Management of pneumonitis in patients treated with immune checkpoint inhibitors (ICI) according to the American Society of Clinical Oncology (ASCO), European Society For Medical Oncology (ESMO) and Society for Immunotherapy of Cancer (SITC)
| ESMO [23] | ASCO [24] | SITC [25] | |
| 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 |
CT: computed tomography; TLCO: transfer factor of the lung for carbon monoxide.