From the Guidelines
Intravenous Immunoglobulin (IVIG) is not currently recommended as a first-line treatment for checkpoint inhibitor-induced colitis, and its use should be reserved for severe or refractory cases that have failed to respond to standard treatments. The primary treatments for checkpoint inhibitor-induced colitis include corticosteroids (such as prednisone 1-2 mg/kg/day or methylprednisolone 1-2 mg/kg/day IV for severe cases) as first-line therapy, followed by infliximab (5-10 mg/kg IV) or vedolizumab (300 mg IV) as second-line options for steroid-refractory cases 1.
Some key points to consider when managing checkpoint inhibitor-induced colitis include:
- Infectious causes of diarrhea should be excluded before treatment of suspected ICI colitis 1
- Early stool testing for inflammatory markers (lactoferrin and calprotectin) may help stratify high-risk patients for endoscopic evaluation 1
- Endoscopic confirmation of the diagnosis and severity of ICI colitis should be considered before initiation of high-dose systemic glucocorticoids 1
- Abdominal imaging may be considered to exclude serious complications in patients with dominant symptoms of pain, fever, or bleeding 1
If a patient fails to respond to these treatments, IVIG may be considered at doses of 1-2 g/kg divided over 3-5 days. IVIG works by modulating the immune response through multiple mechanisms, including neutralization of cytokines, blockade of Fc receptors, and interference with complement activation. However, evidence for IVIG's efficacy in checkpoint inhibitor-induced colitis is limited to case reports and small series, and its use should be reserved for specialized centers with experience managing severe immune-related adverse events 1. Patients receiving IVIG should be monitored for potential adverse effects including headache, thrombotic events, and renal dysfunction.
In terms of the role of IVIG in the treatment of checkpoint inhibitor-induced colitis, it is essential to prioritize the use of established treatments, such as corticosteroids and infliximab or vedolizumab, before considering IVIG. The introduction of either infliximab or vedolizumab within 10 days of onset of colitis can reduce the duration of symptoms and improve steroid taper success 1. Treatment with ≥3 doses of infliximab or vedolizumab, and achieving endoscopic or histologic remission are associated with lower risk of colitis relapse 1.
From the Research
Treatment of Checkpoint Inhibitor-Induced Colitis
- The treatment of checkpoint inhibitor-induced colitis typically involves the use of corticosteroids, with infliximab used in cases of corticosteroid failure 2, 3, 4, 5.
- Infliximab has been shown to be effective in treating severe immune-mediated enterocolitis, with a complete remission rate of 73% after two or more doses 6.
- However, the use of infliximab is not without risks, and patients may experience infections, hospitalizations, and thromboembolic events 6, 5.
Role of IvIG in Treatment
- There is no direct evidence in the provided studies to support the use of Intravenous Immunoglobulin (IvIG) in the treatment of checkpoint inhibitor-induced colitis.
- The studies primarily focus on the use of corticosteroids and infliximab in the treatment of this condition, with no mention of IvIG as a treatment option 6, 2, 3, 4, 5.
Management of Colitis
- Patients with immune checkpoint inhibitor-induced colitis are categorized into different grades based on the severity of their symptoms, and treatment decisions are guided by these grades 3.
- A colonoscopy is recommended for patients with grade 2 or higher symptoms, and treatment with systemic corticosteroids and biologic therapy may be necessary 3.
- Prompt diagnosis and management of immune checkpoint inhibitor-induced colitis is crucial to prevent severe complications and improve patient outcomes 4.