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Zhao SS, Lyu H, Zeng C, Lei G, Wei J, Mackie SL. Angiotensin receptor blockade is associated with increased risk of giant cell arteritis. Rheumatology (Oxford) 2023; 62:2203-2210. [PMID: 36255257 PMCID: PMC10234186 DOI: 10.1093/rheumatology/keac599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/29/2022] [Accepted: 10/08/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Angiotensin II is implicated in GCA pathology. We examined whether the use of angiotensin receptor blockers (ARBs) is associated with GCA risk compared with angiotensin-converting enzyme inhibitors (ACEis) or other antihypertensives. METHODS We performed a matched cohort study including adults who were initiators of antihypertensives in UK primary care data between 1995 and 2019. Treatment-naïve individuals without prior GCA or PMR were categorized into three groups-ARB initiators, ACEi initiators, or other antihypertensive initiators (beta-blockers, calcium channel blockers, diuretics or alpha-adrenoceptor blockers)-and followed for up to 5 years. Incident GCA was defined using validated Read codes, with age of onset ≥50 years and two or more glucocorticoid prescriptions. Inverse probability-weighted Cox models were used to model outcome risk, adjusting for lifestyle parameters, comorbidities and comedications. RESULTS Among >1 million new starters of antihypertensives (81 780 ARBs, 422 940 ACEis and 873 066 other antihypertensives), the incidence rate of GCA per 10 000 patient-years was 2.73 (95% CI 2.12, 3.50) in the ARB group, 1.76 (95% CI 1.25, 2.39) in the ACEi group and 1.90 (95% CI 1.37, 2.56) in the other antihypertensives group. The hazard of GCA was higher in ARB initiators [hazard ratio (HR) 1.55; 95% CI 1.16, 2.06] than initiators of ACEis, but similar between initiators of other antihypertensives and ACEis (HR 1.08; 95% CI 0.87, 1.35). CONCLUSIONS Initiation of ARBs is associated with a higher risk of GCA compared with ACEis or other antihypertensives. Mechanistic studies of angiotensin receptor biology will provide further clarity for our findings.
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Affiliation(s)
- Sizheng Steven Zhao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, School of Biological Sciences, Faculty of Biological Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Houchen Lyu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Methodology, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, General Hospital of Chinese PLA, Beijing, China
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
| | - Jie Wei
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Health Management Center, Xiangya Hospital, Central South University, Changsha, China
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals, University of Leeds, Leeds, UK
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2
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Sanchez-Alvarez C, Bond M, Soowamber M, Camellino D, Anderson M, Langford CA, Dejaco C, Touma Z, Ramiro S. Measuring treatment outcomes and change in disease activity in giant cell arteritis: a systematic literature review informing the development of the EULAR-ACR response criteria on behalf of the EULAR-ACR response criteria in giant cell arteritis task force. RMD Open 2023; 9:e003233. [PMID: 37349123 PMCID: PMC10314653 DOI: 10.1136/rmdopen-2023-003233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 05/12/2023] [Indexed: 06/24/2023] Open
Abstract
OBJECTIVES To identify criteria and descriptors used to measure response to treatment and change in disease activity in giant cell arteritis (GCA). METHODS A systematic literature review (SLR) to retrieve randomised controlled trials (RCTs) and longitudinal observational studies (LOS). Criteria and descriptors of active disease, remission, response, improvement, worsening and relapse were extracted. RCTs, LOS with >20 subjects, and qualitative research studies were included. RESULTS 10 593 studies were retrieved, of which 116 were included (11 RCTs, 104 LOS, 1 qualitative study). No unified definition of response to therapy was found. Most RCTs used composite endpoints to assess treatment outcomes. Active disease was described in all RCTs and 19% of LOS; and was largely defined by a combination of clinical and laboratory components. Remission was reported in 73% of RCTs and 42% of LOS; It was predominantly defined as the combination of clinical and laboratory components. One LOS reported response with a definition resembling the definition of remission from other studies. Improvement was rarely used as an endpoint and it was mostly a surrogate of remission. No study specifically defined worsening. Relapse was reported in all RCTs and 86% of LOS. It was predominantly defined as the combination of clinical, laboratory and treatment components. CONCLUSIONS The results of this SLR demonstrate that definitions of response used in clinical studies of GCA are scant and heterogeneous. RCTs and LOS mainly used remission and relapse as treatment outcomes. The descriptors identified will inform the development of the future European Alliance of Associations for Rheumatology-American College of Rheumatology response criteria for GCA.
