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    Patent Pending

    Immune-Related Adverse Events for GI Toxicity - Hepatitis

    Grades severity of hepatitis secondary to immune checkpoint inhibitor therapy.

    INSTRUCTIONS

    Use in adult patients with symptoms of hepatitis or AST, ALT, or total bilirubin elevation that developed while on treatment with immune checkpoint inhibitors.

    When to Use
    Pearls/Pitfalls
    Why Use

    Adult patients with hepatitis symptoms or AST, ALT, or total bilirubin elevation, while on treatment with immune checkpoint inhibitors including agents against PD-1 (i.e. pembrolizumab, nivolumab), PD-L1 (i.e. atezolizumab, avelumab, durvalumab), or CTLA-4 (i.e. ipilimumab).

    • Immune checkpoint inhibitor (ICPi) hepatitis should be suspected in patients with symptoms of hepatitis (i.e., jaundice, severe nausea or vomiting, pain on the right side of the abdomen, drowsiness, dark (tea-colored) urine, easy bleeding or bruising, anorexia) while on treatment with immune checkpoint inhibitors.

    • May occur any time during immune checkpoint inhibitor treatment, but most frequently seen 6-12 weeks following treatment initiation.

    • More frequently seen with anti-CTLA-4 agents, but is also an important adverse event caused by anti-PD-1 and anti-PD-L1 agents.

    • Management of immune checkpoint inhibitor hepatitis is based on the grade of hepatitis.

    ICPi hepatitis is the third most common cause of hospital admissions due to immune related adverse events. This tool aids in the decision of immune checkpoint inhibitor discontinuation, further diagnostic work-up, and immunosuppressant treatment initiation.

    Asymptomatic (AST or ALT > ULN to 3.0 x ULN and/or total bilirubin > ULN to 1.5 x ULN)
    Asymptomatic (AST or ALT > ULN to 3.0 to 5 x ULN and/or total bilirubin >1.5 to ≤3 x ULN)
    Symptomatic liver dysfunction, fibrosis by biopsy, compensated cirrhosis, reactivation of chronic hepatitis (AST or ALT 5-20 x ULN and/or total bilirubin 3-10 x ULN)
    Decompensated liver function leg, ascites, coagulopathy, encephalopathy, coma; AST or ALT >20 x ULN and/or total bilirubin >10 x ULN)

    Result:

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    Evidence
    Creator Insights
    Dr. Julie R. Brahmer

    About the Creator

    Julie R. Brahmer, MSc, MD, is the co-director of the upper aerodigestive department at Johns Hopkins Medicine in Baltimore, MD. She is also a professor of oncology at Johns Hopkins Medicine. Dr. Brahmer’s primary research is focused on treatment of lung cancer and mesothelioma.

    To view Dr. Julie R. Brahmer's publications, visit PubMed

    Are you Dr. Julie R. Brahmer? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Content Contributors
    • Nazli Dizman, MD
    About the Creator
    Dr. Julie R. Brahmer
    Are you Dr. Julie R. Brahmer?
    Content Contributors
    • Nazli Dizman, MD