Session Information
Date: Saturday, November 16, 2024
Title: Vasculitis – Non-ANCA-Associated & Related Disorders Poster I
Session Type: Poster Session A
Session Time: 10:30AM-12:30PM
Background/Purpose: Giant cell arteritis (GCA) is the most common vasculitis in people over the age of 50. Glucocorticoids are the cornerstone of treatment for GCA, but newer strategies have shown some efficacy. Among these strategies, the anti-interleukin-6 receptor monoclonal antibody, tocilizumab (TCZ), has been approved for the treatment of GCA. However, in some cases, TCZ may fail and prednisone cannot be reduced to less than 5 mg/day. These situations are relatively rare but pose significant challenges. We aimed to describe primary treatment failure with TCZ in patients with GCA and salvage therapeutic strategies.
Methods: We conducted a nationwide, retrospective, multicenter study that included patients who met the 2022 ACR/EULAR classification criteria for GCA, received TCZ to induce remission, and failed to respond to TCZ. Primary treatment failure to TCZ was defined as follows: no clinical response, inability to taper prednisone below 5 mg per day, occurrence of manifestations attributable to GCA, persistence of biological inflammatory syndrome. Clinical, biological, pathological and radiological data were collected for each patient using a standardized case report form.
Results: Twenty-five patients (5 men and 20 women, median age 68 years (IQR 64-78)) with primary treatment failure of TCZ were included.
Upon diagnosis of GCA, 92% of patients exhibited general signs, 84% cephalic signs, 64% had PMR symptoms, 20% ophthalmological symptoms, 8% exhibited CNS involvement, and 40% had BAT abnormalities. The median (interquartile range) C-reactive protein level was 74 (37.75–135.5 mg/L), and 13/23 (57%) of PET-scans were abnormal.
Failure was defined as: 1) occurrence of an ischemic event on TCZ (posterior ischemic optic neuropathy, diplopia and ophthalmoplegia, superior mesenteric artery occlusion, transient ischemic attack, cerebral vascular accident) in 8 cases (32%), 2) inability to reduce prednisone to less than 5 mg/day in 7 cases (28%), and 3) occurrence of a GCA-specific clinical event excluding ischemic complications (limb pain, headache, general symptoms) in 10 cases (40%).
Salvage strategies were as follows: 1) JAK inhibitors (n=7, baricitinib in 3, tofacitinib in 3, ruxolitinib in one), with clinico-biological remission in 6/6 patients (100%), 2) addition of methotrexate to TCZ (n=6), with remission in 4/6 (66%), 3) switch from TCZ to methotrexate (n=4) with remission in 3/4 (75%), 4) increase in glucocorticoids without further modification (n=2), with efficacy in 1/2, 5) switch from TCZ to secukinumab (n=3) or ustekinumab (n=1), with remission in 2/4 (50%), only with secukinumab, 6) no therapeutic modification and maintenance of corticosteroid therapy >7.5 mg/day (n=2).
A comparative study aimed at identifying possible factors predictive of tocilizumab failure is currently underway.
Conclusion: Primary treatment failure with TCZ in GCA is rare. The most common salvage strategies are the addition of methotrexate to TCZ or the initiation of JAK inhibitors, which provide a favorable response in 60% and 83%, respectively. The identification of risk factors for tocilizumab failure is under investigation.
To cite this abstract in AMA style:
Cioni P, de Boysson H, Parreau S, SMETS P, SAMSON M, Melboucy S, Lobbes H, Belfeki N, Perrin F, Rossi P, Liozon E, Le Guenno G, Le Jeunne C, FOGEL O, Prat L, Ladouce F, Grosleron S, Yildiz H, Grosbost V, Puéchal X, Comarmond C, Terrier B. Primary Treatment Failure to Tocilizumab in Giant Cell Arteritis [abstract]. Arthritis Rheumatol. 2024; 76 (suppl 9). https://acrabstracts.org/abstract/primary-treatment-failure-to-tocilizumab-in-giant-cell-arteritis/. Accessed .« Back to ACR Convergence 2024
ACR Meeting Abstracts - https://acrabstracts.org/abstract/primary-treatment-failure-to-tocilizumab-in-giant-cell-arteritis/