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Peron Filho F, Moreira ADS, Janes ALF, de Souza AWS. Effectiveness and safety of adalimumab compared with leflunomide in patients with Takayasu arteritis: a retrospective cohort study. RMD Open 2024; 10:e003992. [PMID: 38443091 PMCID: PMC11146362 DOI: 10.1136/rmdopen-2023-003992] [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: 12/11/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE This study aims to evaluate the effectiveness and safety of adalimumab (ADA) compared with leflunomide (LEF) in patients with Takayasu arteritis (TAK). METHOD A retrospective cohort study was performed with the following inclusion criteria: the fulfilment of the 2022 American College Classification/European Alliance of Associations for Rheumatology criteria for TAK, age ≥18 years, and written informed consent. Forty-four patients were treated with LEF (n=28) or ADA (n=16) therapy due to relapsing/refractory disease or toxicity from previous therapy. Patients were evaluated at baseline (T0), at a median of 7.0 months (T1) and at 15.0 months of follow-up (T2). Data regarding disease activity, daily dose of prednisone, side effects and angiographic progression were analysed. RESULTS LEF and ADA groups had similar features on the baseline visit. However, intravenous methylprednisolone was more frequently prescribed for the ADA group (p=0.019). On T1 and T2 visits, complete response rates were similar for ADA and LEF groups (75.0% and 88.5%; p=0.397 and 62.5% vs 78.3%; p=0.307), respectively. The differences remained non-significant after adjusting for baseline variables by propensity score matching. Although the ADA group had a higher median daily prednisone on visit T1 (p=0.004), it was similar on visit T2 (p=0.595). Similar rates of angiographic progression were observed in ADA and LEF groups (40% vs 25%; p=0.467). Mild-to-moderate adverse events were observed only in the LEF group (17.9%). CONCLUSION LEF and ADA had comparable outcomes after a median of 15.0 months of follow-up. However, withdrawal from therapy and mild-to-moderate adverse events were only observed in the LEF group.
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Affiliation(s)
- Faustino Peron Filho
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Andressa de Souza Moreira
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Anna Larissa Faria Janes
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Alexandre W S de Souza
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
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Narváez J, Estrada P, LLop D, Vidal-Montal P, Brugarolas E, Maymó-Paituvi P, Palacios-Olid J, Nolla JM. Efficacy and safety of leflunomide in the management of large vessel vasculitis: A systematic review and metaanalysis of cohort studies. Semin Arthritis Rheum 2023; 59:152166. [PMID: 36645992 DOI: 10.1016/j.semarthrit.2023.152166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/06/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The search for new glucocorticoid-sparing disease-modifying anti-rheumatic drugs continues to be an unmet need in large vessel vasculitis (LVV). This report aims to assess the effectiveness and safety of leflunomide (LEF) in Takayasu arteritis (TA) and giant cell arteritis (GCA). METHODS We systematically reviewed the literature, searching for studies evaluating the efficacy of LEF in LVV. A meta-analysis was conducted using the random-effects method. RESULTS The literature search identified eight studies that assessed LEF in TAK and seven in GCA. All were uncontrolled observational studies with a high risk of bias, implying a low or very-low certainty of evidence. In TAK, the pooled proportion of patients achieving at least a partial remission was 75% (95% CI: 0.64-0.84), angiographic stabilization was observed in 86% (0.77-0.94) and relapses in 12% (0.05-0.21). The mean reduction in the prednisolone dose (MRPD) after LEF treatment was 15.7 mg/d (10.28-21.16). Adverse events were observed in 8% of patients (0.02-0.16). Comparison of LEF with methotrexate (MTX) or cyclophosphamide revealed LEF to be superior in terms of remission induction, relapse prevention, and tolerance. When compared with tofacitinib, both drugs demonstrated comparable efficacy. In GCA, the pooled proportion of patients achieving at least a partial remission was 60% (0.17-0.95). The MRPD after LEF treatment was 15.63 mg/d (1.29-32.55) and 53% of the patients were able to discontinue glucocorticoids (0.25 - 0.80). Relapses were observed in 21% of cases (0.14- 0.28) and adverse events in 28% (0.12-0.46). Comparison of LEF with MTX showed similar efficacy and tolerance. CONCLUSION LEF is well tolerated and might be effective for patients with TAK and GCA.
