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Keshvani C, Laylani N, Davila-Siliezar P, Kopel J, Lee AG. Neuro-ophthalmic challenges and multi-morbidity in vasculitis among the older adults. Expert Rev Clin Immunol 2024; 20:781-791. [PMID: 38572928 DOI: 10.1080/1744666x.2024.2339893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/03/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Vasculitides are a heterogeneous group of disorders producing inflammation of blood vessels (e.g. arteries or veins). All major vasculitides potentially have ophthalmological symptoms and signs including visual loss. Co-morbidity, multimorbidity, polypharmacy, and geriatric syndromes all play important roles in patient outcomes for these rheumatic conditions in the elderly. This monograph reviews the NCBI PubMed database (Feb 2023) literature on the neuro-ophthalmic and geriatric considerations in vasculitis. AREAS COVERED Cogan Syndrome, Granulomatosis with Polyangiitis, Giant Cell Arteritis, Polyarteritis Nodosa, Takayasu Arteritis, Vasculitis epidemiology, and neuro-ophthalmological symptoms. EXPERT OPINION Geriatric patient care for vasculitis with neuro-ophthalmological manifestations can be complicated by the interplay of multiple co-morbidities, polypharmacy, and specific geriatric syndromes. The valuation and treatment of vasculitis and the complications associated with the disease can negatively impact patient care. Advances in noninvasive imaging and updates in diagnostic criteria have enabled increased identification of patients at earlier stages with less severe disease burden. Novel therapeutic agents can be glucocorticoid sparing and might reduce the adverse effects of chronic steroid use. Holistic care models like the 5 M geriatric care model (mind, mobility, medications, multicomplexity, and matters most) allow patients' needs to be in the forefront with biopsychosocial aspects of a patient being addressed.
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Affiliation(s)
- Caezaan Keshvani
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Noor Laylani
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | | | - Jonathan Kopel
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Andrew G Lee
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Department of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- Department of Ophthalmology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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van der Geest KSM, Sandovici M, Bley TA, Stone JR, Slart RHJA, Brouwer E. Large vessel giant cell arteritis. THE LANCET. RHEUMATOLOGY 2024; 6:e397-e408. [PMID: 38574745 DOI: 10.1016/s2665-9913(23)00300-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 04/06/2024]
Abstract
Giant cell arteritis is the principal form of systemic vasculitis affecting people over 50. Large-vessel involvement, termed large vessel giant cell arteritis, mainly affects the aorta and its branches, often occurring alongside cranial giant cell arteritis, but large vessel giant cell arteritis without cranial giant cell arteritis can also occur. Patients mostly present with constitutional symptoms, with localising large vessel giant cell arteritis symptoms present in a minority of patients only. Large vessel giant cell arteritis is usually overlooked until clinicians seek to exclude it with imaging by ultrasonography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), or [18F]fluorodeoxyglucose-PET-CT. Although the role of imaging in treatment monitoring remains uncertain, imaging by MRA or CTA is crucial for identifying aortic aneurysm formation during patient follow up. In this Series paper, we define the large vessel subset of giant cell arteritis and summarise its clinical challenges. Furthermore, we identify areas for future research regarding the management of large vessel giant cell arteritis.
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Affiliation(s)
- Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thorsten A Bley
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riemer H J A Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Netherlands; Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Sugihara T, Yoshifuji H, Uchida HA, Maejima Y, Watanabe Y, Tanemoto K, Umezawa N, Manabe Y, Ishizaki J, Shirai T, Nagafuchi H, Hasegawa H, Niiro H, Ishii T, Nakaoka Y, Harigai M. Establishing clinical remission criteria for giant cell arteritis: Results of a Delphi exercise carried out by an expert panel of the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis. Mod Rheumatol 2024; 34:568-575. [PMID: 37225423 DOI: 10.1093/mr/road046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/06/2023] [Accepted: 05/09/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To develop a proposal for giant cell arteritis remission criteria in order to implement a treat-to-target algorithm. METHODS A task force consisting of 10 rheumatologists, 3 cardiologists, 1 nephrologist, and 1 cardiac surgeon was established in the Large-vessel Vasculitis Group of the Japanese Research Committee of the Ministry of Health, Labour and Welfare for Intractable Vasculitis to conduct a Delphi survey of remission criteria for giant cell arteritis. The survey was circulated among the members over four reiterations with four face-to-face meetings. Items with a mean score of ≥4 were extracted as items for defining remission criteria. RESULTS An initial literature review yielded a total of 117 candidate items for disease activity domains and treatment/comorbidity domains of remission criteria, of which 35 were extracted as disease activity domains (systematic symptoms, signs and symptoms of cranial and large-vessel area, inflammatory markers, and imaging findings). For the treatment/comorbidity domain, ≤5 mg/day of prednisolone 1 year after starting glucocorticoids was extracted. The definition of achievement of remission was the disappearance of active disease in the disease activity domain, normalization of inflammatory markers, and ≤5 mg/day of prednisolone. CONCLUSION We developed proposals for remission criteria to guide the implementation of a treat-to-target algorithm for giant cell arteritis.
