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Great question. In my practice many years ago in the first days of Ipi clinical trials, we too kind of did the “phone a friend” in whatever sub-specialty we needed at the time. Since that time when Ipi got FDA approved we actually set up a formal “network” of sub-specialists that had in interest in this. Since they obviously can’t see all the patients with toxicity on their own as they have their regular practices to contend with, they have done many trainings with a core group of people in their department so that they are up to speed, etc on irAE’s.
In terms of managing patients with pre-existing autoimmune conditions, we are very similar to Krista in that it depends on the condition. Sometimes this is difficult though as patients may be being managed in their community for their condition. And as such we are unable to get them in for an appointment with a subspecialist here (high demand), because their condition is stable and they won’t be offering any “value-added” to the patient. In that case we will usually connect with their specialist on the outside and/or do an e-consult.