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Affiliation(s)
- Javier Narváez
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain.
| | - Paula Estrada
- Servicio de Reumatología. Hospital de Sant Joan Despí - Moisés Broggi. Barcelona, Spain
| | - Dídac LLop
- Unitat de Recerca de Lípids i Arteriosclerosi. Universitat Rovira i Virgili, Reus. Institut d'Investigació Sanitària Pere Virgili. Tarragona, Spain
| | - Paola Vidal-Montal
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Emma Brugarolas
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Pol Maymó-Paituvi
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Judith Palacios-Olid
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Joan Miquel Nolla
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
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Zheng K, Chen Y, Liu S, He C, Yang Y, Wu D, Wang L, Li M, Zeng X, Zhang F. Leflunomide: Traditional immunosuppressant with concurrent antiviral effects. Int J Rheum Dis 2023; 26:195-209. [PMID: 36371788 DOI: 10.1111/1756-185x.14491] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/06/2022] [Accepted: 10/24/2022] [Indexed: 11/15/2022]
Abstract
Leflunomide is a classic disease-modifying anti-rheumatic drug that is widely used to treat autoimmune diseases. Studies also show its antiviral effects in in vitro and/or in vivo experiments. Considering glucocorticoids, immunosuppressants and newly emerged antibodies commonly used in autoimmune diseases and autoinflammatory disorders bring risk of infection such as viral infection, leflunomide with combination of anti-viral and immunosuppressive features to maintain the balance between infection and anti-inflammation are attractive. Here we summarize the actions and mechanisms of leflunomide in immunoregulatory and antiviral effects.
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Affiliation(s)
- Kunyu Zheng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Yiran Chen
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Suying Liu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Chengmei He
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Yunjiao Yang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Di Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
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4
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Sun Y, Wu B, Zhang W, Ma L, Kong X, Chen H, Jiang L. 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). Ther Adv Chronic Dis 2023; 14:20406223231158567. [PMID: 36895331 PMCID: PMC9989417 DOI: 10.1177/20406223231158567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
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.
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Affiliation(s)
- Ying Sun
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Bingjie Wu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Wei Zhang
- Biomedical Information & Statistics Center, School of Public Health, Fudan University, Shanghai, P.R. China
| | - Lili Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Xiufang Kong
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Huiyong Chen
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, P.R. China
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As C, Danda D. Current Diagnosis and Management of Takayasu Arteritis. Int Heart J 2023; 64:519-534. [PMID: 37518335 DOI: 10.1536/ihj.23-195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Takayasu arteritis (TA or TAK) is a chronic large vessel vasculitis with predilection to affect the aorta and its branches. The new 2022 ACR/EULAR classification criteria for Takayasu arteritis incorporated imaging characteristics as an absolute requirement. ESR and CRP fails in accuracy as disease activity markers. Pentraxin 3 appears to be a relatively superior biomarker, which correlates with ITAS 2010 as per several studies. PET-CT is also increasingly being studied for assessing disease activity with variable results. The management of TAK involves use of steroids with upfront steroid sparing immunosuppressive agents. MMF is one such conventional DMARD/immunosuppressant with good efficacy and better safety profile, as reported in various cohort studies. Tocilizumab is proved to be a rapid remission inducing agent in refractory Takayasu arteritis in observational studies. TNF inhibitors in many uncontrolled studies showed good responses, and there is a need for good RCTs for confirmation. JAK inhibitors have also been used with success in a few reports.
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Affiliation(s)
- Chandhu As
- Department of Clinical Immunology & Rheumatology, Christian Medical College & Hospital
| | - Debashish Danda
- Department of Clinical Immunology & Rheumatology, Christian Medical College & Hospital
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A novel molecular mechanism of vascular fibrosis in Takayasu arteritis: macrophage-derived GPNMB promoting adventitial fibroblast extracellular matrix production in the aorta. Transl Res 2022; 255:128-139. [PMID: 36566014 DOI: 10.1016/j.trsl.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Takayasu arteritis (TAK) is a chronic large vessel disease characterized by aortic fibrotic thickening, which was mainly mediated by activation of aorta adventitial fibroblasts (AAFs). Our previous genetic study demonstrated that TAK-associated locus IL6 rs2069837 regulated glycoprotein non-metastatic melanoma protein B (GPNMB) expression. Thus, this study aimed to investigate the pathogenic role of GPNMB in TAK. Through pathological staining, we find that GPNMB was mainly expressed in vascular adventitia and positively correlated with adventitial extracellular matrix (ECM) expression in TAK vascular lesion. Specifically, GPNMB was increased in adventitial CD68+ macrophages, which were closely located with CD90+ adventitial fibroblasts. In in-vitro cell culture, THP-1-derived macrophages with GPNMB overexpression promoted ECM expression in AAFs. This effect was also confirmed in aortic tissue or AAFs culture with GPNMB overexpression or active GPNMB protein stimulation. Mechanistically, Co-IP assay and siRNA or inhibitor intervention demonstrated that integrin αVβ1 receptor mediated GPNMB effect on AAFs, which also activated downstream Akt and Erk pathway in AAFs. Furthermore, we showed that leflunomide treatment inhibited GPNMB-mediated fibrosis in AAFs, as well as GPNMB expression in macrophages, which were also partially validated in leflunomide-treated patients. Taken together, these data indicated that macrophage-derived GPNMB promotes AAFs ECM expression via the integrin αVβ1 receptor and Akt/Erk signaling pathway and leflunomide might play an anti-fibrotic role in TAK by interfering with the macrophage-derived GPNMB/AAFs axis. This study provides evidence that targeting GPNMB is a potential therapeutic strategy for treating vascular fibrosis in TAK.
