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Hysa E, Bond M, Ehlers L, Camellino D, Falzon L, Dejaco C, Buttgereit F, Aletaha D, Kerschbaumer A. Evidence on treat to target strategies in polymyalgia rheumatica and giant cell arteritis: a systematic literature review. Rheumatology (Oxford) 2024; 63:285-297. [PMID: 37672017 PMCID: PMC10836985 DOI: 10.1093/rheumatology/kead471] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/10/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES To inform an international task force about current evidence on Treat to Target (T2T) strategies in PMR and GCA. METHODS A systematic literature research (SLR) was conducted in Medline, EMBASE, Cochrane Library, clinicaltrials.gov from their inception date to May 2022, and in the EULAR/ACR abstract database (2019-2021). Randomised clinical trials (RCTs) and non-randomised interventional studies published in English and answering at least one of the eleven PICO questions on T2T strategies, treatment targets and outcomes, framed by the taskforce, were identified. Study selection process, data extraction and risk of bias assessment were conducted independently by two investigators. RESULTS Of 7809 screened abstracts, 397 were selected for detailed review and 76 manuscripts were finally included (31 RCTs, eight subgroup/exploratory analyses of RCTs and 37 non-randomised interventional studies). No study comparing a T2T strategy against standard of care was identified. In PMR RCTs, the most frequently applied outcomes concerned treatment (90.9% of RCTs), particularly the cumulative glucocorticoids (GC) dose and GC tapering, followed by clinical, laboratory and safety outcomes (63.3% each). Conversely, the most commonly reported outcomes in RCTs in GCA were prevention of relapses (72.2%), remission as well as treatment-related and safety outcomes (67.0% each). CONCLUSIONS This SLR provides evidence and highlights the knowledge gaps on T2T strategies in PMR and GCA, informing the task force developing T2T recommendations for these diseases.
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Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, San Martino Polyclinic, University of Genoa, Genoa, Italy
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Bruneck, Italy
| | - Lisa Ehlers
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dario Camellino
- Division of Rheumatology, Local Health Trust 3, Genoa, Italy
| | - Louise Falzon
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Bruneck, Italy
- Department of Rheumatology, Medical University Graz, Graz, Austria
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Hysa E, Vojinovic T, Gotelli E, Alessandri E, Pizzorni C, Paolino S, Sulli A, Smith V, Cutolo M. The dichotomy of glucocorticosteroid treatment in immune-inflammatory rheumatic diseases: an evidence-based perspective and insights from clinical practice. Reumatologia 2023; 61:283-293. [PMID: 37745141 PMCID: PMC10515127 DOI: 10.5114/reum/170845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives Glucocorticosteroids (GCs) are the most used anti-inflammatory and immunosuppressive drugs due to their effectiveness in managing pain and disease modification in many immune-inflammatory rheumatic diseases (IRDs). However, their use is limited because of adverse effects (AEs). Material and methods The authors analyzed recent studies, including randomized controlled trials (RCTs), observational, translational studies and systematic reviews, providing an in-depth viewpoint on the benefits and drawbacks of GC use in rheumatology. Results Glucocorticosteroids are essential in managing life-threatening autoimmune diseases and a cornerstone in many IRDs given their swift onset of action, necessary in flares. Several RCTs and meta-analyses have demonstrated that when administered over a long time and on a low-dose basis, GC can slow the radiographic progression in early rheumatoid arthritis (RA) patients by at least 50%, satisfying the conventional definition of a disease-modifying anti-rheumatic drug (DMARD). In the context of RA treatment, the use of modified-release prednisone formulations at night may offer the option of respecting circadian rhythms of both inflammatory response and HPA activation, thereby enabling low-dose GC administration to mitigate nocturnal inflammation and prolonged morning fatigue and joint stiffness. Long-term GC use should be individualized based on patient characteristics and minimized due to their potential AEs. Their chronic use, especially at medium/high dosages, might cause irreversible organ damage due to the burden of metabolic systemic effects and increased risk of infections. Many international guidelines recommend tapering/withdrawal of GCs in sustained remission. Treat-to-target (T2T) strategies are critical in setting targets for disease activity and reducing/discontinuing GCs once control is achieved. Conclusions Glucocorticosteroids' use in treating IRDs should be judicious, focused on minimizing use, tapering and discontinuing treatment, when possible, to improve long-term safety. Glucocorticosteroids remain part of many therapeutic regimens, particularly at low doses, and elderly RA patients, especially with associated chronic comorbidities, may benefit from long-term low-dose GC treatment. A personalized GC therapy is essential for optimal long-term outcomes.
