Novel therapeutic strategies for large vessel vasculitis

Advances in the diagnosis, assessment and outcome of Takayasu's arteritis

Takayasu's arteritis (TAK) is a rare, chronic large-vessel vasculitis (LVV) that predominantly affects aorta, its major branches, and the pulmonary arteries. Segmental stenosis, occlusion, dilatation, or aneurysm formation may occur in the vessel wall during the course of the disease. The vascular involvement can be shown with different imaging modalities to make the diagnosis of TAK. Conventional angiography, the gold standard method for initial diagnosis, seems to be replaced with the new imaging modalities such as magnetic resonance angiography (MRA) and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in recent years. The data coming from the new studies support that MRA and FDG-PET are also promising for the assessment of disease activity. Prognosis is possibly getting better with lower mortality in recent years; however, it is difficult to assess the widely different vascular intervention rates among the clinical series. Leflunomide, TNF-α antagonists, and tocilizumab are new options in patients resistant to conventional therapies. There is a clear need to develop a validated set of outcome measures for use in clinical trials of TAK. The OMERACT Vasculitis Working Group has taken on this task and aims to develop a core set of outcomes for LVV.

Takayasu's arteritis with associated aortic insufficiency and coronary ostial obliteration

PURPOSE

To describe the presentation, assessment, and management of Takayasu's arteritis (TA), a rare vascular condition exhibited predominantly in females in their second and third decades of life.

DATA SOURCES

Thorough review of current scientific literature was obtained from electronic databases and medical journals (CINAHL and PubMed). A case study is presented to illustrate TA, which was reviewed and approved by the Human Subjects Committee for the release of protected health information.

CONCLUSIONS

Clinical presentation of TA varies depending on the location of vessel involvement. Diagnosis is challenging because of the complex pathogenesis of TA. The chronic nature of TA requires ongoing evaluation and adjustment of medication regimens. The patient's quality of life is improved with maintenance of TA in a quiescent state.

IMPLICATIONS FOR PRACTICE

Presentation of a young woman with symptoms suggestive of vascular inflammatory changes should prompt consideration of TA within the differential diagnosis.

Involvement of the heart by small and medium vessel vasculitis

PURPOSE OF REVIEW

The heart may be involved in many different ways by the systemic vasculitides. In this review, we focus on recently described diagnostic and therapeutic issues in small and medium vessel vasculitis of the heart.

RECENT FINDINGS

Data have emerged on the prevalence and significance of cardiac involvement in the systemic vasculitides. There is an increasing array of sophisticated imaging modalities including echocardiography, PET, and cardiac MRI that aid in the clinical diagnosis.

SUMMARY

Most small and medium vessel vasculitides may involve the heart; however, the mode and incidence of cardiac involvement vary with the different vasculitic syndromes. This review describes the various cardiac manifestations of small and medium vessel vasculitis and the advantages of modern imaging modalities including echocardiography, MRI, and PET coupled with biologic biomarkers such as brain natriuretic peptide and antineutrophilic cytoplasmic antibodies in the diagnosis and management of disease.

Giant cell arteritis: an updated review

Giant cell arteritis (GCA) is the most common primary vasculitis of adults. The incidence of this disease is practically nil in the population under the age of 50 years, then rises dramatically with each passing decade. The median age of onset of the disease is about 75 years. As the ageing population expands, it is increasingly important for ophthalmologists to be familiar with GCA and its various manifestations, ophthalmic and non-ophthalmic. A heightened awareness of this condition can avoid delays in diagnosis and treatment. It is well known that prompt initiation of steroids remains the most effective means for preventing potentially devastating ischaemic complications. This review summarizes the current concepts regarding the immunopathogenetic pathways that lead to arteritis and the major phenotypic subtypes of GCA with emphasis on large vessel vasculitis, novel modalities for disease detection and investigative trials using alternative, non-steroid therapies.

Takayasu's Arteritis presenting as a dissecting aortic aneurysm history: a case report

Introduction

Takayasu's Arteritis, formerly known as "pulseless disease", is a chronic idiopathic vasculitis which affects the large vessels in the body. First described in the 1800's, this rare condition is more commonly found in Asian women in their 40's. The aorta and its main branches are the primary vessels affected, with the most typical features reflected as ischemia or aneurysm formation. With Takayasu's Arteritis being a rare condition and its acute phase presentation often similar to other conditions, diagnosis is often difficult.

Case Presentation

A 48 year old Irish Caucasian female, who presented as a typical history of an aortic dissection (chest pain radiating to her back in an interscapular region and a systolic blood pressure differential of 50 mmHg between her right and left upper limbs), was investigated with a number of imaging modalities and diagnosed with Takayasu's Arteritis, involving arteries affecting a number of organs. She was treated as per protocol for Takayasu's Arteritis. A diagnosis of cervical cancer quickly followed.

