1
|
Yoshida M, Hara S, Nishioka R, Kobayashi T, Murase Y, Kimura H, Mizushima I, Kawano M. Development of Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome with Pembrolizumab for Lung Squamous Cell Carcinoma. Intern Med 2024; 63:2089-2096. [PMID: 38072406 DOI: 10.2169/internalmedicine.2475-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). There are a few case reports of remitting seronegative symmetrical synovitis with pitting edema syndrome (RS3PE) as an irAE. We herein report a 49-year-old Japanese man who developed acute-onset polyarthralgia and edema of the back of both hands and bilateral lower legs after pembrolizumab administration for lung cancer. The patient's lung cancer was in complete remission, leading to the diagnosis of RS3PE induced by pembrolizumab rather than malignancy. When patients show RS3PE during ICI treatment, rheumatologists should consider the possibility of an irAE after excluding malignancy and systemic diseases.
Collapse
Affiliation(s)
- Misaki Yoshida
- Department of Rheumatology, Kanazawa University Hospital, Japan
| | - Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Japan
- Medical Education Research Center, Graduate School of Medical Sciences, Kanazawa University, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Kanazawa University Hospital, Japan
| | | | - Yuya Murase
- Department of Respiratory Medicine, Kanazawa University, Japan
| | - Hideharu Kimura
- Department of Respiratory Medicine, Kanazawa University, Japan
| | | | | |
Collapse
|
2
|
Ghosh N, Jivanelli B, Couette N, Singh N, Kostine M, Simon Meara A, Liew DFL. The Need for Classification Criteria of Immune Checkpoint Inhibitor-induced inflammatory Arthritis: A Scoping Review. Rheum Dis Clin North Am 2024; 50:325-335. [PMID: 38670730 DOI: 10.1016/j.rdc.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA) is an immune-related adverse event that can occur as a result of receiving ICIs for cancer treatment. Thus far, ICI-IA has been described variably in the literature, in part due to varying presentations that evolve over time, as well as a lack of standardized definitions and classification. This scoping review aggregates various descriptions of ICI-IA, highlighting the most prominent attributes of ICI-IA from categories such as symptoms, signs, imaging, and laboratory findings as well as discussing potential mimic conditions.
Collapse
Affiliation(s)
- Nilasha Ghosh
- Department of Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Bridget Jivanelli
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Nina Couette
- Department of Rheumatology, Rheumatology Care Center, Genesis Healthcare System, 2525 Maple Avenue, Zanesville, OH 43701, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Marie Kostine
- Department of Rheumatology, Bordeaux University Hospital, 311 Président Wilson Boulevard, Bordeaux 33200, France
| | - Alexa Simon Meara
- Division of Oncology, Department of Medicine, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA
| | - David F L Liew
- Department of Rheumatology, Austin Health; Department of Clinical Pharmacology and Therapeutics, Austin Health; Department of Medicine, University of Melbourne, Level 1, North Wing, 300 Waterdale Road, PO Box 5444, Heidelberg West, Victoria 3081, Australia
| |
Collapse
|
3
|
Ladouceur A, Ezdoglian A, Sparks JA, Hudson M, Jamal S, Clifford A, Roberts J, Ye C. The Utility of Laboratory Investigations for the Assessment and Management of Rheumatic Immune Related Adverse Events. Rheum Dis Clin North Am 2024; 50:181-199. [PMID: 38670720 DOI: 10.1016/j.rdc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have greatly improved survival of several cancers with historically very poor prognosis. ICIs act by stimulating the patient's own immune system to fight cancer. Simultaneously, this immune activation can lead to immune-related adverse events (irAEs), including rheumatic manifestations (Rh-irAEs). Rh-irAEs mimic primary rheumatic diseases including arthritis, polymyalgia rheumatica, myositis, vasculitis, sarcoidosis, and sicca. This article summarizes the latest evidence regarding the utility of laboratory investigations in Rh-irAEs.
Collapse
Affiliation(s)
- Alexandra Ladouceur
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Aiarpi Ezdoglian
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, VU University Medical Center (VUmc), De Boelelaan 1118, Amsterdam 1081 HZ, the Netherlands
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Suite 6016U, Boston, MA 02115, USA
| | - Marie Hudson
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, Lady Davis Institute for Medical Research, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Shahin Jamal
- Arthritis Research Canada, Department of Medicine, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel Street, Ste 8205B, Vancouver, British Columbia V5Z 1M9, Canada
| | - Alison Clifford
- Faculty of Medicine & Dentistry, Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada
| | - Janet Roberts
- Division of Rheumatology, Department of Medicine, Queen Elizabeth II Health Sciences Center and Dalhousie University, Nova Scotia rehabilitation and Arthritis Centre, Arthritis Research Canada; Lady Davis Institute for Medical Research, 1341 Summer Street, Halifax, Nova Scotia B3H 4K4, Canada
| | - Carrie Ye
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada.
| |
Collapse
|
4
|
Kaushik P, Bastible S, Bannon M, Drew Williams C. Pembrolizumab-Induced Axial Spondyloarthritis. Ann Pharmacother 2024; 58:555-556. [PMID: 37365767 DOI: 10.1177/10600280231181400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
|
5
|
Zeng L, Yang K, He Q, Zhu X, Long Z, Wu Y, Chen J, Li Y, Zeng J, Cui G, Xiang W, Hao W, Sun L. Efficacy and safety of gut microbiota-based therapies in autoimmune and rheumatic diseases: a systematic review and meta-analysis of 80 randomized controlled trials. BMC Med 2024; 22:110. [PMID: 38475833 DOI: 10.1186/s12916-024-03303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/13/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Previous randomized controlled trials (RCTs) suggested that gut microbiota-based therapies may be effective in treating autoimmune diseases, but a systematic summary is lacking. METHODS Pubmed, EMbase, Sinomed, and other databases were searched for RCTs related to the treatment of autoimmune diseases with probiotics from inception to June 2022. RevMan 5.4 software was used for meta-analysis after 2 investigators independently screened literature, extracted data, and assessed the risk of bias of included studies. RESULTS A total of 80 RCTs and 14 types of autoimmune disease [celiac sprue, SLE, and lupus nephritis (LN), RA, juvenile idiopathic arthritis (JIA), spondyloarthritis, psoriasis, fibromyalgia syndrome, MS, systemic sclerosis, type 1 diabetes mellitus (T1DM), oral lichen planus (OLP), Crohn's disease, ulcerative colitis] were included. The results showed that gut microbiota-based therapies may improve the symptoms and/or inflammatory factor of celiac sprue, SLE and LN, JIA, psoriasis, PSS, MS, systemic sclerosis, Crohn's disease, and ulcerative colitis. However, gut microbiota-based therapies may not improve the symptoms and/or inflammatory factor of spondyloarthritis and RA. Gut microbiota-based therapies may relieve the pain of fibromyalgia syndrome, but the effect on fibromyalgia impact questionnaire score is not significant. Gut microbiota-based therapies may improve HbA1c in T1DM, but its effect on total insulin requirement does not seem to be significant. These RCTs showed that probiotics did not increase the incidence of adverse events. CONCLUSIONS Gut microbiota-based therapies may improve several autoimmune diseases (celiac sprue, SLE and LN, JIA, psoriasis, fibromyalgia syndrome, PSS, MS, T1DM, Crohn's disease, and ulcerative colitis).
