Vision Loss in Patients With Giant Cell Arteritis Treated With Tocilizumab

Jennifer Amsler; Iveta Kysela; Christoph Tappeiner; Luca Seitz; Lisa Christ; Godehard Scholz; Odile Stalder; Florian Kollert; Stephan Reichenbach; Peter M. Villiger

Disclosures

Arthritis Res Ther. 2021;23(92) 

In This Article

Abstract and Introduction

Abstract

Objectives: Giant cell arteritis (GCA) may lead to vision loss. To what extent tocilizumab (TCZ) is able to prevent vision loss is unknown. The aim was to analyze the occurrence of vision loss in a large GCA cohort treated with TCZ.

Methods: In this observational monocentric study, GCA patients treated with TCZ between the years 2010 and 2018 were studied. Demographic, clinical, and laboratory data were analyzed.

Results: A total of 186 patients were included (62% female); 109 (59%) fulfilled the American College of Rheumatology (ACR) criteria, in 123 (66%) patients, large vessel vasculitis was diagnosed by magnetic resonance-angiography (MRA). Cumulative duration of TCZ treatment was 224 years, median treatment duration was 11.1 (IQR 5.6–17.9) months. Glucocorticoids (GC) were tapered over a median of 5.8 (IQR 3.0–8.5) months. At baseline, visual symptoms were present in 70 (38%) and vision loss in 21 (11%) patients. Patients with vision loss at baseline were older (p = 0.032), had a lower C-reactive protein (p = 0.002), and showed a negative association with MRA of the aorta (p = 0.006). Two patients (1.1%) developed vision loss, both at the initiation of TCZ treatment.

Conclusion: Our data show a very low incidence of vision loss in TCZ-treated patient. The two cases of AION occurred at the initiation of therapy, they support the hypothesis that advanced, and established structural changes of arteries are key factors for this accident. Whether a shorter duration of concomitant GC treatment is risky regarding vision loss needs to be studied.

Introduction

Giant cell arteritis (GCA) is the most common vasculitis in Western populations at older age.[1,2] Vision loss caused by ischemic events of the posterior ciliary arteries of the ophthalmic artery (anterior ischemic optic neuropathy, AION) or of the central retinal artery (central retinal artery occlusion, CRAO) is one of the most feared complication.[3] To revert it, glucocorticoids (GC) are prescribed immediately.[4] However, most often it remains irreversible.

The rate of vision loss in patients with GCA seems to have decreased over the last decades, probably due to earlier diagnosis of GCA and prompt start of GC treatment.[5] Nevertheless, a recent retrospective study showed a prevalence of 2% of vision loss in 840 biopsy-proven GCA compared to the reference population of Skane (Sweden) with a prevalence of 0.6%.[6] Further studies have documented vision loss mainly due to AION during treatment with GC at a variable rate between 0.7 to 10%.[7–10]

IL-6 plays a central role in the pathogenesis of GCA.[11] Accordingly, tocilizumab (TCZ), a monoclonal antibody targeting the IL-6-receptor, was studied in the treatment of GCA. In addition to a remission-maintaining efficacy, the first two randomized controlled trials (RCTs) documented a steroid-sparing effect of approximately 50% compared with a conventional treatment with GC over 1 year.[12,13] While no ocular incidences were recorded in the first trial,[12] one of 149 patients in the GiACTA trial suffered from AION while under TCZ treatment in the first 12 months.[13] So far, no larger study has addressed the question, whether TCZ prevents vision loss comparable to GC monotherapy.

Therefore, we analyzed the frequency of vision loss in a large cohort of patients treated with TCZ and evaluated potential risk factors for vision loss.

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