Myasthenia Gravis: A Rare Neurologic Complication of Immune Checkpoint Inhibitor Therapy.

Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junction, which is characterized by the production of autoimmune antibodies to acetylcholine or muscle-specific kinase receptors, causing an error in transmission of nerve impulses to various muscles. The hallmark of myasthenia gravis is "grave or serious" fluctuating muscle weakness. Ocular, respiratory, bulbar, and skeletal muscles are most commonly affected; therefore, patients often present with fatigable ptosis, blurry vision, diplopia, change in facial expression, dysphagia, dysarthria, dyspnea, and limb weakness. Many medications, including fluroquinolone, aminoglycoside, magnesium sulfate, quinidine, and select beta blockers, are known to unmask or exacerbate symptoms of myasthenia gravis. Although the pathogenesis is not entirely understood, T lymphocytes are thought to play a role by blocking the acetylcholine receptors and causing antibody production. In the era of new immune-modulating therapies emerging for treatment of different cancers, their role in inducing a proinflammatory state has become apparent, thus highlighting a clear need to increase awareness about their role in inducing myasthenia gravis or myasthenia-like symptoms.

Immune Checkpoint Inhibitors: An Innovation in Immunotherapy for the Treatment and Management of Patients with Cancer.

Cancer survival rates are generally increasing in the United States. These trends have been partially attributed to improvement in therapeutic strategies. Cancer immunotherapy is an example of one of the newer strategies used to fight cancer, which primes or activates the immune system to produce antitumor effects. The first half of this review paper concisely describes the cell mechanisms that control antitumor immunity and the major immunotherapeutic strategies developed to target these mechanisms. The second half of the review discusses in greater depth immune checkpoint inhibitors that have recently demonstrated tremendous promise for the treatment of diverse solid tumor types, including melanoma, non-small cell lung cancer, and others. More specifically, the mechanisms of action, side effects, and patient and family management and education concerns are discussed to provide oncology nurses up-to-date information relevant to caring for cancer-affected patients treated with immune checkpoint inhibitors. Future directions for cancer immunotherapy are considered.

Checkpoint Inhibitors: Common Immune-Related Adverse Events and Their Management
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BACKGROUND: Immunotherapy, specifically the use of checkpoint inhibitors, offers patients with cancer an alternative to chemotherapy, targeting different pathways to destroy cancer cells. The side effects of immunotherapies, as well as their impact on normal tissue, need to be assessed and managed based on their mechanisms of action. OBJECTIVES: This article presents an overview of immune-related adverse events (AEs). 
. METHODS: Common immune-related toxicities, as well as rare and refractory toxicities, are reviewed. 
. FINDINGS: Immunotherapy treatment is an option for many patients with cancer, and nurses must understand the distinct side effect profile of these agents. Prompt identification and expert management are the cornerstones of success when dealing with immune-related AEs, and oncology nurses play a key role in improving patient care.

Understanding and Managing Immune-Related Adverse Events Associated With Immune Checkpoint Inhibitors in Patients With Advanced Melanoma.

The immune checkpoint inhibitors ipilimumab, nivolumab, and pembrolizumab represent a substantial improvement in treating advanced melanoma but are associated with adverse events (AEs) likely related to general immunologic enhancement. To ensure that patients receive optimal benefit from these agents, prompt assessment and treatment of AEs are essential. We review the efficacy and safety profiles of these immune checkpoint inhibitors and describe guidelines for managing immune-related AEs. We also present case studies describing the management of toxicities in patients receiving immune checkpoint inhibitor therapy. These cases illustrate the importance of collecting a detailed medical history when administering immunotherapy, as this information is necessary to establish baseline, inform monitoring, and determine the etiology of symptoms. Advanced practice nurses and physician assistants are uniquely positioned to educate patients on the early recognition of AEs and have an important role in establishing appropriate monitoring and open dialogue among services.