| 11.1. IRRs |
Work-up and evaluation: - Physical examination including vital signs
- Pulse oximetry
- ECG if chest pain or sustained tachycardia
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| Grading | Management |
| G1: Mild transient reaction; infusion interruption not indicated; intervention not indicated. | - Continue ICPi.
- May consider premedication with acetaminophen and an antihistamine for subsequent infusions.
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| G2: Therapy or infusion interruption indicated but responds promptly to symptomatic treatment; prophylactic medication indicated for ≤24 hours. | - Consider holding ICPi temporarily and/or reducing the rate of infusion to 50% (or per institutional guidelines).
- Offer symptomatic treatment with antihistamines, NSAIDs, opioids, and IV fluids as clinicially appropriate.
- Offer prophylactic acetaminophen and an antihistamine per institution guidelines for subsequent infusions.
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| G3: Prolonged (eg, not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for other clinical sequelae. | - Hold ICPi temporarily and consider resuming, at an infusion rate of 50% (or per institutional guidelines), once return to ≤G1.
- Offer symptomatic treatment with antihistamines, NSAIDs, opioids, and IV fluids as clinically appropriate.
- Consider antihistamines and corticosteroid medications IV.
- Hospitalization for other clinical sequelae.
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| G4: Life-threatening consequences; urgent intervention indicated. | - Permanently discontinue ICPi.
- ICU-level inpatient care.
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Additional considerations: - Clinicians may consider switching to an alternate agent in the therapeutic class upon rechallenge or consider rechallenging with the offending immunotherapy agent through a desensitization procedure under the supervision of an allergist.
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