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Triage of irAEs
The Role of the Triage Nurse in Management of Immune-Related Adverse Events in NSCLC

Released: June 09, 2017

Expiration: June 08, 2018

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Immune checkpoint inhibitors, including nivolumab and pembrolizumab, which both target and block PD-1, and atezolizumab, which targets and blocks PD-L1, are being used to treat an increasing portion of the estimated 222,500 patients with lung cancer in the United States. These therapies have innovative mechanisms of action but carry a known risk of potentially serious immune-related adverse events (irAEs). As we continue to see improved survival for patients with advanced NSCLC using immune checkpoint inhibition, timely management of irAEs poses a new and growing challenge for healthcare providers.

The Unique Role of the Oncology Triage Nurse in irAE Management
Recognizing the signs of irAEs and taking appropriate action when triaging a patient’s call are relatively new and absolutely necessary roles for oncology nurses. Because the triage nurse is the first point of contact for a patient experiencing these AEs and irAEs require timely initiation of management, the nurse’s keen assessment is pivotal and can be life saving. 

It is important to keep in mind that our patients do not want to have an AE that results in them having to stop their current therapy and try something new. Furthermore, and of most importance, the initial symptoms of an irAE can seem very benign to patients, and even to healthcare providers, such that triage nurses play a critical role in obtaining details from our patients to clarify their symptoms and recognize the critical tipping points when an uncomplicated issue becomes dangerous. Whatever the presentation and however benign an AE may seem to a patient receiving an immune checkpoint inhibitor, if it meets criteria for being immune related, the nurse must jump to secure the patient an opportunity for physical assessment with a provider. However, it is no easy feat to assess and manage irAEs through phone triage.

Common irAEs With Immune Checkpoint Inhibitor Therapy
The first step for triage nurses to be aware of irAEs when they arise is by knowing what symptoms to watch for. Two of the more common irAEs that occur with immune checkpoint inhibition are immune-related colitis and dermatitis. In clinical trials of nivolumab and pembrolizumab for the treatment of NSCLC, 2.9% and 1.7% of patients experienced immune-related colitis (any grade) and 9.0% and 1.4% of patients experienced cutaneous irAEs (any grade), respectively. Similarly, 0.5% of NSCLC patients in clinical trials for atezolizumab experienced immune-related colitis. Other irAEs occurring with immune checkpoint inhibition include endocrine disorders, neurologic manifestations, nephritis, hepatitis, and pneumonitis.

Phone Triage Assessment of Immune-Related Colitis
For immune-related colitis, key identifiers of concern include more stools than normal, mild diarrhea, stomach ache/pain, or dark stools. A patient may have only one presenting symptom, which they may be completely unconcerned by or may fail to mention because they are pleased to be relieved of their constipation. More than one half of the time a patient explains, “My stomach has been a little upset, but other than that I’m doing great.” A patient is less likely to proclaim they have had 6 loose stools in the last 24 hours without prompting from the nurse. Or, a patient calls and admits to an instance of fever never breaking 100 degrees and to having more frequent bowel movements but was previously constipated and only had cramping with one of the movements. The patient adds, “My whole family had this ‘bug’ last week, so I’m sure it’s nothing.” The patient has decided that this “bug” and all of the other symptoms are not concerning. The triage nurse must challenge the patient’s notion that “it’s nothing,” propose that his “bug” could, in fact, be something more severe, and review all of the factors of an “upset stomach.”

There are tools to assist nurses with guiding patients through these unclear scenarios and with following safety guidelines. After grading the patient’s diarrhea, the nurse must establish a plan for frequent (even daily) assessment, via phone, to check for progression or resolution. Reviewing providers’ preferences for how to respond to various grades of diarrhea (ie, physical assessment in the office the same day or daily check-ins by phone until progression) will assist the triage nurse to start an action plan at the first point of contact, which patients will greatly appreciate.

Phone Triage Assessment of Immune-Related Skin Reactions
We have yet to master assessing immune-related rashes over the phone with large success. Presentations of immune-related skin reactions vary widely, and patients often delay assessment by attempting to treat themselves with over-the-counter remedies before calling the clinic. Ideally, a patient would call and tell the nurse, “I have a grade 3 immune-related cutaneous reaction.” However, this is not what happens. A patient is more likely to call saying they have a red rash, it started 2 days ago, and they can’t tell if it’s getting worse. Running through a range of questions to see if they have made any changes to their detergents, lotions, or medications is a great place for a triage nurse to start, but without any identifiable change, or if the rash described is nearly 30% of the patient’s body surface area, the patient will need to come in for physical assessment. As an example of the need for vigilance, I know of a recent case where a spouse contacted the triage nurse about a patient experiencing itching and redness to the forearms and face, areas that had been in the sun; this patient turned out to be having an skin-related irAE and was put on steroids within 48 hours of the call due to the progression of his reaction.

What challenges have you encountered in assessing irAEs in your phone calls with patients being treated with immune checkpoint inhibitors? Please join the conversation below!

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Which immune-related AE do you find most challenging to triage on your phone calls with patients being treated with immune checkpoint inhibitors?
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