1
|
Peyrac G, Mageau A, Gaudemer A, Benali K, Rohmer J, Alexandra JF, Strukov A, Ottaviani S, Papo T, Sacre K. Limb arteries involvement assessed by FDG/PET CT at diagnosis of giant cell arteritis and risk of relapse: An observational study. Joint Bone Spine 2024; 91:105734. [PMID: 38631525 DOI: 10.1016/j.jbspin.2024.105734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/18/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Steroids and anti-IL6 biotherapy are highly effective in obtaining remission in patients with giant cell arteritis (GCA) but the risk of relapses remains high. We aimed to identify predictors of relapse in GCA. METHODS All consecutive patients admitted with a new diagnosis of GCA - according to the 2022 American College of Rheumatology/EULAR (ACR/EULAR) classification criteria - between May 2011 and May 2022 were eligible for this study. The primary outcome was the GCA relapse rate over the 36-months follow up. Factors associated with the primary outcome and time to first relapse were analyzed. RESULTS One hundred and eight patients (74 [69-81] years, 64.8% women) with a new diagnosis of GCA were studied. GCA was biopsy-proven in 65 (60.2%) cases. Ninety-eight (90.7%) FDG/PET CT scans performed at diagnosis were available for review. All patients received steroids given for 21.0 [18.0-28.5] months, associated with methotrexate (n=1, 0.9%) or tocilizumab (n=2, 1.9%). During a median follow-up of 27.5 [11.4-35.0] months, relapse occurred in 40 (37%) patients. Multivariable Cox regression model, including general signs, gender, aortic wall thickness, FDG uptake in arterial wall and IV steroid pulse as covariates, showed that both general signs (HR 2.0 [1.0-4.0, P<0.05) and FDG uptake in limb arteries (HR 2.7 [1.3-5.5], P<0.01) at diagnosis were associated with GCA relapse. CONCLUSION FDG uptake in limb arteries at diagnosis is a predictor of relapse in newly diagnosed GCA.
Collapse
Affiliation(s)
- Geoffroy Peyrac
- Departement de Médecine Interne, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Arthur Mageau
- Departement de Médecine Interne, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Augustin Gaudemer
- Departement de Radiologie, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Khadija Benali
- Departement de Médecine Nucléaire, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Julien Rohmer
- Departement de Médecine Interne, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Jean-Francois Alexandra
- Departement de Médecine Interne, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Andrey Strukov
- Departement d'Information Médicale, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Sebastien Ottaviani
- Departement de Rhumatologie, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Thomas Papo
- Departement de Médecine Interne, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France
| | - Karim Sacre
- Departement de Médecine Interne, Université Paris-Cité, Assistance publique-Hopitaux de Paris, Hôpital Bichat, Paris, France.
| |
Collapse
|
2
|
Tsalapaki C, Lazarini A, Argyriou E, Dania V, Boki K, Evangelatos G, Iliopoulos A, Pappa M, Sfikakis PP, Tektonidou MG, Georgountzos A, Kaltsonoudis E, Voulgari P, Drosos AA, Theotikos E, Papagoras C, Dimitroulas T, Garyfallos A, Kataxaki E, Vosvotekas G, Boumpas D, Hadziyannis E, Vassilopoulos D. Glucocorticoid discontinuation rate and risk factors for relapses in a contemporary cohort of patients with giant cell arteritis. Rheumatol Int 2024; 44:603-610. [PMID: 38300269 PMCID: PMC10914919 DOI: 10.1007/s00296-023-05527-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/22/2023] [Indexed: 02/02/2024]
Abstract
The rates of relapses and therapy discontinuation in patients with giant cell arteritis (GCA) in the modern therapeutic era have not been defined. We aimed to evaluate the glucocorticoid (GC) discontinuation rate and the factors associated with relapses in a contemporary GCA cohort. Patient and treatment data were collected cross-sectionally at first evaluation and 2 years later (second evaluation), in a multicenter, prospective GCA cohort. Predictors of relapses were identified by logistic regression analyses. 243 patients with GCA were initially included (67% women, mean age at diagnosis: 72.1 years, median disease duration: 2 years) while 2 years later complete data for 160 patients were available and analyzed. All patients had received GCs at diagnosis (mean daily prednisolone dose: 40 mg) while during follow-up, 37% received non-biologic and 16% biologic agents, respectively. At second evaluation, 72% of patients were still on therapy (GCs: 58% and/or GC-sparing agents: 29%). Relapses occurred in 27% of patients during follow-up; by multivariable logistic regression analysis, large vessel involvement at diagnosis [odds ratio (OR) = 4.22], a cardiovascular event during follow-up (OR = 4.60) and a higher initial GC daily dose (OR = 1.04), were associated with these relapses. In this large, real-life, contemporary GCA cohort, the rates of GC discontinuation and relapses were 40% and 27%, respectively. Large vessel involvement, a higher GC dose at diagnosis and new cardiovascular events during follow-up were associated with relapses.
Collapse
Affiliation(s)
- Christina Tsalapaki
- School of Medicine, General Hospital of Athens "Hippokration", 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, 114 Vass. Sophias Ave., 115 27, Athens, Greece
| | - Argyro Lazarini
- General Hospital "Asklepieio", Rheumatology Clinic, Athens, Greece
| | | | - Vassiliki Dania
- General Hospital "Sismanogleio", Rheumatology Clinic, Athens, Greece
| | - Kyriaki Boki
- General Hospital "Sismanogleio", Rheumatology Clinic, Athens, Greece
| | | | | | - Maria Pappa
- School of Medicine, General Hospital "Laiko", 1st Department of Propedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros P Sfikakis
- School of Medicine, General Hospital "Laiko", 1st Department of Propedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- School of Medicine, General Hospital "Laiko", 1st Department of Propedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | - Charalampos Papagoras
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | | | | | | | | | - Dimitrios Boumpas
- School of Medicine, 4th Department of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Emilia Hadziyannis
- School of Medicine, General Hospital of Athens "Hippokration", 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, 114 Vass. Sophias Ave., 115 27, Athens, Greece
| | - Dimitrios Vassilopoulos
- School of Medicine, General Hospital of Athens "Hippokration", 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, 114 Vass. Sophias Ave., 115 27, Athens, Greece.
| |
Collapse
|
3
|
Bonnan M, Debeugny S. Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy? Front Neurol 2023; 14:1305093. [PMID: 38130834 PMCID: PMC10733536 DOI: 10.3389/fneur.2023.1305093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023] Open
Abstract
Stroke is a rare and severe complication of giant cell arteritis (GCA). Although early diagnosis and treatment initiation are essential, the mechanism of stroke is often related to vasculitis complicated by arterial stenosis and occlusion. Its recurrence is often attributed to early steroid resistance or late GCA relapse, so immunosuppressive treatment is often reinforced. However, many questions concerning the mechanisms of stroke remain elusive, and no review to date has examined the whole data set concerning GCA-related stroke. We therefore undertook this scoping review. GCA-related stroke does not necessarily display general signs and inflammatory parameters are sometimes normal, so clinicians should observe caution. Ischemic lesions often show patterns predating watershed areas and are associated with stenosis or thrombosis of the respective arteries, which are often bilateral. Lesions predominate in the siphon in the internal carotid arteries, whereas all the vertebral arteries may be involved with a predominance in the V3-V4 segments. Ultrasonography of the cervical arteries may reveal edema of the intima (halo sign), which is highly sensitive and specific of GCA, and precedes stenosis. The brain arteries are spared although very proximal arteritis may rarely occur, if the patient has microstructural anatomical variants. Temporal artery biopsy reveals the combination of mechanisms leading to slit-like stenosis, which involves granulomatous inflammation and intimal hyperplasia. The lumen is sometimes occluded by thrombi (<15%), suggesting that embolic lesions may also occur, although imaging studies have not provided strong evidence for this. Moreover, persistence of intimal hyperplasia might explain persisting arterial stenosis, which may account for delayed stroke occurring in watershed areas. Other possible mechanisms of stroke are also discussed. Overall, GCA-related stroke mainly involves hemodynamic mechanisms. Besides early diagnosis and treatment initiation, future studies could seek to establish specific preventive or curative treatments using angioplasty or targeting intimal proliferation.
Collapse
Affiliation(s)
- Mickael Bonnan
- Service de Neurologie, Hôpital Delafontaine, Saint-Denis, France
| | - Stephane Debeugny
- Département d'Information Médicale, Centre Hospitalier de Pau, Pau, France
| |
Collapse
|
4
|
Unizony S, Matza MA, Jarvie A, O'Dea D, Fernandes AD, Stone JH. Treatment for giant cell arteritis with 8 weeks of prednisone in combination with tocilizumab: a single-arm, open-label, proof-of-concept study. THE LANCET. RHEUMATOLOGY 2023; 5:e736-e742. [PMID: 38251564 DOI: 10.1016/s2665-9913(23)00265-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Even after the approval of tocilizumab, substantial glucocorticoid exposure (usually ≥6 months) and toxicity continue to be important problems for patients with giant cell arteritis. We aimed to assess the outcomes of a group of patients with giant cell arteritis treated with tocilizumab in combination with 8 weeks of prednisone. METHODS This prospective, single arm, proof-of-concept study was conducted at Massachusetts General Hospital (Boston, MA, USA). Individuals aged 50 years or older who had new-onset or relapsing giant cell arteritis with active disease were eligible for inclusion. Participants received 12 months of tocilizumab 162 mg weekly subcutaneously in combination with 8 weeks of prednisone. The primary endpoint was sustained prednisone-free remission at week 52. Adverse events were also evaluated. This trial is registered with ClinicalTrials.gov (NCT03726749), and is complete. FINDINGS Between Nov 28, 2018, and Nov 2, 2020, we enrolled 30 patients (mean age 73·7 years [SD 8·1], 18 [60%] women and 12 [40%] men, 30 [100%] White race, 15 [50%] new-onset disease, 23 [77%] temporal artery biopsy-proven, 14 [47%] imaging-proven). The initial prednisone doses were 60 mg (n=7), 50 mg (n=1), 40 mg (n=7), 30 mg (n=6), and 20 mg (n=9). All patients entered remission within 4 weeks from baseline. 23 (77%) of 30 patients were in sustained prednisone-free remission at week 52 and seven (23%) patients relapsed, with a mean time to relapse of 15·8 weeks (SD 14·7). Overall, four (13%) participants developed a serious adverse event, including one related or probably related to prednisone exclusively, two related or probably related to tocilizumab exclusively, and one related or probably related to prednisone, tocilizumab, or both. Two of the non-responder patients stopped tocilizumab and withdrew from the study prematurely after having a second disease relapse. No cases of giant cell arteritis-related permanent vision loss occurred during the study. INTERPRETATION These results suggest that 12 months of tocilizumab in combination with 8 weeks of prednisone could induce and maintain remission in patients with giant cell arteritis. Confirmation of these findings in a randomised controlled trial is required. FUNDING Genentech.
Collapse
Affiliation(s)
- Sebastian Unizony
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mark A Matza
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam Jarvie
- Emory University School of Medicine, Atlanta, GA, USA
| | - David O'Dea
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ana D Fernandes
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Samec MJ, Rakholiya J, Langenfeld H, Crowson CS, Abril A, Wang B, Mertz L, Rodriguez-Pla A, Bansal P, Burke M, Jaquith J, Weyand C, Warrington KJ, Koster MJ. Relapse Risk and Safety of Long-Term Tocilizumab Use Among Patients With Giant Cell Arteritis: A Single-Enterprise Cohort Study. J Rheumatol 2023; 50:1310-1317. [PMID: 37321636 PMCID: PMC10543396 DOI: 10.3899/jrheum.2022-1214] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of tocilizumab (TCZ) in giant cell arteritis (GCA) in a large North American cohort. METHODS Patients with GCA treated with TCZ between January 1, 2010, and May 15, 2020, were retrospectively identified. Kaplan-Meier methods were used to estimate time to TCZ discontinuation and time to first relapse after TCZ discontinuation. Poisson regression models were used to compare annualized relapse rates before, during, and after TCZ use. Age- and sex-adjusted risk factors associated with relapse on and off TCZ and development of adverse events of significant interest (AESIs) were examined using Cox models. RESULTS One hundred fourteen patients (60.5% female) were included with mean (SD) age 70.4 (8.2) years. Median duration from GCA diagnosis to TCZ start was 4.5 months. Median overall duration of TCZ treatment was 2.3 years. Relapse rate prior to TCZ start (0.84 relapses/person-year) was 3-fold reduced while on TCZ (0.28 relapses/person-year; P < 0.001) but increased to 0.64 relapses/person-year after TCZ discontinuation. Fifty-two patients stopped TCZ after a median of 16.8 months; 27 relapsed after discontinuation (median: 8.4 months; 58% relapsed within 12 months). Only 14.9% of patients stopped TCZ because of AESIs. Neither dose/route of TCZ, presence of large-vessel vasculitis, nor duration of TCZ therapy prior to discontinuation predicted relapse after TCZ stop. CONCLUSION TCZ is well tolerated in GCA, with low rates of discontinuation for AESIs. However, relapse occurred in > 50% despite median treatment > 12 months. Since the duration of TCZ prior to discontinuation did not significantly affect subsequent risk of GCA recurrence, further research is needed to determine the optimal duration of therapy.
