Optimization of Immune Checkpoint Inhibitor Immune Related Adverse Event Management in the Acute Care Setting: A Quality Improvement Project

Pharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Patients receiving immune checkpoint inhibitor (ICI) medications are at risk of auto-inflammatory toxicities called immune related adverse events (irAEs). Although rare, these irAEs can be very different in presentation, severity, onset and duration and studies have indicated that early recognition and prompt appropriate treatment with systemic corticosteroids is essential to improve patient outcomes. The primary objective of this research project was to assess historical management of irAEs at the Kingston Health Sciences Centre (KHSC), Kingston General Hospital (KGH) site and identify toxicity management trends that would assist recommendations for future clinical support tools for toxicity management. This was a single-centre retrospective chart review of patients who experienced an irAE within 6 months of being on an ICI, conducted at the KHSC KGH site from December 2017 to May 2020. Compliance with the Cancer Care Ontario (CCO) Immune Checkpoint Inhibitor Toxicity Management Clinical Practice Guideline, time to corticosteroid order and administration as well as time to irAE toxicity resolution was assessed. Results showed there were inconsistencies with corticosteroid dosing in accordance with the CCO Immune Checkpoint Inhibitor Toxicity Management Clinical Practice Guideline for patients admitted to the acute care setting, most commonly sub- therapeutic dosing, which may have led to delay in toxicity resolution and readmissions to the hospital. Patients admitted through the Cancer Centre of Southeastern Ontario (CCSEO) appeared to have faster time to irAE diagnosis (often through scheduled oncology ambulatory follow-up visits) and faster time to corticosteroid order than those presenting to the Emergency Department (ED), but similar time from corticosteroid order to first corticosteroid dose administration. Recurrent or unresolved irAEs from ICI medications were common, as 55.2% of patients had a prior irAE, and of these patients 75% were on a corticosteroid at home prior to admission. Immune related adverse events (irAEs) can be difficult to diagnose, which may lead to delays in toxicity management for patients admitted through both the ED and the Cancer Centre of South Eastern Ontario (CCSEO). Clinical support tools for irAE identification and management with clear direction on diagnostic laboratory investigations, corticosteroid dosing guidance based on toxicity type and toxicity severity and first corticosteroid dose to be administered immediately would be beneficial to help manage current gaps in patient care and improve patient outcomes for those who experience irAEs