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Danda D, Manikuppam P, Tian X, Harigai M. Advances in Takayasu arteritis: An Asia Pacific perspective. Front Med (Lausanne) 2022; 9:952972. [PMID: 36045929 PMCID: PMC9423100 DOI: 10.3389/fmed.2022.952972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
Abstract
Takayasu Arteritis (TA) is a rare form of chronic granulomatous large vessel vasculitis that is more common in Asia compared to other parts of the world. There have been several developments in the field of Takayasu arteritis in relation to genetics, classification, clinical features, imaging, disease activity assessment and management and much of these works have been done in the Asia Pacific region. We will be discussing selected few in the current review.
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Affiliation(s)
- Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore, India
| | - Prathyusha Manikuppam
- Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore, India
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Masayoshi Harigai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
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Ben Mrid R, Bouchmaa N, Ainani H, El Fatimy R, Malka G, Mazini L. Anti-rheumatoid drugs advancements: New insights into the molecular treatment of rheumatoid arthritis. Biomed Pharmacother 2022; 151:113126. [PMID: 35643074 DOI: 10.1016/j.biopha.2022.113126] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 11/02/2022] Open
Abstract
Rheumatoid arthritis (RA) is one of more than 100 types of arthritis. This chronic autoimmune disorder affects the lining of synovial joints in about 0.5% of people and may induce severe joints deformity and disability. RA impacts health life of people from all sexes and ages with more prevalence in elderly and women people. Significant improvement has been noted in the last two decades revealing the mechanisms of the development of RA, the improvement of the early diagnosis and the development of new treatment options. Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying antirheumatic drugs (DMARDs) remain the most known treatments used against RA. However, not all patients respond well to these drugs and therefore, new solutions are of immense need to improve the disease outcomes. In the present review, we discuss and highlight the recent findings concerning the different classes of RA therapies including the conventional and modern drug therapies, as well as the recent emerging options including the phyto-cannabinoid and cell- and RNA-based therapies. A better understanding of their mechanisms and pathways might help find a specific target against inflammation, cartilage damage, and reduce side effects in arthritis.
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Affiliation(s)
- Reda Ben Mrid
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Najat Bouchmaa
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Hassan Ainani
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Rachid El Fatimy
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Gabriel Malka
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Loubna Mazini
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco.
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Ross C, Lefebvre F, Pagnoux C. Cessation of immunosuppressive therapies in patients with Takayasu arteritis with sustained inactive disease. Semin Arthritis Rheum 2021; 52:151934. [PMID: 35000787 DOI: 10.1016/j.semarthrit.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Takayasu arteritis (TA) is a chronic and relapsing vasculitis. The objectives of this study were to describe the characteristics and identify predictive factors associated with successful treatment discontinuation in a cohort of patients with TA. METHODS We conducted a retrospective monocentric analysis of patients with TA, followed at the tertiary Vasculitis Clinic in Toronto, from inception to January 2021, and for at least 2 years after diagnosis. The objectives were to determine the frequency of patients whose immunosuppressive medications had been stopped for at least 6 months before their last follow-up visit and whose disease remained inactive, and analyze their characteristics, in comparison with the remaining of the cohort still on medications for TA. RESULTS The cohort included 65 patients (95.4% women; 46.7% white). Twenty-five (38.5%) patients had successfully discontinued their treatment for more than 6 months at their last visit. Median disease duration was 18 years (IQR, 10-23 years) in the group off treatment, compared to 9 years (IQR, 5.3-16.0 years) in the group still on treatment (P = 0.004). Renal artery involvement was less frequent in patients who had stopped their immunosuppressants, especially left renal artery (P = 0.035). Median CRP level at diagnosis was 16.4 mg/L (IQR, 5.4-32.2 mg/L) in the group off treatment, and 45 mg/L (IQR, 15.0-75.5 mg/L) in the group on treatment (P = 0.023). No other difference was found when comparing disease characteristics of the two groups, on or off medications. CONCLUSION One third of TA patients were able to discontinue their treatment. They had lower CRP levels at diagnosis, less frequent renal artery involvement and longer disease duration. No other specific disease features seem to help identify patients with greater chances to be weaned off treatment successfully.
