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CHS19/156

Canberra Health ServicesClinical Procedure Immunotherapy Nursing Assessment of Toxicities (Adults Only)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Immune Oncology Triage Tool................................................................................3

Background........................................................................................................................... 3

Using the Tool.......................................................................................................................3

No Hospitalisation Required.................................................................................................3

Hospitalisation Required.......................................................................................................3

Implementation...................................................................................................................... 17

Related Policies, Procedures, Guidelines and Legislation.......................................................17

References.............................................................................................................................. 17

Search Terms.......................................................................................................................... 19

Attachments............................................................................................................................19

Attachment A – Immunotherapy Triage Letter for ED/RAU/Walk in Centre.......................21

Doc Number Version Issued Review Date Area Responsible PageCHS19/156 1 18/09/2019 01/08/2022 CAS 1 of 21

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

To guide and support Canberra Health Services (CHS) nursing staff in the assessment, triage and treatment of patients with suspected immune-related adverse events who are currently receiving immunotherapy agents.

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Alerts

This procedure is a guide only. Medical and nursing staff will make all decisions during the assessment and triage of a patient based on best practice using their own clinical judgement and will not rely solely upon this procedure.

This procedure aims to provide a timely assessment and review of patients admitted to the Canberra Hospital

The Oncology or Haematology treating team must be consulted prior to commencing corticosteroids. Dosage of steroids and route of administration will be based on severity of toxicity and discretion of treating physician.

All patients with a suspected immune-related adverse event require close and careful monitoring.

Grade 3 and grade 4 immune-related adverse events may require hospitalisation and close monitoring

Immune related adverse events (irAEs), including severe irAEs, are more common with combination anti-programmed death 1 (PD1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA4) immunotherapies (e.g. ipilimumab/nivolumab). There should be a high suspicion for irAEs in patients presenting with symptoms on combination immunotherapy, and a low threshold for assessing these patients in the Rapid Assessment Unit (RAU) given the heightened risk for severe irAEs.


Scope

This procedure applies to CHS, Canberra Region Cancer Centre (CRCC), RAU, and the Emergency Department (ED) and any Advanced Practice Nurse who triages patients with cancer including:

Nurse Practitioners, Advanced Practice Nurses and Registered Nurses who are working within their scope of practice and in accordance with CHS policies and procedures

Patients within scope:o Patients over the age of 18 yearso Haematology and Oncology patients.




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Section 1 – Immune Oncology Triage Tool

Background This tool has been designed as an appendix to the United Kingdom Oncology Nursing

Society (UK ONS) Oncology/Haematology Helpline Triage Tool noted below and currently in use in RAU at CHS.

The immune-oncology triage tool is designed to guide and support nursing staff to assess and triage patients with suspected immune-related adverse events who are currently receiving immunotherapy agents.

Using the Tool1. Patient will call or present to the ED or RAU with any symptoms or concerns. Patients

may present with the immunotherapy triage letter (see Attachment 1).2. The Advanced Practice Nurse or the Nurse Practitioner will proceed through the tool by

asking the patient the questions on the following topics: Diarrhoea/Gastrointestinal (GI) Skin/Mucosal Rheumatological/Musculoskeletal Endocrine Neurological Pulmonary Vision Mucosa Renal Hepatic

3. The patient’s answers are then graded by severity on a scale of 1-4 4. A decision regarding advice or further investigations and treatment is then made in

conjunction with the treating team.

No Hospitalisation RequiredBased on an agreed treatment plan with the patients’ treating team patients may receive: Advice over the phone and regular follow up phone calls Where further assessment and treatment is required, the patient will be informed to

present to the ED or RAU for assessment and treatment and be discharged the same day with regular follow up phone calls by the Cancer Specialist

Nurse or other members of the treating team.

Hospitalisation RequiredPatients will be admitted through the ED or RAU. In conjunction with the patient, the treating team will develop a plan of care and commence observation and treatment.



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Link to National Comprehensive Cancer Network (NCCN) Guidelines https://www.nccn.org/professionals/physician_gls/

Management of Immunotherapy-Related ToxicitiesToxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)Diarrhoea/ GIAre you experiencing: Any

diarrhoea? Increase in

bowel movements? If so, how many?

Watery stools?

Abdominal pain or cramping?

