10 years ago we would have thought that someone with an autoimmune disease would never get an immunotherapy but today it turns out that’s not the case. First, someone who has a relatively mild variant or a relatively mild condition certainly should be able to get most immunotherapies. For example, someone who might have a mild variant of Sjogren’s Syndrome which is a dryness of the mucus membranes caused by an inflammatory response. Or a mild version of psoriasis which is an autoimmune disease. Or eczema or had 30 years ago a history of mild rheumatoid arthritis with some joint changes and hasn’t had the disease be active in 30 years. Those patients can probably safely get most immunotherapies. The challenge is when someone comes to you who is not eligible for, say, targeted therapy for melanoma and, again, I’m a melanoma doc so I know that best. And their best option would be immunotherapy but they have rheumatoid arthritis and they’re taking prednisone, a steroid. That’s a real problem. You can’t give immunotherapy successfully to someone on a big time dose of steroids to suppress their autoimmune disease. So what we do is we’ll get them off the steroids as best we can with the rheumatologist with their cooperation and very carefully consider using a PD-1 or a PD-L1 antibody. PD-1 antibody is a very focused drug. The likelihood of causing collateral damage throughout the body would be modest. It could happen. But, for example, ipilimumab or Interleukin-2 or Interferon would be drugs that are a little less focused in their effects and would have more of a chance of causing collateral damage and those we would stay away from. But it is truly amazing that there are multiple reports of patients who either have organ transplants and are stable over years or have significant autoimmune diseases who can be gotten off steroids being successfully treated with PD-1 or PDL-1 antibodies. So all is not lost. If you have an auto immune disease or an organ transplant you could potentially still be treated with immunotherapy.
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