Assessment of the Efficacy and Safety of Tocilizumab in Patients Over 80 Years old With Giant Cell Arteritis

Hubert de Boysson; Maelle Le Besnerais; Félix Blaison; Aurélie Daumas; Pierre-André Jarrot; François Perrin; Nathalie Tieulié; Alexandre Maria; Pierre Duffau; Bruno Gombert; Maxime Samson; Olivier Espitia; Marc Lambert; Arsène Mékinian; Achille Aouba

Disclosures

Arthritis Res Ther. 2021;23(143) 

In This Article

Abstract and Introduction

Abstract

Objective: To assess the efficacy and tolerance of tocilizumab (TCZ) in giant cell arteritis (GCA) patients over 80.

Method: GCA patients over 80 years old from the French Study Group for Large Vessel Vasculitis register who received TCZ were analyzed.

Results: Twenty-one GCA patients (median age 84 [81–90] years old, including nine over 85) received TCZ for the following nonexclusive reasons: glucocorticoid (GC)-sparing effect in 14, relapsing disease in 8, disease severity in 4, and/or failure of another immunosuppressant in 4. TCZ was introduced with GCs at diagnosis in 6 patients and at 8 [3–37] months after GC initiation in 15 others. After a median delay of 8 [2–21] months post-TCZ introduction, 14 (67%) patients were able to definitively stop GCs, including 6 who were GC-dependent before TCZ. At the last follow-up (median 20 [3–48] months), 11 (52%) patients had definitively stopped TCZ, and 2 additional patients had stopped but relapsed and resumed TCZ.

Seven (33%) patients experienced 11 adverse events: hypercholesterolemia in 4 patients; infections, i.e., pyelonephritis, bronchitis, and fatal septic shock associated with mesenteric infarction following planned surgery (GCs were stopped for 1 year and TCZ infusions for 2 months), respectively, in 3 patients; moderate thrombocytopenia and moderate neutropenia in 2 patients; and a 5-fold increase in transaminase levels in another that improved after TCZ dose reduction.

Conclusion: TCZ remains a valuable GC-sparing option in the oldest GCA patients with an interesting risk-benefit ratio. Mild-to-moderate adverse events were observed in one-third of patients.

Introduction

Giant cell arteritis (GCA) is a large- and medium-sized vasculitis occurring mainly in patients over 50 years old and is the most frequent systemic vasculitis in elderly patients from Western countries. Epidemiological data show that the incidence of GCA increases with advancing age, and some studies have suggested that the mean age of GCA onset is still increasing, with a maximal incidence between 70 and 80 years old.[1–5] However, patients over 80 years old are common and represent a subgroup with increased frailty, including age-related immunodeficiency, modification of drug metabolism, increased cardiovascular risk factors, and reduced muscular autonomy.[6] This frailty is worsened by the long-term use of glucocorticoids (GCs), which remain the cornerstone of GCA treatment. Taken together, these findings raise the question of whether different therapeutic strategies could be used for elderly individuals, especially to reduce GC exposure while keeping the disease under control. Little information exists on the use of targeted therapies in elderly patients. To date, immunosuppressants, especially methotrexate, have been advised for patients with relapsing disease or for whom GCs should be spared because of toxicity. More recently, tocilizumab (TCZ), a monoclonal antibody targeting the IL-6 receptor, has been approved for GCA. TCZ has shown effectiveness in achieving disease remission and a good GC-sparing effect with an acceptable tolerance profile in a GCA population.[7] However, the mean age of the population in whom the treatment was validated was 69.5 ± 8.5 years, and no subgroup analysis focused on the efficacy and tolerance of TCZ in the oldest patients. In the present study, we aimed to assess the efficacy and tolerance of TCZ in patients over 80 years included in a French register of GCA patients treated with TCZ.

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