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Kang MK, Hong Y, Kim YH, Park HK, Kim SK, Sohn JH, Kim J, Kwon KH, Cho SJ. Diagnosis, Treatment, and Follow-Up of Giant-Cell Arteritis: A Retrospective Multicenter Study. J Clin Neurol 2024; 20:306-314. [PMID: 38627226 PMCID: PMC11076186 DOI: 10.3988/jcn.2023.0169] [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: 05/11/2023] [Revised: 10/29/2023] [Accepted: 11/22/2023] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND AND PURPOSE Giant-cell arteritis (GCA) is the most common type of vasculitis in the elderly and is associated with high risks of visual loss and recurrence. Owing to its rarity in Asian populations, the current clinical interventions for these patients are not well known. Here we aimed to characterize the current management status of patients with GCA using Korean multicenter data. METHODS This retrospective study analyzed medical records of patients with GCA at six Korean university hospitals from February 2009 to November 2022. GCA had originally been diagnosed based on the 1990 American College of Rheumatology (ACR) criteria, and cases were selected for inclusion in this study based on the 2022 ACR/European Alliance of Associations for Rheumatology criteria. We evaluated treatments, follow-up periods, and outcomes (relapse, remission, and adverse drug reactions) in patients with GCA with or without arteritic anterior ischemic optic neuropathy (AAION). RESULTS This study analyzed 18 patients with a median age of 75.5 years that included 12 females (66.7%). Seven patients (38.8%) had AAION. All patients initially received prednisolone treatment, while four (22.2%) underwent adjuvant treatment with methotrexate and azathioprine during prednisolone tapering. During the median follow-up of 3.5 months (interquartile range: 2.0-23.2 months), 4 patients (22.2%) had prednisolone-related adverse reactions, 2 (11.1%) relapsed, and 13 (72.3%) dropped out. Nine patients (50.0%) experienced remission, with this being sustained in four (36.4%). CONCLUSIONS This study observed high dropout rates and short follow-ups. Adverse effects of prednisolone were common, and relapses occurred in approximately one-tenth of Korean patients with GCA. Thus, optimizing GCA treatment necessitates regular monitoring and long-term follow-up.
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Affiliation(s)
- Mi-Kyoung Kang
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Yooha Hong
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Yoo Hwan Kim
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Soo-Kyoung Kim
- Department of Neurology, Gyeongsang National University College of Medicine and Gyeonsang National University Hospital, Jinju, Korea
| | - Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jiyoung Kim
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Ki-Han Kwon
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
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Rhee RL, Rebello R, Tamhankar MA, Banerjee S, Liu F, Cao Q, Kurtz R, Baker JF, Fan Z, Bhatt V, Amudala N, Chou S, Liang R, Sanchez M, Burke M, Desiderio L, Loevner LA, Morris JS, Merkel PA, Song JW. Combined Orbital and Cranial Vessel Wall Magnetic Resonance Imaging for the Assessment of Disease Activity in Giant Cell Arteritis. ACR Open Rheumatol 2024; 6:189-200. [PMID: 38265177 PMCID: PMC11016572 DOI: 10.1002/acr2.11649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/05/2023] [Accepted: 11/20/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE Acute visual impairment is the most feared complication of giant cell arteritis (GCA) but is challenging to predict. Magnetic resonance imaging (MRI) evaluates orbital pathology not visualized by an ophthalmologic examination. This study combined orbital and cranial vessel wall MRI to assess both orbital and cranial disease activity in patients with GCA, including patients without visual symptoms. METHODS Patients with suspected active GCA who underwent orbital and cranial vessel wall MRI were included. In 14 patients, repeat imaging over 12 months assessed sensitivity to change. Clinical diagnosis of ocular or nonocular GCA was determined by a rheumatologist and/or ophthalmologist. A radiologist masked to clinical data scored MRI enhancement of structures. RESULTS Sixty-four patients with suspected GCA were included: 25 (39%) received a clinical diagnosis of GCA, including 12 (19%) with ocular GCA. Orbital MRI enhancement was observed in 83% of patients with ocular GCA, 38% of patients with nonocular GCA, and 5% of patients with non-GCA. MRI had strong diagnostic performance for both any GCA and ocular GCA. Combining MRI with a funduscopic examination reached 100% sensitivity for ocular GCA. MRI enhancement significantly decreased after treatment (P < 0.01). CONCLUSION In GCA, MRI is a sensitive tool that comprehensively evaluates multiple cranial structures, including the orbits, which are the most concerning site of pathology. Orbital enhancement in patients without visual symptoms suggests that MRI may detect at-risk subclinical ocular disease in GCA. MRI scores decreased following treatment, suggesting scores reflect inflammation. Future studies are needed to determine if MRI can identify patients at low risk for blindness who may receive less glucocorticoid therapy.
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Affiliation(s)
| | - Ryan Rebello
- St Joseph's Hospital and McMaster UniversityHamiltonOntarioCanada
| | | | | | - Fang Liu
- University of PennsylvaniaPhiladelphia
| | - Quy Cao
- University of PennsylvaniaPhiladelphia
| | | | | | | | | | | | | | - Rui Liang
- University of PennsylvaniaPhiladelphia
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Bilton EJ, Mollan SP. Giant cell arteritis: reviewing the advancing diagnostics and management. Eye (Lond) 2023; 37:2365-2373. [PMID: 36788362 PMCID: PMC9927059 DOI: 10.1038/s41433-023-02433-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Giant Cell Arteritis (GCA) is well known to be a critical ischaemic disease that requires immediate medical recognition to initiate treatment and where one in five people still suffer visual loss. The immunopathophysiology has continued to be characterised, and the influencing of ageing in the development of GCA is beginning to be understood. Recent national and international guidelines have supported the directed use of cranial ultrasound to reduce diagnostic delay and improve clinical outcomes. Immediate high dose glucocorticoids remain the standard emergency treatment for GCA, with a number of targeted agents that have been shown in clinical trials to have superior clinical efficacy and steroid sparing effects. The aim of this review was to present the latest advances in GCA that have the potential to influence routine clinical practice.
