Hepatitis at home: ambulatory management of severe immune checkpoint inhibitor-related hepatitis

BACKGROUND: Liver toxicity is common in patients treated with immune checkpoint inhibitor (ICI) therapy. Most guidelines advocate for the admission of patients with grade 3/4 ICI mediated hepatitis. Ambulatory emergency care forms a fundamental part of the strategy of trying to ensure safe and sustainable acute care services. METHODS: An ambulatory pathway for ICI mediated hepatitis (CTCAE grade 3/4) was commenced in March 2023. Patients with ICI mediated hepatitis with normal synthetic liver function (bilirubin <30µmol/L, INR <1.5, albumin >30 g/L and grade ≤2 encephalopathy) were considered as potential candidates for acute ambulatory management. Patients received either ambulatory intravenous methylprednisolone 1 mg/kg for 2-3 days or 1 mg/kg oral prednisolone. The primary outcome measure was 30-day readmission due to progressive/refractory hepatitis. Secondary outcome measures were decision to rechallenge with ICI therapy and 30-day all-cause mortality. RESULTS: Eighty-nine patients treated with ICI therapy presented with grade ≥ 3 transaminase rises during the study period. Thirty-eight patients were diagnosed with ICI mediated hepatitis of whom 23 (59%) patients were managed on the ambulatory pathway.Ambulatory pathway patients had a median age of 62 years (37-78) and 10 (43.5%) were male. Median ALT was 323 u/L (range 10-49 u/L) and AST 302 u/L (range 0-33 u/L).No patients required admission due to failure of ambulatory management or worsening liver function. No patients died of any cause within 30 days. CONCLUSION: Our ambulatory care pathway has been utilised successfully to treat patients with severe ICI-mediated hepatitis. There were no observable adverse outcomes including readmissions and deaths. The adoption of this pathway for appropriate patients could potentially lead to a reduction in hospital admissions, reducing the financial burden of toxicity care, improved patient outcomes and enhancing patient experience.