Discussion
pulmonary embolism, rheumatoid arthritis, infections, infection, RA, venous thrombosis
PULMONARY EMBOLISM, RHEUMATOID ARTHRITIS, STILL, ADVERSE EVENTS, INFECTIONS, INFECTION, ADVERSE EVENT, GCA, CONCOMITANT DISEASE, GIANT CELL ARTERITIS, VENOUS THROMBOSIS
This case series, including 15 Swedish individuals above the age of 60, provides an observational real-life experience of JAKi treatment in GCA for subjects where prednisolone alone was not sufficient or when the IL-6-blocking regimen was considered inappropriate. Our study population was highly selected since the subjects had failed on corticosteroids and that IL-6-blocking regimens such as TCZ were considered inappropriate due to a lack of CRP reaction in case of an infection. Still, the majority of the patients were able to decrease their daily corticosteroids significantly after the initiation of JAKi, and the beneficial effect remained over time. Although the prednisolone doses could be tapered, CRP values were stable or decreased, and the clinical status was improved or stable for all patients.Overall, and as indicated in Assessment of inflammatory activity in GCA is not always straightforward. US as well as CT and PET-CT can support the evaluation but must be combined with laboratory and clinical data. Especially in the elderly, concomitant diseases may indeed blur the clinical picture, as illustrated by the cases with Aside from the two serious infections described, pulmonary embolism was observed in one patient suffering from several comorbidities after only 2 months of exposure to baricitinib. Obviously, causality between JAKi and pulmonary embolism in this patient cannot be excluded. Increased incidence of venous thrombosis and pulmonary embolism has indeed been reported in patients with rheumatoid arthritis (RA) treated with JAKi, both by the Food and Drug Administration’s adverse event reporting system and the Swedish Rheumatology Quality registers (This case series must be interpreted in the context of its limitations, e.g., the absence of relevant controls. In addition, the retrospective design of the study limits the possibility to draw firm conclusions regarding efficacy. However, given the fact that the participants had failed on corticosteroids and were judged inappropriate for TCZ, relevant comparators were impossible to find. In the RCT for TCZ in the Giant Cell Arteritis trial (GiACTA), the median daily prednisolone dose in the placebo group that underwent the 26-week steroid tapering was approximately 18 mg compared with 8 mg in our study population. However, this is indeed not a perfect comparator group, especially since the same placebo group in GiACTA had a GCA duration of 365 days compared with 804 days in our study.Safety is important but particularly challenging in the elderly population. As a reflection of this, in TCZ in GiACTA, adverse events were observed in more than 95% of the participants both in the treatment and placebo study arms (To conclude, in line with the pilot study by Koster et al. and several independent observations, we report the encouraging efficacy data of JAKi in GCA (