Keytruda & Opdivo Queries

The Doctor Is In…

Dr. Richard Joseph, MD

Richard Joseph, MD, is an assistant professor of medicine/oncology at Mayo Clinic. His Hematology/Oncology fellowship was completed at MD Anderson Cancer Center. He is a voting member of the NCCN (National Comprehensive Cancer Network. He belongs to Melanoma International’s Scientific Advisory Board and received MIF’s Doctor of the Year award for 2015.


» KEYTRUDA VS. OPDIVO
Is one Pd1 better than another for response rates? My doctor wants to switch me from Keytruda to Opdivo to see if I get a better response. Is there any evidence out there? Should I do it? My disease is definitely growing.

Dr. Joseph: “The response rates of Keytruda and Opdivo are very similar in trials with a RECIST response of ~40%, when used in the front line and closer to ~30%, when used in the second line or beyond. So, while a randomized study has never been performed to prospectively compare Opidivo and Keytruda, most oncologists feel these drugs are equivalent in efficacy and toxicity. In terms of switching from Keytruda to Opdivo, there is no data that I’m aware of to support this. I would consider alternative treatments including a clinical trial for patients who have progressed on anti-PD1.”
NOTE: RECIST criteria means Response Evaluation Criteria In Solid Tumors (RECIST) is a set of published rules that define when tumors in cancer patients improve (“respond”), stay the same (“stabilize”), or worsen (“progress”) during treatment.

» GOING OFF KEYTRUDA
I am NED after nearly going into hospice with widespread disease and now have been on Keytruda for 9 months. I have decided to go off of it and my doctor says it is okay. Do you think this is a safe path? I feel I can just go back on it if I have progression of disease.

Dr. Joseph: “This is a very important question without a great answer at present. My opinion is that once a patient has a nice response to Keytruda, additional doses may not be necessary. Hopefully prospective trials will look exactly at this question so we can all figure out how much immunotherapy is enough. I also agree that if you disease were to resume growth, there is some data to support it will respond upon resuming the Keytruda. “

» PRE-EXISTING CONDITIONS
I have an auto-immune disease (lupus) pre-existing to my melanoma, can I go on PD1 or will I have issues. My doctor is unsure. He feels that IPI is definitely not in my cards but PD1 might be okay?

Dr. Joseph: “Another great question with not a lot of data to guide us. There are many reports out there of patients trying anti-PD1 or anti-CTLA4 agents with a history of auto-immune disorders and the results are mixed. At this point, I think it is too soon to know how safe the drugs are in the setting of auto-immunity. When pressed to make these decisions, I review with the patient the pros and cons of trying immunotherapy and together we make a decision. I do think if anti-PD1 causes an auto-immune flare, this can likely be reversed with immunosuppressants. “

»SIDE EFFECTS
My disease seems to be gone, but I have side effects from the Keytruda of exhaustion, leg pain and chest pain. What can I do to alleviate these?

Dr. Joseph: “I see this quite often. I’ve had mixed success with low dose steroids in relieving a lot of these symptoms with a plan then to continue tapering down the steroids. In addition, I would encourage your physician to look for a possible thyroid or adrenal disorder that might be causing these symptoms.”

Do you have a question you would like to have considered for the next column? Email cpoole@melanomainternational.org.

7 responses to “Keytruda & Opdivo Queries”

  1. Avatar Janice Nader says:

    I am on Keytruda and had my first PET on 1/25. My lung nodules are disappearing and I am thrilled about that. However, while I have had no side effects except for an occasional skin sore, the inside of my mouth feels like ground chuck and it hurts when I brush my teeth. Have you heard of this? Any suggestions?

  2. Avatar Michele says:

    My father has had 3 infusions of Keytruda with little response, in fact, disease is progressing. He was started on MEK 1mg day in addition to Keytruda. Do you think this is the appropriate treatment option?
    Thank you

  3. Avatar Lorraine says:

    Good Morning, My husband has been on Keytruda over the past 12month and was taken off due to side effects etc. On reading above a person went off Keytruda onto MEK – Could you please explain as to what this treatment is. Is he able to try Nivo.??? or is there any treatment that he would be able to have, as he has been fighting Melanoma for nearly 4 years, and still fighting. Thanking You

    • Catherine Poole Catherine Poole says:

      MEK is one of the targeted therapies normally combined with a BRAF drug. I am guessing your husband is BRAF negative? If NRAS positive MEK might be an option. As I have offered before, you can email me personally and I will be happy to navigate you.

      • Avatar Mohnish says:

        Hi I have been diagnosed with stage 4 melanoma had 5 infusion of keytruda 100 mg kindly suggest best treatment if u have some idea

  4. Avatar Jon Erickson says:

    In 2012 I had a purple and black spot on my right bicep which my incompetent doctor ignored over 10 months. I finally demanded another doctor look at it and he took immediate action and did a biopsy. Two weeks later I had major surgery and lost a big chunk of my arm. (Good doctor but lousy seamstress.) Three years later, I lost my voice and examinations revealed a tumor in my lymph node in my lung pressing against my vocal chord nerve. I went on keytruda February 2016 at 3 week and then 4 week intervals. Only side effects, nausea which I treated with Diet Coke and diarrhea some days 8 or 10 times a day and sometimes not at all. (I was tired some but that I attribute to old age (I’m 72.) In August of this year the CT scan revealed the tumor was gone as well as some minor spots on my liver. Now I am trying to decide on my future action. I could continue 1. every four weeks. 2. extend to 5 or 6 weeks. 3. go off infusions all together. If I go off, can I start up again if something shows up in future CT scans? I have always been healthy, don’t get colds or flue but once every 6 years. I am type 2 diabetic but this whole thing seriously rattled me at first and yet, has hardly been an inconvenience. Any information that might help me decide on my future path??? So far I feel damn lucky and very blessed.

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