Analysis of predictive factors for treatment resistance and disease relapse in Takayasu’s arteritis

Comparison of the efficacy and safety of leflunomide versus placebo combined with basic prednisone therapy in patients with active disease phase of Takayasu arteritis: study protocol for a randomized, double-blinded controlled trial (Takayasu arteritis clinical trial in China: TACTIC)

Background

Takayasu arteritis (TAK) is an immune-induced granulomatous vasculitis that occurs primarily in young Asian women. Our previous cohort studies have indicated that leflunomide (LEF), which can lead to rapid induction and might be a promising alternative treatment for TAK.

Objectives

To compare the efficacy and safety of LEF versus placebo combined with prednisone for active TAK in a Chinese population.

Design

This will be a multicenter, randomized, double-blinded controlled trial aiming to recruit 116 TAK patients with active disease. This study will last 52 weeks.

Methods and analysis

Participants will be assigned randomly to the LEF intervention arm or placebo control arm at a 1:1 ratio. Initially, LEF combined with prednisone will be given to the intervention arm and a placebo tablet combined with prednisone will be given to the placebo arm. At the end of week 24, subjects who achieved clinical remission or partial clinical remission will proceed to maintenance therapy with LEF to the end of week 52; those who did not achieve clinical remission or partial clinical remission in the LEF intervention arm will drop out from the study, and those in the placebo control arm will switch to LEF treatment to week 52. The primary endpoint will be the clinical remission rate of LEF versus placebo at the end of week 24. The secondary endpoints will be the time to clinical remission, mean dose of prednisone, disease recurrence, time to recurrence, adverse events, as well as clinical remission in subjects who switched from the placebo control arm to LEF therapy after week 24. Intention to treat will be the primary analysis.

Discussion

This is the first randomized double-blinded placebo-controlled trial to clarify the efficacy and safety of LEF in treating active TAK. The results will provide more evidence for TAK management.

Registration

ClinicalTrials.gov identifier: NCT02981979.

Outcome Measures and Biomarkers for Disease Assessment in Takayasu Arteritis

Takayasu arteritis (TAK) is a less common large vessel vasculitis where histopathology of involved arteries is difficult to access except during open surgical procedures. Assessment of disease activity in TAK, therefore, relies on surrogate measures. Clinical disease activity measures such as the National Institutes of Health (NIH) score, the Disease Extent Index in TAK (DEI.TAK) and the Indian TAK Clinical Activity Score (ITAS2010) inconsistently associate with acute phase reactants (APRs). Computerized tomographic angiography (CTA), magnetic resonance angiography (MRA), or color Doppler Ultrasound (CDUS) enables anatomical characterization of stenosis, dilatation, and vessel wall characteristics. Vascular wall uptake of 18-fluorodeoxyglucose or other ligands using positron emission tomography computerized tomography (PET-CT) helps assess metabolic activity, which reflects disease activity well in a subset of TAK with normal APRs. Angiographic scoring systems to quantitate the extent of vascular involvement in TAK have been developed recently. Erythrocyte sedimentation rate and C-reactive protein have a moderate performance in distinguishing active TAK. Numerous novel biomarkers are under evaluation in TAK. Limited literature suggests a better assessment of active disease by combining APRs, PET-CT, and circulating biomarkers. Validated damage indices and patient-reported outcome measures specific to TAK are lacking. Few biomarkers have been evaluated to reflect vascular damage in TAK and constitute important research agenda.

Risk factors of aortic regurgitation progression in Chinese patients with Takayasu's arteritis: a prospective cohort study

OBJECTIVE

To elucidate the 3-year follow-up outcomes and risk factors associated with aortic regurgitation progression in Takayasu's arteritis (TAK).

METHODS

This study was a prospective cohort study conducted among 77 patients with TAK at Zhongshan Hospital, Fudan University, China. All the participants were followed up and assessed with echocardiography for 3 years, and the baseline characteristics and dynamic changes in the aortic valve were recorded and investigated. A multivariable Cox model was used to explore the risk factors for aortic regurgitation progression.