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Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Division of Rheumatology and Allergy, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiko Watanabe
- First Department of Physiology, Kawasaki Medical School, Kurashiki, Japan
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Natsuka Umezawa
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Manabe
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroko Nagafuchi
- Division of Rheumatology and Allergy, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Rahimi M, Esalatmanesh K, Daneshvar S, Irvani SSN, Badali A, Khabbazi A. Outcomes of polymyalgia rheumatica in real-world practice: a longitudinal cohort study. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2024; 0:rjim-2024-0009. [PMID: 38470357 DOI: 10.2478/rjim-2024-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 03/13/2024]
Abstract
Background: Polymyalgia rheumatica (PMR) is an inflammatory condition closely linked with giant cell arteritis, which is a large vessel vasculitis. To provide real-world evidence on PMR outcomes and their determinants, we conducted a longitudinal study focusing on symptom relief and acute phase reactant normalization. Methods: We followed patients with PMR who were registered in Tabriz University of Medical Sciences Vasculitis Registry (TUOMS-VR) until February 2023. We measured sustained remission (primary outcome) and secondary outcomes including glucocorticoids (GCs)-free remission, medication-free remission, relapse rate and disease-induced damage. Results: We identified eighty-one patients with PMR and followed them for a median time of 57 months. In a median duration of 3 weeks, 98.8% of patients achieved symptom control, with 86.4% achieving sustained remission in a median duration of 9 weeks. Sustained remission was more common in non-smokers and adherent to therapy patients. Relapse occurred in 22.1% of patients, primarily due to non-adherence. Medication-free remission was observed in 30.9% of patients, especially among females and those with an initial prednisolone dose > 15 mg/d. Damage occurred in 42.0% of patients. Conclusion: Although sustained remission in PMR is not an unattainable goal in daily practice and most patients are in remission at the last visit, two-thirds of patients require long-term treatment.
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Affiliation(s)
- Mehran Rahimi
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
| | - Kamal Esalatmanesh
- 2Internal Medicine Group, Kashan University of Medical Sciences, Kashan, Iran
| | - Sara Daneshvar
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
| | | | - Ahmadreza Badali
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
| | - Alireza Khabbazi
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
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Sugihara T, Uchida HA, Yoshifuji H, Maejima Y, Naniwa T, Katsumata Y, Okazaki T, Ishizaki J, Murakawa Y, Ogawa N, Dobashi H, Horita T, Tanaka Y, Furuta S, Takeuchi T, Komagata Y, Nakaoka Y, Harigai M. Association between the patterns of large-vessel lesions and treatment outcomes in patients with large-vessel giant cell arteritis. Mod Rheumatol 2023; 33:1145-1153. [PMID: 36218378 DOI: 10.1093/mr/roac122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES We aimed to identify associations between patterns of large-vessel lesions of large-vessel giant cell arteritis (LV-GCA) and treatment outcomes. METHODS We extracted data on 68 newly diagnosed patients with LV-GCA from a retrospective, multi-centric, nationwide registry of GCA patients treated with glucocorticoids between 2007 and 2014. Patients with aortic lesions were identified based on the findings from contrast-enhanced computed tomography, magnetic resonance imaging, or positron emission tomography-computed tomography (Group 2, n = 49). Patients without aortic lesions were subdivided into LV-GCA with or without subclavian lesions defined as Group 1 (n = 9) or Group 3 (n = 10), respectively. The primary outcome evaluation was failure to achieve clinical remission by Week 24 and/or relapse within 104 weeks. RESULTS The mean age and proportion of patients with cranial lesions and polymyalgia rheumatica in Group 2 were numerically lower than in the other two groups. Large-vessel lesions in Group 3 included carotid, pulmonary, renal, hepatic, or mesenteric lesions. The cumulative rate of poor treatment outcomes >2 years was 11.1%, 55.3%, and 88.0% in Groups 1, 2, and 3, respectively (by Kaplan-Meier analysis). The mean time to poor outcome was significantly different between the groups. CONCLUSIONS Classification by subclavian and aortic lesions may be useful to determine treatment strategy.
