TY  - CHAP
M1  - Book, Section
TI  - Immune Checkpoint Inhibitors in Patients with Autoimmune Disease
A1  - So, Alfred C.P.
A1  - Board, Ruth E.
A2  - Board, Ruth E.
A2  - Nathan, Paul
A2  - Newsom-Davis, Tom
A2  - Papa, Sophie
A2  - Johnson, Peter
PY  - 2019
T2  - Problem Solving in Cancer Immunotherapy
AB  - A  65-year-old  woman  with  a  history  of  seronegative  arthritis  presented  to  her  rheumatology  follow-up  with  night  sweats,  lethargy,  lower  back  pain  and  discomfort  when  lying  down.  Her  medical  history  included  cutaneous  melanoma,  hypertension  and  hypercholesterolaemia.  A  superficial,  spreading  non-ulcerated  1.2  mm  (pT2a)  malignant  melanoma  had  been  excised  from  her  left  thigh  28  years  earlier.  Her  arthritis  was  well  controlled  with  hydroxychloroquine  only.  A  CT  scan  revealed  metastatic  lesions  in  the  retroperitoneum,  left  external  iliac  nodes  and  pelvic  sidewalls.  Biopsies  confirmed  recurrence  of  a  BRAF  V600E  mutant  melanoma.  Her  performance  status  was  0.  Detailed  discussions  took  place  with  the  patient  about  the  risks  and  benefits  of  starting  immunotherapy  vs  serine/threonine-protein  kinase  B-Raf  (BRAF)-targeted  therapy.  The  patient  decided  to  proceed  with  primary  treatment  with  pembrolizumab  200  mg/kg  every  3  weeks.After  cycle  1  she  experienced  grade  2  arthritis  and  required  treatment  with  prednisolone  30  mg  once  daily  tapered  over  4  weeks.  A  partial  response  to  treatment  was  confirmed  by  CT  scan  12  weeks  after  starting  treatment.  She  continued  to  experience  grades  1–2  exacerbations  of  her  arthritis  throughout  her  treatment  course,  requiring  intermittent  steroid  dosing.  Ultimately,  she  was  kept  on  a  maintenance  dose  of  prednisolone  10  mg  once  daily,  which  controlled  her  arthritis  symptoms.  She  was  later  diagnosed  with  osteoporosis  plus  sacral  stress  fractures  and  was  started  on  bisphosphonates.  She  has  currently  completed  31  cycles  of  pembrolizumab,  with  no  treatment  deferrals.  Follow-up  CT  scans  continue  to  demonstrate  response  to  immunotherapy.What  is  the  evidence  for  the  safety  of  immune  checkpoint  inhibitors  (ICPIs)  in  patients  with  pre-existing  autoimmune  disease?Do  patients  with  pre-existing  autoimmune  disease  have  a  poorer  clinical  outcome  with  anti-  programmed  cell  death  protein  1  (PD-1)  therapy?What  are  the  treatment  options  for  our  patient's  flare  of  arthritis?Can  we  predict  which  patients  are  likely  to  have  severe  exacerbations  of  their  autoimmune  disease?How  should  at-risk  patients  be  managed  by  the  multidisciplinary  team?  
SN  - 
PB  - EBN Health
CY  - New York, NY
Y2  - 2021/03/06
UR  - hemonc.mhmedical.com/content.aspx?aid=1160633056
ER  -