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Abdel-Wahab N, Suarez-Almazor ME. Rheumatic adverse events of immune checkpoint inhibitors in cancer immunotherapy. Expert Rev Clin Immunol 2024; 20:873-893. [PMID: 38400840 DOI: 10.1080/1744666x.2024.2323966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION The advent of immune checkpoint inhibitors (ICIs) in cancer treatment has marked a transformative era, albeit tempered by immune-related adverse events (irAEs), including those impacting the musculoskeletal system. The lack of precise epidemiologic data on rheumatic irAEs is attributed to factors such as potential underrecognition, underreporting in clinical trials, and the tendency to overlook manifestations without immediate life-threatening implications, further complicating the determination of accurate incidence rates, while the complete understanding of the mechanisms driving rheumatic irAEs remains elusive. AREAS COVERED This literature review comprehensively examines rheumatic irAEs in cancer patients undergoing ICI therapy, encompassing epidemiology, risk factors, mechanisms, clinical manifestations, and current management guidance for prevalent conditions such as inflammatory arthritis, polymyalgia rheumatica, and myositis. Less frequent rheumatic and musculoskeletal irAEs are also explored, alongside insights into ongoing clinical trials testing therapeutic and preventive strategies for irAEs. A thorough literature search on Medline and the National Cancer Institute Clinical Trials Database was conducted up to October 2023 to compile relevant information. EXPERT OPINION In light of the evolving landscape of cancer immunotherapy, there is a compelling need for prospective longitudinal studies to enhance understanding and inform clinical management strategies for rheumatic irAEs.
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Affiliation(s)
- Noha Abdel-Wahab
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine; and Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Rheumatology and Rehabilitation, Assiut University Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Maria E Suarez-Almazor
- Department of Health Services Research; and Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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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.
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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
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Chan KK, Bass AR. Impact of Non-steroidal Anti-inflammatory Drugs, Glucocorticoids, and Disease-Modifying Anti-Rheumatic Drugs on Cancer Response to Immune Checkpoint Inhibitor Therapy. Rheum Dis Clin North Am 2024; 50:337-357. [PMID: 38670731 DOI: 10.1016/j.rdc.2024.02.007] [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 (ICI) therapy for advanced malignancies often leads to off-target adverse events. Rheumatic immune-related adverse events can often linger beyond the duration of ICI therapy and sometimes requires the use of immunomodulator therapy. A key question, therefore, is if the commonly used therapies affect cancer outcomes. In this review, the authors summarize the state of the data as it currently stands, taking into consideration the limitations of the various source studies. The most information is known about glucocorticoids, which appear to be harmful especially when used early and at high doses.
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Affiliation(s)
- Karmela K Chan
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Medicine, Division of Rheumatology, Weill Cornell Medicine.
| | - Anne R Bass
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Medicine, Division of Rheumatology, Weill Cornell Medicine
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Liew DFL, Mackie SL, Tison A, Sattui SE, Yates M, Buchanan RRC, Owen CE. Immune Checkpoint Inhibitor-induced Polymyalgia Rheumatica. Rheum Dis Clin North Am 2024; 50:255-267. [PMID: 38670724 DOI: 10.1016/j.rdc.2024.02.001] [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
Polymyalgia rheumatica (PMR) immune-related adverse events (ICI-PMRs) represent a novel, distinct entity, despite many clinical, laboratory, and imaging similarities to classical PMR. Important questions remain in differentiating ICI-PMR from classical PMR, as well as other immune-related adverse events and PMR mimics. Despite this, ICI-PMR currently takes treatment cues from classical PMR, albeit with considerations relevant to cancer immunotherapy. Comparisons between ICI-PMR and classical PMR may provide further bidirectional insights, especially given that important questions remain unanswered about both diseases. The cause of classical PMR remains poorly understood, and ICI-PMR may represent a model of induced PMR, with important therapeutic implications.
