Objective
The introduction of novel immune checkpoint inhibitors has revolutionised immunotherapy. Agents such as pembrolizumab are increasingly prescribed for the treatment of advanced stage solid organ malignancies and Hodgkin’s lymphoma. Increased prescribing has identified new adverse effects not associated with traditional cancer therapies. We present multiple case reports that demonstrate examples of uncommon endocrinopathies likely attributable to the use of checkpoint inhibitor therapy and describe the role the clinical pharmacist in their management.
Clinical Features
Ms AF is a 63 year old female receiving nivolumab immunotherapy for metastatic melanoma who presented with non-specific symptoms including hypotension.
Low plasma cortisol level and associated symptoms supported the diagnosis of adrenal insufficiency, presumed to be related to immunotherapy.
Mrs KK is 52 year old female receiving tislelizumab immunotherapy, in combination with sitravatinib for the treatment of metastatic ovarian cancer. She developed symptoms of sepsis in addition to an undetectable plasma cortisol level.
This was diagnosed as addisonian crisis, presumably related to immunotherapy.
Literature Review
Current management of immune-related adverse effects associated with checkpoint inhibitor therapies is largely based around clinical experience. Evidence in this field is limited. Risk factors for increasing vulnerability to adverse effects are yet to be identified. To date there are no clinical trials researching management strategies.
Pharmacist Intervention
Effective management of immune-related adverse effects requires prompt recognition and early intervention. Presentations of immune-related endocrinopathies are complex and non-specific. Clinical pharmacists are essential for identifying accurate medication reconciliation and reinforcing relevant monitoring. Medication education to clinicians and patients is important to enable timely recognition and management.
Conclusion
Immune-related adverse effects are expected to increase with increasing trends in immunotherapy use. Pharmacists play a pivotal role in ensuring safe and efficacious use through enhancing awareness, monitoring and management strategies of immunotherapy-related endocrinopathies, which may otherwise lead to increased morbidity and mortality.