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Affiliation(s)
- Catalina Sanchez-Alvarez
- Division of Rheumatology & Clinical Immunology, Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck, (ASAA-SABES), Teaching hospital of the Paracelsus University, Bruneck, Italy
| | - Medha Soowamber
- Department of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dario Camellino
- Department of Rheumatology, Local Health Trust, Genoa, Italy
| | - Melanie Anderson
- Department of Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck, (ASAA-SABES), Teaching hospital of the Paracelsus University, Bruneck, Italy
- Rheumatology, Medical University Graz, Graz, Austria
| | - Zahi Touma
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
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3
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Jivraj I. Treatment of Giant Cell Arteritis. Int Ophthalmol Clin 2023; 63:39-54. [PMID: 36963826 DOI: 10.1097/iio.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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4
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Springer JM, Kermani TA. Recent advances in the treatment of giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 37:101830. [PMID: 37328409 DOI: 10.1016/j.berh.2023.101830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 06/18/2023]
Abstract
Giant cell arteritis (GCA) is a systemic, granulomatous, large-vessel vasculitis that affects individuals over the age of 50 years. Morbidity from disease includes cranial manifestations which can cause irreversible blindness, while extra-cranial manifestations can cause vascular damage with large-artery stenosis, occlusions, aortitis, aneurysms, and dissections. Glucocorticoids while efficacious are associated with significant adverse effects. Furthermore, despite treatment with glucocorticoids, relapses are common. An understanding of the pathogenesis of GCA has led to the discovery of tocilizumab as an efficacious steroid-sparing therapy while additional therapeutic targets affecting different inflammatory pathways are under investigation. Surgical treatment may be indicated in cases of refractory ischemia or aortic complications but data on surgical outcomes are limited. Despite the recent advances, many unmet needs exist, including the identification of patients or subsets of GCA who would benefit from earlier initiation of adjunctive therapies, patients who may warrant long-term immunosuppression and medications that sustain permanent remission. The impact of medications like tocilizumab on long-term outcomes, including the development of aortic aneurysms and vascular damage also warrants investigation.
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Affiliation(s)
- Jason M Springer
- Vanderbilt University Medical Center, 1161 21st Avenue Sound, T3113 Medical Center North, Nashville, TN, 37232, USA.
| | - Tanaz A Kermani
- University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
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5
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Moreel L, Betrains A, Molenberghs G, Vanderschueren S, Blockmans D. Epidemiology and predictors of relapse in giant cell arteritis: A systematic review and meta-analysis. Joint Bone Spine 2023; 90:105494. [PMID: 36410684 DOI: 10.1016/j.jbspin.2022.105494] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/27/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to estimate the timing of relapse, the prevalence of multiple relapses and the predictors of relapse in patients with giant cell arteritis (GCA). METHODS PubMed, Embase and Cochrane databases were searched from inception till November, 30 2021. Outcome measures include cumulative relapse rate (CRR) of first relapse at year 1, 2, and 5 after treatment initiation, CRR of second and third relapse and predictors of relapse. RESULTS Thirty studies (2595 patients) were included for timing of relapse, 16 studies (1947 patients) for prevalence of multiple relapses and 40 studies (4213 patients) for predictors of relapse. One-year, 2-year and 5-year CRRs were 32% [95% confidence interval (CI) 22-43%], 44% [95% CI 31-59%], and 47% [95% CI 27-67%], respectively. The duration of scheduled glucocorticoid therapy was negatively associated with the 1-year CRR (P=0.03). CRR of second and third relapse were 30% [95% CI 21-40] and 17% [95% CI 8-33%], respectively. Female sex (OR 1.43) and large vessel involvement (OR 2.04) were predictors of relapse. CONCLUSION Relapse occurred in almost half of GCA patients mainly during the first two years after diagnosis. One in three patients had multiple relapses. The optimal glucocorticoid tapering schedule, which seeks a balance between the lowest relapse risk and the shortest glucocorticoid duration, needs to be determined in future studies. Longer scheduled glucocorticoid therapy or early introduction of glucocorticoid-sparing agents may be warranted in female patients and patients with large vessel involvement.
