Background/Purpose: The management of inflammatory arthritis related to immune-related adverse events (irAEs) from immune checkpoint inhibitors (ICI) is challenging. Arthritis can become chronic and require treatment even after discontinuation of ICI. Guidelines recommend initial treatment with glucocorticoids, but dosing, duration, and next therapeutic choices are not well defined. We conducted a survey of international experts in the area to ascertain their preferences for the management of irAE-arthritis.

Methods: We developed a questionnaire with six open-ended questions in response to a case, described as a 60-year-old patient with recent onset irAE-arthritis, CDAI of 22, categorized as grade III as per CTCAE. Participants were asked about initial dose and route of prednisone, highest dose of prednisone before adding disease-modifying antirheumatic agents (DMARDS), time before adding a DMARD, preferred DMARD and next treatment choice. We asked participants about the potential deleterious effects of drugs used to treat irAE on tumor progression or recurrence, when used for 3 months or more. Respondents were rheumatologists selected on the basis of their knowledge and clinical management of irAE-inflammatory arthritis, participating in the Outcome Measures in Rheumatology (OMERACT) irAEs group and/or a newly formed consortium in the United States interested in collecting prospective data in cancer patients who develop irAEs.

Results: We approached 25 experts, of which 19 (76%) responded (11 were from the United States, 5 from Europe, 2 from Canada, and 1 from Australia). The median number of years in practice was 10. The initial dose of prednisone prescribed varied from 10mg to 60mg daily, most commonly oral administration. The highest dose of prednisone before adding a DMARD also ranged between 10 and 60mg. Participants were asked how many weeks they would wait if patient did not respond to prednisone before adding a DMARD with responses ranging from 2 weeks to 12 weeks. Most (8, 42%) would wait 4 weeks. Choice of first DMARD varied with the most preferred option being methotrexate (MTX) (9, 47%). Other DMARDs included hydroxychloroquine, leflunomide and biologic DMARD, of these most often tumor necrosis factor inhibitors (TNFi) or interleukin-6 receptor inhibitors (IL6ri). Participants would wait between 4 and 12 weeks before deciding to switch DMARDs. For a second DMARD, most respondents considered biologic agents, TNFi or IL6ri. For concerns about potential deleterious effects of drugs on tumor progression, the responses also varied within the 1 to 5 scale, with the following medians from most concerned to least concerned: abatacept (5), prednisone > 20 mg (4), mycophenolate mofetil (3), prednisone < 20 mg, MTX, leflunomide, azathioprine, rituximab, TNFi, IL6ri (2), hydroxychloroquine and sulfasalazine (1).

Conclusion: These findings show variation in preferences for the management of irAE-arthritis among international experts. There is a need for additional studies to determine the efficacy and safety of various approaches, as concerns remain about the potential deleterious effects of glucocorticoids and specific DMARDs on tumor immunity.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/expert-clinical-management-of-immune-related-inflammatory-arthritis-results-from-a-multicenter-international-expert-survey/