Any blood or mucous in stools?

Any nausea or vomiting?

2-4 stools above baseline assessment in 24 hrs Without symptoms of colitis*if any associated abdominal pain/ cramping or blood in stools WITH or WITHOUT diarrhoea proceed to grade 2 management

Advise patient to commence symptomatic treatment, loperamide and oral fluid replacement (Gastrolyte)

Stool culture to exclude infectious causes including microscopy, culture and sensitivity (MCS);

4-6 stools above baseline in 24 hrs Or Colitis: abdominal pain; blood or mucous in stoolPatient should attend ED or RAU for assessment

Stool culture to rule out infectious aetiologies including microscopy, culture and sensitivity (MCS); clostridium difficile toxin and faecal calprotectin (non-MBS item)

Contact treating team Commence oral

prednisolone Monitor daily with phone

calls, if no improvement in 2-3 days increase oral corticosteroids or consider other immunomodulatory agents (infliximab) in consultation with medical

At least 7 stools above baseline Or Colitis: severe abdominal pain

Contact treating team Commence high-dose IV

corticosteroids and if no response in 2 days treating team should consider other immunomodulatory agents (see NCCN guidelines)

Patient may require hospitalisation for supportive care

*Corticosteroids are contraindicated if GI perforation is present, which requires surgical review

Stool culture to rule out infectious aetiologies including microscopy, culture and sensitivity (MCS); clostridium difficile toxin and faecal calprotectin (non-MBS item)

Sigmoidoscopy/ Colonoscopy and

>7 stools above baseline in 24 hrs Or Colitis: life threatening diarrhoea, colitis or perforationUrgent intervention indicated

Hospitalisation indicated.

Manage as per grade 3, with urgent involvement of gastroenterologist

Additional immunosuppressive agents maybe required for steroid refractory cases, at the discretion of the treating oncologist.



https://www.nccn.org/professionals/physician_gls/

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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)clostridium difficile toxin

Follow up phone call in 24 AND 48hrs if persists for 3-5 days proceed to grade 2 management

oncology team (see NCCN guidelines) continued until symptoms resolve to grade 1 then tapered over 4 weeks.

biopsy may be indicated in consultation with gastroenterologist

Referral to dietician is recommended.

Once symptoms resolved to grade 1 steroid should be tapered over at least 4 weeks.

Skin Do you have

any new rashes?

Does your skin feel itchy (pruritis)?

Any blisters on skin; pain or tenderness over skin?

Any itch or rash/ lesions in mouth or genitals?

Any changes

Rash <10% of body surface area (BSA) Patients should be

advised to apply an emollient (QV, Cetaphil, Aveeno, Moo goo brands are available – patients will need to purchase these over the counter)

Administer oral antihistamine for pruritis and topical corticosteroids

Follow up phone call

Rash covering 10-30% of BSA

Full body assessment including oral mucosal assessment. If rash/ pruritis present in mouth, proceed to Grade 3 management

Symptomatic treatment with emollients, antihistamines and topical corticosteroids as per Grade 1.

Follow up phone call within 24hrs, if rash/ itch intolerable, patient should attend RAU for assessment

Rash covering >30% BSAAdvise patient to attend RAU

Commence corticosteroids (see NCCN Guidelines) tapered over 4 weeks once symptoms resolved to grade 1.

Consider Skin biopsy for rashes with blistering or full thickness dermal ulceration and dermatology consult

No formal definition – however life threatening if suspected Stevens-Johnson Syndrome or toxic epidermal necrolysis characterised by >30% BSA skin sloughing, erythema, epidermal detachment

Hospitalisation indicated with urgent referral to dermatologist



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)in pigmentation?

in 48hrs to check symptoms improving

and commencement of oral corticosteroids (see NCCN Guidelines) with 4 week taper.

Referral to dermatologist recommended

Urgent administration corticosteroids (see NCCN guidelines), tapered over 4 weeks once symptoms resolved to grade 1.

Endocrine Have you

noticed any change in sleeping pattern or fatigue level?

Any headaches?

Any changes in mood?

Any sweating? Have you felt

unusually thirsty?

Any confusion?