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Affiliation(s)
- Edward J Bilton
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Transitional Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
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4
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Patel NJ, Jayne DRW, Merkel PA, Bekker P, Zhang Y, McDowell PJ, Johal J, Heaney LG, Murrell D, Stone MN, Yue H, Stone JH. The Glucocorticoid Toxicity Index-Metabolic Domains, an abridged version of the Glucocorticoid Toxicity Index: post-hoc analysis of data from the ADVOCATE trial. THE LANCET. RHEUMATOLOGY 2023; 5:e413-e421. [PMID: 38251552 DOI: 10.1016/s2665-9913(23)00131-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Quantifying glucocorticoid toxicity is crucial to efforts to reduce it. The Glucocorticoid Toxicity Index (GTI) measures toxicity effectively in clinical trials by calculating two scores: the cumulative worsening score (CWS) and the aggregate improvement score (AIS). However, in clinical practice, high patient volumes limit the time available for standardised assessments. We aimed to compare the GTI with an abbreviated version of the GTI, the GTI-Metabolic Domains (GTI-MD), which could help to address this issue by using data that are collected easily at routine visits and do not require additional effort from clinicians. METHODS We did a post-hoc analysis of data from ADVOCATE, a randomised, double-blind, double-dummy, phase 3 trial in which avacopan replaced a standard prednisone taper in patients with antineutrophil cytoplasmic antibody-associated vasculitis. We calculated the cumulative worsening score (CWS) and aggregate improvement score (AIS) for each domain of the GTI-MD-comprising the BMI, glucose tolerance, blood pressure, and lipid metabolism domains of the GTI-to test its ability to differentiate the avacopan and prednisone groups by glucocorticoid toxicity. Data from two additional disease cohorts, one comprising patients with asthma and the other comprising patients with autoimmune blistering disease, constituted the validation set. FINDINGS Complete data were available for 321 (97%) of the 330 participants comprising the intention-to-treat population in the ADVOCATE trial at week 13, and 307 (93%) at week 26; data from these individuals were included in our post-hoc analysis. In ADVOCATE, 98 (59%) of 166 participants in the avacopan group were men and 68 (41%) were women, 88 (54%) of 164 in the prednisone group were men and 76 (46%) were women; the mean age of participants was 61·2 years [SD 14·6] in the avacopan group and 60·5 years [14·5] in the prednisone group. The validation cohort included 159 patients (89 with glucocorticoid-dependent asthma, of whom 40 [45%] were men and 49 [55%] were women, and 70 with autoimmune blistering disease of the skin, of whom 30 [43%] were men and 40 [57%] were women). The Spearman's rank correlation coefficient in ADVOCATE for the GTI-MD CWS with the GTI CWS for the treatment groups combined was 0·78 (95% CI 0·75-0·81; p<0·0001). The corresponding correlation for the AIS was 0·73 (0·69-0·77, p<0·0001). The GTI-MD distinguished the groups by glucocorticoid toxicity at both 13 weeks and 26 weeks. The mean GTI-MD CWS was lower in the avacopan group than in the prednisone group, consistent with less toxicity (15·9 vs 23·0 at 13 weeks [p=0·0010]; 26·7 vs 31·7 at 26 weeks [p=0·0092]). The GTI-MD AIS values were also consistent with less toxicity in the avacopan group (2·5 vs 13·0 at 13 weeks [p=0·0003], 4·4 vs 10·1 at 26 weeks [p=0·027]). A GTI-MD score of 0 corresponded to a low likelihood of toxicity in the other GTI domains. In the validation set, the Spearman's rank correlation coefficient for the GTI-MD CWS with the GTI CWS was 0·61 (95% CI 0·50-0·70; p<0·0001) and the corresponding correlation for the AIS was 0·58 (0·47-0·68; p<0·0001). INTERPRETATION The GTI-MD correlates well with the full GTI and could be incorporated readily into routine clinic workflows without additional input from the clinician. Using the GTI-MD on the background of electronic medical records systems could help clinicians to monitor glucocorticoid toxicity longitudinally, with the goals of preventing the burden of chronic, treatment-related harms and reducing long-term costs to health systems. FUNDING ChemoCentryx.
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Affiliation(s)
- Naomi J Patel
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Yuqing Zhang
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - P Jane McDowell
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Joslin Johal
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Liam G Heaney
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Dedee Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | | | | | - John H Stone
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA.
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Esen I, Arends S, Dalsgaard Nielsen B, Therkildsen P, Hansen I, van 't Ende A, Heeringa P, Boots A, Hauge E, Brouwer E, van Sleen Y. Metabolic features and glucocorticoid-induced comorbidities in patients with giant cell arteritis and polymyalgia rheumatica in a Dutch and Danish cohort. RMD Open 2023; 9:rmdopen-2022-002640. [PMID: 36631159 PMCID: PMC9835962 DOI: 10.1136/rmdopen-2022-002640] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are age-associated inflammatory diseases that frequently overlap. Both diseases require long-term treatment with glucocorticoids (GCs), often associated with comorbidities. Previous population-based cohort studies reported that an unhealthier metabolic profile might prevent the development of GCA. Here, we report metabolic features before start of treatment and during treatment in patients with GCA and PMR. METHODS In the Dutch GCA/PMR/SENEX (GPS) cohort, we analysed metabolic features and prevalence of comorbidities (type 2 diabetes, hypercholesterolaemia, hypertension, obesity and cataract) in treatment-naïve patients with GCA (n=50) and PMR (n=42), and compared those with the population-based Lifelines cohort (n=91). To compare our findings in the GPS cohort, we included data from patients with GCA (n=52) and PMR (n=25) from the Aarhus cohort. Laboratory measurements, comorbidities and GC use were recorded for up to 5 years in the GPS cohort. RESULTS Glycated haemoglobin levels tended to be higher in treatment-naïve patients with GCA, whereas high-density lipoprotein, low-density lipoprotein and cholesterol levels were lower compared with the Lifelines population. Data from the Aarhus cohort were aligned with the findings obtained in the GPS cohort. Presence of comorbidities at baseline did not predict long-term GC requirement. The incidence of diabetes, obesity and cataract among patients with GCA increased upon initiation of GC treatment. CONCLUSION Data from the GCA and PMR cohorts imply a metabolic dysregulation in treatment-naïve patients with GCA, but not in patients with PMR. Treatment with GCs led to the rise of comorbidities and an unhealthier metabolic profile, stressing the need for prednisone-sparing targeted treatment in these vulnerable patients.
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Affiliation(s)
- Idil Esen
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Suzanne Arends
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Berit Dalsgaard Nielsen
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Philip Therkildsen
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Ib Hansen
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Anna van 't Ende
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Heeringa
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands
| | - Annemieke Boots
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ellen Hauge
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
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Low C, Conway R. Metabolic bone health considerations in giant cell arteritis and polymyalgia rheumatica. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057221147385. [PMID: 36627860 PMCID: PMC9837290 DOI: 10.1177/17455057221147385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two common systemic inflammatory conditions with a combined lifetime risk of approximately 3.5% in women and 1.5% in men. They are intimately associated with the aging process, virtually never occurring prior to 50 years of age and becoming more common over time. The reasons for this are unclear, but likely relate in part to factors related to aging of the immune system. The treatment of both GCA and PMR is traditionally based on glucocorticoids, frequently requiring a prolonged treatment course over long periods of time. Other medications are belatedly entering our treatment armamentarium, but their exact place in treatment algorithms remains to be fully defined and it is likely glucocorticoids will remain a cornerstone of our treatment in GCA and PMR for the foreseeable future. As a result, people with GCA and PMR will continue to be exposed to a significant cumulative glucocorticoid burden with all of the attendant potential adverse events, including osteoporosis. The predominantly post-menopausal female population that most commonly develops PMR and GCA is also the population that is most affected by osteoporosis. Given the risk of glucocorticoid-induced osteoporosis and subsequent fragility fractures, a planned treatment approach from glucocorticoid initiation is needed in these conditions. For the majority of patients, this will entail ensuring sufficiency of calcium and vitamin D as well as antiresorptive treatments. In this article, we discuss considerations around optimisation of metabolic bone health in GCA and PMR.
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Affiliation(s)
- Candice Low
- Department of Rheumatology, St. James’s Hospital, Dublin, Ireland
| | - Richard Conway
- Department of Rheumatology, St. James’s Hospital, Dublin, Ireland,Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland,Richard Conway, Department of Clinical Medicine, Trinity College Dublin, Dublin 2, Ireland.
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Patel NJ, Fu X, Zhang Y, Stone JH. Baseline Glucocorticoid-Related Toxicity Scores in Giant Cell Arteritis: A Post Hoc Analysis of the GiACTA Trial. ACR Open Rheumatol 2023; 5:51-58. [PMID: 36604825 PMCID: PMC9837393 DOI: 10.1002/acr2.11520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 11/23/2022] [Accepted: 12/09/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Giant cell arteritis (GCA) requires treatment with high-dose, long-term glucocorticoids (GCs). A score assessing and quantifying patients' baseline GC-related toxicity may be important to risk stratification and therapeutic decision-making in patients initiating immunosuppression. METHODS We analyzed patients with GCA enrolled in the Tocilizumab in Giant Cell Arteritis (GiACTA) trial. Baseline GC-related toxicity scores for 12 domains were derived from the Glucocorticoid Toxicity Index using baseline medications, medical history, vital signs, and laboratory values. The 12 domains examined were body mass index, glucose tolerance, blood pressure, lipid metabolism, bone and/or tendon, GC myopathy, skin toxicity, neuropsychiatric effects, infection, ocular toxicity, gastrointestinal injury, and adrenal function. Potential scores ranged from 0 to 538. We compared differences between those with newly diagnosed versus relapsing disease at baseline. RESULTS A total of 250 patients were included (75% female, mean age 69 years). The mean ± SD baseline GC-related toxicity score among all patients was 111.3 ± 53.2. The domains that contributed most to the overall scores were blood pressure (24.0% of the overall score), followed by glucose tolerance (22.6%) and neuropsychiatric effects (15.9%). Baseline GC-related toxicity scores were higher in patients with relapsing disease compared with those with newly diagnosed disease (mean of 122.5 vs. 98.9; P < 0.001). The body mass index and neuropsychiatric domain scores were significantly higher in patients with relapsing disease. CONCLUSION This approach to the assessment of baseline GC-related toxicity distinguished patients with relapsing GCA from those with newly diagnosed disease. Baseline GC-related toxicity scores may be useful in therapeutic decision-making for patients beginning immunosuppressive treatment.
