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Foré R, Liozon E, Dumonteil S, Sené T, Héron E, Lacombe V, Leclercq M, Magnant J, Beuvon C, Régent A, de Mornac D, Samson M, Smets P, Alexandra JF, Granel B, Robert PY, Curumthaullee MF, Parreau S, Palat S, Bezanahary H, Ly KH, Fauchais AL, Gondran G. BOB-ACG study: Pulse methylprednisolone to prevent bilateral ophthalmologic damage in giant cell arteritis. A multicentre retrospective study with propensity score analysis. Joint Bone Spine 2024; 91:105641. [PMID: 37734440 DOI: 10.1016/j.jbspin.2023.105641] [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: 03/29/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Giant cell arteritis (GCA) is complicated in 10 to 20% of cases by permanent visual ischemia (PVI). International guidelines advocate the use of intravenous pulse of methylprednisolone from 250 to 1000mg per day, for three days, followed by oral prednisone at 1mg/kg per day. The aim of this study is to assess whether this strategy significantly reduces the risk of early PVI of the second eye, compared with direct prednisone at 1mg/kg per day. METHODS We conducted a multicentre retrospective observational study over the past 15 years in 13 French hospital centres. Inclusion criteria included: new case of GCA; strictly unilateral PVI, prednisone at dose greater than or equal to 0.9mg/kg per day; for the intravenous methylprednisolone (IV-MP) group, total dose between 900 and 5000mg, close follow-up and knowledge of visual status at 1 month of treatment, or earlier, in case of contralateral PVI. The groups were compared on demographic, clinical, biological, iconographic, and therapeutic parameters. Statistical analysis was optimised using propensity scores. RESULTS One hundred and sixteen patients were included, 86 in the IV-MP group and 30 in the direct prednisone group. One patient in the direct prednisone group and 13 in the IV-MP group bilateralised, without significant difference between the two strategies (3.3% vs 15.1%). Investigation of the association between IV-MP patients and contralateral PVI through classical logistic regression, matching or stratification on propensity score did not show a significant association. Weighting on propensity score shows a significant association between IV-MP patients and contralateral PVI (OR=12.9 [3.4; 94.3]; P<0.001). Improvement in visual acuity of the initially affected eye was not significantly associated with IV-MP (visual acuity difference 0.02 vs -0.28 LogMar), even in the case of early management, i.e., within the first 48hours after the onset of PVI (n=61; visual acuity difference -0.11 vs 0.25 LogMar). Complications attributable to corticosteroid therapy in the first month were significantly more frequent in the IV-MP group (31.8 vs 10.7%; P<0.05). DISCUSSION Our data do not support the routine use of pulse IV-MP for GCA complicated by unilateral PVI to avoid bilateral ophthalmologic damage. It might be safer to not give pulse IV-MP to selected patients with high risks of glucocorticoids pulse side effects. A prospective randomised multicentre study comparing pulse IV-MP and prednisone at 1mg/kg per day is desirable.
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Affiliation(s)
- Romain Foré
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France.
| | - Eric Liozon
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | | | - Thomas Sené
- Department of Internal Medicine, Rothschild Foundation Hospital, Paris, France
| | - Emmanuel Héron
- Department of Internal Medicine, CH National d'Ophtalmologie des Quinze-Vingt, Paris, France
| | - Valentin Lacombe
- Department of Internal Medicine and Clinical Immunology, CHU d'Angers, Angers, France
| | | | - Julie Magnant
- Department of Internal Medicine, CHU de Tours, Tours, France
| | - Clément Beuvon
- Department of Internal Medicine, CHU La Milétrie, Poitiers, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | | | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU de Dijon, Dijon, France
| | - Perrine Smets
- Department of Internal Medicine, CHU de Clermont-Ferrand, site Gabriel-Montpied, Clermont-Ferrand, France
| | | | - Brigitte Granel
- Department of Internal Medicine, Hôpital Nord, Marseille, France
| | | | | | - Simon Parreau
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | - Sylvain Palat
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | - Holy Bezanahary
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | - Kim Heang Ly
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
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Vision loss in giant cell arteritis: case-based review. Rheumatol Int 2022; 42:1855-1862. [PMID: 35727336 DOI: 10.1007/s00296-022-05160-x] [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: 03/31/2022] [Accepted: 05/28/2022] [Indexed: 10/18/2022]
Abstract
Prompt initiation of pulse glucocorticoid treatment is recommended in case of visual symptoms and suspected or proven giant cell arteritis (GCA). Pulse treatment in most cases prevents involvement of an initially unaffected fellow eye. We present the case of a biopsy-proven GCA in a 79-year-old man, complicated by sequential bilateral blindness. Initial unilateral vision loss was treated by 1 g methylprednisolone intravenously for 3 days, followed by 1 g/kg prednisone daily. Despite treatment, the second eye went completely blind 11 days after the initial vision loss. We performed a systematic search on Medline and Scopus aiming at identifying all cases of GCA complicated with loss of vision in a previously unaffected eye under pulse treatment for initially monocular vision loss. We identified 11 articles reporting 21 patients that met our inclusion criteria. Contralateral vision loss occurred 1-12 days following treatment initiation, with a median of 2 days. Treatment initiation was delayed up to 8 days since the initial vision loss, with a median delay of 2 days. Anterior ischemic optic neuropathy was the dominant mechanism of vision loss. Sequential involvement of the fellow eye in case of unilateral vision loss in GCA is rare. With 12-day interval being the longest reported, we conclude that even though the first 2 days are the most critical for the visual outcome, blindness in the initially unaffected eye may rarely occur later. Nonetheless, immediate initiation of pulse treatment remains of vital importance to preserve vision in the contralateral eye.
