How can the urologist and his care network manage the toxicity of immunotherapies? Application to digestive toxicities

Digestive toxicity is common for 15 % of patients on immunotherapy, and often observed in the first 3 months. To prevent it, patients and caregivers should be informed, looking for: risk factors, a history of autoimmune diseases, and new symptoms or worsening of existing symptoms. Diarrhea should be monitored (dehydration, hypokalemia). Rehydration and loperamide for grades 1–2 will suffice, but at grade 3 treatment by immunotherapy should be suspended, loperamide stopped, and corticosteroid therapy started. Stool culture (Clostridium difficile) should be performed at grade 3. Toxicity should be confirmed by sigmoidoscopy. One to 5 % of cases will result in perforated inflammatory colitis and there is 1 % of deaths related to digestive complications. Liver assessment should be done before each treatment to eliminate cytolysis. The incidence of hepatotoxicity of immunotherapy is 5 to 10 %, and at grade 2 immunotherapy should be stopped and corticosteroid therapy started.