Collapse
Affiliation(s)
- Matthew J Samec
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Jigisha Rakholiya
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Hannah Langenfeld
- H. Langenfeld, MPH, Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Cynthia S Crowson
- C.S. Crowson, PhD, Division of Rheumatology, and Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Andy Abril
- A. Abril, MD, B. Wang, MD, Division of Rheumatology, Mayo Clinic, Jacksonville, Florida
| | - Benjamin Wang
- A. Abril, MD, B. Wang, MD, Division of Rheumatology, Mayo Clinic, Jacksonville, Florida
| | - Lester Mertz
- L. Mertz, MD, A. Rodriguez-Pla, MD, PhD, Division of Rheumatology, Mayo Clinic, Scottsdale, Arizona
| | - Alicia Rodriguez-Pla
- L. Mertz, MD, A. Rodriguez-Pla, MD, PhD, Division of Rheumatology, Mayo Clinic, Scottsdale, Arizona
| | - Pankaj Bansal
- P. Bansal, MBBS, Division of Rheumatology, Mayo Clinic Health System, Eau Claire, Wisconsin, USA
| | - Michelle Burke
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Jane Jaquith
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Cornelia Weyand
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth J Warrington
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Matthew J Koster
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota;
| |
Collapse
|
6
|
Carvajal Alegria G, Nicolas M, van Sleen Y. Biomarkers in the era of targeted therapy in giant cell arteritis and polymyalgia rheumatica: is it possible to replace acute-phase reactants? Front Immunol 2023; 14:1202160. [PMID: 37398679 PMCID: PMC10313393 DOI: 10.3389/fimmu.2023.1202160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/23/2023] [Indexed: 07/04/2023] Open
Abstract
Research into giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) has become more important in the last few decades. Physicians are facing several challenges in managing the diagnosis, treatment, and relapses of GCA and PMR patients. The search for biomarkers could provide elements to guide a physician's decision. In this review, we aim to summarize the scientific publications about biomarkers in GCA and PMR in the past decade. The first point raised by this review is the number of clinical situations in which biomarkers could be useful: differential diagnosis of either GCA or PMR, diagnosis of underlying vasculitis in PMR, prediction of relapse or complications, disease activity monitoring, choice, and modification of treatments. The second point raised by this review is the large number of biomarkers studied, from common markers like C-reactive protein, erythrocyte sedimentation rate, or elements of blood count to inflammatory cytokines, growth factors, or immune cell subpopulations. Finally, this review underlines the heterogeneity between the studies and proposes points to consider in studies evaluating biomarkers in general and particularly in the case of GCA and PMR.
Collapse
Affiliation(s)
- Guillermo Carvajal Alegria
- EA6295 Nanomédicaments et Nanosondes, Université de Tours, Tours, France
- Department of Rheumatology, Centre Hospitalier Régional Universitaire (CHRU) de Tours, Tours Cedex, France
| | - Mathilde Nicolas
- Department of Rheumatology, Centre Hospitalier Régional Universitaire (CHRU) de Tours, Tours Cedex, France
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, Netherlands
| |
Collapse
|
7
|
Tomelleri A, van der Geest KSM, Khurshid MA, Sebastian A, Coath F, Robbins D, Pierscionek B, Dejaco C, Matteson E, van Sleen Y, Dasgupta B. Disease stratification in GCA and PMR: state of the art and future perspectives. Nat Rev Rheumatol 2023:10.1038/s41584-023-00976-8. [PMID: 37308659 DOI: 10.1038/s41584-023-00976-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature, an excellent response to glucocorticoids, a tendency to a chronic and relapsing course, and older age of the affected population. This Review highlights the emerging view that these diseases should be approached as linked conditions, unified under the term GCA-PMR spectrum disease (GPSD). In addition, GCA and PMR should be seen as non-monolithic conditions, with different risks of developing acute ischaemic complications and chronic vascular and tissue damage, different responses to available therapies and disparate relapse rates. A comprehensive stratification strategy for GPSD, guided by clinical findings, imaging and laboratory data, facilitates appropriate therapy and cost-effective use of health-economic resources. Patients presenting with predominant cranial symptoms and vascular involvement, who usually have a borderline elevation of inflammatory markers, are at an increased risk of sight loss in early disease but have fewer relapses in the long term, whereas the opposite is observed in patients with predominant large-vessel vasculitis. How the involvement of peripheral joint structures affects disease outcomes remains uncertain and understudied. In the future, all cases of new-onset GPSD should undergo early disease stratification, with their management adapted accordingly.
Collapse
Affiliation(s)
- Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Alwin Sebastian
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Fiona Coath
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK
| | - Daniel Robbins
- Medical Technology Research Centre, School of Allied Health, Anglia Ruskin University, Chelmsford, UK
| | - Barbara Pierscionek
- Faculty of Health Education Medicine and Social Care, Medical Technology Research Centre, Anglia Ruskin University, Chelmsford Campus, Chelmsford, UK
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Eric Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK.
| |
Collapse
|
8
|
Gomes de Pinho Q, Daumas A, Benyamine A, Bertolino J, Ebbo M, Schleinitz N, Harlé JR, Jarrot PA, Kaplanski G, Berbis J, Boucekine M, Rossi P, Granel B. Predictors of Relapses or Recurrences in Patients With Giant Cell Arteritis: A Medical Records Review Study. J Clin Rheumatol 2023; 29:e25-e31. [PMID: 36727749 DOI: 10.1097/rhu.0000000000001942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Giant cell arteritis (GCA) is the most common systemic vasculitis in individuals aged ≥50 years. Its course is marked by a high relapse rate requiring long-term glucocorticoid use with its inherent adverse effects. We aimed to identify factors associated with relapses or recurrences in GCA at diagnosis. METHODS We reviewed the medical records of consecutive patients with GCA diagnosed between 2009 and 2019 and followed for at least 12 months. We recorded their characteristics at onset and during follow-up. Factors associated with relapses or recurrences were identified using multivariable analysis. RESULTS We included 153 patients, among whom 68% were female with a median age of 73 (47-98) years and a median follow-up of 32 (12-142) months. Seventy-four patients (48.4%) had at least 1 relapse or recurrence. Headache and polymyalgia rheumatica were the most frequent manifestations of relapses. The first relapse occurred at a median time of 13 months after the diagnosis, with a median dose of 5.5 (0-25) mg/d of glucocorticoids.In multivariable analysis, patients with relapses or recurrences had a higher frequency of cough and scalp tenderness at diagnosis (20.3% vs 5.1%; odds ratio [OR], 4.73; 95% confidence interval [CI], 1.25-17.94; p = 0.022; and 41.9% vs 29.1%; OR, 2.4; 95% CI, 1.07-5.39; p = 0.034, respectively). Patients with diabetes mellitus at diagnosis had fewer relapses or recurrences during follow-up (5.4% vs 19%; OR, 0.24; 95% CI, 0.07-0.83; p = 0.024). CONCLUSIONS Cough and scalp tenderness at diagnosis were associated with relapses or recurrences, whereas patients with diabetes experienced fewer relapses or recurrences.
Collapse
Affiliation(s)
- Quentin Gomes de Pinho
- From the Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Service de Médecine Interne
| | - Aurélie Daumas
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Service de Médecine Interne, Gériatrie et Thérapeutique
| | - Audrey Benyamine
- From the Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Service de Médecine Interne
| | - Julien Bertolino
- From the Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Service de Médecine Interne
| | - Mikaël Ebbo
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Service de Médecine Interne
| | - Nicolas Schleinitz
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Service de Médecine Interne
| | - Jean-Robert Harlé
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Service de Médecine Interne
| | - Pierre André Jarrot
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Conception, Service de Médecine Interne et Immunologie Clinique
| | - Gilles Kaplanski
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Conception, Service de Médecine Interne et Immunologie Clinique
| | - Julie Berbis
- Faculté de Médecine de la Timone, Laboratoire de Santé Publique, EA 3279, Centre d'Étude et de Recherche sur les Service de Santé et la Qualité de Vie, Aix-Marseille Université, Marseille, France
| | - Mohamed Boucekine
- Faculté de Médecine de la Timone, Laboratoire de Santé Publique, EA 3279, Centre d'Étude et de Recherche sur les Service de Santé et la Qualité de Vie, Aix-Marseille Université, Marseille, France
| | - Pascal Rossi
- From the Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Service de Médecine Interne
| | - Brigitte Granel
- From the Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Service de Médecine Interne
| |
Collapse
|
9
|
Liozon E, Parreau S, Dumonteil S, Gondran G, Bezanahary H, Ly KH, Fauchais AL. New-onset giant cell arteritis with lower ESR and CRP level carries a similar ischemic risk to other forms of the disease but has an excellent late prognosis: a case-control study. Rheumatol Int 2023; 43:1323-1331. [PMID: 37024620 DOI: 10.1007/s00296-023-05299-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Biopsy-proven giant cell arteritis (GCA) occasionally presents without acute-phase reaction. In this setting, GCA may be initially overlooked and glucocorticoid treatment unduly delayed, potentially increasing ischemic risk. PATIENTS AND METHODS From an inception cohort of patients with newly diagnosed, biopsy-verified GCA, we retrieved all cases without elevation of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level before starting glucocorticoid treatment. We compared the baseline features and outcomes of these patients and two additional patients recruited after GCA diagnosis with those of 42 randomly selected patients with high baseline ESR and CRP. RESULTS Of 396 patients, 14 (3.5%) had lower baseline values of both ESR and CRP. Lower baseline ESR and CRP were associated with fewer American College of Rheumatology criteria met (p < 0.001, 95% CI - 1.1; - 0.9), and less jaw claudication (p = 0.06, 95% CI 0.8; 44.9), but similar rates of permanent blindness (p = 1.0). Patients with lower ESR and CRP also showed obvious differences regarding mean blood cell counts and mean hemoglobin level, but also less anti-cardiolipin antibody positivity (p = 0.04, 95% CI 0.8; ∞) and hepatic cholestasis (p = 0.03, 95% CI 1.0; 422). Patients with lower ESR and CRP had fewer GCA relapses (p = 0.03, 95% CI - 1.1; - 0.1), fewer glucocorticoid-induced complications (p = 0.01, 95% CI - 2.0; - 0.1), and successfully stopped glucocorticoids sooner than the other patients (18.3 months vs 34 months in average, p = 0.02, 95% CI - 27;- 0.9). CONCLUSION Biopsy-proven GCA presenting with lower ESR and CRP is not an exceptional occurrence. It is clinically less typical but carries similar ischemic risk to other forms of the disease. Conversely, the late GCA prognosis of these patients is excellent.
Collapse
Affiliation(s)
- Eric Liozon
- Department of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France.
- Service de Médecine Interne A, CHRU Dupuytren, 16, Rue Bernard Descottes, 87042, Limoges, France.
| | - Simon Parreau
- Department of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Stéphanie Dumonteil
- Department of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Guillaume Gondran
- Department of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Holy Bezanahary
- Department of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Kim-Heang Ly
- Department of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Anne Laure Fauchais
- Department of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| |
Collapse
|
10
|
Trives-Folguera L, Molina-Collada J, López K, Rivera J, Serrano-Benavente B, Anzola-Alfaro AM, Castrejón I, Álvaro-Gracia JM, Martínez-Barrio J. Oral or pulse glucocorticoid use at the onset of giant cell arteritis and its influence on the risk of relapse: a retrospective study. Rheumatol Int 2023; 43:1333-1340. [PMID: 37027021 DOI: 10.1007/s00296-023-05321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/23/2023] [Indexed: 04/08/2023]
Abstract
The objective is to investigate whether initial therapy with intravenous methylprednisolone pulses (ivMTP) or oral glucocorticoid (OG) influences the relapse rate in giant cell arteritis (GCA) patients. This is a retrospective observational study of patients with GCA from 2004 to 2021. Demographics, clinical and laboratory variables, cumulative glucocorticoid dose and relapse rate at 6-month follow-up defined according to EULAR recommendations were recorded. Univariate and multivariate logistic regression models were used to determine possible risk factors for relapse. A total of 74 GCA patients were included for analysis (54 (73%) female, mean (SD) age 77.2 (7.4) years). Overall, 47 (63.5%) patients received ivMTP at disease onset and 27 (36.5%) OG. Mean (SD) cumulative prednisone dose (mg) at 6-month follow-up was 3790.7 (1832.7) for patients with ivMTP vs 4298.1 (2930.6) for the OG group, p = 0.37. A total of 15 (20.3%) relapses occurred at 6-month follow-up. Relapse rates did not differ according to the initial therapy (19.1 vs 22.2%, respectively, p = 0.75). In the multivariate analysis, fever at disease onset (OR 4.837; CI 1.1-21.6) and dyslipidemia (OR 5.651; CI 1.1-28.4) were independent predictors for relapse. Initial therapy with ivMTP or OG does not influence the relapse rate of GCA patients. Fever at disease onset and dyslipidemia are independent predictors of disease relapse.
