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Suzuki Y, Ishiguro S, Shimada H, Ohgami M, Suzuki M. Evaluation of mycophenolic acid exposure in a patient with immune-related hepatotoxicity caused by nivolumab and ipilimumab therapy for malignant melanoma: a case report. Cancer Chemother Pharmacol 2024; 93:633-638. [PMID: 38148336 DOI: 10.1007/s00280-023-04628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Guidelines such as the National Comprehensive Cancer Network recommend mycophenolate mofetil (MMF) for the treatment of severe steroid-refractory immune-related hepatotoxicity. Mycophenolic acid (MPA) is an active form of MMF that suppresses T- and B-lymphocyte proliferation and immune-related adverse events caused by immune checkpoint inhibitors. MPA has a narrow therapeutic range (37-70 µg·h/mL) and overexposure increases the risk of leukopenia in transplantation. However, the optimal use of MMF in oncology has not yet been established; thus, monitoring plasma MPA concentrations is necessary to avoid excessive immunosuppression in oncology practice. CASE PRESENTATION We evaluated plasma MPA concentration in a 75-year-old man with immune-related hepatotoxicity following nivolumab and ipilimumab combination therapy for malignant melanoma. The patient developed severe hepatotoxicity after immunotherapy, and immunosuppressant therapy with corticosteroids was initiated. The patient then developed steroid-refractory immune-related hepatotoxicity; therefore, MMF (1,000 mg twice daily) was co-administered. Seven days after the administration of MMF, the plasma MPA concentration was measured using an enzyme multiplied immunoassay technique. The area under the plasma concentration-time curve for MPA from 0 to 12 h was 41.0 µg·h/mL, and the same dose of MMF was continued. Grade 2 lymphocytopenia, which could be attributed to MMF, was observed during the administration period. Unfortunately, the patient was infected with SARS-CoV-2 and died from respiratory failure. CONCLUSION Our patient did not exceed the upper limit of MPA levels as an index of the onset of side effects of kidney transplantation and achieved rapid improvement in liver function. Prompt initiation of MMF after assessment of the steroid effect leads to adequate MPA exposure. Therapeutic drug monitoring should be considered when MMF is administered, to avoid overexposure.
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Affiliation(s)
- Yoshiharu Suzuki
- Department of Pharmacy, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1973, Japan.
| | - Shingo Ishiguro
- Department of Medical Oncology, Ibaraki Prefectural Central Hospital, Ibaraki, Japan
| | - Hirokazu Shimada
- Department of Pharmacy, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1973, Japan
| | - Masahiro Ohgami
- Department of Pharmacy, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1973, Japan
| | - Mika Suzuki
- Department of Pharmacy, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1973, Japan
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Chen YH, Kovács T, Ferdinandy P, Varga ZV. Treatment options for immune-related adverse events associated with immune checkpoint inhibitors. Br J Pharmacol 2024. [PMID: 38803135 DOI: 10.1111/bph.16405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/14/2024] [Accepted: 03/09/2024] [Indexed: 05/29/2024] Open
Abstract
The immunotherapy revolution with the use of immune checkpoint inhibitors (ICIs) started with the clinical use of the first ICI, ipilimumab, in 2011. Since then, the field of ICI therapy has rapidly expanded - with the FDA approval of 10 different ICI drugs so far and their incorporation into the therapeutic regimens of a range of malignancies. While ICIs have shown high anti-cancer efficacy, they also have characteristic side effects, termed immune-related adverse events (irAEs). These side effects hinder the therapeutic potential of ICIs and, therefore, finding ways to prevent and treat them is of paramount importance. The current protocols to manage irAEs follow an empirical route of steroid administration and, in more severe cases, ICI withdrawal. However, this approach is not optimal in many cases, as there are often steroid-refractory irAEs, and there is a potential for corticosteroid use to promote tumour progression. This review surveys the current alternative approaches to the treatments for irAEs, with the goal of summarizing and highlighting the best attempts to treat irAEs, without compromising anti-tumour immunity and allowing for rechallenge with ICIs after resolution of the irAEs.
