Immune-Related Adverse Event (irAE) Management

Immune-Related Adverse Event (irAE) Management: overview

This algorithm is a grade-based scaffold for managing immune-related adverse events in patients receiving checkpoint inhibitors (ICI); it is educational and not an order set. Grade 1 toxicity is managed by continuing the ICI with monitoring and supportive care. Grade 2 toxicity calls for holding the ICI and starting prednisone 0.5 to 1 mg/kg, with resumption once the event returns to grade 1 or lower. Grade 3 toxicity requires holding or discontinuing the ICI and giving methylprednisolone 1 to 2 mg/kg; if there is no improvement within 48 to 72 hours, second-line immunosuppression with infliximab or mycophenolate mofetil is added. Grade 4 toxicity requires permanent discontinuation of the ICI, IV methylprednisolone 1 to 2 mg/kg, and specialist involvement.

Two special cases are separated out. Myocarditis is treated as a medical emergency with high-dose steroids and permanent discontinuation. Endocrine irAEs are managed with hormone replacement and usually do not require stopping the checkpoint inhibitor. The general principle is grade-driven corticosteroids, with early escalation to second-line immunosuppression for steroid-refractory cases. No specific trials are linked to this chart.

Background reading: Immune Checkpoint Inhibitor Toxicity (irAEs) board review notes.

Immune-Related Adverse Event (irAE) Management: the algorithm in words

Grade-based management of checkpoint-inhibitor toxicity. Educational scaffold: not an order set. Starting point: Immune-related adverse event on checkpoint inhibitor. Full background: Immune Checkpoint Inhibitor Toxicity (irAEs) notes.

Grade 1 (first-line): Mild: Continue ICI + monitor (supportive care).
Grade 2 (first-line): Moderate: Hold ICI; prednisone 0.5-1 mg/kg (resume when ≤ grade 1).
Grade 3 (first-line): Severe: Hold/d-c ICI; methylpred 1-2 mg/kg (if no improvement 48-72h → infliximab / MMF).
Grade 4 (first-line): Life-threatening: Permanently discontinue ICI (IV methylpred 1-2 mg/kg + specialist).
Special cases (first-line): Myocarditis: High-dose steroids + permanent d-c (medical emergency); Endocrine: Hormone replacement (may continue ICI).

Simplified board-prep scaffold; verify against current guidelines and primary literature. General principle: grade-driven steroids; steroid-refractory cases need early second-line immunosuppression. Endocrine irAEs are managed with hormone replacement and usually do not require stopping the checkpoint inhibitor.