Immunotherapy – GCCNurseJobs.com Clinical Guide

Checkpoint Inhibitor Classes

Anti-CTLA-4

Ipilimumab (Yervoy). Blocks CTLA-4 on T cells, enhancing T-cell activation. Used in melanoma, NSCLC (combination). Higher irAE rate than PD-1/PD-L1 agents.

Anti-PD-1

Pembrolizumab (Keytruda), nivolumab (Opdivo). Block PD-1 on T cells. Used in melanoma, NSCLC, RCC, HNSCC, MSI-H tumours. Broadly used across cancers.

Anti-PD-L1

Atezolizumab (Tecentriq), durvalumab, avelumab. Block PD-L1 on tumour cells. NSCLC, urothelial, HCC. Slightly different irAE profile.

CAR-T Cell Therapy

CRS — Cytokine Release Syndrome

Fever, hypotension, hypoxia. Graded 1–4. Treatment: tocilizumab (anti-IL-6) for Grade ≥2 or refractory. Corticosteroids for severe cases. Can require ICU. Monitor ferritin, CRP, IL-6 levels.

ICANS — Neurotoxicity

Immune Effector Cell-Associated Neurotoxicity Syndrome. Confusion, aphasia, seizures, cerebral oedema. Treat with dexamethasone. Distinct from CRS — can occur concurrently or after CRS resolves.

irAE Grading System (CTCAE)

Grade	Description	Action
Grade 1	Mild — asymptomatic or mild symptoms	Continue ICI; monitor closely
Grade 2	Moderate — limiting instrumental ADLs	HOLD ICI + start prednisolone 0.5–1 mg/kg/day
Grade 3	Severe — limiting self-care ADLs	STOP ICI permanently + IV methylprednisolone 1–2 mg/kg/day
Grade 4	Life-threatening — urgent intervention required	STOP permanently + ICU + IV methylprednisolone

Steroid Dose: 1–2 mg/kg/day prednisolone equivalent

Taper over minimum 4–6 weeks once improved. Rapid taper increases relapse risk. For steroid-refractory colitis: infliximab (anti-TNF). For steroid-refractory pneumonitis: mycophenolate or infliximab.

Common irAE Organ Systems

Colitis

Diarrhoea; most common with ipilimumab. Stool culture to exclude infection. Sigmoidoscopy. Steroids; infliximab if refractory.

Pneumonitis

Dry cough, dyspnoea. CT chest (ground-glass). Hold ICI. High-dose steroids.

Hepatitis

Elevated AST/ALT. Check viral hepatitis. Steroids; mycophenolate if refractory. Avoid infliximab (hepatotoxic).

Hypothyroidism

Most common endocrine irAE. Usually permanent — lifelong levothyroxine. Monitor TFTs at each cycle.

Dermatitis

Maculopapular rash; pruritus. Topical steroids for Grade 1–2. Systemic for Grade 3+.

Patient Education — Critical

Explain any organ can be affected — "immune system overreaction"
Report any new symptoms immediately (diarrhoea, cough, rash, fatigue, joint pain)
Carry immunotherapy alert card
Inform ALL healthcare providers about immunotherapy (anaesthetics, ED)
irAEs can occur weeks to months after last dose

Life-Threatening irAEs

Myocarditis

Rare but highly fatal (~50%). ECG + troponin + cardiac MRI. Stop ICI permanently. High-dose IV methylprednisolone + cardiac monitoring. ICU.

Adrenal Crisis

Hypopituitarism/adrenalitis from ICI. Hypotension, hyponatraemia, hypoglycaemia. Hydrocortisone 100 mg IV immediately. Permanent steroid replacement likely needed.

GCC Context

ICI Access at KFSH&RC, HMC, Tawam

Checkpoint inhibitors (pembrolizumab, nivolumab, atezolizumab, ipilimumab) are available at major GCC cancer centres including KFSH&RC (Riyadh/Jeddah), HMC (Qatar), Tawam Hospital (Abu Dhabi), and National Centre for Cancer Care & Research. Access is expanding rapidly across the region.

High HCC & NSCLC Rates

Hepatocellular carcinoma (HCC) is common due to HBV/HCV prevalence and NAFLD. Atezolizumab + bevacizumab is now first-line for advanced HCC. NSCLC incidence is rising in GCC due to high smoking rates. Pembrolizumab is first-line in PD-L1 high NSCLC. Nurses in GCC are increasingly managing patients on these regimens.

Patients with active autoimmune disease (SLE, IBD, rheumatoid arthritis) are at increased risk of severe irAEs. Use ICIs with caution after specialist MDT discussion. Pre-existing thyroid disease is common in GCC populations; baseline TFTs are essential before starting any ICI.

Patients on high-dose steroids for irAE management during Ramadan face challenges with fasting and oral steroid timing. IV methylprednisolone may be preferred for hospitalised patients during Ramadan. Patients should be advised that fasting is not advisable during acute, severe irAE requiring high-dose steroids — consult religious guidance as needed.

Key Exam Points

Anti-CTLA4 = ipilimumab; Anti-PD1 = pembrolizumab/nivolumab; Anti-PDL1 = atezolizumab
Grade 1 irAE = continue; Grade 2 = hold + steroids; Grade 3 = stop permanently + high-dose steroids; Grade 4 = ICU
Steroids: 1–2 mg/kg/day; taper over 4–6 weeks
Steroid-refractory colitis = infliximab
Hypothyroidism = most common endocrine irAE (usually permanent)
CAR-T: CRS → tocilizumab; ICANS → steroids
Patient education critical — report any new symptom; carry alert card

Practice MCQs

1. A patient on pembrolizumab develops Grade 2 colitis with 5 loose stools/day. The appropriate management is:

2. The most common endocrine irAE from checkpoint inhibitors is:

3. A patient receiving CAR-T therapy develops fever, hypotension, and hypoxia 2 days after infusion. The priority treatment is:

4. For steroid-refractory immune colitis from ipilimumab, the preferred second-line agent is:

Cancer Immunotherapy