The incidence of immune related adverse events (irAEs) secondary to oncological immune checkpoint inhibitors (ICIs) are treated as standard with high dose corticosteroids (CST). Grade 3-4 hepatitis is managed with intravenous methylprednisolone (IVMP) as per international protocols. CST treatment is effective but if administered in the inpatient setting can lead to long hospital stays, psychological distress and increased risk of hospital related illness. Clatterbridge Cancer Centre (CCC), a UK tertiary cancer centre, has an established regional pan-tumour immunotherapy (IO) service to support all patients with irAEs and delivers a ambulatory IVMP pathway as part of that service.
A retrospective review of the ambulatory IVMP service since its introduction in 2018 was undertaken. The proportion of patients treated in an ambulatory setting was compared the situation prior to 2018. Additionally the responsiveness of the service and impact on admission, length of stay (LOS) and bed days (BD) was evaluated.
Between 2018 and 2021 2017 patients were treated with checkpoint inhibitors regionally. 1027 patients experienced CST requiring irAEs of which 95 experienced grade 3/4 hepatitis requiring IVMP. Prior to the introduction of the service 100% (17/17) of patients required inpatient admission for IVMP associated with a median LOS of 12.5 days and accounting for 137.5 BD per annum. Following the introduction of the ambulatory service 15% (15/95) required admission for the introduction of IVMP, with 60% (9/15) of them completing their IVMP as an outpatient in the ambulatory setting. 75% (71/95) of patients had treatment commenced as a day case and there was an ambulatory to inpatient conversion of 9.9% (7/71), all of whom displayed CST insensitivity and required additional immunosuppresion. The median LOS was reduced to 4.75 days. Given the average number of patients requiring IVMP between 2020-22 was 34.5 (range 33-36) per year this is a saving of 268 bed days per annum resulting in a cost saving of £123,280 per annum.
The introduction of an ambulatory IVMP service for the management of immunotherapy induced hepatitis has been illustrated to be safe, effective, responsive to CST resistance and result in care provision efficiencies.
The authors.
Has not received any funding.
A.C. Olsson-Brown: Financial Interests, Personal, Invited Speaker: BMS, MSD, Roche, Novartis, AZ, Eisai, B-I. T. Guinan: Financial Interests, Personal, Invited Speaker: BMS, MSD, Roche, Sanofi . All other authors have declared no conflicts of interest.