Year 2023 / Volume 115 / Number 10
Original
Severe and refractory gastrointestinal toxicity due to immune checkpoint inhibitors: clinical experience in a tertiary referral hospital

567-573

DOI: 10.17235/reed.2023.9436/2022

Elena Céspedes Martínez, Virginia Robles Alonso, Claudia Herrera-De Guise, Luis Mayorga, Francesc Casellas, María Roca-Herrera, Natalia Borruel,

Abstract
Introduction: immune checkpoint inhibitors (ICI) are increasingly used to treat several types of cancer. These drugs lead to a wide range of toxicities. Immune-related gastrointestinal adverse events are common and potentially severe. In this manuscript, we recount the real clinical experience in a tertiary center. Methods: a retrospective and observational study was conducted in adult patients under ICI treatment. Included patients had been referred to the Gastrointestinal Service of Hospital Universitario Vall d’Hebron for evaluation of severe toxicities, from January 2017 to January 2020, for whom the clinical, epidemiological and evolutive data were collected. Results: a total of 18 patients were included. Fifty-five percent received anti-programmed cell death protein 1 (PD-1)/anti-programmed death-ligand 1 (anti PD-L1), 11 % received anti-cytotoxic T lymphocyte antigen 4 (CTLA-4) and 33 % received both treatments. The toxicities were manifested as enterocolitis, microscopic colitis and gastritis. Upper gastrointestinal endoscopy was performed in seven patients; all were proved to have histological changes on duodenum biopsies. Treatment was stopped in all patients and steroids were initiated. Sixty-six per cent achieved clinical remission with steroids. Five patients received anti-TNF treatment (infliximab). Only one of the five had responded. Two anti-TNF refractory patients received ustekinumab, with an appropriate clinical response. One patient received apheresis granulocyte as concomitant treatment. A patient with a steroid-dependent course started vedolizumab. Three patients had other immune-related adverse events. Conclusion: gastrointestinal immune-related adverse events are acquiring a higher profile in daily practice and gastroenterologists play an even greater role in the management of these patients.
Lay Summary
This text discusses a study conducted on the use of immune checkpoint inhibitors (ICI) and focused on the severe gastrointestinal toxicities that can occur as a result of the treatment. The study included 18 adult patients who were referred to a Gastrointestinal Unit for severe toxicities between January 2017 and January 2020. The toxicities observed were enterocolitis, microscopic colitis, and gastritis. The study found that stopping ICI treatment and initiating steroid treatment led to clinical remission in most patients. However, some patients required additional treatments such as anti-TNF drugs without as good results as reported previously. Authors found Ustekinumab a good option of treatment in refractory to anti-TNF patients. Other treatment options are Granulocyte-apheresis and Vedolizumab. Moreover, clinicians need to start prophylactic antibiotics and antifungal therapies to prevent treatment related complications. It is important to create multidisciplinary committees to aid the clinicians and oncologists should refer patients to an experienced Gastroenterology Unit. IBD patients under ICI treatment should be monitored in their IBD units. Gastrointestinal immune-related adverse events are becoming increasingly common in daily practice, and gastroenterologists play a critical role in managing these patients.
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Citation tools
Céspedes Martínez E, Robles Alonso V, Herrera-De Guise C, Mayorga L, Casellas F, Roca-Herrera M, et all. Severe and refractory gastrointestinal toxicity due to immune checkpoint inhibitors: clinical experience in a tertiary referral hospital. 9436/2022


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Publication history

Received: 18/12/2022

Accepted: 22/04/2023

Online First: 12/05/2023

Published: 09/10/2023

Article revision time: 101 days

Article Online First time: 145 days

Article editing time: 295 days


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