Abstract
Background
In recent years, a new type of immediate hypersensitivity reaction known as cytokine release began to emerge, and within this phenotype of reactions, interleukin-6 is the most frequently associated with the presence during drug administration. Chemotherapeutic agents (QT) and monoclonal antibodies.
Objective
Determine interleukin-6 levels in hypersensitivity reactions to QT and monoclonal antibodies.
Methods
Observational and prospective study that was carried out from March 1, 2021 to March 1, 2022 in a university hospital in northeastern Mexico. Symptoms, severity, interleukin-6 levels, and skin tests of hypersensitivity reaction were evaluated at QT and monoclonal antibodies.
Results
A total of 41 patients with oncological disease were included, the most frequent being ovarian cancer. Symptoms as initial hypersensitivity reaction were neuromuscular in taxanes and cutaneous in Platinums.
41.5% presented elevation of interleukin-6, and it was found more frequently in presence of metastases. Positive skin tests were found more frequently in the carboplatin and doxorubicin groups. The most frequently presented phenotype was type I in paclitaxel, carboplatin, and doxorubicin, and mixed-reaction (type I and cytokine release) in oxaliplatin.
Conclusion
With the increasing prevalence of hypersensitivity reactions to biologic and antineoplastic therapies, interleukin-6 should be recognized as a biomarker in immediate hypersensitivity reactions to QT and monoclonal antibodies.
Introduction
In the last decade, there has been an increase in the incidence of hemato-oncological and autoimmune diseases, paired with the development of novel biological therapies, chemotherapeutic agents (QT) and drug combinations that have improved survival.1–4 Hypersensitivity reactions (HSRs) to these new therapies have resulted in treatment challenges and increased economic burden related to the need for second-line therapies that are many times unavailable or unattainable in the context of low and middle-income countries, such as ours. Also, recent studies have attributed to HSR a variety of presentations of signs and symptoms that were previously unrecognized and attributed as side effects or toxicity associated with the drug. 5
Drug HSRs are labeled according to the Gell and Coombs classification. Type I reactions can be immunoglobulin E (IgE) and non-IgE mediated, which are triggered by mast cell degranulation, and the biomarkers involved in these reactions are histamine and tryptase. 6 The symptoms and signs related to this type of reaction are flushing, pruritus, urticaria, angioedema, throat tightness, shortness of breath, dyspnea, nausea, vomiting, diarrhea, tachycardia, hypotension, and cardiovascular collapse. These usually present within the first hour after exposure.7–10 In IgE-mediated type I HSR to drugs, positive skin tests, followed by elevated serum tryptase levels during the acute reaction, can be used as biomarkers.1,2,11 Type II and III HSR are also mediated by antibodies, while type IV HSR are mediated by T lymphocytes, characterized by late-onset clinical manifestations, from 12 h to days or weeks after drug exposure.12,13
New approaches to better understand drug hypersensitivity involve the characterization of reactions by phenotype, endotype, and positive biomarkers. 14 Phenotypes are defined by clinical presentation, and endotypes refer to the cellular and molecular mechanisms of HSR, defined by biomarkers such as positive skin tests and elevation of tryptase and interleukins (ILs). 15
According to the new pathways of anaphylaxis, HSR to QT and monoclonal antibodies (mAbs) can occur due to three types of pathological mechanisms: Type I HSR mediated and not mediated by IgE, by release of cytokines, and mixed reactions (IgE/non-IgE mediated and released cytokines).5,16–18 These new immunological mechanisms were previously associated with the presence of vague atypical symptoms such as chills, fever, rigors, headache, back pain, general malaise, followed by hypotension, desaturation, and cardiovascular collapse, as manifestations by cytokine release, which are mediated by T cells, macrophages and monocytes.19–22
Cytokine release reactions are caused by the release of proinflammatory mediators, such as tumor necrosis factor α (TNF-α), IL-1B, and IL-6. 5 IL-6 is a soluble mediator with a pleiotropic effect on inflammation, immune response, and hematopoiesis. 23 The role of IL-6 has been linked to various inflammatory and autoimmune diseases, such as rheumatoid arthritis, juvenile idiopathic arthritis, hematological entities, infections (e.g., coronavirus disease 2019), as well as drug allergy, food allergy, and anaphylaxis. 24 Levels of other serum inflammatory mediators may be increased in patients with cytokine storm-like reactions and anaphylaxis, but their sensitivity or specificity has not been well-documented. 5 IL-6 is an excellent biomarker of cytokine storm reactions due to its correlation with the severity of the reaction and its longevity in blood serum. 25 The aim of this study is to determine the levels of IL-6 in HSR to QT and mAbs.