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Kramarič J, Rotar Ž, Tomšič M, Hočevar A. Performance of leflunomide as a steroid-sparing agent in giant cell arteritis: A single-center, open-label study. Front Med (Lausanne) 2022; 9:1069013. [PMID: 36438047 PMCID: PMC9684628 DOI: 10.3389/fmed.2022.1069013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/25/2022] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The management of giant cell arteritis (GCA) remains challenging and many patients require prolonged glucocorticoid treatment due to high disease relapse rates. We aimed to evaluate the role of leflunomide as a steroid-sparing agent in GCA. METHODS This prospective open-label study included patients diagnosed with GCA between July 2014 and August 2020 and followed them for 96 weeks. At the time of diagnosis all patients received treatment following a predefined glucocorticoid regimen. At week 12 of follow-up, 10 mg of leflunomide per day was recommended as an adjunctive therapy. The decision to start with leflunomide treatment was patient-dependent. Follow-up visits were performed adhering to a predetermined protocol. The number of relapses, the cumulative glucocorticoid dose and treatment-related adverse events were recorded and compared between glucocorticoid-only and leflunomide groups. RESULTS Of the 215 GCA patients [67.6% female, median (IQR) age 74 (66-79) years], 151 (70.2%) received leflunomide at week 12 (leflunomide group); the others continued with glucocorticoids (glucocorticoid-only group). During the study 64/215 (29.8%) patients relapsed. Of the 51 patients who relapsed after 12 weeks, 22/151 patients (14.6%) and 29/64 patients (45.3%) were in the leflunomide and glucocorticoid-only group, respectively (p = 0.001; NNT 3.3 for leflunomide). Furthermore, 80/151 patients in the leflunomide group managed to stop glucocorticoids at week 48 [with relapses in 6/80 patients (7.5%)]. The cumulative glucocorticoid dose was lower in the leflunomide group (p = 0.009). CONCLUSION In our cohort, leflunomide safely and effectively reduced the GCA relapse rate and demonstrated a steroid-sparing effect in over three quarters of patients.
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Affiliation(s)
- Jelka Kramarič
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Žiga Rotar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Tomšič
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Goglin S, Chung SA. New developments in treatments for systemic vasculitis. Curr Opin Pharmacol 2022; 66:102270. [DOI: 10.1016/j.coph.2022.102270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022]
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de Boysson H, Barakat C, Dumont A, Boutemy J, Martin Silva N, Maigné G, Nguyen A, Lavergne A, Castan P, Gallou S, Sultan A, Deshayes S, Aouba A. Tolerance of glucocorticoids in giant cell arteritis: a study of patient-reported adverse events. Rheumatology (Oxford) 2022; 61:3567-3575. [PMID: 34919673 DOI: 10.1093/rheumatology/keab921] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess patients' self-reported glucocorticoid (GC)-related adverse events (AEs) in a GCA population. METHODS A questionnaire was sent to the 100 patients most recently diagnosed with GCA in a tertiary centre. This questionnaire included open- and close-ended questions on the disease and GC effects. Eight primary AE areas were analysed: cardiovascular, metabolic, muscle, cognitive and psychologic, bone, cutaneous and hairiness, infective and visual complications. Including derivative subitems from preceding areas, a total of 18 GC-related AEs were analysed separately and according to GC duration. RESULTS Ninety patients were analysed and 89 (99%) reported at least one GC-related AE [median 6 (range 1-11)]. Cognitive and psychological changes, primarily insomnia (72%), affected 90% of patients. Cutaneous changes and muscle loss affected 70% of patients, with frequent impairment of physical autonomy (P = 0.007) associated with this event. Metabolic issues, especially weight gain (40%) and diabetes mellitus (20%), affected 49% of patients. Conversely, vision troubles and bone fractures were mentioned by 42% and 9% of patients, respectively, and more frequently in patients who received GCs for >18 months (P = 0.01 and P = 0.007, respectively). Cardiovascular changes and infections affected 30% and 26% of patients, respectively. CONCLUSION This real-life study of GC tolerance assessed using a self-evaluation provides pragmatic and updated data reminding us that GC tolerance remains more noteworthy than ever. This study suggests carefully monitoring GC-related AEs during follow-up and encourages GC-sparing strategies in some patients.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | - Clivia Barakat
- Department of Internal Medicine, Caen University Hospital
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | | | | | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital
| | - Alexandre Nguyen
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | | | - Paul Castan
- Department of Internal Medicine, Caen University Hospital
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital
| | - Audrey Sultan
- Department of Internal Medicine, Caen University Hospital
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
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Mok CC. Osteoporosis in Rheumatic Diseases. JOURNAL OF CLINICAL RHEUMATOLOGY AND IMMUNOLOGY 2022. [DOI: 10.1142/s2661341722300026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The risk of osteoporosis and fragility fracture is increased in patients with autoimmune rheumatic diseases. Although the use of glucocorticoids is the major contributing factor, inflammation mediated by cytokines and growth factors and other medications, including the biologic and targeted disease-modifying antirheumatic drugs, also play important roles in bone remodeling. Pro-inflammatory cytokines such as IL-1, IL-6, IL-17, and TNF[Formula: see text] increase RANK expression and promote osteoclast activity while inhibiting osteoblast-mediated bone formation through the Dickkopf-1 pathway. Certain autoantibodies stimulate differentiation of the osteoclasts, resulting in localized bone resorption. This article covers the prevalence and risk factors for osteoporosis in patients with common rheumatic diseases and the role of inflammatory cytokines and other clinical factors. Controlling disease-related inflammation and optimizing the diagnostic and therapeutic instrumentation is needed to reduce fragility fractures in patients with rheumatic diseases.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
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12
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The Glucocorticoid Toxicity Index:Measuring Change in Glucocorticoid Toxicity Over Time. Semin Arthritis Rheum 2022; 55:152010. [DOI: 10.1016/j.semarthrit.2022.152010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 12/27/2022]
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13
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Cid MC, Unizony SH, Blockmans D, Brouwer E, Dagna L, Dasgupta B, Hellmich B, Molloy E, Salvarani C, Trapnell BC, Warrington KJ, Wicks I, Samant M, Zhou T, Pupim L, Paolini JF. Efficacy and safety of mavrilimumab in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial. Ann Rheum Dis 2022; 81:653-661. [PMID: 35264321 PMCID: PMC8995812 DOI: 10.1136/annrheumdis-2021-221865] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/04/2022] [Indexed: 01/11/2023]
Abstract
Objectives Granulocyte-macrophage colony-stimulating factor (GM-CSF) is implicated in pathogenesis of giant cell arteritis. We evaluated the efficacy of the GM-CSF receptor antagonist mavrilimumab in maintaining disease remission. Methods This phase 2, double-blind, placebo-controlled trial enrolled patients with biopsy-confirmed or imaging-confirmed giant cell arteritis in 50 centres (North America, Europe, Australia). Active disease within 6 weeks of baseline was required for inclusion. Patients in glucocorticoid-induced remission were randomly assigned (3:2 ratio) to mavrilimumab 150 mg or placebo injected subcutaneously every 2 weeks. Both groups received a 26-week prednisone taper. The primary outcome was time to adjudicated flare by week 26. A prespecified secondary efficacy outcome was sustained remission at week 26 by Kaplan-Meier estimation. Safety was also assessed. Results Of 42 mavrilimumab recipients, flare occurred in 19% (n=8). Of 28 placebo recipients, flare occurred in 46% (n=13). Median time to flare (primary outcome) was 25.1 weeks in the placebo group, but the median was not reached in the mavrilimumab group (HR 0.38; 95% CI 0.15 to 0.92; p=0.026). Sustained remission at week 26 was 83% for mavrilimumab and 50% for placebo recipients (p=0.0038). Adverse events occurred in 78.6% (n=33) of mavrilimumab and 89.3% (n=25) of placebo recipients. No deaths or vision loss occurred in either group. Conclusions Mavrilimumab plus 26 weeks of prednisone was superior to placebo plus 26 weeks of prednisone for time to flare by week 26 and sustained remission in patients with giant cell arteritis. Longer treatment is needed to determine response durability and quantify the glucocorticoid-sparing potential of mavrilimumab. Trial registration number ClinicalTrials.gov number: NCT03827018, Europe (EUdraCT number: 2018-001003-36), and Australia (CT-2018-CTN-01 865-1).