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Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Tamara Vojinovic
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Elisa Alessandri
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Carmen Pizzorni
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Department of Rheumatology, University Hospital Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
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The Role of Tumor Necrosis Factor Alpha Antagonists (Anti TNF-α) in Personalized Treatment of Patients with Isolated Polymyalgia Rheumatica (PMR): Past and Possible Future Scenarios. J Pers Med 2022; 12:jpm12030329. [PMID: 35330329 PMCID: PMC8953282 DOI: 10.3390/jpm12030329] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Glucocorticoids (GCs) are the cornerstone of polymyalgia rheumatica (PMR) therapy, but their long-term use (as is usually necessary in PMR patients) can induce many adverse events. Alternatives have long been sought. The primary aim of our narrative review is to provide an overview about the use of anti-tumor necrosis factor alpha (TNF-α) drugs in patients with PMR, and discuss advantages and disadvantages. Materials and methods: we performed a non-systematic literature search (PRISMA protocol not followed) on PubMed and Medline (OVID interface). Results and Conclusions: only two anti TNF-α drugs have been prescribed to PMR patients: infliximab in 62 patients and etanercept in 28 patients. These drugs were normally used in addition to GCs when significant comorbidities and/or relapsing PMR were present; less commonly, they were used as first-line therapy. In general, they have been scarcely successful in patients with PMR. Indeed, randomized controlled trials did not confirm the positive results reported in case reports and/or case series. However, an administration schedule and study design different from those proposed in the past could favour new scenarios in the interest of PMR patients.
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Cutolo M, Paolino S, Gotelli E. Glucocorticoids in rheumatoid arthritis still on first line: the reasons. Expert Rev Clin Immunol 2021; 17:417-420. [PMID: 33706640 DOI: 10.1080/1744666x.2021.1903319] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, IRCCS San Martino Polyclinic, Genova, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, IRCCS San Martino Polyclinic, Genova, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, IRCCS San Martino Polyclinic, Genova, Italy
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Chen L, Wang X, Yin L, Ma K, Liu X. Effects of dexamethasone and gamma globulin combined with prednisone on the therapeutic effect and immune function of Henoch-Schonlein purpura nephritis in children. J Clin Lab Anal 2020; 35:e23580. [PMID: 33174652 PMCID: PMC7843260 DOI: 10.1002/jcla.23580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/22/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background Henoch‐Schonlein purpura nephritis (HSPN) is a serious complication of Henoch‐Schonlein purpura (HSP), which is usually treated with immunosuppressant and glucocorticoid. This study was designed to explore the effect of dexamethasone and gamma globulin combined with prednisone in the treatment of pediatric HSPN. Methods According to the treatment plan, 60 children treated with dexamethasone and gamma globulin were included in the control group, and the rest 55 children treated with dexamethasone and gamma globulin combined with prednisone were selected as the research group. The clinical manifestations, therapeutic effect, immune function, serum inflammatory factors, blood coagulation function, urine routine, renal function, and adverse reactions were compared between the two groups. Results The clinical manifestations of children in the research group were significantly better than those in the control group after treatment (P < .05). The total effective rate in the research group (94.55%) was markedly higher than that in the control group (76.67%) (P < .05). CD3+, CD4+, CD8+, IL‐10, PT, and APTT increased while CD4+/CD8+, IgA, IL‐8, TNF‐α, FIB, urine protein, urine red blood cell, Scr, and BUN decreased in both groups after treatment, and the changes of all the above indexes in the research group were significant than those in the control group (P < .05). The incidence of adverse reactions in the research group was remarkably superior to that in the control group (P < .05). Conclusion Dexamethasone and gamma globulin combined with prednisone can improve the immune function of children with HSPN and promote the recovery of renal function.
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Affiliation(s)
- Lei Chen
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Xinning Wang
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Liang Yin
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Kun Ma
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Xiangyang Liu
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
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Carvajal Alegria G, Boukhlal S, Cornec D, Devauchelle-Pensec V. The pathophysiology of polymyalgia rheumatica, small pieces of a big puzzle. Autoimmun Rev 2020; 19:102670. [DOI: 10.1016/j.autrev.2020.102670] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 11/16/2022]
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Abstract
Patients with untreated active giant cell arteritis (GCA) are at high risk of permanent vision loss. Therefore, treatment with glucocorticoids should be immediately initiated at an initial dose of 40-60 mg prednisolone equivalent dose per day. Once remission is achieved, the prednisolone dose should be reduced to 15-20 mg within 2-3 months and then to ≤5 mg per day within 1 year. Glucocorticoid-sparing treatment with tocilizumab or alternatively methotrexate should be initiated in patients with an increased risk or pre-existing complications of glucocorticoid treatment and patients with relapse. In polymyalgia rheumatica, prednisolone dosages of 15-25 mg/day are sufficient. After achieving remission, the dose should then be reduced to 10 mg within 4-8 weeks and then to 1 mg per month thereafter. Glucocorticoid-sparing treatment with methotrexate should be initiated in patients with an increased risk or existing complications of glucocorticoid treatment, relapse or increased glucocorticoid requirements.
