Immune checkpoint inhibitors for cancer are safe to use in rheumatoid arthritis patients

According to research published in The Lancet Rheumatology, patients with pre-existing rheumatoid arthritis (RA) can safely receive immune checkpoint suppression for cancer treatment but with vigilant monitoring for flares. 

The retrospective, comparative cohort study conducted by Dr. McCarter and colleagues evaluated the association between pre-existing RA with higher mortality and immune-mediated adverse events (AEs) risk among patients treated with immune checkpoint inhibitors. Among 11,901 patients who received immune checkpoint inhibitors for cancer, 87 patients with pre-existing RA and 203 non-RA patients were included. Most immune checkpoint inhibitors (92% of RA patients and 93% of comparators) targeted programmed cell death protein 1 (PD-1). Melanoma was the second most prevalent kind of cancer reported among the participants after lung cancer (49% vs.56%). The experts reported that 69% of the RA patients succumbed to death compared to 63% control (P=034). Compared to 49% of comparators, 61% of the RA patients reported all-grade immune-related adverse events (adjusted HR 172 [95% CI 120-247; p=0.0032). Two (1%) grade 5 myocarditis-related immune-related deaths were reported in the comparator group. In contrast to the comparison group (7%), 48% of the RA patients experienced flare-ups. Individuals with RA  were less likely to experience rash or dermatitis (P=0·048), endocrinopathy (P=0·0078), colitis or enteritis (P=0·094), and hepatitis (P=0·043).

A 2022 study discussed the methods for monitoring and managing immune checkpoint inhibitor (ICI)-induced inflammatory arthritis, including polymyalgia rheumatica, based on observational studies, treatment recommendations, and clinical experience. Approximately 4% of cancer patients receiving ICI develop this condition, lasting a year or longer. Typically, non-steroidal anti-inflammatory medications, intraarticular steroid injections, and/or low-dose corticosteroids are used to treat mild arthritis. At each visit, patient-reported measures of physical function, such as the health assessment questionnaire and tender and swollen joint counts, should be acquired to evaluate the efficacy of any arthritis medication. For patients with high-grade arthritis, a referral to a rheumatologist is advised to help direct the use of disease-modifying antirheumatic medications.

Although the present study has reported that patients with pre-existing RA can safely receive immune checkpoint suppression for cancer treatment, it is important to monitor these patients closely for flares and immune-related adverse events (AEs). It is recommended that patients with high-grade arthritis be referred to a rheumatologist and receive appropriate medications, including corticosteroids and steroid-sparing agents, to reduce toxicity and improve their quality of life.

References

  1. McCarter KR, Wolfgang T, Arabelovic S, Wang X, Yoshida K, Banasiak EP, Qian G, Kowalski EN, Vanni KM, LeBoeuf NR, Gedmintas L. Mortality and Immune-Related Adverse Events after Immune Checkpoint Inhibitor Initiation for Cancer Among Patients with Pre-Existing Rheumatoid Arthritis: A Retrospective Comparative Cohort Study.
  2. Chan KK, Bass AR. Monitoring and Management of the Patient with Immune Checkpoint Inhibitor-Induced Inflammatory Arthritis: Current Perspectives. Journal of Inflammation Research. 2022 Jan 1:3105-18.
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