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Neurologic complications of diseases of the aorta. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:221-239. [PMID: 33632441 DOI: 10.1016/b978-0-12-819814-8.00028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neurologic complications of diseases of the aorta are common, as the brain and spinal cord function is highly dependent on the aorta and its branches for blood supply. Any disease impacting the aorta may have significant impact on the ability to deliver oxygenated blood to the central nervous system, resulting in ischemia-and if prolonged-cerebral and spinal infarct. The breadth of pathology affecting the aorta is diverse and neurologic complications can vary dramatically based on the location, severity, and underlying etiology. This chapter outlines the major pathology of the aorta while highlighting the associated neurologic complications. This chapter covers the entire spectrum of neurologic complications associated with aortic disease by beginning with a detailed overview of the spinal cord vascular anatomy followed by a discussion of the most common aortic pathologies affecting the nervous system, including aortic aneurysm, aortic dissection, aortic atherosclerosis, inflammatory and infectious aortopathies, congenital abnormalities, and aortic surgery.
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Koster MJ, Warrington KJ, Matteson EL. Morbidity and Mortality of Large-Vessel Vasculitides. Curr Rheumatol Rep 2020; 22:86. [DOI: 10.1007/s11926-020-00963-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Liozon E, Delmas C, Dumonteil S, Dumont A, Gondran G, Bezanahary H, Aouba A, Fauchais AL, Ly KH, de Boysson H. Features and prognosis of giant cell arteritis in patients over 85 years of age: A case-control study. Semin Arthritis Rheum 2019; 49:288-295. [PMID: 30910217 DOI: 10.1016/j.semarthrit.2019.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 02/23/2019] [Accepted: 02/25/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND We examined the initial features, course, and prognosis of giant cell arteritis (GCA) in patients ≥ 85 years of age (≥85 year) and compared them to those of younger patients. METHODS The present retrospective study included all patients who were newly diagnosed with GCA in the Internal Departments of two French University Hospitals from 1976 or 1998 to 2017 and who were followed up for at least 6 months. Logistic regression analyses were conducted to identify baseline and prognostic characteristics associated with being ≥85 year. RESULTS Of the 865 patients assessed in this study, 87 were ≥85 year. Compared to younger patients, patients ≥ 85 year had more comorbid conditions (odds ratio [OR] = 1.11-1.74, p < 0.01), less often exhibited polymyalgia rheumatica (PMR; OR = 0.33-0.96, p = 0.04), and more often developed permanent visual loss (OR = 1.29-3.81, p < 0.01). The older patients also showed less dependence on glucocorticoid (GC) medications (OR = 0.23-0.94, p = 0.04), had fewer relapses (OR = 0.31-0.87, p = 0.015), less often recovered from GCA (OR = 0.22-0.69, p < 0.01), and more often died during treatment (OR = 1.45-4.65, p = 0.001) compared to younger patients. Being ≥85 year was the only factor associated with an increased 1-year mortality (hazard ratio = 1.77-5.81, p = 0.0001) for the whole cohort. CONCLUSIONS GCA in very elderly patients was characterized by a higher rate of severe ischemic complications and an increased risk for early death compared to younger patients. Thus, there is a need for the early diagnosis of GCA and close clinical monitoring in this unique population.
