Letter to the Editor
New Drugs in Takayasu Arteritis, Role of Tocilizumab
Nuevos fármacos en la arteritis de Takayasu, papel del tocilizumab
Sonia Martín Guilléna, Antonio Álvarez de Cienfuegosb, Roberto Hurtado Garcíac,
Corresponding author
a Servicio de Medicina Interna, Hospital Vega Baja de Orihuela (Alicante), España, Residente de Medicina de Familia y Atención Comunitaria, Spain
b Sección de Reumatología, Servicio de Medicina Interna, Hospital Vega Baja de Orihuela (Alicante), Spain
c Servicio de Medicina Interna, Hospital Vega Baja de Orihuela (Alicante), Spain
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controlled randomized studies. Thus, its treatment is based on retrospective observational studies.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In patients who are refractory to conventional treatment, a marked effect by biological therapies like tocilizumab was recently reported.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 63-year-old woman who had a 4-year-history of TA. She initially presented with left suboccipital headache associated with ipsilateral episcleritis, an increase in acute-phase reactants, and physical examination showed differences in systolic arterial blood pressure of her two arms of more than 10<span class="elsevierStyleHsp" style=""></span>mmHg, as well as, weakness in her temporal, carotid and radial pulses of her left side. The diagnostic study found relevant analytical data, including her positivity for rheumatoid factor, high C-reactive protein and erythrocyte sedimentation rate, and her testing positive for anti-Sp100 and negative for: antinuclear antibodies, extractable nuclear antigen, anti-cyclic citrullinated protein antibodies, human leukocyte antigens B7 and B52 and anti-smooth muscle antibody. She underwent magnetic resonance angiography (MRA) of supraaortic arteries with the following findings: 50% stenosis of right internal carotid artery, insignificant stenoses of left internal carotid artery, left external carotid artery and partially assessed subclavian arteries. Aside from MRA of aorta, which indicated stenosis proximal to the right subclavian and, with a filiform and irregular trajectory, and left subclavian stenosis. On the other hand, whole-body positron emission tomography indicated inflammatory activity at the level of the ascending aorta, aortic arch and abdominal aorta, with no evidence of involvement at other sites. Initially the patient was treated with prednisone (initial dose was 15<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h) for 2 years and azathioprine was incorporated (50<span class="elsevierStyleHsp" style=""></span>mg a day), to be discontinued because of an increase in her transaminases. Then, after only 1 year of corticosteroid therapy, mycophenolate mofetil was introduced at 1<span class="elsevierStyleHsp" style=""></span>g/12<span class="elsevierStyleHsp" style=""></span>h. She continued 1 year later in remission, but it was necessary to increase mycophenolate mofetil to 2.5<span class="elsevierStyleHsp" style=""></span>g daily. Seven months later, treatment with tocilizumab was begun, which achieved the disappearance of her clinical manifestations, together with a decrease in the prednisone dose to 10<span class="elsevierStyleHsp" style=""></span>mg/day.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The treatment of choice in TA is corticosteroids, although they induce an initial remission in 90% of the patients. It is estimated that approximately half of the effects will be resistant to them, and it will be necessary to add immunosuppressive agents (azathioprine, methotrexate or mycophenolate mofetil).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Moreover, we should not forget the secondary toxicity of long-term corticosteroid therapy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The use of immunosuppressive drugs will help to decrease the corticosteroid dose to the minimum necessary.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> However, their effectiveness will not be completely demonstrated by randomized studies, taking into account that an estimated 33% of the patients treated will have relapses.