Collapse
Affiliation(s)
- Liuting Zeng
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Nanjing, China.
| | - Kailin Yang
- Hunan University of Chinese Medicine, Changsha, China
| | - Qi He
- People's Hospital of Ningxiang City, Ningxiang, China
| | | | - Zhiyong Long
- Department of Rehabilitation Medicine, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Yang Wu
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | | | - Yuwei Li
- Hunan University of Science and Technology, Xiangtan, China
| | - Jinsong Zeng
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ge Cui
- Department of Epidemiology and Statistics, School of Public Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wang Xiang
- Department of Rheumatology, The First People's Hospital Changde City, Changde, China
| | - Wensa Hao
- Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Nanjing, China.
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
| |
Collapse
|
6
|
Jungbauer F, Affolter A, Brochhausen C, Lammert A, Ludwig S, Merx K, Rotter N, Huber L. Risk factors for immune-related adverse effects during CPI therapy in patients with head and neck malignancies - a single center study. Front Oncol 2024; 14:1287178. [PMID: 38420014 PMCID: PMC10899674 DOI: 10.3389/fonc.2024.1287178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Checkpoint inhibitors, such as PD1 inhibitors, represent an important pillar in the therapy of advanced malignancies of the head and neck region. The most relevant complications are immune-related adverse effects (irAEs), which represent an immense burden for patients. Currently, no sufficient stratification measures are available to identify patients at increased risk of irAEs. The aim of this retrospective study was to examine whether demographic, histopathological, clinical, or laboratory values at the start of CPI therapy represent a risk factor for the later occurrence of autoimmune complications. Material and methods Data from 35 patients between 2018 and 2021 who received therapy with nivolumab or pembrolizumab for head and neck malignancy were analyzed and assessed for any associations with the subsequent occurrence of irAEs. Results IrAE developed in 37% of patients, with pneumonitis being the most common form (14%). Pneumonitis was found in patients with an average significantly lower T-stage of primary tumors. An increase in basophilic leukocytes was found in patients with dermatitis later in the course. When thyroiditis developed later, the patients had a higher CPS score and lower monocyte levels. Discussion Even though individual laboratory values at the beginning of therapy might show a statistical association with the later occurrence of irAEs, neither demographic, histopathological, nor laboratory chemistry values seem to be able to generate a sound and reliable risk profile for this type of complication. Therefore, patients need to be educated and sensitized to irAEs, and regular screening for irAEs should be carried out.
Collapse
Affiliation(s)
- Frederic Jungbauer
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Annette Affolter
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Brochhausen
- Department of Pathology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Lammert
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Sonja Ludwig
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Kirsten Merx
- Department of Hematology and Oncology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Rotter
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Lena Huber
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| |
Collapse
|
7
|
Zhao J, Dou Y, Liang G, Huang H, Hong K, Yang W, Zhou G, Sha B, Liu J, Zeng L. Global Publication Trends and Research Hotspots of the Immune System and Osteoporosis: A Bibliometric and Visualization Analysis from 2012 to 2022. Endocr Metab Immune Disord Drug Targets 2024; 24:455-467. [PMID: 37881072 DOI: 10.2174/0118715303257269231011073100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/10/2023] [Accepted: 09/15/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Osteoporosis (OP) is a systemic bone metabolism disorder in which the immune system and bone metabolism interact. OBJECTIVE The purpose of this study was to explore the research status, hot spots and trends regarding the influence of the immune system on OP and to provide a basis for research directions and applications in this field. METHODS We searched and collected literature about the immune system and OP published from 2012 to 2022 in the Web of Science Core Collection database. All the included studies were subjected to bibliometrics analysis using Hiplot Pro, VOSviewer and CiteSpace software to produce statistics and visual analyses of the literature output, countries, institutions, authors, keywords and journals. RESULTS A total of 1201 papers were included, and the number of citations of these articles reached 31,776. The number of publications and citations on the immune system and OP has increased year by year. The top three countries with the greatest number of papers published were China, the United States of America (USA) and Italy. The two institutions with the largest number of papers published were Sichuan University and Soochow University, both located in China. De Martinis Massimo (Italy) and Ginaldi Lia (Italy) are prolific authors in this field. The representative academic journals are Osteoporosis International, Frontiers in Immunology, Journal of Bone and Mineral Research, PloS One and Bone. The results of the keyword cooccurrence analysis showed that the research topics in this field mainly focused on T cells, cytokines, signaling pathways, vitamin D, postmenopausal OP and immune diseases. The keyword burst results showed that zoledronic acid, chain fatty acids and gut microbiota are the frontiers and trends of future research on this topic. CONCLUSION The influence of the immune system on OP has been widely studied, and the current research in this field focuses on the effect or mechanism of immune-related cytokines, signaling pathways and vitamin D on OP. Future research trends in this field should focus on the immune regulation mechanism and clinical transformation of zoledronic acid, chain fatty acids and the gut microbiota in OP.
