41
Table 5. Musculoskeletal Toxicities
Additional considerations:
• Caution is advised with rechallenging.
• With elevated transaminases, consider differential with immune-mediated hepatitis.
* Patients with myasthenia gravis-like syndrome or myocarditis and concomitant myositis should be
hospitalized, please see neurologic or cardiovascular sections, respectively, for further information.
5.3 Polymyalgia-like Syndrome
Workup/Evaluation:
G1:
• Complete rheumatologic history regarding differential diagnosis and examination of
all joints and skin
• Rarely patients may also develop concomitant giant cell arteritis (GCA). Check
for symptoms of temporal arteritis, such as headache, visual disturbances, or jaw
claudication. Urgent referral to ophthalmologist if present and consider temporal
artery biopsy as permanent visual loss can occur within days of symptom onset.
• ANA, RF, anti-CCP.
• CK to evaluate differential diagnosis of myositis.
• Inflammatory markers (ESR, CRP).
Monitoring: ESR, CRP
≥G2:
• Complete history and examination as above; autoimmune tests as required for
differential diagnosis.
• Early referral to a rheumatologist.
Grading Management
G1: Mild stiffness and pain • Continue ICPi.
• Initiate analgesia with acetaminophen and/or
NSAIDs if there are no contraindications.
G2: Moderate stiffness and
pain; limiting age-appropriate
instrumental ADL
• Consider holding ICPi and resuming upon
symptom control, prednisone <10 mg ; if worsens,
treat as per G3.
• Initiate prednisone 20 mg/d or equivalent. If
symptoms improve, start to taper dose after 3–4
weeks.
• If no improvement or need for higher dosages after
4 weeks, escalate to G3.
• Consider referral to rheumatolog y.
(cont'd)
