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Ozluk AA, Gunenc D, Yildirim SS, Karaca B. Tocilizumab in the treatment of steroid refractory immune-related hepatotoxicity: a case series and review of the literature. Melanoma Res 2024; 34:335-342. [PMID: 38691011 DOI: 10.1097/cmr.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
With the widespread use of immune checkpoint inhibitors, management of immune-related adverse effects specific to these treatments became an important research era in patient management. Among these, immune-related hepatotoxicity (IRH) is an adverse event that can be fatal. While the first-line treatment of IRH is well established, there is still no consensus regarding the management approach for steroid-refractory, severe IRH. Here, we report four patients with metastatic melanoma who developed IRH during antiprogrammed cell death protein-1 plus anticytotoxic T-lymphocyte-associated protein-4 combination therapy and review of the literature. All of our patients were steroid-refractory and were successfully treated with tocilizumab. Given the rapid improvement in liver enzymes and patient's clinical status with tocilizumab, this treatment should be prioritized in steroid-refractory IRH.
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Affiliation(s)
- Ahmet Anil Ozluk
- Division of Tulay Aktas Oncology, Department of Medicine, Ege University, Bornova, Turkey
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2
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Zhuang D, Zhang D, Riordan S. Hepatobiliary complications of immune checkpoint inhibitors in cancer. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:955-970. [PMID: 39280244 PMCID: PMC11390294 DOI: 10.37349/etat.2024.00257] [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: 04/19/2024] [Accepted: 06/14/2024] [Indexed: 09/18/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have dramatically changed the landscape of cancer therapy. Over the last decade, both their primary focus in trials and clinical application have exponentially risen, with repeated demonstrations of their efficacy in improving survival in various cancer types. The adverse effects of these drugs on various organ systems were recognised in early phase studies. Given their relatively new emergence on the market, there has been increasing interest into short- and long-term effects and management of ICIs in real-world settings. ICI-related hepatobiliary toxicities are often challenging to diagnose and difficult to distinguish from other causes of deranged liver biochemical tests. The aim of this review is to provide an up-to-date and detailed exploration of the hepatobiliary complications of ICIs, including pathogenesis and approaches to diagnosis and management.
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Affiliation(s)
- Donna Zhuang
- Gastrointestinal and Liver Unit, Prince of Wales Hospital, Randwick, New South Wales 2031, Australia
- Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales 2031, Australia
| | - David Zhang
- Gastrointestinal and Liver Unit, Prince of Wales Hospital, Randwick, New South Wales 2031, Australia
- Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales 2031, Australia
| | - Stephen Riordan
- Gastrointestinal and Liver Unit, Prince of Wales Hospital, Randwick, New South Wales 2031, Australia
- Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales 2031, Australia
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3
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Zhou Y, Li J, Ying J. Anti-PD-1/L1 antibody plus anti-VEGF antibody vs. plus VEGFR-targeted TKI as first-line therapy for unresectable hepatocellular carcinoma: a network meta-analysis. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:568-580. [PMID: 38966165 PMCID: PMC11220314 DOI: 10.37349/etat.2024.00236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/19/2024] [Indexed: 07/06/2024] Open
Abstract
Background This article is based on our previous research, which was presented at the 2023 ASCO Annual Meeting I and published in Journal of Clinical Oncology as Conference Abstract (JCO. 2023;41:e16148. doi: 10.1200/JCO.2023.41.16_suppl.e16148). Both anti-programmed death 1/ligand-1 (PD-1/L1) antibody + anti-vascular endothelial growth factor (VEGF) antibody (A + A) and anti-PD-1/L1 antibody + VEGF receptor (VEGFR)-targeted tyrosine kinase inhibitor (A + T) are effective first-line therapies for unresectable hepatocellular carcinoma. However, there lacks evidence from head-to-head comparisons between these two treatments. We conducted a network meta-analysis on the efficacy and safety of them. Methods After a rigorous literature research, 6 phase III trials were identified for the final analysis, including IMbrave150, ORIENT-32, COSMIC-312, CARES-310, LEAP-002, and REFLECT. The experiments were classified into three groups: A + A, A + T, and intermediate reference group. The primary endpoint was overall survival (OS), and secondary endpoints included progression-free survival (PFS), objective response rate (ORR), and incidence of treatment-related adverse events (TRAEs). Hazard ratio (HR) with 95% confidence intervals (CI) for OS and PFS, odds ratio (OR) for ORR, and relative risk (RR) for all grade and grade ≥3 TRAEs were calculated. Under Bayesian framework, the meta-analysis was conducted using sorafenib as intermediate reference. Results With the rank probability of 96%, A + A showed the greatest reduction in the risk of death, without significant difference from A + T (HR: 0.82, 95% CI: 0.65-1.04). A + T showed the greatest effect in prolonging PFS and improving ORR with the rank probability of 77%, but there were no statistical differences with A + A. A + A was safer than A + T in terms of all grade of TRAEs (RR: 0.91, 95% CI: 0.82-1.00) and particularly in those grade ≥3 (RR: 0.65, 95% CI: 0.54-0.77). Conclusions A + A had the greatest probability of delivering the longest OS, while A + T was correlated with larger PFS benefits at the cost of a lower safety rate.