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Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
- Department of Internal Medicine, Division of Rheumatologyand Allergology, St. Marianna University Faculty of Medicine, Kawasaki, Japan
| | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taio Naniwa
- Department of Internal Medicine, Division of Rheumatology, Nagoya City University Hospital, Nagoya, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuhiro Katsumata
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takahiro Okazaki
- Department of Internal Medicine, Division of Rheumatologyand Allergology, St. Marianna University Faculty of Medicine, Kawasaki, Japan
- National Hospital Organization, Shizuoka Medical Center, Shimizu, Japan
| | - Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Noriyoshi Ogawa
- Department of Internal Medicine 3, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tetsuya Horita
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Tsutomu Takeuchi
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Komagata
- First Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayoshi Harigai
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Bilton EJ, Mollan SP. Giant cell arteritis: reviewing the advancing diagnostics and management. Eye (Lond) 2023; 37:2365-2373. [PMID: 36788362 PMCID: PMC9927059 DOI: 10.1038/s41433-023-02433-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Giant Cell Arteritis (GCA) is well known to be a critical ischaemic disease that requires immediate medical recognition to initiate treatment and where one in five people still suffer visual loss. The immunopathophysiology has continued to be characterised, and the influencing of ageing in the development of GCA is beginning to be understood. Recent national and international guidelines have supported the directed use of cranial ultrasound to reduce diagnostic delay and improve clinical outcomes. Immediate high dose glucocorticoids remain the standard emergency treatment for GCA, with a number of targeted agents that have been shown in clinical trials to have superior clinical efficacy and steroid sparing effects. The aim of this review was to present the latest advances in GCA that have the potential to influence routine clinical practice.
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Affiliation(s)
- Edward J Bilton
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Transitional Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
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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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Low C, Conway R. Metabolic bone health considerations in giant cell arteritis and polymyalgia rheumatica. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057221147385. [PMID: 36627860 PMCID: PMC9837290 DOI: 10.1177/17455057221147385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two common systemic inflammatory conditions with a combined lifetime risk of approximately 3.5% in women and 1.5% in men. They are intimately associated with the aging process, virtually never occurring prior to 50 years of age and becoming more common over time. The reasons for this are unclear, but likely relate in part to factors related to aging of the immune system. The treatment of both GCA and PMR is traditionally based on glucocorticoids, frequently requiring a prolonged treatment course over long periods of time. Other medications are belatedly entering our treatment armamentarium, but their exact place in treatment algorithms remains to be fully defined and it is likely glucocorticoids will remain a cornerstone of our treatment in GCA and PMR for the foreseeable future. As a result, people with GCA and PMR will continue to be exposed to a significant cumulative glucocorticoid burden with all of the attendant potential adverse events, including osteoporosis. The predominantly post-menopausal female population that most commonly develops PMR and GCA is also the population that is most affected by osteoporosis. Given the risk of glucocorticoid-induced osteoporosis and subsequent fragility fractures, a planned treatment approach from glucocorticoid initiation is needed in these conditions. For the majority of patients, this will entail ensuring sufficiency of calcium and vitamin D as well as antiresorptive treatments. In this article, we discuss considerations around optimisation of metabolic bone health in GCA and PMR.
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Affiliation(s)
- Candice Low
- Department of Rheumatology, St. James’s Hospital, Dublin, Ireland
| | - Richard Conway
- Department of Rheumatology, St. James’s Hospital, Dublin, Ireland,Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland,Richard Conway, Department of Clinical Medicine, Trinity College Dublin, Dublin 2, Ireland.
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Yamaguchi E, Kadoba K, Watanabe R, Iwasaki T, Kitagori K, Akizuki S, Murakami K, Nakashima R, Hashimoto M, Tanaka M, Morinobu A, Yoshifuji H. Clinical profile and outcome of large-vessel giant cell arteritis in Japanese patients: A single-centre retrospective cohort study. Mod Rheumatol 2023; 33:175-181. [PMID: 35141755 DOI: 10.1093/mr/roac013] [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: 05/25/2021] [Revised: 07/05/2021] [Accepted: 01/31/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Recent advances in imaging revealed that giant cell arteritis (GCA) is frequently associated with large vessel involvement (LVI), but they may also contribute to earlier diagnosis and treatment of LV-GCA. We aimed to compare the clinical characteristics of GCA with or without LVI and evaluate its association with clinical outcomes. METHOD We retrospectively reviewed the medical records of 36 patients with GCA in Kyoto University Hospital. RESULTS Eighteen patients each were assigned to the LVI(+) and LVI(-) groups. Five-year survival rates in the LVI(+) group were better than in the LVI(-) group (p = .034), while five-year relapse-free survival rates were similar between the groups (p = .75). The LVI(+) group required lower doses of glucocorticoid at month 6 (p = .036). Disease activity evaluated with the Birmingham Vasculitis Activity Score at disease onset was higher in the LVI(-) group (p = .014), and the Vasculitis Damage Index score examined at the last visit was higher in the LVI(-) group (p = .011). CONCLUSION GCA without LVI had more active disease, severer vascular damage, and worse survival, possibly because of ophthalmic complications and their greater glucocorticoid requirement. Our results revisit the impact of cranial manifestations on disease severity and morbidity.
