Cancer Immunotherapy: Side Effect Management

Immune checkpoint inhibitors release brakes on T cells against the tumor and unintentionally against normal tissues. Resulting immune-related adverse events (irAEs) can affect skin, gut, lungs, liver, endocrine glands, kidneys, joints, nervous system, and heart. They occur in up to seventy percent of patients on combination ipilimumab and nivolumab and twenty to forty percent on single-agent therapy.

Severity is graded using CTCAE: grade 1 (mild) is monitored with continued therapy, grade 2 (moderate) usually warrants holding immunotherapy and adding oral steroids, grade 3 to 4 (severe) requires hospitalization, intravenous methylprednisolone 1 to 2 mg/kg/day, and possible permanent discontinuation. Steroid-refractory cases (especially colitis or hepatitis) need infliximab, vedolizumab, or mycophenolate.

Endocrine irAEs (thyroiditis, hypophysitis, type 1 diabetes, adrenalitis) are usually permanent and managed with lifelong hormone replacement; immunotherapy can often be continued. Myocarditis is rare but life-threatening and requires immediate ICU care, high-dose steroids, and consideration of plasma exchange or abatacept. Multidisciplinary irAE pathways and patient education on early reporting are now standard.