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Affiliation(s)
- Lien Moreel
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Geert Molenberghs
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), University of Leuven and Hasselt University, Leuven, Belgium
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Belgium
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Belgium
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6
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Das S, Goswami RP, Sinha D, Ghosal A, Datta A, Sarkar S. Efficacy of leflunomide as a steroid‐sparing agent in treatment of Indian giant cell arteritis patients: A 2‐year follow‐up study. Int J Rheum Dis 2022; 25:650-658. [DOI: 10.1111/1756-185x.14319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Shyamashis Das
- Department of Rheumatology Institute of Neurosciences Kolkata (I‐NK) Kolkata India
| | - Rudra Prosad Goswami
- Department of Rheumatology All India Institute of Medical Sciences New Delhi India
| | - Debanjali Sinha
- Department of Rheumatology Institute of Neurosciences Kolkata (I‐NK) Kolkata India
| | - Anirban Ghosal
- Department of Neurology Institute of Neurosciences Kolkata (I‐NK) Kolkata India
| | - Ashis Datta
- Department of Neurology Institute of Neurosciences Kolkata (I‐NK) Kolkata India
| | - Sanjukta Sarkar
- Department of Radiology Institute of Neurosciences Kolkata (I‐NK) Kolkata India
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7
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Turkiewicz A, Stamatis P, Mohammad AJ. Cardiovascular drug treatment, statins and biopsy-confirmed giant cell arteritis: a population-based case-control study. RMD Open 2021; 6:rmdopen-2020-001285. [PMID: 32792416 PMCID: PMC7440225 DOI: 10.1136/rmdopen-2020-001285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/24/2020] [Accepted: 07/18/2020] [Indexed: 12/11/2022] Open
Abstract
Objective To determine whether exposure to cardiovascular medications and statins is associated with increased risk of giant cell arteritis (GCA). Design The population-based case–control study comprised a cohort of patients with biopsy-confirmed GCA linked to the Swedish Prescribed Drug Register to identify all exposure to drugs prior to diagnosis of GCA. Ten controls per GCA case, matched for age, sex and residential area, were included. Using corresponding Anatomical Therapeutic Chemical codes, ACE inhibitors, angiotensin II receptor blockers, beta-blocking agents, calcium antagonists, diuretics, statins and cardiac therapy drugs were investigated from July 1, 2005 to the diagnosis/index date. A conditional logistic regression model was fitted adjusted for income, education level and marital status. We repeated the analyses including only new drug users excluding those with any prescription during the year from July 1, 2005 to July 1, 2006. Results 574 cases (29% men) of diagnosed GCA and 5740 controls (29% men) were included. The mean age at diagnosis is 75 years (SD 8). Of the GCA cases, 71% had at least one dispensation of a cardiovascular drug prior to the index date, compared to 74% of controls. The ORs for the association of target drug exposure with GCA were <1 for most drugs, but close to 1 in the analysis of new users. Statins were consistently associated with lower risk of GCA, OR 0.74 (95% CI 0.61 to 0.90). Conclusion Statins may be associated with lower risk of incident biopsy-confirmed GCA. No association was evident for other studied drugs.
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Affiliation(s)
- Aleksandra Turkiewicz
- Clinical Sciences, Lund, Orthopedics, Lunds University Faculty of Medicine, Lund, Sweden
| | - Pavlos Stamatis
- Rheumatology, Lunds University Faculty of Medicine, Lund, Sweden.,Internal Medicine, Section of Rheumatology, Helsingborgs Lasarett, Helsingborg, Sweden
| | - Aladdin J Mohammad
- Clinical Sciences Lund, Rheumatology, Lunds University Faculty of Medicine, Lund, Sweden .,Department of Medicine, University of Cambridge, Cambridge, UK
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8
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Ma J, Khalidi N, Wierzbicki O, Alqutami A, Ioannidis G, Pagnoux C. Impact of diabetes, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, and statin use on presentation and outcomes in patients with giant cell arteritis. Int J Rheum Dis 2020; 23:1233-1239. [PMID: 32776676 DOI: 10.1111/1756-185x.13914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/17/2020] [Accepted: 06/21/2020] [Indexed: 12/01/2022]
Abstract
AIM Few, separate, small retrospective studies in giant cell arteritis (GCA) reported that patients: (a) with diabetes mellitus had less positive temporal artery biopsies (TAB); (b) on angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) experienced fewer relapses; and (c) on statins experienced the same frequency of clinical complications and relapses as non-exposed patients. This retrospective chart review study simultaneously investigated the impact of these 3 factors on a cohort of patients followed in 2 large Canadian centers (Hamilton and Toronto, ON). METHODS One hundred and thirty-seven patients diagnosed with GCA between 1993 and 2015 were included in the study. Presenting symptoms, TAB results, disease complications and outcomes (relapses, duration of glucocorticoid use) were compared between exposed (diabetes/ACE/ARB/statin) and non-exposed patients, with adjustment for main potential confounding variables. RESULTS Temporal artery biopsies was less often positive in patients with pre-existing diabetes (relative risk 0.24; 95% CI: 0.069-0.81). Patients who developed diabetes after diagnosis had a lower relapse-free survival (adjusted hazards ratio [HR] 0.28; 95% CI: 0.095-0.84). Patients taking ARBs prior to diagnosis were more likely to successfully discontinue glucocorticoids without a flare in the following 3 months (adjusted HR 2.46; 95% CI: 1.2-5.3). Clinical complications and relapse rates did not differ between patients on statin therapy or not. CONCLUSION Diabetic patients with GCA were less likely to have a positive TAB, and more likely to relapse. ARB therapy prior to diagnosis showed an association with success at discontinuing glucocorticoids. Statin therapy did not alter the clinical presentation or course of GCA.
