MDCalc

Immune-Related Adverse Events for Lung Toxicity - Pneumonitis

Grades severity of pneumonitis secondary to immune checkpoint inhibitor therapy.

Use in adult patients with symptoms of pneumonitis or focal or diffuse inflammation of the lung parenchyma typically identified on CT imaging while on treatment with immune checkpoint inhibitors.

Criteria

Result:

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Advice

Monitor patients for symptoms of pneumonitis and carefully review imaging studies of lung for detection of pneumonitis in asymptomatic patients. 

For grade 2 or higher ICPi pneumonitis may include the following infectious work-up: nasal swab, sputum culture and sensitivity, blood culture and sensitivity, urine culture and sensitivity.

Management

For all patients where an IRAE diagnosis is being considered, it is always recommended to involve the specialist or team prescribing the immune checkpoint therapy. 

Grade 1:

  1. Hold ICPi with radiologic evidence of pneumonitis progression.

  2. May offer repeat CT in 3-4 weeks.

  3. May offer a repeat spirometry/diffusing capacity of lung for carbon monoxide if the patients had undergone the test on ICPi initiation.

  4. May resume ICPi if improved or resolved radiographically.

  5. If no improvement, treat as grade 2.

  6. Monitor weekly with history and physical examination, pulse oximetry and optional CXR.

Grade 2:

  1. Should hold ICPi until resolution to ≤ Grade 1. 

  2. Consider prednisone 1-2 mg/kg/d and taper by 5-10 mg/wk over 4-6 weeks per institutional guidelines.

  3. Consider bronchoscopy with bronchoalveolar lavage.

  4. Consider empirical antibiotics.

  5. Monitor every 3 days with history and physical examination, pulse oximetry, consider CXR.

  6. If no improvement in 48-72 hours of prednisone, treat as grade 3.

Grade 3-4:

  1. Permanently discontinue ICPi.

  2. Consider empirical antibiotics.

  3. Consider (methyl)prednisolone IV 1-2 mg/kg/d.

  4. If no improvement after 48 hours, add infliximab 5 mg/kg or mycophenolate mofetil IV 1 g twice a day or IVIG for 5 days or cyclophosphamide. Taper corticosteroids over 4-6 weeks. 

  5. Consult pulmonary and infectious disease if necessary.

  6. Offer bronchoscopy with bronchoalveolar lavage with or without transbronchial biopsy.

  7. Consider admission for further management.

See Brahmer 2018 for full ASCO guidelines.

Critical Actions

When the clinical picture is consistent with pneumonitis, biopsy is generally unnecessary. However, biopsy may assist to rule out other etiologies such as lymphangitic spread of tumor or infection.

The role of prophylactic fluconazole with prolonged corticosteroid use (>12 weeks) remains unclear, and physicians should follow institutional guidelines.

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