Collapse
Affiliation(s)
- Jinlong Zhao
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
| | - Yaoxing Dou
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
| | - Guihong Liang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
| | - Hetao Huang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
| | - Kunhao Hong
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, 510095, China
| | - Weiyi Yang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
| | - Guanghui Zhou
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Bangxin Sha
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Jun Liu
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, 510095, China
| | - Lingfeng Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
| |
Collapse
|
8
|
Sahin E, Cabuk D, Tuncer Kuru F, Yazici A. Atezolizumab-induced myositis in a patient with small-cell lung cancer. J Oncol Pharm Pract 2024; 30:220-224. [PMID: 37750202 DOI: 10.1177/10781552231203190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
OBJECTIVE Myositis, an inflammatory disease affecting muscles, is a rare and potentially fatal immune-related adverse event associated with immune checkpoint inhibitors. There are limited data on its clinical features and management. CASE PRESENTATION Atezolizumab, in combination with etoposide and carboplatin, was initiated in the patient diagnosed with metastatic small-cell lung cancer. After four cycles, maintenance atezolizumab was initiated. At the third visit of the maintenance therapy, the patient reported weakness, edema, and tightness in the muscles that had progressed over the course of a week. Mild solid-food dysphagia was also observed. Neutrophilic leukocytosis with elevated creatine phosphokinase (9234 U/L), erythrocyte sedimentation rate (111 mm/h), and transaminase levels were observed. A diagnosis of myositis was considered based on clinical findings. Atezolizumab was omitted and an oral 0.5 mg/kg/day dose of methylprednisolone was administered. The myositis resolved within 10 days. During the treatment of myositis, the patient underwent prophylactic cranial irradiation. The steroid dose was tapered off within 35 days and then atezolizumab was restarted. CONCLUSION The literature contains only a few case reports about atezolizumab-induced myositis, highlighting the challenges in defining its clinical features and management. Prompt diagnosis and treatment are crucial to prevent severe complications, such as myocarditis or respiratory muscle paralysis.
Collapse
Affiliation(s)
- Elif Sahin
- Department of Medical Oncology, Kocaeli University Faculty of Medicine, Izmit, Turkey
| | - Devrim Cabuk
- Department of Medical Oncology, Kocaeli University Faculty of Medicine, Izmit, Turkey
| | - Fatma Tuncer Kuru
- Department of Rheumatology, Kocaeli University Faculty of Medicine, Izmit, Turkey
| | - Ayten Yazici
- Department of Rheumatology, Kocaeli University Faculty of Medicine, Izmit, Turkey
| |
Collapse
|
9
|
Paroli M, Sirinian MI. When Autoantibodies Are Missing: The Challenge of Seronegative Rheumatoid Arthritis. Antibodies (Basel) 2023; 12:69. [PMID: 37987247 PMCID: PMC10660552 DOI: 10.3390/antib12040069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/25/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
Seronegative rheumatoid arthritis (SNRA) is characterized by the absence of both rheumatoid factor (RF) and antibodies against the cyclic citrullinated protein (ACPA) in serum. However, the differences between the two forms of RA are more complex and have not yet been definitively characterized. Several lines of evidences support the idea that there are specific elements of the two forms, including genetic background, epidemiology, pathogenesis, severity of progression over time, and response to therapy. Clinical features that may differentiate SNRA from SPRA are also suggested by data obtained from classical radiology and newer imaging techniques. Although new evidence seems to provide additional help in differentiating the two forms of RA, their distinguishing features remain largely elusive. It should also be emphasized that the distinctive features of RA forms, if not properly recognized, can lead to the underdiagnosis of SNRA, potentially missing the period called the "window of opportunity" that is critical for early diagnosis, timely treatment, and better prognosis. This review aims to summarize the data provided in the scientific literature with the goal of helping clinicians diagnose SNRA as accurately as possible, with emphasis on the most recent findings available.
Collapse
Affiliation(s)
- Marino Paroli
- Center for Allergy and Immunology, Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome c/o Polo Pontino, 04100 Latina, Italy
| | | |
Collapse
|
10
|
Ono S, Nakamura M, Morise S, Kunieda T, Yakushiji Y. [A case of atezolizumab- and bevacizumab-induced myositis showing high intensity in the pterygoid muscles, soft palate, and tongue on STIR-MRI]. Rinsho Shinkeigaku 2023; 63:582-587. [PMID: 37648475 DOI: 10.5692/clinicalneurol.cn-001876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
A 61-year-old woman was treated with atezolizumab plus bevacizumab for hepatocellular carcinoma with peritoneal dissemination. Blood tests revealed elevated creatine kinase (CK) that peaked at 2,657 U/l. After two cycles of atezolizumab plus bevacizumab combination therapy, she complained of progressive dysarthria and dysphagia. Needle electromyography showed myopathic changes. Initial MRI showed high signal intensity in the orbicularis oris muscle, soft palate, tongue, pterygoid muscles, and paravertebral muscles on STIR images. Myositis-specific autoantibodies were not detected. Based on these findings, the patient was diagnosed with immune checkpoint inhibitor-associated myositis. The clinical symptoms improved after administration of oral prednisone, and follow-up MRI showed reduced extent of areas of high signal intensity and almost complete resolution of signal abnormality in the paravertebral muscles. The CK level normalized after 1 months of oral steroid administration. MRI of the head and neck, including the tongue and soft palate, may be useful in diagnosis and for evaluating therapeutic efficiency in cases of bulbar symptoms that occur following the introduction of immune checkpoint inhibitors.
Collapse
Affiliation(s)
- Shohei Ono
- Department of Neurology, Kansai Medical University
| | | | | | | | | |
Collapse
|
11
|
Kähkönen TE, Halleen JM, MacRitchie G, Andersson RM, Bernoulli J. Insights into immuno-oncology drug development landscape with focus on bone metastasis. Front Immunol 2023; 14:1121878. [PMID: 37475868 PMCID: PMC10355372 DOI: 10.3389/fimmu.2023.1121878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
Bone is among the main sites of metastasis in breast, prostate and other major cancers. Bone metastases remain incurable causing high mortality, severe skeletal-related effects and decreased quality of life. Despite the success of immunotherapies in oncology, no immunotherapies are approved for bone metastasis and no clear benefit has been observed with approved immunotherapies in treatment of bone metastatic disease. Therefore, it is crucial to consider unique features of tumor microenvironment in bone metastasis when developing novel therapies. The vicious cycle of bone metastasis, referring to crosstalk between tumor and bone cells that enables the tumor cells to grow in the bone microenvironment, is a well-established concept. Very recently, a novel osteoimmuno-oncology (OIO) concept was introduced to the scientific community. OIO emphasizes the significance of interactions between tumor, immune and bone cells in promoting tumor growth in bone metastasis, and it can be used to reveal the most promising targets for bone metastasis. In order to provide an insight into the current immuno-oncology drug development landscape, we used 1stOncology database, a cancer drug development resource to identify novel immunotherapies in preclinical or clinical development for breast and prostate cancer bone metastasis. Based on the database search, 24 immunotherapies were identified in preclinical or clinical development that included evaluation of effects on bone metastasis. This review provides an insight to novel immuno-oncology drug development in the context of bone metastasis. Bone metastases can be approached using different modalities, and tumor microenvironment in bone provides many potential targets for bone metastasis. Noting current increasing interest in the field of OIO, more therapeutic opportunities that primarily target bone metastasis are expected in the future.
