背景:免疫检查点抑制剂(ICIs)的发展代表了过去十年癌症治疗中最重要的进步之一。Nivolumab,一种广泛使用的ICI,已被纳入各种癌症的治疗方案中。和任何药物一样,这种药物也有副作用,包括类特异性免疫相关不良反应(irAEs)。虽然irAE并不罕见,他们的诊断可能具有挑战性。这项研究检查了接受纳武单抗治疗的患者的急诊科(ED)就诊,专注于诊断挑战,评估管理层,以及ED设置中IRAE的结果。
方法:对2018年4月1日至2023年3月31日期间接受纳武单抗治疗的任何癌症的成年患者进行了回顾性队列研究,城市三级护理中心。在这项研究中,我们评估了接受nivolumab的患者的ED访视情况.除了以前的研究,我们详细评估了IRAE(百分比,可识别性,危险因素,迟到的原因,和结果)。患者数据来自电子病历和患者医疗档案。回忆,实验室,和成像结果,ED管理,每次急诊就诊都会分别检查咨询记录。采用Logistic回归模型来确定ED访问和irAE的重要单变量预测因子。
结果:本研究共纳入199例患者,所有这些人都患有转移性癌症。其中,154例患者(77.4%)接受nivolumab治疗非小细胞肺癌。大多数患者(71.9%,n=143)具有至少一种额外的共病。111名患者(55.8%)出现在ED中。高血压(OR:2.425,95%CI:1.226-4.795,p=0.011)和慢性阻塞性肺疾病(OR:2.489,95%CI:1.133-5.468,p=0.023)被确定为ED就诊的危险因素。共诊断出21例IRAE(ED中14例,6在肿瘤诊所,和1在住院病房)。单变量分析发现irAE诊断与任何特定因素之间没有显着关联。
结论:接受纳武单抗治疗的晚期癌症患者中,有相当大比例出现与ICI相关的不良事件,尽管大多数病例并非归因于IRAE。由于irAE的症状模糊,他们在ED中的识别和诊断可能具有挑战性。ED医生和肿瘤学家之间的密切合作对于ED中癌症患者的管理至关重要。
BACKGROUND: The development of immune checkpoint inhibitors (ICIs) represents one of the most significant advancements in cancer treatment over the past decade. Nivolumab, a widely used ICI, has been incorporated into the therapeutic regimens for various cancers. As with any drug, this drug also has side effects, including class-specific immune-related adverse effects (irAEs). Although irAEs are not rare, their diagnosis can be challenging. This study examines the emergency department (ED) visits of patients undergoing nivolumab therapy, focusing on diagnostic challenges, evaluating the management, and outcomes of irAEs in the ED setting.
METHODS: A retrospective cohort study was conducted on adult patients who received nivolumab therapy for any cancer between April 1, 2018, and March 31, 2023, at a large, urban tertiary care center. In this study, we evaluated the ED visits of patients receiving nivolumab. In addition to previous studies, we evaluated irAEs in detail (percentage, recognizability, risk factors, reasons for late recognition, and outcome). Patient data were collected from electronic medical records and patient\'s medical files. The anamnesis, laboratory, and imaging results, ED management, and consultation notes were examined separately for each ED visit. Logistic regression models were employed to identify significant univariable predictors of ED visits and irAEs.
RESULTS: A total of 199 patients were included in the study, all of whom had metastatic cancer. Of these, 154 patients (77.4%) received nivolumab therapy for non-small cell lung cancer. Most patients (71.9%, n = 143) had at least one additional comorbidity. One hundred and eleven patients (55.8%) presented to the ED. Hypertension (OR: 2.425, 95% CI: 1.226-4.795, p = 0.011) and chronic obstructive pulmonary disease (OR: 2.489, 95% CI: 1.133-5.468, p = 0.023) were identified as risk factors for ED visits. A total of 21 irAEs were diagnosed (14 in ED, 6 in the oncology clinic, and 1 in the inpatient ward). Univariate analysis found no significant association between irAE diagnosis and any specific factors.
CONCLUSIONS: A significant proportion of the patients treated with nivolumab for advanced cancer present to ED for ICI-related adverse events, although most cases were not attributable to irAEs. Due to the vague symptomatology of irAEs, their recognition and diagnosis in the ED can be challenging. Close collaboration between ED physicians and oncologists is paramount to the management of patients with cancer in the ED.