Collapse
Affiliation(s)
- Laura Trives-Folguera
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - Juan Molina-Collada
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Katerine López
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
| | - Javier Rivera
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Belén Serrano-Benavente
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Ana M Anzola-Alfaro
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Isabel Castrejón
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - José María Álvaro-Gracia
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Julia Martínez-Barrio
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| |
Collapse
|
11
|
Matza MA, Dagincourt N, Mohan SV, Pavlov A, Han J, Stone JH, Unizony SH. Outcomes during and after long-term tocilizumab treatment in patients with giant cell arteritis. RMD Open 2023; 9:rmdopen-2022-002923. [PMID: 37024237 PMCID: PMC10083869 DOI: 10.1136/rmdopen-2022-002923] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/08/2023] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVE To assess outcomes in giant cell arteritis (GCA) patients during and after long-term tocilizumab (TCZ) treatment. METHODS Retrospective analysis of GCA patients treated with TCZ at a single centre (2010-2022). Time to relapse and annualised relapse rate during and after TCZ treatment, prednisone use, and safety were assessed. Relapse was defined as reappearance of any GCA clinical manifestation that required treatment intensification, regardless of C reactive protein levels and erythrocyte sedimentation rate. RESULTS Sixty-five GCA patients were followed for a mean (SD) of 3.1 (1.6) years. The mean duration of the initial TCZ course was 1.9 (1.1) years. The Kaplan-Meier (KM)-estimated relapse rate at 18 months on TCZ was 15.5%. The first TCZ course was discontinued due to satisfactory remission achievement in 45 (69.2%) patients and adverse events in 6 (9.2%) patients. KM-estimated relapse rate at 18 months after TCZ discontinuation was 47.3%. Compared with patients stopping TCZ at or before 12 months of treatment, the multivariable adjusted HR (95% CI) for relapse in patients on TCZ beyond 12 months was 0.01 (0.00 to 0.28; p=0.005). Thirteen patients received >1 TCZ course. Multivariable adjusted annualised relapse rates (95% CI) in all periods on and off TCZ aggregated were 0.1 (0.1 to 0.2) and 0.4 (0.3 to 0.7), respectively (p=0.0004). Prednisone was discontinued in 76.9% of patients. During the study, 13 serious adverse events occurred in 11 (16.9%) patients. CONCLUSION Long-term TCZ treatment was associated with remission maintenance in most patients with GCA. The estimated relapse rate by 18 months after TCZ discontinuation was 47.3%.
Collapse
Affiliation(s)
- Mark A Matza
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Andrey Pavlov
- Everest Clinical Research Corporation, Markham, Ontario, Canada
| | - Jian Han
- Genentech Inc, South San Francisco, California, USA
| | - John H Stone
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian H Unizony
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Springer JM, Kermani TA. Recent advances in the treatment of giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 37:101830. [PMID: 37328409 DOI: 10.1016/j.berh.2023.101830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 06/18/2023]
Abstract
Giant cell arteritis (GCA) is a systemic, granulomatous, large-vessel vasculitis that affects individuals over the age of 50 years. Morbidity from disease includes cranial manifestations which can cause irreversible blindness, while extra-cranial manifestations can cause vascular damage with large-artery stenosis, occlusions, aortitis, aneurysms, and dissections. Glucocorticoids while efficacious are associated with significant adverse effects. Furthermore, despite treatment with glucocorticoids, relapses are common. An understanding of the pathogenesis of GCA has led to the discovery of tocilizumab as an efficacious steroid-sparing therapy while additional therapeutic targets affecting different inflammatory pathways are under investigation. Surgical treatment may be indicated in cases of refractory ischemia or aortic complications but data on surgical outcomes are limited. Despite the recent advances, many unmet needs exist, including the identification of patients or subsets of GCA who would benefit from earlier initiation of adjunctive therapies, patients who may warrant long-term immunosuppression and medications that sustain permanent remission. The impact of medications like tocilizumab on long-term outcomes, including the development of aortic aneurysms and vascular damage also warrants investigation.
Collapse
Affiliation(s)
- Jason M Springer
- Vanderbilt University Medical Center, 1161 21st Avenue Sound, T3113 Medical Center North, Nashville, TN, 37232, USA.
| | - Tanaz A Kermani
- University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
| |
Collapse
|
13
|
Schäfer VS, Brossart P, Warrington KJ, Kurts C, Sendtner GW, Aden CA. The role of autoimmunity and autoinflammation in giant cell arteritis: A systematic literature review. Autoimmun Rev 2023; 22:103328. [PMID: 36990133 DOI: 10.1016/j.autrev.2023.103328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
Giant cell arteritis is the most common form of large vessel vasculitis and preferentially involves large and medium-sized arteries in patients over the age of 50. Aggressive wall inflammation, neoangiogenesis and consecutive remodeling processes are the hallmark of the disease. Though etiology is unknown, cellular and humoral immunopathological processes are well understood. Matrix metalloproteinase-9 mediated tissue infiltration occurs through lysis of basal membranes in adventitial vessels. CD4+ cells attain residency in immunoprotected niches, differentiate into vasculitogenic effector cells and enforce further leukotaxis. Signaling pathways involve the NOTCH1-Jagged1 pathway opening vessel infiltration, CD28 mediated T-cell overstimulation, lost PD-1/PD-L1 co-inhibition and JAK/STAT signaling in interferon dependent responses. From a humoral perspective, IL-6 represents a classical cytokine and potential Th-cell differentiator whereas interferon-γ (IFN- γ) has been shown to induce chemokine ligands. Current therapies involve glucocorticoids, tocilizumab and methotrexate application. However, new agents, most notably JAK/STAT inhibitors, PD-1 agonists and MMP-9 blocking substances, are being evaluated in ongoing clinical trials.
Collapse
|
14
|
Moreel L, Betrains A, Molenberghs G, Vanderschueren S, Blockmans D. Epidemiology and predictors of relapse in giant cell arteritis: A systematic review and meta-analysis. Joint Bone Spine 2023; 90:105494. [PMID: 36410684 DOI: 10.1016/j.jbspin.2022.105494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/27/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to estimate the timing of relapse, the prevalence of multiple relapses and the predictors of relapse in patients with giant cell arteritis (GCA). METHODS PubMed, Embase and Cochrane databases were searched from inception till November, 30 2021. Outcome measures include cumulative relapse rate (CRR) of first relapse at year 1, 2, and 5 after treatment initiation, CRR of second and third relapse and predictors of relapse. RESULTS Thirty studies (2595 patients) were included for timing of relapse, 16 studies (1947 patients) for prevalence of multiple relapses and 40 studies (4213 patients) for predictors of relapse. One-year, 2-year and 5-year CRRs were 32% [95% confidence interval (CI) 22-43%], 44% [95% CI 31-59%], and 47% [95% CI 27-67%], respectively. The duration of scheduled glucocorticoid therapy was negatively associated with the 1-year CRR (P=0.03). CRR of second and third relapse were 30% [95% CI 21-40] and 17% [95% CI 8-33%], respectively. Female sex (OR 1.43) and large vessel involvement (OR 2.04) were predictors of relapse. CONCLUSION Relapse occurred in almost half of GCA patients mainly during the first two years after diagnosis. One in three patients had multiple relapses. The optimal glucocorticoid tapering schedule, which seeks a balance between the lowest relapse risk and the shortest glucocorticoid duration, needs to be determined in future studies. Longer scheduled glucocorticoid therapy or early introduction of glucocorticoid-sparing agents may be warranted in female patients and patients with large vessel involvement.
Collapse
Affiliation(s)
- Lien Moreel
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Geert Molenberghs
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), University of Leuven and Hasselt University, Leuven, Belgium
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Belgium
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Belgium
| |
Collapse
|
15
|
Association of immunological parameters with aortic dilatation in giant cell arteritis: a cross-sectional study. Rheumatol Int 2023; 43:477-485. [PMID: 35996028 PMCID: PMC9968266 DOI: 10.1007/s00296-022-05186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
Aortic dilatation (AD) occurs in up to 30% of patients with giant cell arteritis (GCA). Reliable biomarkers for AD development, however, are still absent. The aim of this exploratory study was to evaluate whether immunological parameters are associated with the occurrence of AD in GCA. Cross-sectional study on 20 GCA patients with AD, 20 GCA patients without AD, and 20 non-GCA controls without AD measuring leukocytes, neutrophils, lymphocytes, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), serum amyloid A (SAA), interferon (IFN)-α, IFN-γ, IFN-γ-induced protein 10 (IP-10), interleukin (IL) 5, IL-8, IL-10, IL-17A, IL-18, IL-1 receptor antagonist, tumor necrosis factor (TNF)-α, platelet-derived growth factor (PDGF), L-selectin, P-selectin, and soluble intercellular adhesion molecule 1 (sICAM-1). AD was measured by aortic contrast-enhanced computed tomography and defined by enlargement of the aorta above population-based aortic diameters adjusted by age, gender, and body surface area. No significant differences were observed between GCA patients with AD and GCA patients without AD concerning levels of leukocytes, neutrophils, lymphocytes, CRP, ESR, SAA, IL-8, IL-18, PDGF, IP-10, selectins, and sICAM-1. Values of IFN-α, IFN-γ, IL-5, IL-10, IL-17A, IL-1 receptor antagonist, and TNF-α were all below the detection limits in more than 70% of subjects. Lymphocytes and CRP revealed positive correlations with the diameter of the thoracic descending aorta. Immunological parameters were not useful to conclude on the presence of AD in GCA. Further studies are required to test if CRP and lymphocytes may be useful to predict future development of AD in GCA.
Collapse
|
16
|
Farina N, Tomelleri A, Campochiaro C, Dagna L. Giant cell arteritis: Update on clinical manifestations, diagnosis, and management. Eur J Intern Med 2023; 107:17-26. [PMID: 36344353 DOI: 10.1016/j.ejim.2022.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
Giant cell arteritis (GCA) is the most common vasculitis affecting people older than 50 years. The last decades have shed new light on the clinical paradigm of this condition, expanding its spectrum beyond cranial vessel inflammation. GCA can be now considered a multifaceted vasculitic syndrome encompassing inflammation of cranial and extra-cranial arteries and girdles, isolated or combined. Such heterogeneity often leads to diagnostic delays and increases the likelihood of acute and chronic GCA-related damage. On the other hand, the approach to suspected GCA patients has been revolutionized by the introduction of vascular ultrasound which allows a rapid, cost-effective, and non-invasive GCA diagnosis. Likewise, the use of tocilizumab is now part of the therapeutic algorithm of GCA and ensures a satisfactory disease control even in steroid-refractory patients. Nonetheless, some aspects of GCA still need to be clarified, including the clinical correlation of different histological patterns, and the prevention of long-term vascular complications. This narrative review depicts the diagnostic and therapeutic aspects of GCA most relevant in clinical practice, with a focus on clinical updates and novelties introduced over the last decade.
