Patients with rheumatoid arthritis can safely use immune checkpoint inhibitors for cancer
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Key takeaways:
- Patients with pre-existing rheumatoid arthritis had similar mortality as patients without RA after immune checkpoint inhibition.
- The most common immune-related adverse event for patients with RA was flare.
Patients with pre-existing rheumatoid arthritis can safely undergo immune checkpoint inhibition for the treatment of cancer, albeit with close monitoring for flares, according to data published in The Lancet Rheumatology.
“We were interested to investigate the safety of immune checkpoint inhibitors (ICI) for patients with pre-existing rheumatoid arthritis,” Jeffrey A. Sparks, MD, MMSc, of the department of medicine at Brigham and Women’s Hospital, told Healio. “ICI stimulate the immune system to treat cancer but can result in immune-related adverse events (irAE), some of which can be lethal.”
To investigate whether patients with RA might be at an increased risk for mortality or other immune-related adverse events relating to immune checkpoint inhibition, Sparks and colleagues conducted a retrospective, comparator cohort study using records from the Mass General Brigham Integrated Healthcare system and the Dana-Farber Cancer Institute. The researchers included patients who had initiated immune checkpoint inhibitor therapy between April 1, 2011, and April 21, 2021. For each patient with RA, up to three comparator patients were identified and matched according to histological cancer types.
The analysis employed two co-primary endpoints. These were the time from index date — defined as the date of the first received prescription for immune checkpoint inhibitors targeting PD-1, PD-L1 or CTLA-4 — to death, and the time from index date to the first immune-related adverse event. To accurately find data on adverse events and deaths, the researchers searched electronic health records as well as obituaries. Each patient’s final clinical visit was documented as the end of follow-up care.
Secondary outcomes included the number of immune-related adverse events, severe immune-related adverse event manifestations and certain specific adverse events. In patients with RA, immune-related adverse events were defined as RA flares. For comparators, they were defined as inflammatory arthritis manifestation.
The analysis included 87 patients with pre-existing RA and 203 comparator patients. In all, 69% of patients with RA died, compared with 63% of comparator patients (HR = 1.16; 95% CI 0.86-1.57). Additionally, 61% of patients with RA, vs. 49% of comparator patients, experienced any immune-related adverse events (HR = 1.72; 95% CI, 1.2-2.47).
There were two cases of myocarditis resulting in death in the comparator group. Meanwhile, there were 42 cases of flares (48%) in patients with RA, and 14 cases of inflammatory arthritis (7%) in the comparator group (P < .0001), according to the researchers. Patients with RA were less likely than their comparator counterparts to experience a rash or dermatitis, endocrinopathy, colitis, enteritis or hepatitis.
“Patients with pre-existing RA had similar mortality as non-RA comparators after ICI initiation,” Sparks said. “While pre-existing RA had a higher overall irAE risk, there was a similar risk for severe irAE. These results suggest that pre-existing RA patients can safely receive ICI for cancer treatment, monitoring closely for RA flares.”
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