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Affiliation(s)
- Yiwen Zhou
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Jingjing Li
- Department of Hepato-Pancreato-Biliary & Gastric Medical Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, Zhejiang, China
| | - Jieer Ying
- Department of Hepato-Pancreato-Biliary & Gastric Medical Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, Zhejiang, China
- Postgraduate training base Alliance of Wenzhou Medical University (Zhejiang Cancer Hospital), Hangzhou 310022, Zhejiang, China
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4
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Fu Z, Liu J, Zhang C, Hu H, Li S, Zhang Y, You R. Hepatitis-related adverse events associated with immune checkpoint inhibitors in cancer patients: an observational, retrospective, pharmacovigilance study using the FAERS database. Front Pharmacol 2024; 15:1383212. [PMID: 38948476 PMCID: PMC11211592 DOI: 10.3389/fphar.2024.1383212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 05/28/2024] [Indexed: 07/02/2024] Open
Abstract
Background: Immune checkpoint inhibitors (ICIs), including anti-PD-1, anti-PD-L1 and anti-CTLA-4 antibodies, have become a standard treatment for multiple cancer types. However, ICIs can induce immune-related adverse events, with hepatitis-related adverse events (HRAEs) being of particular concern. Our objective is to identify and characterize HRAEs that exhibit a significant association with ICIs using real-world data. Methods: In this observational and retrospective pharmacovigilance study, we extracted real-world adverse events reports from the FDA Adverse Event Reporting System database spanning from the first quarter of 2004 to the first quarter of 2023. We conducted both Frequentist and Bayesian methodologies in the framework of disproportionality analysis, which included the reporting odds ratios (ROR) and information components (IC) to explore the intricate relationship between ICIs and HRAEs. Results: Through disproportionality analysis, we identified three categories of HRAEs as being significantly related with ICIs, including autoimmune hepatitis (634 cases, ROR 19.34 [95% CI 17.80-21.02]; IC025 2.43), immune-mediated hepatitis (546 cases, ROR 217.24 [189.95-248.45]; IC025 4.75), and hepatitis fulminant (80 cases, ROR 4.56 [3.65-5.70]; IC025 0.49). The median age of patients who report ICI-related HRAEs was 63 years (interquartile range [IQR] 53.8-72), with a fatal outcome observed in 24.9% (313/1,260) of these reports. Cases pertaining to skin cancer, lung cancer, and kidney cancer constituted the majority of these occurrences. Patients treated with anti-PD-1 or anti-PD-L1 antibodies exhibited a higher frequency of immune-mediated hepatitis in comparison to those undergoing anti-CTLA-4 monotherapy, with a ROR of 3.59 (95% CI 1.78-6.18). Moreover, the dual ICI therapy demonstrated higher reporting rates of ICI-related HRAEs compared to ICI monotherapy. Conclusion: Our findings confirm that ICI treatment carries a significant risk of severe HRAEs, in particular autoimmune hepatitis, immune-mediated hepatitis, and hepatitis fulminant. Healthcare providers should exercise heightened vigilance regarding these risks when managing patients receiving ICIs.
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Affiliation(s)
| | | | | | | | | | | | - Ruxu You
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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5
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Townsend MJ, Benque IJ, Li M, Grover S. Review article: Contemporary management of gastrointestinal, pancreatic and hepatic toxicities of immune checkpoint inhibitors. Aliment Pharmacol Ther 2024; 59:1350-1365. [PMID: 38590108 DOI: 10.1111/apt.17980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are effective oncologic agents which frequently cause immune-related adverse events (irAEs) which can impact multiple organ systems. Onco-Gastroenterology is a novel and emerging subspecialty within gastroenterology focused on cancer treatment-related complications. Gastroenterologists must be prepared to identify and manage diverse immune-mediated toxicities including enterocolitis, hepatitis, pancreatitis and other ICI-induced toxicities. AIM To provide a narrative review of the epidemiology, diagnostic evaluation and management of checkpoint inhibitor-induced gastrointestinal and hepatic toxicities. METHODS We searched Cochrane and PubMed databases for articles published through August 2023. RESULTS Gastrointestinal and hepatic irAEs include most commonly enterocolitis and hepatitis, but also pancreatitis, oesophagitis, gastritis, motility disorders (gastroparesis) and other rarer toxicities. Guidelines from the National Comprehensive Cancer Network, American Society of Clinical Oncology and European Society for Medical Oncology, in combination with emerging cohort and clinical trial data, offer strategies for management of ICI toxicities. Evaluation of irAEs severity by formal classification and clinical stability, and a thorough workup for alternative etiologies which may clinically mimic irAEs underlie initial management. Treatments include corticosteroids, biologics and other immunosuppressive agents plus supportive care; decisions on dosing, timing and choice of steroid adjuncts and potential for subsequent checkpoint inhibitor dosing are nuanced and toxicity-specific. CONCLUSIONS Expanding clinical trial and cohort data have clarified the epidemiology and clinical characteristics of gastrointestinal, pancreatic and hepatic toxicities of ICIs. Guidelines, though valuable, remain based principally on retrospective cohort data. Quality prospective, controlled studies may refine algorithms for treatment and potential immunotherapy rechallenge.
