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Relapsing giant cell arteritis — SCE Rheumatology MCQ

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ModerateGlucocorticoidsRelapsing giant cell arteritisSCE Rheumatology

A 72-year-old woman has biopsy-confirmed giant cell arteritis. During 16 months of treatment, she has had two clinically confirmed relapses while tapering prednisolone, each responding promptly to an increased dose. Her latest relapse presented with recurrent temporal headache and polymyalgic symptoms without visual disturbance or other cranial ischaemia. These symptoms have resolved after prednisolone was increased to 40 mg daily, and she is now taking 30 mg daily. She has developed glucocorticoid-induced diabetes and sustained a low-trauma vertebral fracture. There is no active infection, diverticulitis, cytopenia or hepatic dysfunction. Screening for latent tuberculosis and viral hepatitis is negative. She has not previously received a biologic agent. Which is the most appropriate strategy to reduce her subsequent glucocorticoid exposure in current UK practice?

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Correct answer: A — Start tocilizumab with a tapering course of prednisolone, stopping tocilizumab after at most 1 uninterrupted year

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

This patient has relapsing GCA and substantial glucocorticoid toxicity, including diabetes and a vertebral fragility fracture. She is therefore an appropriate candidate for adjunctive glucocorticoid-sparing treatment. NICE recommends tocilizumab for adults with relapsing or refractory GCA who have not previously received it, used with a tapering course of glucocorticoids and stopped after at most 1 year of uninterrupted treatment. A is less appropriate because further prolonged glucocorticoid monotherapy exposes her to additional harm despite two relapses. B is plausible because methotrexate may be considered as an alternative adjunct in relapsing GCA, but tocilizumab has a directly applicable NICE recommendation for this clinical population and is the better-supported choice given her severe glucocorticoid toxicity. D is incorrect because tocilizumab should accompany a glucocorticoid taper rather than permit abrupt withdrawal; the proposed 2-year course also exceeds the NICE stopping rule. E would be appropriate for an acute relapse with threatened or established visual ischaemia, not for a patient whose non-visual relapse has already responded to oral prednisolone. Her current remission should therefore be consolidated with tocilizumab while prednisolone is progressively reduced.

Reference: Tocilizumab for treating giant cell arteritis: Recommendations (18 April 2018) — https://www.nice.org.uk/guidance/ta518/chapter/1-Recommendations Blog: diagnosis and treatment of giant cell arteritis (2020) — https://www.rheumatology.org.uk/news/details/articleid/217 2018 update of the EULAR recommendations for the management of large vessel vasculitis (2020) — https://ard.bmj.com/content/79/1/19