Methods
Study design
We performed an observational, prospective study where we recruited patients who presented HSR after QT or mAb infusions from March 2021 to March 2022 at the Dr José E. González University Hospital in Monterrey, Mexico. This study was approved by the institutional research ethics committee (approval number: AL21-00005) and informed consent was obtained from all subjects who were recruited.
Patients selection
We included all patients 18 years or older who developed an HSR after receiving a QT or mAb infusion for their underlying disease at the Oncology Department during the study period and who were referred to the Allergy and Clinical Immunology Department, at the Dr José Eleuterio González University Hospital.
Classification of the initial reaction severity and symptoms
Anaphylaxis was defined as an acute onset reaction of symptoms involving 2 or more organs or systems (cutaneous, gastrointestinal, respiratory, cardiovascular, or neurological symptoms).26–31 Symptoms and signs of HSR were classified as cutaneous (flushing, pruritus, urticaria, angioedema, and maculopapular rash), cardiovascular (chest pain, tachycardia, bradycardia, sense of impending doom, presyncope, syncope, hypertension, hypotension, and diaphoresis), respiratory (nasal congestion, rhinorrhea, dyspnea, cough, wheezing, and oxygen desaturation), oropharyngeal (throat tightness, oral, pharyngeal, or palatal pruritus), gastrointestinal (nausea, vomiting, diarrhea, and abdominal pain), neuromuscular (disorientation, visual disturbances, vertigo, back pain, pelvic pain, headache, weakness, dizziness, paresthesia, incontinence, and seizures), and systemic atypical (fever, chills, and rigors). 32
The severity of the HSR was classified according to Brown's grading system: Grade I (mild), for cutaneous and subcutaneous involvement (erythema, urticaria, and angioedema); grade II (moderate), for respiratory, cardiovascular or gastrointestinal involvement (dyspnea, stridor, chest pain, foreign body sensation, wheezing, dizziness, presyncope, diaphoresis, abdominal pain, nausea, vomiting, and diarrhea); and grade III (severe), for hypoxia, hypotension, or neurologic compromise (cyanosis or O2 desaturation <92%, hypotension (systolic blood pressure <90 mmHg), confusion, cardiovascular collapse, loss of consciousness, or incontinence). 33
Skin testing and IL-6 measurement
We performed skin prick testing to confirm the presence of HSR by an IgE-mediated type I mechanism, by placing a drop of the QT or mAb agent in the volar surface of the forearm, and a puncture with a Duotip® device. For intradermal tests, dilutions for skin tests were based on previously recommended non-irritant concentrations,
32
with 0.05 mL of a 1:100 dilution, followed by 1:10 dilutions in case the previous result was negative. The concentrations used for skin prick and intradermal testing are stated as follows:
Concentrations for skin prick testing: Paclitaxel (6 mg/mL), docetaxel (20 mg/mL), carboplatin (10 mg/mL), oxaliplatin (5 mg/mL), cisplatin (1 mg/mL), doxorubicin (2 mg/mL), etoposide (20 mg/mL), gemcitabine (100 mg/mL), nivolumab (10 mg/mL). Concentrations for intradermal testing: Paclitaxel (0.06 mg/mL and 0.6 mg/mL), docetaxel (0.2 mg/mL and 2 mg/mL), carboplatin (0.1 mg/mL and 1 mg/mL), oxaliplatin (0.05 mg/mL and 0.5 mg/mL), cisplatin (0.01 mg/mL and 0.1 mg/mL), doxorubicin (0.02 mg/mL and 0.2 mg/mL), etoposide (0.2 mg/mL and 2 mg/mL), gemcitabine (1 mg/mL and 10 mg/mL), nivolumab (0.1 mg/mL and 1 mg/mL).
2
Skin tests were performed at least 2 weeks after the initial HSR to minimize false-negative results. A positive reaction was defined as a wheel with a diameter of at least 3 mm larger than that produced by a negative control (saline solution), and a histamine positive control (10 mg/mL).
32
For measuring serum IL-6 levels, 5 ml of whole peripheral blood was obtained in tubes without anticoagulant from the patients during the HSR to QT or mAb, as well as 2 weeks after (before skin testing). The samples were centrifuged at 3500r/min at room temperature, and the serum was separated. These were stored at −20 °C for a period of no more than 12 months and were not thawed more than once.
