Steroid-Sparing Effect of Tocilizumab and Methotrexate in Patients with Polymyalgia Rheumatica: A Retrospective Cohort Study

Abstract

Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by pain and stiffness in the shoulders, hips, and proximal limbs; it usually affects elderly patients. The effectiveness of methotrexate and tocilizumab in PMR treatment has not been extensively studied. Thus, we aimed to assess the steroid-sparing effect of tocilizumab and methotrexate in PMR in clinical practice. Consecutive patients with PMR in our hospitals, who were included in our retrospective cohort, were reviewed between 2005 and 2015 and divided into the following groups according to their treatments: prednisolone or none (prednisolone group), methotrexate ± prednisolone (methotrexate group), or tocilizumab ± prednisolone (tocilizumab group). The prednisolone dose at the last follow-up was compared. A total of 227 patients with an average age of 74 years were enrolled. No difference in baseline characteristics was found among the three groups. The prednisolone dose at the last follow-up was lower (0 vs. 3.0 vs. 3.5 mg/day, p < 0.001) and the prednisolone discontinuation rate was higher (80.0% vs. 28.3% vs. 18.8%, p < 0.0001) in the tocilizumab group than in the prednisolone and methotrexate groups. This study suggested that tocilizumab has a steroid-sparing effect in PMR. Tocilizumab can be an option in the management of PMR. Future studies are warranted to confirm our findings.

Is Tocilizumab Effective and Safe in Polymyalgia Rheumatica and Giant-Cell Arteritis With Polymyalgia Rheumatica?

“…Three studies were excluded because we did not find data on the statistical significance or the studies did not pass the quality appraisal evaluation. Therefore, we included eight articles in this review [4,[11][12][13][14][15][16][17]. The PRISMA flowchart is illustrated in Figure 1.…”

“…In PMR, Izumi et al reported no relapses in the TCZ group at the last follow-up visit in their investigation [14]. Bonelli et al's primary efficacy endpoint was to reach GC-free remission at week 16.…”

“…Five studies implemented intravenous (IV) TCZ, 8 mg/kg, every four weeks [4,13,14,16,17]. One study used SC and IV routes.…”

“…Four studies applied GC concomitantly with TCZ (GC combination) [11,12,14,15], and three used TCZ as monotherapy [11,14,15]. In addition, Akiyama et al evaluated monotherapy and GC combinations [4], as represented in Table 4.…”

Diabetes-Modifying Antirheumatic Drugs: The Roles of DMARDs as Glucose-Lowering Agents

“…Controlling inflammation in CIRDs may provide additional clinical benefits, including prevention of chronic diabetes complications, reduction in cardiovascular morbidity and mortality, improvement of quality of life and medication adherence, as well as reduction in healthcare costs related to disease relapses and hospitalizations. The use of DMARDs in CIRD patients can also be advantageous in reducing the daily corticosteroid dose (steroid-sparing effect) [ 203 ], thereby mitigating the risk of incident diabetes (including steroid-induced diabetes, which is highly prevalent in these patients) [ 204 , 205 ] or preventing poor glucose control in diabetic subjects. Indeed, prolonged corticosteroid exposure deriving from long-term corticosteroid therapy leads to diabetogenic effects by enhancing hepatic endogenous glucose production and inducing insulin resistance in all insulin-sensitive tissues [ 206 ].…”