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Affiliation(s)
- Carolyn Ross
- Vasculitis Clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Frederic Lefebvre
- Vasculitis Clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Misra DP, Rathore U, Patro P, Agarwal V, Sharma A. Disease-modifying anti-rheumatic drugs for the management of Takayasu arteritis-a systematic review and meta-analysis. Clin Rheumatol 2021; 40:4391-4416. [PMID: 33932173 PMCID: PMC8087890 DOI: 10.1007/s10067-021-05743-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 01/17/2023]
Abstract
The pharmacotherapy of Takayasu arteritis (TAK) with disease-modifying anti-rheumatic drugs (DMARDs) is an evolving area. A systematic review of Scopus, Web of Science, Pubmed Central, clinical trial databases and recent international rheumatology conferences for interventional and observational studies reporting the effectiveness of DMARDs in TAK identified four randomized controlled trials (RCTs, with another longer-term follow-up of one RCT) and 63 observational studies. The identified trials had some concern or high risk of bias. Most observational studies were downgraded on the Newcastle-Ottawa scale due to lack of appropriate comparator groups. Studies used heterogenous outcomes of clinical responses, angiographic stabilization, normalization of inflammatory markers, reduction in vascular uptake on positron emission tomography, reduction in prednisolone doses and relapses. Tocilizumab showed benefit in a RCT compared to placebo in a secondary per-protocol analysis but not the primary intention-to-treat analysis. Abatacept failed to demonstrate benefit compared to placebo for preventing relapses in another RCT. Pooled data from uncontrolled observational studies demonstrated beneficial clinical responses and angiographic stabilization in nearly 80% patients treated with tumour necrosis factor alpha inhibitors, tocilizumab or leflunomide. Certainty of evidence for outcomes from RCTs ranged from moderate to very low and was low to very low for all observational studies. There is a paucity of high-quality evidence to guide the pharmacotherapy of TAK. Future observational studies should attempt to include appropriate comparator arms. Multicentric, adequately powered RCTs assessing both clinical and angiographic responses are necessary in TAK.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Upendra Rathore
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Pallavi Patro
- School of Telemedicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), -160012, Chandigarh, India
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Wu S, Kong X, Cui X, Chen H, Ma L, Dai X, Ji Z, Yan Y, Huang Q, Sun Y, Jiang L. Effectiveness and safety of tocilizumab in patients with refractory or severe Takayasu's arteritis: A prospective cohort study in a Chinese population. Joint Bone Spine 2021; 88:105186. [PMID: 33892193 DOI: 10.1016/j.jbspin.2021.105186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/26/2021] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To assess the effectiveness and safety of tocilizumab (TCZ) in treating severe/refractory Takayasu's arteritis (TAK). METHODS A prospective cohort study was started on 1 November 2013 and terminated on 10 June 2020. Thirty-seven patients diagnosed as severe/refractory TAK, treated with TCZ combined with or without immunosuppressors were enrolled. Treatment response (complete remission (CR) and partial remission (PR)), imaging progression and side effects were analyzed at 6-month treatment. Disease flare was analyzed during the remaining follow-up. RESULTS The CR and RR rates were 70% and 88% at 6 months of TCZ treatment, respectively. Glucocorticoids was tapered from 30.0 (20.0-40.0) to 15.0 (10.0-15.0) mg/day at 6 months. Younger patients (≤26 years) (OR=14.6, 95% CI 1.27-170.4, P<0.05) and those with involvement of bilateral carotid arteries or vertebral arteries (OR=14.6, 95% CI 1.27-169.1, P<0.05) might show a better response to TCZ at 6 months. Combined therapy of immunosuppressors had no significant effects on the effectiveness of TCZ at 6 months. Among the total 23 patients with CR at 6 months, 14 cases discontinued TCZ therapy after 6 months, and disease flare was observed in six ones (43%), with medium flare at 7 (7-9.8) months. One patient (11%) who continued TCZ therapy suffered disease flare at 8 months. Infections were the most commonly observed side effects (38%), with four patients discontinuing TCZ treatment due to severe infections. CONCLUSION TCZ treatment achieved a favorable response with acceptable adverse effects for TAK.