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Affiliation(s)
- Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona. University of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Sebastian H Unizony
- Vasculitis and Glomerulonephritis Center, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel Blockmans
- Clinical department of General Internal Medicine Department, Research Department of Microbiology and Immunology, Laboratory of Clinical Infectious and Inflammatory Disorders, Katholieke Universiteit Leuven Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Elisabeth Brouwer
- Rheumatology and Clinical Immunology, Universitair Medisch Centrum Groningen afdeling Reumatologie & Klinische Immunologie, Groningen, The Netherlands
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milano, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Bhaskar Dasgupta
- Rheumatology, Mid & South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Basildon, UK
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatolgie und Immunologie, Medius KLINIKEN gemeinnutzige GmbH, Kirchheim unter Teck, Germany
| | - Eamonn Molloy
- Bone and Joint Unit, Saint Vincent's University Hospital, Dublin, Ireland
| | - Carlo Salvarani
- Unit of Rheumatology, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Department of Surgery, Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, Universita degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Bruce C Trapnell
- Translational Pulmonary Science Center, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | - Ian Wicks
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia.,Rheumatology Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Manoj Samant
- Kiniksa Pharmaceuticals Corp, Lexington, Massachusetts, USA
| | - Teresa Zhou
- Kiniksa Pharmaceuticals Corp, Lexington, Massachusetts, USA
| | - Lara Pupim
- Kiniksa Pharmaceuticals Corp, Lexington, Massachusetts, USA
| | - John F Paolini
- Kiniksa Pharmaceuticals Corp, Lexington, Massachusetts, USA
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14
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Impact of Glucocorticoid Cumulative Doses in a Real-Life Cohort of Patients Affected by Giant Cell Arteritis. J Clin Med 2022; 11:jcm11041034. [PMID: 35207305 PMCID: PMC8875204 DOI: 10.3390/jcm11041034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 12/14/2022] Open
Abstract
Objectives: To describe the impact of cumulative glucocorticoid (GC) doses on related adverse events (AEs) in giant cell arteritis (GCA) in a real-life setting. Methods: The medical charts of the last 139 consecutive GCA patients followed in a tertiary centre were retrospectively analysed. The cumulative GC doses were calculated, and the main GC-related AEs were collected during the follow-up. Results: After a median follow-up duration of 35.6 (2–111) months, the median cumulative GC dose in the 139 patients was 9184 (1770–24,640) mg, and 131 patients (94%) presented at least one GC-related AE. Infections (63%) were the most frequently reported GC-related AE, followed by metabolic events (63%), including weight gain in 51% of them. Cardiovascular and neuropsychiatric events occurred in 51% and 47% of patients, respectively. Osteoporotic fractures, muscular involvement, digestive events, geriatric deterioration, skin fragility, ophthalmologic complications and hypokalaemia were reported in <35% of patients. Cardiovascular events (p = 0.01), osteoporotic fractures (p = 0.004), cataract occurrence (p = 0.03), weight gain (p = 0.04) and infections (p = 0.01) were significantly associated with GC cumulative doses > 9 g. Longer GC durations were associated with cataract occurrence (p = 0.01), weight gain (p = 0.03) and all-grade infections (p = 0.048), especially herpes zoster occurrence (p = 0.003). Neuropsychiatric and metabolic events appeared within the first months after GC introduction, whereas herpes zoster recurred, and most cardiovascular AEs emerged after 1 year. Geriatric events, especially osteoporotic fractures, occurred 2 years after GC introduction. Conclusion: This study highlights how frequent GC-related AEs are and the impact of prolonged GC and cumulative doses.
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Box CD, Cronin O, Hauser B. The Impact of High Dose Glucocorticoids on Bone Health and Fracture Risk in Systemic Vasculitides. Front Endocrinol (Lausanne) 2022; 13:806361. [PMID: 35250864 PMCID: PMC8889574 DOI: 10.3389/fendo.2022.806361] [Citation(s) in RCA: 1] [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] [Received: 10/31/2021] [Accepted: 01/07/2022] [Indexed: 12/29/2022] Open
Abstract
Systemic vasculitides are a range of conditions characterized by inflammation of blood vessels which may manifest as single organ or life-threatening multisystem disease. The treatment of systemic vasculitis varies depending on the specific disease but historically has involved initial treatment with high dose glucocorticoids alone or in conjunction with other immunosuppressive agents. Prolonged glucocorticoid treatment is frequently required as maintenance treatment. Patients with small and large vessel vasculitis are at increased risk of fracture. Osteoporosis may occur due to intrinsic factors such as chronic inflammation, impaired renal function and to a large extent due to pharmacological therapy with high dose glucocorticoid or combination treatments. This review will outline the known mechanism of bone loss in vasculitis and will summarize factors attributing to fracture risk in different types of vasculitis. Osteoporosis treatment with specific consideration for patients with vasculitis will be discussed. The use of glucocorticoid sparing immunosuppressive agents in the treatment of systemic vasculitis is a significant area of ongoing research. Adjunctive treatments are used to reduce cumulative doses of glucocorticoids and therefore may significantly decrease the associated fracture risk in patients with vasculitis. Lastly, we will highlight the many unknowns in the relation between systemic vasculitis, its treatment and bone health and will outline key research priorities for this field.