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Affiliation(s)
- Matthew J Townsend
- Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Isaac J Benque
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Michael Li
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Division of Gastroenterology, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Shilpa Grover
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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6
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Ruli TM, Pollack ED, Lodh A, Evers CD, Price CA, Shoreibah M. Immune Checkpoint Inhibitors in Hepatocellular Carcinoma and Their Hepatic-Related Side Effects: A Review. Cancers (Basel) 2024; 16:2042. [PMID: 38893164 PMCID: PMC11171072 DOI: 10.3390/cancers16112042] [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: 04/24/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Primary liver cancer is one of the leading causes of cancer mortality worldwide, with hepatocellular carcinoma (HCC) being the most prevalent type of liver cancer. The prognosis of patients with advanced, unresectable HCC has historically been poor. However, with the emergence of immunotherapy, specifically immune checkpoint inhibitors (ICIs), there is reason for optimism. Nevertheless, ICIs do not come without risk, especially when administered in patients with HCC, given their potential underlying poor hepatic reserve. Given their novelty in the management of HCC, there are few studies to date specifically investigating ICI-related side effects on the liver in patients with underlying HCC. This review will serve as a guide for clinicians on ICIs' role in the management of HCC and their potential side effect profile. There will be a discussion on ICI-related hepatotoxicity, the potential for hepatitis B and C reactivation with ICI use, the potential for the development of autoimmune hepatitis with ICI use, and the risk of gastrointestinal bleeding with ICI use. As ICIs become more commonplace as a treatment option in patients with advanced HCC, it is imperative that clinicians not only understand the mechanism of action of such agents but also understand and are able to identify hepatic-related side effects.
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Affiliation(s)
- Thomas M. Ruli
- Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (E.D.P.); (A.L.); (C.A.P.)
| | - Ethan D. Pollack
- Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (E.D.P.); (A.L.); (C.A.P.)
| | - Atul Lodh
- Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (E.D.P.); (A.L.); (C.A.P.)
| | - Charles D. Evers
- Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (E.D.P.); (A.L.); (C.A.P.)
| | - Christopher A. Price
- Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (E.D.P.); (A.L.); (C.A.P.)
| | - Mohamed Shoreibah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35233, USA;
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Yue M, Li C, Li G. New advances in the study of PD-1/PD-L1 inhibitors-induced liver injury. Int Immunopharmacol 2024; 131:111799. [PMID: 38460297 DOI: 10.1016/j.intimp.2024.111799] [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: 01/24/2024] [Revised: 02/20/2024] [Accepted: 03/01/2024] [Indexed: 03/11/2024]
Abstract
The application of immune checkpoint inhibitors (ICIs) has made extraordinary achievements in tumor treatment. Among them, programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors can improve the prognosis of advanced tumors, and have been widely used in clinical practice to treat many types of cancers. However, excessive immune response can also induce immune-related adverse events (irAEs) involving many organs. Of these, immune-related liver injury is the relatively common and carries the highest morbidity, which has attracted the attention of hepatologists all over the world. The incidence of this type of liver injury depends specifically on factors such as the type of drug being combined, viral infection, type of cancer and liver transplantation. Although there is no unanimity on the mechanism of PD-1/PD-L1 inhibitor-induced liver injury, in this review, we also summarize the current evidence that provides insights into the pathogenesis of PD-1/PD-L1 inhibitor-induced liver injury, including the fact that PD-1/PD-L1 inhibitors cause reactivation of CTLs, aberrant presentation of autoantigens, hepatic immune tolerance environment is disrupted, and cytokine secretion, among other effects. Patients usually develop liver injury after the use of PD-1/PD-L1 inhibitors, and clinical symptoms mainly include weakness, muscle pain, nausea and vomiting, and jaundice. Histologically, the main manifestation is lobular hepatitis with lobular inflammatory infiltration. Since the specific biomarkers for PD-1/PD-L1 inhibitor-associated liver injury have not been identified yet, alpha-fetoprotein, IL-6, and IL-33 have the potential to be biomarkers for predicting this type of liver injury in the future, but this requires further research. We also describe the examination and treatment of this type of liver injury, which usually includes eliminating related influencing factors, regularly monitoring liver function, temporarily retaining or permanently stopping ICIs treatment according to the severity of toxicity, and using corticosteroids. This review may provide useful information for the future clinical practice of PD-1/PD-L1 inhibitors.
