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Bosch P, Espigol-Frigolé G, Cid MC, Mollan SP, Schmidt WA. Cranial involvement in giant cell arteritis. THE LANCET. RHEUMATOLOGY 2024; 6:e384-e396. [PMID: 38574747 DOI: 10.1016/s2665-9913(24)00024-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 04/06/2024]
Abstract
Since its first clinical description in 1890, extensive research has advanced our understanding of giant cell arteritis, leading to improvements in both diagnosis and management for affected patients. Imaging studies have shown that the disease frequently extends beyond the typical cranial arteries, also affecting large vessels such as the aorta and its proximal branches. Meanwhile, advances in comprehending the underlying pathophysiology of giant cell arteritis have given rise to numerous potential therapeutic agents, which aim to minimise the need for glucocorticoid treatment and prevent flares. Classification criteria for giant cell arteritis, as well as recommendations for management, imaging, and treat-to-target have been developed or updated in the last 5 years, and current research encompasses a broad spectrum covering basic, translational, and clinical research. In this Series paper, we aim to discuss the current understanding of giant cell arteritis with cranial manifestations, describe the clinical approach to this condition, and explore future directions in research and patient care.
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Affiliation(s)
- Philipp Bosch
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria.
| | - Georgina Espigol-Frigolé
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Insitut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Insitut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Wolfgang A Schmidt
- Department of Rheumatology, Immanuel Hospital Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
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Xu S, Jiemy WF, Brouwer E, Burgess JK, Heeringa P, van der Geest KSM, Alba-Rovira R, Corbera-Bellalta M, Boots AH, Cid MC, Sandovici M. Current evidence on the role of fibroblasts in large-vessel vasculitides: From pathogenesis to therapeutics. Autoimmun Rev 2024; 23:103574. [PMID: 38782083 DOI: 10.1016/j.autrev.2024.103574] [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: 03/11/2024] [Revised: 04/29/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024]
Abstract
Large-vessel vasculitides (LVV) comprise a group of chronic inflammatory diseases of the aorta and its major branches. The most common forms of LVV are giant cell arteritis (GCA) and Takayasu arteritis (TAK). Both GCA and TAK are characterized by granulomatous inflammation of the vessel wall accompanied by a maladaptive immune and vascular response that promotes vascular damage and remodeling. The inflammatory process in LVV starts in the adventitia where fibroblasts constitute the dominant cell population. Fibroblasts are traditionally recognized for synthesizing and renewing the extracellular matrix thereby being major players in maintenance of normal tissue architecture and in tissue repair. More recently, fibroblasts have emerged as a highly plastic cell population exerting various functions, including the regulation of local immune processes and organization of immune cells at the site of inflammation through production of cytokines, chemokines and growth factors as well as cell-cell interaction. In this review, we summarize and discuss the current knowledge on fibroblasts in LVV. Furthermore, we identify key questions that need to be addressed to fully understand the role of fibroblasts in the pathogenesis of LVV.
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Affiliation(s)
- Shuang Xu
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, the Netherlands
| | - William F Jiemy
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, the Netherlands
| | - Elisabeth Brouwer
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, the Netherlands
| | - Janette K Burgess
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, the Netherlands
| | - Peter Heeringa
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, the Netherlands
| | - Kornelis S M van der Geest
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, the Netherlands
| | - Roser Alba-Rovira
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marc Corbera-Bellalta
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Annemieke H Boots
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, the Netherlands
| | - Maria C Cid
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Maria Sandovici
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, the Netherlands.
