969: Pharmacist Initiative to Improve Appropriate Prophylactic Medications in an Intensive Care Unit

Abstract

INTRODUCTION:Neuromuscular disorders such as Guillain-Barre syndrome (GBS) and myasthenia gravis (MG) can be rare, life-threatening adverse reactions induced by immune checkpoint inhibitors (ICIs). These conditions are characterized by skeletal muscle weakness that may quickly progress to involve the diaphragm, resulting in respiratory failure requiring invasive mechanical ventilation.DESCRIPTION: An 86-year-old male patient with metastatic renal cell carcinoma was started on adjuvant ICI treatment, nivolumab and ipilimumab, following radical left nephrectomy. After one month (two cycles) of ICI treatment, he presented to his ophthalmologist with complaint of new onset diplopia and severe bilateral ptosis. Ophthalmology recommended emergency department evaluation due to the additional discovery of rapidly progressing bilateral lower extremity weakness. He was admitted to the general medicine ward for further evaluation of suspected ICI-induced MG or GBS. After one day of hospitalization, he was transferred to the intensive care unit (ICU) for worsening respiratory muscle weakness and potential need for invasive mechanical ventilation. Treatment with intravenous immunoglobulin (IVIG) and high-dose corticosteroids was initiated. The patient's condition stabilized, and he did not require invasive mechanical ventilation. After two days of ICU admission, he was transferred to the step-down unit where he completed five days of IVIG and corticosteroid treatment. Due to persistent weakness, treatment with plasma exchange (PLEX) was initiated. After five sessions of PLEX, clinical improvement was seen with gradual restoration of strength and resolution of symptoms. The patient was able to be discharged home after two weeks of hospitalization.