Have you felt dizzy or

Primary Adrenal Insufficiency:Symptoms may include: Chronic malaise Lassitude Fatigue that is worsened by exertion, improved with bed rest Generalised weakness not limited to particular muscle groups Anorexia Weight loss Hypotension, hyponatraemia, hyperkalaemia

Management: Patient to present to ED or RAU for assessment Adrenocorticotrophic Hormone (ACTH) and cortisol, check electrolytes if not already performed Referral to endocrine team



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)lightheaded?

Are you taking any steroids?

Symptomatic Hypothyroidism:Symptoms may include: Fatigue Weight gain Weakness Muscle cramps Course/ dry hair and skin Cold intolerance Constipation Depression

Management: Present to ED or RAU for assessment Contact treating team and commence thyroid replacement as needed* Advice from and referral to endocrinologist recommended

*Caution is needed: if patient has concomitant adrenal and thyroid insufficiency – replacement of thyroid hormones before adrenal hormones (cortisol) can precipitate an acute adrenal crisis.

Symptomatic Hyperthyroidism:Symptoms may include: Fatigue Insomnia Appetite change



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening) Weight loss Heart palpitations Heat intolerance Nervousness/ mood changes Tremor Dyspnoea Hair thinning Increased bowel movements

Management: Present to ED or RAU for assessment Contact treating team and commence anti-thyroid medication as needed Referral to endocrinologist recommended

Symptomatic Diabetes:Symptoms may include: Excessive weakness Polydipsia Polyuria Blurred vision Abdominal pain Mood changes Weight loss Tachycardia Hypothermia Hypotensive



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)

Management: Present to ED or RAU for assessment Contact treating team, and initiate insulin replacement if needed, close monitoring of blood glucose levels Referral to endocrinologist recommended

Suspected Hypophysitis:Symptoms may include: Headache Visual disturbances Polydipsia Polyuria Low ACTH, Low testosterone*, low TSH*Testosterone level can decrease in illness irrespective of pituitary function

Management: Present to ED or RAU for assessment Pathology including TSH, FT3, FT4, ACTH, Cortisol, FSH, LH and prolactin for females and males; add testosterone for

males Contact treating team, management with either corticosteroids or hormone replacement will depend on area of

inflammation (steroid replacement should occur prior to thyroid hormone replacement). MRI pituitary may be indicated Hospitalisation may be indicated depending on severity of symptoms

Neurological Any

unsteadiness or loss of

Mild symptoms: Fatigue Dizziness Unsteadiness

Moderate Symptoms: Fatigue Dizziness Unsteadiness

Moderate to severe symptoms impacting on ADL’s Advise patient to attend ED or

RAU or present to nearest

Severe symptoms, advise as per grade 3.



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)balance?

Any dizziness? Noticed any

difficulty gripping or dropping things?

Any numbness or tingling in hands or feet?

Any confusion?

Any headaches?

Any visual changes?

Any weakness in limbs?

Memory impairment Confusion Sensory changes Headache With no change in

instrumental ADL’s

Advise patient to attend ED or RAU

Notify treating team follow up possible

differential diagnosis of progression of disease

Consider referral to neurologist

Memory impairment Confusion Sensory changes Headache Which impact on day to day

activities (instrumental ADL’s)

Advise patient to attend ED or RAU and notify treating team

Consider referral to neurologist

Commence oral corticosteroids (see NCCN Guidelines)

emergency department and notify treating team.

Hospitalisation indicated and urgent referral to neurologist

Commencement of IV corticosteroids (see NCCN Guidelines)

Pulmonary Have you

noticed a dry cough or worsening dry cough?

Any shortness of breath?

Asymptomatic: clinical or diagnostic findings only

Pulse oximetry (resting and with movement)

Reassess in 1-2

New or worsening symptoms of dry cough, dyspnoea with or without fever, chest pain. Advise patient to attend ED

or RAU for assessment Consider infectious

workup: nasal swab, sputum culture

Severe symptoms of dyspnoea and dry cough, feverLife-threatening consequences urgent intervention needed, hospitalisation indicated,

Supportive oxygen therapy initiated

Severe symptoms of dyspnoea and dry cough, feverLife-threatening consequences urgent intervention needed, hospitalisation indicated, as per grade



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening) Any recent

radiotherapy that involved the lung field?

weeks Consider chest CT

with contrast

Contact treating team. If recent radiotherapy to lung, consider differential diagnosis of radiation induced pneumonitis.