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Affiliation(s)
- Eric Liozon
- Departments of Internal Medicine, University Hospital of Limoges, France.
| | - Claire Delmas
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Stéphanie Dumonteil
- Departments of Functional Unit of Clinical Research and Biostatistics, Limoges School of Medicine, Limoges, France
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Guillaume Gondran
- Departments of Internal Medicine, University Hospital of Limoges, France
| | - Holy Bezanahary
- Departments of Internal Medicine, University Hospital of Limoges, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | | | - Kim-Heang Ly
- Departments of Internal Medicine, University Hospital of Limoges, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Caen, France
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Sultan H, Smith SV, Lee AG, Chévez-Barrios P. Pathologic Markers Determining Prognosis in Patients With Treated or Healing Giant Cell Arteritis. Am J Ophthalmol 2018; 193:45-53. [PMID: 29890162 DOI: 10.1016/j.ajo.2018.05.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE To provide quantitative evidence linking the CD68 (cluster of differentiation 68)+ macrophage marker found on temporal artery biopsies (TABs) with disease prognosis. DESIGN Retrospective, cross-sectional study. METHODS We examined 42 consecutive patients who had undergone unilateral TABs at a single hospital in 2015. Clinical data, laboratory data, and histopathologic features of TABs were recorded. Inclusion criteria were clinical diagnosis of giant cell arteritis (GCA) with TAB performed at the same center. CD68 immunohistochemistry was used to label macrophages in the TABs. Primary outcome was multiple logistic regression and bivariate comparisons to measure the association between CD68+ cells per histologic section with placement on immunomodulatory therapy (IMT). RESULTS Twenty seven patients were female (64%), with a mean age of 72 (standard deviation [SD.] ±7.7). Eleven patients (26%) were placed on IMT, 17 (40%) had disease recurrence during steroid taper, and 25 (60%) were referred to rheumatology. Of 42 biopsies, 35 underwent staining with CD68 to confirm active inflammation in suspicious, but not diagnostic, specimens. Patients eventually placed on IMT had increased CD68+ cells per slice compared to those not on IMT (median 5.00 [25th-75th quartile 2.00-7.15] vs 1.21 [0.38-2.57], P = .031, respectively). A receiver operating characteristic (ROC) curve demonstrates that 2.17 CD68+ cells/slice predicts placement on IMT with an odds ratio of 1.54 (95% confidence interval 1.02-2.33, P = .038). CONCLUSIONS Patients refractory to initial steroid tapers and those eventually placed on IMT had increased CD68 cells per section. CD68+ macrophages and their location on the internal elastic lamina may predict disease severity in patients with presumed GCA. Our results suggest that this marker may expedite patient triaging to alternate treatment to the usual steroid therapy.
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Raine C, Stapleton PP, Merinopoulos D, Maw WW, Achilleos K, Gayford D, Mapplebeck S, Mackerness C, Schofield P, Dasgupta B. A 26-week feasibility study comparing the efficacy and safety of modified-release prednisone with immediate-release prednisolone in newly diagnosed cases of giant cell arteritis. Int J Rheum Dis 2017; 21:285-291. [DOI: 10.1111/1756-185x.13149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Charles Raine
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Philip P. Stapleton
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Dimos Merinopoulos
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Win Win Maw
- Department of Rheumatology; Broomfield Hospital; Mid Essex Hospital Services NHS Trust; Chelmsford UK
| | - Katerina Achilleos
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Dawn Gayford
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Sarah Mapplebeck
- Department of Pathology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - Craig Mackerness
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | | | - Bhaskar Dasgupta
- Department of Rheumatology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
- Honorary Professorship at Essex University; Westcliff-on-Seab UK
- Visiting Professorship at Anglia Ruskin University; Westcliff-on-Sea UK
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Prior JA, Ranjbar H, Belcher J, Mackie SL, Helliwell T, Liddle J, Mallen CD. Diagnostic delay for giant cell arteritis - a systematic review and meta-analysis. BMC Med 2017; 15:120. [PMID: 28655311 PMCID: PMC5488376 DOI: 10.1186/s12916-017-0871-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/09/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Giant cell arteritis (GCA), if untreated, can lead to blindness and stroke. The study's objectives were to (1) determine a new evidence-based benchmark of the extent of diagnostic delay for GCA and (2) examine the role of GCA-specific characteristics on diagnostic delay. METHODS Medical literature databases were searched from inception to November 2015. Articles were included if reporting a time-period of diagnostic delay between onset of GCA symptoms and diagnosis. Two reviewers assessed the quality of the final articles and extracted data from these. Random-effects meta-analysis was used to pool the mean time-period (95% confidence interval (CI)) between GCA symptom onset and diagnosis, and the delay observed for GCA-specific characteristics. Heterogeneity was assessed by I 2 and by 95% prediction interval (PI). RESULTS Of 4128 articles initially identified, 16 provided data for meta-analysis. Mean diagnostic delay was 9.0 weeks (95% CI, 6.5 to 11.4) between symptom onset and GCA diagnosis (I 2 = 96.0%; P < 0.001; 95% PI, 0 to 19.2 weeks). Patients with a cranial presentation of GCA received a diagnosis after 7.7 (95% CI, 2.7 to 12.8) weeks (I 2 = 98.4%; P < 0.001; 95% PI, 0 to 27.6 weeks) and those with non-cranial GCA after 17.6 (95% CI, 9.7 to 25.5) weeks (I 2 = 96.6%; P < 0.001; 95% PI, 0 to 46.1 weeks). CONCLUSIONS The mean delay from symptom onset to GCA diagnosis was 9 weeks, or longer when cranial symptoms were absent. Our research provides an evidence-based benchmark for diagnostic delay of GCA and supports the need for improved public awareness and fast-track diagnostic pathways.