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Affiliation(s)
- Yu Hua Chen
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Tamás Kovács
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
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Xu M, Xu L, Hao Y, Shao K, Song Z. Clinical characteristics and prognostic implications of immune-related hepatitis in patients with advanced non-small cell lung cancer treated with immune checkpoint inhibitors: a retrospective study. J Thorac Dis 2024; 16:1900-1910. [PMID: 38617766 PMCID: PMC11009595 DOI: 10.21037/jtd-23-1684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/02/2024] [Indexed: 04/16/2024]
Abstract
Background With the widespread use of immune checkpoint inhibitors (ICIs), patients inevitably experience immune-related adverse events (irAEs). Therefore, the study was conducted on the clinical characteristics and outcomes of patients with non-small cell lung cancer (NSCLC) with immune-related hepatitis (ir-hepatitis). Methods We identified patients with advanced NSCLC who developed ir-hepatitis after immunotherapy between June 2016 and December 2022. Their irAEs were categorized according to the Common Terminology Criteria for Adverse Events version 4.03 (CTCAE 4.03). Kaplan-Meier curves and log-rank tests were used to analyze survival. Results A total of 35 patients were enrolled in the study. The numbers of mild (grade 1-2) and severe (grade 3-4) ir-hepatitis cases were 13 (grade 1, 3; grade 2, 10) and 22 (grade 3, 17; grade 4, 5), respectively. The median onset time of ir-hepatitis was 1.6 months. The median progression-free survival (mPFS) was 8.3 months. PFS differed between patients with early ir-hepatitis developing within two treatment cycles and those with ir-hepatitis developing more than two treatment cycles (5.5 vs. 12.7 months, P=0.004). Patients with severe rather than mild ir-hepatitis tended to poorer PFS survival (5.8 vs. 11.2 months, P=0.130). The appearance of ir-hepatitis within two treatment cycles (P=0.002) and higher severity grades of ir-hepatitis (P=0.005) were independent risk factors for PFS. Conclusions Early and severe ir-hepatitis are associated with worse survival benefits, which still required more basic and perspective studies.
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Affiliation(s)
- Manyi Xu
- The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Lan Xu
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Yue Hao
- Department of Clinical Trail, Zhejiang Cancer Hospital, Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Keda Shao
- Department of Clinical Trail, Zhejiang Cancer Hospital, Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Zhengbo Song
- Department of Clinical Trail, Zhejiang Cancer Hospital, Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
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Yan T, Yu L, Zhang J, Chen Y, Fu Y, Tang J, Liao D. Achilles' Heel of currently approved immune checkpoint inhibitors: immune related adverse events. Front Immunol 2024; 15:1292122. [PMID: 38410506 PMCID: PMC10895024 DOI: 10.3389/fimmu.2024.1292122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/04/2024] [Indexed: 02/28/2024] Open
Abstract
Immunotherapy has revolutionized the cancer treatment landscape by opening up novel avenues for intervention. As the use of immune checkpoint inhibitors (ICIs) has exponentially increased, so have immune-related adverse events (irAEs). The mechanism of irAEs may involve the direct damage caused by monoclonal antibodies and a sequence of immune responses triggered by T cell activation. Common side effects include dermatologic toxicity, endocrine toxicity, gastrointestinal toxicity, and hepatic toxicity. While relatively rare, neurotoxicity, cardiotoxicity, and pulmonary toxicity can be fatal. These toxicities pose a clinical dilemma regarding treatment discontinuation since they can result in severe complications and necessitate frequent hospitalization. Vigilant monitoring of irAEs is vital in clinical practice, and the principal therapeutic strategy entails the administration of oral or intravenous glucocorticoids (GSCs). It may be necessary to temporarily or permanently discontinue the use of ICIs in severe cases. Given that irAEs can impact multiple organs and require diverse treatment approaches, the involvement of a multidisciplinary team of experts is imperative. This review aims to comprehensively examine the pathogenesis, clinical manifestations, incidence, and treatment options for various irAEs.