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Affiliation(s)
- Eriho Yamaguchi
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Keiichiro Kadoba
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryu Watanabe
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Iwasaki
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Center for Genomic Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kitagori
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuji Akizuki
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kosaku Murakami
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ran Nakashima
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Motomu Hashimoto
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masao Tanaka
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Bond M, Tomelleri A, Buttgereit F, Matteson EL, Dejaco C. Looking ahead: giant-cell arteritis in 10 years time. Ther Adv Musculoskelet Dis 2022; 14:1759720X221096366. [PMID: 35634351 PMCID: PMC9136445 DOI: 10.1177/1759720x221096366] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/01/2022] [Indexed: 12/15/2022] Open
Abstract
Although great improvements have been achieved in the fields of diagnosing and treating patients with giant-cell arteritis (GCA) in the last decades, several questions remain unanswered. The progressive increase in the number of older people, together with growing awareness of the disease and use of advanced diagnostic tools by healthcare professionals, foretells a possible increase in both prevalence and number of newly diagnosed patients with GCA in the coming years. A thorough clarification of pathogenetic mechanisms and a better definition of clinical subsets are the first steps toward a better understanding of the disease and, subsequently, toward a better use of existing and future therapeutic options. Examination of the role of different imaging techniques for GCA diagnosing and monitoring, optimization, and personalization of glucocorticoids and other immunosuppressive agents, further development and introduction of novel drugs, identification of prognostic factors for long-term outcomes and management of treatment discontinuation will be the central topics of the research agenda in years to come.
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Affiliation(s)
- Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charitè University Medicine Berlin, Berlin, Germany
| | - Eric L. Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Christian Dejaco
- Professor, Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Via Ospedale 11, 39031 Brunico, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
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11
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Box CD, Cronin O, Hauser B. The Impact of High Dose Glucocorticoids on Bone Health and Fracture Risk in Systemic Vasculitides. Front Endocrinol (Lausanne) 2022; 13:806361. [PMID: 35250864 PMCID: PMC8889574 DOI: 10.3389/fendo.2022.806361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/07/2022] [Indexed: 12/29/2022] Open
Abstract
Systemic vasculitides are a range of conditions characterized by inflammation of blood vessels which may manifest as single organ or life-threatening multisystem disease. The treatment of systemic vasculitis varies depending on the specific disease but historically has involved initial treatment with high dose glucocorticoids alone or in conjunction with other immunosuppressive agents. Prolonged glucocorticoid treatment is frequently required as maintenance treatment. Patients with small and large vessel vasculitis are at increased risk of fracture. Osteoporosis may occur due to intrinsic factors such as chronic inflammation, impaired renal function and to a large extent due to pharmacological therapy with high dose glucocorticoid or combination treatments. This review will outline the known mechanism of bone loss in vasculitis and will summarize factors attributing to fracture risk in different types of vasculitis. Osteoporosis treatment with specific consideration for patients with vasculitis will be discussed. The use of glucocorticoid sparing immunosuppressive agents in the treatment of systemic vasculitis is a significant area of ongoing research. Adjunctive treatments are used to reduce cumulative doses of glucocorticoids and therefore may significantly decrease the associated fracture risk in patients with vasculitis. Lastly, we will highlight the many unknowns in the relation between systemic vasculitis, its treatment and bone health and will outline key research priorities for this field.
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Affiliation(s)
| | - Owen Cronin
- Department of Rheumatology, Bon Secours Hospital Cork, Cork, Ireland
- School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Barbara Hauser,
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12
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Matza MA, Fernandes AD, Stone JH, Unizony SH. Reply. Arthritis Care Res (Hoboken) 2021; 73:1059-1060. [DOI: 10.1002/acr.24378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/07/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Mark A. Matza
- Massachusetts General Hospital and Harvard Medical School Boston Massachusetts
| | - Ana D. Fernandes
- Massachusetts General Hospital and Harvard Medical School Boston Massachusetts
| | - John H. Stone
- Massachusetts General Hospital and Harvard Medical School Boston Massachusetts
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13
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Barra L, Pope JE, Pequeno P, Saxena FE, Bell M, Haaland D, Widdifield J. Incidence and prevalence of giant cell arteritis in Ontario, Canada. Rheumatology (Oxford) 2021; 59:3250-3258. [PMID: 32249899 DOI: 10.1093/rheumatology/keaa095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/06/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To estimate trends in the incidence and prevalence of GCA over time in Canada. METHODS We performed a population-based study of Ontario health administrative data using validated case definitions for GCA. Among Ontario residents ≥50 years of age we estimated the annual incidence and prevalence rates between 2000 and 2018. We performed sensitivity analyses using alternative validated case definitions to provide comparative estimates. RESULTS Between 2000 and 2018 there was a relatively stable incidence over time with 25 new cases per 100 000 people >50 years of age. Age-standardized incidence rates were significantly higher among females than males [31 cases (95% CI: 29, 34) vs 15 cases (95% CI: 13, 18) per 100 000 in 2000]. Trends in age-standardized incidence rates were stable among females but increased among males over time. Incidence rates were highest among those ≥70 years of age. Standardized prevalence rates increased from 125 (95% CI 121, 129) to 235 (95% CI 231, 239) cases per 100 000 from 2000 to 2018. The age-standardized rates among males rose from 76 (95% CI 72, 81) cases in 2000 to 156 (95% CI 151, 161) cases per 100 000 population in 2018. Between 2000 and 2018, the age-standardized rates among females similarly increased over time, from 167 (95% CI 161, 173) to 304 (95% CI 297, 310) cases per 100 000 population. CONCLUSION The incidence and prevalence of GCA in Ontario is similar to that reported in the USA and northern Europe and considerably higher than that reported for southern Europe and non-European populations.