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Affiliation(s)
- James A Prior
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK.
| | - Hoda Ranjbar
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - John Belcher
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Toby Helliwell
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - Jennifer Liddle
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK.,Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christian D Mallen
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
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Wilson JC, Sarsour K, Collinson N, Tuckwell K, Musselman D, Klearman M, Napalkov P, Jick SS, Stone JH, Meier CR. Incidence of outcomes potentially associated with corticosteroid therapy in patients with giant cell arteritis. Semin Arthritis Rheum 2017; 46:650-656. [DOI: 10.1016/j.semarthrit.2016.10.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
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Yates M, MacGregor AJ, Robson J, Craven A, Merkel PA, Luqmani RA, Watts RA. The association of vascular risk factors with visual loss in giant cell arteritis. Rheumatology (Oxford) 2016; 56:524-528. [DOI: 10.1093/rheumatology/kew397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Indexed: 11/13/2022] Open
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Yates M, Graham K, Watts RA, MacGregor AJ. The prevalence of giant cell arteritis and polymyalgia rheumatica in a UK primary care population. BMC Musculoskelet Disord 2016; 17:285. [PMID: 27421253 PMCID: PMC4946178 DOI: 10.1186/s12891-016-1127-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 06/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background To update community-based prevalence values for Polymyalgia Rheumatic (PMR) and Giant Cell Arteritis (GCA) using case record review supplemented by population survey and subsequent clinical review. Methods Clinical data were obtained from case records of a large primary care practice in Norfolk, UK and reviewed for diagnoses of GCA and PMR. In addition postal survey was carried out to capture potentially undiagnosed cases within the practice population. Those screening positive for potential diagnoses of GCA and PMR were invited for clinical review. A cumulative prevalence estimate was subsequently calculated on those diagnosed within the GP practice and subsequently on those fulfilling the various published classification criteria sets. The date of the database lock and mail merge was March 2013. Results Through detailed systematic review of 5,159 GP case records, 21 patients had a recorded diagnosis of GCA and 117 had PMR.No new cases were identified among 2,227 completed questionnaires returned from the population survey of a sample of 4,728. The resulting cumulative prevalence estimate in those aged ≥ 55 years meeting the ACR classification criteria set for GCA was 0.25 % (95 % CI 0.11 to 0.39 %) and for five published criteria sets for PMR ranged from 0.91 to 1.53 % (95 % CI ranges 0.65 %, 1.87 %). The prevalence of both conditions was higher in women than in men and in older age groups. Conclusion This study provides the first UK prevalence estimate of GCA and PMR in over 30 years and is the first to apply classification criteria sets.
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Affiliation(s)
- Max Yates
- Department of Rheumatology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK. .,Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, Norfolk, NR4 7UQ, UK.
| | - Karly Graham
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, Norfolk, NR4 7UQ, UK
| | - Richard Arthur Watts
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, Norfolk, NR4 7UQ, UK
| | - Alexander James MacGregor
- Department of Rheumatology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK.,Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, Norfolk, NR4 7UQ, UK
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Liozon E, Dalmay F, Lalloue F, Gondran G, Bezanahary H, Fauchais AL, Ly KH. Risk Factors for Permanent Visual Loss in Biopsy-proven Giant Cell Arteritis: A Study of 339 Patients. J Rheumatol 2016; 43:1393-9. [DOI: 10.3899/jrheum.151135] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
Abstract
Objective.To determine the risk factors for permanent visual loss (PVL) in patients with biopsy-proven giant cell arteritis (GCA) and the usefulness of the factors in clinical practice.Methods.From 1976 through 2015, the clinical charts and laboratory results of 339 patients with biopsy-proven GCA were recorded prospectively at the time of diagnosis. We used multivariable logistic regression analysis to determine which of 24 pretreatment characteristics were associated with PVL.Results.Visual ischemic manifestations occurred in 108 patients, including PVL in 53 (16%), bilaterally in 15 patients (28%). The independent predictors associated with an increased risk of PVL were age (OR 1.06, 95% CI 1.01–1.12, p = 0.01), a history of transient visual ischemic symptoms (OR 2.62, 95% CI 1.29–5.29, p < 0.01), and jaw claudication (OR 2.11, 95% CI 1.09–4.10, p = 0.03). The presence of fever (OR 0.30, 95% CI 0.14–0.64, p < 0.01) and rheumatic symptoms (OR 0.23, 95% CI 0.10–0.57, p = 0.001) were associated with a markedly reduced risk of developing visual loss (3.7% if features were both present). No laboratory variables were independently associated with PVL.Conclusion.The visual ischemic risk of untreated GCA can be readily estimated upon simple clinical findings, but not laboratory variables. However, we did not identify a subgroup of patients carrying no risk of developing visual loss. Glucocorticoid treatment remains, therefore, urgent for any patient with a high clinical suspicion index.
