Grade 1 | | | |
ICI management | Consider delay of treatment | Hold ICI | Consider holding ICI |
Treatment | No specific treatment | No specific treatment | No specific treatment |
Patient monitoring | Monitor symptoms every 2–3 days | Monitor patients weekly clinically One CT scan to be repeated in 3–4 weeks | Self-monitor symptoms and oxygen saturation every 2–3 days; weekly clinic visits Re-image at least prior to every cycle of ICI treatment |
Drug re-challenge | Not specified | Yes, if radiographic evidence of improvement or resolution | Yes, with chest imaging abnormalities resolution |
Grade 2 | | | |
ICI management | Withhold ICI | Hold ICI | Hold ICI |
Treatment | Prednisolone 1 mg·kg−1 per day−1 orally and taper over ≥6 weeks | Prednisone 1–2 mg·kg−1 per day−1 orally and taper over 4–6 weeks | Methylprednisolone 1 mg·kg−1 per day (i.v. or oral equivalent) and taper over ⩾4 weeks |
Patient monitoring | Bronchoscopy and bronchioloalveolar lavage: optional Monitor symptoms daily/repeat chest radiography weekly/lung function tests including TLCO | Bronchoscopy with bronchial aspiration: optional Monitor every 3 days with history, physical examination and pulse oximetry, consider chest radiography | Bronchoscopy with bronchioloalveolar lavage: recommended Consider hospitalisation |
Drug re-challenge | Not specified | Yes - if resolution to grade ≤1 | Yes, if symptoms and imaging abnormalities resolve |
Grade 3/4 | | | |
ICI management | Discontinue ICI | Discontinue ICI | Discontinue ICI |
Treatment | Empirical antibiotics/(methyl)prednisolone i.v. 2–4 mg·kg−1 per day−1; taper corticosteroids ⩾8 weeks If no improvement after 48 h, add infliximab 5 mg·kg−1 or mycophenolate mofetil | Empirical antibiotics/(methyl)prednisolone i.v. 1–2 mg·kg−1 per day; taper corticosteroids over 4–6 weeks If no improvement after 48 h, may add infliximab 5 mg·kg−1 or mycophenolate mofetil 1 g twice a day or i.v.-immunoglobulins for 5 days or cyclophosphamide | Methylprednisolone i.v., 2 mg·kg−1 per day; taper corticosteroids ⩾8 weeks If no improvement, add infliximab or cyclophosphamide, mycophenolate mofetil or i.v. immunoglobulins |
Patient monitoring | Bronchoscopy and bronchioloalveoar lavage: optional Hospitalisation | Bronchoscopy with bronchioloalveolar lavage: recommended Hospitalisation | Bronchoscopy with bronchioloalveolar lavage: recommended Hospitalisation |
Drug re-challenge | Not specified | No | Grade 3: case-by-case; only if symptoms and imaging abnormalities resolve Grade 4: no, discontinue ICI |