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irAE AIHA — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyirAE AIHASCE Medical Oncology

A 55-year-old woman on pembrolizumab for NSCLC develops immune-related haemolytic anaemia (IHA). DAT (Coombs test) is strongly positive. Hb has dropped from 120 to 65 g/L. Reticulocyte count is high. LDH elevated. Haptoglobin low. What is the management?

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Correct answer: D — Hold pembrolizumab, start prednisolone 1-2 mg/kg, transfuse if symptomatic, haematology review

Immune-related autoimmune haemolytic anaemia (AIHA) is a rare but potentially life-threatening irAE. Diagnosis requires positive DAT, reticulocytosis, elevated LDH, low haptoglobin and elevated indirect bilirubin. Management includes ICI discontinuation, high-dose corticosteroids (prednisolone 1-2 mg/kg), and transfusion if symptomatic. Steroid-refractory cases may need rituximab, IVIG or mycophenolate. Haematology involvement is essential. Other ICI-related haematological toxicities include immune thrombocytopenia, pure red cell aplasia and acquired haemophilia.

Reference: ESMO 2024 irAE Management Guidelines; Leaf et al Blood 2019