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Management of giant cell arteritis: Recommendations of the French Study Group for Large Vessel Vasculitis (GEFA). Rev Med Interne 2016; 37:154-65. [DOI: 10.1016/j.revmed.2015.12.015] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 11/17/2022]
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Abstract
PURPOSE OF REVIEW Giant cell arteritis (GCA) remains a potentially blinding inflammatory vasculitis of the elderly. Because prolonged doses of corticosteroids remain the best established treatment, side-effects during treatment are common and potentially serious. This review addresses the challenges clinicians face in managing this disease. RECENT FINDINGS High-dose corticosteroids with slow tapering and close monitoring are the mainstay of treatment. Investigations into adjunctive treatment have yet to establish other agents as beneficial, but further research is ongoing with some promising results. SUMMARY GCA represents a challenging illness to clinicians because of its potential for causing blindness and the need for prolonged high doses of corticosteroids with their many complications.
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Antonio-Santos AA, Murad-Kejbou SJ, Foroozan R, Yedavally S, Kaufman DI, Eggenberger ER. Preserved Visual Acuity in Anterior Ischemic Optic Neuropathy Secondary to Giant Cell (temporal) Arteritis. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2016; 8:17-21. [PMID: 26958148 PMCID: PMC4762406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To evaluate the prevalence and clinical profile of patients with biopsy-proven arteritic anterior ischemic optic neuropathy presenting with preserved visual acuity of 20/40 or better and those with an initial poor visual acuity of 20/50 or worse through a retrospective chart review. RESULTS Nine of 37 patients with arteritic anterior ischemic optic neuropathy presented with a preserved visual acuity of 20/40 or better in the affected eye. All patients with preserved visual acuity had initial visual field defects that spared the central field. All 37 patients immediately received high-dose corticosteroid therapy. Visual acuity worsened by > 2 lines in one of nine patients (11%) with preserved visual acuity, with a corresponding progression of visual field constriction. CONCLUSION Although preserved visual acuity of 20/40 or better has traditionally been associated with the nonarteritic form of anterior ischemic optic neuropathy, giant cell arteritis should still be strongly considered, especially if they have giant cell arteritis systemic symptoms.
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Diamantopoulos AP, Haugeberg G, Lindland A, Myklebust G. The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment: towards a more effective strategy to improve clinical outcome in giant cell arteritis? Rheumatology (Oxford) 2015; 55:66-70. [DOI: 10.1093/rheumatology/kev289] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Indexed: 11/12/2022] Open
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Abstract
Giant cell arteritis (GCA) is a large-vessel vasculitis predominantly affecting older people, with a peak incidence between 70 and 79 years of age. If untreated, ischaemic complications can be catastrophic for the patient, including blindness. We review the current treatment paradigms for this condition, the mainstay of which is immediate high-dose glucocorticoid therapy with a gradual dose tapering. Adverse events of glucocorticoid therapy are often observed after 12-24 months and corticosteroid-sparing adjuvant therapies are used in severe disease, multiple flares or patients at high risk of prolonged therapy. The current understanding of the pathogenesis of GCA is explored. This has informed the identification of new potential targets and approaches to treatment. Blockade of interleukin (IL)-6 (tocilizumab) and IL-1 (gevokizumab) are being evaluated in phase III clinical trials. It is hoped that improved risk stratification of organ damage and relapses will be developed using imaging and biomarkers, allowing for individualised treatment for patients; however, there remains further work to be done before this becomes a reality.