Conclusion

This case report highlights that a differential diagnosis should never be dispelled based upon a "typical" history. The importance of modern day imaging techniques such as CT, MRI and angiography, can often be paramount to confirming a diagnosis and the extent of the pathology.

A possible link between Takayasu's Arteritis and gynaecological malignancies may exist.

[Results of biological treatments in autoimmune diseases]

The use of the biological therapies has revolutionized in the last years the handling of numerous autoimmune processes. It has taken to numerous physicians and investigators to try to apply these therapies in other diseases (lupus, Sjögren, vasculitis, etc). From the introduction of corticosteroids and immunosupressives, vasculitis were no more a mortal diseases, and it was possible to obtain high rates of remission. Nevertheless, they are delayed, they are not sustained, and require of the use of maintained drugs. Against this background, the new biological drugs have to surpass the challenge to induce an earlier and permanent remission that diminishes irreversible organ damage, to reduce (or to eliminate) the exposition to steroids and immunesupressives and to improve the patient function. This article reviews data present until now in literature with respect to the utility of biological drugs in systemic vasculitis.

Quality of life of patients with Takayasu's arteritis

OBJECTIVE

Takayasu's arteritis (TA) is a chronic immune vasculitis that causes inflammation of the aorta and its branches and is clinically characterized by exacerbations and remissions. This study examined the quality of life (QoL) of patients with TA using the Medical Outcomes Study Short Form 36 (SF-36) Health Survey, a validated health related QoL questionnaire.

METHODS

Questionnaires that included the SF-36 and demographic related variables were mailed to 392 patients enrolled in the Takayasu's Arteritis Research Association. Raw SF-36 scores, as well as Physical Health Summary (PHS) and Mental Health Summary (MHS) scores, were calculated according to standard protocols. Data were analyzed for predictors of superior QoL using univariate and stepwise logistic regression analysis. SF-36 scores were also compared with those of other chronic diseases associated with peripheral vascular disease (PVD) published in the literature. Results are reported as mean +/- standard error of the mean.

RESULTS

A total of 158 patients (144 women, 14 men) with average age of 42.2 +/- 1.1 years responded to the questionnaire. Mean onset of symptoms occurred at 30.5 +/- 1.2 years, with a mean age at diagnosis of 34.7 +/- 1.2, and a median of four doctors were seen before diagnosis. The group underwent 299 TA-related surgical procedures (1.9 +/- 0.3), including coronary (38%), carotid (35%), upper extremity (30%), and lower extremity (26%) revascularization. PHS and MHS summary scores (39.2 +/- 1.0 and 44.5 +/- 1.0, respectively) were worse than mean scores for an age-matched healthy population as well as nationally reported scores for diabetes mellitus, hypertension, and coronary artery disease (all P < .0001). Multivariate predictors of better physical QoL were younger age (P = .003) and remission of the disease (P = .0002). The use of immunomodulating medications was associated with inferior physical QoL (P = .02). The sole predictor of better mental QoL was remission of disease (P = .002).

CONCLUSION

TA is a rare disease with profound consequences on QoL. Scores for physical and mental health are worse compared with many other chronic diseases associated with PVD. Superior physical QoL is seen in younger patients, whereas inferior physical QoL is encountered in those who take immunomodulating medications. Because the only factor to influence positively both physical and mental QoL is disease remission, every effort should be directed to attenuate disease activity.

Takayasu arteritis in children: preliminary experience with cyclophosphamide induction and corticosteroids followed by methotrexate

OBJECTIVE

To review the results of our treatment protocol in the last 7 years.

STUDY DESIGN

Six patients (4 girls, 2 boys) with an age range of 12 to 17 years were diagnosed with Takayasu arteritis (TA) during this period. Patients were allocated to receive (1) oral steroids and methotrexate (MTX) (12.5 mg/m(2)/week) if they had disease limited to one side of the diaphragm only without pulmonary disease involvement (two patients); and (2) oral steroids and oral cyclophosphamide (CYC) (maximum total dose 150 mg/kg) followed by oral MTX for maintenance as above if the disease was more widespread (four patients).

RESULTS

One patient died of pulmonary vasculitis during the first month of therapy. The remaining three patients with involvement of both the thoracic and abdominal aorta and branches received the second protocol for 12 to 18 months. All entered remission. Aortic bypass, aortorenal bypass, balloon dilatation, and unilateral nephrectomy were performed in these patients.

CONCLUSIONS

The presented single-center experience suggests that CYC induction and corticosteroids followed by MTX is an effective and safe treatment for childhood TA.