Immune-checkpoint inhibitor toxicity during a pandemic: Overcoming patient fears to provide care. A case report.

Background: Pembrolizumab is a humanized monoclonal antibody that is used to treat a variety of cancers. It exerts its mechanism of action by blocking the programmed death receptor-1 (PD-1). Toxicity concerns include immune-related toxicities, including colitis, hepatitis, pneumonitis, nephritis, endocrine toxicities and more rarely, myocarditis and other organ system toxicities.

Objective: To review a real-world case involving immunotherapy induced myocarditis after a patient received pembrolizumab and discuss how the current pandemic created complexity in toxicity management.

Discussion: An 83 year old male with metastatic lung cancer developed fatal myocarditis after receiving 2 doses of pembrolizumab. Applying the Naranjo score, the likelihood of pembrolizumab causing the myocarditis is probable, with a score of 6. Severe cardiac toxicities are rare with pembrolizumab, but can still occur. It is vital to be aware of these toxicities, and educate patients on signs and symptoms. Complicating the situation even further was the global pandemic, which created fear and hesitation in the patient and the patient's family to seek medical treatment out of fear of exposure. This pandemic adds another layer to the complexity of care for patients with cancer and management of toxicities. Pharmacists play a significant role in ensuring the safety and efficacy of medications, especially oncology agents.

Conclusion: Proper education of patients regarding symptoms and when to report are paramount to assisting in early detection and intervention for immunotherapy-related adverse events. New management and treatment strategies will need to be discussed and implemented considering the changing landscape around the SARS-CoV-2 pandemic.