Vlog: Tocilizumab can have an influence on ophthalmic outcomes in giant cell arteritis

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On this week's episode of the NeuroOp Guru, Andy Lee, MD, and Elizabeth Fortin, MD, discuss Tocilizumab and the influence it can have on ophthalmic outcomes in giant cell arteritis.

This transcript has been lightly edited for clarity:

Andy Lee, MD:

Hello, and welcome to another edition of the NeuroOp Guru. I'm here with my good friend Elizabeth Fortin.

Elizabeth Fortin, MD:

Hi, Andy.

Andy Lee, MD:

And today we're going to be talking about does Tocilizumab influence a filmic outcomes in John's a lot of writers? And so maybe Elizabeth, you could just tell the audience what is Tocilizumab?

Elizabeth Fortin, MD:

So Tocilizumab is the monoclonal antibody against the IL six receptors that we've been using for treatment of giant cell Arteritis for several years now, is anti-inflammatory medication that is used as a steroid sparing agent.

Andy Lee, MD:

So it's not really a replacement for steroids, right?

Elizabeth Fortin, MD:

No, exactly. So as of now, it's used really as an adjunct therapy for joints and arthritis. So we still use corticosteroids, but we can use Tocilizumab as a steroid sparing agent.

Andy Lee, MD:

And what is the background? And how did the authors decide that Tocilizumab might actually influence ophthalmic outcomes?

Elizabeth Fortin, MD:

There is a lot more literature in the rheumatology in rheumatology patients actually on giant cell Arteritis. And it's showed, it's been shown that Tocilizumab can help reduce the number of flares and the severity of flares that patients have. And so we started thinking that maybe the same thing could be the case for visual outcomes, although a lot of the robust prospective data was really more focused on the rheumatology symptoms and patients. But there have been some case reports of patients that had vision loss, and in which Tocilizumab was using as an adjunct therapy, which actually, and these patients recovered some part of their vision. So that's where the, this, you know, the idea came from about the ophthalmic outcomes.

Andy Lee, MD:

It's fascinating. And I see here on our slide that we have a table on the neurotoxic manifestations of GCA. Maybe you could just highlight for the audience, what these mean, and how frequent are these presentations?

Elizabeth Fortin, MD:

Yes, so actually, a lot of patients with giant cell Arteritis will have atomic manifestation. So it's up to 50% of patients. And now the most common causes of vision loss, which is you will be like is highlighted in this table anterior ischemic optic neuropathy is central retinal artery occlusion. Posterior ischemic optic neuropathy is a little bit less frequent, of course, as we know, and there are also other causes of vision loss like ocular ischemic syndrome. Now, what's important to know is that most patients who have vision loss from giant cell arthritis won't recover their vision. So oftentimes, the vision loss is severe. And it's permanent, which is why we're trying to, you know, find ways other than steroids, which work well in most of patients, but other ways to try to prevent vision loss from happening, especially, you know, and fellow I have patients who have already lost vision and the first time.

Andy Lee, MD:

So in this particular paper, what were their methods? And what would the results of what they found?

Elizabeth Fortin, MD:

So the paper was really a review of the current literature that speaks to atomic manifestations in GCC and patients were treated with Tocilizumab, on top of corticosteroids. And of course, like I was highlighting before, a lot of the literature comes from rheumatology. So there's not a lot of literature out there on specifically neuro ophthalmic findings of GCAA. But there were a couple of case reports of patients who benefited from Tocilizumab on top of steroids. But also, there was an in very interesting recently published, retrospective review of 60 patients with GCC, and of this trial, there were it was patients who were having real relapse from their GCAA. So 70% of patients were having relapses with before they were on Tocilizumab. And when they were started, were started on Tocilizumab, these relapses reduced to 30% of patients, out of these people also the flares that involve the vision reduced significantly to the same extent that this the systemic symptoms reduced. So that was a very, very interesting finding. I think we don't have a lot of good prospective data on the topic. And that's what this study is also mentioning that we will need those good robust prospective studies in the future, and that that's what's going to be most reliable, especially if you want to change a practice with Tocilizumab. But there's still some very good early evidence that it could be helpful to reduce the number of flares but also the severity of flares and potentially helping in reversing some of the vision loss in patients who have vision loss early or late in their disease. So I think that's the very interesting conclusion.

Andy Lee, MD:

Yeah, that's fascinating. And I think the take home message is, stay tuned to this channel, and let's see if it can be validated It's really great for hypothesis generating and maybe the hypothesis needs to be tested at this point. So Elizabeth, what would be your summary statement for our target audience about Tocilizumab and ophthalmic outcomes in GCA?

Elizabeth Fortin, MD:

I would say as of now, Tocilizumab is an excellent adjunct to corticosteroids in the treatment of giant cell Arteritis. It has been shown to be steroids as efficient steroid sparing agents in the disease, but stay tuned because it might be used in the earlier stages of the disease, and even help maybe reversing some of the vision loss in patients if used appropriately and in a timely manner.

Andy Lee, MD:

Well, thank you so much for your time again, Dr. Fortin. And that concludes another edition of the NeuroOp Guru, we'll see you next time.