In patients with grade 3 or 4 colitis due to ICI therapy, the goal of inpatient therapy is to decrease symptoms to the degree that they can be managed at home (fewer stools, resolution of severe abdominal pain). Hospitalized patients with ICI colitis require a multidisciplinary approach including medical oncology, gastroenterology, and surgery consultation.
This algorithm is intended for use in conjunction with other UpToDate content. Refer to UpToDate topics on the diagnosis and management of ICI colitis for additional details, including pretreatment evaluation and evidence supporting the efficacy of these therapies.ICI: immune checkpoint inhibitor; IV: intravenous; CTCAE: Common Terminology Criteria for Adverse Events; ADL: activities of daily living.
* Supportive care includes monitoring vital signs and stool output, IV fluid and electrolyte replacement, and venous thromboembolism prophylaxis. For those able to tolerate an oral diet, we offer a bland, lactose-free diet with no/reduced caffeine. Antidiarrheal agents should be avoided in those with moderate to severe colitis given the potential risk of toxic megacolon.
¶ For IV glucocorticoid therapy, we use methylprednisolone 1 to 2 mg/kg/day and administer in 2 divided doses every 12 hours with a maximum daily dose of 120 mg.
Δ Typically, IV methylprednisolone is converted to oral prednisone 1 mg/kg/day and tapered over 4 to 6 weeks at minimum. Oral prednisone can then be reduced by 10 mg every 3 to 7 days until the dose is 10 mg per day, then reduced by 5 mg every 3 to 7 days. Refer to UpToDate content on toxicities associated with checkpoint inhibitor immunotherapy.
◊ The efficacy and safety of infliximab and vedolizumab appear comparable in this setting. The selection of biologic agent is based upon clinician preference, patient comorbidities, the type of cancer, and the need for rapid treatment response. For example, infliximab is preferred in most patients, including those who require a rapid treatment response and those with concurrent inflammatory arthritis conditions. Vedolizumab is preferred in patients with hematologic malignancies, those with an ongoing tumor response to ICI therapy where the impact of systemic immunosuppression needs to be minimized, and/or those who are able to tolerate a slightly slower treatment response.
§ Patients with severe colitis on endoscopic evaluation (ie, spontaneous bleeding, deep and/or large ulcerations) are typically started on a biologic agent in addition to glucocorticoid therapy.
¥ The initial dose of infliximab is 5 mg/kg. Patients with grade 4 colitis and severe hypoalbuminemia (serum albumin <2.5 g/dl) may be treated with an initial dose of 10 mg/kg.
‡ For patients who respond to the first infusion of infliximab or vedolizumab, the next infusions are given at 2 and at 6 weeks.