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Affiliation(s)
| | - Owen Cronin
- Department of Rheumatology, Bon Secours Hospital Cork, Cork, Ireland
- School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Barbara Hauser,
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16
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de Boysson H, Barakat C, Dumont A, Boutemy J, Martin Silva N, Maigné G, Nguyen A, Lavergne A, Castan P, Gallou S, Sultan A, Deshayes S, Aouba A. Impact of Giant Cell Arteritis and Its Treatment on the Patient's Quality of Life: A Single-Center Self-Assessment Study. Front Med (Lausanne) 2021; 8:777310. [PMID: 34859020 PMCID: PMC8631395 DOI: 10.3389/fmed.2021.777310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022] Open
Abstract
Little is known about the impact of giant cell arteritis (GCA) and its treatment on patient-reported physical, mental, and psychic quality of life (QoL). In this monocentric study, a questionnaire was sent to the 100 last patients diagnosed with GCA and followed-up in a single tertiary center. Their physical, mental and psychic status were self-assessed via close-ended questions, the 12-item short form survey (SF-12) and the 15-item geriatric depression scale (GDS). We aimed to identify parameters that were significantly associated with moderate-to-severe disability in both physical and mental domains. Ninety patients were analyzable. Moderate to severe physical disability was found in 41 (46%) patients. In multivariate analysis, walking difficulties (OR, 95% CI 8.42 [2.98–26.82], p <0.0001), muscle mass and strength reduction (OR, 95% CI 4.38 [1.37–16.31], p = 0.01) and age >80 (OR, 95% CI 4.21 [1.44–13.61], p = 0.008) were independent findings associated with moderate to severe physical disability. Moderate to severe mental disability was found in 30 (33%) patients. In multivariate analysis, depressive mood (OR, 95% CI 11.05 [3.78–37.11], p < 0.0001), felt adverse events attributable to glucocorticoids (OR, 95% CI 10.54 [1.65–213.1], p = 0.01) and use of immune-suppressants (OR, 95% CI 3.50 [1.14–11.87], p = 0.03) were independent findings associated with moderate to severe mental disability. There was a statistically significant negative correlation between GDS and the physical and/or mental disability scores (GDS and PCS-12: r = −0.33, p = 0.0013; GDS and MCS-12: r = −0.36, p = 0.0005). In conclusion, this study identified via a self-assessment of patients with GCA some medical and modifiable findings that significantly affect their physical and mental quality of life. A better knowledge of these factors may help improve the care of GCA patients.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Caen, France.,Caen University-Normandie, Caen, France
| | - Clivia Barakat
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital, Caen, France.,Caen University-Normandie, Caen, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | | | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Alexandre Nguyen
- Department of Internal Medicine, Caen University Hospital, Caen, France.,Caen University-Normandie, Caen, France
| | - Amandine Lavergne
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Paul Castan
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Audrey Sultan
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, Caen, France.,Caen University-Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Caen, France.,Caen University-Normandie, Caen, France
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17
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Antonini L, Dumont A, Lavergne A, Castan P, Barakat C, Gallou S, Sultan A, Deshayes S, Aouba A, de Boysson H. Real-life analysis of the causes of death in patients consecutively followed for giant cell arteritis in a French centre of expertise. Rheumatology (Oxford) 2021; 60:5080-5088. [PMID: 33693495 DOI: 10.1093/rheumatology/keab222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To describe, in a real-life setting, the direct causes of death in a cohort of consecutive patients with GCA. METHODS We retrospectively analysed the deaths that occurred in a cohort of 470 consecutive GCA patients from a centre of expertise between January 2000 and December 2019. Among the 120 patients who died, we retrieved data from the medical files of 101 patients. RESULTS Cardiovascular events were the dominant cause of death (n = 41, 41%) followed by infections (n = 22, 22%), geriatric situations (i.e. falls or senile deterioration; n = 17, 17%) and cancers (n = 15, 15%). Patients in each of these four groups were compared with the other deceased patients pooled together. Patients who died from cardiovascular events were more frequently male (46 vs 27%; P = 0.04) with a past history of coronary artery disease (29 vs 8%; P = 0.006). Patients who died from infections mostly had ongoing glucocorticoid treatment (82 vs 53%; P = 0.02) with higher cumulative doses (13 994 vs 9150 mg; P = 0.03). Patients who died from geriatric causes more frequently had osteoporosis (56 vs 17%; P = 0.0009) and had mostly discontinued glucocorticoid treatment (76 vs 33%; P = 0.001). The predictive factors of death in multivariate analysis were a history of coronary disease [hazard ratio (HR) 2.39; 95% CI 1.27, 4.21; P = 0.008], strokes at GCA diagnosis (HR 2.54; 95% CI 1.05, 5.24; P = 0.04), any infection during follow-up (HR 1.93; 95% CI 1.24, 2.98; P = 0.004) and fever at GCA diagnosis (HR 1.99; 95% CI 1.16, 3.28; P = 0.01). CONCLUSION Our study provides real-life insight on the cause-specific mortality in GCA patients.
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Affiliation(s)
- Luca Antonini
- Department of Internal Medicine, Caen University Hospital
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital.,Caen University-Normandie, Caen, France
| | | | - Paul Castan
- Department of Internal Medicine, Caen University Hospital
| | - Clivia Barakat
- Department of Internal Medicine, Caen University Hospital
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital
| | - Audrey Sultan
- Department of Internal Medicine, Caen University Hospital
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital.,Caen University-Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital.,Caen University-Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital.,Caen University-Normandie, Caen, France
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18
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Stone JH, Spotswood H, Unizony SH, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Spiera R, Bao M. New-onset versus relapsing giant cell arteritis treated with tocilizumab: 3-year results from a randomized controlled trial and extension. Rheumatology (Oxford) 2021; 61:2915-2922. [PMID: 34718434 PMCID: PMC9258533 DOI: 10.1093/rheumatology/keab780] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/12/2021] [Indexed: 01/09/2023] Open
Abstract
Objective Tocilizumab plus prednisone induces sustained glucocorticoid-free remission in patients with GCA. However, its long-term benefits in new-onset vs relapsing disease are uncertain, and the value of weekly vs every-other-week dosing has not been evaluated. Methods In Giant-Cell Arteritis Actemra (GiACTA) part 1, patients with new-onset or relapsing GCA received blinded tocilizumab weekly (TCZ QW), tocilizumab every-other-week (TCZ Q2W) or placebo for 52 weeks, with a prednisone taper. In part 2 (open-label), patients were treated at investigator discretion for 104 weeks. In this analysis, patients were evaluated according to their original treatment assignments, and outcomes beyond 52 weeks were assessed. Outcomes of interest included time to first flare and cumulative glucocorticoid exposure over 3 years according to baseline disease status. Results Part 1 enrolled 250 patients; 215 entered part 2. At baseline, 48% had new-onset disease and 52% had relapsing disease. In patients with new-onset and relapsing disease, the median time to first flare in the TCZ QW group was 577 and 575 days, respectively, vs 479 and 428 days with TCZ Q2W and 179 and 224 days with placebo; the median cumulative glucocorticoid dose was 3068 mg and 2191 mg with TCZ QW, 4080 mg and 2353 mg with TCZ Q2W, and 4639 mg and 6178 mg with placebo. Conclusion TCZ QW delayed the time to flare and reduced the cumulative glucocorticoid dose in patients with relapsing GCA and new-onset GCA. These data support initiating TCZ QW as part of first-line therapy in all patients with active GCA. Trial registration ClinicalTrials.gov, https://clinicaltrials.gov, NCT01791153.
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Affiliation(s)
- John H Stone
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston, MA, USA
| | | | - Sebastian H Unizony
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston, MA, USA
| | - Martin Aringer
- University Medical Center and Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Bhaskar Dasgupta
- Mid and South Essex NHS Foundation Trust, Southend University Hospital, Westcliff-on-Sea, United Kingdom
| | - Juergen Rech
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Carlo Salvarani
- Division of Rheumatology, AUSL IRCCS Reggio Emilia and University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Robert Spiera
- Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Min Bao
- Genentech, South San Francisco, CA, USA
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Functionally Heterogenous Macrophage Subsets in the Pathogenesis of Giant Cell Arteritis: Novel Targets for Disease Monitoring and Treatment. J Clin Med 2021; 10:jcm10214958. [PMID: 34768479 PMCID: PMC8585092 DOI: 10.3390/jcm10214958] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/20/2021] [Accepted: 10/23/2021] [Indexed: 12/19/2022] Open
Abstract
Giant cell arteritis (GCA) is a granulomatous large-vessel vasculitis that affects adults above 50 years of age. In GCA, circulating monocytes are recruited to the inflamed arteries. With cues from the vascular microenvironment, they differentiate into macrophages and play important roles in the pathogenesis of GCA via pro-inflammatory cytokine production and vascular remodeling. However, a deeper understanding of macrophage heterogeneity in GCA pathogenesis is needed to assist the development of novel diagnostic tools and targeted therapies. Here, we review the current knowledge on macrophage heterogeneity and diverse functions of macrophage subsets in the pathogenesis of GCA. We next discuss the possibility to exploit their heterogeneity as a source of novel biomarkers and as targets for nuclear imaging. Finally, we discuss novel macrophage-targeted therapies and future directions for targeting these cells in GCA.
