Improvement of Knee Joint and Laboratory Markers of a Rheumatoid Arthritis Patient Treated with Tocilizumab
*Hiraku Kikuchi Department Of Case Reports, Kinki University, Japan
*Corresponding Author: Hiraku Kikuchi
Department Of Case Reports, Kinki University, Japan Email:firstname.lastname@example.org
Published on: 2014-09-01
Here, we report on the case of 27-year-old women with rheumatoid arthritis [RA] whose symptoms improved after the administration of tocilizumab [TCZ] following long-term biological disease-modifying anti-rheumatic drugs treatment. The clinical changes in her signs and symptoms were confirmed by radiographic analysis of the affected knee joint and laboratory markers including C-reactive protein, matrix metalloproteinase-3, amino-terminal telopeptides of type 1 collagen [NTX], osteocalcin, interleukin-6, anti-cyclic citrullinated peptide, carboxy-terminal telopeptides od type 2 collagen [CTX-2], Dikkopf-1 [DKK-1], and osteoprotegerin [OPG] levels. Changes in disease activity score [DAS] 28-erythrocytes sedimentation rate were also estimated during the clinical physical observation. Initially, she was prescribed bucillamine, methotrexate [MTX] and salazosulfapyridine [SASP], however her RA activity was not improved. Therefore, the prescription was changed to predonisolone, and mizoribine. However, her RA activity was still not controlled and she was referred to our hospital. At our clinic, etenercept and MTX were prescribed, but her RA activity was not controlled. After 1 year, although adalimumab and MTX were prescribed, these agents were not effective in controlling the RA. Finally, TCZ, PD and SASP were prescribed. These medications greatly suppressed her RA activity, which correlated with the improvement of NTX, CTX-2, DKK-1 and OPG levels. Physical changes were also confirmed radiographically, including a widening of the joints space and enlargement of range of motion. Thus, her state of RA was greatly improved by TCZ.
Rheumatoid Arthritis; Joint Space Narrowing; Tocilizumab; Carboxy-Terminal Telopeptides of type 2 collagen; Dickkopf-1; Osteoprotegerin
Rheumatoid arthritis [RA] progression has been markedly improved by the application of biological anti-RA agents, which suppress RA activity and also repair affected joint space under certain conditions. The revised guidelines also indicate the application of newly introduced biological disease-modifying anti-rheumatic drugs [b-DMARD]  , as RA progresses; however, the use of the anti-tumor necrosis factor [TNF] antibody has been decreasing as reported in the latest version of the guidelines . In a study wherein b-DMARDs were administered to RA patients with a high rheumatoid factor and anti-cyclic citrullinated peptide [CCP] antibody titer, 18 of 250 RA cases showed improvement in their joint spaces (7.2%) . RA is often accompanied with high values of C-reactive protein [CRP], receptor activator of nuclear factor kappa-β ligand [RANKL], carboxy-terminal telopeptides of type 2 collagen [CTX-2], Dickkopf-1 [DKK-1] and sclerostin levels, as well as exacerbated cartilage destruction . All b-DMARDs suppress matrix metalloproteinase [MMP]-3, with regard to the early stage of cartilage destruction the CTX-2 level is believed to reflect the pathophysiology . Recently DKK-1 has been noted for new bone formation  . One of the recent b-DMARDs, tocilizumab [TCZ], which suppresses interleukin-6 [IL-6], is expected to induce new bone formation after osteosclerosis in RA . In the present report, the use of TCZ greatly improve the RA status including widening of the affected joint space, and the improvement of laboratory markers. The patient has returned to her workplace and could resume normal work.