The Case of the Mysterious Myalgia

July 20, 2021 by Deborah Christensen MSN, APRN, AOCNS®

Randi is a 57-year-old patient who identifies as female. She was diagnosed with clear cell metastatic renal cell carcinoma (mRCC), and her past medical history includes mild hypertension managed with amlodipine and a two-year history of transient musculoskeletal pain managed with tramadol. She reports a family history of cardiovascular disease and rheumatoid arthritis (RA). Her primary care physician suspects Randi is at the beginning stages of fibromyalgia but has not made a conclusive diagnosis because she hasn’t experienced additional symptoms.

Given Randi’s chronic pain and family history of RA, the interprofessional tumor board recommends treatment with a single immunotherapy plus targeted therapy instead of a couplet immunotherapy regimen. You prepare to educate Randi on her combination treatment with pembrolizumab and axitinib.

What Would You Do?

Cytotoxic T-cell lymphocyte–associated antigen-4 (CTLA-4) and programmed cell death-1/programmed cell death-ligand 1 (PD-1/PD-L1)–blocking agents have been used to treat cancers in patients with a history of autoimmune diseases. A systematic literature review ( showed that 75% of patients with an underlying autoimmune disease developed a flare in their autoimmune condition while on immunotherapy. The majority (90%) of those patients improved, with just 17% requiring a discontinuation of immunotherapy.

Patients with a history of joint pain should be evaluated at baseline ( and educated on the signs and symptoms of adverse events related to immunotherapy and targeted therapy. Baseline measurement of bowel habits is also important, especially when patients require opioids or other constipating medications. Instruct ( patients to maintain their bowel regimen and report any changes in frequency, consistency, cramping, or signs of mucus or blood in the stool.

Blood pressure can be affected by vascular endothelial growth factor (VEGF) inhibitors like axitinib. Monitor patients’ blood pressure at baseline and throughout treatment, reporting blood pressure changes right away. Encourage ( patients to carry an immunotherapy wallet card to share with other medical providers who may be involved in their care.

You educate Randi on the system-wide adverse events that can occur with immunotherapy and provide her with the National Comprehensive Cancer Network handout showing each body system and associated potential immune-related adverse reaction. You explain how immunotherapy works and axitinib’s anti-VEGF effects. Randi agrees to monitor her blood pressure, bowel status, and joint pain and report any changes from baseline. You explain that her blood pressure medication may need to be adjusted and that the oncologist will collaborate with her primary care provider and other specialists as needed to ensure an interprofessional approach to her care.

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