RESULTS

The median onset age was 36.9 (26.0-44.4) years, and 57 patients (74.0%) were females. Fifty patients (64.9%) complained of aortic regurgitation, which was the most common valvular lesion at baseline. During the 3-year follow-up period, the progression of aortic regurgitation was observed in 29 (37.7%) patients with TAK. The progression group had higher baseline erythrocyte sedimentation rate (ESR; p = 0.013) and interleukin (IL)-6 (p = 0.029) levels and lower early treatment remission rates (p = 0.024). According to the Cox model, the elevated baseline IL-6 level [>13 pg/ml, hazard ratio (HR) = 2.4, 95% confidence interval (CI) = 1.0-5.8, p = 0.042] and absence of early treatment remission (HR = 3.3, 95% CI = 1.3-8.2, p = 0.010) were the independent risk factors for aortic regurgitation deterioration.

CONCLUSION

About one-third of patients with TAK experienced aortic regurgitation progression within 3 years from first admission. Elevated IL-6 levels at baseline and absence of early treatment remission were the two important risk factors for subsequent aortic regurgitation progression.

Efficacy and safety of leflunomide versus cyclophosphamide for initial-onset Takayasu arteritis: a prospective cohort study

BACKGROUND

Leflunomide (LEF) has been considered as an alternative treatment for Takayasu arteritis (TA); however, data on its efficacy are still scanty.

OBJECTIVE

To investigate the efficacy and safety of LEF versus cyclophosphamide (CYC) for initial-onset TA.

METHODS

Initial-onset TA patients with active disease were enrolled in this research. Patients enrolled from 1 January 2009 to 31 December 2015 were treated with glucocorticoids and CYC, while patients enrolled from 1 January 2016 to 31 October 2018 received glucocorticoids and LEF. Treatment response including complete remission (CR), partial remission (PR), and effectiveness rate (ER) and side effects were evaluated at 6 and 12 months.

RESULTS AND CONCLUSION

In total, 92 patients were enrolled. A total of 47 patients were treated with LEF, while 45 patients were treated with CYC. The CR and ER rates were 75.55%, and 88.89% at 6 months, and 85.37% and 95.12% at 12 months in the LEF group. The CR and ER rates were 39.02% and 70.73% at 6 months, and 56.41% and 82.05% at 12 months in the CYC group. The CR rate was significantly higher in the LEF group than in the CYC group both at 6 months (75.61% versus 38.24%, p < 0.01) and 12 months (77.42% versus 53.33%, p < 0.05) after adjustment for propensity scores. The incidence of side effects in the LEF group was much lower than that in the CYC group (21.28% versus 44.44%). In conclusion, LEF provided a better treatment response, along with lower reproductive toxicity, compared with CYC in initial-onset TA.

Statins reduce relapse rate in Takayasu arteritis

BACKGROUND

To investigate the effect of statins on relapse of Takayasu arteritis (TAK), which frequently occurs after achievement of remission.

METHODS

We conducted a retrospective study on TAK patients with active disease, diagnosed between 2012 and 2017. Relapse was defined as recurrence of active disease after achieving remission. Demographic and clinical parameters of patients who experienced relapse were compared to those who did not. To identify factors associated with relapse, significant factors identified in this comparison were included in a multivariate Cox regression analysis. Inverse probability of treatment weighting (IPTW)-adjusted analysis was used to evaluate the influence of statins on relapse.

RESULTS

Of the total 74 TAK patients, 40 (54.1%) patients received statins, whereas 34 (45.9%) patients did not. Relapse was observed in 36 (48.6%) patients of the total 74 TAK patients. Compared with patients who did not experience relapse, patients who experienced relapse were younger (44.5 ± 13.5 years vs 34.1 ± 12.6 years, p = 0.001), had lower prevalence of hypertension (63.2% vs 38.9%, p = 0.037), more commonly had carotidynia (7.9% vs 27.8%, p = 0.025), had higher LDL-cholesterol (84.8 ± 18.8 mg/dl vs 100.5 ± 26.1 mg/dl, p = 0.010), and were less commonly taking statins (71.1% vs 36.1%, p = 0.003). The use of statins was significant in multivariate Cox regression analysis (adjusted hazard ratio 0.260, 95% confidence interval 0.120-0.563, p = 0.001). Furthermore, IPTW-adjusted analysis confirmed that statin use was associated with a lower risk of relapse (IPTW-adjusted hazard ratio 0.153, 95% confidence interval 0.038-0.616, p = 0.008).

CONCLUSION

In TAK, statins can be beneficial in reducing relapse rate after achieving remission.