Objective. The interleukin-6 pathway is up-regulated in giant cell arteritis (GCA), Takayasu arteritis (TA), and polymyalgia rheumatica (PMR). We retrospectively assessed the outcomes of 10 patients with relapsing/refractory GCA, TA, or PMR treated with tocilizumab (TCZ). Methods. Patients with GCA (n ‫؍‬ 7), TA (n ‫؍‬ 2), and PMR (n ‫؍‬ 1) received TCZ. Seven subjects had failed at least 1 second-line agent. The outcomes evaluated were symptoms of disease activity, inflammatory markers, ability to taper glucocorticoids, and cross-sectional imaging when indicated clinically. Results. The mean followup time of this cohort since diagnosis was 27 months (range 16 -60 months). The patients were treated with TCZ for a mean period of 7.8 months (range 4 -12 months). Before TCZ therapy, the patients experienced an average of 2.4 flares/year. All patients entered and maintained clinical remission during TCZ therapy. The mean daily prednisone dosages before and after TCZ initiation were 20.8 mg/day (range 7-34.3 mg/day) and 4.1 mg/day (range 0 -10.7 mg/day), respectively (P ‫؍‬ 0.0001). The mean erythrocyte sedimentation rate declined from 41.5 mm/hour (range 11-68 mm/hour) to 7 mm/hour (range 2.2-11.3 mm/hour; P ‫؍‬ 0.0001). The adverse effects of TCZ included mild neutropenia (n ‫؍‬ 4) and transaminitis (n ‫؍‬ 4). One patient flared 2 months after TCZ discontinuation. An autopsy on 1 patient who died from a postoperative myocardial infarction following elective surgery revealed persistent vasculitis of large and mediumsized arteries. Conclusion. TCZ therapy led to clinical and serologic improvement in patients with refractory/relapsing GCA, TA, or PMR. The demonstration of persistent large-vessel vasculitis at autopsy of 1 patient who had shown a substantial response requires close scrutiny in larger studies.

Objective To evaluate whether the classification of ANCA-associated vasculitis (AAV) patients according to ANCA type (anti-proteinase 3 [PR3] or anti-myeloperoxidase [MPO] antibodies) predicts treatment response. Methods Treatment responses were assessed among patients enrolled in the Rituximab in ANCA-associated Vasculitis trial according to both AAV diagnosis (granulomatosis with polyangiitis [GPA]/microscopic polyangiitis [MPA]) and ANCA type (PR3-AAV/MPO-AAV). Complete remission (CR) was defined as disease activity score of 0 and successful completion of the prednisone taper. Results PR3-AAV patients treated with rituximab (RTX) achieved CR at 6 months more frequently than did those randomized to cyclophosphamide (CYC)/azathioprine (AZA) (65% versus 48%; P=0.04). The odds ratio (OR) for CR at 6 months among PR3-AAV patients treated with RTX as opposed to CYC/AZA was 2.11 (95%CI 1.04–4.30) in analyses adjusted for age, sex, and new-onset versus relapsing disease at baseline. PR3-AAV patients with relapsing disease achieved CR more often following RTX treatment at 6 months (OR3.57; 95%CI 1.43–8.93); 12 months (OR4.32; 95%CI 1.53–12.15); and 18 months (OR3.06; 95%CI 1.05–8.97). No association between treatment and CR was observed in the MPO-AAV patient subset or in groups divided according to AAV diagnosis. Conclusion PR3-AAV patients respond better to RTX than to CYC/AZA. An ANCA type-based classification may guide immunosuppression in AAV.

Abstract:Objectives:To develop a Glucocorticoid Toxicity Index (GTI) to assess glucocorticoid (GC)-related morbidity and the GC-sparing ability of other therapies. Methods:Nineteen experts on glucocorticoid use and outcome measures from 11 subspecialties participated. Ten experts were from the United States; 9 from Canada, Europe, or Australia.Group consensus methods and multi-criteria decision analysis (MCDA) were utilized.A Composite GTI and Specific List comprise the overall GTI. The Composite GTI reflects toxicity likely to change during a clinical trial. The Composite GTI toxicities occur commonly, vary with GC exposure, and are weighted and scored. Relative weights for items in the Composite GTI were derived by group consensus and MCDA. The Specific List is designed to capture GC toxicity not included in the Composite GTI. The Composite GTI was evaluated by application to paper cases by the investigators and an external group of 17 subspecialists. Results:Thirty-one toxicity items were included in the Composite GTI and 23 in the Specific List.Composite GTI evaluation showed high inter-rater agreement (investigators kappa 0.88, external raters kappa 0.90). To assess the degree to which the Composite GTI corresponds to expert clinical judgment, participants ranked 15 cases by clinical judgment in order of highest to lowest GC toxicity. Expert rankings were then compared to case ranking by the Composite GTI,

Residents and fellows want to engage in positive teaching interactions in the context of the clinical consult; however, multiple barriers influence both parties in the hospital environment. Many of these barriers are amenable to change. Interventions aimed at reducing barriers to teaching in the setting of consultation hold promise for improving teaching and learning on the wards.