Collapse
Affiliation(s)
| | | | | | | | - Jenni Bernoulli
- University of Turku, Institute of Biomedicine, Turku, Finland
| |
Collapse
|
12
|
De Camps Martinez ER, Gonzalez C, Hassan H, Hassan H, Hassan F. Seronegative Rheumatoid Arthritis Secondary to Immune Checkpoint Inhibitor in a Renal Cell Carcinoma Patient Encountered in a Rural Community-Based Rheumatology Clinic: A Case Report. Cureus 2023; 15:e41394. [PMID: 37546101 PMCID: PMC10401612 DOI: 10.7759/cureus.41394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a widely used class of cancer immunotherapy. Those drugs have improved the treatment of cancer since its introduction in the 2000s. Nivolumab is an ICI that can be used for previously untreated renal cell carcinoma. Immune-related adverse events (irAEs) are a type of adverse event of immunotherapy that is associated with an overreactive immune system. We report a case of a 69-year-old Caucasian man with stage IV renal cell carcinoma who presented to a rural community-based rheumatology clinic referred by his oncologist, after starting to develop morning stiffness for at least three hours, joint swelling, warmth, and erythema five months after starting immunotherapy with nivolumab. The patient was diagnosed with seronegative rheumatoid arthritis secondary to ICIs and required a higher dose of prednisone (up to 40 mg per day) with methotrexate to achieve remission. With the widespread availability of ICIs, rheumatologic irAEs can be encountered in a rural community-based practice. Practicing physicians taking care of cancer patients need to be aware of the adverse effect of ICIs.
Collapse
Affiliation(s)
| | - Camila Gonzalez
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, USA
| | - Hamzah Hassan
- Internal Medicine, Northeast Ohio Medical University, Rootstown, USA
| | - Hafsa Hassan
- Internal Medicine, Northeast Ohio Medical University, Rootstown, USA
| | - Farooq Hassan
- Rheumatology, Trumbull Regional Medical Center, Warren, USA
| |
Collapse
|
13
|
Bouferraa Y, Fares C, Bou Zerdan M, Boyce Kennedy L. Microbial Influences on Immune Checkpoint Inhibitor Response in Melanoma: The Interplay between Skin and Gut Microbiota. Int J Mol Sci 2023; 24:ijms24119702. [PMID: 37298653 DOI: 10.3390/ijms24119702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Immunotherapy has revolutionized the treatment of melanoma, but its limitations due to resistance and variable patient responses have become apparent. The microbiota, which refers to the complex ecosystem of microorganisms that inhabit the human body, has emerged as a promising area of research for its potential role in melanoma development and treatment response. Recent studies have highlighted the role of microbiota in influencing the immune system and its response to melanoma, as well as its influence on the development of immune-related adverse events associated with immunotherapy. In this article, we discuss the complex multifactorial mechanisms through which skin and gut microbiota can affect the development of melanoma including microbial metabolites, intra-tumor microbes, UV light, and the immune system. In addition, we will discuss the pre-clinical and clinical studies that have demonstrated the influence of different microbial profiles on response to immunotherapy. Additionally, we will explore the role of microbiota in the development of immune-mediated adverse events.
Collapse
Affiliation(s)
- Youssef Bouferraa
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Callie Fares
- Faculty of Medicine, American University of Beirut, Beirut 2020, Lebanon
| | - Maroun Bou Zerdan
- Department of Internal Medicine, SUNY Upstate Medical University, New York, NY 13205, USA
| | - Lucy Boyce Kennedy
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW Immune check point inhibitors (ICIs) are a unique class of cancer treatments that harness the body's innate antitumor response. Although these medications have transformed oncology care, they also lead to generalized immune activation that can result in toxicities across a spectrum of organ systems called immune-related adverse events. This article reviews the most common rheumatologic immune-related adverse events and their management. RECENT FINDINGS Inflammatory arthritis, polymyalgia rheumatic, sicca symptoms, systemic sclerosis, myositis, and vasculitis have all been reported as ICI adverse events. Treatment includes nonsteroidal anti-inflammatory drugs, glucocorticoids, traditional DMARDs, and biologics. SUMMARY Rheumatologists have an important role in the management of patients with rheumatologic immune-related adverse events. Working with our oncology colleagues, we can help manage rheumatologic immune-related adverse events while optimally preserving ICI's antitumor effects.
Collapse
Affiliation(s)
- Melissa Defoe
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | |
Collapse
|
15
|
Dosoden N, Kuzuya T, Ito Y, Nishino J, Ohno E, Kawabe N, Hashimoto S, Hirooka Y, Yasuoka H. Polymyalgia rheumatica during combination therapy with atezolizumab plus bevacizumab for advanced hepatocellular carcinoma. Clin J Gastroenterol 2023:10.1007/s12328-023-01800-2. [PMID: 37071371 DOI: 10.1007/s12328-023-01800-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/03/2023] [Indexed: 04/19/2023]
Abstract
The combination therapy of atezolizumab, an anti-programmed cell death ligand-1 antibody, plus bevacizumab (Atz/Bev) is widely used to treat patients with advanced hepatocellular carcinoma (HCC). The development of polymyalgia rheumatica (PMR) during immune checkpoint inhibitor therapy for patients with HCC has not been reported to date. Two patients who developed PMR during Atz/Bev therapy for advanced HCC are reported. Both patients developed fever, bilateral symmetrical shoulder pain, morning stiffness, and an elevated C-reactive protein level. Their symptoms improved rapidly with prednisolone (PSL) 15-20 mg/d, and their C-reactive protein levels decreased. In PMR, long-term low-dose PSL should be administered. In the present patients who developed PMR as immune-related adverse events, starting with a small dose of PSL resulted in rapid improvement of symptoms.
Collapse
Affiliation(s)
- Naoki Dosoden
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Teiji Kuzuya
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan.
| | - Yumi Ito
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Jo Nishino
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Naoto Kawabe
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Senju Hashimoto
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| |
Collapse
|
16
|
Rheumatic Immune-Related Adverse Events due to Immune Checkpoint Inhibitors—A 2023 Update. Int J Mol Sci 2023; 24:ijms24065643. [PMID: 36982715 PMCID: PMC10051463 DOI: 10.3390/ijms24065643] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/05/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
With the aging of the population, malignancies are becoming common complications in patients with rheumatoid arthritis (RA), particularly in elderly patients. Such malignancies often interfere with RA treatment. Among several therapeutic agents, immune checkpoint inhibitors (ICIs) which antagonize immunological brakes on T lymphocytes have emerged as a promising treatment option for a variety of malignancies. In parallel, evidence has accumulated that ICIs are associated with numerous immune-related adverse events (irAEs), such as hypophysitis, myocarditis, pneumonitis, and colitis. Moreover, ICIs not only exacerbate pre-existing autoimmune diseases, but also cause de novo rheumatic disease–like symptoms, such as arthritis, myositis, and vasculitis, which are currently termed rheumatic irAEs. Rheumatic irAEs differ from classical rheumatic diseases in multiple aspects, and treatment should be individualized based on the severity. Close collaboration with oncologists is critical for preventing irreversible organ damage. This review summarizes the current evidence regarding the mechanisms and management of rheumatic irAEs with focus on arthritis, myositis, and vasculitis. Based on these findings, potential therapeutic strategies against rheumatic irAEs are discussed.
