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444-Oncology and Neurology > EGFRi , immune checkpoint inhibitor toxicities > Flashcards

EGFRi , immune checkpoint inhibitor toxicities Flashcards

1
Q

EGFR main toxicities include

A

diarrhea
acneiform rash

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2
Q

EGFR diarrhea most likely will occur within

A

first 4 wks after starting

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3
Q

mechanism of EGFR med diarrhea

A

unclear but primarily secretory

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4
Q

EGFRi diarrhea is usually grade

A

1-2

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5
Q

↑ ≤4 stools/day over baseline

A

grade 1

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6
Q

↑ 4-6 stools/day over baseline

A

grade 2

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7
Q

↑ 7 or more stools/ day over baseline, incontinence, hospitalization indicated, limits self care activities of daily living

A

grade 3

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8
Q

treatment for grade 1 EGFRi diarrhea

A

hydrate
start loperamide 4mg ASAP, 2mg after each loose bowel until BM stops for 12 hrs

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9
Q

treatment for grade 2 EGFRi diarrhea

A

loperamide as grade 1
if does not improve in 48hrs, hold EGFRi and restart once settled to grade 1 (can consider reducing dose)

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10
Q

treatment for grade 3 EGFRi diarrhea

A

referral
stool culture to rule out fnectious process
aggressive fluid replacement- with IV
temp stop EGFR and restart at reduced dose once at lvl 1
stop permanently if diarrhea doesn’t improve to grade 1 within 14 days

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11
Q

when should EGFRi be stopped permanently due to diarrhea AE

A

if grade 3 doesn’t resolve to grade 1 by 14 days of holding med

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12
Q

why do EGFRi cause acneiform rashes

A

Epidermal growth factor (EGF) and EGF receptor play essential role in wound healing through stimulating epidermal and dermal regeneration

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13
Q

rank the following EGFRi for acneiform rash risk
cetuximab, osimertinib, afatinib, pantumumab

A

afatinib > cetuximab > osimertinib >panitumumab

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14
Q

does acneiform rash respond to OTC acne products

A

no

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15
Q

acneiform rash from EGFRi usually start within ______, peaks at ____, then regresses with continuation of therapy

A

1-2wks
2-4wks

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16
Q

Sensory disturbances with erythema and edema phase + wk

A

grade1
wk 0-1

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17
Q

papulopustular eruptions phase + wk

A

phase 2
wk 1-3

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18
Q

crusting phase + wk

A

phase 3
wk 3-5

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19
Q

erythema telangiectasias phase + wk

A

phase 4
wk 5-8

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20
Q

does acneiform rash from EGFRi result in permanent scaring?

A

no

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21
Q

when should acneiform rash resolve after therapy?

A

within 2mths of d/c

22
Q

what are some positives of seeing acneiform rash from EGFRi

A

rash may be accurate surrogate marker of efficacy of anti-EGFR therapy, as well as clinical response of the pt

23
Q

grade 1 acneiform rash: Papules and/or pustules _____ BSA. may or may not be assoc with sx fo pruritus or tenderness

A

<10%

24
Q

grade 1 acneiform rash tx

A

hydrocortisone 1% + clindamycin cream 2%

25
Q

grade 2 acneiform rash tx

A

HC1% + Clinda cream 2% + mino/doxycycline 100mg PO BID F4wks

26
Q

grade 2 acneiform rash: Papules and/or pustules covering ____ BSA, may or may not be assoc w/ sx of _____
Assoc w/ ____ impact + limits instrumental ADL

A

10-30%
pruritus or tenderness
psych

27
Q

grade 3 acneiform rash: Papules and/or pustules covering ____ BSA, may or may not be assoc with sx of pruritus or tenderness
Assoc w/ ______ - ______ indicated

A

> 30%
local superinfection
oral abx

28
Q

grade 4 acneiform rash: Papules and/or pustules covering ____ BSA which may or may not be assoc w/ sx pruritus or tenderness
Associated with ______with _____indicated
Life threatening

A

any %
extensive superinfection
IV abx

29
Q

prevents inhibition on dendritic cells, which activate the T cell
is a CTLA4i

A

ipilimumab

30
Q

AEs from immunotherapy usually related to

A

autoimmunity and inflammatory response due to self reactive T cells

31
Q

AEs from immunotherapy can occur at

A

any time, even after therapy termination

32
Q

5 pillars of immunotherapy toxicity management

A

prevent
anticipate
detect
treat
monitor

33
Q

3 common AEs from immune modulators

A

immune mediated dermatitis
pneumonitis
enterocolitis

34
Q

immune mediated dermatitis is usually
1. mild,very common
2. severe bu rare- SJS, TEN
3. pruritis with rash is rare
4. usually happens after therapy is d/c

A

1

35
Q

when does immune med derm happen

A

at any time, usually ~wk 3

36
Q

what is grade 1-2 immune med derm

A

rash ≤30% skin surface

37
Q

tx for grade 1-2 immune med derm

A

Moisturizers
Sun safety
Mod potency topical CS
Oral antihistamines
if persists: consider skin biopsy + withholding CI, add oral prednisone + taper over 1mth when improved

38
Q

what is a grade 3-4 immune med derm

A

rash >30% BSA
treatment resistant with high QoL impact
or <10% if skin is sloughing off

39
Q

tx for grade 3-4 immune med derm

A

Refer to oncologist ASAP
Withhold CI
Consider skin biopsy/ derm consult
High potency topical CS and/or systemic CS daily until improves to grade 1, then taper over at least 1mth

40
Q

med time to immune mod pneumonitis

A

~12 wks

41
Q

what is grade 1 pneumonitis

A

radiographic changes only

42
Q

tx for grade 1 pneumonitis

A

Consider withholding CI, pulmonary/ID consult
If improves, resume
If worsens, tx as grade 2/3

43
Q

what is grade 2 pneumonitis

A

mild-mod new or worsening cough, chest pain, SOB

44
Q

what is grade 3/4 pneumonitis

A

Severe new or worsening cough, chest pain, SOB or hypoxia
Can be life threatening

45
Q

tx for grade 2 pneumonitis

A

Refer to oncologist/ team
Hold CI
Prednisone daily
If improves, taper prednisone over at least 1 mth
If worsens, treat as grade 3/4

46
Q

tx for grade 3/4 pneumonitis

A

Hospitalize + d/c CI
High dose corticosteroids
If improves to baseline, taper prednisone over at least 6wks
If worsens, consider nonsteroid immunosuppression

47
Q

when does immune therapy med enterocolitis happen

A

anytime, including after therapy

48
Q

usual time entercolotis happens from PD1/PD-L1 i

A

2-3mths

49
Q

usual time entercolotis happens from CTLA4i

A

1-5mths

50
Q

tx for grade 2 enterocolitis

A

Refer to oncologist/ team- assess need for hospitalization
Hold CI
IV fluids
Rule out infection
Antidiarrheal tx, if >3days = start prednisone
If improves taper prednisone over at least 1mth

51
Q

tx for grade 3 enterocollitis

A

May need to hospitalize
Gastroenterology consult and consider endoscopy
withhold/dc CI
High dose corticosteroids- unless bowel perforation
If perforated or septic = abx
If improves to baseline, taper prednisone over at least 1mth
If no response or recurs within 5 days = nonsteroid immunosuppression

444-Oncology and Neurology (22 decks)

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