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Howell TA, Matza LS, Stone JH, Gelinas D, Stone MN, Rao VTS, Phillips GA. Qualitative interviews to support development of a patient-reported companion measure to the Glucocorticoid Toxicity Index. J Neurol Sci 2024; 458:122907. [PMID: 38309251 DOI: 10.1016/j.jns.2024.122907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Glucocorticoids (GCs) are associated with multiple toxicities that have substantial impact on patients. We conducted qualitative interviews with patients to identify the toxicities that are most relevant from their perspective, with the goal of creating a patient-reported companion measure to the Glucocorticoid Toxicity Index (GTI), a clinician-facing instrument. METHODS Thirty-one patients with recent or current GC use participated in concept elicitation interviews. Participants received GC treatment for myasthenia gravis, chronic inflammatory demyelinating polyradiculoneuropathy, vasculitis, or systemic lupus erythematosus. Transcripts were coded following a thematic analysis approach. RESULTS Participants reported more than 100 toxicities they believed to be associated with their GC medications. Common toxicities included weight gain (87%), increased appetite (84%), insomnia/sleep problems (77%), cognitive impairment/brain fog (71%), easy bruising (68%), anxiety (65%), irritability/short temper (65%), and osteoporosis (39%). These toxicities often centered on self-esteem, neuropsychiatric effects, skin toxicities, and musculoskeletal function. They can be categorized into domains such emphasizing neuropsychiatric, metabolic/endocrine, musculoskeletal, and dermatological effects, highlighting aspects of GC toxicity that patients are uniquely positioned to appreciate and report. CONCLUSION Our results confirm that the toxicities associated with GCs are pervasive and diverse, with substantial impact on patients' lives. These data will be used to inform the development of a patient-reported outcome measure assessing GC toxicity. This patient-reported instrument will be designed to complement the clinician-reported GTI, facilitating a more detailed understanding of the nuances of change in GC toxicity.
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Affiliation(s)
| | - Louis S Matza
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
| | - Deborah Gelinas
- Health Economics and Outcomes Research, Argenx, Boston, MA, USA
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Nageswaran P, Ahmed S, Tahir H. Review of phase 2/3 trials in polymyalgia rheumatica and giant cell arteritis. Expert Opin Emerg Drugs 2024; 29:5-17. [PMID: 38180809 DOI: 10.1080/14728214.2024.2303093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/04/2024] [Indexed: 01/07/2024]
Abstract
INTRODUCTION GCA (giant cell arteritis) and PMR (polymyalgia rheumatica) are two overlapping inflammatory rheumatic conditions that are seen exclusively in older adults, sharing some common features. GCA is a clinical syndrome characterized by inflammation of the medium and large arteries, with both cranial and extracranial symptoms. PMR is a clinical syndrome characterized by stiffness in the neck, shoulder, and pelvic girdle muscles. Both are associated with constitutional symptoms. AREAS COVERED In this review, we assess the established and upcoming treatments for GCA and PMR. We review the current treatment landscape, completed trials, and upcoming trials in these conditions, to identify new and promising therapies. EXPERT OPINION Early use of glucocorticoids (GC) remains integral to the immediate management of PMR and GCA but being aware of patient co-morbidities that may influence treatment toxicity is paramount. As such GC sparing agents are required in the treatment of PMR. Currently there are limited treatment options available for PMR and GCA, and significant unmet needs remain. Newer mechanisms of action, and hence therapeutic options being studied include CD4 T cell co-stimulation blockade, IL-17 inhibition, IL-12/23 inhibition, GM-CSF inhibition, IL-1β inhibition, TNF-α antagonist and Jak inhibition, among others, which will be discussed in this review.
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Affiliation(s)
| | - Saad Ahmed
- Department of Rheumatology, East Suffolk and North Essex Foundation Trust, Colchester, UK
| | - Hasan Tahir
- Department of Rheumatology, Royal Free London NHS Trust, London, UK
- Department of Medicine, University College London, London, UK
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Lally L, Spiera R. Advances in the treatment of polymyalgia rheumatica and giant cell arteritis. Nat Rev Rheumatol 2024; 20:77-78. [PMID: 38191699 DOI: 10.1038/s41584-023-01069-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Affiliation(s)
- Lindsay Lally
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | - Robert Spiera
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA.
