Management of immune checkpoint inhibitor pneumonitis

This algorithm is intended for the management of patients with ICI pneumonitis. The diagnosis of ICI pneumonitis is based on a history of treatment with ICIs, a combination of clinical symptoms and radiographic findings consistent with pulmonary inflammation, and a diagnostic work-up to exclude other causes of pneumonitis. The differential diagnosis of ICI pneumonitis is broad and includes infection, exacerbations of obstructive lung disease, sarcoid-like reactions, cancer progression, interstitial lung disease, pneumonitis due to another drug, pulmonary hemorrhage, pulmonary embolism, and pulmonary edema. We obtain pulmonary consultation to assist with the diagnostic evaluation of alternate etiologies and monitoring of symptoms. For additional details, refer to UpToDate topics on the diagnosis and management of ICI pneumonitis.

ADL: activities of daily living; CT: computed tomography; CTCAE: Common Terminology Criteria for Adverse Events; ICI: immune checkpoint inhibitor; ICU: intensive care unit; IV: intravenously; IVIG: intravenous immune globulin; NCI: National Cancer Institute; PCP: pneumocystis pneumonia.

* Follow-up with history and physical examination every 2 to 4 weeks (weekly if on ICI therapy), home or office pulse oximetry, and follow-up CT chest (with or without contrast) in 3 to 4 weeks.

¶ Chronic ICI pneumonitis is defined as long-term, steroid-dependent pneumonitis that stabilizes or diminishes with initial glucocorticoid therapy but worsens upon tapering of the glucocorticoid, requiring 12 weeks or more of immunosuppressive therapy after discontinuing ICI therapy.

Δ Depending on disease severity and institutional practice, high-dose IV methylprednisolone may be administered as 1 to 2 mg/kg/day, or 500 to 1000 mg/day for 72 hours, followed by 1 to 2 mg/kg/day. The daily dose is administered once daily or in divided doses. Patients who do not respond to these doses likely have steroid-refractory disease.

◊ Time to clinical improvement is variable and can be seen as soon as 42 to 78 hours in some patients and as long as 7 to 14 days in others. Clinical stability often occurs first and is reassuring, particularly when the initial clinical deterioration was rapid. Worsening symptoms should prompt re-evaluation of the diagnosis and treatment for steroid-refractory pneumonitis.

§ Glucocorticoids are usually tapered over a period of 4 to 8 weeks. Length of the taper varies based on symptom severity and initial treatment dose, robustness of initial response to glucocorticoids, pace of improvement, and severity of glucocorticoid-related adverse effects. For suggested tapering schedules, refer to UpToDate content on ICI pneumonitis.

¥ Administer appropriate antimicrobial, antiviral, and antifungal prophylaxis per institutional guidelines. PCP prophylaxis is indicated in patients receiving a glucocorticoid dose equivalent to ≥20 mg oral prednisone daily for more than 1 month. Refer to UpToDate content on PCP prophylaxis.

‡ Retreating with an ICI depends on the clinical resolution of symptoms, severity of the ICI pneumonitis, the potential benefits of continued ICI therapy, and patient values and preferences. For further discussion, refer to UpToDate content on ICI pneumonitis.

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Management of immune checkpoint inhibitor pneumonitis