Monitoring and Management of the Patient with Immune Checkpoint Inhibitor-Induced Inflammatory Arthritis: Current Perspectives

Abstract

In this review, we draw from observational studies, treatment guidelines and our own clinical experience to describe approaches to monitoring and management of immune checkpoint inhibitor (ICI)-induced inflammatory arthritis, including polymyalgia rheumatica. This condition occurs in about 4% of ICI-treated cancer patients and can persist for a year or longer. Mild arthritis can generally be managed with non-steroidal anti-inflammatory drugs, intraarticular steroids injections and/or low dose corticosteroids. Higher grade arthritis should be brought under control with corticosteroids, but early introduction of a steroid-sparing agent is recommended to minimize steroid toxicity. In order to assess the effectiveness of any arthritis treatment, tender and swollen joint counts and patient reported measures of physical function, such as the health assessment questionnaire, should be obtained at each visit. Referral to a rheumatologist is recommended for patients with high grade arthritis to help guide the use of disease-modifying antirheumatic drugs.

Rapid identification of inflammatory arthritis and associated adverse events following immune checkpoint therapy: a machine learning approach

“…Twenty-two of the 55 top codes were determined to be relevant to ICI-IA including lab and procedure codes for ESR, CRP, and rheumatoid factor, diagnosis codes for joint pain, and medication codes for steroids. These factors are consistent with the ICI-IA literature regarding ICI-IA presentation, diagnostic tests, and therapy (27,29,37,49). The density of ICI-IA relevant codes in the group of features with the highest feature importancethe top 8 codes were ICI-IA relevant codesindicates that our strategy constructed a clinically sensible model to capture ICI-IA relevant information without manual guidance on which codes should be used, increasing the credibility of the other unexpected key EHR codes we found.…”

Rheumatic complications of checkpoint inhibitors: Lessons from autoimmunity

“…However, as there is a high risk of irAE‐arthritis persistence after cessation of treatment (around 49% at 6 months), 57 there is likely to be greater use of more targeted therapies in future. To date multiple agents have shown efficacy, including anti‐TNF, 58 anti‐IL6R (tocilizumab), 59 and tofacitnib (JAK inhibitor), 60 but numbers are small. There is evidence to suggest the IL17/23 axis is active in irAE‐arthritis with enrichment of Th17 cells, but there has been a reticence to target this pathway because of a concern that it can negatively affect anti‐tumor immunity 61 .…”