Pneumonitis (inflammation of lung alveoli)

Grading Toxicity

Definition: A disorder characterized by inflammation focally or diffusely affecting the lung parenchyma

Asymptomatic; clinical or diagnostic observations only; intervention not indicated

Definition: A disorder characterized by decrease in the level of oxygen to the body

Assess for other etiologies such as infection, pulmonary embolism, progressive lung metastases, or lung disease
Early intervention to maintain or improve physical function and impact on QOL
Assess pulse oximetry (resting & on exertion) at baseline and at each visit to assist in identifying a decrease at early onset.

Immunotherapy to be withheld for Grade 2 events (resume when Grade 0/1)
Immunotherapy to be discontinued for recurrent (pembrolizumab, nivolumab) or persistent Grade 2 events (ipilimumab, pembrolizumab, nivolumab)
Anticipate treatment with:
- Corticosteroids (e.g., prednisone 1-2 mg/kg/day or equivalent) until symptoms improve to baseline, and then slow taper over at least 1 month
- If symptoms do not improve within 48-72 hours, corticosteroid dose will be escalated. IV corticosteroids may be considered
- Additional supportive care medications may also be initiated
Anticipatory guidance on proper administration
Anticipate the use of empiric antibiotics until infection is excluded
Anticipate that bronchoscopy may be ordered by provider
Assess patient & family understanding of recommendations and rationale
Identify barriers to adherence

Discontinue immunotherapy for Grade 3/4 events
Patient will likely need to be admitted to the hospital for further management and supportive care
Anticipate the use of high-dose IV corticosteroids (e.g., methylprednisolone 2-4 mg/kg/day or equivalent)
Once symptoms have resolved to baseline or Grade 1, convert to equivalent oral corticosteroid dose and then taper slowly over at least 1 month
Anticipate the use of empiric antibiotics until infection is excluded
Anticipate the use of additional immunosuppressive agents if symptoms do not improve in 48-72 hours (e.g., infliximab, mycophenolate, cyclophosphamide)
Assess patient & family understanding of toxicity and rationale for treatment discontinuation
Identify barriers to adherence, specifically compliance with medication, physical activity.

Identify high-risk individuals (e.g., asthma, COPD) and those with cardiopulmonary symptoms prior to initiating immunotherapy. Establish a thorough baseline
Educate patients that new pulmonary symptoms should be reported immediately
Anticipate that the steroid requirements to manage pneumonitis are high (1-4 mg/kg/day) and patient will be on corticosteroid therapy for at least 1 month
Educate patients and family about the rationale for discontinuation of immunotherapy in patients who do develop moderate or severe pneumonitis

Risk of acute onset
Risk of mortality if pneumonitis treatment is delayed
Risk of pneumonitis is greater in patients receiving combination immunotherapy regimens