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Affiliation(s)
- Meijun Yue
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Chunyu Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | - Guohui Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
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8
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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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9
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Tong X, Zhan T, Dong X, Xu D. Fever of unknown origin associated with immune checkpoint inhibitors. Front Immunol 2024; 15:1364128. [PMID: 38533499 PMCID: PMC10963505 DOI: 10.3389/fimmu.2024.1364128] [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: 01/01/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
Since the approval for the treatment of melanoma in 2014, immune checkpoint inhibitors (ICIs) have revolutionized the therapy pattern across various malignancies. Coinciding with their frequent usage, their adverse effects, including fever, cannot be neglected. In the context of cancer diseases and cancer treatments, fever of unknown origin (FUO), which has long posed a challenge for clinicians in terms of diagnosis and management, brings forth new connotation and significance. In this paper review, we present the concept of ICIs-associated FUO, consider activated immune system and elevated cytokines as common mechanisms by which ICIs induce fever and various immune-related adverse events (irAEs), summarize and compare the primary etiologies of ICI-associated FUO, and compare it with conventional types of FUO.
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Affiliation(s)
- Xu Tong
- The Second Clinical Medical College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tao Zhan
- The Second Clinical Medical College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaoqin Dong
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dong Xu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei, China
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10
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Lasagna A, Sacchi P. The ABC of Immune-Mediated Hepatitis during Immunotherapy in Patients with Cancer: From Pathogenesis to Multidisciplinary Management. Cancers (Basel) 2024; 16:795. [PMID: 38398187 PMCID: PMC10886483 DOI: 10.3390/cancers16040795] [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: 11/16/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Immune-mediated hepatotoxicity (IMH) is not-so-rare complication during treatment with immune checkpoint inhibitors (ICIs). This narrative review aims to report the current knowledge on hepatic immune-related adverse events (irAEs) during immunotherapy from pathogenesis to multidisciplinary management. The majority of cases of IMH are asymptomatic and only a few patients may have clinical conditions. The severity of IMH is usually stratified according to Common Terminology for Clinical Adverse Events (CTCAE) criteria, but these scores may overestimate the clinical severity of IMH compared to the Drug-Induced Liver Injury Network (DILIN) scale. The differential diagnosis of IMH is challenging because the elevated liver enzymes can be due to a number of etiologies such as viral infection, autoimmune and metabolic diseases, liver metastases, biliary diseases, and other drugs. The cornerstones of IMH management are represented by withholding or delaying ICI administration and starting immunosuppressive therapy. A multidisciplinary team, including oncologists, hepatologists, internists, and emergency medicine physicians, is essential for the management of IMH.
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Affiliation(s)
- Angioletta Lasagna
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Paolo Sacchi
- Division of Infectious Diseases I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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11
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Shojaie L, Bogdanov JM, Alavifard H, Mohamed MG, Baktash A, Ali M, Mahov S, Murray S, Kanel GC, Liu ZX, Ito F, In GK, Merchant A, Stohl W, Dara L. Innate and adaptive immune cell interaction drives inflammasome activation and hepatocyte apoptosis in murine liver injury from immune checkpoint inhibitors. Cell Death Dis 2024; 15:140. [PMID: 38355725 PMCID: PMC10866933 DOI: 10.1038/s41419-024-06535-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024]
Abstract
Immune checkpoints (CTLA4 & PD-1) are inhibitory pathways that block aberrant immune activity and maintain self-tolerance. Tumors co-opt these checkpoints to avoid immune destruction. Immune checkpoint inhibitors (ICIs) activate immune cells and restore their tumoricidal potential, making them highly efficacious cancer therapies. However, immunotolerant organs such as the liver depend on these tolerogenic mechanisms, and their disruption with ICI use can trigger the unintended side effect of hepatotoxicity termed immune-mediated liver injury from ICIs (ILICI). Learning how to uncouple ILICI from ICI anti-tumor activity is of paramount clinical importance. We developed a murine model to recapitulate human ILICI using CTLA4+/- mice treated with either combined anti-CTLA4 + anti-PDL1 or IgG1 + IgG2. We tested two forms of antisense oligonucleotides to knockdown caspase-3 in a total liver (parenchymal and non-parenchymal cells) or in a hepatocyte-specific manner. We also employed imaging mass cytometry (IMC), a powerful multiplex modality for immunophenotyping and cell interaction analysis in our model. ICI-treated mice had significant evidence of liver injury. We detected cleaved caspase-3 (cC3), indicating apoptosis was occurring, as well as Nod-like receptor protein 3 (NLRP3) inflammasome activation, but no necroptosis. Total liver knockdown of caspase-3 worsened liver injury, and induced further inflammasome activation, and Gasdermin-D-mediated pyroptosis. Hepatocyte-specific knockdown of caspase-3 reduced liver injury and NLRP3 inflammasome activation. IMC-generated single-cell data for 77,692 cells was used to identify 22 unique phenotypic clusters. Spatial analysis revealed that cC3+ hepatocytes had significantly closer interactions with macrophages, Kupffer cells, and NLRP3hi myeloid cells than other cell types. We also observed zones of three-way interaction between cC3+ hepatocytes, CD8 + T-cells, and macrophages. Our work is the first to identify hepatocyte apoptosis and NLRP3 inflammasome activation as drivers of ILICI. Furthermore, we report that the interplay between adaptive and innate immune cells is critical to hepatocyte apoptosis and ILICI.
