Management of the adverse effects of cancer immunotherapy with a focus on the gastrointestinal and hepatic systems

Background: Immunotherapy has become established as a new cancer treatment that enhances patients’ immune systems’ ability to fight cancer. Immune checkpoint inhibitors (ICI) have demonstrated remarkable benefits in the treatment of a range of cancer types. The increasing use of immune-based therapies has exposed a discrete group of immune-related adverse effects. Effective recognition and treatment of ICI-induced toxicities have emerged as essential goals of ICI management.Current Concepts: Gastrointestinal (GI) and hepatic adverse effects of ICI treatment are relatively common. Immune-related GI or hepatic toxicities occur in approximately 30% of patients. The incidence of grade 3 or 4 adverse effects ranges from 0.5% to 2%. The management strategy for immune-related adverse effects depends on their severity. In general, ICI treatment can be continued with close monitoring for mild (grade 1) GI/hepatic toxicities. ICI treatment should be interrupted for most grade 2 to 4 toxicities, and systemic steroid administration is recommended. If steroids are ineffective, immunosuppressive agents such as infliximab may be used. When symptoms and laboratory values revert to grade 1 or less, ICI treatment may be resumed with caution. Grade 4 toxicities warrant permanent discontinuation of ICI treatment.Discussion and Conclusion: Most immune-related GI and hepatic adverse effects are mild to moderate in severity and can be managed with supportive care, steroid therapy, and other immunomodulatory agents. Management of ICI-related toxicities in the GI and hepatic systems requires close collaboration between the patient, the treating oncologist, and other specialists.