To assist in treating patients with immune-related adverse events (irAEs), nurses can follow 5 pillars: prevent, anticipate, detect, treat, and monitor.
“To go through your role, really talking about what framework you can use as nurses in oncology to help manage the toxicity profile that your patients have, I really like the Champlat et al model, which goes through the 5 pillars of management of immunotherapy,” Marianne Davies, DNP, RN, CNS, ACNP-BC, AOCNP, who is an associate professor and oncology nurse practitioner at the Yale Comprehensive Cancer Center, said during a presentation at the 3rd Annual School of Nursing Oncology. “It can help guide your practice.”
The first part to preventing irAEs is to evaluate patients for autoimmune risks before starting treatment. These can include Addison’s disease, celiac disease, Crohn’s disease, Grave’s disease, Hashimoto’s thyroiditis, multiple sclerosis, myasthenia gravis, pernicious anemia, rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus, type 1 diabetes, and ulcerative colitis.
In addition, nurses should be aware of patients who have had any prior organ transplantations or hematopoietic stem cell transplantation for the potential risk of graft rejection.
Nurses should also be prepared for medication reconciliation, which includes over-the-counter drugs and herb supplements.
“There are several levels of prevention or preparing patients for treatment,” Davies said. “One of the key ones is that your institution needs to be behind you and provide appropriate resources to help you manage your patients that are on therapy.”
The next pillar is how nurses can anticipate irAEs through assessment at baseline, during treatment, and after treatment. Assessments can include a review of systems, physical examinations, and laboratory evaluations for complete blood count, a comprehensive metabolic panel, and a thyroid panel.
“How do we prevent toxicities for patients, or prepare to be able to best manage those? That is by understanding not only the mechanism of action of the checkpoint inhibitors, but also understanding how we manage each of the specific toxicities,” Davies said, adding that patients also have a responsibility when it comes to anticipating irAEs.
“Patients need to be encouraged and instructed to report any new symptoms that they do have because even subtle symptoms may be an immune-related toxicity and that is really important for us to understand. The earlier we can manage the toxicity, most often, these patients can successfully go on to continue on that therapy. So, we need to encourage and educate our patients of that.”
Similar to anticipation, both the healthcare providers and the patients play a role in detecting irAEs.
Healthcare providers should conduct regular monitoring of the patients, using standardized irAE assessment checklists, telephone triages, and toxicity management guidelines. In addition, nurses should be sure to always rule out any other cause of toxicity. Lastly, they should assess and monitor the kinetics of the toxicity after it is treated.
Following these steps, the healthcare team is then responsible for determining the need for hospitalization or ambulatory care.
On the other hand, treatment with immunotherapy requires patients to have close communication with their healthcare providers. They should report any new signs or symptoms they develop, as well as if they have been seen by any other healthcare provider or were admitted to the hospital for an irAE.
After detecting irAEs, the next pillar is to actually treat the toxicity. To do so, Davies offered various sources that nurses can utilize for reference, including guidelines from the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), the Society for Immunotherapy of Cancer (SITC), and the AiM with Immunotherapy Foundation.
Similar to detection, when monitoring irAEs, healthcare providers must monitor the kinetics of the toxicity. In addition, nurses should monitor for resolution of the toxicity, complications of the immune suppressant drugs, and treatment response.
“Communication is the essential thread,” Davies said, adding that the multidisciplinary team plays a key role in managing irAEs. “Some other key things we can do is helping to identify ‘IO champions’ within your facility that can help be there and be a resource to you as you are going through this.”