Critical Analysis of Immune Checkpoint Inhibitor Immunotoxicity Management

Immune checkpoint inhibitors are a revolution in cancer treatment, having a better toxicity profile than chemotherapy. However, many mechanisms and management of immune-related adverse events are still unknown, and guidelines are a crucial tool to take clinical decisions. However, even the most recent guidelines lack information about alternative treatments for steroid-refractory immune-related adverse events, safety in special populations, biomarkers and therapy reinstitution. The aim of this article is to review the management of immune checkpoint inhibitors immunotoxicity and analyse the possible gaps in the clinical practice guidelines. Search on PubMed, Scopus and Clarivate Analytics of articles related to immune-related adverse events’ management. The summary of product characteristics of each immune checkpoint inhibitor approved by EMA and/or FDA was also considered. Based on this general literature search, an analysis of what is included in the most cited guidelines was made. Overall, 83 records were included in the descriptive review. The least developed topics in guidelines that are important to consider in future versions of the guidelines are the conditions to reinstitute immunotherapy after adverse events, possible biomarkers useful for clinical practice, if special populations such as patients with prior autoimmune diseases and elderly are eligible for treatment and options in the management of steroid-refractory adverse events. Furthermore, the grading system used for immunotoxicity classification may underestimate toxicity, and it is not optimized for immunotherapy. Clinical practice guidelines need to be updated and include information about special populations, biomarkers, treatment reinstitution and steroid-refractory immune adverse events.