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Immunotherapy Update Review of Immune Checkpoint Inhibitor and CAR T-Cell Therapy Adverse Effects and Treatments

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Immunotherapy Update Review of Immune Checkpoint Inhibitor and CAR T-Cell Therapy Adverse Effects and Treatments Cancer immunotherapy update Review of immune checkpoint inhibitor and CAR T-cell therapy adverse effects and treatments. By Victoria L. Anderson, MSN, CRNP, FAANP, and Leslie Smith, MSN, RN, AOCNS, APRN-CNS BECAUSE cancer treatment (surgery, radia- ments—immune checkpoint inhibitors and CNE tion, and chemotherapy) frequently fails, chimeric antigen receptor (CAR) T-cell thera- 1.5 contact hours research ers began asking why patients’ im- py—their immune-related adverse effects, mune systems don’t respond to cancer cells and treatment options. By understanding LEARNING like they do to bacteria and viruses. Under how these treatments work and their possible OBJECTIVES normal conditions, T lymphocytes (T-cells) adverse effects, nurses can better educate pa- 1. Describe how bind to a tumor cell via programmed cell tients and intervene quickly when necessary. immune check- death protein 1 (PD-1) and programmed point inhibitors death ligand 1 (PD-L1) receptors and then Immune checkpoint inhibitors and chimeric send signals that recruit antigen-presenting Immune checkpoint inhibitors (CTLA-4, PD-1, antigen recep- cells (APCs) that attach to the T-cells via and PD-L1) have emerged as potential targets tor (CAR) T-cell the cytotoxic T lympho cyte antigen-4 (CT- in the development of new cancer drugs. therapy work. LA-4) binding arm. Next, a series of cy- 2. Discuss adverse tokines (such as gamma interferon, inter- CTLA-4 inhibitors effects related leukin 12 and B7) work to kill the T-cell and Immune tolerance is the process described to immune the tumor cell through apoptosis (cell by Schwartz as an “anticipatory organ” that checkpoint in- death). Cancer tumor cells, however, block has learned to recognize self from nonself hibitors. T-cells from binding to dendritic cells, al- and prevent self-destruction through a series 3. Discuss adverse lowing the cancer to escape detection by of mechanisms that include T-cells, APCs, effects related the patient’s immune system. cellular receptors, and mediators. CTLA-4 is to CAR T-cell The U.S. Food and Drug Administration key in this process. therapy. (FDA) has approved several immunotherapy CTLA-4 is a receptor that competes for The authors and plan- agents to treat cancer. They help the immune binding with other receptors to regulate T-cell ners of this CNE activi- ty have disclosed no system recognize tumor cells, prevent im- proliferation and inflammatory cytokine pro- relevant financial re - mune system tolerance of tumor cells, and duction. Intact CTLA-4 dampens inflammation lationships with any commercial companies manipulate translational proteins in the tu- and preserves immune tolerance, keeping the pertaining to this activi- mor microenvironment. However, these body’s immune response in check. Tumors ty. See the last page of the article to learn how drugs come with accompanying toxicities recognize the advantage of stimulating T-cells to earn CNE credit. (immune-related adverse effects). This article to express many CTLA-4 antigens on their Expiration: 9/1/23 focuses on two recently approved treat- surface and inhibit APCs from recognizing 6 American Nurse Journal Volume 15, Number 9 MyAmericanNurse.com and killing tumor cells. Anti-CTLA-4 mono- or delay of the immune checkpoint inhibitor clonal antibodies block CTLA-4, so that T- and the need for adjunctive treatments to cells can then destroy tumor cells. ameliorate its side effects. Ipilimumab is the only anti-CTLA-4 mono- Almost all adverse effects require treatment clonal antibody FDA-approved to treat cancer; with immunosuppression. Glucocorticoid ster- it’s indicated for advanced melanoma and re- oids are the primary drug of choice; however, nal cell and colon cancer. It is also used for other immunosuppressant agents may be used liver carcinoma, small cell lung cancer, and to regulate an overwhelming inflammatory re- esophageal cancer with orphan drug status. sponse caused by immune checkpoint in- Ipilimumab is used as an adjunct to alkylating hibitors. (See Adverse effect treatment options.) drugs like dacarbazine for mela noma and do- Organizational protocols are used for grad- cetaxel for renal cell cancer or in combination ing adverse effects, choosing treatment strate- with an anti-PD-1 drug. It’s administered I.V. gies, and determining whether immunothera- in a monitored setting. py will continue. PD-1 and PD-L1 inhibitors Common adverse effects PD-1 in healthy tissue promotes self-tolerance; Common immune checkpoint inhibitor–related when deficient, it leads to autoimmune dis- adverse effects occur most frequently within eases. PD-L1 rarely occurs in healthy tissue, but