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O'Neill L, McCormick J, Gao W, Veale DJ, McCarthy GM, Murphy CC, Fearon U, Molloy ES. Interleukin-6 does not upregulate pro-inflammatory cytokine expression in an ex vivo model of giant cell arteritis. Rheumatol Adv Pract 2019; 3:rkz011. [PMID: 31431999 PMCID: PMC6649906 DOI: 10.1093/rap/rkz011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/17/2019] [Indexed: 11/14/2022] Open
Abstract
Objective The aim of this study was to examine the pro-inflammatory effects of IL-6 in ex vivo temporal artery explant cultures. Methods Patients meeting 1990 ACR classification criteria for GCA were prospectively recruited. Temporal artery biopsies were obtained and temporal artery explants cultured ex vivo with IL-6 (10-40 ng/ml) in the presence or absence of its soluble receptor (sIL-6R; 20 ng/ml) for 24 h. Explant supernatants were harvested after 24 h and assayed for IFN-γ, TNF-α, Serum amyloid A, IL-1β, IL-17, IL-8, angiotensin II and VEGF by ELISA. Myofibroblast outgrowths, cytoskeletal rearrangement and wound repair assays were performed. Results IL-6 augmented production of VEGF, but not of any of the other pro-inflammatory mediators assayed. No differences were observed in the explants cultured in the presence or absence of the sIL-6R or between those with a positive (n = 11) or negative (n = 17) temporal artery biopsy. IL-6 did not enhance myofibroblast proliferation or migration. Western blot analysis confirmed signalling activation, with increased expression of pSTAT3 in response to IL-6+sIL-6R. Conclusion IL-6 stimulation of temporal artery explants from patients with GCA neither increased expression of key pro-inflammatory mediators nor influenced myofibroblast proliferation or migration.
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Affiliation(s)
- Lorraine O'Neill
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Jennifer McCormick
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Wei Gao
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Douglas J Veale
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Geraldine M McCarthy
- Mater Misericordiae University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Conor C Murphy
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Royal College of Surgeons, Ireland
| | - Ursula Fearon
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Eamonn S Molloy
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
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Clinical and pathological evolution of giant cell arteritis: a prospective study of follow-up temporal artery biopsies in 40 treated patients. Mod Pathol 2017; 30:788-796. [PMID: 28256573 PMCID: PMC5650068 DOI: 10.1038/modpathol.2017.10] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/19/2017] [Accepted: 01/22/2017] [Indexed: 12/21/2022]
Abstract
Although clinical signs and symptoms of giant cell arteritis improve promptly after starting glucocorticoid therapy, reports have suggested that the vascular inflammation may persist. To assess the duration and quality of histopathologic changes in treated patients, we prospectively obtained second temporal artery biopsies in patients treated for 3 to 12 months after their first diagnostic biopsy. Forty patients (28 women, 12 men, median age 77 years) agreed to have a second temporal artery biopsy randomly assigned to 3, 6, 9, or 12 months subsequent to the first. Clinical and laboratory evaluation of the patient cohort revealed a typical rapid response and continued suppression of clinical manifestations as a result of glucocorticoid treatment. Histopathologic findings, evaluated in a blinded manner by a cardiovascular pathologist, showed unequivocal findings of vasculitis in 7/10 patients with second temporal artery biopsy at 3 months, 9/12 at 6 months, 4/9 at 9 months, and 4/9 at 12 months. Lymphocytes were present in all positive initial biopsies and remained the dominant cell population in chronically treated patients. Granulomatous inflammation decreased in a time-dependent manner from 78 to 100% at initial biopsy to 50% at 9 months and 25% at 12 months. The increased medial fibrosis noted in the second biopsies (60 vs 33% in primary temporal artery biopsies) suggested that the finding may represent a chronic finding in arteritis. In summary, the response to glucocorticoids in giant cell arteritis was frequently discordant. Clinical manifestations were readily suppressed, but vascular changes were gradual and often incomplete.
