Williams Cancer Institute

Autoimmune Side Effects

Autoimmune Side Effects

We have discussed that with the common immunotherapy drugs used today, mostly anti-PD-1/PD-L1 or anti-CTLA-4,block receptors that prevent your immune system from attacking your own body, it is certainly understood that this can increase autoimmune conditions. In general, you could expect to see any type of autoimmune conditions that may occur in normal disease processes, such as rheumatoid arthritis, Hashimoto’s thyroiditis, and colitis. However, with cancer immunotherapy it is possible to see autoimmune issues almost anywhere in the body, and certainly some that would be very strange or extremely rare to occur naturally.

There is a long list of possible autoimmune conditions, but certainly ones to consider are: pneumonitis (lung), hepatitis (liver), thyroiditis (thyroid), colitis (colon), diabetes (pancreas), hypophysitis (pituitary gland), rash (skin). Though I will not go into the detailed treatment of these issues, in many cases, corticosteroid treatment may be necessary. We usually warn our patients that any changes in breathing or shortness of breath could be from pneumonitis, an autoimmune inflammation in the lung. This needs to be evaluated immediately, and my suggestion is with a CT scan of the chest. I would like to mention here that a chest X-ray alone is not very sensitive for picking up this condition. Though it may be the first step, ultimately a CT scan probably will be needed. It is important to note that the appearance of autoimmune pneumonitis can resemble pneumonia in some cases, but thetreatment is clearly different. Every effort needs to be made to distinguish these apart from each other. In general pneumonia (lung infection) will have an elevated white blood count and fever, whereas pneumonitis typically would not. Sometimes the distinction is not so clear.

In regards to thyroid issues, most commonly the autoimmune issue results in a low thyroid hormone, hypothyroid. In some cases this may start as a high or hyperthyroid condition, because the gland is being destroyed by the immune system, which causes a rapid sudden release of thyroid hormone, later followed by a decrease in thyroid hormone production. The increase in thyroid hormone may cause symptoms such as anxiety and a rapid heart rate, which may need to be treated with medicines to control these symptoms, such as a Beta blocker. In other cases the autoimmune antibodies can actually stimulate the thyroid, causing an increased production of thyroid hormone, also known as Grave’s disease. This is where the increased thyroid hormone production can persist, unlike the first condition I described of thyroiditis, where hormone levels may first come up, but later become low. In either case, it may be necessary to have an endocrinologist evaluate and treat these situations.

In regards to autoimmune hepatitis, it is important to periodically monitor liver enzymes. Mild increases can just be monitored, but more significant increases will need to be treated with steroids or, in rare cases, other immune suppressing drugs. There are many different recommendations on how to treat these related autoimmune conditions. I would refer someone to either the prescribing information provided by the drug manufacturer or to consult with their doctor. There are also helpful treatment guidelines on the website www. uptodate.com, which is an evidence-based medicine website used by many physicians. The book SITC’s Guide to Managing Immunotherapy Toxicity by Ernstoff, et al., published in 2019, is an excellent reference book and a must for the library of any doctor involved in the use of cancer immunotherapy.

Reference: Jason R. Williams, 15 Oct 2019, The Immunotherapy Revolution: The Best New Hope For Saving Cancer Patients’ Lives, https://williamscancerinstitute.com/the-immunotherapy-revolution

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