Tocilizumab for active rheumatoid arthritis in a patient with concomitant primary biliary cholangitis: a case based review.
Goran Šukara, Petra Dinjar Kujundžić, Anita Madir et al.
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Case in brief
A 59-year-old woman presented with highly active, seropositive rheumatoid arthritis and marked cholestatic biochemical activity. Evaluation identified active primary biliary cholangitis without advanced liver fibrosis. Because of the active cholestatic disease, methotrexate and leflunomide were avoided after multidisciplinary assessment. Subcutaneous tocilizumab was started alongside ursodeoxycholic acid and fenofibrate. It was well tolerated, with progressive improvement in arthritis and sustained improvement in cholestatic liver parameters, without reported hepatic adverse effects.
What made this case unusual
Active rheumatoid arthritis and active primary biliary cholangitis created a treatment-selection challenge: commonly considered disease-modifying drugs were avoided because of cholestatic liver disease, while both arthritis and liver parameters improved during tocilizumab therapy.
Diagnostic / clinical pearl
In a patient with rheumatoid arthritis and marked cholestatic biochemical activity, evaluate for concomitant primary biliary cholangitis and assess fibrosis before selecting therapy; this case describes improvement in both conditions during tocilizumab treatment.
Why it matters
The authors found only two directly relevant prior case reports, underscoring how limited the published experience is for choosing rheumatoid arthritis therapy when active primary biliary cholangitis is also present.