Written by: Natasha Heimbigner, PharmD, Summit Cancer Centers
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Description of PQI: The use of immunotherapy in cancer treatment has expanded tremendously over the last several years. The most common adverse effects include dermatologic, gastrointestinal, hepatic, and endocrine toxicities. Management of immunotherapy-related rash is an important intervention for the patient’s quality of life and buy-in for continuation of therapy.

Background: Immunotherapy is being used increasingly 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 wide 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 toxic 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 for fear of discontinuing treatment; ask directly if they have a rash
  • Determine the grading of the rash

    • Grade 1: Covers < 10% body surface area or without symptoms, with mild or localized itching
    • Grade 2: Covers 10-30% body surface area with or without symptoms, with intense or widespread itching
    • Grade ¾: Covers > 30% body surface area, limiting actives of daily living, severe itching, affects sleep, life threatening or requiring possible hospitalization

    PQI Process Continued:

    • Recommend appropriate treatment based on grade of rash, discuss therapy to physician, and document in EMR *dose reduction of immunotherapy is not recommended*
      • Grade 1
        • Use fragrance-free soaps for bathing and detergents for 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 10 mg TID or Gabapentin 300 mg TID or Pregabalin 50 mg TID
      • Grade 3
        • Hold immunotherapy until rash is grade 1 or symptoms have resolved
        • Oral corticosteroids until rash is grade 1 or symptoms have resolved
          • Prednisone 0.5-1 mg/kg/day (or equivalent)
      • Grade 4
        • Permanently discontinue immunotherapy
        • 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 and provide Oral Chemotherapy Education (OCE) sheets as applicable
      • Proper skin care tips and tricks
      • Provide infection prevention education
      • Monitor skin and stress importance of calling provider if rash worsens

References:

  1. Linardou, Helena, and Helen Gogas. “Toxicity Management of Immunotherapy for Patients with Metastatic Melanoma.” Annals of Translational Medicine, AME Publishing Company, 4 July 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4971373/.
  2. “Toxicities Associated with Checkpoint Inhibitor Immunotherapy.” UpToDate, www.uptodate.com/contents/toxicities-associated-with-checkpoint-inhibitor-immunotherapy#H645515.
  3. “ICLIO.” Institute for Clinical Immuno-Oncology, accc-iclio.org/.
  4. National Comprehensive Cancer Network. Management of Immunotherapy-Related Toxicities (Version 1.2018). https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf.
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Victoria

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