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Immune-related Adverse Events from Immune Checkpoint Inhibitor Therapy

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39 Table 5. Musculoskeletal Toxicities 5.2 Myositis Workup/Evaluation • Complete rheumatologic and neurologic history regarding differential diagnosis and rheumatologic and neurologic examination including muscle strength, and examination of the skin for findings suggestive of dermatomyositis. Muscle weakness is more typical of myositis than pain. Consider pre-existing conditions that can cause similar symptoms. • Blood testing to evaluate muscle inflammation; CK and aldolase. Transaminases (AST, ALT) and lactate dehydrogenase (LDH) can also be elevated. • Troponin to evaluate myocardial involvement. Other cardiac testing such as ECG and echocardiogram or cardiac MRI (see CV section for further details). • Autoantibody testing to evaluate possible concomitant myasthenia gravis (anti- acetylcholine receptor (AChR) and anti-striational antibodies) • Inflammatory markers (ESR and CRP). • Consider electromyography (EMG), imaging (MRI) and/or biopsy on an individual basis when diagnosis is uncertain and overlap with neurologic syndromes such as myasthenia gravis is suspected. • Consider paraneoplastic autoantibody testing for myositis (e.g., anti-TIF1-γ, anti- NXP2, and other myositis autoantibodies as indicated), especially if patient had muscle-related manifestations before receiving ICPi. • Urinalysis for rhabdomyolysis. Monitoring: CK, ESR, CRP, Aldolase if CK has not been elevated G1: Complete examination and laboratory work-up as above. G2: Complete history and examination as above; autoimmune myositis blood panel; EMG, MRI imaging of affected joints Early referral to a rheumatologist or neurologist. G3–4: As for Grade 2 Urgent referral to a rheumatologist or neurologist. Grading Management of Myositis alone* G1: Mild weakness with or without pain. • Continue ICPi. • If CK and/or aldolase are elevated and patient has muscle weakness may offer oral corticosteroids, starting prednisone at 0.5 mg/kg/day. Offer analgesia with acetaminophen or NSAIDs for myalgia if there are no contraindications. • Consider holding statins. (cont'd)

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