Temporal Trends and Outcomes Among Patients Admitted for Immune-Related Adverse Events: A Single-Center Retrospective Cohort Study from 2011 to 2018

Abstract

Background The aim of this study was to characterize severe immune‐related adverse events (irAEs) seen among hospitalized patients and to examine risk factors for irAE admissions and clinically relevant outcomes, including length of stay, immune checkpoint inhibitor (ICI) discontinuation, readmission, and death. Methods Patients who received ICI therapy (ipilimumab, pembrolizumab, nivolumab, atezolizumab, durvalumab, avelumab, or any ICI combination) at Massachusetts General Hospital (MGH) and were hospitalized at MGH following ICI initiation between January 1, 2011, and October 24, 2018, were identified using pharmacy and hospital admission databases. Medical records of all irAE admissions were reviewed, and specialist review with defined criteria was performed. Demographic data, relevant clinical history (malignancy type and most recent ICI regimen), and key admission characteristics, including dates of admission and discharge, immunosuppressive management, ICI discontinuation, readmission, and death, were collected. Results In total, 450 admissions were classified as irAE admissions and represent the study's cohort. Alongside the increasing use of ICIs at our institution, the number of patients admitted to MGH for irAEs has gradually increased every year from 9 in 2011 to 92 in 2018. The hospitalization rate per ICI recipient has declined over that same time period (25.0% in 2011 to 8.5% in 2018). The most common toxicities leading to hospitalization in our cohort were gastrointestinal (30.7%; n = 138), pulmonary (15.8%; n = 71), hepatic (14.2%; n = 64), endocrine (12.2%; n = 55), neurologic (8.4%; n = 38), cardiac (6.7%; n = 30), and dermatologic (4.4%; n = 20). Multivariable logistic regression revealed statistically significant increases in irAE admission risk for CTLA‐4 monotherapy recipients (odds ratio [OR], 2.02; p < .001) and CTLA‐4 plus PD‐1 combination therapy recipients (OR, 1.88; p < .001), relative to PD‐1/PD‐L1 monotherapy recipients, and patients with multiple toxicity had a 5‐fold increase in inpatient mortality. Conclusion This study illustrates that cancer centers must be prepared to manage a wide variety of irAE types and that CTLA‐4 and combination ICI regimens are more likely to cause irAE admissions, and earlier. In addition, admissions for patients with multi‐organ involvement is common and those patients are at highest risk of inpatient mortality. Implications for Practice The number of patients admitted to Massachusetts General Hospital for immune‐related adverse events (irAEs) has gradually increased every year and the most common admissions are for gastrointestinal (30.7%), pulmonary (15/8%), and hepatic (14.2%) events. Readmission rates are high (29% at 30 days, 49% at 180 days) and 64.2% have to permanently discontinue immune checkpoint inhibitor therapy. Importantly, multiple concurrent toxicities were seen in 21.6% (97/450) of irAE admissions and these patients have a fivefold increased risk of inpatient death.

Effects of immune checkpoint inhibitor therapy resumption in patients with malignant tumors after moderate-to-severe immune-related adverse events

“…These agents activate cytotoxic T cells to damage tumor cells, leading to favorable responses and survival [ 1 – 11 ]. However, ICIs sometimes trigger immune-related adverse events (irAEs) by disrupting the balance of the autoimmune system, thereby affecting multiple organs, including the lungs, skin, liver, gastrointestinal tract, and endocrine system [ 12 , 13 ]. Although most irAEs are manageable with discontinuation of ICI therapy or corticosteroid treatment, some are severe and potentially fatal [ 14 ].…”

Effect of a multidisciplinary Severe Immunotherapy Complications Service on outcomes for patients receiving immune checkpoint inhibitor therapy for cancer

“…Subsequently, specialists (allergy: JRF; cardiology: TGN, DZ; dermatology: STC; endocrinology: ATF, MR; gastroenterology/hepatology: MD, MFT; hematology: RSKL; nephrology: MES; neurology: ACG; pulmonology: DO, BDM; rheumatology: MN, MK, SS) followed published organ-specific diagnostic criteria to identify cases of suspected or confirmed irAEs admitted to the hospital. 26 In patients with multiple confirmed toxicities, the primary irAE was defined as that which prompted hospitalization and/or determined treatment.…”

A review of neurotoxicities associated with immunotherapy and a framework for evaluation

“… 17 Similarly, in a cohort of patients hospitalized with severe irAEs, 21.6% had multiple concurrent toxicities. 16 Multiple toxicities were most frequent in patients on combination CTLA-4/PD-1 therapy (35.9%), followed by CTLA-4 monotherapy (22.6%) and PD-1/PD-L1 monotherapy (17.2%). 16 …”

“… 16 Multiple toxicities were most frequent in patients on combination CTLA-4/PD-1 therapy (35.9%), followed by CTLA-4 monotherapy (22.6%) and PD-1/PD-L1 monotherapy (17.2%). 16 …”

“… 13 , 14 Suspicion that a new neurologic symptom represents an irAE should be higher when another irAE is present, as multiorgan system involvement is common. 15 , 16 In patients with ICI-related neuropathy, 58% had irAEs affecting other organ systems. 17 Similarly, in a cohort of patients hospitalized with severe irAEs, 21.6% had multiple concurrent toxicities.…”