Abstract
BackgroundGlucocorticoid treatment remains the cornerstone of therapy for immune checkpoint inhibitor (ICI) myocarditis, but data supporting the use of additional immunotherapy for steroid refractory cases remains limited. We investigate the safety and efficacy of infliximab in patients with ICI myocarditis who are refractory to corticosteroids. Additionally, we highlight the importance of a multi-disciplinary approach in the care for these complex patients.MethodsWe retrospectively identified consecutive patients who developed ICI myocarditis at our institution between January 2017 and January 2020. Baseline characteristics, laboratory data and clinical outcomes were compared between patients who received infliximab and those who did not.ResultsOf a total of 11 patients who developed ICI myocarditis, 4 were treated with infliximab. Aside from age, there were no significant differences in baseline patient characteristics between the two groups including total number of ICI doses received and duration from initial ICI dose to onset of symptoms. The time to troponin normalization was 58 vs. 151.5 days (p = 0.25). The duration of prednisone taper was longer in the infliximab group (90 vs. 150 days p = 0.32). All patients survived initial hospital admission. Over a median follow-up period of 287 days, two of the 4 patients died from sepsis 2 and 3 months after initial treatment of their myocarditis; one of these patients was on a steroid taper and the other patient had just completed a steroid taper.ConclusionsInfliximab, despite its black box warning in patients with heart failure, may be a safe and effective treatment for ICI myocarditis.
Highlights
Glucocorticoid treatment remains the cornerstone of therapy for immune checkpoint inhibitor (ICI) myocarditis, but data supporting the use of additional immunotherapy for steroid refractory cases remains limited
We describe our single center experience with four patients who had steroid-refractory ICI myocarditis that improved with infliximab administration
Grading of ICI myocarditis was performed according to the American Society of Clinical Oncology (ASCO) practice guidelines [13]
Summary
Glucocorticoid treatment remains the cornerstone of therapy for immune checkpoint inhibitor (ICI) myocarditis, but data supporting the use of additional immunotherapy for steroid refractory cases remains limited. Various additional immunosuppressive agents have been used in steroidrefractory cases; data supporting the use of these therapies are limited. In this retrospective study, we describe our single center experience with four patients who had steroid-refractory ICI myocarditis that improved with infliximab administration. We describe our single center experience with four patients who had steroid-refractory ICI myocarditis that improved with infliximab administration We compare their clinical characteristics and outcomes with those who did not require immunosuppression beyond steroids. We provide a suggested treatment algorithm created by a multi-disciplinary team of experts in cardio-oncology, heart failure, infectious disease, medical oncology and cardiothoracic surgery
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