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Affiliation(s)
- Lillian Barra
- Department of Medicine, Western University, Schulich School of Medicine & Dentistry, London, Ontario, Canada.,Department of Medicine, St. Joseph's Health Care London, Ontario, Canada
| | - Janet E Pope
- Department of Medicine, Western University, Schulich School of Medicine & Dentistry, London, Ontario, Canada.,Department of Medicine, St. Joseph's Health Care London, Ontario, Canada
| | | | | | - Mary Bell
- Holland Bone & Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Derek Haaland
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Northern Ontario School of Medicine, Laurentian University Campus, Sudbury, Ontario, Canada
| | - Jessica Widdifield
- ICES, Toronto, Ontario, Canada.,Holland Bone & Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
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Long-term follow-up of 89 patients with giant cell arteritis: a retrospective observational study on disease characteristics, flares and organ damage. Rheumatol Int 2020; 41:439-448. [PMID: 33113000 DOI: 10.1007/s00296-020-04730-1] [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: 08/19/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
The objective of the study is to investigate the clinical characteristics and long-term prognosis including flares and organ damage in patients with giant cell arteritis (GCA) from a tertiary referral centre and compare these features in different subgroups. In this retrospective observational study, patients with GCA who were followed up in our vasculitis clinic between 1998 and 2018 were evaluated by a predefined protocol. Patients with and without cranial symptoms were compared for clinical and laboratory features, flares and permanent damage findings. Vasculitis Damage Index and Large Vessel Vasculitis Index of Damage were used for damage assessment. Records of 89 patients (median follow-up time 46 months) were analysed; mean time to diagnosis after initial symptom was longer in patients with acute vision loss (11 ± 4 vs. 4.8 ± 1.1 months p = 0.002). EGG (n = 19) was younger (63 ± 2 vs. 69 ± 1 years old p = 0.01); had higher mean CRP (141.8 ± 107.3 vs. 76.6 ± 67.9 mg/dL p = 0.023) and ESR (120.8 ± 25.1 vs. 99.3 ± 24.3 mm/h p = 0.004) at diagnosis. PET-CT detected large vessel vasculitis in 42/48 (87.5%) cases of the entire cohort. Thirty-one patients had flares and proportion of flared patients was significantly higher in patients with cranial symptoms. At least one damage item (DI) was present in 54 (60.7%) patients. The development of damage was found to be associated with flares. Evaluation of our cohort revealed the importance of early diagnosis for prevention of vision loss in GCA. Patients without cranial symptoms were younger, present with higher inflammatory response and for these, PET-CT was the main diagnostic tool. Relapse rate was higher in patients with cranial symptoms. Flares and accompanying corticosteroid treatment may contribute to organ damage in GCA.
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15
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Wipfler-Freißmuth E, Dejaco C, Both M. [Long-term complications, monitoring and interventional treatment of large vessel vasculitis]. Z Rheumatol 2020; 79:523-531. [PMID: 32430565 DOI: 10.1007/s00393-020-00807-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Giant cell arteritis (GCA) and Takayasu's arteritis (TAK) both belong to the group of large vessel vasculitides and require long-term drug treatment. Glucocorticoids (GC) are the first choice for the treatment of both diseases. For GCA immunosuppressants, such as tocilizumab or methotrexate should be considered in cases of treatment refractory and relapses or if there is a high risk for GC-related adverse events. In TAK patients the use of immunosuppressive agents should be considered for all patients. In the course of the disease, severe disease-associated and treatment-associated complications can occur. The most frequent disease-associated complications include visual impairment up to blindness in GCA, as well as vascular stenoses with ischemia and aortic aneurysms with possible dissection in GCA and TAK. Percutaneous transluminal angioplasty (PTA) and stenting are minimally invasive, low-risk interventional procedures for GCA and TAK patients with clinically significant vascular stenoses, despite a tendency to restenosis. Interventional procedures should be weighed up against vascular surgical approaches depending on the localization and the total clinical situation. All interventions should be conducted in a phase of stable remission when possible. For monitoring of disease activity in patients with GCA and TAK, assessment of clinical manifestations as well as C‑reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) are useful; however, both are unreliable under interleukin‑6 block with tocilizumab. The value of new biomarkers independent from interleukin‑6 and the importance of imaging (sonography, magnetic resonance angiography, computed tomography and positron emission tomography-CT) for monitoring GCA and TAK still have to be investigated in future studies.
