Researchers Seek the Best Methods to Maintain Remission in Vasculitis

GCA Remission

Lisa Christ, MD, of the University of Bern, Switzerland, ended the session, discussing the maintenance of remission in patients with giant cell arteritis (GCA). Tocilizumab is a potential new therapy for GCA treatment. This monoclonal antibody binding the alpha chain of the human interleukin (IL) 6 receptor has been licensed as a therapeutic agent to induce and maintain remission in GCA. Two randomized clinical trials—one trial using 8 mg/kg body weight of intravenous tocilizumab every four weeks and the other trial using 162 mg of subcutaneous tocilizumab given weekly or every two weeks—showed the glucocorticoid dose could be reduced by at least 50%.^8,9

Subsequent questions have arisen: What happens to patients after one year of follow-up with regard to relapse? Are there factors that may predict relapse after tocilizumab treatment discontinuation?

To answer these questions, researchers in Switzerland and Germany evaluated the patients in the 52-week tocilizumab treatment arm of a clinical trial from 2016 for signs of disease relapse, including with magnetic resonance angiography (MRA).⁸ At a mean follow-up time of 28 months, it was shown that half of the GCA patients remained in lasting remission after stopping tocilizumab treatment. No clinical, laboratory or imaging findings predicted relapse or lasting remission in GCA patients. Of interest, however, researchers noted that although a trend to a reduction of enhancing areas of the wall of the descending aorta existed, all patients in lasting remission showed MRA enhancement at follow-up, which indicates the potential of ongoing subclinical disease activity.¹⁰

The session demonstrated that it’s an exciting time in the area of vasculitis treatment and research, and the next frontier in the field may be devising the best methods to induce and monitor for disease remission. As in treatment of these conditions, researchers will stay the course and seek to better understand the ideal way to help patients in the years to come. 

Jason Liebowitz, MD, recently completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his MD. He is currently in practice with Arthritis, Rheumatic, and Back Disease Associates, New Jersey.

References

1. Jardel S, Puéchal X, Le Quellec A, et al. Mortality in systemic necrotizing vasculitides: A retrospective analysis of the French Vasculitis Study Group registry. Autoimmun Rev. 2018 Jul;17(7):653–659.
2. Wallace ZS, Lu N, Miloslavsky E, et al. Nationwide trends in hospitalizations and in-hospital mortality in granulomatosis with polyangiitis (Wegener’s). Arthritis Care Res (Hoboken). 2017 Jun;69(6):915–921.
3. Wallace ZS, Zhang Y, Lu N, et al. Improving mortality in end-stage renal disease due to granulomatosis with polyangiitis (Wegener’s) from 1995 to 2014: Data from the U.S. Renal Data System. Arthritis Care Res (Hoboken). 2018 Oct;70(10):1495–1500.
4. Jayne D, Rasmussen N, Andrassy K, et al. A randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies. N Engl J Med. 2003 Jul 3;349(1):36–44.
5. Pagnoux C, Mahr A, Hamidou MA, et al. Azathioprine or methotrexate maintenance for ANCA-associated vasculitis. N Engl J Med. 2008 Dec 25;359(26):2790–2803.
6. Guillevin L, Pagnoux C, Karras A, et al. Rituximab vs. azathioprine for maintenance in ANCA-associated vasculitis. N Engl J Med. 2014 Nov 6;371(19):1771–1780.
7. Charles P, Terrier B, Perrodeau É, et al. Comparison of individually tailored versus fixed-schedule rituximab regimen to maintain ANCA-associated vasculitis remission: Results of a multicentre, randomized controlled, phase 3 trial (MAINRITSAN2). Ann Rheum Dis. 2018 Aug;77(8):1143–1149.
8. Villiger PM, Adler S, Kuchen S, et al. Tocilizumab for induction and maintenance of remission in giant cell arteritis: A phase 2, randomized, double-blind, placebo-controlled trial. Lancet. 2016 May 7;387(10031):1921–1927.
9. Stone JH, Tuckwell K, Dimonaco S, et al. Trial of tocilizumab in giant cell arteritis. N Engl J Med. 2017 Jul 27;377(4):317–328.
10. Adler S, Reichenbach S, Gloor A, et al. Risk of relapse after discontinuation of tocilizumab therapy in giant cell arteritis. Rheumatology (Oxford). 2019 Mar 26. [Epub ahead of print]