Tocilizumab for active rheumatoid arthritis in a patient with concomitant primary biliary cholangitis: a case based review.

The coexistence of active rheumatoid arthritis and active primary biliary cholangitis represents a distinct therapeutic challenge. Evidence-based guidance for treatment selection in this clinical setting remains limited, and published experience with tocilizumab is restricted to isolated case reports. We report a 59-year-old woman with highly active, seropositive rheumatoid arthritis and marked cholestatic biochemical activity, in whom diagnostic evaluation revealed active primary biliary cholangitis in the absence of advanced liver fibrosis. Following multidisciplinary assessment, methotrexate and leflunomide were avoided because of active cholestatic liver disease, and treatment with subcutaneous tocilizumab was initiated in combination with ursodeoxycholic acid and fenofibrate. Tocilizumab was well tolerated and led to a progressive improvement in arthritis. In parallel, cholestatic liver parameters showed sustained improvement in the absence of hepatic adverse effects. To contextualize this observation, we performed a focused literature review and identified only two directly relevant case reports, both reporting favorable rheumatologic and hepatic outcomes during tocilizumab therapy. This case adds to the limited body of evidence suggesting that tocilizumab may represent a feasible therapeutic option for selected patients with active rheumatoid arthritis and concomitant primary biliary cholangitis.