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Challenge of immune-mediated adverse reactions in the emergency department
  1. Gregory A Daniels1,
  2. Angela D Guerrera2,
  3. Donna Katz3,
  4. Jayne Viets-Upchurch4
  1. 1 Department of Medicine, Moores UCSD Cancer Center, La Jolla, California, USA
  2. 2 Department of Emergency Medicine, Cooper University Health Care, Camden, New Jersey, USA
  3. 3 Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, USA
  4. 4 Department of Emergency Medicine, MD Anderson Cancer Center, Houston, Texas, USA
  1. Correspondence to Dr Gregory A Daniels, Department of Medicine, Moores UCSD Cancer Center, La Jolla, CA , 92037-0987, USA; gdaniels{at}


Multiple drugs of a new class of cancer treatments called immune checkpoint inhibitors, which work by enabling the immune system to attack tumour cells, have been approved for a variety of indications in recent years. Immune checkpoints, such as cytotoxic T-lymphocyte antigen-4 and programmed death-1, are part of the normal immune system and regulate immune activation. Treatment with inhibitors of these checkpoints can significantly improve response rates, progression-free survival and overall survival of patients with cancer; it can also result in adverse reactions that present similarly to other conditions. These immune-mediated adverse reactions (IMARs) are most commonly gastrointestinal, respiratory, endocrine or dermatologic. Although patients’ presentations may appear similar to other types of cancer therapy, the underlying causes, and consequently their management, may differ. Prompt recognition is critical because, with appropriate management, most IMARs resolve and patients can continue receiving immune checkpoint inhibitor treatment. Rarely, these IMARs may be life-threatening and escape detection from the usual evaluations in the emergency environment. Given the unusual spectrum and mechanism of IMARs arising from immune checkpoint inhibitors, emergency departmentED staff require a clear understanding of the evaluation of IMARs to enable them to appropriately assess and treat these patients. Treatment of IMARs, most often with high-dose steroids, differs from chemotherapy-related adverse events and when possible should be coordinated with the treating oncologist. This review summarises the ED presentation and management of IMARs arising from immune checkpoint inhibitors and includes recommendations for tools and resources for ED healthcare professionals.

  • clinical management
  • emergency department
  • communications
  • clinical assessment

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  • Contributors All authors reviewed and approved the manuscript.

  • Funding Medical writing support was provided by Jason Hoffman, and editorial support was provided by Jay Rathi, both of Spark Medica, supported by Bristol-Myers Squibb according to Good Publication Practice guidelines (no grant number).

  • Competing interests JV-U reports consulting fees from Bristol-Myers Squibb. No other authors have commercial, financial or other relationships in any way related to the subject of this article to disclose, per ICMJE conflict of interest guidelines. Outside the submitted work, GD reports clinical trial support from Bristol-Myers Squibb, Nektar, Regeneron, Viralytics, Dynavax, OncoSec and Merck. DK reports personal fees and non-financial support from Bristol-Myers Squibb.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Press Release Yes.

  • Patient consent for publication Not required.

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