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Zeisbrich M, Thiel J, Venhoff N. The IL-17 pathway as a target in giant cell arteritis. Front Immunol 2024; 14:1199059. [PMID: 38299156 PMCID: PMC10828953 DOI: 10.3389/fimmu.2023.1199059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 12/15/2023] [Indexed: 02/02/2024] Open
Abstract
The network of IL-17 cytokines is considered a key component of autoimmune and inflammatory processes. Blocking IL-17 showed great success in psoriasis as well as psoriatic arthritis, and in patients with axial spondyloarthritis. Secukinumab is one of the approved IL-17A inhibitors for these diseases and is now routinely used. In giant cell arteritis, a large vessel vasculitis, there is accumulating evidence for a pathogenic role of IL-17 and Th17 cells, which are part of the CD4+ T-cell subset. Giant cell arteritis occurs in individuals over 50 years of age and many have relative contraindications to glucocorticoid therapy, which today still represents the mainstay therapy. Despite the approval of tocilizumab, which targets the IL-6 receptor, a high demand for glucocorticoid-sparing agents remains that combine the effective suppression of the acute inflammation observed in giant cell arteritis with a safety profile that matches the needs of an older patient population. The first results from a phase II proof-of-principle study (TitAIN) support an optimistic outlook on a potential new treatment option with secukinumab in giant cell arteritis.
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Affiliation(s)
- Markus Zeisbrich
- Department of Rheumatology and Clinical Immunology, Medical Center – University of Freiburg, Freiburg, Germany
| | - Jens Thiel
- Department of Rheumatology and Clinical Immunology, Medical Center – University of Freiburg, Freiburg, Germany
- Division of Rheumatology and Clinical Immunology, Medical University Graz, Graz, Austria
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center – University of Freiburg, Freiburg, Germany
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Kaushik S, Junek M, Putman M. Advocating for better trials in rheumatology. Rheumatology (Oxford) 2023; 62:3776-3777. [PMID: 37665753 DOI: 10.1093/rheumatology/kead459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/18/2023] [Indexed: 09/06/2023] Open
Affiliation(s)
- Sharanya Kaushik
- Bangalore Medical College and Research Institute, Bangalore, India
| | - Mats Junek
- McMaster University Faculty of Health Sciences, Division of Rheumatology, Hamilton, ON, Canada
| | - Michael Putman
- Medical College of Wisconsin, Department of Rheumatology, Milwaukee, WI, USA
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Unizony S, Matza MA, Jarvie A, O'Dea D, Fernandes AD, Stone JH. Treatment for giant cell arteritis with 8 weeks of prednisone in combination with tocilizumab: a single-arm, open-label, proof-of-concept study. THE LANCET. RHEUMATOLOGY 2023; 5:e736-e742. [PMID: 38251564 DOI: 10.1016/s2665-9913(23)00265-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Even after the approval of tocilizumab, substantial glucocorticoid exposure (usually ≥6 months) and toxicity continue to be important problems for patients with giant cell arteritis. We aimed to assess the outcomes of a group of patients with giant cell arteritis treated with tocilizumab in combination with 8 weeks of prednisone. METHODS This prospective, single arm, proof-of-concept study was conducted at Massachusetts General Hospital (Boston, MA, USA). Individuals aged 50 years or older who had new-onset or relapsing giant cell arteritis with active disease were eligible for inclusion. Participants received 12 months of tocilizumab 162 mg weekly subcutaneously in combination with 8 weeks of prednisone. The primary endpoint was sustained prednisone-free remission at week 52. Adverse events were also evaluated. This trial is registered with ClinicalTrials.gov (NCT03726749), and is complete. FINDINGS Between Nov 28, 2018, and Nov 2, 2020, we enrolled 30 patients (mean age 73·7 years [SD 8·1], 18 [60%] women and 12 [40%] men, 30 [100%] White race, 15 [50%] new-onset disease, 23 [77%] temporal artery biopsy-proven, 14 [47%] imaging-proven). The initial prednisone doses were 60 mg (n=7), 50 mg (n=1), 40 mg (n=7), 30 mg (n=6), and 20 mg (n=9). All patients entered remission within 4 weeks from baseline. 23 (77%) of 30 patients were in sustained prednisone-free remission at week 52 and seven (23%) patients relapsed, with a mean time to relapse of 15·8 weeks (SD 14·7). Overall, four (13%) participants developed a serious adverse event, including one related or probably related to prednisone exclusively, two related or probably related to tocilizumab exclusively, and one related or probably related to prednisone, tocilizumab, or both. Two of the non-responder patients stopped tocilizumab and withdrew from the study prematurely after having a second disease relapse. No cases of giant cell arteritis-related permanent vision loss occurred during the study. INTERPRETATION These results suggest that 12 months of tocilizumab in combination with 8 weeks of prednisone could induce and maintain remission in patients with giant cell arteritis. Confirmation of these findings in a randomised controlled trial is required. FUNDING Genentech.