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Affiliation(s)
- Layla Shojaie
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
| | - Jacob M Bogdanov
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
| | - Helia Alavifard
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
- Research Center for Liver Disease, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
| | - Mahmoud G Mohamed
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
- Research Center for Liver Disease, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
| | - Aria Baktash
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
- Research Center for Liver Disease, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
| | - Myra Ali
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
| | - Simeon Mahov
- Division of Hematology and Cellular Therapy, Department of Medicine, Cedars-Sinai Medical Center, 127 S. San Vicente Boulevard Pavilion A8700, Los Angeles, CA, 90048, USA
| | - Sue Murray
- Ionis Pharmaceuticals, Inc, 2855 Gazelle Ct, Carlsbad, CA, 92010, USA
| | - Gary C Kanel
- Research Center for Liver Disease, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA
- Department of Pathology, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 211, Los Angeles, CA, 90033, USA
| | - Zhang-Xu Liu
- Translational Research Laboratory (TRLab), Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences of the University of Southern California, 1985 Zonal Avenue, Los Angeles, CA, 90033, USA
| | - Fumito Ito
- Department of Surgery, Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Los Angeles, CA, 90033, USA
| | - Gino K In
- Division of Oncology, Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Los Angeles, CA, 90033, USA
| | - Akil Merchant
- Division of Hematology and Cellular Therapy, Department of Medicine, Cedars-Sinai Medical Center, 127 S. San Vicente Boulevard Pavilion A8700, Los Angeles, CA, 90048, USA
| | - William Stohl
- Division of Rheumatology, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 711, Los Angeles, CA, 90033, USA
| | - Lily Dara
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA.
- Research Center for Liver Disease, Keck School of Medicine of the University of Southern California, 2011 Zonal Avenue HMR 101, Los Angeles, CA, 90033, USA.
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12
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Velarde-Ruiz Velasco JA, Tapia Calderón DK, Cerpa-Cruz S, Velarde-Chávez JA, Uribe Martínez JF, García Jiménez ES, Aldana Ledesma JM, Díaz-González Á, Crespo J. Immune-mediated hepatitis: Basic concepts and treatment. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:106-120. [PMID: 38485561 DOI: 10.1016/j.rgmxen.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/26/2023] [Indexed: 04/20/2024]
Abstract
Immunotherapy with immune checkpoint inhibitors (ICIs) has revolutionized advanced cancer management. Nevertheless, the generalized use of these medications has led to an increase in the incidence of adverse immune-mediated events and the liver is one of the most frequently affected organs. Liver involvement associated with the administration of immunotherapy is known as immune-mediated hepatitis (IMH), whose incidence and clinical characteristics have been described by different authors. It often presents as mild elevations of amino transferase levels, seen in routine blood tests, that spontaneously return to normal, but it can also manifest as severe transaminitis, possibly leading to the permanent discontinuation of treatment. The aim of the following review was to describe the most up-to-date concepts regarding the epidemiology, diagnosis, risk factors, and progression of IMH, as well as its incidence in different types of common cancers, including hepatocellular carcinoma. Treatment recommendations according to the most current guidelines are also provided.
