Table 1.
Immune Checkpoint Inhibitor Myocarditis Steroid Therapy Recommendations
| ESC Cardio-Oncology Guidelines | ASCO CPG irAE Guidelines | SITC irAE Guidelines | NCCN irAE Guidelines | Our Approach | |
|---|---|---|---|---|---|
| Initial dose and severity | 500-1,000 mg/d IV for patients with nonfulminant and fulminant myocarditis | 1-2 mg/kg/d oral or IV prednisone; if no immediate response, then 1,000 mg IV methylprednisolone; only for those with ≥grade 2 severity | 1,000 mg/d IV methylprednisolone | 1,000 mg/d IV methylprednisolone; only for those with ≥grade 3 severity | 1,000 mg/d IV methylprednisolone daily for 3 days if patients present with MACE. Consider lower-dose steroids for asymptomatic or mild troponin elevations without another obvious etiology. |
| Timing | Within 24 hours | Within 24 hours | As soon as possible | No recommendation | Rapid initiation within 24 hours for patients with MACE without another etiology on initial evaluation; perform full diagnostic work-up for asymptomatic, mild severity disease, or low suspicion, and initiate steroids if a diagnosis of myocarditis is confirmed. |
| Duration | Pulse dose minimum 3 days 17- to 20-week taper |
1-2 mg/kg prednisone and if no immediate response, use 1,000 mg IV methylprednisolone 4- to 6-week taper |
Pulse dose for 3 to 5 days 4- to 6-week taper |
Pulse dose for 3 to 5 days 4- to 6-week taper |
Pulse dose steroids for 3 days followed by 5-week taper. Continue taper and if clinical deterioration or persistent troponin elevation, then use nonsteroidal immunomodulator rather than delay steroid taper. 5-week steroid taper
|
| Nonsteroidal immunomodulator therapy | Hemodynamically unstable fulminant myocarditis or steroid refractory | No immediate response or in life-threatening cases | No improvement within 24 hours on steroids | No improvement within 24 hours on steroids | Early initiation for patients with MACE, clinical deterioration, or lack of consistent troponin reduction |
ASCO = American Society of Clinical Oncology; CPG = Clinical Practice Guideline; ESC = European Society of Cardiology; irAE = immune-related adverse event; IV = intravenous; MACE = major adverse cardiovascular event; NCCN = National Comprehensive Cancer Network; SITC = Society for Immunotherapy of Cancer.