Collapse
Affiliation(s)
- Nicola Farina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
17
|
Scolnik M, Brance ML, Fernández-Ávila DG, Inoue Sato E, de Souza AWS, Magri SJ, Saldarriaga-Rivera LM, Ugarte-Gil MF, Flores-Suarez LF, Babini A, Zamora NV, Acosta Felquer ML, Vergara F, Carlevaris L, Scarafia S, Soriano Guppy ER, Unizony S. Pan American League of Associations for Rheumatology guidelines for the treatment of giant cell arteritis. THE LANCET. RHEUMATOLOGY 2022; 4:e864-e872. [PMID: 38261393 DOI: 10.1016/s2665-9913(22)00260-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/20/2022] [Accepted: 08/30/2022] [Indexed: 11/27/2022]
Abstract
Considerable variability exists in the way that health-care providers treat patients with giant cell arteritis in Latin America, with patients commonly exposed to excessive amounts of glucocorticoids. In addition, large health disparities prevail in this region due to socioeconomic factors, which influence access to care, including biological treatments. For these reasons, the Pan American League of Associations for Rheumatology developed the first evidence-based giant cell arteritis treatment guidelines tailored for Latin America. A panel of vasculitis experts from Mexico, Colombia, Peru, Brazil, and Argentina generated clinically meaningful questions related to the treatment of giant cell arteritis in the population, intervention, comparator, and outcome (PICO) format. Following the grading of recommendations, assessment, development, and evaluation methodology, a team of methodologists did a systematic literature search, extracted and summarised the effects of the interventions, and graded the quality of the evidence. The panel of vasculitis experts voted on each PICO question and made recommendations, which required at least 70% agreement among the voting members to be included in the guidelines. Nine recommendations and one expert opinion statement for the treatment of giant cell arteritis were developed considering the most up-to-date evidence and the socioeconomic characteristics of Latin America. These recommendations include guidance for the use of glucocorticoids, tocilizumab, methotrexate, and aspirin for patients with giant cell arteritis.
Collapse
Affiliation(s)
- Marina Scolnik
- Rheumatology Unit, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Maria L Brance
- School of Medicine, National Rosario University, Santa Fe, Argentina
| | | | - Emilia Inoue Sato
- Medicine Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Sebastián J Magri
- Rheumatology Unit, Hospital Italiano de La Plata, La Plata, Argentina
| | | | | | - Luis F Flores-Suarez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Alejandra Babini
- Rheumatology Unit, Hospital Italiano de Cordoba, Cordoba, Argentina
| | | | - María L Acosta Felquer
- Rheumatology Unit, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Santiago Scarafia
- Rheumatology Unit, Hospital Municipal San Cayetano, Virreyes, Argentina
| | - Enrique R Soriano Guppy
- Rheumatology Unit, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sebastian Unizony
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
18
|
Saha P, Srikantharajah D, Kaul A, Sofat N. Tocilizumab for relapsing and remitting giant cell arteritis: a case series. J Med Case Rep 2022; 16:389. [PMID: 36289554 PMCID: PMC9607773 DOI: 10.1186/s13256-022-03625-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 06/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Giant cell arteritis is a large vessel vasculitis of the arteries in the head and neck. The mainstay of management is with high-dose corticosteroids, and patients often face difficulties stopping or reducing steroids without recurrence of symptoms. Corticosteroids are well established to have numerous associated side effects, including osteoporosis, weight gain, and diabetes. Therefore, when tocilizumab was approved for up to 1 year for cases of relapsing or refractory giant cell arteritis by the National Institute of Health and Care Excellence (NICE) in April 2018, this offered an opportunity to benefit from new funding and to reduce steroid burden. CASE PRESENTATION This case series describes the impact of the establishment of a new hub and spoke referral pathway for the use of tocilizumab in refractory or relapsing giant cell arteritis, with case examples from consecutive patients who accessed the funding between August 2018 and April 2021. A total of 16 patients were identified: 11 female and 5 male, with an average age of 72.4 (range 61-82) years, with a majority of 11 ethnically white. The central assessing hub is St George's University Hospitals NHS Foundation Trust Hospital, serving a population of 1.3 million in the south of England. This is the first large case series looking into the impact of the establishment of a regional clinical pathway for the new tocilizumab funding. CONCLUSIONS The case series demonstrates that the use of tocilizumab has reduced both the duration and the dose of corticosteroids in these 16 cases (mean prednisolone reduction 20.4 mg: 95% CI 13.0-27.8 mg), with 50% of patients continuing on tocilizumab after the initial 12 month funding period. The disease course, patterns of response, and maintenance of remission are discussed, and we describe the benefits of replicating this hub and spoke tocilizumab pathway in other centers.
Collapse
Affiliation(s)
- Pratyasha Saha
- grid.264200.20000 0000 8546 682XInstitute for Infection & Immunity, St George’s University of London, Cranmer Terrace, London, SW17 0RE UK ,grid.451349.eSt George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK
| | - Denesh Srikantharajah
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK
| | - Arvind Kaul
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK
| | - Nidhi Sofat
- grid.264200.20000 0000 8546 682XInstitute for Infection & Immunity, St George’s University of London, Cranmer Terrace, London, SW17 0RE UK ,grid.451349.eSt George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK
| |
Collapse
|
19
|
Tomelleri A, van der Geest KSM, Sebastian A, van Sleen Y, Schmidt WA, Dejaco C, Dasgupta B. Disease stratification in giant cell arteritis to reduce relapses and prevent long-term vascular damage. THE LANCET RHEUMATOLOGY 2021. [DOI: 10.1016/s2665-9913(21)00277-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
20
|
Palamidas DA, Argyropoulou OD, Georgantzoglou N, Karatza E, Xingi E, Kapsogeorgou EK, Anagnostopoulos CD, Lazaris AC, Ritis K, Goules AV, Kambas K, Tzioufas AG. Neutrophil extracellular traps in giant cell arteritis biopsies: presentation, localization and co-expression with inflammatory cytokines. Rheumatology (Oxford) 2021; 61:1639-1644. [PMID: 34260696 DOI: 10.1093/rheumatology/keab505] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To explore the presence of neutrophil extracellular traps (NETs) in inflamed temporal artery biopsies (TABs) of patients with giant cell arteritis (GCA). METHODS Ten patients with GCA [5 with limited and 5 with associated generalized vascular involvement, as defined by 18F-fluorodeoxyglucose (FDG) positron-emission tomography with computed tomography (PET/CT)] and 8 with polymyalgia rheumatica (PMR) were studied. The presence, location, quantitation, and decoration of NETs with IL-6, IL-1β, and IL-17A were assessed in TABs at the time of disease diagnosis by tissue immunofluorescence and confocal microscopy. Paired serum levels of IL-6 and IL-17A were also evaluated in all patients. RESULTS All temporal artery biopsies from GCA, but not PMR patients, had NETs located mainly in the adventitia, adjacent to the vasa vasorum. NETs decorated with IL-6 were present in 8/10 TABs of GCA patients, of whom 5 were -PET/CT(+) and 3 PET/CT(-) patients. IL-17A(+) NETs were observed in all GCA patients. IL-1β(+)NETs were not detected in any GCA patient. No relation was found between serum IL-6 and IL-17A levels and NETs containing IL-6 and/or IL-17A. CONCLUSIONS NETs bearing pro-inflammatory cytokines are present in inflamed GCA-TABs. Future studies with a larger number of patients from different centers will show whether the findings regarding neutrophils/NETs in the TAB are consistent and disclose their clinical impact.
Collapse
Affiliation(s)
- Dimitris Anastasios Palamidas
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Joint Rheumatology Academic program, University of Athens, Athens, Greece
| | - Ourania D Argyropoulou
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Joint Rheumatology Academic program, University of Athens, Athens, Greece
| | - Natalia Georgantzoglou
- 1st Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Elli Karatza
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Evangelia Xingi
- Light Microscopy Unit, Hellenic Pasteur Institute, Athens, Greece
| | - Efstathia K Kapsogeorgou
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Joint Rheumatology Academic program, University of Athens, Athens, Greece
| | | | - Andreas C Lazaris
- 1st Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Ritis
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Alexandroupolis, Greece.,Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Andreas V Goules
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Joint Rheumatology Academic program, University of Athens, Athens, Greece
| | - Konstantinos Kambas
- Laboratory of Molecular Genetics, Department of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Joint Rheumatology Academic program, University of Athens, Athens, Greece
| |
Collapse
|
21
|
Laurent C, Prieto-González S, Belnou P, Carrat F, Fain O, Dellal A, Cid MC, Hernández-Rodríguez J, Mekinian A. Prevalence of cardiovascular risk factors, the use of statins and of aspirin in Takayasu Arteritis. Sci Rep 2021; 11:14404. [PMID: 34257320 PMCID: PMC8277815 DOI: 10.1038/s41598-021-93416-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 06/16/2021] [Indexed: 11/12/2022] Open
Abstract
The aim of this study was to assess the prevalence of cardiovascular risk factors in TAK, to describe the use of aspirin and statins and the risk factors associated with vascular ischemic complications and relapses. We conducted a retrospective study on TAK patients diagnosed between 2010 and 2018. Demographic, clinical, laboratory data and treatments were evaluated at diagnosis and during the follow-up. We included fifty-two TAK patients with median age 37.5 years [range 16–53] and 43 (83%) women. At diagnosis, cardiovascular risk factors were present in 32 (62%) patients: hypertension (n = 20, 38%), hyperlipidemia (n = 8, 15%), tobacco use (n = 16, 31%). During the median 4-year follow-up [range 0.1–17 years], 17 (33%) patients had at least one ischemic event and 15 (29%) patients needed endovascular procedure. Whereas TAK patients with cardiovascular risk factors were more frequently on statins and anti-hypertensive drugs, they have higher rates of cumulative ischemic complications (5 (24%) versus 21 (67%); p = 0.004), but similar rates of aspirin-treated patients. Patients who have developed vascular ischemic events were more frequently smokers (53% versus 20%; p = 0.03). The vascular complication-free survival was not significantly different in TAK patients with or without statins or aspirin at diagnosis. During the follow-up, 27 (52%) patients had at least one relapse, and the relapse-free survival was not significantly different in patients treated with statins or aspirin. Cardiovascular risk factors in TAK have to be strictly controlled since these risk factors could be associated with increased risk of ischemic complications.
Collapse
Affiliation(s)
- Charlotte Laurent
- AP-HP, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3), Hôpital Saint-Antoine, Sorbonne Université, 75012, Paris, France.
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Pierre Belnou
- INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Sorbonne Universités, UPMC Université Paris 06, 75012, Paris, France.,Unité de Santé Publique, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, 75012, Paris, France
| | - Fabrice Carrat
- INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Sorbonne Universités, UPMC Université Paris 06, 75012, Paris, France.,Unité de Santé Publique, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, 75012, Paris, France
| | - Olivier Fain
- AP-HP, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3), Hôpital Saint-Antoine, Sorbonne Université, 75012, Paris, France
| | - Azeddine Dellal
- Service de Rhumatologie, Hôpital Montfermeil, Montfermeil, France
| | - Maria C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Arsène Mekinian
- AP-HP, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3), Hôpital Saint-Antoine, Sorbonne Université, 75012, Paris, France
| |
Collapse
|
22
|
Ponte C, Monti S, Scirè CA, Delvino P, Khmelinskii N, Milanesi A, Teixeira V, Brandolino F, Saraiva F, Montecucco C, Fonseca JE, Schmidt WA, Luqmani RA. Ultrasound halo sign as a potential monitoring tool for patients with giant cell arteritis: a prospective analysis. Ann Rheum Dis 2021; 80:1475-1482. [PMID: 34215646 DOI: 10.1136/annrheumdis-2021-220306] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/16/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To assess the sensitivity to change of ultrasound halo features and their association with disease activity and glucocorticoid (GC) treatment in patients with newly diagnosed giant cell arteritis (GCA). METHODS Prospective study of patients with ultrasound-confirmed GCA who underwent serial ultrasound assessments of the temporal artery (TA) and axillary artery (AX) at fixed time points. The number of segments with halo and maximum halo intima-media thickness (IMT) was recorded. Time points in which >80% of patients were assessed were considered for analysis. Halo features at disease presentation and first relapse were compared. RESULTS 49 patients were assessed at 354 visits. Halo sensitivity to change was assessed at weeks 1, 3, 6, 12 and 24 and showed a significant standardised mean difference between all time points and baseline for the TA halo features but only after week 6 for the AX halo features. The number of TA segments with halo and sum and maximum TA halo IMT showed a significant correlation with erythrocyte sedimentation rate (0.41, 0.44 and 0.48), C reactive protein (0.34, 0.39 and 0.41), Birmingham Vasculitis Activity Score (0.29, 0.36 and 0.35) and GC cumulative dose (-0.34, -0.37 and -0.32); no significant correlation was found for the AX halo features. Halo sign was present in 94% of first disease relapses but with a lower mean number of segments with halo and sum of halo IMT compared with disease onset (2.93±1.59 mm vs 4.85±1.51 mm, p=0.0012; 2.01±1.13 mm vs 4.49±1.95 mm, p=0.0012). CONCLUSIONS Ultrasound is a useful imaging tool to assess disease activity and response to treatment in patients with GCA.
