PubMed Central, : RMMJ Rambam Maimonides Medical Journal Rambam Health Care Campus 2026; 17(1): e0005. ISSN: 2076-9172Published online 2026 January 28. doi: 10.5041/RMMJ.10571

ILICI Grade	Management
Grade 1	Continue immune checkpoint inhibitors (ICI) Close monitoring Investigate other possible causes of hepatitis and withhold hepatotoxicity drugs If asymptomatic, no specific treatment is required If symptomatic, continue ICI unless symptoms are concerning or worsening. Give symptomatic treatment and frequent monitoring. Manage as grade 2 if clinical condition worsens
Grade 2	Temporarily withhold ICI Investigate other possible causes of hepatitis and withhold hepatotoxicity drugs Initiate prednisone 0.5–1.0 mg/kg/day Monitor liver function every 3 days If no improvement, consider liver biopsy and start adding immunosuppressant If there is improvement, begin gradual steroid taper over 4–6 weeks Consider ICI rechallenge after resolution, with close monitoring
Grade 3	Permanently discontinue ICI Investigate other possible causes of hepatitis and withhold hepatotoxicity drugs Hospitalization and close monitoring Start IV methylprednisolone 1–2 mg/kg/day Monitor liver function every 1–2 days Consider liver biopsy if not previously performed If no improvement, add immunosuppressant: Preferred first line, mycophenolate mofetil; preferred second line, azathioprine, tacrolimus; preferred as rescue therapy, anti-thymocyte globulin Once improved to grade ≤1, begin gradual steroid taper over 4–6 weeks
Grade 4	Same management as grade 3 IV methylprednisolone can be considered, starting at 2 mg/kg/day Monitor liver function daily