Table 1. Anti-PD-1: immune-related pneumonitis management guidance.

Management guidance

Grade 1

Continue anti-PD-1 with monitoring

If pneumonitis is suspected, evaluate with radiographic imaging

Grade 2

Withhold anti-PD-1

Consider pulmonary consultation with bronchoscopy and biopsy, along with ID consult

Conduct an in-person evaluation approx. twice per week and consider frequent chest X-rays

Administer corticosteroids

Upon improvement to grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month

Discontinue anti-PD-1 if upon re-challenge patient develops a second episode of grade 2 or higher pneumonitis

Grade 3 and 4

Discontinue anti-PD-1

Consider pulmonary function tests with pulmonary consultation

Bronchoscopy with biopsy and/or BAL is recommended

Treat with IV steroids; when symptoms improve to grade 1 or less, administer oral steroids, then initiate taper over at least 1 month

Add prophylactic antibiotics for opportunistic infections*

If IV steroids followed by oral steroids does not reduce initial symptoms within 48 to 72 h, treat with infliximab at 5 mg/kg once every 2 weeks; discontinue upon symptom relief and initiate a prolonged steroid taper over 45 to 60 days

*, Add anti-inflammatory drugs—antibiotics, antifungal agents 1, except the most common infections (such as viral and bacterial), consider to exclude Legionella and Pneumocystis carinii.