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J Clin Oncol. 2018 Jun 10;36(17):1714-1768. doi: 10.1200/JCO.2017.77.6385. Epub 2018 Feb 14.

Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline.

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Julie R. Brahmer, Johns Hopkins Kimmel Cancer Center; Jennifer S. Mammen, Johns Hopkins University, Baltimore, MD; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Alexander Spira, Virginia Cancer Specialists and US Oncology Research, Fairfax, VA; Bryan J. Schneider, University of Michigan Health System, Ann Arbor, MI; Michael B. Atkins, Georgetown Lombardi Comprehensive Cancer Center; Cristina A. Reichner, Georgetown University; Laura D. Porter, Colon Cancer Alliance; Washington, DC; Kelly J. Brassil, Aung Naing, Loretta J. Nastoupil, Maria E. Suarez-Almazor, and Yinghong Wang, MD Anderson Cancer Center, Houston, TX; Jeffrey M. Caterino, The Ohio State University Wexner Medical Center, Columbus, OH; Ian Chau, The Royal Marsden Hospital and Institute of Cancer Research, London and Surrey, United Kingdom; Marc S. Ernstoff and Igor Puzanov, Roswell Park Cancer Institute, Buffalo; Bianca D. Santomasso and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center; Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Pamela Ginex, Oncology Nursing Society, Pittsburgh, PA; Jennifer M. Gardner, Seattle Cancer Care Alliance and University of Washington, Seattle, WA; Sigrun Hallmeyer, Oncology Specialists SC, Park Ridge, IL; Jennifer Holter Chakrabarty, University of Oklahoma, Stephenson Cancer Center, Oklahoma City, OK; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; David F. McDermott, Beth Israel Deaconess Medical Center; Carole Seigel, Massachusetts General Hospital Cancer Center, Boston, MA; John A. Thompson, Seattle Cancer Care Alliance, University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle, WA; and Tanyanika Phillips, CHRISTUS St Frances Cabrini Cancer Center, Alexandria, LA.


Purpose To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events in patients treated with immune checkpoint inhibitor (ICPi) therapy. Methods A multidisciplinary, multi-organizational panel of experts in medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, urology, neurology, hematology, emergency medicine, nursing, trialist, and advocacy was convened to develop the clinical practice guideline. Guideline development involved a systematic review of the literature and an informal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, randomized controlled trials, and case series published from 2000 through 2017. Results The systematic review identified 204 eligible publications. Much of the evidence consisted of systematic reviews of observational data, consensus guidelines, case series, and case reports. Due to the paucity of high-quality evidence on management of immune-related adverse events, recommendations are based on expert consensus. Recommendations Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, with the exception of some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert to grade 1 or less. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids (prednisone 1 to 2 mg/kg/d or methylprednisolone 1 to 2 mg/kg/d). Corticosteroids should be tapered over the course of at least 4 to 6 weeks. Some refractory cases may require infliximab or other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, with the exception of endocrinopathies that have been controlled by hormone replacement. Additional information is available at and .

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