ASCO and NCCN released today, their new clinical guidelines for managing immunotherapy-related toxicities. The key guideline recommendations include:

#) In general, immune checkpoint inhibitors can be continued with close monitoring for mild (grade 1) toxicities, with the exception of neurologic and some hematologic toxicities.

#) For moderate (grade 2) toxicities, checkpoint inhibitors should be held until symptoms and/or lab values revert to grade 1 levels or lower. Corticosteroids may be offered.

#) For severe (grade 3) toxicity, patients should receive high-dose corticosteroids for at least 6 weeks. Extreme caution when restarting immunotherapy after a grade 3 toxicity is recommended, if it is restarted at all.

#) In general, very severe (grade 4) toxicity necessitates stopping checkpoint inhibitor therapy permanently.

While I think the above general guidelines are prudent to follow, particularly for providers with minimal or limited experience with ICIs, I was surprised to read the 2nd bullet above- holding ICIs for Grade 2 toxicity.

The way it is currently stated, it would imply that this is the case for ALL toxicities. I agree that certain grade 2 toxicities warrant holding, notably pneumonitis & neuro related, however there are some grade 2 toxicities that would not warrant a hold, such as certain endocrinopathies including hypothyroidism, hypophysitis, etc.

I believe our care step pathways, available on our site are wonderful resources for nurses in other providers to review at the same time they are familiarizing themselves with the new guidelines from ASCO/NCCN.

I also find an very interesting that corticosteroid taper guidelines recommend 6 weeks, rather than the standard 4 weeks that has typically been advised.

I plan to review the guidelines in much more detail in the very near future.

What are your thoughts?