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Affiliation(s)
- Sifan Wu
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Xiufang Kong
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Xiaomeng Cui
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Huiyong Chen
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Lili Ma
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China; Evidence-base Medicine Center, Fudan University, 200032 Shanghai, People's Republic of China
| | - Xiaomin Dai
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Zongfei Ji
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Yan Yan
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Qingrong Huang
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China
| | - Ying Sun
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China.
| | - Lindi Jiang
- Departments of Rheumatology, Zhongshan Hospital, Fudan University, 180, Fenglin Road, 200032 Shanghai, People's Republic of China; Evidence-base Medicine Center, Fudan University, 200032 Shanghai, People's Republic of China.
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12
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Ortiz-Fernández L, Saruhan-Direskeneli G, Alibaz-Oner F, Kaymaz-Tahra S, Coit P, Kong X, Kiprianos AP, Maughan RT, Aydin SZ, Aksu K, Keser G, Kamali S, Inanc M, Springer J, Akar S, Onen F, Akkoc N, Khalidi NA, Koening C, Karadag O, Kiraz S, Forbess L, Langford CA, McAlear CA, Ozbalkan Z, Yavuz S, Çetin GY, Alpay-Kanitez N, Chung S, Ates A, Karaaslan Y, McKinnon-Maksimowicz K, Monach PA, Ozer HT, Seyahi E, Fresko I, Cefle A, Seo P, Warrington KJ, Ozturk MA, Ytterberg SR, Cobankara V, Onat AM, Duzgun N, Bıcakcıgil M, Yentür SP, Lally L, Manfredi AA, Baldissera E, Erken E, Yazici A, Kısacık B, Kaşifoğlu T, Dalkilic E, Cuthbertson D, Pagnoux C, Sreih A, Reales G, Wallace C, Wren JD, Cunninghame-Graham DS, Vyse TJ, Sun Y, Chen H, Grayson PC, Tombetti E, Jiang L, Mason JC, Merkel PA, Direskeneli H, Sawalha AH. Identification of susceptibility loci for Takayasu arteritis through a large multi-ancestral genome-wide association study. Am J Hum Genet 2021; 108:84-99. [PMID: 33308445 DOI: 10.1016/j.ajhg.2020.11.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/17/2020] [Indexed: 12/21/2022] Open
Abstract
Takayasu arteritis is a rare inflammatory disease of large arteries. We performed a genetic study in Takayasu arteritis comprising 6,670 individuals (1,226 affected individuals) from five different populations. We discovered HLA risk factors and four non-HLA susceptibility loci in VPS8, SVEP1, CFL2, and chr13q21 and reinforced IL12B, PTK2B, and chr21q22 as robust susceptibility loci shared across ancestries. Functional analysis proposed plausible underlying disease mechanisms and pinpointed ETS2 as a potential causal gene for chr21q22 association. We also identified >60 candidate loci with suggestive association (p < 5 × 10-5) and devised a genetic risk score for Takayasu arteritis. Takayasu arteritis was compared to hundreds of other traits, revealing the closest genetic relatedness to inflammatory bowel disease. Epigenetic patterns within risk loci suggest roles for monocytes and B cells in Takayasu arteritis. This work enhances understanding of the genetic basis and pathophysiology of Takayasu arteritis and provides clues for potential new therapeutic targets.
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Kang K, Sun Y, Li YL, Chang B. Pathogenesis of liver injury in Takayasu arteritis: advanced understanding leads to new horizons. J Int Med Res 2020; 48:300060520972222. [PMID: 33275473 PMCID: PMC7720339 DOI: 10.1177/0300060520972222] [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] [Indexed: 11/16/2022] Open
Abstract
Liver injury in Takayasu arteritis (TA) is a rare phenomenon. Most symptoms are nonspecific, and the exact pathogenesis remains to be elucidated. Early diagnosis and new treatment methods are important for an improved prognosis. A summary of the clinical information and mechanistic analyses may contribute to making an early diagnosis and development of new treatment methods. A PubMed search was conducted using the specific key words “Takayasu arteritis” and “liver” or “hepatitis” or “hepatic”. Symptoms and treatment of TA with an accompanying liver injury were reviewed retrospectively. Many factors are presumed to be involved in the mechanism of TA with liver injury, including the immune response, genes, infections, and gut microbiota. There are several lines of evidence indicating that immune dysfunction is the main pathogenic factor that triggers granuloma formation in TA patients. However, the role of genetics and infections has not been fully confirmed. Recently, the gut microbiota has emerged as an essential component in the process. We reviewed in detail the current concepts that support the complex pathogenesis of TA accompanied by liver injury, and we presented recent theories from the literature. Finally, we discussed future research directions of liver injury in TA.