Collapse
|
17
|
Zekić T, Benić MS. Anti-programmed death-1 inhibitor nivolumab-induced immune-related adverse events: hepatitis, renal insufficiency, myositis, vitiligo, and hypothyroidism: a case-based review. Rheumatol Int 2023; 43:559-565. [PMID: 36449057 DOI: 10.1007/s00296-022-05247-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022]
Abstract
Nivolumab (NIVO) is a monoclonal antibody used to treat renal cell cancer. It is an anti-programmed death-1 (anti-PD-1) inhibitor, enhancing the tumor-targeted immune response of T lymphocytes, resulting in immune-mediated adverse events (AEs). We present five immunological AEs in a single patient treated with NIVO. A 68-year-old male patient with metastatic renal cell carcinoma and right-sided nephrectomy received NIVO after pazopanib and sunitinib treatment. Two and a half months after starting NIVO, hepatocellular enzymes and creatinine were elevated. Concomitantly, the patient noticed hypopigmentation of the hand skin and a change in voice and speech. Due to hepatitis, he has been treated with dexamethasone 16 mg daily for 22 days, after which hypothyroidism and increased creatine kinase were found without muscle pain and functional impairment. Dexamethasone was continued, and a rapid decline in all parameters except thyroid-stimulating hormone (TSH) and vitiligo was observed. Myositis was initially considered a part of hypothyroidism and elevated renal parameters due to hypohydration. The rapid regression on glucocorticoid treatment and a longer time for creatinine normalization than expected with hydration were noticed. Nivolumab likely induced those side effects as assessed by Naranjo Adverse Drug Reaction Probability Scale. The literature review shows that the consequences of PD-1 inhibition are not uniform. Side effects of checkpoint inhibitors should be monitored carefully in the early and later treatment schedules evaluating subclinical manifestations like myositis and worsening of kidney parameters. Early administered higher doses of glucocorticoids can stop drug toxicity and reverse-induced tissue damage.
Collapse
Affiliation(s)
- Tatjana Zekić
- Faculty of Medicine, Clinical Hospital Center Rijeka, Department of Rheumatology and Clinical Immunology, University of Rijeka, Rijeka, Croatia.
| | | |
Collapse
|
18
|
Dora D, Bokhari SMZ, Aloss K, Takacs P, Desnoix JZ, Szklenárik G, Hurley PD, Lohinai Z. Implication of the Gut Microbiome and Microbial-Derived Metabolites in Immune-Related Adverse Events: Emergence of Novel Biomarkers for Cancer Immunotherapy. Int J Mol Sci 2023; 24:ijms24032769. [PMID: 36769093 PMCID: PMC9916922 DOI: 10.3390/ijms24032769] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/04/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have changed how we think about tumor management. Combinations of anti-programmed death ligand-1 (PD-L1) immunotherapy have become the standard of care in many advanced-stage cancers, including as a first-line therapy. Aside from improved anti-tumor immunity, the mechanism of action of immune checkpoint inhibitors (ICIs) exposes a new toxicity profile known as immune-related adverse effects (irAEs). This novel toxicity can damage any organ, but the skin, digestive and endocrine systems are the most frequently afflicted. Most ICI-attributed toxicity symptoms are mild, but some are severe and necessitate multidisciplinary side effect management. Obtaining knowledge on the various forms of immune-related toxicities and swiftly changing treatment techniques to lower the probability of experiencing severe irAEs has become a priority in oncological care. In recent years, there has been a growing understanding of an intriguing link between the gut microbiome and ICI outcomes. Multiple studies have demonstrated a connection between microbial metagenomic and metatranscriptomic patterns and ICI efficacy in malignant melanoma, lung and colorectal cancer. The immunomodulatory effect of the gut microbiome can have a real effect on the biological background of irAEs as well. Furthermore, specific microbial signatures and metabolites might be associated with the onset and severity of toxicity symptoms. By identifying these biological factors, novel biomarkers can be used in clinical practice to predict and manage potential irAEs. This comprehensive review aims to summarize the clinical aspects and biological background of ICI-related irAEs and their potential association with the gut microbiome and metabolome. We aim to explore the current state of knowledge on the most important and reliable irAE-related biomarkers of microbial origin and discuss the intriguing connection between ICI efficacy and toxicity.
Collapse
Affiliation(s)
- David Dora
- Department of Anatomy, Histology, and Embryology, Semmelweis University, Tuzolto St. 58, 1094 Budapest, Hungary
- Correspondence: (D.D.); (Z.L.)
| | | | - Kenan Aloss
- Translational Medicine Institute, Semmelweis University, 1094 Budapest, Hungary
| | - Peter Takacs
- Department of Anatomy, Histology, and Embryology, Semmelweis University, Tuzolto St. 58, 1094 Budapest, Hungary
| | - Juliane Zsuzsanna Desnoix
- Department of Anatomy, Histology, and Embryology, Semmelweis University, Tuzolto St. 58, 1094 Budapest, Hungary
| | - György Szklenárik
- Translational Medicine Institute, Semmelweis University, 1094 Budapest, Hungary
| | | | - Zoltan Lohinai
- Translational Medicine Institute, Semmelweis University, 1094 Budapest, Hungary
- National Korányi Institute of Pulmonology, Pihenő út 1-3, 1121 Budapest, Hungary
- Correspondence: (D.D.); (Z.L.)
| |
Collapse
|
19
|
Yasui S, Yoshida A, Takata M, Kamitani Y, Nakada Y, Kurumi H, Ikebuchi Y, Kawaguchi K, Yashima K, Isomoto H. Rheumatoid Arthritis Symptoms Diagnosed by Rheumatic Immune-related Adverse Events Caused by Nivolumab in a Patient with Esophageal Cancer. Intern Med 2023; 62:215-220. [PMID: 35732452 PMCID: PMC9908395 DOI: 10.2169/internalmedicine.9663-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
This report described the case of a 70-year-old man who developed polyarthralgia after nivolumab treatment for recurrent esophageal cancer. Arthritis developed after initiating nivolumab therapy, and the patient tested positive for rheumatoid factor and anti-citrullinated peptide antibodies. The hand and elbow joints were already deformed, suggesting that he had had rheumatoid arthritis for several years and that the symptoms had only become apparent after nivolumab administration. This patient had rheumatoid arthritis, which was diagnosed as a nivolumab-induced rheumatic immune-related adverse event (rh-irAEs). Arthralgia during nivolumab administration can occur in rh-irAE cases. Patients should be assessed for autoimmune diseases before initiating immune checkpoint inhibitors.
