Case Report

Tocilizumab in grade 4 hepatitis secondary to immune checkpoint inhibitor: a case report and review of the literature

*Author for correspondence: Tel.: +61 08 8204 7201;

E-mail Address: syed.ali@sa.gov.au

https://orcid.org/0000-0002-4103-6953

Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, 5042, Australia

School of Medicine and Public Health, Flinders University, Bedford Park, 5042, Australia

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Preethi Vembar

Department of Oncology, Flinders Medical Centre, Bedford Park, 5042, Australia

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Shawgi Sukumaran

Department of Oncology, Flinders Medical Centre, Bedford Park, 5042, Australia

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Dimuth Gunawardane

Department of Anatomical Pathology, SA Pathology, Flinders Medical Centre, Bedford Park, 5042, Australia

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Tiffany Hughes

Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, 5042, Australia

School of Medicine and Public Health, Flinders University, Bedford Park, 5042, Australia

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Anthony Smith

Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, 5042, Australia

School of Medicine and Public Health, Flinders University, Bedford Park, 5042, Australia

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Published Online:4 Jul 2023https://doi.org/10.2217/imt-2023-0085

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Abstract

First- and second-line treatments for immune checkpoint inhibitor-related hepatotoxicity (IRH) are well established; however, evidence for third-line therapies is limited. We present a 68-year-old female with relapsed metastatic non-small-cell lung carcinoma despite multiple treatments. A fortnight after the second cycle of CTLA-4 inhibitor immunotherapy, she developed scleral icterus and mild jaundice with significant elevation in liver enzymes. A diagnosis of IRH was made, and despite corticosteroids, mycophenolate and tacrolimus, liver enzymes continued to worsen. One infusion of tocilizumab was given, which resulted in a remarkable improvement. Prednisolone and tacrolimus were then tapered over the ensuing months, and mycophenolate was continued. Given the rapid improvement in liver enzymes with tocilizumab, this treatment should be considered as a third-line treatment in IRH.

Plain language summary

A lady had cancer of the lung. A new medication was started but the liver became damaged. Three medications were tried to help the liver. None of these worked. Another drug (called tocilizumab) was tried and worked. The liver got better.

Tweetable abstract

A case report on the utility of tocilizumab as a third-line treatment for refractory grade 4 hepatitis as a complication of immune checkpoint inhibitor therapy.

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Papers of special note have been highlighted as: • of interest; •• of considerable interest

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Vol. 15, No. 14

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History

Received 4 April 2023

Accepted 20 June 2023

Published online 4 July 2023

Published in print October 2023

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Keywords

Author contributions

S Ali wrote and devised the concept for the manuscript. P Vembar, S Sukumaran, D Gunawardane, T Hughes and A Smith contributed to feedback and revision on the manuscript.

Acknowledgments

The authors would like to acknowledge the medical, nursing and pharmacy staff involved in the hospitalization of this patient.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Informed consent disclosure

The authors state that they have obtained verbal and written informed consent from the patient for the inclusion of their medical and treatment history within this case report.

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