Collapse
Affiliation(s)
- Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Sara Monti
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy .,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Carlo Alberto Scirè
- Epidemiology Research Unit, Italian Society of Rheumatology, Milano, Italy.,Department of Medical Sciences, Rheumatology Unit, University of Ferrara, Ferrara, Italy
| | - Paolo Delvino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Nikita Khmelinskii
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Alessandra Milanesi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vítor Teixeira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal.,Rheumatology Department, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - Fabio Brandolino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fernando Saraiva
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
| | | | - João Eurico Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Wolfgang A Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Krankenhaus Berlin, Berlin, Germany
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
23
|
Unizony SH, Bao M, Han J, Luder Y, Pavlov A, Stone JH. Treatment failure in giant cell arteritis. Ann Rheum Dis 2021; 80:1467-1474. [PMID: 34049857 PMCID: PMC8522464 DOI: 10.1136/annrheumdis-2021-220347] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/24/2021] [Indexed: 11/19/2022]
Abstract
Objective Identify predictors of treatment failure in patients with giant cell arteritis (GCA) receiving tocilizumab in combination with glucocorticoids and in patients with GCA receiving only glucocorticoids. Methods Posthoc analysis of the Giant-Cell Arteritis Actemra trial including 250 patients who received tocilizumab every week plus a 26-week prednisone taper (n=100), tocilizumab every-other-week plus a 26-week prednisone taper (n=49) or placebo plus a 26-week (n=50) or 52-week (n=51) prednisone taper in the intention-to-treat population. Responders for this analysis were patients who maintained remission (no GCA signs/symptoms and no erythrocyte sedimentation rate elevation) through week 52. Treatment failure was defined as inability to achieve remission by week 12 or relapse between weeks 12 and 52. Predictors investigated in univariate and multivariable analyses included patient characteristics, disease-related and treatment-related factors and patient-reported outcomes (PROs). Results 149 patients received tocilizumab plus prednisone (TCZ/PDN) and 101 received placebo plus prednisone (PBO+PDN). After adjustment for confounders, treatment failure was significantly less likely in the TCZ/PDN group than the PBO/PDN group (OR, 0.2; 95% CI, 0.1 to 0.3; p<0.0001). Risk for treatment failure was significantly higher in women than men in the PBO/PDN group (OR, 5.2; 95% CI, 1.6 to 17.2; p=0.007) but not in the TCZ/PDN group. Predictors of treatment failure in the TCZ/PDN group included lower baseline prednisone doses and worse PROs at baseline. Conclusion The strongest risk factors for treatment failure in GCA are treatment with prednisone alone and female sex. Lower starting prednisone doses and impaired PROs are associated with failure to respond to tocilizumab. Trial registration number NCT01791153.
Collapse
Affiliation(s)
- Sebastian H Unizony
- Vasculitis and Glomerulonephritis Center, Rheumatology, Immunology and Allergy Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Min Bao
- Genentech Inc, South San Francisco, California, USA
| | - Jian Han
- Genentech Inc, South San Francisco, California, USA
| | - Yves Luder
- F Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | - John H Stone
- Vasculitis and Glomerulonephritis Center, Rheumatology, Immunology and Allergy Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
24
|
[Glucocorticoids in the treatment of giant cell arteritis : How much, how long and how to spare?]. Z Rheumatol 2021; 80:322-331. [PMID: 33710440 DOI: 10.1007/s00393-021-00975-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 10/21/2022]
Abstract
Treatment of giant cell arteritis (GCA) with high-dose glucocorticoids (GC) regularly leads to a control of the inflammatory activity, so that high-dose GC is still the recommended standard treatment in the current guidelines; however, after discontinuation of GC treatment or reduction of the GC dosage, relapses occur in up to 70% of patients in the further course of the disease, making it necessary to resume treatment or increase the dosage. As a consequence many patients therefore have to be treated with GC often in high doses over several years, which results in a high cumulative exposure to GC. The risk for GC-associated diseases, such as diabetes, glaucoma, osteoporosis or severe infections is therefore significantly increased for patients with giant cell arteritis. For patients with GC-associated comorbidities or increased risk of developing them or patients with a relapse, the current guidelines therefore recommend GC-sparing treatment with tocilizumab or alternatively methotrexate. It is currently unclear over what period of time patients should be treated with GC and GC-sparing treatment, since high-quality study data on de-escalation strategies for GCA are currently still lacking. Decisions on treatment duration and intensity must therefore be made individually for each patient, taking into account general and patient-specific risk factors for a GC-dependent course, GCA-associated vascular damage (stenoses, aneurysms, visual loss) and treatment-associated complications.
Collapse
|
25
|
|
26
|
Tombetti E, Hysa E, Mason JC, Cimmino MA, Camellino D. Blood Biomarkers for Monitoring and Prognosis of Large Vessel Vasculitides. Curr Rheumatol Rep 2021; 23:17. [PMID: 33569633 PMCID: PMC7875948 DOI: 10.1007/s11926-021-00980-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Large vessel vasculitides (LVVs) are inflammatory conditions of the wall of large-sized arteries, mainly represented by giant cell arteritis (GCA) and Takayasu arteritis (TA). The inflammatory process within the vessel wall can lead to serious consequences such as development of aneurysms, strokes and blindness; therefore, early diagnosis and follow-up of LVV are fundamental. However, the arterial wall is poorly accessible and blood biomarkers are intended to help physicians not only in disease diagnosis but also in monitoring and defining the prognosis of these conditions, thus assisting therapeutic decisions and favouring personalised management. The field is the object of intense research as the identification of reliable biomarkers is likely to shed light on the mechanisms of disease progression and arterial remodelling. In this review, we will discuss the role of blood biomarkers in LVVs in the light of the latest evidence. RECENT FINDINGS In clinical practice, the most widely performed laboratory investigations are the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). However, these indices may be within normal limits during disease relapse and they are not reliable in patients receiving interleukin-6 (IL-6) receptor inhibitors. New biomarkers struggle to gain traction in clinical practice and no molecule with good accuracy has been identified to date. IL-6, a pro-inflammatory cytokine that drives CRP synthesis and increases the ESR, is one of the most promising biomarkers in the field. IL-6 analysis is increasingly performed, and serum levels are more sensitive than ESR for active GCA and might reflect persistent inflammation with high risk of relapse in patients on IL-6 receptor inhibitors. A future with biomarkers that reflect different disease features is an important aspiration. Accordingly, intense effort is being made to identify IL-6-independent inflammatory biomarkers, such as S100 proteins, pentraxin-3 and osteopontin. Moreover, metalloproteinases such as MMP2/9 and angiogenic modulators such as VEGF, YLK-40 and angiopoietins are being studied as markers of arterial remodelling. Lastly, biomarkers indicating organ damage may guide prognostic stratification as well as emergency therapeutic decisions: the most promising biomarkers so far identified are NT-proBNP, which reflects myocardial strain; pentraxin-3, which has been associated with recent optic nerve ischemia; and endothelin-1, which is associated with ischaemic complications. Currently, the use of these molecules in clinical practice is limited because of their restricted availability, lack of sufficient studies supporting their validity and associated costs. Further evidence is required to better interpret their biological and clinical value.
Collapse
Affiliation(s)
- Enrico Tombetti
- Internal Medicine, Department of Biomedical and Clinical Sciences "Luigi Sacco", Milan, Italy
- Internal Medicine and Rheumatology, Sacco and Fatebenefratelli Hospitals, Milan, Italy
| | - Elvis Hysa
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Justin C Mason
- National Heart and Lung Institute, Imperial College London, London, UK
- Rheumatology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Marco A Cimmino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Dario Camellino
- Division of Rheumatology, Musculoskeletal System Department, La Colletta Hospital, Local Health Trust 3 Genoa, Via del Giappone 3, 16011, Arenzano, Italy.
- Autoimmunology Laboratory, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| |
Collapse
|
27
|
Monti S, Bartoletti A, Bellis E, Delvino P, Montecucco C. Fast-Track Ultrasound Clinic for the Diagnosis of Giant Cell Arteritis Changes the Prognosis of the Disease but Not the Risk of Future Relapse. Front Med (Lausanne) 2020; 7:589794. [PMID: 33364248 PMCID: PMC7753207 DOI: 10.3389/fmed.2020.589794] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/19/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Color Duplex sonography (CDS) of temporal arteries and large vessels (LV) is a recently validated diagnostic methodology for Giant Cell Arteritis (GCA). CDS combined with a fast-track approach (FTA) has improved the early diagnosis of the disease. Objectives: To assess FTA effects on the prevention of permanent visual loss (PVL), relapse and late complications of GCA compared to conventional practice. To assess the impact of COVID-19 pandemic on outcomes of GCA patients assessed with FTA. Methods: GCA patients diagnosed up to June 2020 at the Rheumatology Department, University of Pavia, were included. FTA was implemented since October 2016. FTA consists in the referral within 1 working day of a suspected GCA case to an expert rheumatologist who performs clinical evaluation and CDS. Results: One hundred sixty patients were recruited [female 120 (75%), mean age 72.4 ± 8.2 years]. Sixty-three (39.4%) evaluated with FTA, 97 (60.6%) with conventional approach. FTA patients were older (75.1 ± 7.6 vs. 70.6 ± 8.2 years old; p < 0.001). Median follow-up duration was shorter in the FTA group compared to the conventional one (0.9 vs. 5.0 years; p < 0.001). There was no difference between the two cohorts regarding major vessel district involvement (LV-GCA 17.5% vs. 22.7%; p = 0.4). PVL occurred in 8 (12.7%) FTA patients and 26 (26.8%) conventional ones (p = 0.03). The relative risk of blindness in the conventional group was 2.11 (95% C.I. 1.02–4.36; P = 0.04) as compared to FTA. Median symptom latency of patients experiencing PVL was higher in the conventional group (23 days IQR 12–96 vs. 7 days IQR 4–10, p = 0.02). During COVID-19 there was a significant increase in the occurrence of PVL (40%) including bilateral blindness despite a regularly operating FTA clinic. Cumulative incidence of relapses and time to first relapse did not change after FTA introduction (P = 0.2). No difference in late complications (stenosis/aneurysms) was detected. Conclusions: FTA including CDS evaluation contributed to a substantial reduction of PVL in GCA by shortening the time to diagnosis and treatment initiation. Relapse rate did not change upon FTA introduction, highlighting the need for better disease activity monitoring and treatment strategies optimization based on risk stratification that would predict the occurrence of relapse during glucocorticoid de-escalation.
Collapse
Affiliation(s)
- Sara Monti
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy.,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Alice Bartoletti
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Elisa Bellis
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Paolo Delvino
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy.,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| |
Collapse
|
28
|
Liozon E, Dumonteil S, Parreau S, Gondran G, Bezanahary H, Palat S, Ly KH, Fauchais AL. Risk profiling for a refractory course of giant cell arteritis: The importance of age and body weight: "Risk profiling for GC resistance in GCA". Semin Arthritis Rheum 2020; 50:1252-1261. [PMID: 33065420 DOI: 10.1016/j.semarthrit.2020.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is a disease that relapses often, and some patients run a refractory course. Although prompt recognition of resistant GCA is a major issue, there is no well-recognized, baseline risk factor for poor response to glucocorticoid (GC) treatment. METHODS We included all patients consecutively diagnosed with GCA and homogeneously treated since 1976 in a single department and regularly followed-up for at least 18 months. Using a set of customized criteria defining response to GCs, we separated patients into highly responsive, usually responsive, dependent on GCs, and resistant to GCs. We determined which of the baseline variables were associated with GC-resistance and conducted factor analyses of mixed data and decision tree analyses. We also determined whether being GC-resistant was associated with poorer tolerance to GCs and higher death rates. RESULTS In all, 455 patients were followed for 93.4 ± 67.6 (standard deviation) months; 41 (9%) and 21 (4.6%) patients developed GC-dependent and GC-resistant disease, respectively. Factor analyses suggested an association between clinical pattern and degree of responsiveness to GCs; The decision tree analyses, built on an age at GCA onset 〈 66 years and body weight 〉 71 kg, delineated a high risk profile (44% of the patients who featured both characteristics were GC-resistant vs. less than 3% who featured neither, p < 0.001). Infections were more prevalent in the GC-resistant or GC-dependent patients, but without decreasing their survival. CONCLUSION Extra-cranial, large-vessel GCA may be associated with prolonged GC requirements. A simple combination of age and body weight defined a subgroup of patients at high risk for developing GC resistance. Our findings need confirmation in prospective controlled studies.
