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Tocilizumab in Early Diffuse SSc — SCE Rheumatology MCQ

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HardSystemic SclerosisTocilizumab in Early Diffuse SScSCE Rheumatology

A 55-year-old woman has diffuse cutaneous systemic sclerosis of 18 months' duration with progressive skin thickening (modified Rodnan skin score 24), C-reactive protein 22 mg/L and anti-topoisomerase I antibodies. HRCT shows fibrotic non-specific interstitial pneumonia, and FVC has fallen from 85% to 78% predicted over 6 months on mycophenolate mofetil. Which statement most accurately describes the trial evidence and current guideline position for tocilizumab in this situation?

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Correct answer: A — focuSSced did not meet its primary modified Rodnan skin score endpoint, yet FVC% predicted favoured tocilizumab as a secondary outcome, and EULAR's 2023 update includes tocilizumab as an option in systemic-sclerosis-associated ILD rather than an antibody-selected first-line drug.

Explanation lettering: B = shown as A · A = shown as B · E = shown as C · C = shown as D · D = shown as E

focuSSced randomised patients with dcSSc of ≤60 months and mRSS 10–35 to weekly subcutaneous tocilizumab 162 mg or placebo for 48 weeks. Its primary endpoint, change in mRSS, was not met; FVC% predicted, a secondary endpoint, favoured tocilizumab, generating the rationale for repurposing IL-6 blockade for lung rather than skin outcomes. The 2023 EULAR update accordingly places tocilizumab among options for SSc-ILD (alongside mycophenolate, rituximab and nintedanib), which fits this patient with progressive fibrotic ILD despite mycophenolate. A and C invert the trial result. D overstates antibody/CRP data, which are post hoc and hypothesis-generating, not a first-line indication. E is wrong: tocilizumab has no role in renal crisis (ACE inhibition) or PAH-specific therapy, and does have fibrotic-disease evidence.

Reference: Del Galdo F, Lescoat A, Conaghan PG, et al. EULAR recommendations for the treatment of systemic sclerosis: 2023 update — skin fibrosis and interstitial lung disease recommendations. Ann Rheum Dis, 2023 update (published 2025). https://pubmed.ncbi.nlm.nih.gov/39874231/ (with pivotal trial: Khanna D, et al. focuSSced, Lancet Respir Med 2020;8:963–74. https://pubmed.ncbi.nlm.nih.gov/32866440/?dopt=Abstract)