Steroid-Sparing Effect of Tocilizumab and Methotrexate in Patients with Polymyalgia Rheumatica: A Retrospective Cohort Study.

Keisuke Izumi,Misako Higashida-Konishi,Yuko Kaneko,Hisaji Oshima,Tsutomu Takeuchi,Okinori Murata

doi:10.3390/jcm10132948

Abstract

Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by pain and stiffness in the shoulders, hips, and proximal limbs; it usually affects elderly patients. The effectiveness of methotrexate and tocilizumab in PMR treatment has not been extensively studied. Thus, we aimed to assess the steroid-sparing effect of tocilizumab and methotrexate in PMR in clinical practice. Consecutive patients with PMR in our hospitals, who were included in our retrospective cohort, were reviewed between 2005 and 2015 and divided into the following groups according to their treatments: prednisolone or none (prednisolone group), methotrexate ± prednisolone (methotrexate group), or tocilizumab ± prednisolone (tocilizumab group). The prednisolone dose at the last follow-up was compared. A total of 227 patients with an average age of 74 years were enrolled. No difference in baseline characteristics was found among the three groups. The prednisolone dose at the last follow-up was lower (0 vs. 3.0 vs. 3.5 mg/day, p < 0.001) and the prednisolone discontinuation rate was higher (80.0% vs. 28.3% vs. 18.8%, p < 0.0001) in the tocilizumab group than in the prednisolone and methotrexate groups. This study suggested that tocilizumab has a steroid-sparing effect in PMR. Tocilizumab can be an option in the management of PMR. Future studies are warranted to confirm our findings.

Highlights

Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by severe pain and stiffness in the shoulders, hips, and proximal limbs; PMR usually affects elderly patients [1,2]
Our study demonstrated that tocilizumab has a strong steroid-sparing effect compared to prednisolone alone or methotrexate in patients with PMR, with acceptable safety even in the elderly with an average age of 76 years in clinical practice
Given that IL-6 plays a critical role in PMR [10,18], IL-6 blocking has been a promising strategy for PMR

Summary

Introduction

Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by severe pain and stiffness in the shoulders, hips, and proximal limbs; PMR usually affects elderly patients [1,2]. Despite acute and severe symptoms and laboratory systemic inflammation, low-to-moderate dose of systemic glucocorticoid therapy is quite effective [3,4]. Long-term glucocorticoid use induces many adverse events, such as infection, diabetes mellitus, and osteoporosis, especially in elderly patients [5]; various immunosuppressive agents have been used to reduce the glucocorticoid dose. Tocilizumab, a monoclonal antibody to interleukin-6 receptor (IL-6R), is another treatment for PMR; recently, there have been promising studies on the cytokine profiles in PMR and the pilot use of tocilizumab in patients with PMR [9,10]. Tocilizumab reduces inflammation markers [11] and imaging findings [12] in PMR, and there are reports of its therapeutic [13]

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