High resolution CT chest Commencement of oral

corticosteroids (see NCCN Guidelines) tapering over 1 month once symptoms resolve to grade 1.

Consider Respiratory consult

*Patient will require follow up phone calls to ensure resolution of symptoms

Consider infectious workup: nasal swab, sputum culture

Contact treating team. If recent radiotherapy to lung, consider differential diagnosis of radiation induced pneumonitis. Commencement of IV corticosteroids (see NCCN Guidelines)

Consider Respiratory consult

Once symptoms return to baseline taper over at least 6 weeks to avoid rebound.

*Patient will require follow up phone calls post discharge to ensure continued improving symptoms

3

Vision Have you

noticed any changes in vision?

Any blurred vision?

Mild redness, pain, blurred vision, photophobia or other symptoms Advise patient to

attend ED or RAU for assessment, contact

Moderate symptoms of eye redness, pain, blurred vision, photophobia or other symptoms Advise patient to attend ED

or RAU for assessment, contact ophthalmologist

Moderate to severe symptoms as described in Grade 2. Patient at risk of permanent eye damage and blindness, urgent intervention indicated by ophthalmologist,

Severe symptoms as described in Grade 2. Patient at risk of permanent eye damage and blindness, urgent intervention indicated by



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening) Any eye pain? ophthalmologist on-

call for assessment and guidance on use of topical steroid eye drops

Phone call follow up to ensure resolution of symptoms

on-call for assessment, consider topical steroid eye

drops Phone call follow up to

ensure resolution of symptoms

topical steroid eye drops and systemic steroids indicated under guidance of oncology/ haematology treating team and opthamologist,

hospisation indicated

ophthalmologist,

topical steroid eye drops and systemic steroids indicated,

hospitalisation indicated

Mucosa Have you

noticed a dry mouth?

Mild mucosal dryness. check patient’s oral

hydration, educate on oral hygiene, use of artificial saliva spray, frequent sips of water, regular non-alcohol based mouthwashes.

No action required. Monitor at each follow up

Moderate dryness . some difficulty with mastication and swallowing food.

Advise patient to attend ED or RAU for assessment.

Referral to speech pathology and dietician recommended.

Moderate to severe dry mouth.Manage as per Grade 2.

Renal Have you

noticed any change in urination?

Frequency? Pain?

Creatinine elevated 1.5-2.0x baselineProteinuria 1+

Urinalysis for casts and protein

Exclude other causes,

Creatinine elevated 2 to 3 x baselineProteinuria 2+

Advise pt to attend ED or RAU

Urinalysis for casts and

Creatinine elevated 3.0 to 6.0 x baseline

Advise pt to attend ED or RAU Urinalysis for casts and protein,

consider hydration status and nephrotoxic medications

Creatinine >6.0 x baseline

Manage as per Grade 3

Hospitalisation and dialysis indicated



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)consider hydration status and nephrotoxic medications

Notify treating team of change in creatinine,

Advise patient to promote oral hydration

weekly monitoring of creatinine and urine protein

protein, consider hydration status and nephrotoxic medications

Notify treating team Monitor creatinine every 2-

3 days Referral to nephrologist –

consider renal biopsy Commence oral

corticosteroids (see NCCN Guidelines)

Notify treating team Monitor creatinine daily commence IV corticosteroids

(see NCCN Guidelines) Referral to nephrologist –

consider renal biopsy

Urgent Nephrology consult

Hepatic*Usually asymptomatic, check when patient last had LFT’s

AST/ ALT >1 to 3 x ULN and/ or Total Bilirubin >1 to 1.5 x ULN Notify treating team Monitor LFT’s weekly,

if LFT’s deteriorate or patient is unwell proceed to grade 2

Rule out infection, viral etiology, disease-related hepatic dysfunction or drug induced dysfunction

AST/ ALT 3-5 x ULN, total bilirubin >1.5-3 x ULN Advise patient to attend

RAU Evaluate to exclude other

causes of hepatic injury Notify treating team If persists more than 3-5

days commence oral corticosteroids (see NCCN Guidelines)

Monitor LFT’s every 5 days, if persisting treat as grade 3.

