EMedHome's Clinical Pearl
Acute care for cancer patients is increasingly becoming a major component of ED care. The landscape of cancer treatment and its adverse effects are quickly changing as immune checkpoint inhibitors are rapidly being approved by the FDA for a variety of cancers.
Immune checkpoint inhibitors trigger an immune response to the malignancy. The expected adverse effects vary significantly from those of cytotoxic chemotherapy and frequently mimic autoimmune responses. Symptoms can manifest weeks to months after treatment is initiated or completed.
The potential presence of immune-related adverse events necessitates a new approach to evaluating cancer patients in the ED if they are on immune checkpoint inhibitors:
- Consider immune-mediated pneumonitis in addition to considering pneumonia or pulmonary embolus for patients with dyspnea. (Ann Emerg Med. 2019;73:88; http://bit.ly/2EW6Dy1.)
- Myocarditis and pericarditis must be considered for patients with chest pain. (Ann Emerg Med. 2019;73:88; http://bit.ly/2EW6Dy1.)
- Consider hypophysitis for patients with headache. (Ann Emerg Med. 2019;73:88; http://bit.ly/2EW6Dy1.)
- Traditional lab-value red flags, such as neutropenia, are not likely to be present.
- Thyroiditis was a common adverse effect in a 2017 study of ED patients on immune checkpoint inhibitors. (Urol Oncol. 2017;35:701; Ann Emerg Med. 2019;73:79; http://bit.ly/2EQFHQb.)
- Systemic glucocorticoids may need to be initiated expeditiously in the ED with potentially serious immune-related adverse effects such as neurologic, pulmonary, and cardiac toxicities. (Ann Emerg Med. 2019;73:79; http://bit.ly/2EQFHQb.)
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