Collapse
Affiliation(s)
- Eric Liozon
- Departments of 1Internal Medicine, University Hospital of Limoges, France.
| | - Stéphanie Dumonteil
- Departments of 1Internal Medicine, University Hospital of Limoges, France; Functional Unit of Clinical Research and Biostatistics, Limoges School of Medicine, Limoges Cedex, France
| | - Simon Parreau
- Departments of 1Internal Medicine, University Hospital of Limoges, France
| | - Guillaume Gondran
- Departments of 1Internal Medicine, University Hospital of Limoges, France
| | - Holy Bezanahary
- Departments of 1Internal Medicine, University Hospital of Limoges, France
| | - Sylvain Palat
- Departments of 1Internal Medicine, University Hospital of Limoges, France
| | - Kim-Heang Ly
- Departments of 1Internal Medicine, University Hospital of Limoges, France
| | | |
Collapse
|
29
|
Yin Y, Zhang Y, Wang D, Han X, Chu X, Shen M, Zeng X. Complete blood count reflecting the disease status of giant cell arteritis: A retrospective study of Chinese patients. Medicine (Baltimore) 2020; 99:e22406. [PMID: 32991468 PMCID: PMC7523864 DOI: 10.1097/md.0000000000022406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Giant cell arteritis (GCA) is the most common vasculitis in elderly, with ischemic and constitutional symptoms caused by vascular involvement and systemic inflammation. Early initiation of therapy results in prompt remission, while patients may still experience flares or severe complications during glucocorticoid tapering. This study was to identify the characteristics of Chinese GCA patients with different prognosis.Ninety-one patients diagnosed with GCA in Peking Union Medical College Hospital in the last 20 years were followed up. Those who were lost to follow up or were followed up for less than 1 year were excluded. According to the prognosis, patients were divided into the group of favourable prognosis (patients who sustained disease remission for over 1 year) and unfavorable prognosis (patients who had relapses or severe complications). Clinical data at disease onset and after treatment were collected and analysed between the 2 groups.Thirty-seven patients with favourable prognosis and 40 patients with unfavourable prognosis were admitted into the study. Fever as an onset symptom was less common in favourable group (P=.016). As for presentations of GCA, fever, tenderness and abnormal pulsation of temporal artery and jaw claudication were less frequently observed in patients with favourable prognosis (P=.029, .049, .043, respectively). At onset, medium-size arteries were affected more in unfavorable prognosis group (P = .048), and involvement of branches below the aortic arch were more common in favorable prognosis group (P = .034). Erythrocyte sedimentation rate in group of favourable prognosis were significantly lower after treatment (P = .041). Compared with healthy subjects, GCA patients had increased monocytes and decreased lymphocytes at disease onset (P < .01). Monocyte counts were higher in patients with favourable prognosis at disease onset (P = .043), while no significant differences were seen between the 2 groups after treatment. Lymphocyte counts were lower in patients with unfavourable prognosis (P = .014) after treatment.Complete blood count may reflect the disease status of GCA. Little change in monocyte during treatment and lower lymphocytes after treatment may serve as potential predictors of unfavourable clinical prognosis.
Collapse
Affiliation(s)
- Yue Yin
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing
| | - Yun Zhang
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing
| | - Dongmei Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Xinxin Han
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing
| | - Xiaotian Chu
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Xuejun Zeng
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing
| |
Collapse
|
30
|
Matza MA, Fernandes AD, Stone JH, Unizony SH. Reply. Arthritis Care Res (Hoboken) 2020; 73:1057-1058. [PMID: 32961035 DOI: 10.1002/acr.24454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Mark A Matza
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ana D Fernandes
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John H Stone
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sebastian H Unizony
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
31
|
Ma J, Khalidi N, Wierzbicki O, Alqutami A, Ioannidis G, Pagnoux C. Impact of diabetes, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, and statin use on presentation and outcomes in patients with giant cell arteritis. Int J Rheum Dis 2020; 23:1233-1239. [PMID: 32776676 DOI: 10.1111/1756-185x.13914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/17/2020] [Accepted: 06/21/2020] [Indexed: 12/01/2022]
Abstract
AIM Few, separate, small retrospective studies in giant cell arteritis (GCA) reported that patients: (a) with diabetes mellitus had less positive temporal artery biopsies (TAB); (b) on angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) experienced fewer relapses; and (c) on statins experienced the same frequency of clinical complications and relapses as non-exposed patients. This retrospective chart review study simultaneously investigated the impact of these 3 factors on a cohort of patients followed in 2 large Canadian centers (Hamilton and Toronto, ON). METHODS One hundred and thirty-seven patients diagnosed with GCA between 1993 and 2015 were included in the study. Presenting symptoms, TAB results, disease complications and outcomes (relapses, duration of glucocorticoid use) were compared between exposed (diabetes/ACE/ARB/statin) and non-exposed patients, with adjustment for main potential confounding variables. RESULTS Temporal artery biopsies was less often positive in patients with pre-existing diabetes (relative risk 0.24; 95% CI: 0.069-0.81). Patients who developed diabetes after diagnosis had a lower relapse-free survival (adjusted hazards ratio [HR] 0.28; 95% CI: 0.095-0.84). Patients taking ARBs prior to diagnosis were more likely to successfully discontinue glucocorticoids without a flare in the following 3 months (adjusted HR 2.46; 95% CI: 1.2-5.3). Clinical complications and relapse rates did not differ between patients on statin therapy or not. CONCLUSION Diabetic patients with GCA were less likely to have a positive TAB, and more likely to relapse. ARB therapy prior to diagnosis showed an association with success at discontinuing glucocorticoids. Statin therapy did not alter the clinical presentation or course of GCA.
Collapse
Affiliation(s)
- Jocelyn Ma
- Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Nader Khalidi
- Division of Rheumatology, St Joseph's Healthcare, McMaster University, Hamilton, Canada
| | - Ola Wierzbicki
- Division of Rheumatology, St Joseph's Healthcare, McMaster University, Hamilton, Canada
| | - Abdallah Alqutami
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.,Division of Rheumatology, King Fahad Hospital, Jeddah, Saudi Arabia
| | - George Ioannidis
- Division of Rheumatology, St Joseph's Healthcare, McMaster University, Hamilton, Canada
| | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
32
|
Muratore F, Boiardi L, Restuccia G, Cavazza A, Catanoso M, Macchioni P, Spaggiari L, Cimino L, Aldigeri R, Pipitone N, Fontana A, Casali M, Croci S, Salvarani C. Relapses and long-term remission in large vessel giant cell arteritis in northern Italy: Characteristics and predictors in a long-term follow-up study. Semin Arthritis Rheum 2020; 50:549-558. [DOI: 10.1016/j.semarthrit.2020.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/18/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022]
|
33
|
Cid MC, Ríos-Garcés R, Terrades-García N, Espígol-Frigolé G. Treatment of giant-cell arteritis: from broad spectrum immunosuppressive agents to targeted therapies. Rheumatology (Oxford) 2020; 59:iii17-iii27. [DOI: 10.1093/rheumatology/kez645] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/26/2019] [Indexed: 12/13/2022] Open
Abstract
Abstract
For decades, the treatment of GCA has relied on glucocorticoids. Work over the past two decades has supported a modest efficacy of MTX but no clear benefit from anti-TNF-based therapies. More recently, the therapeutic armamentarium for GCA has expanded. The availability of agents targeting specific cytokines, cytokine receptors or signalling pathways, along with a better, although still limited, understanding of the immunopathology of GCA, are opening further therapeutic possibilities. Blocking IL-6 receptor with tocilizumab has been effective in maintaining remission and reducing glucocorticoid exposure and tocilizumab has been approved for the treatment of GCA. However, nearly half of the patients do not benefit from tocilizumab and additional options need to be investigated. This review focuses on standard therapeutic approaches and on targeted therapies that have been or are currently under investigation.
Collapse
Affiliation(s)
- Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona. Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Roberto Ríos-Garcés
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona. Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Nekane Terrades-García
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona. Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona. Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| |
Collapse
|
34
|
|
35
|
Monti S, Águeda AF, Luqmani RA, Buttgereit F, Cid M, Dejaco C, Mahr A, Ponte C, Salvarani C, Schmidt W, Hellmich B. Systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis: focus on giant cell arteritis. RMD Open 2019; 5:e001003. [PMID: 31673411 PMCID: PMC6803016 DOI: 10.1136/rmdopen-2019-001003] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/10/2019] [Accepted: 08/17/2019] [Indexed: 12/13/2022] Open
Abstract
Objectives To analyse the current evidence for the management of large vessel vasculitis (LVV) to inform the 2018 update of the EULAR recommendations. Methods Two systematic literature reviews (SLRs) dealing with diagnosis/monitoring and treatment strategies for LVV, respectively, were performed. Medline, Embase and Cochrane databases were searched from inception to 31 December 2017. Evidence on imaging was excluded as recently published in dedicated EULAR recommendations. This paper focuses on the data relevant to giant cell arteritis (GCA). Results We identified 287 eligible articles (122 studies focused on diagnosis/monitoring, 165 on treatment). The implementation of a fast-track approach to diagnosis significantly lowers the risk of permanent visual loss compared with historical cohorts (level of evidence, LoE 2b). Reliable diagnostic or prognostic biomarkers for GCA are still not available (LoE 3b).The SLR confirms the efficacy of prompt initiation of glucocorticoids (GC). There is no high-quality evidence on the most appropriate starting dose, route of administration, tapering and duration of GC (LoE 4). Patients with GCA are at increased risk of dose-dependent GC-related adverse events (LoE 3b). The addition of methotrexate or tocilizumab reduces relapse rates and GC requirements (LoE 1b). There is no consistent evidence that initiating antiplatelet agents at diagnosis would prevent future ischaemic events (LoE 2a). There is little evidence to guide monitoring of patients with GCA. Conclusions Results from two SLRs identified novel evidence on the management of GCA to guide the 2018 update of the EULAR recommendations on the management of LVV.
Collapse
Affiliation(s)
- Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Ana F Águeda
- Rheumatology, Baixo Vouga Hospital Centre Agueda Unit, Agueda, Portugal
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Frank Buttgereit
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Maria Cid
- Vasculitis Research Unit, Hospital Clinic; Institute d'Investiacions Biomèdiques August pi I Sunyer, University of Barcelona, Barcelona, Spain
| | - Christian Dejaco
- Rheumatology; South Tyrol Health Trust, Gesundheitsbezirk Bruneck, Brunico, Italy.,Rheumatology, University of Graz, Graz, Austria
| | - Alfred Mahr
- Internal Medicine, Université Paris Diderot Institut Saint Louis, Paris, France
| | - Cristina Ponte
- Rheumatology, Hospital de Santa Marta, Lisboa, Portugal.,Rheumatology Research Unit, University of Lisbon Institute of Molecular Medicine, Lisboa, Portugal
| | - Carlo Salvarani
- Rheumatology, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Modena, Italy
| | - Wolfgang Schmidt
- Klinik für Innere Medizin, Rheumatologie und Klinische Immunologie Berlin-Buch, Immanuel Krankenhaus Berlin Standort Berlin-Wannsee, Berlin, Germany
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitis-Zentrum Süd, Medius Kliniken, Universitatsklinikum Tubingen, Tubingen, Germany
| |
Collapse
|
36
|
Hellmich B, Agueda A, Monti S, Buttgereit F, de Boysson H, Brouwer E, Cassie R, Cid MC, Dasgupta B, Dejaco C, Hatemi G, Hollinger N, Mahr A, Mollan SP, Mukhtyar C, Ponte C, Salvarani C, Sivakumar R, Tian X, Tomasson G, Turesson C, Schmidt W, Villiger PM, Watts R, Young C, Luqmani RA. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis 2019; 79:19-30. [PMID: 31270110 DOI: 10.1136/annrheumdis-2019-215672] [Citation(s) in RCA: 545] [Impact Index Per Article: 109.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Since the publication of the European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis (LVV) in 2009, several relevant randomised clinical trials and cohort analyses have been published, which have the potential to change clinical care and therefore supporting the need to update the original recommendations. METHODS Using EULAR standardised operating procedures for EULAR-endorsed recommendations, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 13 countries. We modified existing recommendations and created new recommendations. RESULTS Three overarching principles and 10 recommendations were formulated. We recommend that a suspected diagnosis of LVV should be confirmed by imaging or histology. High dose glucocorticoid therapy (40-60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active giant cell arteritis (GCA) or Takayasu arteritis (TAK). We recommend adjunctive therapy in selected patients with GCA (refractory or relapsing disease, presence of an increased risk for glucocorticoid-related adverse events or complications) using tocilizumab. Methotrexate may be used as an alternative. Non-biological glucocorticoid-sparing agents should be given in combination with glucocorticoids in all patients with TAK and biological agents may be used in refractory or relapsing patients. We no longer recommend the routine use of antiplatelet or anticoagulant therapy for treatment of LVV unless it is indicated for other reasons. CONCLUSIONS We have updated the recommendations for the management of LVV to facilitate the translation of current scientific evidence and expert opinion into better management and improved outcome of patients in clinical practice.
