Can we give Tremfaya (atezolizumab and cobimetinib) to a patient with a cough?

Can Tremfya be Given to a Patient with Cough?

The presence of cough alone is not a contraindication to Tremfya (guselkumab), but you must first rule out serious pulmonary conditions—particularly pneumonitis, active infection, or other immune-mediated lung disease—before initiating or continuing this biologic therapy.

Critical Clarification on Drug Identity

There appears to be confusion in the question. Tremfya is guselkumab (an IL-23 inhibitor used for psoriasis), not atezolizumab plus cobimetinib (which is an immunotherapy combination used in oncology). The provided evidence discusses atezolizumab, so I will address both scenarios:

If the Question is About Atezolizumab (Tecentriq)

Immediate Safety Assessment Required

Before administering atezolizumab to any patient with cough, you must actively exclude pneumonitis and other serious pulmonary pathology, as this is a potentially fatal immune-mediated adverse reaction 1.

Key Contraindications and Warnings

• Patients with active pneumonitis or a history of idiopathic pulmonary fibrosis are excluded from atezolizumab therapy 2
• Cough occurred in 22% of patients receiving atezolizumab as monotherapy, making it a common adverse event 1
• Patients must be counseled to contact their healthcare provider immediately for any new or worsening cough, chest pain, or shortness of breath, as these may indicate immune-mediated pneumonitis 1

Diagnostic Workup Before Treatment

If a patient presents with cough before starting atezolizumab:

• Obtain chest radiograph and consider chest CT to exclude pneumonia, pneumonitis, or other pulmonary pathology 3
• Perform spirometry to assess baseline lung function 3
• Evaluate for infectious causes, particularly if accompanied by fever, tachycardia (>100 bpm), tachypnea (>24 breaths/min), or abnormal chest examination findings 3
• If pneumonia is suspected based on clinical criteria, do not proceed with immunotherapy until infection is treated and resolved 3

Management Algorithm

For patients already on atezolizumab who develop cough:

1. Immediately assess for immune-mediated pneumonitis by obtaining chest imaging and clinical evaluation 1
2. If pneumonitis is confirmed, hold atezolizumab and initiate corticosteroids per FDA guidance 1
3. If cough is due to upper respiratory infection without pneumonia, symptomatic treatment is appropriate but antibiotics are not indicated for viral bronchitis 3
4. Consider other common causes: GERD (requires 3 months of intensive PPI therapy), post-nasal drip (trial of topical corticosteroids), or ACE inhibitor use (must discontinue the drug) 3

If the Question is About Actual Tremfya (Guselkumab)

Cough is not listed as a contraindication or significant adverse event with guselkumab, as it is an IL-23 inhibitor with a different safety profile than checkpoint inhibitors. However:

• Rule out active tuberculosis or other serious infections before initiating any biologic therapy
• Ensure the cough is not indicative of underlying infection requiring treatment first
• Proceed with standard infectious disease screening per biologic therapy protocols

Common Pitfalls to Avoid

• Do not dismiss new or worsening cough in patients on checkpoint inhibitors like atezolizumab—this can be the first sign of potentially fatal pneumonitis 1
• Do not prescribe antibiotics for acute bronchitis with cough unless pneumonia is confirmed, as more than 90% of acute cough is viral 3
• Do not continue ACE inhibitors in patients with persistent cough, as this is a class effect that will not resolve until the medication is stopped 3, 4
• Do not assume purulent sputum indicates bacterial infection—purulence reflects inflammatory cells, not necessarily bacteria 3