A Case Series of Rheumatic Immune-Related Adverse Events in Patients with Immune Check Point Inhibition
Background: Immune check point inhibitors (ICIs) have a potent anti-tumour effect and up to 43% of people receiving therapy will develop rheumatic adverse effects (RirAEs). People with pre-existing autoimmune disease (AID) were excluded from clinical trials.
Aim: To define the characteristics of rheumatic symptoms in people on ICIs for malignancy and subsequent prescribed immunosuppression to manage adverse events.
Methods: A case series formed from a retrospective audit of the Northern Territory Top End Health Service electronic records over a two year period, 2016-2017.
Results: Sixty-three people received ICIs over the two year period for non-small cell lung carcinoma, melanoma and renal cell carcinoma. One patient had confirmed pre-existing rheumatoid arthritis and a further two had likely undiagnosed inflammatory arthritis preceding therapy. Sixteen (25%) patients developed RirAEs with nine requiring simple analgesia, glucocorticoids or biologic therapy. The autoimmunity phenotype was predominantly joint related, seronegative and polyarticular in nature. Five required alterations to immunotherapy and six were referred to rheumatology.
Conclusion: A significant number of people receiving ICIs will develop RirAEs, with arthritis and myalgia occurring most commonly. People with pre-existing AID remain a challenge to treat. Vigilant monitoring and early referral to a rheumatology service will facilitate appropriate investigations and encourage early treatment if required.
A new and varied phenotype of rheumatological disease is emerging with a range treatment options available. As an increasing number of patients are treated with ICIs for an ever-growing list of malignancies, there will be an increasing need for oncologists and rheumatologists to collaborate. Navigating the intricacies linked to manipulating the immune system and delicate balance between tolerance of self and autoimmunity will continue to produce interesting sequelae of rheumatic symptoms.
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Journal of Clinical & Cellular Immunology