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Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico; Departamento de Clínicas Médicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico.
| | | | - S Cerpa-Cruz
- Servicio de Reumatología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J A Velarde-Chávez
- Servicio de Medicina Interna, Hospital Civil de Guadalajara Juan I. Menchaca, Guadalajara, Jalisco, Mexico
| | - J F Uribe Martínez
- Servicio de Reumatología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - E S García Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J M Aldana Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Á Díaz-González
- Servicio de Gastroenterología y Hepatología, Grupo de Investigación Clínica y Traslacional en Enfermedades Digestivas, Instituto de Investigación Valdecilla (IDIVAL), Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - J Crespo
- Servicio de Gastroenterología y Hepatología, Grupo de Investigación Clínica y Traslacional en Enfermedades Digestivas, Instituto de Investigación Valdecilla (IDIVAL), Hospital Universitario Marqués de Valdecilla, Santander, Spain
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13
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Parlati L, Sakka M, Retbi A, Bouam S, Hassani L, Meritet JF, Rufat P, Bonnefont-Rousselot D, Batista R, Terris B, Bellanger A, Thabut D, Vozy A, Spano JP, Coriat R, Goldwasser F, Aractingi S, Sogni P, Pol S, Mallet V. Burden of grade 3 or 4 liver injury associated with immune checkpoint inhibitors. JHEP Rep 2023; 5:100880. [PMID: 38074948 PMCID: PMC10701119 DOI: 10.1016/j.jhepr.2023.100880] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND & AIMS There is concern about the burden of liver injury in patients with cancer exposed to immune checkpoints inhibitors (ICIs). METHODS In a retrospective cohort study, we evaluated the likelihood of grade 3/4 liver injury, of grade 3/4 cholestatic liver injury, and of liver failure, as per the Common Terminology Criteria for Adverse Events (CTCAE) version 5, following treatment with ICIs. We compared these occurrences with a group of cancer patients who were propensity-matched and treated with conventional chemotherapy. For all ICI patients experiencing grade 3/4 liver injury, we conducted a causality assessment using the RUCAM method and examined patient outcomes. RESULTS Among 952 patients (median [IQR] age 66 [57-73] years, 64% males) who were treated with ICI between January 1, 2015, and December 31, 2019, a total of 86 (9%) progressed to grade 3/4 liver injury, and liver failure was not observed. Anti-PD-(L)1/anti-CTLA-4 antibodies combinations (adjusted hazard ratio 3.36 [95% CI: 1.67-6.79]; p <0.001), and chronic hepatitis B (adjusted hazard ratio 5.48 [95% CI: 1.62-18.5]; p = 0.006], were independent risk factors. Liver injury was attributed to ICI treatment in 19 (2.0%) patients. Patients with ICI toxicity typically presented with granulomatous hepatitis or cholangiocyte inflammation. ICI withdrawal was associated with cancer progression and mortality. Re-introduction of ICI was not associated with recurrent grade 3/4 liver injury. Compared with matched patients treated with conventional, non-ICI-based chemotherapy, anti-PD-(L)1/anti-CTLA-4 combinations (p <0.001) and anti-PD-(L)1 monotherapies (p = 0.053) increased the risk of grade 3/4 liver injury and of grade 3/4 cholestatic liver injury, respectively. CONCLUSIONS An increased risk of grade 3/4 liver injury under anti-PD-(L)1/anti-CTLA-4 antibodies was observed, whereas no substantial increase in the likelihood of liver failure occurred even after treatment reintroduction. IMPACT AND IMPLICATIONS There is concern about liver injury in patients with cancer exposed to immune checkpoints inhibitors (ICIs). We investigated the burden of grade 3/4 liver injury after treatment with ICIs in a multicentric cohort of patients with cancer. Overall, a 9% incidence of grade 3/4 liver injury was detected after ICIs, and direct ICI hepatotoxicity was demonstrated in 2% of patients. Anti-PD-(L)1/Anti-CTLA-4 antibody combinations, and chronic HBV infection were independent risk factors. ICI withdrawal for grade 3/4 liver injury was associated with cancer progression. Re-introduction of ICI treatment was not associated with recurrent grade 3/4 liver injury.