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Affiliation(s)
- Ting Yan
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Lun Yu
- Department of Positron Emission Tomography–Computed Tomography (PET-CT) Center, Chenzhou No. 1 People’s Hospital, Chenzhou, China
| | - Jiwen Zhang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
- School of Pharmacy, University of South China, Hengyang, China
| | - Yun Chen
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yilan Fu
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Jingyi Tang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Dehua Liao
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
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Alouani E, Laparra A, Perret A, Sakkal M, Messayke S, Danlos FX, Ouali K, Hollebecque A, Even C, Ammari S, Baldini C, Champiat S, Besse B, Robert C, Guettier C, Samuel D, Lambotte O, De Martin E, Michot JM. Immunosuppressant mycophenolate mofetil for patients with steroid-refractory immune-related hepatitis induced by checkpoint inhibitors in oncology. Eur J Cancer 2023; 193:113313. [PMID: 37748398 DOI: 10.1016/j.ejca.2023.113313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Immune-checkpoint inhibitor (ICI) hepatitis, which does not improve with steroids and requires additional immunosuppressant, is defined as steroid-refractory ICI hepatitis. The outcome of patients with steroid-refractory ICI hepatitis remains poorly determined. Herein, we investigated the incidence, clinical features, and outcome of patients treated with second-line immunosuppressant for steroid-refractory ICI hepatitis. METHODS This is a retrospective analysis of patients who presented ICI hepatitis from 1st June 2016 to 30th September 2022. Steroid-refractory ICI hepatitis was defined as no clinical and biological improvement after systemic steroid therapy ≥1 mg/kg/d. Main objectives were to assess the frequency and risk factors associated with steroid-refractory ICI hepatitis and to evaluate the efficacy of second-line immunosuppressants. RESULTS In total, 130 patients with grade ≥3 ICI hepatitis were screened, of them 60 (46.2%) were treated with systemic steroids. In total, 11/130 (8.5%) had steroid-refractory hepatitis. Statistically significant factors associated with steroid-refractory hepatitis included previous liver comorbidities (54.5% versus 11.6%; p < 0.01), hyperbilirubinemia (p < 0.001), and general symptoms (fever, jaundice, ascites, and/or encephalopathy) associated with hepatitis (72.7% versus 30.8%; p = 0.015). The 11 patients with steroid-refractory hepatitis were treated with mycophenolate mofetil. In total, resolution or return to grade ≤1 for hepatitis was observed in 81.8% (9/11) of patients. CONCLUSIONS Steroid-refractory ICI hepatitis accounted for 8.5% of patients with grade ≥3 immune-related hepatitis and was statistically associated with previous liver comorbidities, hyperbilirubinemia, and general symptoms. Mycophenolate mofetil was a suitable option of therapy for steroid-refractory ICI hepatitis.
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Affiliation(s)
- Emily Alouani
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; Digestive Medical Oncology Department, IUCT-Rangueil, Toulouse Hospital University, Toulouse, France
| | - Ariane Laparra
- Département Interdisciplinaire d'Organisation des Parcours Patients, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Audrey Perret
- Département Interdisciplinaire d'Organisation des Parcours Patients, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Madonna Sakkal
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Sabine Messayke
- Pharmacovigilance Unit, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Francois-Xavier Danlos
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; INSERM U1015 and CIC1428 BIOTHERIS, Gustave Roussy, Villejuif, France
| | - Kaissa Ouali
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Antoine Hollebecque
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Caroline Even
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Samy Ammari
- ELSAN Department of Radiology, Institut de Cancérologie Paris Nord, Sarcelles, France; Department of Radiology, Gustave Roussy Cancer Campus, Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, Villejuif, France
| | - Capucine Baldini
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Stéphane Champiat
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Benjamin Besse
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Caroline Robert
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Catherine Guettier
- Department of Pathology, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Paris-Saclay University, UMR-S 1193, Le Kremlin Bicêtre, France
| | - Didier Samuel
- Department of Hepatology, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Centre Hépato-Biliaire, INSERM 1193, Villejuif, France
| | - Olivier Lambotte
- Internal Médecine Department, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Paris-Saclay University, Le Kremlin-Bicêtre, France; IDMIT Department, IBFJ, Centre Immunology of Viral Infections and Autoimmune Diseases, INSERM, CEA, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Eleonora De Martin
- Department of Hepatology, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Centre Hépato-Biliaire, INSERM 1193, Villejuif, France
| | - Jean-Marie Michot
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; INSERM U1170, Université Paris-Saclay, Gustave Roussy, Villejuif, France.
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