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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
Large vessel vasculitis (LVV) covers a spectrum of primary vasculitides predominantly affecting the aorta and its major branches. The two main subtypes are giant cell arteritis (GCA) and Takayasu arteritis (TA). Less commonly LVV occurs in various other diseases. Clinical manifestations result from vascular stenosis, occlusion, and dilation, sometimes complicated by aneurysm rupture or dissection. Occasionally LVV is discovered unexpectedly on pathological examination of a resected aortic aneurysm. Clinical evaluation is often unreliable in determining disease activity. Moreover, the diagnostic tools are imperfect. Acute phase reactants can be normal at presentation and available imaging modalities are more reliable in delineating vascular anatomy than in providing reliable information on degree of vascular inflammation. Glucocorticoids are the mainstay of therapy of LVV. Patients may develop predictable adverse effects from long-term glucocorticoid use. Several steroid-sparing agents have also shown some promise and are currently in use. Endovascular revascularization procedures and open surgical treatment for aneurysms and dissections are sometimes necessary, but results are not always favorable and relapses are common. This article, the first in a series of two, will be devoted to GCA and isolated (idiopathic) aortitis, while TA will be covered in detail in the next article.
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Nabili S, Bhatt P, Roberts F, Gracie A, McFadzean R. Local Expression of IL-18 in the Temporal Artery Does Not Correlate with Clinical Manifestations of Giant Cell Arteritis. Neuroophthalmology 2009. [DOI: 10.1080/01658100701818172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Veyssier-Belot C, Zuech P, Somogyi A. [Temporal artery biopsy may remain positive even after long-term corticosteroid treatment: report of two cases]. Rev Med Interne 2007; 28:623-6. [PMID: 17624640 DOI: 10.1016/j.revmed.2007.03.335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Accepted: 03/26/2007] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Temporal arteritis is the most common systemic vasculitis of the elderly. It is diagnosed with the combination of a clinico-biological syndrome and typical histologic features recognized on temporal artery biopsy (TAB). Cortisteroid therapy is quickly recommended, before the TAB is performed or before the histologic results confirm the diagnosis. It is recommended to perform TAB as soon as possible after the treatment has begun in order to avoid a presumed improvement or normalisation of the histological features. EXEGESIS We report the cases of two patients, a 76-year-old woman and a 78-year-old man who had persistent clinical and histological features of temporal arteritis 5 years and one year respectively after corticosteroid therapy was initiated. CONCLUSION Histological changes in the temporal artery biopsy may persist for as long as five years in a patient receiving a corticosteroid treatment for temporal arteritis. Even when largely delayed after the beginning of the treatment, temporal artery biopsy may prove to be important in diagnosing persistent temporal arteritis.
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Affiliation(s)
- C Veyssier-Belot
- Service de médecine interne, centre hospitalier de Poissy-Saint-Germain-en-Laye, site de Sant-Germain-en-Laye, 20, rue Armagis, 78100 Saint-Germain-en-Laye, France.
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Mazlumzadeh M, Hunder GG, Easley KA, Calamia KT, Matteson EL, Griffing WL, Younge BR, Weyand CM, Goronzy JJ. Treatment of giant cell arteritis using induction therapy with high-dose glucocorticoids: A double-blind, placebo-controlled, randomized prospective clinical trial. ACTA ACUST UNITED AC 2006; 54:3310-8. [PMID: 17009270 DOI: 10.1002/art.22163] [Citation(s) in RCA: 217] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Glucocorticoid (GC) therapy for giant cell arteritis (GCA) is effective but requires prolonged administration, resulting in adverse side effects. The goal of the current study was to test the hypothesis that induction treatment with high-dose pulse intravenous (IV) methylprednisolone permits a shorter course of therapy. METHODS Twenty-seven patients with biopsy-proven GCA were enrolled in a randomized, double-blind, placebo-controlled study to receive IV methylprednisolone (15 mg/kg of ideal body weight/day) or IV saline for 3 consecutive days. All patients were started on 40 mg/day prednisone and followed the same tapering schedule as long as disease activity was controlled. The numbers of patients with disease in remission after 36, 52, and 78 weeks of treatment and taking <or=5 mg/day prednisone were compared. Cumulative prednisone dose, number of relapses, and development of adverse GC effects were assessed. RESULTS Ten of the 14 IV GC-treated patients, but only 2 of 13 control patients, were taking <or=5 mg/day prednisone at 36 weeks (P = 0.003). This difference was maintained; there was a higher number of sustained remissions after discontinuation of treatment in the IV GC-treated group and a lower median daily dose of prednisone at 78 weeks (P = 0.0004). The median cumulative dose of oral prednisone, excluding the IV GC dose, was 5,636 mg in the IV GC-treated group compared with 7,860 mg in the IV saline-treated group (P = 0.001). CONCLUSION Initial treatment of GCA with IV GC pulses allowed for more rapid tapering of oral GCs and had long-term benefits, with a higher frequency of patients experiencing sustained remission of their disease after discontinuation of treatment.