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Affiliation(s)
- E Wipfler-Freißmuth
- Rheumatologische Spezialambulanz, Krankenhaus der Barmherzigen Brüder Graz-Eggenberg, Bergstr. 27, 8010, Graz, Österreich.
| | - C Dejaco
- Landesweiter Dienst für Rheumatologie, Südtiroler Sanitätsbetrieb, Krankenhaus Bruneck, Bruneck, Italien
| | - M Both
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
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16
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Watanabe R, Berry GJ, Liang DH, Goronzy JJ, Weyand CM. Pathogenesis of Giant Cell Arteritis and Takayasu Arteritis-Similarities and Differences. Curr Rheumatol Rep 2020; 22:68. [PMID: 32845392 DOI: 10.1007/s11926-020-00948-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Giant cell arteritis (GCA) and Takayasu arteritis (TAK) are auto-inflammatory and autoimmune diseases with a highly selective tissue tropism for medium and large arteries. In both diseases, CD4+ T cells and macrophages form granulomatous lesions within the arterial wall, a tissue site normally protected by immune privilege. Vascular lesions can be accompanied by an extravascular component, typically an intense hepatic acute phase response that produces well-known laboratory abnormalities, e.g., elevated ESR and CRP. It is unclear whether GCA and TAK lie on a spectrum of disease or whether they represent fundamentally different disease processes. RECENT FINDINGS GCA and TAK share many clinical features, but there are substantial differences in genetics, epidemiology, disease mechanisms, response to treatment, and treatment complications that give rise to different disease trajectories. A significant difference lies in the composition of the wall-infiltrating immune cell compartment, which in TAK includes a significant population of CD8+ T cells as well as natural killer cells, specifying disparate disease effector pathways mediating tissue damage and vessel wall remodeling. Despite the similarities in tissue tropism and histomorphology, GCA and TAK are two distinct vasculitides that rely on separate disease mechanisms and require disease-specific approaches in diagnosis and management.
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Affiliation(s)
- Ryu Watanabe
- Department of Medicine, Stanford University School of Medicine, CCSR Building Room 2225, 269 Campus Drive West, Stanford, CA, 94305-5166, USA.,Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Gerald J Berry
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - David H Liang
- Department of Medicine, Stanford University School of Medicine, CCSR Building Room 2225, 269 Campus Drive West, Stanford, CA, 94305-5166, USA
| | - Jörg J Goronzy
- Department of Medicine, Stanford University School of Medicine, CCSR Building Room 2225, 269 Campus Drive West, Stanford, CA, 94305-5166, USA
| | - Cornelia M Weyand
- Department of Medicine, Stanford University School of Medicine, CCSR Building Room 2225, 269 Campus Drive West, Stanford, CA, 94305-5166, USA.
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17
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da Cruz Escaleira ALR, Kalogeropoulos D, Kalogeropoulos C, Ch'Ng SW, Sung VCT, Asproudis I, Papoudou-Bai A, Malamos K, Mitra A. Four common diseases causing sudden blindness or death in the eye emergency department. Postgrad Med J 2020; 97:256-263. [PMID: 32788313 DOI: 10.1136/postgradmedj-2020-138163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022]
Abstract
Neuro-ophthalmological emergency disorders typically present with symptoms of visual loss, diplopia, ocular motility impairment or anisocoria. The ocular manifestations of these disorders are sometimes indicative of a more serious global neurology disease rather than an isolated ocular disease. The aim of this review is to highlight four important neuro-ophthalmological emergency disorders that must not be missed by an ophthalmologist. These include acute painful Horner's syndrome, painful cranial nerve III palsy, giant cell arteritis and transient ischaemic attack with amaurosis fugax. The delayed diagnosis of these clinical entities puts the patient at risk of blindness or death. Therefore, prompt diagnosis and management of these conditions are essential. This can be acquired from understanding the main signs and symptoms of the disease presentation together with a high index of suspicion while working at a busy eye emergency department.