Collapse
Affiliation(s)
- Sho Yasui
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Akira Yoshida
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Miki Takata
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Japan
| | - Yu Kamitani
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Yusuke Nakada
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Hiroki Kurumi
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Koichiro Kawaguchi
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Kazuo Yashima
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Japan
| |
Collapse
|
20
|
Grümme L, Schulze-Koops H. [Rheumatological side effects of checkpoint inhibitors and their treatment]. Z Rheumatol 2023; 82:187-194. [PMID: 36607420 DOI: 10.1007/s00393-022-01311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/07/2023]
Abstract
The spectrum of tumors for which checkpoint inhibitor (CI) treatment is used is constantly expanding. The European Medicines Agency has currently approved nine CIs: one anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) CI, one anti-lymphocyte activation gene 3 (LAG-3) CI, four anti-programmed cell death protein 1 (PD-1) CIs and three anti-programmed death ligand 1 (PD-L1) CIs. By blocking immune checkpoints the physiological downregulation of T cell activity against autologous tissue is prevented. This results in an immunologically unregulated activation of T cells directed against malignant cells. Healthy tissue also expresses antigens and thereby continuously activates autologous T cells. Thus, the blockade of immune checkpoints can lead to T cell activity against healthy tissue (immune-related adverse events, irAE). The irAEs can occur in any organ system and approximately 10% of all patients under CI treatment develop rheumatological irAEs, mostly arthralgia and myalgia. The classification criteria of rheumatological diseases do not need to be met to initiate treatment and the primary goal of treatment of irAEs is to enable continuation of CI treatment. Rheumatological irAEs should be recognized and treated quickly. In the treatment of musculoskeletal irAEs, three stages can be defined. In the first stage, nonsteroidal anti-inflammatory drugs or intra-articular as well as systemic glucocorticoids are used. In the second stage, conventional synthetic and in the third stage, biologic disease-modifying antirheumatic drugs are used. The most severe musculoskeletal irAE is myositis with cardiac and/or respiratory involvement and/or myasthenia gravis. In addition to high-dose glucocorticoids, intravenous immunoglobulins or plasma exchange are used in treatment.
Collapse
Affiliation(s)
- Lea Grümme
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - Hendrik Schulze-Koops
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| |
Collapse
|
21
|
Melia A, Fockens E, Sfumato P, Zemmour C, Madroszyk A, Lafforgue P, Pham T. Musculoskeletal immune-related adverse events in 927 patients treated with immune checkpoint inhibitors for solid cancer. Joint Bone Spine 2023; 90:105457. [PMID: 36116771 DOI: 10.1016/j.jbspin.2022.105457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 07/31/2022] [Accepted: 08/17/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The prevalence of the musculoskeletal immune-related adverse events (irAEs) is probably underestimated, as most studies report only severe side effects. Our aim was to describe and characterize all musculoskeletal irAEs in a large cohort of patients treated with immune checkpoint inhibitors (ICI). METHODS We conducted a retrospective study among patients who received ICI from 07/27/2014 to 05/08/2020 at the medical oncology department of the Institut Paoli-Calmettes, Marseille, France. All medical files were systemically reviewed by a rheumatologist who collected clinical features, time of occurrence, treatment regimen, irAEs management, course and outcomes. We also assessed tumor response 3 months after introduction of ICI, according to severity and treatments used to manage musculoskeletal irAEs. RESULTS Among 927 patients treated with ICI for a solid tumor, 118 patients (12.7%) presented a musculoskeletal irAE. Their median age was 66.5, 61% were male, and they mainly had a lung (57.6%) or urological cancer (27.1%). The most frequently involved ICI was an anti PD-1. Arthralgias and myalgias were the most frequent musculoskeletal irAEs (9.8%) and inflammatory rheumatic features were reported in 36 patients (3.9%) with elevated acute phase reactants and negative immunological markers. The median time of onset was 2 months (IC 95% 1.8; 2.7). Tumor response at 3 months did not differ according to musculoskeletal irAE severity, type of manifestation (arthralgias/myalgias versus inflammatory rheumatic features), pain patterns (mechanical versus inflammatory) or irAE treatments. CONCLUSION Musculoskeletal irAEs in this large cohort of patients treated with ICI were frequent (12.7%), mostly mild and well tolerated.
Collapse
Affiliation(s)
- Angélique Melia
- Department of Rheumatology, University Hospital of Marseille Sainte-Marguerite, Aix Marseille University, AP-HM, Marseille, France.
| | - Emilie Fockens
- Department of Rheumatology, University Hospital of Marseille Sainte-Marguerite, Aix Marseille University, AP-HM, Marseille, France
| | - Patrick Sfumato
- Biostatistics department, Institut Paoli-Calmettes, Marseille, France
| | | | - Anne Madroszyk
- Oncology department, Institut Paoli-Calmettes, Marseille, France
| | - Pierre Lafforgue
- Department of Rheumatology, University Hospital of Marseille Sainte-Marguerite, Aix Marseille University, AP-HM, Marseille, France
| | - Thao Pham
- Department of Rheumatology, University Hospital of Marseille Sainte-Marguerite, Aix Marseille University, AP-HM, Marseille, France
| |
Collapse
|
22
|
Hayashi H, Sawada K, Hasebe T, Nakajima S, Sawada J, Takiyama Y, Takiyama Y, Okumura T, Fujiya M. A Successful Case of Hepatocellular Carcinoma Treated with Atezolizumab Plus Bevacizumab with Multisystem Immune-related Adverse Events. Intern Med 2022; 61:3497-3502. [PMID: 35491133 PMCID: PMC9790772 DOI: 10.2169/internalmedicine.9393-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A 63-year-old man with hepatitis C was treated with atezolizumab plus bevacizumab for unresectable diffuse hepatocellular carcinoma (HCC). After four cycles of atezolizumab plus bevacizumab, the diffuse HCC markedly shrank; however, he complained of general fatigue, loss of appetite, and slight loss of muscle strength in the lower legs. He was diagnosed with isolated adrenocorticotropic hormone deficiency (IAD), hypothyroidism, and myopathy, suggesting multisystem immune-related adverse events (irAEs). After administration of hydrocortisone, the clinical symptoms rapidly disappeared. Patients with multisystem irAEs can have favorable outcomes; thus, to continue immune-checkpoint inhibitors therapy, a correct diagnosis and management of multisystem irAEs are important.
