Pôster:

Rheumatoid arthritis (RA) is an inflammatory, systemic and chronic disease of unknown etiology that mainly affects synovial joints. Renal impairment is common, but when it occurs the main causes are glomerulonephritis, amyloidosis, tubulointerstitial nephritis and drug toxicity, which may progress to end-stage renal disease. The treatment of RA consists in disease-modifying anti-rheumatic drugs (DMARDs). The synthetics are the first-line, but in refractory cases biological DMARDs or small molecules (tofacitinib) may be used as second line therapy, including the humanized monoclonal antibody anti-interleukin 6 (tocilizumab), playing a crucial role in the modulation of joint inflammation and extra-articular manifestations. The treatment of RA with immunobiologicals in dialytic patients with renal insufficiency are scarce in literature. Some case reports using infliximab and etanercept in dialytic patients have been described. This study reports the experience of tocilizumab in a RA dialytic patient.

Case report

Female patient, 63 years old, with RA for 14 years (symmetric polyarthritis of small and large joints, morning stiffness greater than 2 hours, multiple erosions, cysts and secondary osteoarthritis, with positive rheumatoid factor and HSV 60mm/1ª hour). After diagnosis in 2002, prednisone (5mg/day), methotrexate (15mg/week) and folic acid (10mg/week) were started, and later associated with leflunomide, due to partial treatment response. It was used irregularly, maintaining symmetrical polyarthritis and anemia. In 2013, started with adalimumab and maintained methotrexate and folic acid. She lost follow-up, and remained without regular rheumatologist care. She used non-steroidal anti-inflammatory drugs and prednisone, without monitoring. In september 2017, she returned to the rheumatology outpatient clinic using 20mg of prednisone and osteoporosis’s therapy. She presented with oligoarthritis and chronic renal failure. In May 2018, she underwent dialysis 3 times/week and had high Clinical Disease Activity Index (CDAI) 48. Sulfasalazine was then chosen, but she presented with gastric intolerance. In October 2018, tocilizumab (8mg/kg) was started and the CDAI reduction was over 50%. At present she is with leflunomide, tocilizumab and prednisone (5mg/day), undergoing hemodialysis 3 times per week and in disease remission.

Conclusion

There are few reports in the literature with the use of immunobiologicals in RA patients on hemodialysis. The choice of tocilizumab was motivated by its important action in the control of joint inflammation and extra-articular manifestations, in addition to the monthly dosage and intravenous application, aiming for greater compliance, clinical and laboratory control. Its use has been shown to be safe and effective, with a substantial improvement in the clinical picture and without worsening renal function.