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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.