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Kay J, Finn DS, Stone JR. Case records of the Massachusetts General Hospital. Case 4-2006. A 79-year-old woman with myalgias, fatigue, and shortness of breath. N Engl J Med 2006; 354:623-30. [PMID: 16467550 DOI: 10.1056/nejmcpc059040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jonathan Kay
- Department of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, USA
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Abstract
Temporal arteritis was first described in the late nineteenth century. Despite considerable progress in understanding the disease, its rarity in the young and in those who are not of Scandinavian ethnicity remains unexplained. Microbiologic agents and immunologic mechanisms have been implicated as causative factors. Although steroids remain the drug of choice, the use of other immunologic therapies has been proposed. This paper reviews the disease's history, probable etiologies, clinical manifestations, and its diagnostic and treatment challenges.
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Affiliation(s)
- Carol Redillas
- Department of Neurology, Marshfield Clinic, 1000 N. Oak Avenue, Marshfield, WI 54449, USA.
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Rüegg S, Engelter S, Jeanneret C, Hetzel A, Probst A, Steck AJ, Lyrer P. Bilateral vertebral artery occlusion resulting from giant cell arteritis: report of 3 cases and review of the literature. Medicine (Baltimore) 2003; 82:1-12. [PMID: 12544706 DOI: 10.1097/00005792-200301000-00001] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Giant cell arteritis (GCA) is known to affect the extracranial part of the vertebral arteries. Bilateral vertebral artery occlusion (BVAO) is a rare but serious neurologic condition. We report 3 patients with autopsy-proven (2 patients) or clinically diagnosed (1 patient) GCA causing BVAO. A review of the literature concerning BVAO revealed 5 other cases of BVAO resulting from GCA and 110 cases with underlying arteriosclerotic disease. Our 3 patients (mean age, 66 yr; range, 60-78 yr) with BVAO resulting from GCA all had initial severe headache followed by the onset of stepwise progressive, partly side-alternating neurologic deficits due to bilateral infarctions in the vertebrobasilar circulation territory. This course, more accelerated in BVAO due to GCA than in BVAO of arteriosclerotic origin, seems to be a typical, if not particular, clinical syndrome. BVAO was the first clinical manifestation of GCA in 1 of our patients and in 1 published case. From a clinical view, BVAO resulting from GCA differs from BVAO of arteriosclerotic origin by the much higher mortality rate (75% versus 19%, respectively), the presence of headache (100% versus 22%), fever (50% versus 0%), and elevated erythrocyte sedimentation rate (ESR in all GCA cases >45 mm/h; no data in the arteriosclerotic patient group), but not by the neurologic signs themselves. Therapy of BVAO resulting from GCA is purely empiric. In view of the serious prognosis, we propose treatment with intravenous high-dose glucocorticoids and additional immunosuppression with cyclophosphamide; the use of anticoagulation depends on the individual patient's estimated risk-benefit profile. Although BVAO due to GCA is rare, physicians and especially rheumatologists or neurologists should be aware of this entity because of its high mortality in patients without immediate introduction of a high-dose immunosuppressive therapy. Suspicion of GCA should arise in a patient aged over 50 years with no other vascular risk factors suffering from bilateral symptoms of ischemia in the vertebrobasilar territory, with a quickly progressing stepwise course and with headache, fever, or history of myalgia. ESR and temporal artery biopsy should be performed without delay. Early diagnosis of GCA is necessary for immediate initiation of intensive antiinflammatory and immunosuppressive treatment, without which progressive deterioration and systemic involvement are likely to be fatal.
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Affiliation(s)
- Stephan Rüegg
- Department of Neurology, University Clinics Basel, Switzerland.