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Affiliation(s)
- David F L Liew
- Department of Rheumatology, Austin Health, Heidelberg West VIC 3081, Australia; Department of Clinical Pharmacology and Therapeutics, Austin Health, Heidelberg VIC 3084, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria 3052, Australia.
| | - Sarah L Mackie
- Division of Rheumatic and Musculoskeletal Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Worsley Building, Leeds, West Yorkshire LS2 9NL, England
| | - Alice Tison
- LBAI UMR1227, Univ Brest, Inserm, Brest, France; Department of Rheumatology, CHU Brest, France Boulevard TANGUY PRIGENT, Brest, Brittany 29609, France
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, BST S723, 3500 Terrace Street, Pittsburgh, PA 15261, USA
| | - Max Yates
- Norwich Medical School, University of East Anglia, Norwich, UK; Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Russell R C Buchanan
- Department of Rheumatology, Austin Health, Heidelberg West VIC 3081, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria 3052, Australia
| | - Claire E Owen
- Department of Rheumatology, Austin Health, Heidelberg West VIC 3081, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria 3052, Australia
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Yang H, Ding Z, An Z, Zhao Y, Lu H. Immune checkpoint inhibitor related myositis: an observational, retrospective, pharmacovigilance study. Expert Opin Drug Saf 2024:1-6. [PMID: 38629402 DOI: 10.1080/14740338.2024.2343023] [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: 09/11/2023] [Accepted: 01/26/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) show promise in cancer treatment, but recent cases highlight myositis as a serious complication. RESEARCH DESIGN AND METHODS We did a retrospective study on drug safety using FAERS data up to Q3 2022, focusing on immune checkpoint inhibitors (ICIs) and myositis. We used IC and ROR to assess the association. Logistic regression in R 3.2.5 helped identify factors linked to fatal outcomes. RESULTS We identified 558 cases of ICIs-associated myositis. Our study found a significant link between ICIs and myositis (ROR 15.54 [14.23-16.96], IC 3.79 [3.66-3.92], see Figure 1). Notably, myositis was more common in patients on ICI combination therapy compared to monotherapy (ROR 1.72 [1.39-2.11], IC 0.63 [0.30-0.93]). Age increased the risk of ICI-associated myositis and was also a factor in fatality (p = 0.011). Common accompanying adverse events included myocarditis (21.33%), severe myasthenia gravis (16.49%), and malignant neoplasm progression (8.06%). Fatal cases were more common when myositis was accompanied by myocarditis, severe myasthenia gravis, or malignant neoplasm progression. CONCLUSIONS Clinicians must note the risk of ICI-associated myositis, especially dangerous in older patients or when combined with other issues like myocarditis or severe myasthenia gravis.
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Affiliation(s)
- Hui Yang
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhexin Ding
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Zhuoling An
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yong Zhao
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
- Faculty of Synthetic Biology, Shenzhen University of Advanced Technology, Shenzhen, China
- CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hezhe Lu
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
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Yamamoto S, Yoshida A, Gono T, Kuwana M. The Role of Environmental Factors in the Development of Idiopathic Inflammatory Myopathies: a Narrative Review. Curr Rheumatol Rep 2023; 25:264-275. [PMID: 37971581 DOI: 10.1007/s11926-023-01120-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW This review aims to evaluate recent findings on the role of environmental factors in the development and clinical presentation of idiopathic inflammatory myopathies (IIMs). RECENT FINDINGS A targeted literature review was conducted to identify reports relevant to the association between environmental factors and IIMs published over the past three years. There has been an increasing number of publications dealing with the association of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or vaccination with the development of IIMs, highlighting the significant role of the antiviral immune response in the pathogenesis of the disease. Traditional environmental factors associated with the pathogenic process of IIM subclassifications included drugs such as statins and immune checkpoint inhibitors, ultraviolet radiation, smoking, air pollutants, and vitamin D deficiency. Correlations of seasonality and residence with the onset of certain IIM subtypes suggest a potential role of environmental triggers in the pathogenic process. An interplay between genetic predisposition and various environmental factors might contribute to the development of IIMs as well as the heterogeneous clinical and serological presentation of IIMs. The growing evidence on the role of environmental factors in the development of IIMs provides important clues to elucidate the pathophysiology of these disease entities. The mechanisms underlying the interactions between genetic predisposition and environmental factors should be investigated in the future.
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Affiliation(s)
- Shintaro Yamamoto
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Akira Yoshida
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan.
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan.
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Khoo T, Lilleker JB, Thong BYH, Leclair V, Lamb JA, Chinoy H. Epidemiology of the idiopathic inflammatory myopathies. Nat Rev Rheumatol 2023; 19:695-712. [PMID: 37803078 DOI: 10.1038/s41584-023-01033-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of systemic autoimmune diseases that affect the skeletal muscles and can also involve the skin, joints, lungs and heart. The epidemiology of IIM is obscured by changing classification criteria and the inherent shortcomings of case identification using healthcare record diagnostic coding. The incidence of IIM is estimated to range from 0.2 to 2 per 100,000 person-years, with prevalence from 2 to 25 per 100,000 people. Although the effects of age and gender on incidence are known, there is only sparse understanding of ethnic differences, particularly in indigenous populations. The incidence of IIM has reportedly increased in the twenty-first century, but whether this is a genuine increase is not yet known. Understanding of the genetic risk factors for different IIM subtypes has advanced considerably. Infections, medications, malignancy and geography are also commonly identified risk factors. Potentially, the COVID-19 pandemic has altered IIM incidence, although evidence of this occurrence is limited to case reports and small case series. Consideration of the current understanding of the epidemiology of IIM can highlight important areas of interest for future research into these rare diseases.
