Rob Volansky , 2025-05-05 09:30:00
DESTIN, Fla. — Inflammatory arthritis as a result of immune checkpoint cancer therapy remains a pressing challenge for patients and rheumatologists alike, according to a speaker at the Congress of Clinical Rheumatology East annual meeting.
“There is no free lunch with immune checkpoint inhibitors,” Laura C. Cappelli, MD, MHS, co-director of the Immune-Related Toxicity Team, and associate professor of medicine, at Johns Hopkins University, told attendees.
“There is no free lunch with immune checkpoint inhibitors,” Laura Cappelli, MD, MHS, told attendees. Image: Rob Volansky | Healio
Like all of the immune-related adverse events (irAEs) that can occur in patients with various malignancies treated with these medications, inflammatory arthritis often has a heterogeneous presentation, according to Cappelli. These patients may present with synovitis, dactylitis or enthesitis, in addition to other musculoskeletal complications.
“The types of joints can vary,” she added.
Axial disease is rare, as is reactive arthritis, according to Cappelli.
However, when these patients present to the rheumatology clinic, immediate action is necessary.
“People can develop erosions within the first few months of symptoms,” Cappelli said. “It is important to ask about inflammatory back pain.”
Inflammatory markers “tend to be elevated” in these patients, she added. However, most patients with immune checkpoint inhibitor-associated arthritis are HLA-B27-negative.
“Most are seronegative for [rheumatoid factor] and anti-[cyclic citrullinated peptide] antibodies,” Cappelli said.
Although some patients demonstrate seropositivity for rheumatoid arthritis, they often had antibodies prior to checkpoint inhibitor therapy.
“There are patients who walk around for years with antibodies before having clinical RA,” Cappelli said. “Immune checkpoint inhibitors were like pouring lighter fluid onto the fire.”
Cappelli offered several pearls for managing immune checkpoint inhibitor-associated inflammatory arthritis and other conditions.
“When you are treating irAEs, it is almost always a team effort,” she said.
Rheumatologists should consider the way oncologists approach adverse events. Specifically, they grade patients as having mild, moderate or severe manifestations.
Mild events can be managed with NSAIDs or low steroid doses, according to Cappelli. Meanwhile, moderate events can be managed with steroid doses ranging from 10 mg to 40 mg daily.
“Moderate events are impacting their ability to get around in the world,” Cappelli said.
Patients with severe adverse events require higher or pulse doses of steroids.
“This is where we typically get involved as rheumatologists,” Cappelli said.
Other immunosuppressive agents may then be necessary, including methotrexate, TNF inhibition, interleukin-6 inhibition or mycophenolate.
“The choice of your agent depends on the type of irAE,” Cappelli said.
Another complicating factor, for those seeking guidance on treatment, is the fact that the data currently available on patients with arthritis associated with immune checkpoint inhibition can be variable.
“You need to recognize where data is limited and not specific enough to fully guide the situation at hand,” Cappelli said.
Regarding the timing of intervention, Cappelli stressed patience.
“Try to avoid all immunosuppression for about the first 2 months of immune checkpoint inhibitor therapy unless there is a life-threatening irAE,” she said.
Sources/Disclosures
Collapse
Cappelli L. Adverse Effects of Immune Checkpoint Inhibitor Therapy for the Rheumatologist. Presented at The Congress of Clinical Rheumatology East; May 1-4, 2025; Destin, Florida (hybrid meeting).
Disclosures:
Cappelli reports research funding from Bristol Myers Squibb and consulting fees from Amgen.