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Vinters HV. Cerebrovascular disease--practical issues in surgical and autopsy pathology. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 2001; 95:51-99. [PMID: 11545057 DOI: 10.1007/978-3-642-59554-7_2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- H V Vinters
- Department of Pathology and Laboratory Medicine, Section of Neuropathology, Brain Research Institute and Neuropsychiatric Institute, UCLA Medical Center, CHS 18-170, Los Angeles, California 90095-1732, USA
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Riordan-Eva P, Landau K, O'Day J. Temporal artery biopsy in the management of giant cell arteritis with neuro-ophthalmic complications. Br J Ophthalmol 2001; 85:1248-51. [PMID: 11567973 PMCID: PMC1723724 DOI: 10.1136/bjo.85.10.1248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- P Riordan-Eva
- Department of Ophthalmology, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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Gumà Uriel M, Valls Roc M, Olivé Marquès A. [Treatment of systemic necrotizing vasculitis and giant cell arteritis]. Med Clin (Barc) 2001; 117:191-5. [PMID: 11481086 DOI: 10.1016/s0025-7753(01)72055-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- M Gumà Uriel
- Sección de Reumatología. Hospital Universitari Germans Trias i Pujol. Badalona
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Abstract
PMR and GCA are related conditions that seem to represent a continuum of disease. These conditions are relatively common and seem to be mediated by a cellular inflammatory response. Increasing evidence suggests an infectious cause (or causes) precipitating this immune response in genetically susceptible individuals. Whereas previously thought to affect primarily branch vessels of the aortic arch, GCA is now thought of as a disease in which proximal aortic involvement is frequent. Despite the potential for serious, even fatal complications, overall prognosis for patients with GCA or PMR is excellent. Corticosteroids remain the standard treatment, although not curative. Whereas the ESR is a useful indicator of disease activity, other markers which may be more precise such as creative protein and Il-6 seem to offer added information about disease activity.
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Affiliation(s)
- J M Evans
- Section of Geriatrics, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Giant cell arteritis and polymyalgia rheumatica are linked conditions that frequently occur in the same patient. They are more common in northern Europe and persons of European descent than in other populations. Recent investigations have begun to provide information about the pathogenesis of both syndromes. Both respond to corticosteroids but at different dose levels. Although a number of vascular complications may occur, the outlook is excellent.
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Affiliation(s)
- G G Hunder
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
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Michet CJ, Evans JM, Fleming KC, O'Duffy JD, Jurisson ML, Hunder GG. Common rheumatologic diseases in elderly patients. Mayo Clin Proc 1995; 70:1205-14. [PMID: 7490924 DOI: 10.4065/70.12.1205] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To review common rheumatologic disorders that affect elderly patients and emphasize the unique diagnostic and therapeutic challenges inherent in the management of rheumatologic diseases in this age-group. DESIGN We summarize our approach to treatment and management of specific rheumatologic problems in geriatric patients and discuss pertinent studies from the literature. RESULTS Among the spectrum of rheumatologic disorders frequently encountered in the elderly population are polymyalgia rheumatica, fibromyalgia, giant cell arteritis, crystalline arthropathies (gout and pseudogout), and degenerative joint disease. The initial manifestations of these rheumatologic diseases in elderly patients may differ from the typical findings in younger patients. Geriatric patients may have nonspecific complaints, a decline in physical function, or even confusion. Because of physiologic changes associated with aging and a decrease in functional reserves, elderly patients are susceptible to adverse effects of pharmacologic therapy (including nonsteroidal anti-inflammatory medications, corticosteroids, narcotic analgesics, allopurinol, and colchicine). Clinicians should be alert for such problems as hepatotoxicity and occult gastrointestinal blood loss. Comorbid conditions such as cardiovascular disease and cognitive impairment may complicate management strategies and may limit the goals of both surgical intervention and rehabilitation programs in elderly patients. CONCLUSION Rheumatologic disorders in geriatric patients pose special challenges to primary-care physicians. In the selection of optimal pharmacologic and nonpharmacologic therapeutic modalities, clinicians should focus on maintaining or improving the patient's quality of life and level of independent function.
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Affiliation(s)
- C J Michet
- Division of Rheumatology and Internal Medicine, Mayo Clinic Scottsdale, Arizona, USA
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