Collapse
Affiliation(s)
- Hidemi Hayashi
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Koji Sawada
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Takumu Hasebe
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Shunsuke Nakajima
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Jun Sawada
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Medicine, Asahikawa Medical University, Japan
| | - Yuri Takiyama
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Yumi Takiyama
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Toshikatsu Okumura
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Mikihiro Fujiya
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| |
Collapse
|
23
|
Su Y, Li G, Xu J, Zheng J, Jiao J, Zhang J, Gu X, Cai Z, Luo H, Li Z, Han S. Immune-related keratitis is a rare complication associated with nivolumab treatment in a patient with advanced colorectal cancer: A case report. Front Oncol 2022; 12:1021713. [PMID: 36457511 PMCID: PMC9706189 DOI: 10.3389/fonc.2022.1021713] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/13/2022] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Immunotherapy has been widely used to treat Colorectal cancer but has also observe some immune-related adverse effects. With proper treatment, most irAE can be solved and the effect of immunotherapy will not be affected by temporary immunosuppression. However, there are few reports about corneal irAE, and the current understanding of irAE is incomplete. Here we report a metastatic colorectal cancer case of immune-related keratitis caused by nivolumab and to explore the occurrence of immune-related keratitis. CASE DESCRIPTION Here we report the case of a 49-year-old man with mCRC who had no previous ocular disease but developed immune-related ulcerative keratitis after treatment with nivolumab. We summarize a large amount of literature to discuss the mechanism of immune-related keratitis. In addition, we conclude a method that may be used to detect the occurrence of immune keratitis, by monitoring MMPs and maspin in patients treated with nivolumab. We believe immune-related keratitis may be a rare complication of nivolumab in the treatment of mCRC. The effect of simple anti-infective therapy and repair-promoting drugs was not obvious, but the effect of glucocorticoid combined with autologous serum was significant. CONCLUSION The mechanism of immune-related keratitis is that nivolumab destroys the immune microenvironment and ACAID, and affects corneal healing. Patients who use nivolumab can prevent immune keratitis by testing MMPs and maspin. The occurrence of immune keratitis may be a good indicator of the efficacy of ICI, and further study can be done in the follow-up.
Collapse
Affiliation(s)
- Yuqi Su
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Guoquan Li
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Jiaxin Xu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jiale Zheng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jiapeng Jiao
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jianhui Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Xiaokang Gu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zhai Cai
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hongyu Luo
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Zhou Li
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shuai Han
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
24
|
Kato K, Mizuno T, Koseki T, Ito Y, Takahashi K, Tsuboi N, Yamada S. Frequency of Immune Checkpoint Inhibitor-Induced Vasculitides: An Observational Study Using Data From the Japanese Adverse Drug Event Report Database. Front Pharmacol 2022; 13:803706. [PMID: 35401222 PMCID: PMC8992371 DOI: 10.3389/fphar.2022.803706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
Information on immune checkpoint inhibitor-induced vasculitides is limited, and predictors for this condition have not been identified. Therefore, we have examined the frequency of immune checkpoint inhibitor-induced vasculitides by analyzing the data recorded in the Japanese Adverse Drug Event Report database. Data from April 2004 to March 2020 were extracted, and vasculitides as an immune-related adverse event was defined according to the 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Adverse event signals were recognized as significant when the reporting odds ratio estimates and lower limits of the corresponding 95% confidence intervals exceeded 1. The use of nivolumab showed a significant signal for vasculitides. Furthermore, significant signals of polymyalgia rheumatica were found when the patients were treated with nivolumab, pembrolizumab, and ipilimumab. In addition, the frequencies of nivolumab- and pembrolizumab-induced polymyalgia rheumatica were higher in patients aged ≥70 years and female patients, respectively. Polymyalgia rheumatica was reported in 38 patients treated with nivolumab; 31 (82%) of these were either in recovery or in remission. Further, polymyalgia rheumatica was reported in 17 patients treated with pembrolizumab; 13 (76%) of these were in recovery or remission, while three (18%) were not. Polymyalgia rheumatica was reported in 12 patients treated with ipilimumab; seven (58%) of these were in recovery or remission. Our study highlights that careful monitoring for the symptom of PMR (e.g., bilateral pain in shoulder and pelvic girdles) is required when the patients are aged >70 years and have been treated with nivolumab and when the patients are women and have been treated with pembrolizumab.
Collapse
Affiliation(s)
- Koki Kato
- Department of Clinical Pharmacy, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tomohiro Mizuno
- Department of Clinical Pharmacy, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takenao Koseki
- Department of Clinical Pharmacy, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoshimasa Ito
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuo Takahashi
- Department of Biomedical Molecular Sciences, Fujita Health University School of Medicine, Toyoake, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shigeki Yamada
- Department of Clinical Pharmacy, Fujita Health University School of Medicine, Toyoake, Japan
| |
Collapse
|
25
|
Jensen AK, Chatzidionysiou K, Torp CK, Sørensen AS, Tenstad HB, Schäfer VS, Kostine M, Jacobsen S, Leipe J, Kragstrup TW. Comparison of immune checkpoint inhibitor-induced arthritis and reactive arthritis to inform therapeutic strategy. Biomed Pharmacother 2022; 148:112687. [PMID: 35228067 DOI: 10.1016/j.biopha.2022.112687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA) is a relatively new disease entity caused by ICI agents during cancer therapy. Reactive arthritis (ReA) is a well-known disease entity caused by urogenital or gastrointestinal bacterial infection or pneumonia. In this sense, ICI-IA and ReA are both defined by a reaction to a well-specified causal event. As a result, comparing these diseases may help to determine therapeutic strategies. METHODS We compared ICI-IA and ReA with special focus on pharmacological management. Specifically regarding treatment, we conducted a literature search of studies published in the PubMed database. Inclusion criteria were studies on treatment with non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GC), or disease modifying antirheumatic drugs (DMARDs) in ICI-IA or ReA. During systematic selection, 21 studies evaluating ICI-IA and 14 studies evaluating ReA were included. RESULTS In ICI-IA, prospective and retrospective studies have shown effects of non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoid (GC), sulfasalazine (SSZ), methotrexate (MTX), hydroxychloroquine (HCQ) and TNFi. In ReA, retrospective studies evaluated NSAIDs and GC. A randomized controlled trial reported the effect of SSZ, and a retrospective study reported the effect of MTX and SSZ in combination with tumor necrosis factor alpha inhibition (TNFi). For both entities, small case reports show treatment effects of interleukin 6 receptor inhibition (IL-6Ri). DISCUSSION This literature review identified both similarities and differences regarding the pathogenesis and clinical features of ReA and ICI-IA. Studies on treatment reported effectiveness of NSAIDs, GC, MTX, SSZ and TNFi in both diseases. Further, small case reports showed effects of IL-6Ri.