Collapse
Affiliation(s)
- Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim-Teck, Germany
| | - Ana Agueda
- Rheumatology Department, Centro Hospitalar do Baixo Vouga E.P.E, Aveiro, Portugal
| | - Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Frank Buttgereit
- Department of Rheumatology and Immunology, University Hospital Charité, Berlin, Germany
| | - Hubert de Boysson
- Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen, Basse-Normandie, France
| | - Elisabeth Brouwer
- Rheumatology and Clinical Immunology, UMCG, Groningen, The Netherlands
| | | | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Christian Dejaco
- Rheumatology, Medical University Graz, Graz, Austria.,Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Nicole Hollinger
- Department of Internal Medicine, Rheumatology and Immunology, Medus Klinken, Karl-Albrechts-Universität Tübingen, Kirchheim-Teck, Germany
| | - Alfred Mahr
- Hospital Saint-Louis, University Paris Diderot, Paris, France
| | - Susan P Mollan
- Ophthalmology, University Hospitals Birmingham, Birmingham, UK.,Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Chetan Mukhtyar
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Cristina Ponte
- Rheumatology, Hospital de Santa Maria - CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal.,Rheumatology Research Unit; Instituto de Medicina Molecular, Instituto de Medicina Molecular, Lisboa, Portugal
| | | | - Rajappa Sivakumar
- Stroke and Neurocritical Care, GLB Hospitals and Acute Stroke Centers, Chennai, India
| | - Xinping Tian
- Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | | | - Carl Turesson
- Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - Wolfgang Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Krankenhaus Berlin, Berlin, Germany
| | - Peter M Villiger
- Rheumatology and Clinical Immunology / Allerg, University Hospital (Inselspital), Bern, Switzerland
| | - Richard Watts
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
| | | | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| |
Collapse
|
37
|
van Sleen Y, Sandovici M, Abdulahad WH, Bijzet J, van der Geest KSM, Boots AMH, Brouwer E. Markers of angiogenesis and macrophage products for predicting disease course and monitoring vascular inflammation in giant cell arteritis. Rheumatology (Oxford) 2019; 58:kez034. [PMID: 30805622 PMCID: PMC6649803 DOI: 10.1093/rheumatology/kez034] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/21/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE GCA, a systemic vasculitis, is characterized by an IL-6-dependent acute-phase response. This response is typically suppressed by treatment rendering CRP/ESR unreliable for monitoring vascular inflammation. Also, there are no accurate biomarkers predicting a non-favourable disease course. Here we investigated macrophage products and markers of angiogenesis as biomarkers for prognosis and monitoring of vascular inflammation. METHODS Forty-one newly diagnosed, glucocorticoid-naive GCA patients were prospectively followed for relapses and glucocorticoid requirement for a median of 30 months (range 0-71). Serum markers at baseline and during follow-up were compared with 33 age-matched healthy controls and 13 infection controls. Concentrations of IL-6, serum amyloid A, soluble CD163, calprotectin, YKL-40, VEGF, angiopoietin-1 and -2 and sTie2 were determined by ELISA/Luminex assay. RESULTS Serum concentrations of all markers, but not angiopoietin-1, were elevated in GCA patients at baseline when compared with healthy controls. High VEGF (P = 0.0025) and angiopoietin-1 (P = 0.0174) and low YKL-40 (P = 0.0369) levels at baseline were predictive of a short time to glucocorticoid-free remission. Elevated angiopoietin-2 levels were associated with an imminent relapse during treatment (P < 0.05). IL-6 correlated strongly with acute-phase markers and soluble CD163 but not with markers of angiogenesis, YKL-40 or calprotectin. Glucocorticoid treatment down-modulated all markers except for calprotectin and YKL-40. Tissue expression of markers in temporal arteries was confirmed. CONCLUSION Markers of angiogenesis at baseline and during treatment predict GCA disease course, suggesting utility in patient stratification for glucocorticoid-sparing therapy. Calprotectin and YKL-40 are candidate markers for monitoring vessel wall inflammation.
Collapse
Affiliation(s)
- Yannick van Sleen
- Vasculitis Expertise Center Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria Sandovici
- Vasculitis Expertise Center Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wayel H Abdulahad
- Vasculitis Expertise Center Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johan Bijzet
- Vasculitis Expertise Center Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kornelis S M van der Geest
- Vasculitis Expertise Center Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annemieke M H Boots
- Vasculitis Expertise Center Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth Brouwer
- Vasculitis Expertise Center Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
38
|
van der Geest KSM, Sandovici M, van Sleen Y, Sanders JS, Bos NA, Abdulahad WH, Stegeman CA, Heeringa P, Rutgers A, Kallenberg CGM, Boots AMH, Brouwer E. Review: What Is the Current Evidence for Disease Subsets in Giant Cell Arteritis? Arthritis Rheumatol 2018; 70:1366-1376. [PMID: 29648680 PMCID: PMC6175064 DOI: 10.1002/art.40520] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
Giant cell arteritis (GCA) is an autoimmune vasculitis affecting large and medium‐sized arteries. Ample evidence indicates that GCA is a heterogeneous disease in terms of symptoms, immune pathology, and response to treatment. In the current review, we discuss the evidence for disease subsets in GCA. We describe clinical and immunologic characteristics that may impact the risk of cranial ischemic symptoms, relapse rates, and long‐term glucocorticoid requirements in patients with GCA. In addition, we discuss both proven and putative immunologic targets for therapy in patients with GCA who have an unfavorable prognosis. Finally, we provide recommendations for further research on disease subsets in GCA.
Collapse
Affiliation(s)
| | - Maria Sandovici
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Yannick van Sleen
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Stephan Sanders
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Nicolaas A Bos
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Wayel H Abdulahad
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Coen A Stegeman
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Heeringa
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Abraham Rutgers
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Cees G M Kallenberg
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Annemieke M H Boots
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth Brouwer
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
39
|
Schirmer M, Muratore F, Salvarani C. Tocilizumab for the treatment of giant cell arteritis. Expert Rev Clin Immunol 2018; 14:339-349. [DOI: 10.1080/1744666x.2018.1468251] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Michael Schirmer
- Department of Internal Medicine, Clinic II, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Francesco Muratore
- Rheumatology Unit, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, and Università di Modena e Reggio Emilia, Modena, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, and Università di Modena e Reggio Emilia, Modena, Italy
| |
Collapse
|
40
|
A concise review of significantly modified serological biomarkers in giant cell arteritis, as detected by different methods. Autoimmun Rev 2018; 17:188-194. [DOI: 10.1016/j.autrev.2017.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
41
|
Prieto-González S, Terrades-García N, Corbera-Bellalta M, Planas-Rigol E, Miyabe C, Alba MA, Ponce A, Tavera-Bahillo I, Murgia G, Espígol-Frigolé G, Marco-Hernández J, Hernández-Rodríguez J, García-Martínez A, Unizony SH, Cid MC. Serum osteopontin: a biomarker of disease activity and predictor of relapsing course in patients with giant cell arteritis. Potential clinical usefulness in tocilizumab-treated patients. RMD Open 2017; 3:e000570. [PMID: 29299342 PMCID: PMC5743901 DOI: 10.1136/rmdopen-2017-000570] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/23/2017] [Accepted: 11/24/2017] [Indexed: 11/03/2022] Open
Abstract
Background Osteopontin (OPN) is a glycoprotein involved in Th1 and Th17 differentiation, tissue inflammation and remodelling. We explored the role of serum OPN (sOPN) as a biomarker in patients with giant cell arteritis (GCA). Methods sOPN was measured by immunoassay in 76 treatment-naïve patients with GCA and 25 age-matched and sex-matched controls. In 36 patients, a second measurement was performed after 1 year of glucocorticoid treatment. Baseline clinical and laboratory findings, as well as relapses and glucocorticoid requirements during follow-up, were prospectively recorded. sOPN and C reactive protein (CRP) were measured in 32 additional patients in remission treated with glucocorticoids or tocilizumab (interleukin 6 (IL-6) receptor antagonist). In cultured temporal arteries exposed and unexposed to tocilizumab, OPN mRNA expression and protein production were measured by reverse transcription polymerase chain reaction (RT-PCR) and immunoassay, respectively. Results sOPN concentration (ng/mL; mean±SD) was significantly elevated in patients with active disease (116.75±65.61) compared with controls (41.10±22.65; p<0.001). A significant decline in sOPN was observed in paired samples as patients entered disease remission (active disease 102.45±57.72, remission 46.47±23.49; p<0.001). sOPN correlated with serum IL-6 (r=0.55; p<0.001). Baseline sOPN concentrations were significantly higher in relapsing versus non-relapsing patients (relapsers 129.08±74.24, non-relapsers 90.63±41.02; p=0.03). OPN mRNA expression and protein production in cultured arteries were not significantly modified by tocilizumab. In tocilizumab-treated patients, CRP became undetectable, whereas sOPN was similar in patients in tocilizumab-maintained (51.91±36.25) or glucocorticoid-maintained remission (50.65±23.59; p=0.49). Conclusions sOPN is a marker of disease activity and a predictor of relapse in GCA. Since OPN is not exclusively IL-6-dependent, sOPN might be a suitable disease activity biomarker in tocilizumab-treated patients.
Collapse
Affiliation(s)
- Sergio Prieto-González
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Nekane Terrades-García
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Marc Corbera-Bellalta
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Ester Planas-Rigol
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Chie Miyabe
- Division of Rheumatology, Allergy and Immunology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marco A Alba
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Ariel Ponce
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Itziar Tavera-Bahillo
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Giuseppe Murgia
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Javier Marco-Hernández
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - José Hernández-Rodríguez
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Ana García-Martínez
- Department of Emergency Medicine, Hospital Clínic, University of Barcelona, IDIBAPS, CRB-CELLEX, Barcelona, Spain
| | - Sebastian H Unizony
- Division of Rheumatology, Allergy and Immunology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria C Cid
- Department of Autoimmune Diseases, Vasculitis Research Unit, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| |
Collapse
|
42
|
[Efficacy and tolerance of tocilizumab for corticosteroid sparing in giant cell arteritis and aortitis: Experience of Nimes University Hospital about eleven patients]. Rev Med Interne 2017; 39:78-83. [PMID: 29221884 DOI: 10.1016/j.revmed.2017.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 10/25/2017] [Accepted: 11/09/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Giant cell arteritis is a large-vessels vasculitis, which treatment consists in a slowly-tappered steroid-therapy. Immunosuppressive agents are sometimes used in case of steroid-dependance. We have conducted an observationnal retrospective study including patients treated with tocilizumab for a giant cell arteritis or an aortitis in the internal medicine department at the Nîmes University Hospital. RESULTS Eleven patients were included between 2011 and 2016, who had been treated only with prednisone. Tocilizumab was used because of steroid-dependance for nine patients, delirium under steroids for one patient and unefficiency of steroids for an other patient. Infusions of tocilizumab, administred monthly at 8mg/kg, led to clinical and biological remission for all patients. Consequently, prednisone was tappered under 10mg/d for ten patients after six months of treatment with tocilizumab. Eight cases of non-severe infection were reported; also two cases of dyslipidemia, one case of prurit and one case of moderate neutropenia. Two relapses were observed after the end of treatment, in patients treated with less than twelve infusions. CONCLUSION Tocilizumab could be efficient and well-tolerated in steroid-dependent giant cell arteritis and aortitis. The modalities of its use remain to be precised.
Collapse
|
43
|
Stone JH, Tuckwell K, Dimonaco S, Klearman M, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Schett G, Schulze-Koops H, Spiera R, Unizony SH, Collinson N. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med 2017; 377:317-328. [PMID: 28745999 DOI: 10.1056/nejmoa1613849] [Citation(s) in RCA: 755] [Impact Index Per Article: 107.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Giant-cell arteritis commonly relapses when glucocorticoids are tapered, and the prolonged use of glucocorticoids is associated with side effects. The effect of the interleukin-6 receptor alpha inhibitor tocilizumab on the rates of relapse during glucocorticoid tapering was studied in patients with giant-cell arteritis. METHODS In this 1-year trial, we randomly assigned 251 patients, in a 2:1:1:1 ratio, to receive subcutaneous tocilizumab (at a dose of 162 mg) weekly or every other week, combined with a 26-week prednisone taper, or placebo combined with a prednisone taper over a period of either 26 weeks or 52 weeks. The primary outcome was the rate of sustained glucocorticoid-free remission at week 52 in each tocilizumab group as compared with the rate in the placebo group that underwent the 26-week prednisone taper. The key secondary outcome was the rate of remission in each tocilizumab group as compared with the placebo group that underwent the 52-week prednisone taper. Dosing of prednisone and safety were also assessed. RESULTS Sustained remission at week 52 occurred in 56% of the patients treated with tocilizumab weekly and in 53% of those treated with tocilizumab every other week, as compared with 14% of those in the placebo group that underwent the 26-week prednisone taper and 18% of those in the placebo group that underwent the 52-week prednisone taper (P<0.001 for the comparisons of either active treatment with placebo). The cumulative median prednisone dose over the 52-week period was 1862 mg in each tocilizumab group, as compared with 3296 mg in the placebo group that underwent the 26-week taper (P<0.001 for both comparisons) and 3818 mg in the placebo group that underwent the 52-week taper (P<0.001 for both comparisons). Serious adverse events occurred in 15% of the patients in the group that received tocilizumab weekly, 14% of those in the group that received tocilizumab every other week, 22% of those in the placebo group that underwent the 26-week taper, and 25% of those in the placebo group that underwent the 52-week taper. Anterior ischemic optic neuropathy developed in one patient in the group that received tocilizumab every other week. CONCLUSIONS Tocilizumab, received weekly or every other week, combined with a 26-week prednisone taper was superior to either 26-week or 52-week prednisone tapering plus placebo with regard to sustained glucocorticoid-free remission in patients with giant-cell arteritis. Longer follow-up is necessary to determine the durability of remission and safety of tocilizumab. (Funded by F. Hoffmann-La Roche; ClinicalTrials.gov number, NCT01791153 .).
