Trial of Tocilizumab in Giant-Cell Arteritis

Stone, John H.; Tuckwell, Katie; Dimonaco, Sophie; Klearman, Micki; Aringer, Martin; Blockmans, Daniel Engelbert; Brouwer, Elisabeth; Cid, María C.; Dasgupta, Bhaskar; Rech, Juergen; Salvarani, Carlo; Schett, Georg; Schulze‐Koops, Hendrik; Spiera, Robert; Unizony, Sebastian; Collinson, Neil

doi:10.1056/nejmoa1613849

Cited by 1,085 publications

(976 citation statements)

References 26 publications

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“…A recent report that treatment of PMR with modest doses of CSs is devoid of devastating long-term side effects [7] is not universally accepted [8], and does little to clarify the confusion. There exists a long list of DMARD's that can be tested, including il-6 inhibitors [9], but since this latter medication is now utilized for its CSs sparing effect in biopsy proven GCA [10], such studies need to be properly designed.…”

Section: Discussionmentioning

confidence: 99%

Anarthritic Rheumatoid Arthritis and the Continuing Dilemma of Polymyalgia Rheumatica: Case Report

Brawer

2018

IAM

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A 71 year-old female presented with classical symptoms of polymyalgia rheumatica (PMR), accompanied by multiple other clinical phenomena highly suggestive of giant-cell arteritis (GCA). The latter diagnosis could not be confirmed by temporal artery biopsy, and nine months later her PMR evolved into seronegative rheumatoid arthritis (SNRA). Corticosteroid (CSs) treatment was avoided by utilizing traditional disease modifying anti-rheumatic drugs (DMARD's), thereby sparing this patient from a multitude of potentially devastating CSs-induced side effects. This case reinforces a recently published clinical study emphasizing the need for reassessment of prevailing knowledge and treatment recommendations in PMR.

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Section: Discussionmentioning

confidence: 99%

Anarthritic Rheumatoid Arthritis and the Continuing Dilemma of Polymyalgia Rheumatica: Case Report

Brawer

2018

IAM

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“…Several case series and retrospective studies have highlighted the potential efficacy of the anti-interleukin 6 receptor tocilizumab (TCZ) in PMR and GCA (37)(38)(39). The Gi-ACTA trial (40), which tested the effect of TCZ in patients with GCA, showed impressive results regarding both remission rate and cumulative steroid dose, leading to the approval of TCZ by FDA as a breakthrough therapy for GCA. In contrast to GCA, the potential benefit of TCZ for treatment of PMR is less clear.…”

Section: Biologic Dmardsmentioning

confidence: 99%

Update on treatment of polymyalgia rheumatica

Camellino

Dejaco²

2018

Reumatismo

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SUMMARYPolymyalgia rheumatica (PMR) is the second most common inflammatory rheumatic disease in the elderly after rheumatoid arthritis. It is clinically characterised by pain and stiffness in the neck, proximal shoulder and hip girdle. Glucocorticoids (GCs) are the cornerstone of PMR treatment, but they are associated with potentially severe side effects. Among GC-sparing agents, methotrexate revealed a modest benefit in clinical trials, and recently, there have been promising reports from tocilizumab. In this review, we summarize the available evidence on the treatment of PMR and the possible role in the future of other agents under investigation.

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“…There are currently no published guidelines for using steroid-sparing immunomodulatory agents; however, there is growing evidence for use of anti-interleukin-6 (tocilizumab) as well as T cell costimulation inhibition (abatacept) along with corticosteroids to decrease GCA relapse rate and improve outcomes. 7,8 Management of GCA-related stroke requires potent immunosuppression with high-dose systemic corticosteroids. Pulse dosing or 1-2 mg/kg/d of methylprednisolone have been used but neither dosing regimen has been found superior.…”

Section: Sectionmentioning

confidence: 99%

Clinical Reasoning: A 77-year-old man presenting with episodic expressive aphasia

et al. 2018

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A 77-year-old white man presented to the emergency department with a 1-week history of episodic expressive aphasia, lasting between 3 and 30 minutes and increasing in frequency. He denied any associated symptoms with the aphasia and between episodes returned to baseline. His medical history included psoriatic arthritis, remote biopsy-confirmed giant cell arteritis (GCA), and metastatic urothelial adenocarcinoma for which he was being treated with programmed death ligand 1 (PD-L1) checkpoint inhibitor therapy.Initial neurologic examination, including language evaluation, was normal. The patient's musculoskeletal examination revealed features of chronic arthritis with dorsal hand soft tissue atrophy and bony joint hypertrophy without active synovitis. There were no findings of cutaneous, cardiopulmonary, or gastrointestinal abnormalities.The patient's initial brain MRI (figure) showed acute infarction in the right internal capsule. MRI fluid-attenuated inversion recovery sequence was otherwise unremarkable with minimal evidence of small vessel disease. CT angiogram was striking for several focal areas of high-grade stenosis of the large intracranial vessels: the right internal carotid artery (ICA) terminus, the proximal left M1 segment, and the left A1 origin had near-complete stenosis. In contrast, the other intracranial and extracranial neck vessels were patent with minimal atherosclerotic disease.The patient was started on dual antiplatelet therapy (aspirin and Plavix) as well as high-dose statin for severe, symptomatic large vessel intracranial stenosis.Questions for consideration: 1. What are the potential causes of focal proximal stenosis of the large intracranial arteries? 2. Given this differential diagnosis, what additional workup is recommended? GO TO SECTION 2

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Trial of Tocilizumab in Giant-Cell Arteritis

Cited by 1,085 publications

References 26 publications

Anarthritic Rheumatoid Arthritis and the Continuing Dilemma of Polymyalgia Rheumatica: Case Report

Anarthritic Rheumatoid Arthritis and the Continuing Dilemma of Polymyalgia Rheumatica: Case Report

Update on treatment of polymyalgia rheumatica

Clinical Reasoning: A 77-year-old man presenting with episodic expressive aphasia

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