Background/Purpose: The incidence and management of rheumatologic immune-related adverse events (irAEs) as a consequence of the checkpoint inhibitor (CPI) therapy in patients with cancer has been investigated, but no studies have synthetized the management of preexisting rheumatologic diseases in patients receiving CPI. We systematically review all reported cases describing the use of CPI in patients with a preexisting rheumatologic disease.

Methods: We searched 5 electronic databases through November 2016 and handsearched the references of relevant articles. We collected data on the specific CPI received, disease activity and anti-rheumatic modifying drugs while receiving CPI, and development and management of irAEs.

Results: Eleven publications met inclusion criteria, reporting on 30 cases (18 rheumatoid arthritis (RA)/inflammatory arthritis (IA); 3 seronegative spondyloarthropathy (2 psoriatic and 1 reactive arthritis); 3 sarcoidosis; 2 systemic erythematosus lupus (SLE); 2 vasculitis; 1 rheumatic fever; 1 Sjögren’s syndrome). Age of the cases ranged from 30 to 84 years. All had melanoma. Of the 18 patients with RA/IA, 16 received ipilimumab, 1 nivolumab, and 1 pembrolizumab. Sixteen patients had active arthritis before starting CPI and 6 were kept on treatment (steroids, hydroxychloroquine, or leflunomide) while receiving CPI. Fifteen of 18 had irAEs (8 flare, 2 colitis, 1 autoimmune thyroiditis, 4 flare plus colitis or hypophysitis). Nonsteroidal anti-inflammatory drugs or steroids were used to treat all irAEs which resulted in improvement. However, infliximab and surgical resection were required for a patient with exacerbation of colitis after steroids tapering and CPI discontinuation was recommended in 5 patients. One patient with inactive RA was maintained on methotrexate and prednisolone, with no irAEs. Of the 3 patients with seronegative spondyloarthropaty, all received ipilimumab. Two patients with psoriatic arthritis had active disease, and one was maintained on methotrexate with no irAEs reported. The other patient stopped methotrexate prior to receiving the CPI and had worsening of plaques and de novo colitis that required steroids. No irAEs were reported in the patient with reactive arthritis. Of the 3 patients with sarcoidosis, all received ipilimumab. Only one had active disease and was maintained on steroids while receiving CPI. All had irAEs (2 flare and 1 glaucoma) and improved with increasing steroids dose. The 2 patients with SLE, received ipilimumab. One had active disease, and both were maintained on hydroxychloroquine and/or steroids. None developed adverse events. irAEs were reported in one patient each with Behcet, eosinophilic granulomatosus with polyangiitis, and Sjögren’s , but none for the rheumatic fever.

Conclusion: Flares and irAEs in patients with rheumatologic disease receiving CPI can be managed, often not requiring therapy discontinuation. No difference was noted in the occurrence of irAEs in patients with active versus non-active preexisting diseases. CPI can be offered to these patients considering risk-benefit ratios and patient preferences.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-systematic-review-of-the-management-of-patients-with-preexisting-rheumatologic-diseases-receiving-checkpoint-inhibitors-for-cancer/