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PD-L1 Inhibitor Pregnancy: Contraindicated — PD-L1 inhibition disrupts fetal tolerance; effective contraception during and for 5 months after treatment

Atezolizumab

Brand names: Tecentriq

Adult dose

Dose: 1200 mg IV every 3 weeks or 1680 mg IV every 4 weeks
Route: Intravenous infusion over 60 minutes (30 minutes if first dose tolerated)
Frequency: Every 3 weeks or every 4 weeks
Max: 1680 mg per dose (4-weekly flat dosing)
Metastatic urothelial carcinoma — cisplatin-ineligible with PD-L1 IC ≥5% (first-line) or post-platinum; NSCLC (non-GU use); continue until progression or unacceptable toxicity

Paediatric dose

Dose: Not established for urothelial carcinoma N/A/kg
Route: N/A
Frequency: N/A
Max: N/A
Not licensed for GU malignancies in paediatrics

Dose adjustments

Renal

No dose adjustment required

Hepatic

No dose adjustment for mild impairment; moderate-severe: limited data

Paediatric weight-based calculator

Not licensed for GU malignancies in paediatrics

Clinical pearls

  • IMvigor210 trial (Rosenberg et al. Lancet 2016): atezolizumab achieved 15% ORR in platinum-refractory metastatic UC, with durable responses in responders — first PD-L1 inhibitor approved in bladder cancer; IMvigor211 (NEJM 2018): did not meet OS endpoint vs chemotherapy in unselected population
  • PD-L1 testing difference: atezolizumab uses IC (immune cell) scoring system (Ventana SP142 assay) — PD-L1 IC ≥5% selects for first-line cisplatin-ineligible patients; different from PD-L1 CPS scoring used for pembrolizumab; assay selection matters
  • MHRA 2022 update: first-line use restricted to PD-L1 IC ≥5% following IMvigor130 showing no OS benefit in unselected patients; pembrolizumab (CPS ≥10, KEYNOTE-361) and atezolizumab (IC ≥5%) are both options in cisplatin-ineligible first-line UC
  • Mechanism distinction: atezolizumab targets PD-L1 (the ligand), while nivolumab/pembrolizumab target PD-1 (the receptor) — theoretical advantage: blocking PD-L1 preserves PD-L2 signalling (which regulates pulmonary tolerance) potentially reducing pneumonitis; not consistently demonstrated clinically
  • Cross-resistance: patients progressing on PD-1 inhibitor may not benefit from PD-L1 inhibitor (and vice versa) — checkpoint cross-resistance is well-established; clinical trials preferred for this population

Contraindications

  • Active severe autoimmune disease
  • Known hypersensitivity

Side effects

  • Immune-mediated adverse events (pneumonitis, colitis, hepatitis, endocrinopathies)
  • Fatigue
  • Nausea
  • Infusion reactions
  • Rash

Interactions

  • Corticosteroids — reduce efficacy if used prophylactically; use only for irAE management
  • Live vaccines — avoid

Monitoring

  • PD-L1 IC testing (companion diagnostic before first-line use)
  • TFTs, LFTs, creatinine (each cycle)
  • Chest imaging if respiratory symptoms
  • GI symptoms
  • Infusion reactions (first 3 infusions)

Reference: BNFc; BNF 90; IMvigor210 (Rosenberg et al. Lancet 2016); IMvigor211 (Powles et al. NEJM 2018); IMvigor130; MHRA SPC Tecentriq; NICE TA525; EAU Bladder Cancer Guidelines 2024. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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