Practical management of rheumatic immune-related adverse events occurring with immune checkpoint inhibitors: a narrative review.

Abstract

Immune checkpoint inhibitors (ICIs) have dramatically changed the management of cancer and their indications are expanding, leading to an increase in immune-related adverse events (irAEs). Recently, attention has focused on previously underestimated rheumatic irAEs, including inflammatory arthritis (IA), polymyalgia rheumatica-like phenotypes and Sicca syndrome, but also fasciitis, and rare but severe immune mediated myositis, with a possible association with myasthenia-like symptoms or myocarditis. Rheumatic irAEs may have a prolonged course and affect a patient's quality of life. Patients with IA or systemic autoimmune disease prior to ICI initiation are also at risk of flares. Current management of rheumatic toxicities relies on the opinion of experts, mostly based on the management of the classical rheumatic conditions they mimic. Due to the lack of high-quality data in the literature, few recommendations are available, with remaining concerns regarding the impact of immunosuppressive drugs on cancer response. The aim of this article is to provide practical guidelines to help rheumatologists and oncologists in their daily practice to deal with ICI related inflammatory rheumatic conditions, from the introduction of an ICI in the case of preexisting autoimmune disease, to the occurrence of rheumatic toxicity, as well as discussions concerning ICI rechallenge after a severe rheumatic irAE.