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Immune-related Adverse Events from Immune Checkpoint Inhibitor Therapy

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37 Table 5. Musculoskeletal Toxicities 5.1 Inflammatory Arthritis Workup/Evaluation G1: • Complete rheumatologic history and examination of all peripheral joints for tenderness, swelling, and range of motion. Examination of the spine. • Consider plain X-ray/imaging to exclude metastases and evaluate joint damage (erosions) if appropriate. • Consider autoimmune blood panel including ANA, rheumatoid factor (RF), anti- citrullinated protein antibody (CCP), and inflammatory markers — erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) — if symptoms persist. If symptoms are suggestive of reactive arthritis or affect the spine, consider HLA B27 testing. G2: • Complete history and examination as above; laboratory tests as above. • Consider US +/- MRI imaging of affected joints if clinically indicated (e.g., persistent arthritis unresponsive to treatment, suspicion for differential diagnoses such as metastatic lesions or septic arthritis). Consider arthrocentesis if septic arthritis or crystal-induced arthritis are suspected. • Consider early referral to a rheumatologist, if there is joint swelling (synovitis) or if symptoms persist >4 weeks. G3–4: • As for Grade 2. • Seek rheumatologist advice and review. • Test for viral hepatitis B, C and latent/active TB test prior to disease-modifying antirheumatic drug (DMARD) treatment. Repeated screening labs annually in patients who require biologic treatment for >1 year until treatment is completed. Monitoring • Patients with inflammatory arthritis should be monitored with serial rheumatologic examinations, including inflammatory markers, every 4–6 weeks after treatment is instituted. Grading Management All Grades Clinicians should follow reports of new joint pain to determine if IA is present. Question whether symptoms new since receiving ICPi. G1: Mild pain with inflammation, erythema, or joint swelling. • Continue ICPi. • Initiate analgesia with acetaminophen and/or NSAIDs.

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