From the Guidelines
For immunotherapy-induced inflammatory arthritis, prednisone should be initiated at a moderate dose of 10-20 mg daily, as recommended by the most recent and highest quality study [ 1 ]. This approach is supported by the 2022 ESMO clinical practice guideline for diagnosis, treatment, and follow-up of toxicities from immunotherapy, which emphasizes the importance of early evaluation and treatment of immune-related adverse events, including inflammatory arthritis [ 1 ]. The guideline suggests that most patients will require systemic corticosteroids, which should be initiated at a moderate dose of 10-20 mg prednisone, with some patients requiring long-term, low- to moderate-dose corticosteroids to enable immunotherapy treatment continuation [ 1 ]. Key considerations in managing immunotherapy-induced inflammatory arthritis include:
- Initial evaluation with joint count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (CCP), antinuclear antibodies (ANAs), analysis of synovial fluid, X-rays, and ultrasound (US) of affected joints [ 1 ]
- Use of NSAIDs for mild forms of arthritis and intra-articular corticosteroids for cases of mono- or oligoarthritis [ 1 ]
- Early referral to a rheumatologist for patients with grade 2 symptoms, insufficient response to acceptable doses of corticosteroids, or those requiring corticosteroid-sparing regimens [ 1 ]
- Consideration of csDMARDs, such as methotrexate, hydroxychloroquine, or sulfasalazine, for patients who require long-term corticosteroid use or have an insufficient response to corticosteroids [ 1 ]
- Use of IL-6R inhibitors or TNF-α inhibitors for severe inflammatory arthritis or insufficient response to csDMARDs [ 1 ].
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Steroid Dosing for Immunotherapy-Induced Inflammatory Arthritis
- The treatment of immune checkpoint inhibitor-induced inflammatory arthritis typically involves low doses of corticosteroids or conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs) 2.
- A survey of expert rheumatologists found that most experts (63%) agreed on 20 mg or less of prednisone as the initial dose for moderate irAE-IA 3.
- In patients with rheumatoid arthritis, initial treatment with methotrexate and a tapered high dose of prednisone (60 mg/day tapered to 7.5 mg/day in 7 weeks) resulted in similarly high remission percentages after 4 months (about 60%) 4.
- For patients whose initial DMARD therapy failed, the second choice was either a tumor necrosis factor inhibitor (TNFi) (38%) or interleukin-6 receptor antagonist (IL6ri) (33%) 3.
Disease-Modifying Antirheumatic Drugs (DMARDs)
- DMARDs, such as methotrexate, leflunomide, sulfasalazine, injectable gold, and (hydroxy)chloroquine, are capable of controlling synovial inflammation and are therefore named 'disease-modifying antirheumatic drugs' 5.
- Methotrexate was selected as the initial DMARD by 41% of experts if there was no improvement with corticosteroids 3.
- The combination of methotrexate with other non-biological DMARDs, such as prednisolone, leflunomide, chloroquine, and sulfasalazine, showed a decrease in the severity of disease activity in 80% of patients with RA 6.
Treatment Strategies
- The majority of patients with inflammatory arthritis due to cancer treatment with immune checkpoint inhibitors can be successfully treated with low doses of corticosteroids or conventional synthetic DMARDs 2.
- Some patients will develop severe symptoms requiring biologic therapy, including TNF inhibitors and IL-6 receptor inhibitors 2.
- Patients with preexisting inflammatory arthritis (e.g., rheumatoid arthritis) commonly flare on ICI therapy, but can usually be managed with corticosteroids 2.