Meghan J Mooradian1, Mazen Nasrallah2, Justin F Gainor1, Kerry L Reynolds1, Justine V Cohen1, Donald P Lawrence1, Eli M Miloslavsky2, Minna J Kohler2, Ryan J Sullivan1, Sara R Schoenfeld3. 1. Division of Medical Oncology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. 2. Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. 3. Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. Electronic address: srschoenfeld@mgh.harvard.edu.
Abstract
BACKGROUND: The use of immune checkpoint inhibition (ICI) has revolutionized cancer treatment. However, these medications are associated with significant and potentially debilitating immune-related adverse events (irAEs). While certain toxicities have been well studied, rheumatic complications have been less widely recognized and characterized. METHODS: We report our experience of patients who were evaluated by rheumatology after the development of a suspected rheumatic irAE following ICI treatment. Cases of rheumatic irAEs were included if active rheumatic signs or symptoms developed during or after ICI treatment and were confirmed by a treating rheumatologist. RESULTS: Twenty-nine patients were evaluated by rheumatology for suspected rheumatic irAEs. Eighteen patients had confirmed toxicity including inflammatory arthritis (n = 12) and PMR (n = 6). Twelve patients had de novo toxicity and six had a flare of a pre-existing rheumatic condition. The onset of de novo toxicity occurred late into treatment (median 38 weeks), while patients with pre-existing rheumatic disease flared soon after initiation of ICI treatment (median 4.6 weeks). Management often required systemic or intra-articular steroids, with initiation of disease modifying anti-rheumatic drug (DMARD) therapy in those unable to wean off steroids. CONCLUSION: De novo rheumatic irAEs are generally delayed in onset after ICI initiation, while flares of pre-existing rheumatic conditions occur shortly after ICI initiation. Effective management often requires systemic corticosteroids as well as DMARDs in a subset of patients. Future prospective studies are needed to accurately describe the incidence and spectrum of rheumatic irAEs and to identify the most effective management strategies.
BACKGROUND: The use of immune checkpoint inhibition (ICI) has revolutionized cancer treatment. However, these medications are associated with significant and potentially debilitating immune-related adverse events (irAEs). While certain toxicities have been well studied, rheumatic complications have been less widely recognized and characterized. METHODS: We report our experience of patients who were evaluated by rheumatology after the development of a suspected rheumatic irAE following ICI treatment. Cases of rheumatic irAEs were included if active rheumatic signs or symptoms developed during or after ICI treatment and were confirmed by a treating rheumatologist. RESULTS: Twenty-nine patients were evaluated by rheumatology for suspected rheumatic irAEs. Eighteen patients had confirmed toxicity including inflammatory arthritis (n = 12) and PMR (n = 6). Twelve patients had de novo toxicity and six had a flare of a pre-existing rheumatic condition. The onset of de novo toxicity occurred late into treatment (median 38 weeks), while patients with pre-existing rheumatic disease flared soon after initiation of ICI treatment (median 4.6 weeks). Management often required systemic or intra-articularsteroids, with initiation of disease modifying anti-rheumatic drug (DMARD) therapy in those unable to wean off steroids. CONCLUSION: De novo rheumatic irAEs are generally delayed in onset after ICI initiation, while flares of pre-existing rheumatic conditions occur shortly after ICI initiation. Effective management often requires systemic corticosteroids as well as DMARDs in a subset of patients. Future prospective studies are needed to accurately describe the incidence and spectrum of rheumatic irAEs and to identify the most effective management strategies.
Authors: Amy Cunningham-Bussel; Jiaqi Wang; Lauren C Prisco; Lily W Martin; Kathleen M M Vanni; Alessandra Zaccardelli; Mazen Nasrallah; Lydia Gedmintas; Lindsey A MacFarlane; Nancy A Shadick; Mark M Awad; Osama Rahma; Nicole R LeBoeuf; Ellen M Gravallese; Jeffrey A Sparks Journal: Arthritis Rheumatol Date: 2022-01-25 Impact factor: 10.995
Authors: Ami A Shah; Laura C Cappelli; Tawnie J Braaten; Julie R Brahmer; Patrick M Forde; Dung Le; Evan J Lipson; Jarushka Naidoo; Megan Schollenberger; Lei Zheng; Clifton O Bingham Journal: Ann Rheum Dis Date: 2019-09-20 Impact factor: 19.103