by cancer immunotherapy with checkpoint inhibitors. The task force consistedof 23 members from Europe and NorthAmerica, including 3 oncologists at theforefront of cancer immunotherapy research.
Rheumatic irAEs occur in about 10% ofpatients who are treatedwith immune checkpointinhibitors and are a relatively new entity, Dr. KarolinaBenesova of University Hospital Heidelberg (Germany)explained in an interview.She will run through therecently published guidancewith a practical eye, highlighting the essence of the10 points to consider andfour overarching principles(Ann Rheum Dis. 2020 Apr23. doi: 10.1136/annrheum-dis-2020-217139).
“There are various ways of managingirAEs found in the literature, but they canbe contradictory,” she said, noting thatthere was also variation on how theywere managed in different countries. TheEULAR guidance thus sought to providea comprehensive overview of how bestto manage these emerging side effects,which are increasingly being seen in clinical practice.
The recommendations cover two important populations of patients – those whohave preexisting RMDs and need treatment with a checkpoint inhibitor and thosewho don’t have an existing RMD but develop de novo symptoms. Unlike with irAEsinvolving other organ systems, rheumaticirAEs can become chronic and remain longafter the cancer therapy has stopped.
“Particularly inflammatory arthritis as
a rheumatic irAE seems to be chronic in
about half of the cases,” Dr. Benesova
said. That’s another reason why rheu-
matologists need their own recommen-
dations, as even if they have not seen
patients with these side effects yet, “they
will at some point – the prevalence will
just go up.”
With the exception of myositis and
severe organ involvement, the EULAR
guidance is to “be rather defensive,” Dr.
Benesova said. “Leave your treat-to-target
strategy,” at least while the cancer treat-
ment is ongoing. “We can potentially harm
our irAE patients with this approach.”
This view may change in the future based
on the scientific evidence, but “at the
moment, we don’t know enough, so treat
defensively. Of particular interest will be
the data from early clinical trials on poten-
tial synergic effects of TNF inhibitors and
checkpoint inhibitors,” she added.
The other point to note
is that rheumatic irAEs do
not act like classical RMDs
and they can respond well
already to NSAIDs and/or
Indeed, the recommenda-
tions say that glucocor-
ticoid treatment should
be considered before
csDMARDs, and escalation
to cs/bDMARDs in mild to
moderate irAEs should be
considered only if there is
an insufficient response or
a need for steroid sparing.
“You have the established treat-to-target strategy in our classical RMDs, butin rheumatic irAEs you have to search fora compromise. You’re trying to get thepatients as good as you can, relieve symptoms, so patients can function with improved quality of life, but it’s not remissionthat you are trying to get. The major taskfor the rheumatologist is to work handin hand with the oncologists and enablecontinuation of the effective oncologictreatment whenever possible,” Dr. Benesova said.
The use of intra-articular therapy may bea mainstay of rheumatologic practice butuntil now there were no actual official recommendations on how best to use it in everyday practice. That’s the reason behindthe new “EULAR recommendations for theintra-articular treatment of arthropathies,”explained the convenor of the EULARtask force on intra-articular therapy, Prof.
Jacqueline Uson of Clinic Santa Elena inMadrid.
“This is the first time that there’sbeen a joint effort to develop these ev-idence-based recommendations,” Prof.
Uson said in an interview. She noted
that the task force consisted of rheuma-
tologists working alongside orthopaedic
surgeons, radiologists, nuclear medicine
specialists, among others, as well as
patients. Where literature evidence was
poor, information from two surveys – one
asking patients about their experiences
and the other looking at how healthcare
professionals were giving intra-articular
injections – were used to help form expert
consensus and opinion.
“We hope that this will help with uniformity and better practice when performingintra-articular therapy in adults withperipheral arthropathies,” she said. Why,how, or when intra-articular injectionsshould be given was not the intent of therecommendations, she added, nor was ittheir scope.
“I would really call in young rheumatologists and health professionals to seemy presentation because intra-articulartherapy is something that you learn anddo, but you never really investigate in it,”Prof. Uson said.
During her presentation, Prof. Uson will
run through the 5 overarching principles
and 11 recommendations that look at
before, during, and after intra-articular
therapy. “Everything that we are saying is
pretty logical, but it’s nice to see it put in
recommendations based on evidence.”
The recommendations also look at the
optimal settings for performing injections
and the use of ultrasound where available
to ensure accurate injection into the joint.
This is an area where further research
could be performed, she said. Another rec-
ommendation focusses on when intra-ar-
ticular injections are safe to use during
pregnancy, and there is one on the use of
local anaesthetics. Special populations
of patients are also considered, such as
those with diabetes and those taking anti-
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