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Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - James B Lilleker
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neuroscience, Manchester Academic Health Science Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valérie Leclair
- Department of Medicine, Division of Rheumatology, McGill University, Montreal, Canada
| | - Janine A Lamb
- Epidemiology and Public Health Group, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.
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Opinc-Rosiak AH, Makowska JS. Environmental exposures as risk factors for idiopathic inflammatory myopathies. J Autoimmun 2023; 140:103095. [PMID: 37797402 DOI: 10.1016/j.jaut.2023.103095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/25/2023] [Indexed: 10/07/2023]
Abstract
Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of rare autoimmune diseases, with increasing incidence rates observed in the recent years. The pathogenesis of IIM remains not fully understood, and the interaction of genetic and environmental factors is suspected. It is unclear whether the observed upward trend in the IIM incidence is solely due to improved access to effective diagnostics or perhaps due to increased exposure to external risk factors. The PUBMED database was thoroughly searched for articles describing environmental exposures potentially triggering the onset of IIM. The article summarizes the current knowledge available on this subject, taking into account various environmental factors, including among others UV radiation, infectious agents with SARS-CoV-2, inhaled particles, or iatrogenic effects. Limitations and unmet needs requiring further studies were highlighted.
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Affiliation(s)
| | - Joanna S Makowska
- Department of Rheumatology, Medical University of Lodz, Zeromskiego 113, 90-549, Lodz, Poland.
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Boutros A, Vera L, Gatto F, Fornarini G, Zanardi E. Case report: Pembrolizumab plus Axitinib related hypothyroid myopathy in two kidney cancer patients. Front Oncol 2022; 12:1048526. [DOI: 10.3389/fonc.2022.1048526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022] Open
Abstract
The first-line therapy in advanced kidney cancer has changed in recent years due to the introduction of combinations of tyrosine kinase inhibitors (TKIs) of vascular endothelial growth factor receptors (VEGFR) and immune checkpoint inhibitors (ICIs). Although immune-related adverse events are well-known, in the case of combination treatments, the determination of which drug is related to an adverse event may be challenging. We reported two cases of patients who developed muscle enzyme elevation in association with hypothyroidism during therapy with pembrolizumab plus axitinib for metastatic kidney cancer. The myopathy rapidly resolved after hormone replacement therapy with levothyroxine. Hypothyroid myopathy is a scarcely known and underreported adverse event. This adverse event may be relevant in the differential diagnosis with immune-related myositis, which has an autoimmune pathogenesis and a potentially fatal course.
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Abstract
Immune checkpoint inhibitors (ICIs), used to treat many advanced cancers, activate the immune system to elicit an antitumor response. ICIs can also cause immune-related adverse events (irAEs) when nontumor tissues are affected by excess inflammation and autoimmunity. Rheumatic irAEs include inflammatory arthritis, myositis, sicca syndrome, polymyalgia rheumatica, and several other rare phenotypes. Treating rheumatic irAEs requires balancing the desire to decrease off-target inflammation while not negatively impacting the antitumor immune response. In this review, treatment recommendations for rheumatic irAEs have been discussed. Pathogenesis of rheumatic irAEs has been briefly reviewed. Knowledge about the effects of corticosteroids and steroid-sparing agents on tumor responses has been detailed to give context for treatment decisions. Recommendations ultimately depend not only on the clinical presentation and severity of the irAE but also on the goals of cancer treatment. Finally, how to safely use ICI therapy in patients with preexisting autoimmune diseases is considered.
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Affiliation(s)
- Pankti Reid
- University of Chicago, Department of Medicine, Section of Rheumatology, 5841 South Maryland Ave. MC 0930, Chicago, IL, 60637, USA.
| | - Laura C Cappelli
- Johns Hopkins University, Department of Medicine, Division of Rheumatology, 5501 Hopkins Bayview Circle, Suite 1B1, Baltimore, MD, 21224, USA.
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