Presenter: Christin M. Molnar, PharmD, BCOP, Cancer & Hematology Centers of Western Michigan, Grand Rapids, MI
BACKGROUND: Immune-related adverse events (irAEs) are a known risk with immune checkpoint inhibitor (ICI) therapy that may lead to significant morbidity and/or mortality in patients. The use of ICI therapies is widespread across many tumor types, which presents an opportunity for interdisciplinary collaboration to ensure safe and effective use. Patients with higher-grade irAEs may be initiated on systemic corticosteroid therapy to mitigate the adverse events (AEs). The proper management of patients throughout their corticosteroid course is essential; this includes upfront education on the potential AEs of corticosteroid therapy, routine reassessment and regrading of the irAE, potential escalation of care, and the initiation of corticosteroid tapering when appropriate. At Cancer & Hematology Centers of Western Michigan, a community oncology practice with 5 clinic locations, we identified a need for standardization and optimization of this process for our patient population.
OBJECTIVE: To standardize the use of corticosteroids for irAEs to ensure safe and effective use practice-wide.
METHOD: An interdisciplinary team was formed in late 2021 with the goal of assessing and improving the care provided to patients receiving ICI therapies. The team included a physician, a registered nurse, and a pharmacist. The team designed a regimen within the electronic medical record (EMR); this was to be assigned to any patient prescribed systemic corticosteroids for an irAE. The regimen included the corticosteroid order, supportive-care medications at appropriate intervals, scheduled nurse telehealth visits, and scheduled provider (physician or advanced practice provider) visits. In addition, a standard note template for nurse telehealth visits was developed to ensure consistent documentation. After the regimen was built within the EMR, education and training were provided to all clinical staff to ensure an understanding of the new protocol.
RESULTS: The regimen went active on September 26, 2022. In a 2-month period, the regimen was initiated for 21 patients who were prescribed a systemic corticosteroid for an irAE. The most common irAEs were hepatotoxicity (N = 6), diarrhea/colitis (N = 4), and pneumonitis (N = 3). Of the 70 scheduled nurse telehealth assessments, 58 (82.9%) were completed. The standard documentation template was appropriately used in 35 (60.3%) of the 58 encounters.
CONCLUSION: Managing irAEs is a complex process requiring interdisciplinary collaboration. With this initiative, we implemented a method by which a practice such as ours can more effectively manage patients requiring systemic corticosteroids for an irAE. To date, we have identified additional opportunities for improvement, such as ensuring that all assessments and documentation occur per protocol.
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