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20
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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.
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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
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21
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[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.
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22
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Mohammad AJ, Turkiewicz A, Stamatis P, Turesson C, Englund M, Kiadaliri A. Trajectory of Healthcare Resource Utilization in Giant Cell Arteritis: A Population-based Study. J Rheumatol 2021; 48:1307-1313. [PMID: 33649063 DOI: 10.3899/jrheum.201131] [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: 02/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To estimate the healthcare resource utilization (HRU) in patients with giant cell arteritis (GCA) compared with the general population in southern Sweden. METHODS The study sample comprised 653 patients with GCA along with 10 age-, sex-, and residency area-matched reference subjects per patient. Data on public and private healthcare consultations and hospitalizations were extracted from the Skåne Healthcare Register. We assessed trajectories of primary and specialist healthcare visits, as well as hospital admissions and inpatient days from 3 years before through 5 years after the date of GCA diagnosis for patients and matched references. HRU was analyzed using generalized estimating equations adjusted for sex, age at the index year, calendar year of diagnosis, education, income, marital status, place of birth, and Charlson Comorbidity Index. Inverse probability weighting was used to account for dropout during study. RESULTS Patients with GCA had higher rates of healthcare visits than the references from the year before GCA diagnosis and up to 4 years after diagnosis, with the largest relative (rate ratio 1.85, 95% CI 1.68-2.05) and absolute (mean difference 10.2, 95% CI 8.1-12.3 visits per person) differences in the year of diagnosis. Similar trajectories were observed for primary and specialist healthcare visits. For hospital admissions and inpatient days, the differences disappeared 1 year after diagnosis date. CONCLUSION Patients with GCA utilized healthcare services at a significantly higher rate than the reference population. The increased utilization among Swedish patients with GCA was evident 1 year before and prolonged up to 4 years after diagnosis date.
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Affiliation(s)
- Aladdin J Mohammad
- A.J. Mohammad, MD, MPH, PhD, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden, and Department of Medicine, University of Cambridge, Cambridge, UK;
| | - Aleksandra Turkiewicz
- A. Turkiewicz, PhD, M. Englund, MD, PhD, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Pavlos Stamatis
- P. Stamatis, MD, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
| | - Carl Turesson
- C. Turesson, MD, PhD, Department of Clinical Sciences, Rheumatology, Lund University, Malmö, Sweden
| | - Martin Englund
- A. Turkiewicz, PhD, M. Englund, MD, PhD, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Ali Kiadaliri
- A. Kiadaliri, PhD, Clinical Epidemiology Unit, and Centre for Economic Demography, Lund University, Lund, Sweden
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Serling-Boyd N, Stone JH. Recent advances in the diagnosis and management of giant cell arteritis. Curr Opin Rheumatol 2021; 32:201-207. [PMID: 32168069 DOI: 10.1097/bor.0000000000000700] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Giant cell arteritis (GCA) has classically been diagnosed by temporal artery biopsy and treated with high-dose, long-term glucocorticoid therapy. Noninvasive imaging increasingly is employed for diagnostic purposes, but further studies are needed to determine the role of imaging in monitoring longitudinal disease activity. Glucocorticoid-sparing therapy mitigates the numerous adverse effects of glucocorticoids. This review addresses new developments in these areas. RECENT FINDINGS For diagnosis, when performed at a center with expertise in its use, temporal artery ultrasound has an estimated sensitivity and specificity of 78 and 79%, respectively. State-of-the-art time-of-flight positron emission tomography/computed tomography (PET/CT) has an estimated sensitivity and specificity of 71 and 91%, respectively. The sensitivities of both imaging modalities decrease following glucocorticoid administration. Tocilizumab is an effective glucocorticoid-sparing therapy, demonstrating sustained glucocorticoid-free remission in 56% of patients receiving weekly tocilizumab compared with 18% of patients receiving a 52-week prednisone taper. The traditional acute phase reactants are of no value in patients treated with interleukin-6 receptor (IL6-R) blockade, and thus, the development of new biomarkers is an important priority in the field. SUMMARY Noninvasive imaging techniques are increasingly used in the absence of temporal artery biopsy to confirm diagnostic suspicions of GCA. Tocilizumab reduces the cumulative glucocorticoid exposure and increases the rate of sustained remission. Ongoing efforts are directed towards new methods to identify disease flares.
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Affiliation(s)
- Naomi Serling-Boyd
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
Purpose of Review Guidelines for the management of large vessel vasculitides have been recently updated by several scientific societies. We have evaluated the current recommendations for treatment of giant cell arteritis (GCA) and Takayasu arteritis (TA) and addressed potential future therapeutic strategies. Recent Findings While glucocorticoids (GCs) remain the gold standard for induction of remission, many patients relapse and acquire high cumulative GC exposure. Thus, GC-sparing therapies such as methotrexate are recommended for selected patients with GCA and all patients with TA. Recent high-quality evidence shows that tocilizumab is an effective GC-sparing agent in GCA. Non-biologic and biologic immunomodulators also appear to have GC-sparing properties in TA. Summary Tocilizumab is now considered to be part of the standard treatment for GCA, particularly with relapsing disease, but questions on its use such as length of treatment and monitoring of disease activity remain open. High-quality evidence to guide treatment of TA is still lacking.
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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.
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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
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Brekke LK, Fevang BTS, Diamantopoulos AP, Assmus J, Esperø E, Gjesdal CG. Survival and death causes of patients with giant cell arteritis in Western Norway 1972-2012: a retrospective cohort study. Arthritis Res Ther 2019; 21:154. [PMID: 31238961 PMCID: PMC6593490 DOI: 10.1186/s13075-019-1945-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/14/2019] [Indexed: 11/25/2022] Open
Abstract
Background Our objective was to determine the survival and causes of death in a large and well-characterized cohort of patients with giant cell arteritis (GCA). Methods This is a hospital-based, retrospective, observational cohort study including patients diagnosed with GCA in Western Norway during 1972–2012. Patients were identified through computerized hospital records using the International Classification of Diseases (ICD)-coding system. Medical records were reviewed. Patients were randomly assigned population controls matched on age, sex, and geography from the Central Population Registry of Norway (CPRN). Date and cause of death were obtained from the Norwegian Cause of Death Registry (NCoDR). The survival was analyzed using Kaplan-Meier methods with the Gehan-Breslow test and the causes of death using cumulative incidence and Cox models for competing risks. Results We identified 881 cases with a clinical diagnosis of GCA of which 792 fulfilled the American College of Rheumatology (ACR) 1990 classification criteria. Among those fulfilling the ACR criteria, 528 were also biopsy-verified. Cases were matched with 2577 population controls. A total of 490 (56%) GCA patients and 1517 (59%) controls died during the study period. We found no difference in the overall survival of GCA patients compared to controls, p = 0.413. The most frequent underlying causes of death in both groups were diseases of the circulatory system followed by cancer. GCA patients had increased risk of dying of circulatory disease (HR 1.31, 95% CI 1.13–1.51, p < 0.001) but lower risk of dying of cancer (HR 0.56, 95% CI 0.42–0.73, p < 0.001) compared to population controls. Conclusions We found no difference in the overall survival of GCA patients compared to matched controls, but there were differences in the distribution of underlying death causes.
