Table 2.
| Common adverse reactions | Research of alternative/noninflammatory etiologies | Degree of toxicity | Recommended management of irAEs |
|---|---|---|---|
| Gastrointestinaldiarrhea/colitis | Exclude infectious etiology (Clostridium difficile) | Grade 1 (Mild) | Symptomatic treatment Consider budesonide 9 mg/day Continue immunotherapy |
| Grade 2 (Moderate) | Delay immunotherapy Methylprednisolone IV 0.5–1 mg/kg/day (or oral equivalent) Consider gastroenterology and colonoscopy consultation When improving to ≤ grade 1, reduce the dose for at least 4 weeks |
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| Grades 3–4 (Severe) | Stop immunotherapy Methylprednisolone IV 1–2 mg/kg/day When improving to ≤ grade 1, reduce the dose for at least 4 weeks If no improvement in symptoms within 48–72 h, consider 2nd-line immunosuppression (infliximab) |
||
| Hepatitis | Evaluate for
|
Grade 1 (Mild) | Continue immunotherapy Repeat LFTs within 1 week |
| Grade 2 (Moderate) | Delay immunotherapy Repeat LFTs every 3–5 days Methylprednisolone IV 0.5–1 mg/kg/day (or oral equivalent) When improving to mild or baseline, reduce the dose of steroids for at least 4 weeks |
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| Grades 3–4 (Severe) | Stop immunotherapy Increase the frequency of LFTs to 1–2 days Methylprednisolone IV 1–2 mg/kg/day Gastroenterology consultation If no improvement in symptoms within 48–72 h, consider 2nd-line immunosuppression (infliximab) |
||
| Pneumonitis | Evaluate for
|
Grade 1 (Mild) | Delay immunotherapy Monitor symptoms Repeat chest X-ray in 2–4 weeks |
| Grade 2 (Moderate) | Delay immunotherapy Monitor symptoms closely, consider hospitalization Reimage every 1–3 days Pneumology and infectious disease consultations, consider bronchoscopy Methylprednisolone IV 1–2 mg/kg/day (or oral equivalent) When symptoms improve, reduce the dose of steroids for at least 4 weeks |
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| Grades 3–4 (Severe) | Stop immunotherapy Methylprednisolone IV 2–4 mg/kg/day, discontinue steroids for a period of at least 6 weeks If no improvement in symptoms within 48–72 h, consider 2nd-line immunosuppression (infliximab, mycophenolate mofetil, IVIG) |
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| Dermatological adverse reactions | Exclude noninflammatory causes (allergic reaction to other drugs, photosensitivity, etc.) | Grade 1 (Mild) | Continue immunotherapy Supportive therapy emollients, low-potency topical steroids, antihistamines |
| Grade 2 (Moderate) | Continue immunotherapy Topical steroids of moderate-high potency If persistent, despite optimized topical treatment, consider methylprednisolone 0.5–1 mg/kg/day (or oral equivalent) If it improves slightly or resolves, reduce the dose of steroids for at least 4 weeks Consider dermatological evaluation and skin biopsy |
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| Grades 3–4 (Severe) | Delay immunotherapy Methylprednisolone IV 1–2 mg/kg/day (or oral equivalent) If it improves to mild or resolves, reduce the dose of steroids for at least 4 weeks. Consider skin biopsy |
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| Endocrinopathies | Exclude noninflammatory etiology of symptoms | Grade 1 (Mild) | Continue immunotherapy If TSH is abnormal, add free T4 and T3 Consider morning cortisol and ACTH |
| Grade 2 (Moderate) | TSH, free T4, morning cortisol and ACTH Consider pituitary MRI Methylprednisolone IV 1–2 mg/kg/day (or oral equivalent) If it improves, reduce the dose of steroids for at least 4 weeks Hormone replacement therapy if indicated Endocrinology consultation |
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| Grades 3–4 (Severe) | Delay or discontinue immunotherapy If adrenal crisis is suspected, exclude infection/sepsis, BP support Stress doses of mineralocorticosteroid |
ACTH, adrenocorticotrophin; COPD, chronic obstructive pulmonary disease; GI, gastrointestinal; IVIG, intravenous immunoglobulin; IV, intravenous; MRI, magnetic resonance image; BP, blood pressure; T3, triiodothyronine; T4, thyroxine; LFTs, liver function tests; TSH, thyroid-stimulating hormone; irAEs, immune-related adverse effects.