Article
Characteristics and treatment of rheumatic irAEs due to immune checkpoint inhibitor therapy
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Authors
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Jan Leipe
- Universitätsklinik Mannheim, V. Medizinische Klinik, Abteilung für Rheumatologie, Mannheim
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Alina Patroi
- Universitätsklinik Mannheim, V. Medizinische Klinik, Abteilung für Rheumatologie, Mannheim
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Karolina Benesova
- Universitätsklinikum Heidelberg, Innere Medizin V. Hämatologie, Onkologie, Rheumatologie, Heidelberg
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Bernhard Karl Krämer
- Universitätsklinik Mannheim, Abteilung für Nephrologie, Mannheim
| Published: | September 9, 2020 |
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Outline
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Introduction: Since immune checkpoint inhibitors (ICIs) are becoming the standard of care in a growing number of indications and prevalence of exposure to these drugs is rising among cancer patients, rheumatologists are increasingly challenged with the management of rheumatic immune-related adverse events (irAEs). Since the understanding of this unique spectrum of side effects is only just beginning, each case report describing the characteristics and patterns of rheumatic irAEs gives a valuable insight into these challenging entities.
Methods: In this observational study, six patients affected by rheumatic irAEs due to ICI therapy were evaluated regarding demographics, ICI regime, time of irAE-onset, clinical characteristics, imaging and laboratory analysis.
Results: Most patients had stage IV cancer (renal cell, urothelial, non-small-cell lung, melanoma and esophagus squamous cell one case each), one had stage III B melanoma and the mean age at irAE-onset was 62 ± 15.9 years. Two of six received combination therapy of ipilimumab and nivolumab and the remaining four were treated with pembrolizumab. Arthritis was found in four patients, patterns of arthritis were monoarthritis in one, oligoarthritis in two and RA-like polyarthritis in one patient. Interestingly, two patients had new-onset of psoriatic arthritis (one presenting atypically with atlantodental synovitis). A high disease burden was reflected by withholding of ICI treatment in 3/6. The median time from start of ICI therapy to onset of irAEs was 34.04 weeks. Laboratory findings demonstrated elevated CRP in all patients, ANA positivity in 4/6 (albeit with a low titre of 1:320), rheumatoid factor positivity in 1/6 and no ACPA positivity. Patients were managed with NSAR (4/6) and glucocorticoids (5/6) and only one patient needed to be treated with methotrexate (successfully). Regarding other rheumatic irAEs, five patients additionally developed sicca syndrome.
Conclusion: In contrast to classical rheumatic diseases, patients of our cohort demonstrated partially atypical findings including atlantodental synovitis in new onset of psoriatic arthritis. All patients were successfully managed with a step-up approach (NSAR, glucocorticoids, one methotrexate), no biological DMARDs were needed.
Disclosures: None declared
