Background/Purpose:
The growing use of cancer immunotherapy and checkpoint inhibitors has led to a steep rise in immune-related adverse events (irAEs). Despite expanding research efforts, definitive methods of predicting irAE onset or severity and reliable therapeutic approaches beyond steroids are lacking. Evaluation and management of irAEs requires a multidisciplinary approach. At the University of Chicago, we have developed a dedicated irAE pilot clinic with the aim to facilitate diagnosis and management for irAE patients in a timely fashion.

Methods:
The pilot clinic was run by Rheumatology over seven months with one hour per week dedicated to new or follow up irAE patient visits. No limit was placed on organ involvement so a wide breadth of complications was observed and treated. The indications for referral included: irAE refractory to steroids with possible need for steroid sparing immunosuppression (IS), high severity irAE needing early steroid-sparing agent, and concern for any Rheumatologic irAE. Referrals were placed through an order in our electronic medical record system. Physicians were informed about the irAE clinic through multiple presentations at Hematology-Oncology grand rounds and fellow rounds and Internal Medicine conferences. In addition to the primary irAE clinic, we have developed a network of specified “point person” physicians within various medical subspecialties (Hepatology, Dermatology, Pulmonary, Nephrology, Neurology) to coordinate diagnostic procedures and discuss therapeutic options in each case.

Results:
A total of fifteen new patients were evaluated; eight of these required more than one follow up. Oncologists referred twelve patients and three were new referrals after hospital discharge. Most of the patients were seen for possible Rheumatologic irAE (40%). About 33% were seen for irAE refractory to steroids and 27% for high severity irAE requiring Rheumatology assistance for steroid-sparing IS. Malignancy history ranged from melanoma, non-small cell lung cancer to gynecologic tumors. Patients were able to be seen within an average of 7 days (0-19 days) and 93% of the Oncologists noted utilization of and followed Rheumatology recommendations in patient’s care. Of the evaluated patients, 3 were ruled out for irAE. The irAEs diagnosed included the following: 2 arthritis, 1 vasculitis, 1 myocarditis, 1 dermatitis, 3 pneumonitis, 2 hepatitis and 2 neurologic. Of those with irAEs diagnosed, 8 had serologies checked and all had some antibody positivity (5 of 8 with ANA >1:160, 2 with RF positive (1 also with CCP positive), 1 ANCA positive). The patient with dermatitis had eosinophilia on differential and 40% of patients with diagnoses of irAE had lymphopenia on their differential (patient without irAE did not have abnormality on differential).

Conclusion:
A dedicated irAE clinic can help Oncologists streamline care of their high risk patients resulting in more efficient and effective care for challenging cases. In addition, creation of an irAE clinic cohort allows for trends to be identified such as the development of lymphopenia in association with irAE, serological findings, and which steroid-sparing strategies are most effective.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/immune-related-adverse-events-development-of-a-pilot-immune-related-adverse-events-clinic-for-expedited-and-effective-patient-care/