Collapse
Affiliation(s)
- John H Stone
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Katie Tuckwell
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Sophie Dimonaco
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Micki Klearman
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Martin Aringer
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Daniel Blockmans
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Elisabeth Brouwer
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Maria C Cid
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Bhaskar Dasgupta
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Juergen Rech
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Carlo Salvarani
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Georg Schett
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Hendrik Schulze-Koops
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Robert Spiera
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Sebastian H Unizony
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Neil Collinson
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| |
Collapse
|
44
|
O'Connor MB, O'Donovan N, Bond U, Phelan MJ. Successful treatment of Takayasu arteritis with rituximab as a first-line immunosuppressant. BMJ Case Rep 2017; 2017:bcr-2016-217313. [PMID: 28073870 DOI: 10.1136/bcr-2016-217313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Takayasu arteritis is a rare large vessel vasculitis which has traditionally been treated with high-dose steroids. There have been a small number of publications where biological agents have been used to manage refractory cases. To the authors knowledge, there are no publications using biological agents in combination with steroids as a first-line treatment in Takayasu arteritis. In this publication, we document the case of Takayasu arteritis, in a 39-year-old woman, where rituximab was used in combination with steroids as a first-line agent in the setting of poorly controlled bipolar affective disorder.
Collapse
Affiliation(s)
- Mortimer B O'Connor
- Department of Medicine, Mercy University Hospital, Cork, Ireland.,Department of Rheumatology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Neil O'Donovan
- Department of Radiology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Ursula Bond
- Department of Rheumatology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Mark J Phelan
- Department of Medicine, Mercy University Hospital, Cork, Ireland.,Department of Rheumatology, South Infirmary Victoria University Hospital, Cork, Ireland
| |
Collapse
|
45
|
Toussirot É, Régent A, Devauchelle-Pensec V, Saraux A, Puéchal X. Interleukin-6: a promising target for the treatment of polymyalgia rheumatica or giant cell arteritis? RMD Open 2016; 2:e000305. [PMID: 27738520 PMCID: PMC5013443 DOI: 10.1136/rmdopen-2016-000305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/11/2016] [Indexed: 11/18/2022] Open
Affiliation(s)
- Éric Toussirot
- Clinical Investigation Centre Biotherapy INSERM CIC-1431, University Hospital of Besançon, Besançon, France; Fédération Hospitalo-Universitaire INCREASE, University Hospital of Besançon, Besançon, France; Department of Rheumatology, University Hospital of Besançon, Besançon, France; Department of Therapeutics and UPRES EA 4266 « Agents Pathogènes et Inflammation», University of Bourgogne Franche-Comté, Besançon, France
| | - Alexis Régent
- Paris-Descartes University, Paris, France; Department of Internal Medicine, Centre de référence maladies auto-immunes et systémiques rares, Hôpital Cochin, AP-HP, Paris, France
| | | | - Alain Saraux
- Department of Rheumatology , University Hospital of Brest , Brest , France
| | - Xavier Puéchal
- Department of Internal Medicine , Centre de référence maladies auto-immunes et systémiques rares, Hôpital Cochin, AP-HP , Paris , France
| |
Collapse
|
46
|
|
47
|
Restuccia G, Boiardi L, Cavazza A, Catanoso M, Macchioni P, Muratore F, Soriano A, Cimino L, Aldigeri R, Crescentini F, Pipitone N, Salvarani C. Long-term remission in biopsy proven giant cell arteritis: A retrospective cohort study. J Autoimmun 2016; 77:39-44. [PMID: 27742223 DOI: 10.1016/j.jaut.2016.10.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/01/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the frequency of long-term remission after glucocorticoids (GCs) suspension in an Italian cohort of patients with biopsy-proven GCA and to identify factors that may predict long-term remission. METHODS We evaluated 131 patients with biopsy-proven transmural GCA diagnosed and followed up at the Rheumatology Unit of Reggio Emilia Hospital (Italy) for whom sufficient information was available from the time of diagnosis until at least 18 months of follow-up. Long-term remission was defined as complete clinical remission without elevation of inflammatory markers for at least one year after the GC withdrawal. RESULTS 73 patients (56%) experienced long-term remission. Disease flares were less frequently observed in patients with long-term remission compared to those without (p = 0.002). The cumulative doses of prednisone at 1 year and for the entire followup duration were significantly lower (p < 0.0001 for both parameters) in patients with long-term remission; similarly, the duration of prednisone treatment was also significantly lower (p < 0.0001). The presence of PMR at diagnosis (HR 0.46) was significantly negatively associated with long-term remission (p = 0.008), while hemoglobin levels (HR 1.48) were significantly positively associated (p < 0.0001). Patients with long-term remission were able to reach 10 mg/day and 5 mg/day of prednisone sooner than the patients without (p = 0.02 and p < 0.0001, respectively). CONCLUSION In our cohort of GCA patients around half of the patients were able to attain long-term remission. Recognition of findings which predict disease course may aid decisions regarding therapy.
Collapse
Affiliation(s)
- Giovanna Restuccia
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luigi Boiardi
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alberto Cavazza
- Operative Unit of Pathologic Anatomy, Department of Oncology and Advanced Technology, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Mariagrazia Catanoso
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Pierluigi Macchioni
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Francesco Muratore
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alessandra Soriano
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Cimino
- Ophthalmology Unit, Department of Surgery, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Raffaella Aldigeri
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Filippo Crescentini
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| |
Collapse
|
48
|
Dejaco C, Duftner C, Buttgereit F, Matteson EL, Dasgupta B. The spectrum of giant cell arteritis and polymyalgia rheumatica: revisiting the concept of the disease. Rheumatology (Oxford) 2016; 56:506-515. [DOI: 10.1093/rheumatology/kew273] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Indexed: 01/17/2023] Open
|
49
|
Restuccia G, Boiardi L, Cavazza A, Catanoso M, Macchioni P, Muratore F, Cimino L, Aldigeri R, Crescentini F, Pipitone N, Salvarani C. Flares in Biopsy-Proven Giant Cell Arteritis in Northern Italy: Characteristics and Predictors in a Long-Term Follow-Up Study. Medicine (Baltimore) 2016; 95:e3524. [PMID: 27175649 PMCID: PMC4902491 DOI: 10.1097/md.0000000000003524] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This study evaluated the frequency, timing, and characteristics of flares in a large cohort of Italian patients with biopsy-proven giant cell arteritis (GCA) and to identify factors at diagnosis able to predict the occurrence of flares. We evaluated 157 patients with biopsy-proven transmural GCA diagnosed and followed at the Rheumatology Unit of Reggio Emilia Hospital (Italy) for whom sufficient information was available from the time of diagnosis until at least 4 years of follow-up. Fifty-seven patients (36.5%) experienced ≥1 flares. Fifty-one (46.4%) of the 110 total flares (88 relapses and 22 recurrences) were experienced during the first 2 years after diagnosis. The majority of relapses occurred with doses of prednisone ≤ 10 mg/day (82.9%), whereas only 3.4% of relapses occurred for doses ≥ 25 mg/day. Polymyalgia rheumatica (46.5%) and cranial symptoms (41.9%) were the most frequent manifestations at the time of the first relapse. Cumulative prednisone dose during the first year and total cumulative prednisone dose were significantly higher in flaring patients compared with those without flares (7.8 ± 2.4 vs 6.7 ± 2.4 g, P = 0.02; 15.5 ± 8.9 vs 10.0 ± 9.2 g, P = 0.0001, respectively). The total duration of prednisone treatment was longer in flaring patients (58 ± 44 vs 30 ± 30 months, P = 0.0001).Patients with disease flares had at diagnosis more frequently systemic manifestations (P = 0.02) and fever ≥ 38°C (P = 0.02), significantly lower hemoglobin levels (P = 0.05), more frequent presence at temporal artery biopsy (TAB) specimens of giant cells (P = 0.04) and intraluminal acute thrombosis (P = 0.007), and more moderate/severe arterial inflammation (P = 0.009) compared with those without flares. In the multivariate model fever ≥ 38 °C (hazard ratio 2.14; 95% confidence interval, 1.06-4.32, P = 0.03) and the severity of inflammatory infiltrate (moderate/severe versus mild) (hazard ratio 5.41; 95% confidence interval, 1.64-17.87, P = 0.006) were significantly associated with an increased risk of flares. In conclusion, a flaring course is common in GCA and it is associated with prolonged GC requirements. Fever at diagnosis and severity of inflammation at TAB appear to predict the development of disease flares.
Collapse
Affiliation(s)
- Giovanna Restuccia
- From the Department of Internal Medicine, Rheumatology Unit (GR, LB, MC, PM, FM, FC, NP, CS); Department of Oncology and Advanced Technology (AC), Operative Unit of Pathologic Anatomy; Department of Surgery (LC), Ophthalmology Unit, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia; and Department of Clinical and Experimental Medicine (RA), University of Parma, Parma, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Hocevar A, Rotar Z, Jese R, Semrl SS, Pizem J, Hawlina M, Tomsic M. Do Early Diagnosis and Glucocorticoid Treatment Decrease the Risk of Permanent Visual Loss and Early Relapses in Giant Cell Arteritis: A Prospective Longitudinal Study. Medicine (Baltimore) 2016; 95:e3210. [PMID: 27057850 PMCID: PMC4998766 DOI: 10.1097/md.0000000000003210] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To determine the incidence of permanent visual loss (PVL) in giant cell arteritis (GCA) and the GCA relapse rate during glucocorticoid (GC) tapering.This prospective, longitudinal single secondary/tertiary rheumatology centre study was conducted between September 2011 and September 2014 in Slovenia. Predetermined clinical and laboratory tests were performed at 12, 24, 48, 96, and 144 weeks after diagnosis.Sixty-eight GCA patients (72.1% female), with a median (IQR) age of 73.2 (67.3-76.1) years and a symptom duration before the diagnosis of a median (IQR) 30 (14-70) days were included. Thirty-nine of 68 patients had symptoms for less than 31 days (14 (10-28) days-early GCA) and 29/68 for 31 days or longer (90 (60-120) days-late GCA). Four (5.9%) patients presented with PVL (1 early GCA). The median (IQR) follow-up was (IQR) 104 (53-126) weeks. GCA relapsed in 17/39 (43.6%) and 14/29 (48.3%) in early and late GCA, respectively. The median (IQR) time to the first relapse was 24.8 (13.6-46.5) weeks (early GCA 14 (13-34) weeks; late GCA 25 (22-48) weeks, P = 0.117), at the methyl-prednisolone dose of 6.0 (4.0-12.0) mg. The patients who relapsed had significantly higher levels of inflammation parameters at the baseline (including ESR, CRP, serum amyloid A, haptoglobin, and fibrinogen).An early GCA diagnosis and prompt GC treatment decreased the PVL rate in comparison to historic controls, but seem to have no impact on the frequency of relapses, which are predicted by the high baseline levels of the biomarkers of inflammation.
Collapse
Affiliation(s)
- Alojzija Hocevar
- From the Department of Rheumatology (AH, ZR, RJ, SSS, MT); Department of Ophthalmology (MH); University Medical Centre Ljubljana, Institute of Pathology (JP); Faculty of Medicine (MT), University of Ljubljana, Ljubljana, Slovenia; and Faculty of Mathematics, Natural Science and Information Technology (SSS), University of Primorska, Koper, Slovenia
| | | | | | | | | | | | | |
Collapse
|