Atezolizumab and bevacizumab as first line therapy in advanced hepatocellular carcinoma: Practical considerations in routine clinical practice

Table 4 Advanced hepatocellular carcinoma in special subset of population with absolute and relative contraindication for atezolizumab and bevacizumab combination

Special population	Absolute contraindication for atezolizumab and bevacizumab combination	Relative contraindication for atezolizumab and bevacizumab combination	Comments
Solid organ transplantation	Yes	N/A	If HCC in patients with liver transplant, transplant rejection can be potentially lethal. Sorafenib or lenvatinib are preferred first line options
HIV patients	N/A	No data	This was an exclusion criteria in IMBrave150 trial. The NCT04487067 AMETHISTA study of atezolizumab and bevacizumab in HCC is including patients with HIV disease who are stable on HAART, with CD4+T cell count ≥ 200/µL, and an undetectable viral load
Prior or active autoimmune disease (AID)	Yes, in patients when AID including autoimmune hepatitis, reactivation can be life threatening, neurological or neuromuscular disorders, poorly controlled AID on high dose immunosuppression	Can be used after discussion with patients and care givers about risk and benefit if do not fall in subgroups described in absolute contraindications	Patients with symptomatic AID are at higher risk for flare. Sorafenib or lenvatinib are preferred first line options in such patients
Inflammatory bowel disease	Bevacizumab can increase complication risk in patients with Crohn’s disease with fistula	Can be used after discussion with patients and care givers about risk and benefit in patients with quiescent disease	Selective immunosuppressants like vedolizumab may be better before considering the ICP therapy
Significant cardiovascular/thromboembolic disease	N/A	Bevacizumab increases risk of HTN, thromboembolic and cardiovascular events	Can be used after discussion with patients and care givers and treating hypertension
Haemodialysis	N/A	No data available, can be considered after discussing risk and benefit and limited evidence	A recent study of 55 patients with metastatic RCC on haemodialysis showed relative safety of sorafenib, nivolumab and atezolizumab in small subgroup of patients[33]

N/A: Not applicable; HTN: Hypertension; RCC: Renal cell carcinoma; HCC: Hepatocellular carcinoma; HIV: Human immunodeficiency virus; ICP: Individualized care plan.