Pneumotox » Drug » Nivolumab

Nivolumab

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An anti–PD-1 monoclonal antibody formerly known as BMS-936558 (PMID 23714523). Approximate rate of pneumonitis is 3%, with 1% being severe (Grade 3/4). Incidence of pneumonitis is higher in those patients on concomitant nivolumab plus ipilimumab or other ICPI combo therapy (PMID 25891304)

Last update : 25/10/2018

I.a Pneumonitis (ILD), acute and/or severe (may cause ARDS)

3

I.b Pneumonitis (ILD)

5

I.c Eosinophilic pneumonia (pulmonary infiltrates and eosinophilia)

1

I.d Organizing pneumonia pattern (an area or areas of consolidation on imaging)

1

I.e Acute eosinophilic pneumonia (AEP)

1

I.f Acute fibrinous organizing pneumonia (AFOP)

1

I.h Subclinical pulmonary infiltrates/ILD

1

I.ad Radiation recall pneumonitis

1

I.aj Shrinking lung syndrome

1

II.b ARDS - Acute lung injury

1

II.d Pulmonary edema, cardiogenic

1

III.g Bleeding/hemorrhage from/around preexisting lung tumor (Localized AH)

-

III.j Anti-GBM-related pneumorenal syndrome and DAH (Goodpasture) or flare of

1

III.m Coagulopathy

1

IV.a Bronchospasm - Wheezing - Asthma

1

IV.c Obliterative bronchiolitis (a pattern consistent with) (see also IVn, XVx)

1

IV.n Obstructive airway dysfunction (see also IVc, XVx)

1

IV.y Eosinophilic airway disease (asthma, bronchitis, bronchiolitis)

1

V.a Pleural effusion (uni- or bilateral) (can accompany DI-LDs)

1

V.m Pleuropericarditis - Pleuropericardial effusion (ANA unknown or negative)

1

VI.b Pulmonary arterial hypertension

1

VIII.t Vocal cord paresis/paralysis

1

IX.a Diaphragm/inspiratory muscle weakness/paralysis (w/wo ARF)

1

IX.d Respiratory failure from ventilatory depression (due to neuromuscular blockade/paralysis)

1

IX.h Dyspnea, unexplained otherwise

1

IX.r Myasthenia gravis - Myasthenic-like syndrome

1

IX.y A flare or relapse of preexisting myasthenia gravis

1

IX.ab Guillain-Barré (or GB-like) syndrome (w/wo ARF)

1

X.a DRES syndrome - DRESS-like reaction

1

X.d Lupus - Lupus syndrome (see also Vd)

1

X.f Anaphylaxis-Anaphylactoid reaction (can be fatal)

1

X.g Hypersensitivity reaction (may manifest with fever and/or skin, throat or airway involvement)

3

X.j Myopathy-Myositis-Polymyositis (see also under Xba)

1

X.k Sarcoid-like granulomatosis (endo-/extrathoracic)

1

X.m Vascultis (pulmonary, extrathoracic or systemic)-ANCA status unknown or negative)

1

X.n Tumor lysis syndrome (TLS)

1

X.s Vasculitis, pulmonary (w/wo AH), extrapulmonary, systemic: ANCA-positive

1

X.u Multiple organ dysfunction/failure (MODS/MOF)

1

X.ac Anti-GBM antibody disease (Goodpasture-like or flare of preexisting GS)

1

X.ay Polymyalgia rheumatica

1

XI.i Esophageal toxicity

1

XI.av Deterioration of graft function in SOT recipients

1

XI.ax Esophageal stenosis/stricture

1

XII.c Pericardial effusion (w/wo tamponade)

1

XII.d Myocarditis (can be fulminant)

1

XII.g Coronary artery disease (acute) - Myocardial ischemia/infarction

1

XII.n Cardiovascular collapse - Cardiogenic shock - Hypotension

1

XII.s Heart block (bundle branch- or AV-)

1

XII.ai Cardiotoxicity

1

XII.ax Necrotizing myocarditis (w/o evidence for CAD)

1

XV.c Path: Organizing pneumonia (OP/BOOP) pattern (see also Id)

1

XV.d Path: Acute fibrinous organizing pneumonia (AFOP-pattern) (see also If)

1

XV.g Path: Alveolar hemorrhage (see also IIIa)

1

XV.x Path: Acute/subacute bronchiolitis (see also IVc, IVi)

1

XV.bb Path: Airway inflammation

1

XV.cv Path: Peribronchiolar granulomas

1

XVI.i Imaging: An area or areas of involvement with a recognizable anatomic distribution

1

XVI.v Imaging: Centrilobular micronodules (can be diffuse)

1

XVI.w Imaging: Lung nodule or nodules

1

XVI.ab Imaging: Cavitating/cavitary lung nodule, mass or nodules (see also Iq, XIs, XIIi, XVIaa and XVIIp)

1

XVI.af Imaging: Lung cysts or bullae (see also XVI ah/bf)

1

XVI.ai Imaging: A 'tree-in-bud' pattern

1

XVII.a Respiratory tract infection incl. pneumonia

1

XVII.c Aspergillosis, pulmonary (invasive, allergic [ABPA], or mycetoma)

1

XVII.g Tuberculosis (pulmonary, pulmonary, extrapulmonary or disseminated). Reactivation or de novo

1

XVII.aj Bordetella bronchiseptica pulmonary infection

1

XIX.a BAL: An excess proportion of lymphocytes

1

XIX.b BAL: An excess proportion of neutrophils

1

XIX.c BAL: An excess proportion of eosinophils

1

Diagnosing DIRD

1

Drug and radiation history

2

Drug singularity - Correct identification of the drug

3

Consistent timing of exposure v. onset of symptoms

4

Clinical, imaging, BAL, pathological pattern consistent with the specific drug

5

Careful exlusion of another cause

6

Remission of symptoms with removal of drug

7

Recurrence with rechallenge (rarely advisable)

8

Causality assessment

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