Practical management of rheumatic immune-related adverse events with immune checkpoint inhibitors

Jack Cush, MD

Jul 23, 2025 7:17 pm

Joint Bone Spine has published a full read review of the management of immune-related adverse events (irAEs) in patients receiving Immune checkpoint inhibitors (ICIs) for cancer. ICIs have dramatically changed cancer management and their increasing use has lead to an in increase in immune-related adverse events (irAEs).

These rheumatic irAEs include inflammatory arthritis (IA), polymyalgia rheumatica-like phenotypes and Sicca syndrome, fasciitis, myositis, and possibly myasthenia-like symptoms or myocarditis.

Patients with IA or systemic autoimmune disease prior to ICI initiation are also at risk of flares of disease (these would also be irAEs).

This review outlines the opinions of experts who have dealt with these issues. Below are exerpts from this review article; that deserves a download and full read by most. The article provides practical guidelines to help rheumatologists and oncologists in their daily practice to deal with ICI related inflammatory rheumatic conditions.

Key takeaways:

Autoimmune disease patients starting ICIs need a minimal immunosuppressives.
Low-dose glucocorticoids can be used, without ICI discontinuation, in mild rheumatic irAEs
ICI cessation and high-dose steroids/IV steroid pulses are used for severe irAEs such as myositis
Disease-modifying antirheumatics are used in glucocorticoid dependence/resistance
- The safety of DMARD therapy regarding tumour response is still to be determined
- ICI rechallenge is most of the time possible, with an irAE recurrence risk of around 50%

Key Questions

How should we deal with preexisting inflammatory arthritis (IA) or autoimmune disease?

ICI use is possible in patients with autoimmune disease, with a risk of flare of 30–50%.
Multidisciplinary discussions are essential to balance the risks and benefits
A minimal immunosuppressive regimen should be implemented before ICI initiation.

Is there any value in autoantibody (Ab) screening before ICI initiation?

Systematic screening for auto-Abs is not recommended at ICI initiation

Are there any specific diagnostic tools for rheumatic irAEs?

As for classical autoimmune disease, an exhaustive interview along with a thorough physical examination is advised.
Despite the high incidence of negative results, screening for specific auto-Abs should be carried out in the case of rheumatic irAEs, supporting an immune-mediated origin in the case of positivity.
Imaging such as radiography, ultrasound, magnetic resonance imaging and positron emission tomography scans may be of help

At what dosage should glucocorticoids be initiated? How to taper?

In mild rheumatic irAEs, low-dose glucocorticoids (10–20 mg/day) can be used, with progressive tapering below 10 mg/day over 4–8 weeks, without ICI discontinuation in most cases.
Severe irAEs such as myositis require inpatient care, ICI discontinuation and higher steroid doses (1–2 mg/kg/day) or intravenous steroid pulses.

How should other disease modifying antirheumatic drugs (DMARDs) be used?

A DMARD can be used in the case of dependence or resistance to glucocorticoids.
The safety profile of DMARD use in combination with ICI regarding tumour response is still unknown in the absence of RCTs and prompts to their use with caution.

Specific considerations for ICI rechallenge after rheumatic irAEs

Rechallenge is possible in patients with ICI-induced IA and polymyalgia rheumatica, with a recurrence rate of around 50%, prompting close monitoring, especially in the first 4 weeks.
For severe rheumatic irAEs, multidisciplinary team discussions along with close monitoring are needed.

Continue Reading Here

Practical management of rheumatic immune-related adverse events occurring with immune checkpoint inhibitors: A narrative review