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Affiliation(s)
| | | | | | - Soon Wai Ch'Ng
- Ophthalmology, Birmingham and Midland Eye Centre, Birmingham, UK
| | - Velota C T Sung
- Ophthalmology, Birmingham and Midland Eye Centre, Birmingham, UK
| | - Ioannis Asproudis
- Ophthalmology, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | | | | | - Arijit Mitra
- Ophthalmology, Birmingham and Midland Eye Centre, Birmingham, UK
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18
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Monitoring and long-term management of giant cell arteritis and polymyalgia rheumatica. Nat Rev Rheumatol 2020; 16:481-495. [DOI: 10.1038/s41584-020-0458-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 02/08/2023]
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19
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Kaymaz-Tahra S, Alibaz-Oner F, Direskeneli H. Assessment of damage in Takayasu's arteritis. Semin Arthritis Rheum 2020; 50:586-591. [PMID: 32470706 DOI: 10.1016/j.semarthrit.2020.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/11/2020] [Accepted: 04/13/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To assess the progression and the factors associated with damage in Takayasu's arteritis (TAK) patients during routine follow-up. METHODS Patients diagnosed with TAK and had >6 months follow-up were enrolled in this study retrospectively. Takayasu's arteritis damage score (TADS) and vasculitis damage index (VDI) were determined at diagnosis and at the end of the follow-up and variables associated with damage scores were assessed. RESULTS One-hundred fourteen patients (F/M: 101/13) were included in the study. The mean age at diagnosis, median symptom duration at baseline visit and mean follow-up duration were 35.3±13.3 years, 12 (0-360) months and 76.9±51.4 months, respectively. Median VDI score was 4.0 (1-8) and median TADS score was 7.0 (1-15) at baseline assessment. At the end of the follow-up, median VDI score increased to 5.0 (1-17) and TADS score to 8.0 (1-19). The median number of disease-related items were higher in TADS (8 items vs 4 items). At least one new corticosteroid (CS)-related damage item occurred in 35 patients (31%). Age at symptom-onset and cumulative CS doses were predictor factors for higher VDI score (≥5), whereas age at symptom-onset and disease duration were associated with increase in TADS (≥8). Gender and number of relapses were not associated with damage scores. CONCLUSION Damage assessment with VDI seems to capture treatment-related damage better, whereas TADS provides some additional information on disease-related damage in Takayasu's arteritis. Older age at symptom onset, disease duration and cumulative CS dose were associated with higher damage scores. The relapse frequency did not influence the damage level in our routine-follow-up of TAK patients.
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Affiliation(s)
- Sema Kaymaz-Tahra
- Division of Rheumatology, Department of Internal Medicine, Marmara University, Turkey.
| | - Fatma Alibaz-Oner
- Division of Rheumatology, Department of Internal Medicine, Marmara University, Turkey
| | - Haner Direskeneli
- Division of Rheumatology, Department of Internal Medicine, Marmara University, Turkey
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20
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Sugihara T, Hasegawa H, Uchida HA, Yoshifuji H, Watanabe Y, Amiya E, Maejima Y, Konishi M, Murakawa Y, Ogawa N, Furuta S, Katsumata Y, Komagata Y, Naniwa T, Okazaki T, Tanaka Y, Takeuchi T, Nakaoka Y, Arimura Y, Harigai M, Isobe M. Associated factors of poor treatment outcomes in patients with giant cell arteritis: clinical implication of large vessel lesions. Arthritis Res Ther 2020; 22:72. [PMID: 32264967 PMCID: PMC7137303 DOI: 10.1186/s13075-020-02171-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background Relapses frequently occur in giant cell arteritis (GCA), and long-term glucocorticoid therapy is required. The identification of associated factors with poor treatment outcomes is important to decide the treatment algorithm of GCA. Methods We enrolled 139 newly diagnosed GCA patients treated with glucocorticoids between 2007 and 2014 in a retrospective, multi-center registry. Patients were diagnosed with temporal artery biopsy, 1990 American College of Rheumatology classification criteria, or large vessel lesions (LVLs) detected by imaging based on the modified classification criteria. Poor treatment outcomes (non-achievement of clinical remission by week 24 or relapse during 52 weeks) were evaluated. Clinical remission was defined as the absence of clinical signs and symptoms in cranial and large vessel areas, polymyalgia rheumatica (PMR), and elevation of C-reactive protein (CRP) levels. A patient was determined to have a relapse if he/she had either one of the signs and symptoms that newly appeared or worsened after achieving clinical remission. Re-elevation of CRP without clinical manifestations was considered as a relapse if other causes such as infection were excluded and the treatment was intensified. Associated factors with poor treatment outcomes were analyzed by using the Cox proportional hazard model. Results Cranial lesions, PMR, and LVLs were detected in 77.7%, 41.7%, and 52.5% of the enrolled patients, respectively. Treatment outcomes were evaluated in 119 newly diagnosed patients who were observed for 24 weeks or longer. The mean initial dose of prednisolone was 0.76 mg/kg/day, and 29.4% received any concomitant immunosuppressive drugs at baseline. Overall, 41 (34.5%) of the 119 patients had poor treatment outcomes; 13 did not achieve clinical remission by week 24, and 28 had a relapse after achieving clinical remission. Cumulative rates of the events of poor treatment outcomes in patients with and without LVLs were 47.5% and 17.7%, respectively. A multivariable model showed the presence of LVLs at baseline was significantly associated with poor treatment outcomes (adjusted hazard ratio [HR] 3.54, 95% CI 1.52–8.24, p = 0.003). Cranial lesions and PMR did not increase the risk of poor treatment outcomes. Conclusion The initial treatment intensity in the treatment algorithm of GCA could be determined based upon the presence or absence of LVLs detected by imaging at baseline.
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Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan. .,Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan.