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Affiliation(s)
- Jocelyn Ma
- Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Nader Khalidi
- Division of Rheumatology, St Joseph's Healthcare, McMaster University, Hamilton, Canada
| | - Ola Wierzbicki
- Division of Rheumatology, St Joseph's Healthcare, McMaster University, Hamilton, Canada
| | - Abdallah Alqutami
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.,Division of Rheumatology, King Fahad Hospital, Jeddah, Saudi Arabia
| | - George Ioannidis
- Division of Rheumatology, St Joseph's Healthcare, McMaster University, Hamilton, Canada
| | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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9
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Rosenblum JS, Quinn KA, Rimland CA, Mehta NN, Ahlman MA, Grayson PC. Clinical Factors Associated with Time-Specific Distribution of 18F-Fluorodeoxyglucose in Large-Vessel Vasculitis. Sci Rep 2019; 9:15180. [PMID: 31645635 PMCID: PMC6811531 DOI: 10.1038/s41598-019-51800-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/07/2019] [Indexed: 01/06/2023] Open
Abstract
18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can detect vascular inflammation in large-vessel vasculitis (LVV). Clinical factors that influence distribution of FDG into the arterial wall and other tissues have not been characterized in LVV. Understanding these factors will inform analytic strategies to quantify vascular PET activity. Patients with LVV (n = 69) underwent 141 paired FDG-PET imaging studies at one and two hours per a delayed image acquisition protocol. Arterial uptake was quantified as standardized uptake values (SUVMax). SUVMean values were obtained for background tissues (blood pool, liver, spleen). Target-to-background ratios (TBRs) were calculated for each background tissue. Mixed model multivariable linear regression was used to identify time-dependent associations between FDG uptake and selected clinical features. Clinical factors associated with FDG distribution differed in a tissue- and time-dependent manner. Age, body mass index, and C-reactive protein were significantly associated with arterial FDG uptake at both time points. Clearance factors (e.g. glomerular filtration rate) were significantly associated with FDG uptake in background tissues at one hour but were weakly or not associated at two hours. TBRs using liver or blood pool at two hours were most strongly associated with vasculitis-related factors. These findings inform standardization of FDG-PET protocols and analytic approaches in LVV.
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Affiliation(s)
| | - Kaitlin A Quinn
- Systemic Autoimmunity Branch, NIAMS, Bethesda, Maryland, USA.,Division of Rheumatology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Casey A Rimland
- Systemic Autoimmunity Branch, NIAMS, Bethesda, Maryland, USA.,University of North Carolina at Chapel Hill School of Medicine, Medical Scientist Training Program, Chapel Hill, NC, USA
| | - Nehal N Mehta
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Mark A Ahlman
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, NIAMS, Bethesda, Maryland, USA.
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10
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Monti S, Águeda AF, Luqmani RA, Buttgereit F, Cid M, Dejaco C, Mahr A, Ponte C, Salvarani C, Schmidt W, Hellmich B. Systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis: focus on giant cell arteritis. RMD Open 2019; 5:e001003. [PMID: 31673411 PMCID: PMC6803016 DOI: 10.1136/rmdopen-2019-001003] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/10/2019] [Accepted: 08/17/2019] [Indexed: 12/13/2022] Open
Abstract
Objectives To analyse the current evidence for the management of large vessel vasculitis (LVV) to inform the 2018 update of the EULAR recommendations. Methods Two systematic literature reviews (SLRs) dealing with diagnosis/monitoring and treatment strategies for LVV, respectively, were performed. Medline, Embase and Cochrane databases were searched from inception to 31 December 2017. Evidence on imaging was excluded as recently published in dedicated EULAR recommendations. This paper focuses on the data relevant to giant cell arteritis (GCA). Results We identified 287 eligible articles (122 studies focused on diagnosis/monitoring, 165 on treatment). The implementation of a fast-track approach to diagnosis significantly lowers the risk of permanent visual loss compared with historical cohorts (level of evidence, LoE 2b). Reliable diagnostic or prognostic biomarkers for GCA are still not available (LoE 3b).The SLR confirms the efficacy of prompt initiation of glucocorticoids (GC). There is no high-quality evidence on the most appropriate starting dose, route of administration, tapering and duration of GC (LoE 4). Patients with GCA are at increased risk of dose-dependent GC-related adverse events (LoE 3b). The addition of methotrexate or tocilizumab reduces relapse rates and GC requirements (LoE 1b). There is no consistent evidence that initiating antiplatelet agents at diagnosis would prevent future ischaemic events (LoE 2a). There is little evidence to guide monitoring of patients with GCA. Conclusions Results from two SLRs identified novel evidence on the management of GCA to guide the 2018 update of the EULAR recommendations on the management of LVV.
