Evaluation of emergency department visits and immune-related adverse effects (irAEs) in patients treated with nivolumab

Abstract

Abstract Introduction : One of the most important innovations in cancer treatment is the development of immune checkpoint inhibitors (ICI) in the last decade. Nivolumab which is one of ICI is used in many cancer treatments. As with any drug, this drug also have some side effects including the class-spesific immune-related adverse effects (irAEs). Although irAE is not rare, it is challenging to diagnose. Therefore, we examined the emergency department (ED) visits of patients receiving nivolumab therapy. In addition to previous studies, this study aims to evaluate the irAE management, diagnostic difficulties and outcome of irAEs in the ED. Material and Methods A retrospective cohort study was conducted on adult patients who received nivolumab therapy for any cancer between 1 April 2018 and 31 March 2023 at a large, urban tertiary care center. In this study we evaluated the ED visits of patients receiving nivolumab. In adddition to previous studies, we evaluated irAEs in detail (percentage, recognizability, risk factors, reasons for late recognition and outcome). Patient data was collected from electronic medical records and patient’s medical files. The anamnesis, laboratory, and imaging results, ED management, and consultation notes were examined separately for each ED visit. Logistic regression models were used to identify significant univariable predictors of ED visit and irAEs. Results One hundred ninety-nine patients were included in the study. All patients had metastatic cancer, and 154 patients (77.4%) received nivolumab therapy for non-small cell lung cancer. Most patients (71.9%, n = 143) had at least one additional comorbidity. One hundred and eleven patients (55.8%) presented to the ED. Hypertension (OR: 2.425, 95% CI: 1.226–4.795, p = 0.011) and chronic obstructive pulmonary disease (OR: 2.489, 95% CI: 1.133–5.468, p = 0.023) are risk factors for presenting ED. Twenty-one visits were diagnosed (14 in ED, 6 in the oncology clinic, and 1 in the ward) as irAEs. The univariate analysis found no association between irAE diagnosis and any factors. Conclusion A significant part of the patients treated with nivolumab for advanced cancer presents to ED for ICI-related adverse events, although most cases were unrelated to irAEs. Close collaboration between ED physicians and oncologist is paramount to management of patients with cancer in the ED.