Management of Checkpoint Inhibitor-Induced Colitis

Established Treatment Algorithm

The American Society of Clinical Oncology recommends systemic corticosteroids at 1-2 mg/kg/day prednisone equivalent, tapered over 4-6 weeks, for grade 2 or higher colitis 1, 2
The American Gastroenterological Association suggests excluding infectious causes before initiating immunosuppression 3, 4
Fecal lactoferrin and calprotectin should be obtained to stratify risk and determine the need for urgent endoscopy, as recommended by the American Society of Clinical Oncology and the American Gastroenterological Association 2, 3
Endoscopic confirmation with colonoscopy and biopsy is highly recommended before high-dose steroids, as ulceration predicts steroid-refractory disease, according to the American Society of Clinical Oncology and the American Gastroenterological Association 2, 3

The American Society of Clinical Oncology and the American Gastroenterological Association recommend infliximab and vedolizumab as biologic options for patients failing to improve within 3 days of corticosteroids 1, 2, 5
These agents specifically target mechanisms relevant to immune-mediated colitis, such as TNF-alpha and gut-selective integrin pathways, as noted by the American Society of Clinical Oncology 1, 2

The American Gastroenterological Association guideline on ulcerative colitis demonstrates risankizumab efficacy only in moderate-to-severe ulcerative colitis, not immune-related adverse events 6
No guidelines, including those from the American Society of Clinical Oncology and the American Gastroenterological Association, mention IL-23 inhibitors as treatment options for checkpoint inhibitor colitis 1, 2, 3, 4, 7
Checkpoint inhibitor colitis can progress rapidly within days, requiring prompt treatment, as noted by the American Gastroenterological Association 2, 4

The American Society of Clinical Oncology recommends not delaying proven therapies, such as corticosteroids, infliximab, and vedolizumab, to trial unproven agents like risankizumab, as this increases the risk of complications 3
The American Society of Clinical Oncology and the American Gastroenterological Association advise not confusing checkpoint inhibitor colitis with inflammatory bowel disease, despite clinical similarities, as the treatment algorithms differ 1, 3, 4
Monitoring for complications with imaging, such as CT abdomen/pelvis, is recommended if pain, fever, or bleeding predominate, as these suggest perforation or abscess requiring surgical intervention, according to the American Society of Clinical Oncology and the American Gastroenterological Association 2, 3