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Affiliation(s)
- L K Brekke
- Hospital for Rheumatic Diseases, Haugesund, Norway. .,Department of Clinical Science, University of Bergen, Bergen, Norway. .,Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease (BEaBIRD), Department of Rheumatology, Haukeland University Hospital, Bergen, Norway.
| | - B-T S Fevang
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease (BEaBIRD), Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | | | - J Assmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - E Esperø
- Hospital for Rheumatic Diseases, Haugesund, Norway
| | - C G Gjesdal
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease (BEaBIRD), Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
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Daumas A, Bichon A, Rioland C, Benyamine A, Berbis J, Ebbo M, Jarrot PA, Gayet S, Rossi P, Schleinitz N, Harle JR, Kaplanski G, Villani P, Granel B. [Characteristics of giant cell arteritis patients under and over 75-years-old: A comparative study on 164 patients]. Rev Med Interne 2018; 40:278-285. [PMID: 30573331 DOI: 10.1016/j.revmed.2018.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 11/02/2018] [Accepted: 11/11/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Giant cell arteritis (GCA) is the most common vasculitis of the elderly. In order to assess the impact of age at diagnosis, we compared the characteristics of patients of less than 75 years (<75 years), to those of the 75 years and over (≥75 years). PATIENTS AND METHODS We conducted a retrospective study on 164 patients with GCA diagnosed from 2005 to 2017. All patients had at least 3/5 of the ACR criteria and had a CT-scan at diagnosis. The mean age was of 73±9.6 years. The age was<75 years for 84 patients (59 women) and≥75 years for 80 patients (53 women). RESULTS Patients≥75 years had more cardiovascular underlying diseases (P=0.026), a higher rate of hypertension (P=0.005) and more ophthalmic complications (P=0.02). They had less large vessel involvement (P<0.001), showed lower biological inflammatory reaction and had a more frequently positive temporal artery histology (P=0.04). The oral initial dose of corticosteroids did not differ between the groups. Corticosteroids pulse therapy was more frequent in patients≥75 years (P=0.01). The frequency of anti-platelet agents use was similar in the two groups. Relapse rate, corticodependance and the rate of corticosteroids weaning were similar in both groups. CONCLUSION Patients≥75 years at diagnosis of GCA were at lower risk of aortitis but were more likely to suffer from ophthalmic complications and to receive corticosteroid pulse therapy.
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Affiliation(s)
- A Daumas
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, gériatrie et thérapeutique, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille (AP-HM), 264, rue Saint-Pierre, 13385 Marseille cedex 05, France.
| | - A Bichon
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, gériatrie et thérapeutique, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille (AP-HM), 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - C Rioland
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, gériatrie et thérapeutique, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille (AP-HM), 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - A Benyamine
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne et gériatrie, hôpital Nord, AP-HM, chemin des Bourrely, 13915 Marseille cedex 15, France
| | - J Berbis
- Aix-Marseille université, 13284 Marseille, France; EA 3279/laboratoire de santé publique évaluation des systèmes de soins et santé perçue, UFR médecine, 27, boulevard Jean Moulin, 13385 Marseille cedex 05, France
| | - M Ebbo
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, hôpital de la Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - P-A Jarrot
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, hôpital de la Conception, AP-HM, 147, boulevard Baille, 13385 Marseille cedex 05, France
| | - S Gayet
- Service de médecine interne, gériatrie et thérapeutique, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille (AP-HM), 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - P Rossi
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne et gériatrie, hôpital Nord, AP-HM, chemin des Bourrely, 13915 Marseille cedex 15, France
| | - N Schleinitz
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, hôpital de la Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - J-R Harle
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, hôpital de la Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - G Kaplanski
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, hôpital de la Conception, AP-HM, 147, boulevard Baille, 13385 Marseille cedex 05, France
| | - P Villani
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne, gériatrie et thérapeutique, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille (AP-HM), 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - B Granel
- Aix-Marseille université, 13284 Marseille, France; Service de médecine interne et gériatrie, hôpital Nord, AP-HM, chemin des Bourrely, 13915 Marseille cedex 15, France
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Macchioni P, Boiardi L, Muratore F, Restuccia G, Cavazza A, Pipitone N, Catanoso M, Mancuso P, Luberto F, Giorgi Rossi P, Salvarani C. Survival predictors in biopsy-proven giant cell arteritis: a northern Italian population-based study. Rheumatology (Oxford) 2018; 58:609-616. [DOI: 10.1093/rheumatology/key325] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/19/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
To evaluate the influence of disease-related findings and treatment outcomes on survival in a population-based cohort of Northern Italian patients with GCA.
Methods
A total of 281 patients with incident temporal artery biopsy (TAB)-proven GCA, diagnosed over a 26-year period (1986–2012) and living in the Reggio Emilia area, were retrospectively evaluated. We analysed clinical, imaging and laboratory findings at diagnosis, pathological patterns of TAB, CS treatment and therapeutic outcomes, and traditional cardiovascular risk factors as factors predictive of survival.
Results
Univariate analysis showed that increased mortality was associated with large vessel involvement at diagnosis [hazard ratio (HR) 5.84], while reduced mortality was associated with female sex (HR 0.66), PMR (HR 0.54), higher haemoglobin levels (HR 0.84) at diagnosis, long-term remission (HR 0.47) and inflammation limited to adventitia or to the adventitial vasa vasorum (HR 0.48) at TAB examination. Multivariate analysis confirmed the association between increased mortality and large vessel involvement (HR 5.14) at diagnosis, between reduced mortality and PMR (HR 0.57) at diagnosis and adventitial inflammation (HR 0.31) at TAB.
Conclusion
PMR at diagnosis and inflammation limited to the adventitia at TAB appear to identify subsets of patients with more benign disease, while large vessel involvement at diagnosis is associated with reduced survival.
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Affiliation(s)
- Pierluigi Macchioni
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Luigi Boiardi
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Francesco Muratore
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia, Italy
| | - Giovanna Restuccia
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Alberto Cavazza
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Mariagrazia Catanoso
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Pamela Mancuso
- Interinstitutional Epidemiology Unit, Azienda USL-IRCCS di Reggio Emilia (Local Health Authority), Reggio Emilia, Italy
| | - Ferdinando Luberto
- Interinstitutional Epidemiology Unit, Azienda USL-IRCCS di Reggio Emilia (Local Health Authority), Reggio Emilia, Italy
| | - Paolo Giorgi Rossi
- Interinstitutional Epidemiology Unit, Azienda USL-IRCCS di Reggio Emilia (Local Health Authority), Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia, Italy
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Smoking as a risk factor for giant cell arteritis: A systematic review and meta-analysis. Semin Arthritis Rheum 2018; 48:529-537. [PMID: 30093239 DOI: 10.1016/j.semarthrit.2018.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 07/01/2018] [Accepted: 07/02/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To investigate the association between smoking and giant cell arteritis (GCA). METHODS A systematic review was performed and meta-analysis conducted on observational studies that reported absolute numbers and/or statistical comparisons with 95% confidence intervals comparing smoking history and presence of GCA, among patients with GCA and non-GCA controls. Studies were reviewed in accordance with PRISMA guidelines. Point estimates and standard errors were extracted from individual studies and were combined by the generic inverse variance method of DerSimonian and Laird. A random-effects meta-analysis was performed. Statistical heterogeneity was assessed using the Cochran's Q test which was complemented with the I2 statistic. RESULTS The initial search yielded 3312 articles. Of these, thirteen studies (8 prospective and, 5 retrospective case-control studies) with unique cohorts were identified and included in the primary analysis (ever vs. never smoking history). Patients in the GCA cohort were more likely to have a history of smoking with an odds ratio of 1.19 (95% CI, 1.01-1.39). Considerable heterogeneity was present (I2 = 85%). Five of these studies included information on current smoking status. One additional study, which only reported current smoking status, was also included. The GCA cohort showed an association with current smoking with an odds ratio of 1.18 (95% CI, 1.01-1.38). CONCLUSION Our study demonstrated a statistically significant increased risk of GCA among both current and ever smokers compared to non-smokers.
