Tocilizumab taper ‘reasonable’ in giant cell arteritis remission despite flare risk

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DESTIN, Fla. — Rheumatologists should consider tapering tocilizumab for patients with giant cell arteritis in remission despite the increased risk for flare, said a speaker at the Congress of Clinical Rheumatology East annual meeting.

“You can taper tocilizumab, but there does seem to be a dose response, where the lower the tocilizumab dose goes, the higher the risk for relapse is,” Philip Seo, MD, MHS, rheumatology medical editor for UpToDate and associate professor of medicine at the Johns Hopkins Vasculitis Center, told attendees. “And yet, I still think it’s reasonable to taper tocilizumab for these patients who have been in remission for at least a year.”

“I still think it’s reasonable to taper tocilizumab for these patients who have been in remission for at least a year,” Philip Seo, MD, MHS, told attendees. Image: Justin Cooper | Healio

According to Seo, new data on tocilizumab (Actemra, Genentech) for GCA have emerged since publication of the GiACTA trial in 2017, particularly on the question of how long treatment is required.

“The patient is doing well, and they want to know, ‘How long do I have to get these injections for it?’ And then you rapidly try to switch the conversation to sports, because you don’t know the answer either,” he said. “There’s no good data.”

Seo added that “a lot of small studies” are attempting to answer this question. He highlighted an Italian study of 17 patients diagnosed with GCA and treated with tocilizumab weekly for a year.


Philip Seo

“At the end of that year, not surprisingly, all these patients were in remission,” Seo said. “They then switched these patients to every other week tocilizumab and again, not surprisingly, some of these patients flared — 12%. After that they stopped tocilizumab completely and 6 months later the flare rate doubled.”

Seo’s take: Even though some patients relapsed, “a lot of patients didn’t.” He added that across multiple studies of tocilizumab duration, the “relapses are minor.”

“The flares they’re talking about are like achiness,” Seo said. “It’s like polymyalgia rheumatica-type symptoms that you treat with a whiff of steroids, and that’s exactly how these patients were managed. Because the flares tend to be minor and because you’re watching these patients carefully, I think that tapering tocilizumab is reasonable with the caveat that some patients will fail.”

However, the question will ultimately “be answered for real” by MAGICA, an ongoing French trial of 120 patients in remission from GCA, comparing abrupt discontinuation of tocilizumab vs. gradual tapering, he said. According to Seo, results are expected “maybe next year.”

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