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irAE Arthritis — SCE Medical Oncology MCQ

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ModerateImmunotherapy & Targeted TherapyirAE ArthritisSCE Medical Oncology

A 62-year-old man on pembrolizumab develops new bilateral knee and ankle joint swelling with morning stiffness >1 hour. He is HLA-B27 positive. Anti-CCP and RF are negative. X-rays show no erosions. ANA is negative. What is the most appropriate initial management for this moderate immune-related arthritis?

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Correct answer: C — NSAIDs (if no contraindications) as first line; if inadequate, low-dose prednisolone (10-20 mg/day)

For grade 2 immune-related inflammatory arthritis (moderate symptoms interfering with instrumental ADLs), initial management is NSAIDs ± low-dose oral prednisolone (10-20 mg/day). Higher-dose steroids (0.5-1 mg/kg) are reserved for grade 3. DMARDs (methotrexate, sulfasalazine, hydroxychloroquine) are considered for chronic/persistent arthritis not responding to steroids. Pembrolizumab can often be continued during management of grade 1-2 arthritis, unlike most other grade 2+ irAEs.

Reference: ESMO 2024 irAE Management Guidelines; Cappelli et al J Immunother Cancer 2019