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Review
. 2025 Dec;51(12):2289-2304.
doi: 10.1007/s00134-025-08155-x. Epub 2025 Oct 22.

Life-threatening immune-related adverse events in the intensive care unit: a narrative review

Samuel Pichon #  1 , Ghadi Zebian #  2   3 , Côme Bureau  4 , Clémentine Levy  4 , Charlotte Lacombe  4 , Eve Desmedt  5 , Pauline Wils  6 , Emilie Merlen  7 , Arnaud Lionet  8   9 , Louis Terriou  10 , Aurore Collet  6   11 , Emmanuel Ledoult  10 , Helene Zephir  12 , Massih Ningarhari  13 , Vincent Sobanski  10   14 , Arnaud Scherpereel  15 , Alexandra Forestier  16 , David Launay #  10 , Mercedes Jourdain #  17
Affiliations
Review

Life-threatening immune-related adverse events in the intensive care unit: a narrative review

Samuel Pichon et al. Intensive Care Med. 2025 Dec.

Abstract

Background: Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment by significantly improving survival across various malignancies. However, they are associated with immune-related adverse events (irAEs), resulting from excessive immune activation. Some irAEs can be life-threatening and require intensive care unit (ICU) management. These toxicities involve cardiovascular, pulmonary, hepatic, gastrointestinal, neurologic, endocrine, and hematologic systems and often occur early in the ICI course. As ICI become increasingly integrated into earlier phases of cancer care, intensivists must be prepared to manage irAEs.

Design: Narrative review objectives: To summarize the evolving evidence on the epidemiology, diagnosis, and management of severe irAEs requiring intensive care by looking for the most relevant articles up to August 2025. The review emphasizes (1) the rationale and timing for immunosuppression beyond corticosteroids, (2) the integration of hemodynamic and organ support strategies, and (3) the importance of multidisciplinary coordination between oncology and critical care teams.

Results: Early recognition, structured diagnostic evaluation, and multidisciplinary management are key to optimizing outcomes. Although overall mortality remains high-particularly in myocarditis and multisystem involvement-timely diagnosis and individualized immunosuppressive therapy can improve survival. Rechallenge with ICIs may be cautiously considered in selected patients after full clinical recovery and comprehensive risk assessment. This review aims to support intensivists facing this emerging clinical scenario by synthesizing current evidence and practical strategies for balancing immune modulation with oncologic efficacy in the ICU setting.

Keywords: Cancer immunotherapy; Cancer patients; Immune toxicity; Immune-related adverse events; Intensive care unit; Life-threatening.

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Conflict of interest statement

Declarations. Conflicts of interest: DL reports consultancies from CSL, Takeda and Biocryst outside the submitted work. VS reports consultancies and speaking fees from Boehringer-Ingelheim, EDF, Fresenius Kabi, Grifols, Ultragenyx (less than 10,000$) and research support from Grifols, outside the submitted work. Ethical approval and consent to participate: Not applicable.

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