Written by: Natasha Heimbigner, PharmD, Summit Cancer Centers
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Proper prevention and management of immunotherapy related rash is an important intervention for the patient’s quality of life and continuation of therapy.
Background
Immunotherapy is increasingly used in cancer treatment; improving outcomes for many patients with melanoma, non-small cell lung cancer, breast cancer, and a growing number of tumor types.1 Although these agents have a range of adverse effects, the most commonly seen is dermatologic. These dermatologic adverse effects can manifest weeks to months after the first treatment, manifesting as a maculopapular or pruritic rash.2,3,4 Other potential toxicities skin reactions include but are not limited to: bullous eruptions and Stevens–Johnson syndrome so understanding the difference of these specific skin reactions as well is important.
PQI Process
- Identify high risk patients – All immunotherapy patients
- Note – patients may be reluctant to bring up adverse effects that they are experiencing. Ask directly if they have a rash.
- Determine the grading of the rash (pharmacist or provider)
- Grade 1 – Covers < 10% body surface area or without symptoms. Mild or localized itching.
- Grade 2 – Covers 10-30% body surface area with or without symptoms. Intense or widespread itching.
- Grade 3-4 – Covers > 30% body surface area, limiting actives of daily living, severe itching, affects sleep, life threatening or requiring possible hospitalization.
- Recommended appropriate treatment based on grade of rash (additionally discuss therapy to physician/document in EMR) NOTE: Dose reduction of immunotherapy is not a recommended option. View associated NCCN references and sources for further information4.
- Grade 1
- Use fragrance free soaps for bathing and detergents for the clothes
- Consult with medically integrated team to determine best relief care for patient
- Topical corticosteroids twice daily
- Triamcinolone 0.1% lotion or fluocinonide 0.05% cream
- Use fragrance free soaps for bathing and detergents for the clothes
- Grade 2
- Topical corticosteroids twice daily
- Triamcinolone 0.1% lotion or fluocinonide 0.05% cream
- Oral antihistamines or GABA agonists for pruritus
- Hydroxyzine 10mg tid or gabapentin 300mg tid, pregabalin 50mg tid
- Topical corticosteroids twice daily
- Grade 3
- Hold immunotherapy until rash is grade ≤1
- Oral corticosteroids (prednisone 0.5-1mg kg/day or equivalent) until symptoms are grade ≤1
- Grade 4
- Permanently discontinue
- Consider topical antibiotics in combination with oral retinoids, IV corticosteroids, IM/IV antihistamines, IV Antibiotics and/or hydration
- Grade 1
Patient-Centered Activities
- Provide education:
- Counsel patient on all medications
- Proper skin care tips and tricks
- Infection Prevention
- Monitor skin
- Importance of calling provider if rash worsens
References:
- Thompson JA, Schneider BJ, Brahmer J, et. Al. “Management of IOmmunotherapy-Related Toxicities, Version 1.2019” J Natl Compr Canc Netw. 2019 Mar 1;17(3):255-289. doi: 10.6004/jnccn.2019.0013. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/30865922
- “Toxicities Associated with Checkpoint Inhibitor Immunotherapy.” UpToDate, uptodate.com/contents/toxicities-associated-with-checkpoint-inhibitor-immunotherapy#H645515. 23 March 2018
- Puzanov I, Diaab A, Abdallah K, Al. “Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group.” J Immunother Cancer. 2017 Nov 21;5(1):95. doi: 10.1186/s40425-017-0300-z.
- Phillips GS, Wu J, Hellmann MD, et. Al. “Treatment Outcomes of Immune-Related Cutaneous Adverse Events.” J Clin Oncol. 2019 Oct 20;37(30):2746-2758. doi: 10.1200/JCO.18.02141. Epub 2019 Jun 19