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Camellino D, Giusti A, Girasole G, Bianchi G, Dejaco C. Pathogenesis, Diagnosis and Management of Polymyalgia Rheumatica. Drugs Aging 2020; 36:1015-1026. [PMID: 31493201 DOI: 10.1007/s40266-019-00705-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Polymyalgia rheumatica is an inflammatory rheumatic disease of the elderly characterised by pain and stiffness in the neck and pelvic girdle, and is the second most common inflammatory rheumatic condition in this age group, after rheumatoid arthritis. Polymyalgia rheumatica can occur independently or in association with giant cell arteritis, which is the most common form of primary vasculitis. The diagnosis of polymyalgia rheumatica is usually based on clinical presentation and increase of inflammatory markers. There are no pathognomonic findings that can confirm the diagnosis. However, different imaging techniques, especially ultrasonography, can assist in the identification of polymyalgia rheumatica. Glucocorticoids are the cornerstone of the treatment of polymyalgia rheumatica, but they might be associated with different adverse events. A subgroup of patients presents with a refractory disease course and, in these cases, adding methotrexate as a steroid-sparing agent could be useful. In this review, we summarise the latest findings regarding the pathogenesis, diagnosis and management of polymyalgia rheumatica and try to highlight the possible pitfalls, especially in elderly patients.
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Affiliation(s)
- Dario Camellino
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy.
- Autoimmunology Laboratory, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Andrea Giusti
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy
| | - Giuseppe Girasole
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy
| | - Gerolamo Bianchi
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy
| | - Christian Dejaco
- Dienst für Rheumatologie, Servizio di reumatologia, Südtiroler Sanitätsbetrieb, Azienda Sanitaria dell'Alto Adige, Krankenhaus Bruneck, Ospedale di Brunico, Bruneck, Italy
- Department of Rheumatology, Medical University Graz, Graz, Austria
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Miler E, Stapleton PP, Mapplebeck S, Mackerness C, Gayford D, Aung T, Wilson L, Schofield P, Dasgupta B. Circulating interleukin‐6 as a biomarker in a randomized controlled trial of modified‐release prednisone vs immediate‐release prednisolone, in newly diagnosed patients with giant cell arteritis. Int J Rheum Dis 2019; 22:1900-1904. [DOI: 10.1111/1756-185x.13702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/03/2019] [Accepted: 07/12/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Emma Miler
- Department of Biochemistry Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
| | - Philip P. Stapleton
- Department of Rheumatology Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
| | - Sarah Mapplebeck
- Department of Biochemistry Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
| | - Craig Mackerness
- Research & Development Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
| | - Dawn Gayford
- Department of Rheumatology Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
| | - Tin Aung
- Department of Rheumatology Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
| | - Lisa Wilson
- Department of Biochemistry Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
| | | | - Bhaskar Dasgupta
- Department of Rheumatology Southend University Hospital NHS Foundation Trust Westcliff‐on‐Sea UK
- Honorary Professorship at Essex University Westcliff‐on‐Sea UK
- Visiting Professorship at Anglia Ruskin University Westcliff‐on‐Sea UK
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10
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Treatment of polymyalgia rheumatica. Biochem Pharmacol 2019; 165:221-229. [DOI: 10.1016/j.bcp.2019.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 03/18/2019] [Indexed: 12/13/2022]
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González-Gay MA, Matteson EL, Castañeda S. Polymyalgia rheumatica. Lancet 2017; 390:1700-1712. [PMID: 28774422 DOI: 10.1016/s0140-6736(17)31825-1] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 12/12/2022]
Abstract
Polymyalgia rheumatica is an inflammatory disease that affects the shoulder, the pelvic girdles, and the neck, usually in individuals older than 50 years. Increases in acute phase reactants are typical of polymyalgia rheumatica. The disorder might present as an isolated condition or in association with giant cell arteritis. Several diseases, including inflammatory rheumatic and autoimmune diseases, infections, and malignancies can mimic polymyalgia rheumatica. Imaging techniques have identified the presence of bursitis in more than half of patients with active disease. Vascular uptake on PET scans is seen in some patients. A dose of 12·5-25·0 mg prednisolone daily or equivalent leads to rapid improvement of symptoms in most patients with isolated disease. However, relapses are common when prednisolone is tapered. Methotrexate might be used in patients who relapse. The effectiveness of biological therapies, such as anti-interleukin 6, in patients with polymyalgia rheumatica that is refractory to glucocorticoids requires further investigation. Most population-based studies indicate that mortality is not increased in patients with isolated disease.