AST/ ALT >5 X ULN, bilirubin >3 x ULN Advise patient to attend RAU or

closest ED immediately contact treating team and initiate

IV corticosteroids (see NCCN Guidelines)

Hospitalisation may be indicated Referral to Gastroenterologist/

Hepatologist

AST/ ALT >20 X ULN

Manage as per Grade 3Hospitalisation indicated



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening) Assess dietary

supplement use, alcohol use and paracetamol use

Musculoskeletal

Arthralgia: Have you had

any joint pain or swelling, stiffness after inactivity?

Myalgias/ Myositis: Any pain or

tenderness in

Mild symptoms not affecting ADL’s Assess number of

joints involved, Advise to use NSAIDS,

heat packs to affected areas

Monitor with follow up phone call in 48hrs

Please refer to NCCN Guidelines for further information

Ask patient to attend ED or RAU for assessment

Consider monitoring serial aldolase/

Moderate symptoms affecting ADL’s Assess number of joints

involved Contact treating team as

patient may require oral corticosteroids until symptoms <grade 1 then taper over 4-6 weeks

Monitor with follow up phone call in 48hrs if no improvement, notify treating team and consider referral to rheumatology


Monitor serial aldolase/ creatine kinase

Contact treating team as

Moderate to severe symptoms affecting ADL’s Assess number of joints involved Contact treating team Patient will require high dose

corticosteroids and regular analgesia

Rheumatology consultation advised if no improvement by week 2

Patient may require hospitalisation


Contact treating team Monitor serial aldolase/ creatine

kinase until symptoms resolve

Severe symptoms affecting ADL’s Assess number of

joints involved Contact treating

team Patient will require

high dose corticosteroids and regular analgesia

Rheumatology consultation advised if no improvement by week 2



Contact treating team



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)your muscles?

Any muscle weakness?

creatine kinase Advise patient to use

pain analgesia as required

Phone call follow up in 48hrs to assess symptoms

patient will require oral corticosteroids

Pain analgesia Phone call follow up in

48hrs to assess symptoms

Oral corticosteroids or IV equivalent

Consider muscle MRI and EMG Consider muscle biopsy Patient may require

hospitalisation Consider rheumatology or

neurology referral

Monitor serial aldolase/ creatine kinase until symptoms resolve

Oral corticosteroids or IV equivalent

Consider muscle MRI and EMG

Consider muscle biopsy


Consider rheumatology or neurology referral

Cardiovascular Any chest

pain? Does the

pain get worse on breathing in?

Any shortness of breath?

Any heart palpitations

Advise patient to attend emergency departmentSee NCCN Guidelines for detailed assessment and grading requirements

Will require cardiology consultationECG, Cardiac biomarkers including Creatine Kinase and troponinInflammatory biomarkers including ESR, CRP, WBC count,Cardiac MRIIf severe Grade 3 or 4 will require hospitalisation and high dose steroids



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Toxicity 1 (mild) 2 (moderate) 3 (severe) 4 (life-threatening)or feelings of racing heart?

Any low grade fever?

Any fatigue? Any swelling

in legs?




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Implementation

The procedure will be implemented through the following: Communication at Department meetings Tabled at Division of Cancer and Ambulatory Support (CAS) Clinical Governance

Committee Included in the CAS UpdatED Newsletter CHS Policy Alerts to all CHS staff.

Related Policies, Procedures, Guidelines and Legislation

Policies Consent and Treatment Medication Handling Policy

Procedures CHS Healthcare Associated Infections Clinical Procedure CHS Patient Identification and Procedure Matching Policy

GuidelinesNational Comprehensive Cancer Network (NCCN) Guidelines https://www.nccn.org/professionals/physician_gls/

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011 Medication, Poisons and Therapeutic Goods Act (2008)


References

1. Andrews, S., & Holden, R. (2012). Characteristics and management of immune-related adverse effects associated with ipilimumab, a new immunotherapy for metastatic melanoma. Cancer Management and Research, 4, 299-307. DOI: 10.2147/CMAR.S1873.

2. Bartell, H., Wolchok, J., Hodi, S., Liu, H., Wojtaszek, C., & Weber, J. (2015). Immuno-oncology safety education experience: key lessons from ipilimumab (IPI). From the 30th Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2015) National Harbor, MD, USA. 4-8 November 2015. Retrieved from Journal for Immunotherapy of Cancer, 3, (2), 384. Doi: 10.1186/2051-1426-3-S2-P384.

