A 48-year-old presents to his primary care provider for evaluation for shortness of breath. Following a negative laboratory evaluation, he underwent a CT of chest which demonstrated bilateral pulmonary disease concerning for metastatic disease. He proceeded with a CT guided biopsy of a pleural based lung lesion which demonstrate metastatic melanoma (BRAF wild-type). Additional staging work-up with an MRI of the brain demonstrated no evidence of intracranial disease. He is subsequently started on nivolumab therapy. Following initiation of nivolumab which side effects is correctly matched with their typically time of onset?
In the elegant manuscript by Weber et al. J Clin Oncol 2012, they detail the management of immune related adverse events and kinetics of response with immunotherapy. In figure 2 on the manuscript, they demonstrate the expected kinetics of the appearance of immune related adverse events. Typically the following time frame for the onset of symptoms is as follows:
Rash/pruritus: ~ 4 weeks
Diarrhea/colitis: ~ 5-6 weeks
Liver toxicity: ~ 6-7 weeks
Hypophysitis: ~ 6-7 weeks
Clinical Pearl: The appearance of a rash and/or pruritus typically occurs ~ 4 weeks following the initiation of therapy. The majority of these rashes can be effectively managed with topical steroid therapy.