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Affiliation(s)
- Lucia Parlati
- Université Paris Cité, Paris, France
- Service de Maladies du foie, AP-HP.Centre, DMU Cancérologie et Spécialités Médico-Chirurgicales, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Mehdi Sakka
- Service de Biochimie Métabolique, AP-HP.Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Aurelia Retbi
- Département d’Information Médicale, AP-HP.Sorbonne Université, DMU Esprit, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Samir Bouam
- Unité d’Information Médicale, AP-HP.Centre, DMU Prime, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Lamia Hassani
- Pharmacie à Usage Intérieur, AP-HP.Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Jean-François Meritet
- Service de Virologie, AP-HP.Centre, DMU Biophygen, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Pierre Rufat
- Département d’Information Médicale, AP-HP.Sorbonne Université, DMU Esprit, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Dominique Bonnefont-Rousselot
- Université Paris Cité, Paris, France
- Service de Biochimie Métabolique, AP-HP.Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
- CNRS, INSERM, UTCBS, Paris, France
| | - Rui Batista
- Pharmacie Clinique, AP-HP.Centre, DMU Prime, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Benoit Terris
- Université Paris Cité, Paris, France
- Service d’Anatomopathologie, AP-HP.Centre, DMU Prime, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Agnès Bellanger
- Département d’Information Médicale, AP-HP.Sorbonne Université, DMU Esprit, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Dominique Thabut
- Université Paris-Sorbonne, Paris, France
- Service d’Hépatogastroentérologie, AP-HP.Sorbonne Université, DMU Sapere, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Aurore Vozy
- Université Paris-Sorbonne, Paris, France
- Service d’Oncologie Médicale, AP-HP.Sorbonne Université, DMU Orphe, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Jean-Philippe Spano
- Université Paris-Sorbonne, Paris, France
- Service d’Oncologie Médicale, AP-HP.Sorbonne Université, DMU Orphe, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Paris, France
| | - Romain Coriat
- Université Paris Cité, Paris, France
- Service de Gastroentérologie et Oncologie Digestive, AP-HP.Centre, DMU Cancérologie et Spécialités Médico-Chirurgicales, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - François Goldwasser
- Université Paris Cité, Paris, France
- Service de Cancérologie, AP-HP.Centre, DMU Cancérologie et Spécialités Médico-Chirurgicales, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Selim Aractingi
- Université Paris Cité, Paris, France
- Département de Dermatologie, AP-HP.Centre, DMU Endromed, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Philippe Sogni
- Université Paris Cité, Paris, France
- Service de Maladies du foie, AP-HP.Centre, DMU Cancérologie et Spécialités Médico-Chirurgicales, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Stanislas Pol
- Université Paris Cité, Paris, France
- Service de Maladies du foie, AP-HP.Centre, DMU Cancérologie et Spécialités Médico-Chirurgicales, Groupe Hospitalier Cochin Port Royal, Paris, France
| | - Vincent Mallet
- Université Paris Cité, Paris, France
- Service de Maladies du foie, AP-HP.Centre, DMU Cancérologie et Spécialités Médico-Chirurgicales, Groupe Hospitalier Cochin Port Royal, Paris, France
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14
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Gudd CLC, Sheth R, Thursz MR, Triantafyllou E, Possamai LA. Immune Checkpoint Inhibitor-Induced Liver Injury. Semin Liver Dis 2023; 43:402-417. [PMID: 38101418 DOI: 10.1055/s-0043-1776761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
In recent years cancer treatment has been revolutionized by the development and wide application of checkpoint inhibitor (CPI) drugs, which are a form of immunotherapy. CPI treatment is associated with immune-related adverse events, off-target tissue destructive inflammatory complications, which may affect a range of organs, with liver inflammation (hepatitis) being one of the more commonly noted events. This is a novel form of drug-induced liver injury and a rapidly evolving field, as our understanding of both the basic immunopathology of CPI hepatitis (CPI-H) and optimal clinical management, races to catch up with the increasing application of this form of immunotherapy in clinical practice. In this review, we summarize current evidence and understanding of CPI-H, from fundamental immunology to practical patient management.
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Affiliation(s)
- Cathrin L C Gudd
- Section of Hepatology and Gastroenterology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Roosey Sheth
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Mark R Thursz
- Section of Hepatology and Gastroenterology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
- Liver and Antiviral Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Evangelos Triantafyllou
- Section of Hepatology and Gastroenterology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Lucia A Possamai
- Section of Hepatology and Gastroenterology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
- Liver and Antiviral Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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15
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Sacchi de Camargo Correia G, Pai T, Li S, Connor D, Zhao Y, Lou Y, Manochakian R. Immune-Related Adverse Events in Patients with Lung Cancer. Curr Oncol Rep 2023; 25:1259-1275. [PMID: 37782426 DOI: 10.1007/s11912-023-01462-w] [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] [Accepted: 08/30/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICI) have been widely adopted for the treatment of lung cancer since receiving first U.S Food and Drug Administration (FDA) approval in 2015. However, along with their use, the occurrence of immune-related adverse events (irAEs) has presented a challenge for both patients and oncology providers. In this manuscript, we reviewed the clinical trials that led to the approval of ICI by the FDA for the treatment of lung cancer between 2015 and 2023 to establish the frequency of irAEs in this patient population. Among the adverse events associated with ICI, we focused on the most common and relevant ones, including hypothyroidism, pneumonitis, diarrhea/colitis, skin rash, and hepatitis. RECENT FINDINGS We thoroughly examined the available literature, including society guidelines concerning these complications, to discuss various aspects such as their pathophysiology, epidemiology, diagnostic process, grading system, and clinical management. Additionally, we explored the association between irAEs and disease response. The management of irAEs is a crucial aspect of oncologic care, particularly due to their potential to cause severe and life-threatening clinical manifestations. We present each pertinent aspect in a concise and organized manner to provide guidance and assistance to oncology providers managing these patients in both outpatient and inpatient settings.
