EULAR Provides Guidance on Rheumatic Immune-Related Adverse Events

The European League Against Rheumatism (EULAR) has published guidance for the diagnosis and management of rheumatic and systemic immune-related adverse events (irAEs) among patients receiving cancer immunotherapy.

“Rheumatic and musculoskeletal irAEs are observed in about 10% of patients with cancer receiving checkpoint inhibitors,” the authors wrote. “Given the recent emergence of these events and the lack of guidance for rheumatologists addressing them, a [EULAR] task force was convened to harmonize expert opinion regarding their identification and management.”

Through a systematic literature review and subsequent consensus process, the task force developed 4 overarching principles that define the role of rheumatologists in managing irAEs and promote shared decision-making among patients, oncologists, and rheumatologists.  

The paper also put forth 10 points for rheumatologists to consider, including differential diagnoses for a wide spectrum of musculoskeletal irAEs. The task force recommends early referral to a rheumatologist to document inflammation in the target organ.

“Regarding therapeutic, 3 treatment escalations were defined: (1) local/systemic glucocorticoids if symptoms are not controlled by symptomatic treatment, then tapered to the lowest efficient dose, (2) conventional synthetic disease-modifying antirheumatic drugs, in case of inadequate response to glucocorticoids or for steroid sparing, and (3) biological disease-modifying antirheumatic drugs, for severe or refractory irAEs,” the authors reported. “A warning has been made on severe myositis, a life-threatening situation, requiring high dose of glucocorticoids and close monitoring.”

In cases of preexisting rheumatic disease, the guidance advises the lowest efficient dose of immunosuppression before beginning immunotherapy.

—Jolynn Tumolo

Reference:

Kostine M, Finckh A, Bingham CO, et al. EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitors. Ann Rheum Dis. 2021;80(1):36-48. doi:10.1136/annrheumdis-2020-217139