypo / hyper- thyroid, colitis do you routinely contact the pts specialist provider before the start of therapy to include them in the plan of careFebruary 7, 2018 at 3:39 pm #4664Expert NurseKrista Rubin
Great question. When we first began to treat numerous patients with immune checkpoint inhibitors, we found out quickly that it was ideal to have a “go to” person in subspecialty practices. Notably, GI and dermatology were identified as the greatest need at the time (this was going back about 10 years now when ipilimumab was in clinical trials). Honestly, many of the relationships we now have, stemmed from fellows being “assigned” to these patients. I would often have a conversation with these individuals describing these therapies and the need to have a “go to”. Many were very intrigued by the science behind the toxicity and from there, interest and curiosity blossomed. Eventually with use of ICIs by other cancer disease groups and more and more patients were experiencing toxicity, these other groups reached out to us (the Melanoma Team) for our contacts.
Over time, we had established a contact within multiple subspecialties and developed a “List” – this eventually turned into what is now an established “Immunotherapy Severe Toxicity Team”. Often, one of the physicians would reach out to a department head, explain the need for an established contact along with the rationale. This approach,for us, was incredibly helpful.
Regarding your second question- for the most part, if we have a patient with underlying autoimmune issue- depending on what it is, we may or may not reach out. For example, for someone with underlying hypothyroidism, we “take over” the management of TFTs an replacement dosing. I make a point of noting this in the patient progress note and ensure a copy is sent to the patients provider. If it is a case of underlying UC or Crohn’s- then YES, we typically do reach out with the intended plan to co-manage these patients. Ideally, co-management is the best approach, but not always feasible.
Thanks for posting.
PS- I would add one more thing. For community practices, I believe proactive identification of subspecialty providers in the community is CRITICAL to successful outcomes for patients receiving ICIs.February 7, 2018 at 5:21 pm #4666Expert NurseLisa Kottschade
Great question. In my practice many years ago in the first days of Ipi clinical trials, we too kind of did the “phone a friend” in whatever sub-specialty we needed at the time. Since that time when Ipi got FDA approved we actually set up a formal “network” of sub-specialists that had in interest in this. Since they obviously can’t see all the patients with toxicity on their own as they have their regular practices to contend with, they have done many trainings with a core group of people in their department so that they are up to speed, etc on irAE’s.
In terms of managing patients with pre-existing autoimmune conditions, we are very similar to Krista in that it depends on the condition. Sometimes this is difficult though as patients may be being managed in their community for their condition. And as such we are unable to get them in for an appointment with a subspecialist here (high demand), because their condition is stable and they won’t be offering any “value-added” to the patient. In that case we will usually connect with their specialist on the outside and/or do an e-consult.
LisaFebruary 8, 2018 at 11:34 pm #4669Expert NurseVirginia Seery
We are similar to Lisa and Krista in that we have identified specialists with an interest in, and experience with, ICI immune related AE’s. This group has blossomed in recent years. It is a great concept to have a whole team identified as is done at Krista’s institution. We are not quite that organized, but it is something to work toward!
In terms of a pre-existing autoimmune condition, it depends on the severity and our comfort level managing the issue. We try to at least notify the managing team so they are aware of potential problems.
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