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiko Watanabe
- First Department of Physiology, Kawasaki Medical School, Kurashiki, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masanori Konishi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Noriyoshi Ogawa
- Department of Internal Medicine 3, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Yasuhiro Katsumata
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoshinori Komagata
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Taio Naniwa
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Japan.,Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takahiro Okazaki
- Division of Rheumatology & Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.,National Hospital Organization, Shizuoka Medical Center, Shimizu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshikazu Nakaoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan.,Kichijoji Asahi Hospital, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan.,Sakakibara Heart Institute, Tokyo, Japan
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Osteoporosis in Rheumatic Diseases. Int J Mol Sci 2019; 20:ijms20235867. [PMID: 31766755 PMCID: PMC6928928 DOI: 10.3390/ijms20235867] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/16/2019] [Accepted: 11/21/2019] [Indexed: 12/17/2022] Open
Abstract
Osteoporosis is a chronic disease characterized by an increased risk of fragility fracture. Patients affected by rheumatic diseases are at greater risk of developing osteoporosis. The purpose of the present review is to discuss the pathogenesis, epidemiology, and treatment of osteoporosis in patients affected by rheumatic diseases with special focus for rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, vasculitides, Sjogren syndrome, and crystal-induced arthritis.
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22
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Michailidou D, Rosenblum JS, Rimland CA, Marko J, Ahlman MA, Grayson PC. Clinical symptoms and associated vascular imaging findings in Takayasu's arteritis compared to giant cell arteritis. Ann Rheum Dis 2019; 79:262-267. [PMID: 31649025 DOI: 10.1136/annrheumdis-2019-216145] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/21/2019] [Accepted: 10/10/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To compare the presence of head, neck and upper extremity symptoms in patients with Takayasu's (TAK) and giant cell arteritis (GCA) and their association with vascular inflammation assessed by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) or arterial damage assessed by magnetic resonance angiography (MRA). METHODS Patients with TAK and GCA underwent clinical and imaging assessments within 24 hours, blinded to each other. Vascular inflammation was defined as arterial FDG-PET uptake greater than liver by visual assessment. Arterial damage was defined as stenosis, occlusion, or aneurysm by MRA. Clinically reported symptoms were compared with corresponding imaging findings using generalised mixed model regression. Cranial symptoms were studied in association with burden of arterial disease in the neck using ordinal regression. RESULTS Participants with TAK (n=56) and GCA (n=54) contributed data from 270 visits. Carotidynia was reported only in patients with TAK (21%) and was associated with vascular inflammation (p<0.01) but not damage (p=0.33) in the corresponding carotid artery. Posterior headache was reported in TAK (16%) and GCA (20%) but was only associated with corresponding vertebral artery inflammation and damage in GCA (p<0.01). Arm claudication was associated with subclavian artery damage (p<0.01) and inflammation (p=0.04) in TAK and with damage in GCA (p<0.01). Patients with an increased burden of damaged neck arteries were more likely to experience positional lightheadedness (p<0.01) or a major central nervous system event (p=0.01). CONCLUSION The distribution of symptoms and association with imaging abnormalities differs in patients with TAK and GCA. These findings may help clinicians predict associated FDG-PET and MRA findings based on a specific clinical symptom. CLINICAL TRIAL REGISTRATION NUMBER NCT02257866.
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Affiliation(s)
- Despina Michailidou
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Joel S Rosenblum
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Casey A Rimland
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Jamie Marko
- Radiology and Imaging Services, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Mark A Ahlman
- Radiology and Imaging Services, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
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Treat to Target: A Valid Concept for Management of Polymyalgia Rheumatica and Giant Cell Arteritis? Rheum Dis Clin North Am 2019; 45:549-567. [PMID: 31564296 DOI: 10.1016/j.rdc.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common inflammatory diseases of the elderly. They have variable clinical courses and are usually treated with glucocorticoids (GCs). Relapses are frequent in both conditions. Physicians should balance the tradeoff of treatment-related adverse events and risk of relapse. The ultimate goal of treatment is control of the disease while maintaining patient well-being. A treat-to-target approach may achieve the aim of controlling inflammation and preserving patient's functioning and quality of life, and would require pursuit and evaluation of clinical, laboratory, imaging, and structural targets to tackle the different manifestations of GCA and PMR.
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24
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Aging in Primary Systemic Vasculitis: Implications for Diagnosis, Clinical Manifestations, and Management. Drugs Aging 2018; 36:53-63. [DOI: 10.1007/s40266-018-0617-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Does leflunomide have a role in giant cell arteritis? An open-label study. Clin Rheumatol 2018; 38:291-296. [DOI: 10.1007/s10067-018-4232-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/11/2018] [Accepted: 07/23/2018] [Indexed: 01/26/2023]
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Kermani TA, Warrington KJ. Prognosis and monitoring of giant cell arteritis and associated complications. Expert Rev Clin Immunol 2018; 14:379-388. [DOI: 10.1080/1744666x.2018.1467758] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Tanaz A. Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Ponte C, Águeda A, Luqmani R. Clinical features and structured clinical evaluation of vasculitis. Best Pract Res Clin Rheumatol 2018; 32:31-51. [DOI: 10.1016/j.berh.2018.10.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 09/14/2018] [Indexed: 10/27/2022]
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