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Affiliation(s)
| | - Tanmayi Pai
- Division of Hematology and Medical Oncology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Shenduo Li
- Division of Hematology and Medical Oncology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Dana Connor
- Division of Hematology and Medical Oncology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Yujie Zhao
- Division of Hematology and Medical Oncology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Yanyan Lou
- Division of Hematology and Medical Oncology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Rami Manochakian
- Division of Hematology and Medical Oncology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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16
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Teschke R, Danan G. Advances in Idiosyncratic Drug-Induced Liver Injury Issues: New Clinical and Mechanistic Analysis Due to Roussel Uclaf Causality Assessment Method Use. Int J Mol Sci 2023; 24:10855. [PMID: 37446036 DOI: 10.3390/ijms241310855] [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: 05/19/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Clinical and mechanistic considerations in idiosyncratic drug-induced liver injury (iDILI) remain challenging topics when they are derived from mere case narratives or iDILI cases without valid diagnosis. To overcome these issues, attempts should be made on pathogenetic aspects based on published clinical iDILI cases firmly diagnosed by the original RUCAM (Roussel Uclaf Causality Assessment Method) or the RUCAM version updated in 2016. Analysis of RUCAM-based iDILI cases allowed for evaluating immune and genetic data obtained from the serum and the liver of affected patients. For instance, strong evidence for immune reactions in the liver of patients with RUCAM-based iDILI was provided by the detection of serum anti-CYP 2E1 due to drugs like volatile anesthetics sevoflurane and desflurane, partially associated with the formation of trifluoroacetyl (TFA) halide as toxic intermediates that form protein adducts and may generate reactive oxygen species (ROS). This is accompanied by production of anti-TFA antibodies detected in the serum of these patients. Other RUCAM-based studies on serum ANA (anti-nuclear antibodies) and SMA (anti-smooth muscle antibodies) associated with AIDILI (autoimmune DILI) syn DIAIH (drug-induced autoimmune hepatitis) provide additional evidence of immunological reactions with monocytes as one of several promoting immune cells. In addition, in the blood plasma of patients, mediators like the cytokines IL-22, IL-22 binding protein (IL-22BP), IL-6, IL-10, IL 12p70, IL-17A, IL-23, IP-10, or chemokines such as CD206 and sCD163 were found in DILI due to anti-tuberculosis drugs as ascertained by the prospective updated RUCAM, which scored a high causality. RUCAM-based analysis also provided compelling evidence of genetic factors such as HLA (human leucocyte antigen) alleles contributing to initiate iDILI by a few drugs. In conclusion, analysis of published RUCAM-based iDILI cases provided firm evidence of immune and genetic processes involved in iDILI caused by specific drugs.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, Leimenstrasse 20, D-63450 Hanau, Germany
| | - Gaby Danan
- Pharmacovigilance Consultancy, Rue des Ormeaux, 75020 Paris, France
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17
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Karna R, S Deliwala S, Ramgopal B, Asawa P, Mishra R, P Mohan B, Jayakrishnan T, Grover D, Kalra T, Bhalla J, Saraswati U, K Gangwani M, Dhawan M, G Adler D. Gastrointestinal treatment-related adverse events of combined immune checkpoint inhibitors: a meta-analysis. Immunotherapy 2023. [PMID: 37190949 DOI: 10.2217/imt-2023-0001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Introduction: Combined immune checkpoint inhibitors can cause gastrointestinal adverse events. Methods: We performed a meta-analysis of pooled colonic, hepatic and pancreatic treatment-related adverse events of combined ICI. Results: 53 trials reporting treatment-related adverse events in 6581 patients. All grade diarrhea was the most common adverse event seen in 25.4% patients, followed by all grade hepatitis in nearly 13% patients and pancreatitis in nearly 7.5% patients. Conclusion: Our study provides pooled data of treatment-related adverse events from different combination immune checkpoint inhibitors use in solid tumors and demonstrates a high incidence of all grades and ≥3 grade gastrointestinal adverse events. Further studies are required to characterize these adverse events and assess their overall impact on treatment course and outcomes.
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Affiliation(s)
- Rahul Karna
- Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Smit S Deliwala
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Balasubramanian Ramgopal
- Foundation Fellowship Doctor, University Hospital, Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Palash Asawa
- Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Rahul Mishra
- Postdoctoral research fellow, Cleveland Clinic, OH, USA
| | - Babu P Mohan
- Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, UT, USA
| | | | - Dheera Grover
- Internal Medicine, University of Connecticut, Hartford, CT, USA
| | - Tanisha Kalra
- Internal Medicine, SUNY Downstate Health Science University, NY, USA
| | | | | | - Manesh K Gangwani
- Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Manish Dhawan
- Gastroenterology & Hepatology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA
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