[Mandi Murph]

Well stated, Virginia!

An additional point- a more general one for PD-1 inhibitors, since so many changes are occurring so rapidly, checking the PI information on the manufacturers web site will provide the most up to date prescrbing and administration guidelines, and more changes are slated ahead!

-Kathy

[Mandi Murph]

Hi Krista,
These are tough situations with patients receiving adjuvant treatment. Just a few questions, has treatment been with held at all to allow time for resolution? What is the patients level of motivation to continue in light of this persistent irAE which is impacting QOL? Was Sjogren’s considered or investigated with labs?

So taking inventory that:
This irAE being one of the less common one but it is no less impactful that other irAE’s & we don’t know potential long term issues ( ie dental issues)
It can be difficult to treat and and have prolonged resolution
The pt is almost half finished with therapy

My thoughts are; this is adjuvant I would hold treatment allow all toxicity to resolve, let the patient regain the lost weight if appropriate and see if patient can be restarted on therapy to complete a 12 month course of therapy successfully.

Thanks for bringing this challenging case for discussion, Looking forward to your reply!

-Kathy

[Mandi Murph]

Our approach is consistent with Virgina’s. I will add that there are some centers which have guidelines to premed before therapies, several years ago when ICI’s were launced, it was identified that some community based centers were pre-meding prior to infusions of ICI’s. An emphasis of education and understanding of the mechanism of action of these agents was and continues to be underscored.

[Mandi Murph]

We have utilized both approaches, by using 1 syringe and changing the safety needle between injections and we have used several prefilled syringes for multiple tumors.Either approach is acceptable, it’s a matter of preference.

[Mandi Murph]

We too have had limited experience with T-VEC but of those patients, the only AE’s we observed were more consistent with flu like symptoms which were treated with benadryl, acetaminophen & sometimes prednisone, but typically for the first 24 hours after the injection. Regarding ocular herpes, my experiences with this is a compication typically associated with an outbreak of shingles along the ophthalmic or maxiallary dermatome which has impacted the eye, but none of these were related to T-Vec. It is possible to aquire a localized herpetic infection from other sources of contact.

[Mandi Murph]

Hi Virginia,
Regarding your adjuvant patient who is experiencing ongoing colitis despite 3 doses of infliximab,vedolizumab would have been a good next step consideration, unfortunately, this is not an option. Just a thought, could the patient be treated on a routine “colitis” regimen with maintenance dosing rather than episodic dosing until sx are under long term control. Thoughts?

[Mandi Murph]

Keeping close clinical track of our patients on combination therapy is important for their safety in recognizing irAE’s early on and intervening at the onset if needed. Glad to hear that we have parallel practice approaches!
Thank you so much, Yael, for coming by to check out the site, glad to hear that you like it and we hope that you continue to find it helpful to your practice.

[Mandi Murph]

HI Yael,
You are so correct that although each clinical provider on the team is responsible for understanding, educating and assessing immune related adverse events ( irAE’s), it is more often nurses who are the point person for education. Educational encounters occur at the beginning of treatment, during treatment and ongoing support after treatment. The types of adverse events covered in educational sessions are the ones that are found in the prescrbing information for immunotherapies:
We commonly start with the most prevalent, Derm & GI, then discussing less common irAE’s but ones that could become clinically significant if not identified & intervened with, which are Endocrine, Pulmonary, Renal, Hepatotoxicity, Neuropathy/ other Neurologic changes, ocular toxicity. We always keep in mind that ANY organ system can be impacted but we know that the above listed organ systems are the ones recommended that we oversee closely for patients who are or have been tretated with an immuontherapy.

For additional supportive resources please visit the Home page of themelanomastg.wpengine.com, there are downloadable & printable materials, that can serve as a guide when you are reviewing irAE’s with a patient. Visiting the product / drug homepages and prescribing information is always recommended to keep abreast of any updates or changes.

thank you so much for your inquiry, I hope it is helpful to you!

[Mandi Murph]

Just tossing another consideration into the ring. When patients develop rash and or itching, we typically recommend anti-histamine therapy to manage mild to moderate grading of this adverse event. Rash +/- itching can occur early, recur often and can be a prolonged experience which may warrant frequent and possibly prolonged intervention. Anti-histamines can by drying, especially to the oral mucosa, this added dryness could potentially accelerate dental issues. This is not the norm but it could be an experince of a small subset. Any at risk patients should consider partaking in regular dental checkups.

[Author]

Posts