3. EviQ: Cancer Treatments Online. (2016). Management of immune-related adverse events (irAEs). Approved 6th December 2016, retrieved from http: //www.eviq.org.au

4. Cancer Research UK. (2015). How long a new drug takes to go through clinical trials. Retrieved from Cancer Research UK website: http://www.cancerresearchuk.org/about-



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cancer/find-a-clinical-trial/how-clinical-trials-are-planned-and-organised/how-long-it-takes-for-a-new-drug-to-go-through-clinical-trials

5. Caturegli , P., Newschaffer, C., Olivi, A., Pomper, M.G., Burger, P.C., & Rose, N.R. (2011). Autoimmune Hypophysitis. Endocrine Reviews, 26,(5), DOI: http://dx.doi.org/10.1210/er.2004-0011.

6. Eigentler, T.K., Hassel, J.C., Berking, C., Aberle, J., Bachmann, O., Grunwald, V…Gutzmer, R. (2016). Diagnosis, monitoring and management of immune-related adverse drug reactions of anti-PD-1 antibody therapy. Cancer Treatment Reviews, 45, 7-18. Doi: 10.1016/j.ctrv.2016.02.003

7. Haanen, J.B.A.G., Van Thienen, H., & Blank, C.U. (2015). Toxicity patterns with immunomodulating antibodies and their combinations. Seminars in Oncology, 42, (3), 423-428. Doi:10.1053/j.seminoncol.2015.02.011.

8. Haanen, J.B.A.G., Carbonnel, F., Robert, C., Kerr, K.M., Peters, S., Larkin, J., Jordan, K. (2017). Management of toxicities from immunotherapy: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 28, (4), iv119-iv142. DOI: 10.1093/annonc/mdx225

9. Howell M; Lee R; Bowyer S; Fusi A; Lorigan P.(2015). Optimal management of immune-related toxicities associated with checkpoint inhibitors in lung cancer. Lung Cancer. 88(2):117-23.

10. Ivashko, I.N., & Kolesar, J.M. (2016). Pembrolizumab and nivolumab: PD-1 inhibitors for advanced melanoma. American Journal of Health-System Pharmacy, 73, (4), p 193-201. Doi: 10.2146/ajhp140768

11. Kannan, R., Madden, K., & Andrews, S. (2014). Primer on immune-oncology and immune response. Clinical Journal of Oncology Nursing, 18, (3), 311-317. Doi: 10.1188/14.CJON.311-317

12. Ledezma, B., & Heng, A. (2014). Real-world impact of education: treating patients with ipilimumab in a community practice setting. Cancer Management and Research, 6, 5-14. Doi: 10.2147/CMAR.S52543.

13. Lomax, A., Nielsen, T., Visintin, L., O’Carrigan, B., Honeyball, F., Shum, B., Saw, R.P.M., McNeil, C. 2017. Clinical Nurse Consultant Support: Management of patients with melanoma receiving immunotherapy and targeted therapy. Clinical Journal of Oncology Nursing. 21 (2), ppE93-E98. Doi: 10.1188/17.CJON.E93-E98.

14. Michot, J.M., Bigenwald, C., Champiat, S., Collins, M., Carbonnel, F., Postel-Vinay, S.Lambotte, O. (2015). Immune-related adverse events with immune checkpoint blockade: a comprehensive review. European Journal of Cancer, 54, 139-148. Doi: 10.1016/j.ejca.2015.11.016

15. National Cancer Institute. (2010). Common Terminology Criteria for Adverse Events (CTCAE) version 4.03. Retrieved from the National Institutes of Health website: https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=CTCAE&commit=Search

16. Pasquali, S., Kefford, R., Chiarion Sileni, V., Nitti, D., Rossi, C.R., Pilati, P & Mocellin, S. (2014). Systemic treatments for metastatic cutaneous melanoma (protocol), Cochrane Database of Systematic Reviews, 5, (CD011123). Doi: 10.1002/14651858.CD011123.

