Synopsis
Recognise life-threatening checkpoint-inhibitor, CAR-T and bispecific-antibody toxicity, treat infection and other mimics in parallel and start severity- and organ-specific immune rescue without waiting for routine oncology review.
- Immune toxicity can affect any organ and may begin during treatment or weeks to months after the last checkpoint dose; ask specifically about the exact immune product and date.
- Withhold further immune therapy for clinically significant suspected toxicity and contact acute oncology or the cellular-therapy centre immediately.
- First-line assessment combines ABCDE, sepsis cultures and lactate, FBC, renal, liver, glucose, cortisol and thyroid tests with organ-specific ECG, troponin, CT, stool or neurological evaluation.
Key red flags
New breathlessness, hypoxaemia or diffuse lung change during checkpoint therapy may be pneumonitis, infection or embolism and requires urgent imaging and oncology review.
Increasing stool frequency, nocturnal diarrhoea, blood, pain or fever can progress to dehydration, toxic dilatation and perforation.
Investigation priorities
Identify infection, shock and the organ systems requiring immediate support.
Management branches
A patient exposed to immune therapy develops a new inflammatory, endocrine, cardiac or neurological syndrome.
- Use ABCDE and monitoring, identify exact product and dates, hold further immune treatment and contact acute oncology or the cellular-therapy centre immediately.
- Obtain sepsis and organ-directed tests and start antimicrobials and other emergency treatment when indicated without waiting for a toxicity grade.
Key medicines
Intravenous methylprednisolone for severe checkpoint toxicityGive methylprednisolone 1 to 2 mg/kg intravenously once daily, or the divided organ-specific equivalent, for severe immune-mediated toxicity, with pulse dosing reserved for selected life-threatening cardiac or neurological disease under specialist protocol.
Hydrocortisone for adrenal crisisGive hydrocortisone 100 mg intravenously or intramuscularly immediately, then 200 mg over 24 hours by infusion or 50 mg intravenously every 6 hours with intravenous 0.9% sodium chloride and glucose as required.