Collapse
Affiliation(s)
- Anders Kirkegaard Jensen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Sygehus Lillebælt, Kolding, Denmark
| | - Katerina Chatzidionysiou
- Department of Medicine Solna, Karolinska Institutet, Rheumatology Unit, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Valentin S Schäfer
- Clinic of Internal Medicine III, Department of Oncology, Hematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Bonn, Germany
| | - Marie Kostine
- Department of Rheumatology, Bordeaux, University, Hospital, France
| | - Søren Jacobsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Germany.
| | - Tue Wenzel Kragstrup
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.
| |
Collapse
|
26
|
Klavdianou K, Melissaropoulos K, Filippopoulou A, Daoussis D. Should we be Afraid of Immune Check Point Inhibitors in Cancer Patients with Pre-Existing Rheumatic Diseases? Immunotherapy in Pre-Existing Rheumatic Diseases. Mediterr J Rheumatol 2021; 32:218-226. [PMID: 34964025 PMCID: PMC8693295 DOI: 10.31138/mjr.32.3.218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/10/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Cancer immunotherapy is rapidly expanding but its clinical efficacy is hampered by immune related adverse events (ir-AE). There is a concern regarding patients with pre-existing auto-immune diseases (PAD) undergoing immunotherapy. Methods: An electronic search was performed (Medline) to identify cases of patients with PAD treated with immune checkpoint inhibitors (ICI). Results: Published data are rather limited but continue to emerge. Patients with PAD exhibit a high risk of PAD flare and/or de novo ir-AE. In most cases PAD flares and de novo irAEs were not severe and could be managed effectively with standard treatment. Conclusions: This risk in patients with PAD appears acceptable, and therefore, these patients could receive immunotherapy under close monitoring. Collaboration of oncologists and rheumatologists for the management of these patients is crucial.
Collapse
Affiliation(s)
| | | | - Alexandra Filippopoulou
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Daoussis
- Department of Rheumatology, Patras University Hospital, University of Patras Medical School, Patras, Greece
| |
Collapse
|
27
|
Ogawa K, Kozuka Y, Uno H, Utsumi K, Noyori O, Hosoki R. Spontaneous and Immune Checkpoint Inhibitor-Induced Autoimmune Diseases: Analysis of Temporal Information by Using the Japanese Adverse Drug Event Report Database. Clin Drug Investig 2021; 41:615-627. [PMID: 34110613 DOI: 10.1007/s40261-021-01042-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Immune checkpoint inhibitors (ICIs) such as programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte antigen 4 (CTLA-4) inhibitors have greatly improved cancer treatment. However, they are associated with immune-related adverse events, including autoimmune diseases (ADs) owing to their immune enhancement effect. As there are few comprehensive studies of ADs by ICIs, it is necessary to analyze the period information of drug-induced ADs. We also assumed that the temporal information may be useful to estimate the similarity of the pathogenic mechanism between spontaneous and ICI-induced ADs. METHODS A period analysis including the Weibull analysis was performed on ICI-induced ADs using the Japanese Adverse Drug Event Report (JADER) database. For evaluating the similarity of spontaneous and ICI-induced ADs, a hierarchical cluster analysis was conducted to compare the different onset-time ranges. RESULTS Type 1 diabetes mellitus, autoimmune colitis, and pemphigoid occurred earlier with CTLA-4 inhibitors (median: 46, 29.5 and 28 days, respectively) than with PD-1 inhibitors (> 130 days). Myasthenia gravis had a median time to onset of approximately 1 month, and the risk of onset would increase over time in ipilimumab combination therapy. This result reveals ADs that require attention. Using cluster analysis, we estimated six clusters with different patterns of onset times. Based on these results and a detailed previous research survey, the possible pathogenesis of drug-induced ADs was also discussed. CONCLUSIONS This paper describes risk profiles with temporal information of ICI-induced ADs and proposes certain indicators for deciphering the mechanism of AD onset.
Collapse
Affiliation(s)
- Keiko Ogawa
- Laboratory of Regulatory Science, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-Higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Yoshihiro Kozuka
- Laboratory of Regulatory Science, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-Higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Hitomi Uno
- Laboratory of Regulatory Science, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-Higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Kosuke Utsumi
- Laboratory of Regulatory Science, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-Higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Osamu Noyori
- Laboratory of Immunology and Microbiology, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-Higashi, Kusatsu, Shiga, 525-8577 , Japan
| | - Rumiko Hosoki
- Laboratory of Regulatory Science, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-Higashi, Kusatsu, Shiga, 525-8577, Japan.
| |
Collapse
|
28
|
Cappelli LC, Bingham CO. Expert Perspective: Immune Checkpoint Inhibitors and Rheumatologic Complications. Arthritis Rheumatol 2020; 73:553-565. [PMID: 33186490 DOI: 10.1002/art.41587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Rheumatologists increasingly receive consults for patients treated with immune checkpoint inhibitors (ICIs) for cancer. ICIs can cause inflammatory syndromes known as immune-related adverse events (IRAEs). Several rheumatic IRAEs have been reported, including inflammatory arthritis, polymyalgia rheumatica, and myositis. For patients who present with musculoskeletal symptoms while receiving ICI therapy, it is important to have an algorithm for evaluation. The differential diagnosis includes a range of musculoskeletal syndromes, such as crystalline arthritis, mechanical issues, and osteoarthritis, in addition to IRAEs. After diagnosing a rheumatic IRAE, rheumatologists must work with the patient and the oncologist to form a treatment plan. Treatment of IRAEs is guided by severity. Evidence for management is limited to observational studies. Inflammatory arthritis and polymyalgia rheumatica are treated with nonsteroidal antiinflammatory drugs in mild cases, glucocorticoids for moderate-to-severe cases, and sometimes require other disease-modifying antirheumatic drugs. Myositis due to ICIs can be accompanied by myocarditis or myasthenia gravis. Glucocorticoids and withholding the ICI are usually required to treat myositis; some patients with severe myositis require intravenous immunoglobulin or plasmapheresis. Further research is needed to optimize treatment of IRAEs that does not compromise the antitumor effect of ICIs.
Collapse
|