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Before immunotherapy such as pembrolizumab or nivolumab starts, your team checks your blood count, kidney and liver tests, thyroid and often cortisol and sugar levels, and asks about autoimmune and lung conditions. Some tests are repeated before each dose, because immunotherapy side effects are often found on a blood test before you feel them.
SITC 2021: before starting, full blood count with differential, a comprehensive metabolic panel, TSH and free T4; consider urinalysis for baseline kidney disease; consider an ECG for people at higher risk of myocarditis (cardiac disease, diabetes, combined anti-PD-(L)1 and anti-CTLA-4), and baseline troponin may be considered. Liver tests before every infusion; blood count, metabolic panel, TSH and free T4 intermittently throughout, with thyroid tests every 4 to 6 weeks on treatment and every 6 to 12 months after it ends. Education on irAEs, contraception and fertility; a careful risk-benefit discussion for people with autoimmune disease (LE: 1) and specialist referral with lung function tests for autoimmune interstitial lung disease (LE: 3).
ESE 2022 sets a baseline minimum for everyone of morning (08:00 to 09:00) TSH, free T4, cortisol, glucose and electrolytes (sodium, potassium, calcium), repeated every 4 to 6 weeks, preferably before each cycle, and adds ACTH, LH, FSH, oestradiol or testosterone, prolactin and HbA1c where hypophysitis risk is higher, such as with ipilimumab. ESMO 2022 and the ESC 2022 cardio-oncology guideline could not be read.
Why: Most side effects start between visits; knowing what to report and carrying a card speeds up treatment elsewhere.
“Patients should receive dedicated education on irAEs by a medical professional and may receive additional materials such as informational booklets or reference cards.”
Why: The effects of these drugs on pregnancy and fertility are not fully known.
“Patients should be encouraged to use contraception while receiving immunotherapy. Fertility should be discussed prior to treatment.”
Why: A baseline makes it possible to tell later whether a change is a side effect.
“The following tests should be performed prior to beginning ICI therapy: complete blood count (CBC) with differential, comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), free thyroxine (fT4). Urinalysis should be considered to evaluate for baseline kidney disease.”
Why: Hormone problems are common with these drugs and can be dangerous if missed; a morning baseline makes later results interpretable.
“Baseline minimum tests : Morning (8:00–9:00 h) thyroid-stimulating hormone (TSH), free thyroxine (fT4), cortisol (with attention to any recent or current glucocorticoid treatment), glucose, and electrolytes (Na, K, Ca).”
European Society of Endocrinology, European Journal of Endocrinology 2022
Why: Myocarditis is rare but often fatal; a baseline helps interpret a later rise.
“Consider performing a baseline electrocardiogram (EKG) on patients deemed at a higher risk for myocarditis (eg, cardiac comorbidities, diabetes mellitus, anti-PD-(L)1 with anti-CTLA-4 ICI combination therapy, etc). Baseline troponin testing may also be considered to provide information for evaluating potential future cardiac toxicity.”
Why: Checkpoint inhibitors can flare existing autoimmune disease, but for many cancers the survival benefit outweighs that risk.
“For patients with life-threatening autoimmune disorders, the decision to initiate ICI therapy should only be considered after a careful risk-benefit discussion between patient and provider, and consideration of alternative therapies.”
Why: Existing lung disease raises the risk of pneumonitis.
“Patients with pre-existing autoimmune ILD should be referred to a specialist where possible before initiation of ICI therapy for the consideration of pulmonary function tests (PFTs) and risk assessment”
Why: Immune hepatitis is usually silent and found on the blood test.
“Liver biochemical tests (aka liver function tests (LFTs)) should be checked prior to each ICI infusion.”
Why: Thyroid, pituitary and adrenal problems and diabetes can start at any time on treatment.
“These tests should be repeated every 4–6 weeks, preferably before each treatment cycle starts.”
European Society of Endocrinology, European Journal of Endocrinology 2022
Why: Thyroid problems can appear months after the last dose.
“Thyroid function (TSH, fT4) should be tested every 4–6 weeks during ICI treatment, and should continue to be tested every 6–12 months following the conclusion of ICI treatment.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
SITC 2021 and ESE 2022 agree on a baseline blood count, metabolic panel and thyroid function, liver tests before each dose and thyroid tests every 4 to 6 weeks on treatment and every 6 to 12 months after. ESE goes further, asking for a morning cortisol, glucose and electrolytes in everyone and a full pituitary panel where hypophysitis risk is higher, while SITC asks for cortisol only when symptoms or other results point to it. SITC adds risk-based ECG and optional troponin, urinalysis, and specialist review for autoimmune disease and interstitial lung disease. The cardiac baseline in the 2022 ESC cardio-oncology guideline and the ESMO 2022 baseline list could not be read and are not compared.
SITC, Journal for ImmunoTherapy of Cancer 2021 · European Society of Endocrinology, European Journal of Endocrinology 2022 · ESMO, Annals of Oncology 2022 · European Society of Cardiology, European Heart Journal 2022
Where it differs: Adds cortisol, glucose and electrolytes to every baseline and repeat, drawn at 08:00 to 09:00, and a comprehensive panel (ACTH, LH, FSH, oestradiol or testosterone, prolactin, HbA1c) when hypophysitis risk is higher, such as ipilimumab alone or with a PD-1 inhibitor.
Evidence: Guideline consensus; the testing schedule is not a graded recommendation.
European Society of Endocrinology, European Journal of Endocrinology 2022
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Risk-benefit discussion before checkpoint inhibitors in life-threatening autoimmune disease | LE: 1 | SITC, Journal for ImmunoTherapy of Cancer 2021 |
| Specialist referral and lung function tests for autoimmune interstitial lung disease | LE: 3 | SITC, Journal for ImmunoTherapy of Cancer 2021 |
| Mild thyroid dysfunction may be monitored without treatment, with TSH and free T4 every 3 to 6 weeks early on “We suggest that cases of clinically and biochemically mild thyrotoxicosis or hypothyroidism can be monitored without treatment (good clinical practice).” | good clinical practice | European Society of Endocrinology, European Journal of Endocrinology 2022 |
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