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The pathogenesis of TA involves the secretion of proinflammatory cytokines (tumor necrosis factor, interleukin [IL] 6), and it has been demonstrated that serum IL-6 levels are markers of the its own activity.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> For this reason, tocilizumab (a monoclonal antibody that blocks IL-6 receptor) is an effective option for the treatment of refractory TA.</p><p id="par0020" class="elsevierStylePara elsevierViewall">One of the largest long-term studies, which deals with biological therapy in TA, indicates that, whether corticosteroid-resistant or dependent, the association with immunosuppressive agents can improve the control of the disease, and even, reduces the corticosteroid dose to the minimum necessary.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> However, relapses and the progression of vascular involvement persist. The use of tocilizumab in refractory TA is safe and effective. The clinical response is good (improvement in 83%), and it even enables reduction of the corticosteroid dose (up to 50%).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4</span></a> Nevertheless, when the drug is discontinued, there is a reactivation of the disease, a fact that points to the need for a maintenance therapy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite the good results observed with tocilizumab, studies performed to date reveal limitations. As they are retrospective, the sample size is small, and they are carried out without a control group.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,5</span></a> However, we can consider it an alternative to be studied in patients with TA that is difficult to control. In conclusion, this is a good therapeutic option, even in patients who are easy to manage. Nonetheless, multicenter randomized studies must be performed to confirm these findings.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín Guillén S, Álvarez de Cienfuegos A, Hurtado García R. Nuevos fármacos en la arteritis de Takayasu, papel del tocilizumab. Reumatol Clin. 2016;12:358–359.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on Takayasu's arteritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Alibaz-Oner" 1 => "H. 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Hashimoto-Kataoka" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int Heart J" "fecha" => "2013" "volumen" => "54" "paginaInicial" => "405" "paginaFinal" => "411" "itemHostRev" => array:3 [ "pii" => "S0168827812003376" "estado" => "S300" "issn" => "01688278" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001200000006/v1_201611050033/S2173574316300922/v1_201611050033/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001200000006/v1_201611050033/S2173574316300922/v1_201611050033/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574316300922?idApp=UINPBA00004M" ]
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| 2022 March | 36 | 41 | 77 |
| 2022 February | 44 | 26 | 70 |
| 2022 January | 29 | 28 | 57 |
| 2021 December | 33 | 42 | 75 |
| 2021 November | 25 | 35 | 60 |
| 2021 October | 43 | 54 | 97 |
| 2021 September | 25 | 53 | 78 |
| 2021 August | 25 | 39 | 64 |
| 2021 July | 21 | 25 | 46 |
| 2021 June | 35 | 21 | 56 |
| 2021 May | 53 | 41 | 94 |
| 2021 April | 66 | 114 | 180 |
| 2021 March | 82 | 36 | 118 |
| 2021 February | 61 | 19 | 80 |
| 2021 January | 44 | 20 | 64 |
| 2020 December | 36 | 24 | 60 |
| 2020 November | 29 | 19 | 48 |
| 2020 October | 21 | 14 | 35 |
| 2020 September | 34 | 23 | 57 |
| 2020 August | 48 | 20 | 68 |
| 2020 July | 51 | 10 | 61 |
| 2020 June | 25 | 36 | 61 |
| 2020 May | 37 | 15 | 52 |
| 2020 April | 27 | 29 | 56 |
| 2020 March | 5 | 9 | 14 |
| 2020 February | 2 | 0 | 2 |
| 2018 May | 3 | 1 | 4 |
| 2018 April | 92 | 9 | 101 |
| 2018 March | 66 | 12 | 78 |
| 2018 February | 79 | 7 | 86 |
| 2018 January | 77 | 4 | 81 |
| 2017 December | 71 | 12 | 83 |
| 2017 November | 62 | 11 | 73 |
| 2017 October | 48 | 7 | 55 |
| 2017 September | 42 | 20 | 62 |
| 2017 August | 34 | 11 | 45 |
| 2017 July | 55 | 17 | 72 |
| 2017 June | 40 | 23 | 63 |
| 2017 May | 35 | 25 | 60 |
| 2017 April | 40 | 18 | 58 |
| 2017 March | 30 | 26 | 56 |
| 2017 February | 27 | 23 | 50 |
| 2017 January | 46 | 38 | 84 |
| 2016 December | 63 | 50 | 113 |
| 2016 November | 61 | 46 | 107 |
| 2016 October | 3 | 4 | 7 |
Show all
