Immune-mediated colitis and diarrhoea
Inflammation of the bowel caused by immunotherapy releasing the immune system against the gut lining, producing diarrhoea that can be severe. It is the commonest serious side effect of CTLA-4 antibodies and is treated with steroids and, if needed, infliximab.
Colitis occurs in 10-15% of patients on ipilimumab (higher with nivolumab combination) and 1-3% on PD-1 antibodies alone, typically 6-8 weeks in; grade 3 diarrhoea (≥7 stools/day over baseline) requires holding treatment and high-dose steroids, with infliximab or vedolizumab for refractory cases, and perforation is the feared complication. Faecal microbiota transplantation has reversed refractory colitis in case series, and the gut microbiome influences both colitis risk and response. Chemotherapy and kinase inhibitors (irinotecan, capecitabine, neratinib, abemaciclib, EGFR inhibitors) cause diarrhoea by different mechanisms managed with loperamide and dose adjustment, and diarrhoea is a leading reason for stopping oral targeted drugs.
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