Immune Checkpoint Inhibitor Therapies: Identifying and Managing Adverse Effects

A new session at the 2020 virtual Directions in Pharmacy® conference was a discussion of immune checkpoint inhibitor therapies. Jacob Kettle, PharmD, BCOP, discussed managing immune-related adverse effects (AEs) associated with immune checkpoint inhibitor therapies.

Dr Kettle began his discussion on cancer immunotherapy and the clinical benefits for various malignancies with immunooncology (IO). In contrast to traditional cancer therapies, IO therapies typically involve the immune system to recognize and eradicate tumor cells. Immune checkpoint inhibitors have revolutionized treatment for patients with certain solid tumors targeting cytotoxic T-lymphocyte-associated protein 4 (CTLA- 4), programmed death protein 1 (PD-1), and programmed deathligand 1 (PD-L1).

Dr Kettle emphasized the distinct mechanism of toxicity of IO therapies compared with conventional cytotoxic medications and targeted therapy. The frequency of AEs varies but may be affected by the site of malignancy, previous cancer therapy, current cancer therapy, and the selection of immunotherapy agents. Pharmacists need to be aware that any organ system can be affected by immune toxicities; however, the endocrine, dermal, pulmonary, hepatic, and gastrointestinal systems are most commonly affected.

AEs are characterized by a broad spectrum of severity, with severe events, such as diabetic ketoacidosis, hepatic failure, and colitis, occurring uncommonly. However, fatalities have been reported. The majority of AEs occur within 6 to 12 weeks of initiating therapy (but they can occur at any time). Dr Kettle emphasized that the majority of AEs (eg, diarrhea, weight loss) are reversible, and key components to management include proactive monitoring, dose interruption, glucocorticoids, and collaboration. Corticosteroids are the mainstay of treatment for immune toxicity. Proton pump inhibitors or H2 receptor blockers are used for the prevention of gastritis, and vitamin D and calcium are used for osteoporosis prevention.

Dr Kettle concluded by emphasizing the role of pharmacists in all practice settings to care for patients with cancer receiving immunotherapy. Dr Kettle highlighted the importance of nononcology practitioners being familiar with immune checkpoint inhibitors due to the large numbers of cancers targeted. Pharmacists are, as a result, likely to come into contact with patients being treated with these agents and their associated immune-related AEs in their pharmacies. It is crucial for them to be equipped with the proper materials to feel comfortable counseling patients on these therapies and screen their medication profile to identify potential interactions and AEs as well as how to address them so that they can help manage them appropriately.

JACOB KETTLE, PharmD, BCOP, received his Doctor of Pharmacy degree in 2007, graduating summa cum laude from the University of Missouri—Kansas City School of Pharmacy in Kansas City, Missouri. He completed a pharmacy practice residency at the Kansas City Veterans Affairs Medical Center in Kansas City, Missouri, and a hematology/oncology pharmacy residency at the University of Kansas Medical Center in Kansas City, Kansas.Dr Kettle is currently the pharmacy manager for the Ellis Fischel Cancer Center and Ambulatory Infusion Unit at the University of Missouri in Columbia, Missouri. Prior to his administrative work, Dr Kettle spent over a decade in oncology clinical practice both at the University of Missouri and the Kansas City Veterans Affairs Medical Center. In addition to his clinical practice, Dr Kettle is as an adjunct clinical professor for the University of Missouri—Kansas City School of Pharmacy.