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Refractory irAE Hepatitis — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyRefractory irAE HepatitisSCE Medical Oncology

A 60-year-old man receiving nivolumab + ipilimumab develops rapidly worsening liver function (ALT 25× ULN, bilirubin 120 µmol/L, INR 2.1). Despite 5 days of IV methylprednisolone 2 mg/kg, LFTs continue to rise. Mycophenolate 1 g BD has been added for 72 hours without improvement. What should be considered for steroid/MMF-refractory hepatitis?

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Correct answer: B — Anti-thymocyte globulin (ATG) or tacrolimus, and urgent hepatology/transplant assessment

For steroid- and MMF-refractory immune-related hepatitis, options include anti-thymocyte globulin (ATG) and tacrolimus. Infliximab is CONTRAINDICATED in ICI hepatitis (hepatotoxic itself). Rising INR with very high bilirubin suggests evolving hepatic failure, requiring urgent hepatology assessment and transplant centre consultation. The mortality of grade 4 ICI hepatitis refractory to steroids is significant. Liver biopsy (if coagulation permits) helps guide further immunosuppressive therapy.

Reference: ESMO 2024 irAE Management Guidelines; ASCO irAE Guidelines; De Martin et al Hepatology 2018