AB0767 Efficacy of subcutaneous tocilizumab in patients with rheumatoid arthritis and systemic sclerosis overlap syndrome

Abstract

BackgroundSystemic sclerosis (SSc) is a connective tissue disease that develops sclerotic changes in the skin and visceral organs. SSc is a disease of uncertain etiology, and is characterised by fibrotic changes. Pulmonary, cardiac, gastrointestinal, and renal complications contribute to patient morbidity and decreased survival1. And patients present with stiffness of the limbs because of sclerosis and joint swelling in the skin and periarticular connective tissues. Interleukin-6 (IL-6) is a pleiotropic factor that plays a major role in inflammation; furthermore, IL-6 overexpression and pathogenicity in SSc have been demonstrated2. IL-6 expression is reportedly high in both the skin and serum of SSc patients3, and its elevation depends on the skin score4. And it is a candidate factor that can reproduce the pathological conditions of SSc as well as RA.ObjectivesWe report the cases of rheumatoid arthritis (RA) patients with SSc who was administered anti-interleukin-6 receptor antibody tocilizumab (TCZ).MethodsTwo RA with refractory SSc patients were administered tocilizumab at 162 mg/kg twice a month for 12 months. RA disease activity is evaluated by DAS28-ESR and CDAI. Skin condition of SSc is evaluated by pinching the skin according to the modified Rodnan total skin score (mRTSS).ResultsThey were both female, and age at the time of SSc diagnosis was 74 (patient 1) and 51 (patient 2) years old. The time lapse since SSc diagnosis was at first visit and 14 years, respectively. And it since RA diagnosis was 14 years and 6 years, respectively. Tocilizumab was administered at 162 mg every 2 weeks, which is equal to the dosage used for RA. Administration of prednisolone at 5 mg/day and DMARDs were continued. Overall, TCZ was well tolerated, and both patients experienced a general improvement in coping with normal daily activities. During the 12 month tocilizumab therapy, both RA disease activity and mRTSS decreased. The patient global assessment improved by 70 (75 to 5) and 44 (68 to 24) in patients 1 and 2 in 12 months, respectively. In RA disease activity, DAS28 decreased from 5.66 to 1.73 in 12 months in patient 1 and 7.14 to 4.43 in patient 2. CDAI decreased from 31.8 to 7.4 in 12 months in patient 1 and 34.6 to 10.7 in patient 2. Skin thickness evaluated with the 17 site modified Rodnan skin score improved in patient 1 (from 23 to 2) and patient 2 (from 15 to 8) in 12 months.Adverse reactions were observed cellulitis in right foot planter at 6 week treatment in patient 2. She did withdrawal tocilizumab for 4 week. After cure cellulitis, she continued tocilizumab treatment.ConclusionsIn the two cases of RA with SSc that we report here, softening of the skin was observed during the treatment with tocilizumab. Tocilizumab may be effective against RA and SSc for which conventional treatment is inadequate.References[1] Best Pract Res Clin Rheumatol2010;24:857–69[2] Inter J Rheumatol2011;2011:721608[3] J Rheumatol;25:308–13[4] J Dermatol Sci2001;27:140–6Disclosure of InterestNone declared