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Affiliation(s)
- Lauren Steel
- Rheumatology, Southend University Hospital, Prittlewell Chase, Westcliff-on-sea, Essex, SS0 0RY, UK
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Raine C, Maw W, Williams M, Gayford D, Mapplebeck S, Mackerness C, Dasgupta B. 13. A 26-week study of efficacy and safety of delayed-release prednisone in newly diagnosed cases of giant cell arteritis: an interim analysis. Rheumatology (Oxford) 2014. [DOI: 10.1093/rheumatology/keu198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Tomasson G, Peloquin C, Mohammad A, Love TJ, Zhang Y, Choi HK, Merkel PA. Risk for cardiovascular disease early and late after a diagnosis of giant-cell arteritis: a cohort study. Ann Intern Med 2014; 160:73-80. [PMID: 24592492 PMCID: PMC4381428 DOI: 10.7326/m12-3046] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Involvement of large arteries is well-documented in giant-cell arteritis (GCA), but the risk for cardiovascular events is not well-understood. OBJECTIVE To evaluate the risks for incident myocardial infarction (MI), cerebrovascular accident (CVA), and peripheral vascular disease (PVD) in individuals with incident GCA in a general population context. DESIGN Observational cohort study. SETTING U.K. primary care database. PATIENTS 3408 patients with incident GCA and 17 027 age- and sex-matched reference participants without baseline cardiovascular disease (MI, CVA, or PVD). MEASUREMENTS Diagnoses of GCA, outcomes, and cardiovascular risk factors were identified from electronic medical records. One combined and 3 separate cohort analyses were conducted for the outcomes of MI, CVA, and PVD. The association of GCA with study outcomes is expressed with hazard ratios (HRs) with 95% CIs after adjustment for potential cardiovascular risk factors. RESULTS Among 3408 patients with GCA (73% female; mean age, 73 years), the incidence rates of MI, CVA, and PVD were 10.0, 8.0, and 4.2 events per 1000 person-years, respectively, versus 4.9, 6.3, and 2.0 events per 1000 person-years, respectively, among reference participants. The HRs were 1.70 (95% CI, 1.51 to 1.91) for the combined outcome, 2.06 (CI, 1.72 to 2.46) for MI, 1.28 (CI, 1.06 to 1.54) for CVA, and 2.13 (CI, 1.61 to 2.81) for PVD. The HRs were more pronounced in the first month after GCA diagnosis (combined HR, 4.92 [CI, 2.59 to 9.34]; HR for MI, 11.89 [CI, 2.40 to 59.00]; HR for CVA, 3.93 [CI, 1.76 to 8.79]; HR for PVD, 3.86 [CI, 0.78 to 19.17]). LIMITATION Information on temporal arterial biopsies was not available, and there was a substantial amount of missing data on cardiovascular risk factors. CONCLUSION Giant-cell arteritis is associated with increased risks for MI, CVA, and PVD. PRIMARY FUNDING SOURCE National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Hershberger R, Cho JS. Neurologic complications of aortic diseases and aortic surgery. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:223-238. [PMID: 24365299 DOI: 10.1016/b978-0-7020-4086-3.00016-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Aortic disease processes have a wide range of clinical manifestations. The inflammatory disease process of Takayasu's arteritis differs dramatically from the visceral ischemia of aortic dissection. The catastrophic event of aortic rupture tends to overshadow life-altering events such as stroke and paraplegia. However, these neurologic manifestations of aortic diseases have dramatic effects that extend beyond the individual patient to include both social and financial ramifications. This chapter focuses on the major aortic disease processes and how they can initiate, both directly and indirectly, adverse neurologic events. The chapter concludes with a brief discussion of aortic surgery, how interventions on the aorta can cause neurologic complications, and techniques to avoid these feared adverse neurologic outcomes.
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Affiliation(s)
- Richard Hershberger
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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McKay A, Hussey K, Stuart WP. Temporal artery biopsy--how can we improve performance? Surgeon 2013; 13:73-6. [PMID: 24119976 DOI: 10.1016/j.surge.2013.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 09/09/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Temporal arteritis is a rare systemic disease of undefined aetiology. The British Society for Rheumatology has issued evidence-based guidance in the form of an investigative algorithm, central to which is biopsy of the superficial temporal artery (TA). Currently in Glasgow these patients are being referred to the regional vascular unit. We sought to identify areas where local practice could be improved. METHODS This was a retrospective review of TA biopsy performed since the amalgamation of vascular services in Glasgow. RESULTS There were 32 cases with a complete dataset. The majority of patients referred were women (66%), with a mean age of 68 years (range 43-86 years). A variety of different clinical symptoms were reported. The mean ESR was 53 (range 2-122). The median waiting time from referral to surgical biopsy was 6 days (inter-quartile range 2-8 days). Seven patients waited for more than 14 days for the procedure to be performed. There were four positive biopsies in this case series. TA biopsy influenced the duration of glucocorticosteroid therapy. CONCLUSION From this study we believe that the following changes to local practice would be simple, cost effective and could improve the quality of patient care delivered.
