Tuesday, 21 Jan 2020

You are here

Understanding Non-arthritic Rheumatic iRAEs

A better understanding of rheumatic immune-related adverse event phenotypes beyond inflammatory arthritis has been furthered by work from three abstracts presented at EULAR 2019 in Madrid.

Ever since the emergence of immune checkpoint inhibitor immunotherapy for cancer and the rheumatic immune-related adverse events (iRAEs) they cause, questions have arisen as to what rheumatic irAEs represent, and whether they represent classical autoimmune disease or a separate entity. Increased awareness has paved the way for improved characterisation through clinical descriptions and imaging studies, which represents the basis for determining optimal therapies in the future.

Manuel Ramos-Casals, from the Hospital Clinic in Barcelona, presented work he led grouping the existing disparate reports of rheumatic irAEs published in the peer-reviewed literature into phenotypic clusters. Up until this point, the substantial majority of reports have involved case reports or small case series, which only give a limited view of phenotypes and their implications.

In Dr Ramos-Casals’s work, five phenotypic clusters were identified: articular (including inflammatory arthritis and polymyalgia rheumatica-like), muscular (including myositis and myasthenia gravis), systemic (including sicca syndrome and hemophagocytic lymphohistiocytosis), vasculitic, and granulomatous. These clusters might form the basis for more in-depth prospective characterisation, and more extensive data is likely to be available in the near future as the use of cancer immunotherapy escalates worldwide.

One fascinating description of a potential new irAE came from work presented by Alexandra Filippopoulou from Patras, Greece, in the form of myofasciitis noted on MRI. Periarticular manifestations have been prominent in early descriptions of rheumatic irAEs. While, of these descriptions, polymyalgia rheumatica-like disease has been most frequently described, a number of other disparate periarticular manifestations have been noted following cancer immunotherapy, although myofasciitis is not one of them.

In Dr. Filippopoulou’s study, patients with new musculoskeletal symptoms following PD-1 inhibitor immunotherapy underwent MRI scans of symptomatic areas. Most of these scans demonstrated periarticular and myofascial changes as the predominant finding, rather than synovitis, even though all these patients reported articular symptoms. This is in contrast to the predominant finding of synovitis in ultrasound studies of rheumatic irAE patients with articular symptoms, including in work also presented at EULAR 2019 by Fulvia Ceccarelli and colleagues from Sapienza Universita di Roma in Italy, and also work published online first during EULAR 2019 by Jemima Albayda and colleagues from Johns Hopkins in ACR Open Rheumatology.

It is also of interest that similar observations of myofasciitis on MRI have previously been made in classical polymyalgia rheumatica patients, although it was notable the patients described by Dr. Filippopoulou did not describe joint stiffness. These manifestations have not been noted elsewhere and further imaging studies in rheumatic irAEs elsewhere may help to delineate their importance.

 

Add new comment

More Like This

CDC: 15% of US Adults are Physically Inactivie

All states and territories had more than 15% of adults who were physically inactive and this estimate ranged from 17.3 to 47.7%,  according to new state maps of adult physical inactivity prevalence released today by the Centers for Disease Control and Prevention (CDC).

RheumNow Podcast- The Down Side of Steroids (1.17.20)

Dr. Jack Cush reviews the journal reports and news from RheumNow.com. Be sure to register for RheumNow Live 3/13/2020 in Fort Worth Rheumnow.live.

RheumNow Podcast- Knee Pain Knockout (1.10.20)

Dr. Jack Cush reviews the news and journal reports from this past week on RheumNow.com. The podcast covers: best therapies for dactylitis and enthesitis; we have a new knockout for knee pain in OA; and are you on the naughty or nice list when it comes to the new ACR-AF guidelines for arthritis? This and more. Tune in.

2019 Rheumatology Year in Review

2019 was a year marked by major advances, hallmark research, and big news items affecting rheumatology.   Herein you will find our top 10 list, formulated by what I think rheumatologists should know and what will likely change their standards and practice in 2020 and beyond. 

RheumNow Podcast - 2019 Rheumatology Year in Review

Dr. Jack Cush reviews highlights from 2019 on RheumNow.com. Topics covered in this annual review include: superheroes lost; venous thromboembolic events and JAKs; free medical tuition; women in rheumatology; 52 new drug approvals in 2019 and 330 drugs with a 2020 price hike; scleroderma disappointments; novel new treatments and newer tests; the boom of Shingrix; RheumNow.Live - and more.