title: Ipilimumab-Induced Gastrointestinal Toxicities: A Management Algorithm.
abstract: Ipilimumab is a cytotoxic T-lymphocyte-associated antigen-4-blocking monoclonal antibody, which has shown a significant survival benefit in metastatic melanoma patients. Despite being a promising therapy for a disease with an otherwise rather dismal prognosis, it is associated with several immune-related adverse effects (IRAE) mainly targeted toward the digestive tract, skin, liver, and hypothalamic-pituitary axis. Ipilimumab-induced gastrointestinal toxicity (IGT) include diarrhea (~44 %), colitis (~18 %), bowel perforation (<1 %), and pancreatitis (<1.5 %). Early recognition of IRAE and treatment initiation are critical to decrease the risk of further complications. Management included steroids as initial therapy, followed by infliximab (anti-tumor necrosis factor alpha antibody) and/or surgical option for complications like bowel perforation. We present a series of three patients with metastatic melanoma, who received treatment with ipilimumab, and presented with varying gastrointestinal clinical manifestations and complications. Through this case series, our attempt is to make practicing gastroenterologists cognizant about the wide spectrum of gastrointestinal toxicity of this rather new clinical entity, as well as to discuss management algorithm for IGT.
authors: Department of Internal Medicine, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA. klairjagpal@yahoo.com.
authors: Jagpal S
authors: JS
authors: Klair
authors: Department of Internal Medicine, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA.|Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences (UAMS), 4301 W. Markham Street, Shorey S8/68, Slot # 567, Little Rock, AR, 72205, USA.
authors: Mohit
authors: M
authors: Girotra
authors: Department of Internal Medicine, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA.|Division of Hematology and Oncology, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA.
authors: Laura F
authors: LF
authors: Hutchins
authors: Department of Pathology, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA.
authors: Kari D
authors: KD
authors: Caradine
authors: Department of Internal Medicine, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA.|Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences (UAMS), 4301 W. Markham Street, Shorey S8/68, Slot # 567, Little Rock, AR, 72205, USA.
authors: Farshad
authors: F
authors: Aduli
authors: Department of Internal Medicine, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA.|Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences (UAMS), 4301 W. Markham Street, Shorey S8/68, Slot # 567, Little Rock, AR, 72205, USA.
authors: Mauricio
authors: M
authors: Garcia-Saenz-de-Sicilia
mesh_terms: D000369:Aged, 80 and over; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000009:adverse effects* / Q000627:therapeutic use; D003092:Colitis / Q000139:chemically induced*; D005260:Female; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D005767:Gastrointestinal Diseases / Q000139:chemically induced*; D006801:Humans; D000069285:Infliximab / Q000627:therapeutic use; D000074324:Ipilimumab; D008297:Male; D008545:Melanoma / Q000188:drug therapy; D008875:Middle Aged; D011241:Prednisone / Q000627:therapeutic use
chemical_list: D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D005765:Gastrointestinal Agents; D000074324:Ipilimumab; D000069285:Infliximab; D011241:Prednisone
keywords: Colitis; Ipilimumab; Metastatic melanoma; Perforation