38
Treatment
Table 5. Musculoskeletal Toxicities
G2: Moderate pain associated
with signs of inflammation,
erythema, or joint swelling ;
limiting instrumental ADL.
• Consider holding ICPi.
• Escalate analgesia and consider higher doses of
NSAIDS as needed.
• If inadequately controlled, initiate prednisone
10–20 mg/day or equivalent.
• If improvement, slow taper according to response
during the next 4–6 weeks. If no improvement after
initial 4 weeks treat as G3.
• If unable to lower corticosteroid dose to below 10
mg/d after 6–8 weeks, consider DMARD.
• Consider intra-articular steroid injections for large
joints.
• Referral to rheumatolog y.
G3–4: Severe pain associated
with signs of inflammation,
erythema, or joint swelling ;
irreversible joint damage;
disabling ; limiting self-care
ADL.
• Hold ICPi temporarily and may resume in
consultation with rheumatolog y, if recover to ≤G1.
• Initiate oral prednisone 0.5–1 mg/kg.
• If failure of improvement after 2 weeks or
worsening in meantime, consider synthetic or
biologic DMARD.
▶ Synthetic: methotrexate, leflunomide,
hydroxychloroquine, sulfasalazine alone or in
combination.
▶ Biologic: Consider anti-cytokine therapy such
as tumor necrosis factor (TNF) -α or IL-6
antagonists.
Note: As caution, IL6 inhibition can cause
intestinal perforation. While this is extremely rare,
it should not be used in patients with concomitant
immune-related colitis.
• Referral to rheumatolog y.
Additional considerations:
• Early recognition is critical to avoid erosive joint damage.
• Corticosteroids can be used as part of initial therapy in IA, but due to likely
prolonged treatment requirements, physicians should consider starting steroid-
sparing agents earlier than one would with other irAEs.
• Oligoarthritis can be treated early on with intra-articular steroids, consider early referral.
(cont'd)
