Hepatitis at Home: Ambulatory management of severe immune checkpoint inhibitor related hepatitis

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.

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.

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.

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.