• Immune-mediated pneumonitis
• Immune-mediated colitis
• Immune-mediated hepatitis
• Immune-mediated endocrinopathies (thyroid disorders, type I diabetes, hypophysitis)
• Immune-mediated nephritis
• Immune-mediated adverse skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis
• Infusion-related reactions

Then There’s the Cost

Most people have no idea how expensive mabs are. For example, the psoriasis pill Otezla (apremilast) costs $4,067 for 60 30-mg pills at Walmart. Once on a maintenance program, the dose is two tablets a day—totaling about $50,000 a year for a chronic disease that may last a lifetime.

That pales in comparison to the price tag for Keytruda, which is given as an infusion of 200 mg every three weeks. Costco sells a 50-mg vial for $2,171. If the drug were taken for half a year, it would cost $75,261. According to a Reuters article from April 3, 2017, the combination of Opdivo and Yervoy costs $256,000 for a year’s treatment.²

With more and more patients taking immune-modulating mabs, it will just be a matter of time until emergency clinicians see the diverse range of side effects that can be caused by these medications. And given that it will be impossible to remember all of the side effects of these drugs, clinicians should have a low threshold for considering patient’s symptoms to be manifestations of the mabs in the ever-growing number of patients who are, and will be, taking them.

Dr. Bukata is medical director for The Center for Medical Education.

References

1. McCaffrey K. Merck launches DTC campaign for Keytruda. MM&M website. Accessed June 19, 2019.
2. Beasley D. The cost of cancer: new drugs show success at a steep price. Reuters website. Accessed June 10, 2019.