Episode 403: Pharmacology 101: Checkpoint Inhibitors

“Because the premise of immune checkpoint blockade centers around elevating the immune function, we should always take a great deal of caution around those patients who have high immune risks. Those include patients with autoimmune disorders. That’s one of our biggest questions that we ask, usually every consult that we’re seeing with solid tumor. ‘Do you have any history of autoimmune disorders? Tell me a little bit more about it. Is it being treated? What are your symptoms like?’ And then also patients who have undergone organ transplants. Now, interestingly, this does include stem cell transplants,” Kelsey Finch, PharmD, BCOP, oncology pharmacist practitioner at Columbus Regional Health in Indiana, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS^®, manager of oncology nursing practice at ONS, during a conversation about checkpoint inhibitors.

Music Credit: “Fireflies and Stardust” by Kevin MacLeod

Licensed under Creative Commons by Attribution 3.0 

Earn 0.5 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at courses.ons.org by February 20, 2027. Kelsey Finch has disclosed a speakers bureau relationship with AstraZeneca. This financial relationship has been mitigated. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Learning outcome: Learners will report an increase in knowledge related to checkpoint inhibitors in the treatment of cancer.

Episode Notes 

• Complete this evaluation for free NCPD. 
• ONS Podcast™ episodes:
  • Pharmacology 101 series
  • Episode 273: Updates in Chemotherapy and Immunotherapy
  • Episode 174: Administer Pembrolizumab Immunotherapy With Confidence
  • Episode 139: How CAR and Other T Cells Are Revolutionizing Cancer Treatment
• ONS Voice articles:
  • Here’s Why Oncology Nurses Are Pivotal in Managing Immune-Related Adverse Events
  • Make Subcutaneous Administration More Comfortable for Your Patients
  • Nursing Considerations for ICI-Related Myocarditis
  • Oncology Nurses Navigate the Changing Landscape of Immuno-Oncology
  • Postdischarge ICI Patient Education Eliminates Hospital Readmissions
  • Shorter Administration Times Still Require High-Acuity Care
• ONS Voice oncology drug reference sheets:
  • Dostarlimab-Gxly
  • Nivolumab and Hyaluronidase-Nvhy
  • Nivolumab and Relatlimab-Rmbw
  • Pembrolizumab and Berahyaluronidase Alfa-Pmph
  • Retifanlimab-Dlwr
  • Toripalimab-Tpzi
• ONS books:
  • Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (second edition)
  • Guide to Cancer Immunotherapy (second edition)
• ONS course: ONS/ONCC^® Chemotherapy Immunotherapy Certificate^™
• Clinical Journal of Oncology Nursing articles:
  • Immune Checkpoint Inhibitor–Related Myocarditis: Recognition, Surveillance, and Management
  • Immune Checkpoint Inhibitor Therapy: Key Principles When Educating Patients
  • Triple M Syndrome: Implications for Hematology-Oncology Advanced Practice Providers
• ONS Huddle Cards:
  • Checkpoint Inhibitors
  • Immunotherapy
• ONS Learning Libraries:
  • Genomics and Precision Oncology Learning Library
  • Immuno-Oncology Learning Library
• Drugs@FDA package inserts
• National Comprehensive Cancer Network homepage
• OncoLink: All About Immunotherapy

To discuss the information in this episode with other oncology nurses, visit the ONS Communities. 

To find resources for creating an ONS Podcast club in your chapter or nursing community, visit the ONS Podcast Library.

To provide feedback or otherwise reach ONS about the podcast, email [e-mail].

Highlights From This Episode

“Before immune checkpoint blockade, the two-year overall survival rate in metastatic melanoma was hovering around 10%. After these agents came to market, depending on the trial and the agents used, that number actually increased to about 50%–65%. So, five times the amount of patients were actually living at the two-year mark. Not surprisingly, studies then exploded across several tumor types, leading to approvals in all sorts of cancers, mostly in the solid tumor. But there are a couple hematologic as well. Lung cancer, kidney cancer, head and neck, Hodgkin lymphoma, hepatocellular, the list goes on. So, it’s really just transforming the stage IV setting across all tumors, specifically from uniformly fatal prognosis to one where durable responses and long-term survival is also possible.” TS 3:03

“There are four different mechanisms officially being used in therapies that are approved by the U.S. Food and Drug Administration (FDA). Those are cytotoxic T-lymphocyte–associated protein 4, programmed cell death protein 1, and programmed cell death ligand 1, which I’m counting as two different mechanisms, even though they somewhat work together. And lymphocyte-activation gene 3 is the fourth one that’s in there. So, all these mechanisms impact the T cell in our immune system. The T cell is traditionally responsible for protecting our body from harmful things like bacteria, viruses, and cancer. When the tumor binds to cytotoxic T-lymphocyte–associated protein 4 receptors, that happens on the T cell itself. And that inhibits the activation of the T cells, essentially allowing that tumor to then live. So when developing medications that block this receptor, they noted an added benefit that it actually increased the T-cell proliferation as well as keeping that T cell active. So not only are we not blocking the T cells, we’re making them more productive.” TS 5:38 

“If you have a chance of any sort of tissue rejection, specifically with allogeneic stem cell transplants or where we see that focusing on it, there’s a little bit of controversy, mixed bag on opinions as far as autologous stem cell transplants. But it’s best to at least exercise a little bit of caution. If they have a chance of organ rejection, is that worth the risk of the therapy that we’re looking to give? And then, patients with HIV, any sort of immunologic concerns at baseline that we could potentially worsen.” TS 14:37

“As a rule of thumb, with immune checkpoint blockade, regardless of what mechanism you’re looking at, if something in your body can get inflamed, that can wind up as an adverse event. So, whenever I talk to my patients, the key word is anything ending in ‘-itis.’ ... The most common adverse events that we end up seeing are dermatitis and hypothyroidism. Immune checkpoint blockade can cause both hyper- and hypothyroidism. Very often, we actually start in the hyper- and then end up, for lack of better words, burning out the thyroid, ultimately leading to a sustained hypothyroidism.” TS 18:34

“The half-life of immune checkpoint inhibitors is usually around 30 days, meaning that once these agents are given, the drug will be in the patient’s system for up to five months. Specifically, it will probably build month to month, so often we don’t even see a lot of our adverse events until month three or four. Usually, when we’re that far into treatment, we’re not looking for new adverse events in things like chemotherapy. But these drugs do build over time.” TS 24:28

“As far as safe handling is concerned, these agents are not chemotherapy. That makes drug compounding and administration pretty straightforward. When looking at the follow-up care, the most important thing, in my opinion, is to engage in meaningful dialogue with your patients. A lot of the side effects can be nonspecific. So, really listening to the patient and evaluating changes in their lifestyle, I think it’ll get you far. We usually hark in on the new, worsening, or persistent whenever we’re talking to patients because they’ll be looking for things as well. So, just having a dialogue of how their life has changed can certainly help.” TS 26:17