What is the treatment for abdominal pain with checkpoint inhibitor-induced colitis?

From the Guidelines

The treatment for abdominal pain due to checkpoint inhibitor-induced colitis typically involves a stepwise approach starting with high-dose systemic glucocorticoids, such as prednisone 0.5–2 mg/kg equivalent daily, with a taper of 4–6 weeks, as recommended by the American Gastroenterological Association 1.

Treatment Approach

The approach to treating abdominal pain with checkpoint inhibitor-induced colitis involves:

• Excluding infectious causes of diarrhea before treatment of suspected ICI colitis 1
• Considering endoscopic confirmation of the diagnosis and severity of ICI colitis before initiation of high-dose systemic glucocorticoids 1
• Using infliximab or vedolizumab as reasonable options for treatment of glucocorticoid refractory colitis 1
• Providing supportive care, including IV fluids, electrolyte replacement, and antidiarrheal medications for mild symptoms

Stepwise Treatment

The stepwise treatment approach involves:

• Starting with corticosteroids, such as prednisone 1-2 mg/kg/day orally for mild cases, or methylprednisolone 1-2 mg/kg/day intravenously for severe cases
• Adding infliximab (5 mg/kg IV) if symptoms don't improve within 3-5 days of steroid treatment, with additional doses at 2 and 6 weeks if needed 1
• Using vedolizumab (300 mg IV at weeks 0,2, and 6, then every 8 weeks) for steroid-refractory cases 1

Considerations

When treating abdominal pain with checkpoint inhibitor-induced colitis, it is essential to consider:

• Temporarily withholding checkpoint inhibitor therapy during treatment and resuming once symptoms resolve to grade 1 or less
• The risk of recurrent ICI colitis when re-treating with immunotherapy, particularly when switching ICI classes 1
• The potential benefits of maintenance therapy with a biologic, such as infliximab or vedolizumab, in reducing the risk of ICI enterocolitis recurrence 1

From the Research

Treatment for Abdominal Pain with Checkpoint Inhibitor-Induced Colitis

• The treatment for abdominal pain with checkpoint inhibitor-induced colitis typically involves the use of corticosteroids as the first line of treatment 2, 3.
• Infliximab can be used in cases of corticosteroid failure, with a complete remission rate of 73% after two or more doses 4.
• Other treatment options include mycophenolate mofetil alongside high-dose corticosteroids, which may enable reduction of corticosteroids without precipitating resurgence of colitis 5.
• Vedolizumab can also be used as an additional treatment option for patients who do not respond to infliximab 4.

Management of Checkpoint Inhibitor-Induced Colitis

• The management of checkpoint inhibitor-induced colitis requires a balance between treatment toxicity and efficacy 3.
• Patients with severe colitis may require hospitalization and treatment with intravenous corticosteroids 4.
• Endoscopic investigations, such as rectosigmoïdoscopy or colonoscopy, should be performed when severe immune checkpoint inhibitor-induced colitis is suspected, but should not delay treatment 2.
• Patient education and cooperation between oncologists and gastroenterologists are essential for optimal patient care 2.

Clinical Presentation and Diagnosis

• The hallmark symptom of colitis is diarrhea, which may be accompanied by mucus or blood in stools, abdominal pain, fever, vomiting, and nausea 3.
• The diagnosis of immune checkpoint inhibitor-related colitis relies on clinical evaluation, endoscopic and histopathologic examination, and exclusion of other potential etiologies 6.
• The common histopathologic manifestations of immune checkpoint inhibitor-related colitis include acute active colitis, chronic active colitis, microscopic colitis, and ischemic colitis 6.