Hepatitis – Grade 2
Management escalation pathway
- Withhold ICPI treatment until normalisation of ALT/AST to grade I
- If rising ALT/AST when re-checked wait until normalisation unless grade III or bilirubin increases: start methylprednisolone 1mg/kg (https://www.ncbi.nlm.nih.gov/pubmed/29427729)
Assessment and Investigations
- Re-check LFTs/INR/albumin every 3 days
- Review medications, e.g. statins, antibiotics and alcohol history
- Perform liver screen: – Hepatitis A/B/C serology – Hepatitis E PCR – Anti-ANA/SMA/LKM/SLA/LP/LCI – Iron studie
- Consider imaging for metastases/portal trombosis
More information
Steroid wean:
-G2: once G1, wean over 2 weeks; re-escalate if worsening; treatment may be resumed once prednisolone < 10 mg
-G3/4: once improved to G2, can change to oral prednisolone and wean over 4 weeks; for G3, rechallenge only at consultant discretion
Worsening despite steroids:
– If on oral change to i.v. (methyl)prednisolone
– If on i.v. add MMF 500-1000 mg b.d.
– If worse on MMF, consider addition of tacrolimus
– A case report has described the use of anti-thymocyte globulin in steroid + MMF-refractory fulminant hepatitis
Abbrevations:
ICPi: Immune Checkpoint Blockade Inhibition
ALT: Alanine Transaminase
AST: Aspartate Transaminase
ANA: Anti Nuclear Antibodies
ULN: Upper Limit of Normal
LFT: Liver Function Test
SMA: Smooth Muscle Antibody
LKM: Liver/Kidney Microsome type 1
SLA: Soluble Liver Antigen
LP: Liver/Pancreas
US: Ultra Sound