the integument, endocrine, and GI systems, al- is present on cancer cells. It’s induced by the though less common effects can occur as well. production of the chemokine interferon gamma Integument. Skin rashes, vitiligo, and pru- by T-cells recruited to the tumor microenviron- ritis occur in more than 30% of patients receiv- ment. Interferon gamma initiates inflammation ing immune checkpoint inhibitor therapy. and PD-L1 expression. PD-1 on the T-cell binds Integument signs and symptoms generally to PD-L1 on the tumor surface, permanently man i fest early in ipilimumab and PD-1 inhibitor switching off T-cell recognition and preventing treatment. Rashes and pruritus usually can be T-cells from inducing tumor cell death and managed with topical glucocorticoid steroids causing immune fatigue. Monoclonal antibodies and don’t require immunotherapy suspension. have been developed that bind to PD-1 or PD- However, some patients who experience refrac- L1 to modulate immune suppression induced tory pruritus or Stevens-Johnson syndrome by the tumor in its microenvironment and re- (toxic epidermal necrolysis) may require an im- suscitate the patient’s immune system. mediate dermatology consultation and im- munotherapy discontinuation. Immune checkpoint inhibitor–related Endocrine. The endocrine system is partic- adverse effects ularly vulnerable to CTLA-4 checkpoint inhibi- Immune checkpoint inhibitor disruption of tion but toxicities also can be seen in PD-1 and the tolerance of self vs. nonself leads to mul- PD-L1 therapy when combined with ipilimum- tiple organ system alterations. Before initiating ab. Patients show evidence of adverse effects therapy, providers should obtain a detailed related to ipilimumab typically after the sixth patient baseline history, perform a compre- or seventh week of treatment. Time to onset of hensive physical, and document findings in endocrinopathies caused by pembrolizumab is the electronic health record. 10 weeks and 11 weeks for nivolumab. Medi- Baseline lab tests include a complete meta- an onset can be between 1 to 5 months de- bolic panel, liver enzymes, complete blood pending on the drug. Endocrinopathies fre- count, thyroid levels, cortisol levels, baseline quently are permanent, and patients require scans, ECG, weight, and body mass index. As lifetime hormone replacement therapy. indicated by pre-existing conditions, echocar- Endocrine adverse effects include autoim- diograms, pulmonary function tests, pancreat- mune diabetes, thyroiditis, adrenal insufficien- ic enzymes, and musculoskeletal exams also cy, and hypophysitis. The decision to continue, should be performed. Monitoring the findings, hold, or discontinue immunotherapy after an obtaining detailed histories at each clinic visit, endocrine toxicity diagnosis depends on symp- and testing per patient status or clinical proto- tom severity, treatment response, and organiza- col can help identify adverse signs and symp- tion protocols and guidelines. toms for grading that determines continuation Autoimmune diabetes presents classically MyAmericanNurse.com September 2020 American Nurse Journal 7 Adverse effect treatment options Several immunosuppressants are used to treat immune checkpoint inhibitor–related adverse effects. Immunosuppressant Mode of action Indication Anti-thymocyte globulin Destroys lymphocytes in secondary lymphoid tissue • Cardiac toxicity (myocarditis, pericarditis, and antigen-dependent cell-mediated cytotoxicity arrhythmias, ventricular dysfunction) Azathioprine Inhibits DNA and RNA synthesis by interfering with • Inflammatory arthritis the precursors of purine synthesis and suppressing de novo purine synthesis; suppresses lymphocyte proliferation in vitro and production of IL-2, thereby inhibiting T-cell proliferation Cyclophosphamide Alkylating agent is toxic to all human cells to differing • Renal toxicity degrees, with hematopoietic cells forming a particularly sensitive target Cyclosporine Inhibits synthesis of ILs, including IL-2, which is • Hepatitis essential for self-activation of T-lymphocytes and • Renal toxicity their differentiation Infliximab Blocks the interaction of tumor necrosis factor alpha • Enterocolitis and its receptors, inhibiting induction of pro- • Inflammatory arthritis inflammatory cytokines (IL-1, IL-6) and modulating • Pneumonitis the activity of immune effectors such as leukocytes, • Renal toxicity neutrophils, and eosinophils • Cardiac toxicity (myocarditis, pericarditis, arrhythmias, and ventricular dysfunction) I.V. immunoglobulin-G Directly binds to natural antibodies, immuno- • Pneumonitis modulatory proteins (e.g., cytokines), or superantigens • Neurologic toxicity (Guillain-Barré and pathogens syndrome, myasthenia gravis, encephalopathy, transverse myelitis) • Inflammatory arthritis Leflunomide Inhibits T-cell expansion • Inflammatory arthritis Methotrexate Unknown in inflammation; may promote adenosine
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