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Affiliation(s)
- Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Ana F Águeda
- Rheumatology, Baixo Vouga Hospital Centre Agueda Unit, Agueda, Portugal
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Frank Buttgereit
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Maria Cid
- Vasculitis Research Unit, Hospital Clinic; Institute d'Investiacions Biomèdiques August pi I Sunyer, University of Barcelona, Barcelona, Spain
| | - Christian Dejaco
- Rheumatology; South Tyrol Health Trust, Gesundheitsbezirk Bruneck, Brunico, Italy.,Rheumatology, University of Graz, Graz, Austria
| | - Alfred Mahr
- Internal Medicine, Université Paris Diderot Institut Saint Louis, Paris, France
| | - Cristina Ponte
- Rheumatology, Hospital de Santa Marta, Lisboa, Portugal.,Rheumatology Research Unit, University of Lisbon Institute of Molecular Medicine, Lisboa, Portugal
| | - Carlo Salvarani
- Rheumatology, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Modena, Italy
| | - Wolfgang Schmidt
- Klinik für Innere Medizin, Rheumatologie und Klinische Immunologie Berlin-Buch, Immanuel Krankenhaus Berlin Standort Berlin-Wannsee, Berlin, Germany
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitis-Zentrum Süd, Medius Kliniken, Universitatsklinikum Tubingen, Tubingen, Germany
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11
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Dumont A, Parienti JJ, Delmas C, Boutemy J, Maigné G, Martin Silva N, Sultan A, Planchard G, Aouba A, de Boysson H. Factors Associated with Relapse and Dependence on Glucocorticoids in Giant Cell Arteritis. J Rheumatol 2019; 47:108-116. [PMID: 30877210 DOI: 10.3899/jrheum.181127] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify characteristics and factors associated with relapse and glucocorticoid (GC) dependence in patients with giant cell arteritis (GCA). METHODS We retrospectively analyzed 326 consecutive patients with GCA followed for at least 12 months. Factors associated with relapse and GC dependence were identified in multivariable analyses. RESULTS The 326 patients (73% women) were followed up for 62 (12-262) months. During followup, 171 (52%) patients relapsed, including 113 (35%) who developed GC dependence. Relapsing patients had less history of stroke (p = 0.01) and presented large-vessel vasculitis (LVV) more frequently on imaging (p = 0.01) than patients without relapse. During the first months, therapeutic strategy did not differ among relapsing and nonrelapsing patients. GC-dependent patients were less likely to have a history of stroke (p = 0.004) and presented LVV on imaging more frequently (p = 0.005) than patients without GC-dependent disease. In multivariable analyses, LVV was an independent predictive factor of relapse (HR 1.49, 95% CI 1.002-2.12; p = 0.04) and GC dependence (OR 2.19, 95% CI 1.19-4.05; p = 0.01). Conversely, stroke was a protective factor against relapse (HR 0.21, 95% CI 0.03-0.68; p = 0.005) and GC-dependent disease (OR 0.10, 95% CI 0.001-0.31; p = 0.0005). Patients with a GC-dependent disease who received a GC-sparing agent had a shorter GC treatment duration than those without (p = 0.008). CONCLUSION In this study, LVV was an independent predictor of relapse and GC dependence. Further prospective studies are needed to confirm these findings and to determine whether patients with LVV require a different treatment approach.
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Affiliation(s)
- Anael Dumont
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Jean-Jacques Parienti
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Claire Delmas
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Jonathan Boutemy
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Gwénola Maigné
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Nicolas Martin Silva
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Audrey Sultan
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Gaétane Planchard
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Achille Aouba
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France.,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital
| | - Hubert de Boysson
- From the Department of Internal Medicine, Department of Pathology, and Department of Biostatistics, Caen University Hospital, Caen, France. .,A. Dumont, MD, Department of Internal Medicine, Caen University Hospital; J.J. Parienti, PhD, Department of Biostatistics, Caen University Hospital; C. Delmas, MD, Department of Internal Medicine, Caen University Hospital; J. Boutemy, MD, Department of Internal Medicine, Caen University Hospital; G. Maigné, MD, Department of Internal Medicine, Caen University Hospital; N. Martin Silva, MD, Department of Internal Medicine, Caen University Hospital; A. Sultan, PhD, Department of Internal Medicine, Caen University Hospital; G. Planchard, MD, Department of Pathology, Caen University Hospital; A. Aouba, MD, PhD, Department of Internal Medicine, Caen University Hospital; H. de Boysson, MD, MSc, Department of Internal Medicine, Caen University Hospital.
