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Clinical characteristics, diagnosis and management of nivolumab-induced myocarditis

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Summary

Nivolumab can cause fatal myocarditis. We aimed to analyze the clinical characteristics of nivolumab-induced myocarditis and provide evidence for clinical diagnosis, treatment, and prevention. Studies involving nivolumab-induced myocarditis were identified in electronic databases from 2000 to 2023 for retrospective analysis. A total of 66 patients were included, with a median age of 68 years. The median onset time of myocarditis is 11.5 days. The main organs affected in persons presented with myocarditis are heart (100.0%) and skeletal muscle (22.7%). The main clinical manifestations are dyspnea (49.2%), fatigue (47.6%), and myalgias (25.4%). The levels of troponin, troponin T, troponin I, creatine kinase, creatine kinase myocardial band, creatine phosphokinase, C-reactive protein, brain natriuretic peptide, and N-terminal brain natriuretic peptide precursor were significantly increased. Histopathology often shows lymphocyte infiltration, myocardial necrosis, and fibrosis. Myocardial immunological parameters usually present positive. Cardiac imaging often suggests complete heart block, intraventricular conduction delay, arrhythmia, myocardial infarction, edema, left ventricular ejection fractions reduction, ventricular dysfunction, and other symptoms of myocarditis. Forty-two (63.6%) patients achieved remission within a median time of 8 days after discontinuation of nivolumab and treatment with systemic corticosteroids, immunoglobulins, plasmapheresis, and immunosuppressant. Thirty-five patients eventually died attributed to myocarditis (68.6%), cancer (20.0%), respiratory failure (5.7%), and other reasons (5.7%). Nivolumab-induced myocarditis should be comprehensively diagnosed based on clinical symptoms, histopathological manifestations, immunological parameters, and cardiac function imaging examinations. Nivolumab should be discontinued immediately, plasmapheresis and systemic corticosteroids combined with immunoglobulins or immunosuppressants may be an effective treatment.

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Funding

This study was supported by the National Key Clinical Specialty Construction Project (Clinical Pharmacy) and High-Level Clinical Key Specialty (Clinical Pharmacy) in Guangdong Province, with the funder being the subsidy fund for medical service and security capacity improvement of the Central Department of Finance, code Z155080000004.

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Authors and Affiliations

  1. Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, 510080, Guangdong Province, China

    Meng-Ting Li, Si-Yong Huang, Xiao Hu & Ji-Sheng Chen

  2. Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, 410007, China

    Yang He

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Contributions

Meng-Ting Li and Ji-Sheng Chen designed the study. Meng-Ting Li and Yang He provided the information on included studies and assisted with data collection and management. Meng-Ting Li, Si-Yong Huang, and Xiao Hu conducted data analysis. All authors contributed to completing the final manuscript and have approved the final article.

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Correspondence to Ji-Sheng Chen.

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This study did not require an ethical board approval because the study was a retrospective study and did not involve sensitive personal information.

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Li, MT., He, Y., Huang, SY. et al. Clinical characteristics, diagnosis and management of nivolumab-induced myocarditis. Invest New Drugs 42, 116–126 (2024). https://doi.org/10.1007/s10637-024-01421-7

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