Corticoid-sparing agents

[LCHRISTOP10]

Therapeutic Advances in Chronic Disease

Update on the management of giant cell arteritis

Janet Roberts, Alison Clifford First Published March 28, 2017 Review Article

Review of corticoid-sparing agents.

[Hindags]

ncbi.nlm.nih.gov/pmc/articl... This link might make it easier to find the complete article, free. Very interesting to me even though I have PMR and not GCA (I hope).

I really do wonder about the enduring changes caused by the vasculitis that were found in one woman who died after elective surgery. She had been treated by tocilizumab and was clinically in remission from GCA.

"A single death, however, (a postoperative myocardial infarction) occurred in an 82-year-old female following an elective surgery, during a period of perceived clinical remission on TCZ. Despite the clinical impression, post-mortem examination revealed extensive active arteritis involving the thoracic and abdominal aorta, brachiocephalic, subclavian, carotid, vertebral, temporal and femoral arteries. This case represents the only reported example in which tissue has been available for correlation of disease activity in a TCZ-treated GCA patient."

"The discordance observed raises the possibility that, despite dramatic clinical improvements reported with TCZ, subclinical vasculitis may persist. Indeed, persistence of tissue infiltrates have also occasionally been observed in patients receiving weeks, or sometimes months, of prednisone.40,41 Further studies evaluating correlation of histopathology with clinical parameters in TCZ-treated patients will be of interest."

Also for me, the discussion of the early introduction of GCA with a goal of tapering off Pred in 12 weeks is quite spectacular.

And the conclusion:

In support of the numerous positive observational reports, the recent completion of two randomized control trials have provided evidence that the addition of TCZ (in either intravenous or subcutaneous form) may provide additional benefit to prednisone for both inducing and maintaining remission in GCA patients for up to 52 weeks. TCZ appears to be quick in onset, and helps to minimize glucocorticoid exposure over time. Whether early introduction of TCZ at diagnosis can influence the natural history of disease remains to be investigated. Additional future studies evaluating the longer-term safety outcomes and risk of relapse after drug discontinuation are anticipated.

I am assuming that the "natural history" refers to the relapse rate. I also wonder about the persistence of subclinical vasculitis as identified in the post mortem evaluation of the woman who was autopsied.

[PMRpro Ambassador in reply to Hindags]

This has been a topic of discussion before because we aren't monitored to see if the lack of symptoms correlates with total lack of disease activity.

No - unless I'm misunderstanding what you mean. The natural history will be the way the vasculitis itself progresses - is it still active even though the drug is managing the inflammation? I do bang on about that being the case with pred - it's only dealing with the symptoms and the disease itself it still there attacking the body and that is what causes you to still be weak and feeble and the sweats, easily upset muscles and so on. I think they really had thought that the TCZ was stopping the actual disease process and so removing the potential damage the inflammation can cause. I suspect that what they really need to do is a more extended course of high dose steroids, despite the TCZ. They won't like that...

[CT-5012]

Many thanks for sharing this, also to Hindhags for making it easy to access.