Version May 2024
| 12.1. Pretreatment considerations |
| Baseline work-up to include viral hepatitis B and C serology and consideration for latent or active TB test. In patients with pre-existing HIV, testing HIV viral load and CD4 count would be appropriate. |
| Patients with pre-existing comorbid conditions, such as DM, hypertension, HF, cataract, glaucoma, infection, or osteoporosis, should have their condition optimally managed before commencing steroids. |
| Ideal steroid dosing and duration is individualized and can vary by patient, oncologic agents, and type of irAE. Refer to each individual irAE section for more detail. |
| The lowest dose of steroids should be used for the shortest duration of time needed to achieve treatment goals and control deleterious effects of irAE, as the risk of toxicity with steroids is generally dose- and duration-dependent. |
| 12.2. Prevention of opportunistic infection |
| Please refer to UpToDate content on toxicities associated with immunotherapy regarding the use of prophylaxis for an opportunistic infection with PJP. |
| The role of prophylactic fluconazole with prolonged steroid use (>12 weeks) remains unclear and physicians should proceed according to institutional guidelines. |
| Use of prophylaxis against herpes zoster reactivation may be offered to patients who have had zoster before and will be receiving corticosteroids. |
| 12.3. Monitoring for acute or short-term and long-term adverse effects |
| Patients should be routinely asked about adverse effects related to glucocorticoids. During treatment with glucocorticoids and depending upon individual risk factors such as dose and duration of glucocorticoid usage, other medications being used, and comorbidities, particular attention should be given to the following acute or short-term and long-term adverse effects: |
| Acute or short-term AEs: |
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| Long-term AEs: |
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| GI prophylaxis with PPI or H2 antagonist is recommended. |
| To limit steroid-induced bone loss, patient should receive adequate calcium (dietary or supplementation), vitamin D, and weight-bearing exercise should be encouraged when feasible. Bone-modifying agents may be offered to patients on steroids for >3 months and are recommended for all patients with pre-existing osteoporosis. Patients with or at risk for osteoporosis who have long-term survival potential should undergo bone mineral density testing. |
| 12.4. Tapering of steroids |
| The length of steroid-taper should occur according to the type and severity of irAE, the initial steroid dose, and individual patient responses rather than other prespecified criteria. |
| Steroid taper should occur slowly, generally over 4 to 6 weeks. |
| Regular clinical evaluation should occur during steroid tapering as there is a risk of irAE rebound or recurrence. |
| In general, oral steroid tapering is recommended to occur over 4 to 6 weeks, with a reduction in prednisone or prednisolone of 10 mg every 3 to 7 days (as irAE allows) until the dose is 10 mg/d, and then reduced by 5 mg every 3 to 7 days for patients who respond quickly to steroids. For those who have received steroids for several weeks, tapering may be more prolonged. |
| In general, for patients who require IV steroids, tapering is recommended to occur over 4 weeks or longer. The initial IV conversion from methylprednisolone if ≥1 mg/kg/d would be to oral prednisone 1 mg/kg/day at minimum and then taper as above. |
| Longer steroid tapers (>4 to 6 weeks) may be required for complete resolution or to avoid recurrence or rebound of irAE events. |
| Patients should be monitored for the symptoms of adrenal insufficiency after prolonged exogenous steroids. |
| Stress doses may be needed in the event of illness, injury, and surgery. |
| Option when ready to drop below 5 mg of prednisone or 0.5 mg of dexamethasone after a longer course with concern for iatrogenic adrenal insufficiency is to transition to hydrocortisone at physiologic dosing (10 mg in the morning and 5 mg in the afternoon). This allows for faster recovery of the HPA axis because it restores diurnal patterns. |
| If indicated to control disease, a simultaneous slow, low-dose taper of the long-acting steroid can be given (for example, decreasing by 1 mg prednisone per week). |
| HPA axis function can be tested 24 hours from last oral hydrocortisone (skip PM dose and hold AM dose for labs) – measured AM cortisol and ACTH will reflect endogenous function. Ambiguous results can be clarified with an ACTH stimulation test similarly prepared for. |
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