17. Redman, J.M., Gibney, G.T., & Atkins, M.B. (2016). Advances in immunotherapy for melanoma. BMC Medicine, 14, (20), 1-11. Doi: 10.1186/s12916-016-0571-0



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http://press.endocrine.org/action/doSearch?text1=Rose%2C+Noel+R&field1=Contrib

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18. Reimschissel, E., Dela Cruz, B., Gonzales, M., Buitrago, J., Goodman, C. & Johnston, P.A. 2017. Immunotherapy Toxicities: A new electronic documentation template to improve patient care. Clinical Journal of Oncology Nursing. 21, (2), pp 41-44. Doi: 10.1188/17.CJON.S2.41-44.

19. Rubin, K. 2017. Advances in melanoma: The rationale for the Melanoma Nursing Initiative. Clinical Journal of Oncology Nursing. 21, (4), pp7-10. Doi: 10.1188/17.CJON.S4.7-10

20. Spain, L., Diem, S., & Larkin, J. (2015). Management of toxicities of immune checkpoint inhibitors. Cancer Treatment Reviews, 44, 51-60. Doi: 10.1016/j.ctrv.2016.02.001.

21. Thompson, J., Schneider, B., Brahma, J., Andrews, S., Armand, P., Davies, M…Wolchok, J. 2018 NCCN Guidelines Management of immunotherapy-related toxicities. Version 1 retrieved 21 march 2018 from http://www.nccn.org

22. Thompson, J., Schneider, B., Brahma, J., Andrews, S., Armand, P., Bhatia, S. 2019. Management of Immunotherapy Related Toxicities. Journal of the National Comprehensive Cancer Network. 17, (3), pp.255-289. Doi:10.6004/jnccn.2019.0013

23. Villadolid, J., & Amin, A. (2015). Immune checkpoint inhibitors in clinical practice: update on management of immune-related toxicities. Translational Lung Cancer Research, 4 (5), 560-575.


Search Terms

Immunotherapy, Toxicities, Immunotherapy: Nursing Assessment of Toxicities, Immune-related adverse events, Rapid Assessment Unit.

Attachments

Attachment A – Immunotherapy Triage Letter for ED/RAU/Walk in Centre



http://www.nccn.org/

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Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 17/07/2019 Complete Review Cathie O’Neill, ED CAS CHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS17/051 Immunotherapy Nursing Assessment of Toxicities (Adults Only)



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Attachment A – Immunotherapy Triage Letter for ED/RAU/Walk in Centre

Attention: Treating Clinician in ED, RAU/ Walk-In Centre

The following patient …………………………………………………… is on Immunotherapy called …………………….

Immunotherapy is a type of cancer treatment that helps your immune system fight cancer. This is NOT Chemotherapy. Immunotherapies can cause inflammation in healthy tissue in any part of the body. Immune-related adverse events (irAE’s) above grade 3 can be life-threatening and fatal if untreated. Unlike chemotherapy, management for toxicities associated with immunotherapies often involve early initiation of corticosteroids depending on grade of irAE*.

If the patient has any of the following:Gastrointestinal Diarrhoea

Abdominal pain Fever Blood or mucous in stool

Liver AST or ALT 3-5 times > ULN Bilirubin >1.5 ULN

Endocrine Moderate to severe symptoms of fatigue, headache, changes in mental status, hypotension, abnormal TFT’s, increase in thirst or urine output, low cortisol

Pulmonary Dry cough, fine inspiratory crackles, dyspnoea

Skin Moderate to severe diffuse rash covering > 30% body surface area

Neurologic Moderate to severe neurological symptoms impacting on ADL’sRenal Decreased urinary output, elevated creatinineOcular Any eye redness, pain, blurred vision or photophobiaMusculoskeletal Severe joint, muscle pain affecting ADL’sCardiac Immune-mediated myocarditis is rare - testing for serum troponin and CK may

be required on discussion with the treating team

If you suspect any of the above please contact the patients’ treating team below:



Surname:Given Name:DOB: Sex:Address:

Oncologist: …………………………………………………………………………………………………………………Cancer Specialist Nurse: ……………………………………………………………………………………………..After hours: Contact the Medical Oncology registrar on-call at the Canberra Hospital, via switch 9.

Documents

| Health - Adults Only.docx · Web viewCardiac biomarkers including Creatine Kinase and troponin Inflammatory biomarkers including ESR, CRP, WBC count, Cardiac MRI If severe Grade