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Affiliation(s)
- Sebastian Unizony
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mark A Matza
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam Jarvie
- Emory University School of Medicine, Atlanta, GA, USA
| | - David O'Dea
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ana D Fernandes
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Chu CQ. Advances and challenges in management of large vessel vasculitis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:188-195. [PMID: 38125643 PMCID: PMC10729599 DOI: 10.2478/rir-2023-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 05/20/2023] [Indexed: 12/23/2023]
Abstract
Glucocorticoids (GC) remains the mainstay for management of large vessel vasculitis (LVV). Recent introduction of interleukin-6 signaling blocker, tocilizumab has substantially changed the practice in management of patients with LVV, in particular, giant cell arteritis (GCA). Benefit of tocilizumab to patients with Takayasu arteritis (TAK) is supported by observational studies, but randomized clinical trials are lacking. Addition of tocilizumab enables reduction of the total amount of GC in patients with GCA, but GC burden remains high and to be further reduced. Ongoing studies aim at minimal use of GC or even GC-free. Tumor necrosis factor inhibitors appear to be beneficial to TAK despite their ineffectiveness to GCA. Randomized clinical trials are undergoing to target other inflammatory cytokines in both GCA and TAK. Janus kinase inhibitors alone or in combination with conventional disease modifying anti-rheumatic drugs showed promising results in treatment of TAK.
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Affiliation(s)
- Cong-Qiu Chu
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, PortlandOregon 97239USA
- Rheumatology Section, Veterans Affairs Portland Health Care System, PortlandOregon 97239USA
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Samson M, Bonnotte B. [What about the new ACR/EULAR classification criteria for giant cell arteritis?]. Rev Med Interne 2023; 44:391-393. [PMID: 37574223 DOI: 10.1016/j.revmed.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Affiliation(s)
- M Samson
- Service de médecine interne et immunologie clinique, centre de référence maladies rares « maladies auto-immunes et auto-inflammatoires systémiques rares de l'adulte » (MAIS), CHU de Dijon Bourgogne, 2, boulevard Mal-de-Lattre-de-Tassigny, 21000 Dijon, France; Inserm, EFS BFC, UMR1098, RIGHT Interactions greffon-hôte-tumeur/ingénierie cellulaire et génique, université de Bourgogne, Dijon, France.
| | - B Bonnotte
- Service de médecine interne et immunologie clinique, centre de référence maladies rares « maladies auto-immunes et auto-inflammatoires systémiques rares de l'adulte » (MAIS), CHU de Dijon Bourgogne, 2, boulevard Mal-de-Lattre-de-Tassigny, 21000 Dijon, France; Inserm, EFS BFC, UMR1098, RIGHT Interactions greffon-hôte-tumeur/ingénierie cellulaire et génique, université de Bourgogne, Dijon, France
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Rajeswaran T, Mackie SL. Game-changing therapies for people with giant cell arteritis? THE LANCET. RHEUMATOLOGY 2023; 5:e307-e308. [PMID: 38251595 DOI: 10.1016/s2665-9913(23)00126-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Thurkka Rajeswaran
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds LS7 4SA, UK; Leeds Teaching Hospitals NHS Trust, Leeds LS7 4SA, UK
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds LS7 4SA, UK; Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS7 4SA, UK; Leeds Teaching Hospitals NHS Trust, Leeds LS7 4SA, UK.
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