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Affiliation(s)
- A McKay
- Department of Vascular Surgery, Western Infirmary, Glasgow, United Kingdom
| | - K Hussey
- Department of Vascular Surgery, Western Infirmary, Glasgow, United Kingdom.
| | - W P Stuart
- Department of Vascular Surgery, Western Infirmary, Glasgow, United Kingdom
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Prednisolone combined with adjunctive immunosuppression is not superior to prednisolone alone in terms of efficacy and safety in giant cell arteritis: meta-analysis. Clin Rheumatol 2013; 33:227-36. [PMID: 24026674 DOI: 10.1007/s10067-013-2384-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 08/27/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023]
Abstract
To conduct a meta-analysis of published data of the effectiveness of drug treatment in giant cell arteritis (GCA) to provide evidence to support the optimal use of glucocorticoids (GCs) and adjunct therapy. MEDLINE, CENTRAL and EMBASE searches were used to identify randomised control trials on the treatment of GCA. Studies included were trials in which: (1) the participants were classified as having GCA by the 1990 ACR criteria or biopsy proven disease; (2) parallel-group randomised control of at least 16 weeks duration had been conducted with at least 20 participants; (3) the design included either alternative adjunct immunosuppressant regimens, alternative GCs dosing or routes of administration; and (4) outcome data was included on either relapse rates or rates of infection. One thousand eight hundred thirty-six articles were retrieved, of which only 37 met the primary inclusion criteria. Sixteen of these studies reported some information about the GCs or adjuvant regimen used. Only ten studies were of sufficient quality to be included in the meta-analysis. Together these comprised 638 participants of which 72 % were female. Three studies compared various GCs regimens, with two comparing IV GCs, the latter showing a marginal benefit with respect to relapse (risk ratio (RR) = 0.78, 95 % CI = 0.54 to 1.12) but a greater risk of infection (RR = 1.58, 95 % CI = 0.90 to 2.78). Another three used methotrexate as an adjunctive agent and showed marginal benefit with respect to relapse (RR = 0.85, 95 % CI = 0.66 to 1.11). The remaining four trials compared prednisolone to dapsone, infliximab, adalimumab and hydroxychloroquine, respectively. There are various clinical trials of varying quality. The results from this meta-analysis show that the use of adjunct agents is not associated with improved outcome.
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Liozon E, Ly KH, Robert PY. Manifestations ophtalmologiques de la maladie de Horton. Rev Med Interne 2013; 34:421-30. [DOI: 10.1016/j.revmed.2013.02.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 10/27/2022]
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Abstract
Giant cell arteritis is the most common vasculitis in Caucasians. Acute visual loss in one or both eyes is by far the most feared and irreversible complication of giant cell arteritis. This article reviews recent guidelines on early recognition of systemic, cranial, and ophthalmic manifestations, and current management and diagnostic strategies and advances in imaging. We share our experience of the fast track pathway and imaging in associated disorders, such as large-vessel vasculitis.
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Affiliation(s)
| | | | - Shaifali Jain
- Department of Radiology, Southend University Hospital, Westcliff, Essex, United Kingdom
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Treatment of acute visual loss in giant cell arteritis: should we prescribe high-dose intravenous steroids or just oral steroids? J Neuroophthalmol 2013; 32:278-87. [PMID: 22914694 DOI: 10.1097/wno.0b013e3182688218] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dejaco C, Duftner C, Dasgupta B, Matteson EL, Schirmer M. Polymyalgia rheumatica and giant cell arteritis: management of two diseases of the elderly. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ahe.11.50] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) present with a broad spectrum of clinical manifestations and almost exclusively occur in the population aged over 50 years. After rheumatoid arthritis, PMR is the second most common autoimmune rheumatic disorder. Visual loss is the most feared complication in temporal arteritis, and extracranial arteries and/or aorta are more often involved in GCA than previously estimated. No specific laboratory parameter exists for diagnosis of PMR. Imaging techniques such as ultrasonography, MRI or 18F-fluorodeoxyglucose PET may be helpful in the diagnosis and evaluation of the extent of vascular involvement in these diseases. This article highlights upcoming new classification criteria for PMR, recent advances of diagnostic and therapeutic procedures as well as ongoing research on biomarkers and corticosteroid-sparing medications, which should improve management of PMR and GCA.