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12
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Iudici M, Porcher R, Riveros C, Ravaud P. Time-dependent biases in observational studies of comparative effectiveness research in rheumatology. A methodological review. Ann Rheum Dis 2019; 78:562-569. [DOI: 10.1136/annrheumdis-2018-214544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/02/2019] [Accepted: 01/23/2019] [Indexed: 01/10/2023]
Abstract
ObjectiveTo assess to what extent time-dependent biases (ie, immortal time bias (ITB) and time-lag bias (TLB)) occur in the latest rheumatology observational studies, describe their main mechanisms and increase the awareness on this topic.MethodsWe searched PubMed for observational studies on rheumatic diseases published in leading medical journals in the last 5 years. Only studies with a time-to-event analysis exploring the association of one or more interventional strategies with an outcome were included. Each study was labelled as free from bias, at risk of TLB, at risk of misclassified ITB if the period of immortal time was incorrectly attributed to an intervention group, or at risk of excluded ITB if the immortal time was discarded from the analysis.ResultsWe included 78 papers. Most studies were performed in Europe or North America (46% each), were not industry funded (62%) and had a safety primary outcome (59%). In total, 13 (17%) studies were considered at risk of time-dependent biases. Among the studies at risk of ITB (n=8; 10%), in 5 (6%), waiting time to receive treatment was wrongly attributed to the treatment exposure group, which indicated misclassified ITB. Five (6%) studies were at risk of TLB: patients on conventional synthetic disease-modifying antirheumatic drugs (DMARD; first-line drugs) were compared with patients on biologic DMARDs (second or third-line drugs) without accounting for disease duration or prior medication use.ConclusionsOne in six comparative effectiveness observational studies published in leading rheumatology journals is potentially flawed by time-dependent biases.
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Ninan JV, Lester S, Hill CL. Giant cell arteritis: beyond temporal artery biopsy and steroids. Intern Med J 2018; 47:1228-1240. [PMID: 28485026 DOI: 10.1111/imj.13483] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/25/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
Giant cell arteritis is the most common primary vasculitis of the elderly. The acute complications of untreated giant cell arteritis, such as vision loss or occasionally stroke, can be devastating. The diagnosis is, however, not altogether straightforward due to variable sensitivities of the temporal artery biopsy as a reference diagnostic test. In this review, we discuss the increasing role of imaging in the diagnosis of giant cell arteritis. Glucocorticoid treatment is the backbone of therapy, but it is associated with significant adverse effects. A less toxic alternative is required. Conventional and novel immunosuppressive agents have only demonstrated modest effects in a subgroup of steroid refractory Giant cell arteritis due to the different arms of the immune system at play. However, recently a study of interleukin-6 blockade demonstrated benefits of giant cell arteritis. The current status of these immunosuppressive agents and novel therapies are also discussed in this review.
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Affiliation(s)
- Jem V Ninan
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, Modbury Hospital, Adelaide, South Australia, Australia
| | - Susan Lester
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Catherine L Hill
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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14
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Ninan JV, Lester S, Hill CL. Diagnosis and management of giant cell arteritis: an Asia-Pacific perspective. Int J Rheum Dis 2018; 22 Suppl 1:28-40. [PMID: 29667308 DOI: 10.1111/1756-185x.13297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Giant cell arteritis is the commonest primary vasculitis of the elderly. However, the prevalence does vary widely between populations with highest incidence amongst Northern Europeans and lowest amongst East Asians. Preliminary studies suggest that clinical manifestations may differ between different populations. Newer diagnostic approaches including ultrasound, MR angiography and PET imaging are under review. While there have been recent advances in the diagnosis of GCA particularly with regard to imaging, there is an urgent need for improvements in methods of diagnosis, treatment and requirement for screening. Glucocorticoid treatment remain the backbone of therapy. However, glucocorticoid therapy is associated with significant adverse effects. Conventional and novel immunosuppressive agents have only demonstrated modest effects in a subgroup of steroid refractory GCA due to the different arms of the immune system at play. However, recently a study of IL-6 blockade demonstrated benefit in GCA. Newer approaches such as fast-track pathways can also result in improvements in consequences of GCA including blindness.
