Management of rheumatic complications of immune checkpoint inhibitor therapy - an oncological perspective

Abstract

Immune checkpoint inhibitors (CPIs) are an effective treatment for many cancers but cause diverse immune-related adverse events (IrAEs). Rheumatological IrAEs include arthralgia, arthritis, tenosynovitis, myositis, polymyalgia rheumatica and sicca syndrome. CPI use can unmask RA as well as causing flares of prior autoimmune or connective tissue disease. Oncologists categorize and grade IrAEs using the Common Terminology Criteria for Adverse Events and manage them according to international guidelines. However, rheumatological events are unfamiliar territory: oncologists need to work with rheumatologists to elicit and assess symptoms, signs, results of imaging and autoantibody testing and to determine the use of steroids and DMARDs. Myositis may overlap with myasthenic crisis and myocarditis and can be life-threatening. Treatment should be offered on balance of risk and benefit, including whether to continue CPI treatment and recognizing the uncertainty over whether glucocorticoids and DMARDs might compromise cancer control.

Keywords: NSCLC; arthralgia; arthritis; immune checkpoint inhibitor; immune related adverse events; ipilimumab; melanoma; myositis; nivolumab; pembrolizumab.

Fig. 1

Evidence of rheumatological IrAEs may be observed on scans requested by oncologists In this example, PET-CT for a patient with melanoma previously treated with anti-PD-1 therapy, requested to investigate for possible oncological relapse, showed peri-articular uptake in both knees (arrows), with associated effusions, and consistent with known synovitis triggered by anti-PD-1 therapy.