Our study suggests that TCZ can be used with a good tolerance profile in elderly GCA patients. Although GC remains the cornerstone of the treatment and is sufficient for most patients, some circumstances can require an adjunctive immunosuppressant to achieve disease remission or to decrease GC use more quickly. Tocilizumab was recently included among the few therapeutic options available, in addition to methotrexate, for patients with relapsing GCA or those for whom a GC-sparing effect is needed. Based on our results, two main points should be highlighted and discussed.
First, in accordance with the main studies dealing with TCZ, GC doses can be rapidly decreased in patients receiving TCZ. In France, current guidelines recommend using GCs for 18–24 months. However, little information exists on the morbidity of such prolonged GC treatment in elderly people, in whom GC toxicity on metabolism, the cardiovascular system, muscle, or bone can be life-threatening. A reduction in GC exposure in this subset of patients should be a priority, and TCZ appears to be an option. In our study, two-thirds of patients were able to stop GC use after a median delay of 8 months, including some patients with GC-dependent disease. This result is concordant with published studies that reported sustained remission in 54 to 70% of patients, including mainly patients <80.[7,11] Some future studies and consensus are needed to determine whether different strategies should be proposed in elderly patients, as suggested for systemic necrotizing vasculitides.
Second, our study indicated that serious adverse events were limited, affecting 19% of our patients. We did not observe an over-representation of serious adverse events when compared to other published studies. In the patients of the Giacta trial who received TCZ, serious adverse events were reported in 15% of patients, mainly infections. Serious infections, grade 3 neutropenia, and transaminase elevations were observed in 7%, 4%, and 2% of patients, respectively. In the Spanish study from Calderón-Goercke et al. including 134 patients in a real-life setting, serious adverse events were observed in 23.9%, mainly infections. In the two aforementioned studies, TCZ was discontinued due to side effects in 6% and 12.7% of the Giacta and the Spanish cohort, respectively. Of note, no gastrointestinal perforations were reported in either study.[7,11] Three of our patients developed infective toxicities, which are also common in patients treated with GCs alone.[13,14] One of our patients, however, died from infection and mesenteric infarction, and the role of the underlying immunodepression cannot be excluded. Other TCZ toxicities observed in our study were common and not serious. Interestingly, no signal emerged from patients with previous diverticulosis or myelodysplasia.
Although our work demonstrates the availability of TCZ in therapeutic strategies for elderly GCA patients, the relatively small sample size, retrospective design, and short follow-up time should be acknowledged. Our patients over 80 were selected and might differ from other GCA patients regarding their baseline characteristics and outcomes. However, we believe that a description of TCZ use in this population remains useful in clinical practice. Regarding safety, our small sample might limit the capture of other adverse events. However, the comparison with larger cohorts was reassuring and indicates that the side effects we observed were representative of described tolerance profiles.
Arthritis Res Ther. 2021;23(143) © 2021 BioMed Central, Ltd.
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