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Affiliation(s)
- Christian Dejaco
- Department of Rheumatology & Immunology, Medical University of Graz, Auenbruggerplatz 2/4, A-8036 Graz, Austria
| | - Christina Duftner
- Department of Internal Medicine, Bezirkskrankenhaus Kufstein, Endach 27, A-6330 Kufstein, Austria
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Essex, UK
| | - Eric L Matteson
- Division of Rheumatology & Division of Epidemiology, Departments of Internal Medicine & Health Sciences Research Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michael Schirmer
- Department of Internal Medicine I, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
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Ghosh P, Borg FA, Dasgupta B. Current understanding and management of giant cell arteritis and polymyalgia rheumatica. Expert Rev Clin Immunol 2011; 6:913-28. [PMID: 20979556 DOI: 10.1586/eci.10.59] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are linked conditions that occur in the elderly. GCA is a vasculitis of large- and medium-sized vessels causing critical ischemia. It is a medical emergency owing to the high incidence of neuro-ophthalmic complications. PMR is an inflammatory disease characterized by abrupt-onset pain and stiffness of the shoulder and pelvic girdle muscles. Both conditions are associated with a systemic inflammatory response and constitutional symptoms. The pathogeneses are unclear. The initiating step may be the recognition of an infectious agent by activated dendritic cells. The key cell type involved is CD4(+) T cells and the key cytokines are IFN-γ (implicated in granuloma formation) and IL-6 (key to the systemic response). The pathogenesis of PMR may be similar to that of GCA, however, PMR exhibits less clinical vascular involvement. The mainstay of therapy is corticosteroids, and disease-modifying therapy is indicated in relapsing disease. This article reviews recent guidelines on early recognition, investigations and management of these diseases, as well as advances in imaging.
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Affiliation(s)
- Parasar Ghosh
- Department of Rheumatology, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex, SS0 0RY, UK
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Tehrani R, Ostrowski RA, Hariman R, Jay WM. Giant Cell Arteritis: Oral Versus Intravenous Corticosteroids. Neuroophthalmology 2009. [DOI: 10.1080/01658100802716754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Borg FA, Dasgupta B. Treatment and outcomes of large vessel arteritis. Best Pract Res Clin Rheumatol 2009; 23:325-37. [DOI: 10.1016/j.berh.2009.04.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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[Vasculitis. Treatment outcome parameters]. Z Rheumatol 2008; 68:44-8. [PMID: 19096856 DOI: 10.1007/s00393-008-0358-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The definition of outcome parameters has improved the care of vasculitis patients dramatically in recent decades. In the first phase of joint European studies, disease stages and activity were defined. In the second and third phases results of the randomized and controlled trials were summarized and published as European recommendations for the care of small and large vessel vasculitis. Irrespective of the type of vasculitis, inducing remission, maintaining remission and preventing disease- and therapy-related complications are the main outcome criteria.
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Borg FA, Salter VLJ, Dasgupta B. Neuro-ophthalmic complications in giant cell arteritis. Curr Allergy Asthma Rep 2008; 8:323-30. [PMID: 18606086 DOI: 10.1007/s11882-008-0052-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Giant cell arteritis (GCA) is a medical emergency characterized by systemic inflammation and critical ischemia. Neuro-ophthalmic complications occur early, with permanent vision loss in up to one fifth of patients. This mainly results from failure of prompt recognition and treatment. Diagnosis of GCA is often preceded by unrecognized symptoms, including constitutional upset and jaw claudication. Features predictive of permanent visual loss include jaw claudication and temporal artery abnormalities on physical examination. These patients often do not mount high inflammatory responses. Modern imaging techniques show diagnostic promise, and have led to an increased recognition of major artery involvement in GCA. However, temporal artery biopsy remains the gold standard for investigation. Intimal hyperplasia on histologic examination is associated with neuro-ophthalmic complications. The mainstay of therapy remains corticosteroids. Experience using conventional disease-modifying drugs has been mixed, and biologic therapies require further evaluation for their steroid-sparing potential.
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Affiliation(s)
- Frances A Borg
- Department of Rheumatology, Southend University Hospital, Prittlewell Chase, Westcliffe-on-Sea, Essex, SS0 0RY, UK
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Fraser JA, Weyand CM, Newman NJ, Biousse V. The treatment of giant cell arteritis. REVIEWS IN NEUROLOGICAL DISEASES 2008; 5:140-52. [PMID: 18838954 PMCID: PMC3014829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Although giant cell arteritis (GCA) is a well-known vasculitis sensitive to corticosteroid-mediated immunosuppression, numerous issues of long-term therapeutic management remain unresolved. Because GCA encompasses a broad spectrum of clinical subtypes, ranging from devastating visual loss and neurological deficits to isolated systemic symptoms, the treatment of GCA must be adjusted to each case, and recommendations vary widely in the literature. This article systematically reviews the treatment options for patients with neuro-ophthalmic and neurological complications of GCA, as well as the evidence for possible adjuvant therapies for patients with GCA. Although there is no randomized controlled clinical trial specifically evaluating GCA patients with ocular and neurological complications, we recommend that GCA patients with acute visual loss or brain ischemia be admitted to the hospital for high-dose intravenous methyl-prednisolone, close monitoring, and prevention of steroid-induced complications. Aspirin may also be helpful in these cases. The evidence supporting the use of steroid-sparing immunomodulatory agents such as methotrexate for long-term management remains debated.
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Affiliation(s)
- J Alexander Fraser
- Department of Clinical Neurological Sciences, University of Western Ontario School of Medicine, London, Ontario, Canada
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