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Kermani TA, Warrington KJ. Prognosis and monitoring of giant cell arteritis and associated complications. Expert Rev Clin Immunol 2018; 14:379-388. [DOI: 10.1080/1744666x.2018.1467758] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Tanaz A. Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Update on the epidemiology, risk factors, and outcomes of systemic vasculitides. Best Pract Res Clin Rheumatol 2018; 32:271-294. [DOI: 10.1016/j.berh.2018.09.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 02/07/2023]
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Lai LYH, Harris E, West RM, Mackie SL. Association between glucocorticoid therapy and incidence of diabetes mellitus in polymyalgia rheumatica and giant cell arteritis: a systematic review and meta-analysis. RMD Open 2018. [PMID: 29531778 PMCID: PMC5845432 DOI: 10.1136/rmdopen-2017-000521] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are almost always treated with glucocorticoids (GCs), but long-term GC use is associated with diabetes mellitus (DM). The absolute incidence of this complication in this patient group remains unclear. Objective To quantify the absolute risk of GC-induced DM in PMR and GCA from published literature. Methods We identified literature from inception to February 2017 reporting diabetes following exposure to oral GC in patients with PMR and/or GCA without pre-existing diabetes. A random-effects meta-analysis was performed to summarise the findings. Results 25 eligible publications were identified. In studies of patients with GCA, mean cumulative GC dose was almost 1.5 times higher than in studies of PMR (8.2 g vs 5.6 g), with slightly longer treatment duration and longer duration of follow-up (6.4 years vs 4.4 years). The incidence proportion (cumulative incidence) of patients who developed new-onset DM was 6% (95% CI 3% to 9%) for PMR and 13% (95% CI 9% to 17%) for GCA. Based on UK data on incidence rate of DM in the general population, the expected background incidence rate of DM over 4.4 years in patients with PMR and 6.4 years in patients with GCA (follow-up duration) would be 4.8% and 7.0%, respectively. Heterogeneity between studies was high (I2=79.1%), as there were differences in study designs, patient population, geographical locations and treatment. Little information on predictors of DM was found. Conclusion Our meta-analysis produced plausible estimates of DM incidence in patients with PMR and GCA, but there is insufficient published data to allow precise quantification of DM risk.
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Affiliation(s)
- Lana Yin Hui Lai
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Emma Harris
- Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sarah Louise Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Mollan SP, Horsburgh J, Dasgupta B. Profile of tocilizumab and its potential in the treatment of giant cell arteritis. Eye Brain 2018; 10:1-11. [PMID: 29416384 PMCID: PMC5790065 DOI: 10.2147/eb.s127812] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Giant cell arteritis (GCA) remains a medical emergency due to the threat of permanent sight loss. High-dose glucocorticoids (GCs) are effective in inducing remission in the majority of patients, however, relapses are common which lengthen GC therapy. GC toxicity remains a major morbidity in this group of patients, and conventional steroid-sparing therapies have not yet shown enough of a clinical benefit to change the standard of care. As the understanding of the underlying immunopathophysiology of GCA has increased, positive clinical observations have been made with the use of IL-6 receptor inhibitor therapies, such as tocilizumab (TCZ). This has led to prospective randomized control trials that have highlighted the safety and efficacy of TCZ in both new-onset and relapsing GCA.
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Affiliation(s)
- Susan Patricia Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham
- Institute of Metabolism and Systems Research, University of Birmingham
| | - John Horsburgh
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Southend-on-Sea, UK
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Paskins Z, Whittle R, Sultan AA, Muller S, Blagojevic-Bucknall M, Helliwell T, Hider S, Roddy E, Mallen C. Risk of fracture among patients with polymyalgia rheumatica and giant cell arteritis: a population-based study. BMC Med 2018; 16:4. [PMID: 29316928 PMCID: PMC5761155 DOI: 10.1186/s12916-017-0987-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/06/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Glucocorticoids are associated with increased fracture risk and are the mainstay of treatment in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). However, fracture risk in these conditions has not been previously quantified. The aim of this study was to quantify the risk of fracture among patients with PMR and GCA. METHODS A retrospective cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident diagnoses of PMR or GCA were separately identified from 1990-2004 and followed up until 2015. For each exposed individual, four age-, sex- and practice-matched controls were randomly selected. Incidence rates of fracture per 10,000 person-years were calculated for each disease group and hazard rates were compared to the unexposed using Cox regression models. RESULTS Overall, 12,136 and 2673 cases of PMR and GCA, respectively, were identified. The incidence rate of fracture was 148.05 (95% CI 141.16-155.28) in PMR and 147.15 (132.91-162.91) in GCA per 10,000 person-years. Risk of fracture was increased by 63% in PMR (adjusted hazard ratio 1.63, 95% CI 1.54-1.73) and 67% in GCA (1.67, 1.49-1.88) compared to the control populations. Fewer than 13% of glucocorticoid-treated cases were prescribed bisphosphonates. CONCLUSIONS This study reports, for the first time, a similar increase in fracture risk for patients with PMR and GCA. More needs to be done to improve adherence to guidelines to co-prescribe bisphosphonates. Further research needs to identify whether lower glucocorticoid starting doses and/or aggressive dose reduction reduces fracture risk.
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Affiliation(s)
- Zoe Paskins
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK. .,Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent Partnership Trust, Stoke-on-Trent, Staffordshire, UK.
| | - Rebecca Whittle
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Alyshah Abdul Sultan
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Sara Muller
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Milica Blagojevic-Bucknall
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Toby Helliwell
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Samantha Hider
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent Partnership Trust, Stoke-on-Trent, Staffordshire, UK
| | - Edward Roddy
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent Partnership Trust, Stoke-on-Trent, Staffordshire, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
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Babigumira JB, Li M, Boudreau DM, Best JH, Garrison LP. Estimating the Cost of Illness of Giant Cell Arteritis in the United States. Rheumatol Ther 2017; 4:111-119. [PMID: 28084585 PMCID: PMC5443721 DOI: 10.1007/s40744-017-0052-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Indexed: 01/30/2023] Open
Abstract
Introduction Giant cell arteritis (GCA) is a chronic vasculitis affecting approximately 230,000 Americans. Limited data exist on the healthcare resource utilization and costs attributable to GCA. The objective of this study was to estimate the cost of illness in patients with GCA in the US. Methods A cohort of patients with a new GCA diagnosis was identified from a large US claims database between 1 January 2008 and 31 December 2012. Newly diagnosed GCA patients were defined by two claims with GCA (ICD-9 446.5) as one of the listed diagnoses during the study period and no GCA diagnosis in the 12 months prior. Subjects without a GCA diagnosis were matched 5:1 to cases. One-year healthcare costs were compared among cases and controls, adjusting for covariates using generalized linear models. Results A cohort of 1293 GCA patients and 6465 controls was identified. The mean age was 73 years, and 69% were females. Mean Charlson Comorbidity Index was 1.9 for GCA patients and 1.0 for controls. Mean 1-year cost for GCA patients was $34,065 [standard deviation (SD) $52,411], and mean 1-year cost for controls was $12,890 (SD $37,345). After multivariate adjustment, the difference in 1-year cost between GCA patients and controls was $16,431 (95% CI $13,821–$19,041). Conclusions Patients with GCA experience substantially higher healthcare costs in the first year following diagnosis compared to patients without GCA. These results add to the limited evidence available to inform researchers, clinicians, and policymakers on the cost burden of GCA in the US. Funding Genentech Inc.
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Affiliation(s)
- Joseph B Babigumira
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, USA. .,Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Meng Li
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Denise M Boudreau
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | | | - Louis P Garrison
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, USA.,Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA
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