9

January

Managing Immunotherapy Treatment Related Rash

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
    • 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
    • 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

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:

  1. 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
  2. “Toxicities Associated with Checkpoint Inhibitor Immunotherapy.” UpToDate, uptodate.com/contents/toxicities-associated-with-checkpoint-inhibitor-immunotherapy#H645515. 23 March 2018
  3. 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.
  4. 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

 

Important notice: National Community Oncology Dispensing Association, Inc. (NCODA), has developed this Positive Quality Intervention platform. This platform represents a brief summary of medication uses and therapy options derived from information provided by the drug manufacturer and other resources. This platform is intended as an educational aid and does not provide individual medical advice and does not substitute for the advice of a qualified healthcare professional. This platform does not cover all existing information related to the possible uses, directions, doses, precautions, warning, interactions, adverse effects, or risks associated with the medication discussed in the platform and is not intended as a substitute for the advice of a qualified healthcare professional. The materials contained in this platform are for informational purposes only and do not constitute or imply endorsement, recommendation, or favoring of this medication by NCODA, which assumes no liability for and does not ensure the accuracy of the information presented. NCODA does not make any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual consuming the medication. All decisions related to taking this medication should be made with the guidance and under the direction of a qualified healthcare professional.
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