irAE AIHA Steroid-Refractory — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyirAE AIHA Steroid-RefractorySCE Medical Oncology

A 55-year-old woman on pembrolizumab develops autoimmune haemolytic anaemia (AIHA). Direct antiglobulin test (DAT/Coombs) is positive for IgG. Her oncologist starts prednisolone 1 mg/kg. After 2 weeks, the haemolysis has not improved. What is the second-line treatment for steroid-refractory ICI-induced AIHA?

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Correct answer: C — Rituximab (anti-CD20)

For steroid-refractory ICI-induced AIHA, rituximab (anti-CD20 monoclonal antibody) is the recommended second-line agent, targeting the B-cells producing the anti-erythrocyte autoantibodies. IVIG can be used as a bridge in severe cases. Splenectomy is a third-line option. Mycophenolate may be used as a steroid-sparing agent for maintenance. Haematology involvement is essential. DAT-positive warm AIHA (IgG-mediated) responds differently to cold agglutinin disease (complement-mediated).

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