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Checkpoint Inhibitor Hepatitis — RACP Adult Medicine MCQ

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HardGastroenterologyCheckpoint Inhibitor HepatitisRACP Adult Medicine

A 65-year-old man on ipilimumab/nivolumab combination for melanoma develops acute hepatitis at week 6. ALT is 650 U/L (Grade 3, >5× ULN), bilirubin 55 μmol/L. Hepatitis serology is negative. Imaging shows no biliary obstruction. What is the most appropriate management?

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Correct answer: A — Hold pembrolizumab and start IV methylprednisolone 1-2 mg/kg/day

Grade 3 immune-mediated hepatitis (ALT >5× ULN) requires holding immunotherapy and high-dose IV methylprednisolone (1-2 mg/kg/day). If no response in 3-5 days, mycophenolate is second-line (NOT infliximab — hepatotoxic). Ipilimumab-containing regimens have higher hepatitis risk (~10-15% vs ~3% with anti-PD-1 alone). Liver biopsy shows lobular hepatitis with CD8+ T-cell infiltrate.

Reference: ASCO – 2024 – irAE Management; ESMO 2024