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Affiliation(s)
- Jem V Ninan
- Rheumatology Unit, Modbury Hospital, Modbury, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Susan Lester
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Catherine L Hill
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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15
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Abstract
OPINION STATEMENT Giant cell arteritis (GCA) is a systemic inflammatory vasculitis affecting medium and large vessels with potentially sight and life-threatening complications. Early diagnosis and prompt treatment are imperative in order to prevent vision loss and progression of the disease. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are inflammatory markers which are elevated in the majority of patients and support the diagnosis of GCA among patients who present with typical symptoms. GCA is confirmed with superficial temporal artery biopsy which demonstrates characteristic pathological findings. Treatment of suspected ophthalmic involvement must be initiated urgently, even when diagnostic studies are pending. High dose corticosteroid therapy is the mainstay of treatment and is administered either intravenously or orally to prevent further vision loss and treat systemic vasculitis. Oral corticosteroid therapy is required for months to years with careful follow-up and periodic laboratory evaluations with ESR and CRP. Corticosteroids are tapered gradually over months and may be associated with complications such as hypertension, diabetes mellitus, osteoporosis, psychosis, peptic ulcer disease, and infection. Supplementation with calcium, vitamin D, bisphosphonate therapy, antimicrobial prophylaxis, and initiation of a proton pump inhibitor or Histamine H2-receptor antagonist should be considered. Recurrence of inflammation is common in GCA and necessitates an escalation of corticosteroid dose. Adjunctive immunomodulatory therapy may be considered in patients experiencing relapsing inflammation despite high doses of corticosteroids or those with corticosteroid-induced complications. Emerging evidence for adjunctive therapy with tocilizumab, methotrexate, aspirin, angiotensin receptor blockers, and statins is encouraging and may lead to a more mainstream role for these therapies among patients with GCA.
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16
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Abstract
Giant cell arteritis (GCA) is the most common vasculitis of the elderly. The diagnosis can be challenging at times because of the limitation of the American Rheumatology Association (ARA) classification criteria and the significant proportion of biopsy-negative patients with GCA. We discuss the role of advanced imaging techniques, including positron emission tomography (PET) scanning, in establishing diagnosis and improved histopathology techniques to improve the sensitivity of temporal artery biopsy. There have been significant advances in the understanding of the pathogenesis of GCA, particularly the role of cytokine pathways such as the interleukins, IL-6-IL-17 axis, and the IL-12-interferon-γ axis and their implication for new therapies. We highlight that glucocorticoids remain the primary treatment for GCA, but recognize the risk of steroid-induced side effects. A number of pharmacotherapies to enable glucocorticoid dose reduction and prevent relapse have been studied. Early diagnosis and fast-track pathways have improved outcomes by encouraging adherence to evidence-based practice.
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Affiliation(s)
- Jem Ninan
- Rheumatology Unit, Modbury Hospital, Modbury, South Australia, Australia
| | - Susan Lester
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia; Department of Medicine, University of Adelaide, Adelaide, Australia
| | - Catherine Hill
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia; Department of Medicine, University of Adelaide, Adelaide, Australia; Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia.
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17
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Carbonella A, Berardi G, Petricca L, Biscetti F, Alivernini S, Bosello SL, Fedele AL, Ferraccioli G, Gremese E. Immunosuppressive Therapy (Methotrexate or Cyclophosphamide) in Combination with Corticosteroids in the Treatment of Giant Cell Arteritis: Comparison with Corticosteroids Alone. J Am Geriatr Soc 2016; 64:672-374. [DOI: 10.1111/jgs.14004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Angela Carbonella
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Giorgia Berardi
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Luca Petricca
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Federico Biscetti
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Stefano Alivernini
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Silvia Laura Bosello
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Anna Laura Fedele
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Gianfranco Ferraccioli
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Elisa Gremese
- Division of Rheumatology; Institute of Rheumatology and Affine Sciences; School of Medicine; Catholic University of the Sacred Heart; Rome Italy
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Abstract
PURPOSE OF REVIEW Giant cell arteritis (GCA) remains a potentially blinding inflammatory vasculitis of the elderly. Because prolonged doses of corticosteroids remain the best established treatment, side-effects during treatment are common and potentially serious. This review addresses the challenges clinicians face in managing this disease. RECENT FINDINGS High-dose corticosteroids with slow tapering and close monitoring are the mainstay of treatment. Investigations into adjunctive treatment have yet to establish other agents as beneficial, but further research is ongoing with some promising results. SUMMARY GCA represents a challenging illness to clinicians because of its potential for causing blindness and the need for prolonged high doses of corticosteroids with their many complications.
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Labarca C, Koster MJ, Crowson CS, Makol A, Ytterberg SR, Matteson EL, Warrington KJ. Predictors of relapse and treatment outcomes in biopsy-proven giant cell arteritis: a retrospective cohort study. Rheumatology (Oxford) 2016; 55:347-56. [PMID: 26385368 PMCID: PMC4939727 DOI: 10.1093/rheumatology/kev348] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/13/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate characteristics of relapse, relapse rates, treatment and outcomes among patients with biopsy-proven GCA in a large, single-institution cohort. METHODS We conducted a retrospective review of all patients with biopsy-proven GCA from 1998 to 2013. Demographic, clinical, laboratory and treatment data at presentation and during follow-up were collected. Comparisons by relapse rate were performed using chi-square tests. Prednisone discontinuation by initial oral dose ≤40 and >40 mg/day was compared using Cox models. RESULTS The cohort included 286 patients [74% female, mean age at diagnosis 75.0 years (s.d. 7.6), median follow-up 5.1 years). During follow-up, 73 patients did not relapse, 80 patients had one relapse and 133 had two or more relapses. The first relapse occurred during the first year in 50% of patients, by 2 years in 68% and by 5 years in 79%. More patients with established hypertension (P = 0.007) and diabetes (P = 0.039) at GCA diagnosis were in the high relapse rate group ( ≥ 0.5 relapses/year) and more females were in the low or high relapse groups than in the no relapse group (P = 0.034). Patients receiving an initial oral prednisone dose >40 mg/day were able to reach a dose of <5 mg/day [hazard ratio (HR) 1.46 (95% CI 1.09, 1.96)] and discontinue prednisone [HR 1.56 (95% CI 1.09, 2.23)] sooner than patients receiving ≤40 mg/day without an increase in observed glucocorticoid-associated adverse events. CONCLUSION Females and patients with hypertension or diabetes at GCA diagnosis have more relapses during follow-up. Patients treated with an initial oral prednisone dose >40 mg/day achieved earlier prednisone discontinuation.