For this study's purposes, we will refer to the IL-6 measurement during HSR as HSR IL-6 and the later measurement as basal IL-6. An elevated or high IL-6 was considered when IL-6 was above 7 pg/mL. 19 IL-6 levels from samples were measured by a chemiluminescence method using the IL-6 Elecsys® test according to manufacturer instructions and reeded in the Roche Cobas e411 analyzer (Roche Diagnostics International, Basel Switzerland).
Statistical analysis
The statistical analysis was carried out using the IBM SPSS Statistics for Windows, Version 25.0 software package (IBM Corp., Armonk, NY, USA). Descriptive statistics were undertaken using frequency and proportions for categorical variables and median and interquartile range for quantitative variables to summarize clinical and sociodemographic characteristics, as well as data regarding information provision about initial HSR and the desensitization experience. A non-parametric distribution of continuous variables was confirmed by the Kolmogorov–Smirnov test. Pearson's chi-square and Fisher's exact tests were used for exploring differences according to the most frequently employed chemotherapeutic agents, as appropriate. Statistical significance was set at p < 0.05.
Results
Patient characteristics
A total of 41 patients were included. Patients’ median age was 48 (39–58) years, 36 (87.8%) women and 5 (12.2%) men. All patients were treated for malignancies, the most frequent were breast (36.6%), ovarian (26.8%), colon (7.3%), and cervical (7.3%). Other patients’ baseline characteristics were reported in Table 1.
Patients’ baseline characteristics.
Symptoms that occurred most frequently during the initial HSR according to the administered agent were neuromuscular in 100% and 87.5% of patients with HSR to oxaliplatin and paclitaxel, respectively; cutaneous in 100%, 83.3%, and 75% of patients with HSR to carboplatin, docetaxel and doxorubicin respectively; and respiratory in 100% of those with HSR to oxaliplatin (Figure 1).
Symptoms during the breakthrough hypersensitivity reaction (HSR).
Overall, 17 (41.5%) patients presented an elevated IL-6 during their breakthrough HSR event. We did not find any differences in associated drugs, prick test positivity, HSR severity and symptoms, atopy history, and QT cycle in which HSR was administered. However, we observed a trend of a higher proportion of men (23.5% vs. 4.2%, P = 0.084) and the presence of metastasis (58.8% vs. 29.2%, P = 0.057) in patients with high IL-6, compared to those with normal levels. After measuring IL-6, we observed that no patients with high IL-6 had previously documented HSR to taxanes, while a higher proportion of patients with high IL-6 had previous HSR to platinum-based drugs (40% vs. 28.6%) and other QT (60% vs. 11.4%, P = 0.011). Also, there continued to be a trend of higher proportion of patients with metastasis under the high basal IL-6 group (80% vs. 37.1%, P = 0.093) (Table 2).
Factors related to high IL-6 levels during the breakthrough HSR and baseline measurement two weeks after the initial HSR.
IL-6: interleukin-6; HSR: hypersensitivity reactions; QT: chemotherapy.
There was a significantly higher proportion of patients that presented high IL-6 during the breakthrough HSR but not during the basal measurement 2 weeks after (41.5% vs. 12.5%, P = 0.003). We observed that this was similar in patients who had HSR to taxanes (31.8% vs. 0%, P = 0.005) and platinum drugs (58.3% vs. 16.7%, P = 0.045), but not with other QT (P = 0.704) (Table 3).
Overall change in IL-6 elevation after the breakthrough HSR.
IL-6: interleukin-6; HSR: hypersensitivity reactions.
After classifying HSR according to the involved positive biomarkers, patients with HSR related to carboplatin and doxorubicin presented the highest percentage of positive skin tests (71.4% and 75%, respectively), while oxaliplatin was the drug group that was associated with the highest increase in IL-6 (in 75%). Patients who presented HSR to cisplatin, gemcitabine, and etoposide presented elevated IL-6, while in those with HSR to nivolumab, skin tests, and IL-6 were negative (Table 4).
Positive biomarkers in patients who presented HSR according to QT and mAb..
HSR: hypersensitivity reactions; QT: chemotherapy; mAb: monoclonal antibodies.
IL-6 was elevated in 17 (41.5%) of the 41 patients, of whom 76.5% presented moderately severe Brown grade II symptoms, and 35.3% had positive skin tests (Table 5).
Patients with elevated IL-6 during HSR to QT.
