From the Guidelines
Immunotherapy-related hepatitis should be managed based on the severity of the toxicity, with mild cases allowing for continued immunotherapy and monitoring, while moderate to severe cases require withholding or discontinuing immunotherapy and initiating corticosteroid therapy.
Management of Immunotherapy-Related Hepatitis
- For mild liver toxicity, immunotherapy can be continued and the patient should be monitored with increased frequency 1.
- For moderate toxicity, immunotherapy should be withheld, the patient should be monitored, and steroids should be considered if liver function test results worsen 1.
- For severe and life-threatening liver toxicity, ICI therapy should be permanently discontinued, inpatient care should be considered, and infliximab should not be used 1.
Treatment Options
- Corticosteroids are the most common method of treatment for ICI-mediated hepatotoxicity, with a dose of 0.5-1 mg/kg/day of prednisone or equivalent 1.
- For steroid-refractory cases, mycophenolate mofetil can be used as a second-line treatment to control hepatitis 1, and cyclosporine or tacrolimus may also be considered as additional immunosuppressants 1.
Monitoring and Follow-up
- Patients with immunotherapy-related hepatitis should be closely monitored for worsening liver function and adjusted treatment accordingly 1.
- The median time of onset of immunotherapy-related hepatotoxicity is typically 5 to 6 weeks from the start of treatment, but it can occur months later 1.
From the Research
Management of Immunotherapy-Related Hepatitis
- The management of immunotherapy-related hepatitis typically involves the use of corticosteroids as first-line treatment 2, 3, 4
- Corticosteroid monotherapy is often sufficient, but additional immunosuppression may be necessary in cases of steroid-resistant hepatitis 2, 5
- The use of mycophenolate mofetil or tacrolimus may be considered in cases where hepatitis remains refractory to corticosteroids 2, 5
- Infliximab has also been used safely in the treatment of immunotherapy-related hepatitis 2
- The severity of immunotherapy-related hepatitis can range from mild to severe, and management strategies require regular monitoring for early diagnosis and interventions 3
- Liver enzyme improvement one week after steroid initiation may predict ultimate immunotherapy-related hepatitis resolution 4
- In some cases, immunotherapy may need to be permanently suspended due to severe immunotherapy-related hepatitis 3
Treatment Approaches
- Corticosteroids are the backbone of treatment in moderate and high-grade immunotherapy-related hepatitis damage, alone or in combination with additional immunosuppressive drugs for resistant or refractory cases 3
- The use of high-dose steroids is not necessarily associated with improved outcomes, and the addition of other immunosuppressive agents may be necessary in some cases 2, 4
- Tacrolimus has been shown to be effective in the management of immunotherapy-related hepatitis that is refractory to other treatments 5
Predictive Factors and Biomarkers
- There are currently no reliable predictive markers or models for immunotherapy-related hepatotoxicity, although pre-existing autoimmune and liver diseases, the type of immunotherapy, and combination regimens may play a role in its development 3
- Further research is needed to identify useful biomarkers and predictors of immunotherapy-related hepatitis 2