CETUXIMAB: A POTENTIALLY UNDER RECOGNIZED ETIOLOGY OF SUDDEN CARDIAC DEATH

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Certain medications have been linked to an increased risk of sudden cardiac death through varying mechanisms. Herein, we describe a case of a cardiac arrest where cetuximab was presumed the culprit. CASE PRESENTATION: A 58-year-old female with a history relevant for TxN3bM0 squamous cell carcinoma of the neck on chemoradiation therapy was transferred to the hospital after having a cardiac arrest while receiving cetuximab. She presented earlier to the cancer center with no complaints. During cetuximab infusion, she had a cardiac arrest (pulseless electrical activity). She was resuscitated per ACLS guidelines and had a return of spontaneous circulation (ROSC) within eight minutes. Post ROSC, she was hemodynamically stable, with appropriate oxygenation and ventilation. An electrocardiogram showed normal sinus rhythm with no signs of ischemia. Point of care ultrasonography (POCUS) showed a normal left ventricular ejection fraction, with no evidence of wall motion abnormalities, right ventricular strain, or pericardial effusion. POCUS also ruled out deep vein thrombosis and pneumothorax. Cardiac enzymes, brain natriuretic peptide, potassium, calcium, and magnesium, were normal. Post-cardiac arrest care was provided, including targeted temperature management. The next day, she was following commands and meeting extubation criteria. She was extubated and transferred to the floor one day after. Formal echocardiography confirmed POCUS findings. In the absence of another explanation for her cardiac arrest, cetuximab was to blame. DISCUSSION: Cetuximab is a monoclonal antibody that binds the epidermal growth factor receptor (EGFR), competitively inhibiting the binding of EGF and resulting in inhibition of cell growth and induction of apoptosis. Cetuximab is indicated for locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) in combination with radiation therapy. The addition of cetuximab in this population increased median overall survival by 20 months1. In patients with SCCHN treated with cetuximab and radiation therapy, 2% had sudden death1. Cardiac arrest also occurred in 3% of SCCHN patients treated with cetuximab in combination with platinum-based therapy and fluorouracil2. As a result, cetuximab's package has "sudden death" as a black box warning. Of note, 50% of patients treated with cetuximab may develop hypomagnesemia, and weekly monitoring of electrolytes is recommended. In our patient, electrolytes were normal, and the exact mechanism of cetuximab-induced cardiac arrest remains unclear. CONCLUSIONS: Cetuximab-induced cardiac arrest occurs in 2%-3% of treated patients in controlled studies. Real-world incidence may be higher. We report this case to add to the literature what we believe is a case of cetuximab-related cardiac arrest. REFERENCE #1: 1. Bonner JA, et. al. New England Journal of Medicine. 2006 Feb 9;354(6):567-78. REFERENCE #2: 2. Vermorken JB, et al. New England Journal of Medicine. 2008 Sep 11;359(11):1116-27. DISCLOSURES: No relevant relationships by Tony Abdo, source=Web Response No relevant relationships by Ammaar Azeem, source=Web Response No relevant relationships by SYED HUSSAIN, source=Web Response