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Affiliation(s)
- Cristian Labarca
- Department of Internal Medicine, Universidad del Desarrollo, Clinica Alemana de Santiago, Santiago, Chile
| | | | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Division of Biostatistics and
| | - Ashima Makol
- Division of Rheumatology, Department of Medicine
| | | | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Abstract
Giant cell arteritis (GCA) is a large-vessel vasculitis predominantly affecting older people, with a peak incidence between 70 and 79 years of age. If untreated, ischaemic complications can be catastrophic for the patient, including blindness. We review the current treatment paradigms for this condition, the mainstay of which is immediate high-dose glucocorticoid therapy with a gradual dose tapering. Adverse events of glucocorticoid therapy are often observed after 12-24 months and corticosteroid-sparing adjuvant therapies are used in severe disease, multiple flares or patients at high risk of prolonged therapy. The current understanding of the pathogenesis of GCA is explored. This has informed the identification of new potential targets and approaches to treatment. Blockade of interleukin (IL)-6 (tocilizumab) and IL-1 (gevokizumab) are being evaluated in phase III clinical trials. It is hoped that improved risk stratification of organ damage and relapses will be developed using imaging and biomarkers, allowing for individualised treatment for patients; however, there remains further work to be done before this becomes a reality.
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Affiliation(s)
- Lauren Steel
- Rheumatology, Southend University Hospital, Prittlewell Chase, Westcliff-on-sea, Essex, SS0 0RY, UK
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21
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Prieto-González S, García-Martínez A, Tavera-Bahillo I, Hernández-Rodríguez J, Gutiérrez-Chacoff J, Alba MA, Murgia G, Espígol-Frigolé G, Sánchez M, Arguis P, Cid MC. Effect of glucocorticoid treatment on computed tomography angiography detected large-vessel inflammation in giant-cell arteritis. A prospective, longitudinal study. Medicine (Baltimore) 2015; 94:e486. [PMID: 25654393 PMCID: PMC4602705 DOI: 10.1097/md.0000000000000486] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Computed tomography angiography (CTA) detects signs of large-vessel vasculitis (LVV) in about 67.5% of patients with giant-cell arteritis (GCA) at the time of diagnosis and early aortic dilatation in 15%. The outcome of CTA-findings of LVV upon glucocorticoid treatment has not been prospectively evaluated. The aim of our study was to prospectively assess glucocorticoid-induced changes in CTA findings of LVV in patients with GCA. Forty biopsy-proven GCA patients evaluated by CTA at diagnosis were prospectively followed and scheduled a new CTA approximately after 1 year of treatment. Vessel wall thickening, diameter, and contrast enhancement of the aorta and its tributaries were evaluated. Results were compared to those obtained at the time of diagnosis. CTA was repeated to 35 patients after a median follow-up of 13.5 months (IQ25-75% 12.4-15.8). Arterial wall thickening was still present in 17 patients (68% of the patients who initially had LVV). The number of affected segments and wall thickness at various aortic segments significantly decreased and no patients developed new lesions, new aortic dilation or increase in previous dilation. Contrast enhancement disappeared in 15 (93.75%) of 16 patients in whom this finding could be assessed. Signs of LVV improve with treatment. While contrast enhancement resolves in the majority of patients, vessel wall thickening persists in two thirds. However, the number of affected aortic segments as well as aortic wall thickness significantly decreases. Longer follow-up is necessary to determine the clinical significance of persisting wall thickening and its relationship with relapses or subsequent development of aortic dilatation or large-vessel stenoses.
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Affiliation(s)
- Sergio Prieto-González
- From the Vasculitis Research Unit, Departments of Systemic Autoimmune Diseases (SP-G, IT-B, JH-R, MAA, GM, GE-F, MCC); Emergency Medicine (AG-M); and Radiology (JG-C, MS, PA), Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
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