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Affiliation(s)
- Kai Kang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Yue Sun
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Yi Ling Li
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Bing Chang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, China
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14
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Wu C, Sun Y, Cui X, Wu S, Ma L, Chen H, Yan Y, Ji Z, Liu Y, Lin J, Lv P, Chen R, Yang P, Jiang L. Effectiveness and safety of methotrexate versus leflunomide in 12-month treatment for Takayasu arteritis. Ther Adv Chronic Dis 2020; 11:2040622320975233. [PMID: 33294149 PMCID: PMC7705767 DOI: 10.1177/2040622320975233] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/29/2020] [Indexed: 12/31/2022] Open
Abstract
Aims: The study investigates the effectiveness and safety of methotrexate (MTX)
versus leflunomide (LEF) in 12-month treatment of
Takayasu arteritis (TAK). Methods: This was a cohort study. Patients diagnosed with TAK between 1 January 2013
and 1 January 2019 were enrolled from First Hospital of China Medical
University and Zhongshan Hospital of Fudan University. Patients had active
disease and were treated with glucocorticoid combined with LEF or MTX.
Treatment response, imaging assessment and side-effects were evaluated
during 12-month follow-up. Results: In total, 68 patients were enrolled (40 cases treated with LEF and 28 treated
with MTX). At baseline, age, sex, disease duration and disease activity
index showed no significant differences between groups. Prevalence of
complete remission (CR) at 6 months was significantly higher in the LEF
group than that in the MTX group (LEF versus MTX: 72.50%
versus 53.57%, p = 0.04), though the
CR prevalence at 9 months and 12 months showed no significant differences
between groups. At 9 months, the prevalence of treatment resistance was much
lower in the LEF group compared with MTX group (5.41%
versus 11.54%, p = 0.03). Furthermore,
prevalence of disease relapse in the LEF group was lower than that in MTX
group at 12 months (7.24% versus 16.67%,
p = 0.03). Patients with high baseline C-reactive protein
levels (⩾15 mg/L) carried a higher risk of treatment resistance (OR = 1.36,
95% CI 1.07–13.41, p = 0.06) and disease relapse
(HR = 2.51, 95% CI 1.36–12.98, p = 0.04). Conclusion: LEF might provide a quicker treatment response with lower prevalence of
disease relapse compared with that elicited in MTX during 12 months
follow-up for TAK.
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Affiliation(s)
- Chunling Wu
- Department of Rheumatology and Immunology, The First Hospital of China Medical University, Shenyang, P. R. China
| | - Ying Sun
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Xiaomeng Cui
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Sifan Wu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lili Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Huiyong Chen
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Yan Yan
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Zongfei Ji
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Yun Liu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Peng Lv
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Rongyi Chen
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Pingting Yang
- Department of Rheumatology and Immunology, The First Hospital of China Medical University, Shenyang, Liaoning, P. R. China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Xuhui District, Shanghai, 200032, P. R. China Centre of Evidence-based Medicine, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
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15
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Ying S, Xiaomeng C, Xiaomin D, Jiang L, Peng L, Lili M, Rongyi C, Zongfei J, Huiyong C, Lindi J. Efficacy and safety of leflunomide versus cyclophosphamide for initial-onset Takayasu arteritis: a prospective cohort study. Ther Adv Musculoskelet Dis 2020; 12:1759720X20930114. [PMID: 32536986 PMCID: PMC7268110 DOI: 10.1177/1759720x20930114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/07/2020] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Sun Ying
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Cui Xiaomeng
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Dai Xiaomin
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lin Jiang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lv Peng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Ma Lili
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Chen Rongyi
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Ji Zongfei
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Chen Huiyong
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Jiang Lindi
- Department of Rheumatology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road Shanghai, 200032, P. R. China Centre of Evidence-based Medicine, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
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