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Affiliation(s)
- Miguel A González-Gay
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla, University of Cantabria, Santander, Spain; Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Eric L Matteson
- Division of Rheumatology and Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, Instituto de Investigación Sanitaria-Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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Giant cell arteritis and polymyalgia rheumatica: current challenges and opportunities. Nat Rev Rheumatol 2017; 13:578-592. [PMID: 28905861 DOI: 10.1038/nrrheum.2017.142] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The fields of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) have advanced rapidly, resulting in a new understanding of these diseases. Fast-track strategies and improved awareness programmes that prevent irreversible sight loss through early diagnosis and treatment are a notable advance. Ultrasonography and other imaging techniques have been introduced into routine clinical practice and there have been promising reports on the efficacy of biologic agents, particularly IL-6 antagonists such as tocilizumab, in treating these conditions. Along with these developments, which should improve outcomes in patients with GCA and PMR, new questions and unmet needs have emerged; future research should address which pathogenetic mechanisms contribute to the different phases and clinical phenotypes of GCA, what role imaging has in the early diagnosis and monitoring of GCA and PMR, and in which patients and phases of these diseases novel biologic drugs should be used. This article discusses the implications of recent developments in our understanding of GCA and PMR, as well as the unmet needs concerning epidemiology, pathogenesis, imaging and treatment of these diseases.
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Switching From Immediate-Release to Delayed-Release Prednisone in Moderate to Severe Rheumatoid Arthritis: A Practice-Based Clinical Study. Rheumatol Ther 2017; 4:363-374. [PMID: 28819927 PMCID: PMC5696287 DOI: 10.1007/s40744-017-0075-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Indexed: 01/20/2023] Open
Abstract
Introduction Rheumatoid arthritis (RA) produces debilitating morning stiffness. Exogenous glucocorticoids can help with these symptoms when timed appropriately. Bedtime dosing of delayed-release prednisone (DR-prednisone) matches the rise of inflammatory cytokines before awakening and can improve stiffness and other RA symptoms. A prospective open-label study was conducted in patients currently on stable doses of immediate-release prednisone (IR-prednisone) who were switched to DR-prednisone to analyze the incremental benefit of better timed and lower dose glucocorticoid therapy. Methods Twelve US sites enrolled patients with moderate-severe RA into a 12-week prospective study. Patients were switched from IR- to DR-prednisone while maintaining other existing background therapies. Change from baseline in morning stiffness severity, morning stiffness duration, swollen and tender joint counts (S-TJC), 28 joint disease activity score (DAS28), and patient/physician global assessment (PGA/PhGA), among others, were measured. Post-hoc analyses were performed on those completing 10 weeks of treatment and those with >60 min of morning stiffness at baseline. Results Fifty-six patients had at least one follow-up visit and were similar in demographics to previous controlled trials with DR-prednisone with regard to baseline age and DAS28-CRP but had lower morning stiffness and RA duration. DR-prednisone produced a trend toward lower morning stiffness severity and duration with a reduction in daily prednisone dose of almost 1 mg. Patients treated with DR-prednisone for ≥10 weeks demonstrated significant reductions in morning stiffness duration, SJC, TJC, DAS28-CRP, and PhGA (all p ≤ 0.04). Patients treated for ≥10 weeks with >60 min of baseline morning stiffness produced similar results in these measures as well as a 21% reduction in morning stiffness severity (p = 0.02). Conclusion Patients switched to DR-prednisone from IR-prednisone in this practice-based study maintained or improved their outcomes across a variety of domains, and results were comparable to previous controlled trials in which patients completed at least 10 weeks of treatment. Funding Horizon Pharma USA, Inc. Trial Registration ClinicalTrials.gov identifier, NCT02287610.
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Raine C, Stapleton PP, Merinopoulos D, Maw WW, Achilleos K, Gayford D, Mapplebeck S, Mackerness C, Schofield P, Dasgupta B. A 26-week feasibility study comparing the efficacy and safety of modified-release prednisone with immediate-release prednisolone in newly diagnosed cases of giant cell arteritis. Int J Rheum Dis 2017; 21:285-291. [DOI: 10.1111/1756-185x.13149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Charles Raine
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Philip P. Stapleton
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Dimos Merinopoulos
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Win Win Maw
- Department of Rheumatology; Broomfield Hospital; Mid Essex Hospital Services NHS Trust; Chelmsford UK
| | - Katerina Achilleos
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Dawn Gayford
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Sarah Mapplebeck
- Department of Pathology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Craig Mackerness
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | | | - Bhaskar Dasgupta
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
- Honorary Professorship at Essex University; Westcliff-on-Seab UK
- Visiting Professorship at Anglia Ruskin University; Westcliff-on-Sea UK
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