Oncologic therapy related adverse events

Background

Many of the oncologic therapies currently employed involved immune system checkpoint inhibition which allow for improvement of T-cell activation towards cancer cells. This boost to the immune system can occur by many mechanisms that encompass the list of "novel" oncologic agents" described below.[1]

Clinical Features

  • Many novel oncologic therapies and Biologic immunomodulators adverse reactions may mimic common ED presentations such as sepsis.

Types of novel oncologic agents

  • Genetically engineered T cells
    • CD19–chimeric antigen receptor (CAR)-T cell therapy
  • Monoclonal Antibodies against PD-1 checkpoints
  • Small-molecule inhibitors
  • Monoclonal antibodies against cell surface antigens
  • Antibody-drug conjugates
  • Immunotoxins
  • Bispecific T-cell engagers

Differential Diagnosis


CAR-T cells medications

Tisagenlecleucel (Kymriah)

Axicabtagene ciloleucel (Yescarta)

PD1 Monoclonal Antibodies

Pembrolizumab (Keytruda)

  • A PD-1 humanized mouse mAb
  • Adverse events include:
    • Infusion reactions
    • Musculoskeletal pain
    • Dyspnea
    • Diarrhea
  • (Arrhythmias
  • (Myocardial infarctions
  • (Pericardial effusions

Nivolumab (OPDIVO)


Small molecule inhibitors

Enasidenib (IDHIFA)


Ivosidenib (Tibsovo)

Midostaurin (Rydapt)

Nilotinib (Tasigna)

  • Adverse events
    • QT prolongation
    • Sudden death
    • Myelosuppression
    • Arterial thrombosis
    • Pancreatitis
    • Hepatotoxicity

Bosutinib (Bosulif)

  • Adverse Events:
    • Myelosuppression
    • Diarrhea
    • Pancreatitis
    • Hepatotoxicity
    • Cardiac arrest
    • Arrythmia
    • ACS

Ibrutinib (Imbruvica)


Acalabrutinib (Calquence)

Duvelisib (Copiktra)

  • Adverse Events:

Copanlisib (Aliqopa)


Panobinostat lactate (Farydak)

  • Adverse Events:

Ixazomib citrate (Ninlaro)

Venetoclax (Venclexta)

Monoclonal antibodies against cell surface antigens

Ofatumumab (Arzerra)


Obinutuzumab (Gazyva)


Daratumumab (Darzalex)

Elotuzumab (Empliciti)

Empliciti (Poteligeo)

Antibody-drug conjugates

Inotuzumab ozogamicin (Besponsa)


Gemtuzumab ozogamicin (Mylotarg)

Brentuximab vedotin (Adcetris)

Immunotoxin

Moxetumomab pasudotox-tdfk (Lumoxiti)

Bispecific T-cell engager (Blincyto)

Blinatumomab

Disposition

  • Most of these patients should be admitted and coordination should occur with hematology/oncology

See Also


References

  1. Shah, M., Rajha, E., DiNardo, C., Muckey, E., Wierda, W. G., & Yeung, S. C. J. (2020). Adverse Events of Novel Therapies for Hematologic Malignancies: What Emergency Physicians Should Know. Annals of Emergency Medicine, 75(2), 264–286. https://doi.org/10.1016/j.annemergmed.2019.07.015
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