Expert Perspectives . . . Shouldpatients with autoimmune diseases not receive immunotherapy?

Recently, the journal CA published that patients with autoimmune diseases may accept the treatment of immune checkpoint inhibitors (ICI).How do medical experts interpret patients with autoimmune diseases receiving immunotherapy? See below.at present, ICI therapy has become the first-line treatment for melanoma, non-small cell lung cancer and renal cell carcinoma, and adjuvant treatment for locally advanced melanoma. However, due to immune related adverse events (Irae), patients with previous autoimmune diseases are often excluded from the clinical trials of immunotherapy Whether patients can benefit from immunotherapy is doubtful. The concern is that severe inflammation and autoimmune toxicity may aggravate the condition of autoimmune diseases or affect the tolerance of immunotherapy.recently, a study in France [1] explored whether patients with autoimmune diseases can benefit from ICI treatment. The researcher Dr. divi cornec pointed out that the management of these patients is a real problem in clinical practice. In addition to safety, the study also evaluated the effectiveness of ICI treatment.this new study provides new information for cancer immunotherapy in patients with autoimmune diseases. It also compares the results of different subgroups of patients and draws more reliable conclusions.study details this multicenter, retrospective study included 112 patients, all of whom were diagnosed with autoimmune diseases and cancer and were treated with immunosuppressive checkpoint inhibitors between January 2017 and January 2018.the researchers collected data on the types of immunotherapy, autoimmune disease flares and / or other immunotherapy related adverse events, and classified the adverse events into mild events (1-2) and severe events (3-4), and recorded the use of glucocorticoids or immunosuppressive therapy (is).the study cohort included patients with psoriasis or psoriatic arthritis (31 cases), rheumatoid arthritis (20 cases), rheumatoid myalgia and / or giant cell arteritis (7 cases), systemic lupus erythematosus (4 cases), localized skin lupus erythematosus (3 cases) or inflammatory bowel disease (14 cases).Irae in 112 patients, 79 (71%) patients had immunotoxicity, 53 (47%) had flare, 47 (42%) had immune related adverse events unrelated to autoimmune diseases, and 20 (18%) patients had both immunotoxicity and Irae.1 patient died due to immunotoxicity, and 24 patients stopped ICI permanently due to immunotoxicity.Table 1 safety of using ICI in patients with autoimmune diseases: nearly half of the patients with autoimmune disease were treated with glucocorticoids (24 cases), 6 patients were treated with conventional synthetic anti rheumatic drugs, and 3 patients were treated with biological anti rheumatic drugs.a total of 24 patients with immune related adverse events of non initiating autoimmune diseases received glucocorticoid treatment, and 7 patients received additional is treatment, including methotrexate (a tumor necrosis factor inhibitor) and intravenous immunoglobulin.it is safer to use ICI in patients with autoimmune diseases. Dr. divi cornec pointed out that in general, the use of ICI in patients with autoimmune diseases is quite safe. Serious adverse events may occur, but most of them are mild and controllable after steroid treatment.close monitoring is necessary during treatment.the researchers found that is treatment at the beginning of ICI seems to have a negative impact on the prognosis of cancer. For patients with stable autoimmune diseases, is treatment should be minimized.contrary to previous studies, the researchers found that Irae was associated with worse cancer prognosis, and the source of this difference may be due to different statistical methods.patients with better prognosis and better response to ICI may have more time to experience Irae than patients with shorter survival. this phenomenon may lead researchers to conclude that patients who experience Irae have better prognosis. In order to avoid this deviation, French researchers used time-related covariates, and finally found that iraes was associated with poor prognosis, which is the reason for using is or stopping ICI. Figure 1 PFS and OS of patients receiving is treatment at the beginning of ICI Table 2 PFS multivariate analysis suggested that the treatment of is should be minimized at the beginning of ICI. According to Dr. April Salama, this study emphasizes that the potential disease risk of reactivation is high, but not 100%. therefore, clinicians should not absolutely exclude patients with rheumatic cancer who may benefit from immunotherapy, which is very important. Clinicians can discuss with patients whether they will consider continuing immunotherapy. Dr. divi cornec believes that for patients with stable autoimmune diseases, it is necessary to reduce is treatment as much as possible to avoid reducing the response to immunotherapy. this has been used in clinical practice in the general population. Several studies have shown that more than 10 mg daily steroids (relieving symptoms such as dyspnea, fatigue or brain metastases) during ICI treatment has adverse effects on the prognosis, but prospective studies in a larger population are needed for further verification. basic research is also needed to identify predictors of immunotoxicity and immunotherapy response. References: [1] tison a, Qu é R é g, misery L, et al. Safety and efficiency of immune checkpoint inhibitors in patients with cancer and preexisting autoimmune disease: a nationwide, multicenter cohort study [published online ahead of print, 2019 Aug 5]. Artistis rheumatol. 2019; 10.1002/art.41068. doi:10.1002/art.41068 [2] Fillon M. Immune checkpoint inhibitors may be safe for patients with preexisting autoimmune disease [published online ahead of print, 2019 Nov 8]. CA Cancer J Clin. 2019;10.3322/caac.21587. doi:10.3322/caac.21587