IL-6: interleukin-6; HSR: hypersensitivity reactions; QT: chemotherapy; +: positive; –: negative.
Paclitaxel, carboplatin, and doxorubicin we related to a type I HSR phenotype in 75%, 57.1%, and 75%, respectively, while oxaliplatin was associated with a mixed reaction phenotype (type I and cytokine release), in 75% (Figure 2).
Phenotype, endotype and biomarkers in hypersensitivity reactions to chemotherapy (QT).
Discussion
We present the results of the measurement of IL-6 and skin tests in HSR of QT and mAb in 41 patients. Skin testing is an in vivo diagnostic test that determines an IgE-mediated immune mechanism. In recent years, new anaphylaxis pathways have been suggested, as well as phenotypes, endotypes, and biomarkers involved in HSR, mediated by cytokine release.
The patients who developed HSR after the application of QT and mAb were recruited for 12 months, and IL-6 levels and skin tests were determined.
Our study evaluated the signs and symptoms of HSR, classification of severity by the Brown scale, 33 and determination of biomarkers involved.
The drugs that showed the most HSR were paclitaxel and carboplatin since it is the first-line treatment for gynecological tumors such as breast and ovarian cancer, which are the most frequent oncological pathologies in our study population.
The symptoms most frequently associated with carboplatin are cutaneous, 1 while respiratory and neuromuscular symptoms (rigors) are those found with the highest incidence in oxaliplatin. 34 On the other hand, one of the symptoms that has been most closely related to the administration of paclitaxel is back pain. 35 These results are similar to those found in our population.
During the analysis of the elevation of IL-6 we found that this biomarker was present during the HSRs of all groups of drugs: Taxanes, Platinums, and mAbs; and in the same way, they were found elevated in patients with the metastatic oncological disease, as a biomarker present in inflammatory processes, 36 as well as in the male population, although the groups compared to women are not homogeneous.
Skin tests were positive in most of the patients with HSR to carboplatin, demonstrating an immunological mechanism mediated by IgE,37–40 but they were also positive in a large number of patients with HSR to doxorubicin.
Finally, the phenotypes, endotypes, and biomarkers in HSRs to chemotherapeutics were mostly mediated by a type I immune mechanism, similar published by Isabwe 19 in the group of mAbs.
As limitations, we found that IL-6 levels were higher in patients who presented HSRs to taxanes and platinums, but we could not verify this in other chemotherapeutics since the study groups were not the same, and analysis between combined therapies was not performed. Furthermore, the only mAb that we determined measurement of this biomarker was nivolumab.
Patients with metastatic disease presented higher levels of IL-6, although it has been evidenced in other autoimmune pathologies, and more future studies are needed to clarify this correlation and measure other biomarkers such as IL-1B and TNF-α.
Conclusion
With the increasing prevalence of HSRs to biologic and antineoplastic therapies, IL-6 should be recognized as an immediate biomarker for chemotherapeutics and mAbs.
The personalized analysis of drug allergy through signs and symptoms presented, the cells involved, and biomarkers, will allow us to carry out a precision medicine approach, diagnosis, and treatment.
Summary box
In recent years, IL-6 has gained prominence in its role in inflammatory, infectious, and autoimmune diseases, as well as a biomarker in HSRs to chemotherapy and mAbs. The approach using in vitro biomarkers such as IL-6 opens a gap in molecular diagnosis and its role in the cytokine storm during HSRs to chemotherapy and mAbs.
Footnotes
Acknowledgments
No organizations have made contributions to the research of the manuscript. A special acknowledgment to the Allergy and Clinical Immunology Service and Oncology Service of the University Hospital “Dr José Eleuterio González”, Faculty of Medicine of the Autonomous University of Nuevo León for making this study possible.
Authors’ contributions
RVG, SGD, and OVG designed the study. RVG and CDD wrote the manuscript. RVG, MLGR, and DCPI contributed to data collection. CDD performed the statistical analysis. RVG and CDD performed interpretation of the results. SGD, OVG, MLGR, and DCPI performed critical analysis and review. All authors read and approved the final manuscript.
Availability of data and materials
If you require access to the data, you can contact the corresponding author.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval
Research was conducted ethically in accordane with the Declaration of Helsinki. This was not a human or animal study, therefore informed consent was not required. It was approved by the Bioethics and Research Committee of the Faculty of Medicine and University Hospital of the Autonomous University of Nuevo León with the approval code RVS21-009.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
