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Kreis L, Dejaco C, Schmidt WA, Németh R, Venhoff N, Schäfer VS. The Meteoritics Trial: efficacy of methotrexate after remission-induction with tocilizumab and glucocorticoids in giant cell arteritis-study protocol for a randomized, double-blind, placebo-controlled, parallel-group phase II study. Trials 2024; 25:56. [PMID: 38225579 PMCID: PMC10790384 DOI: 10.1186/s13063-024-07905-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/02/2024] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Glucocorticoids (GC) are the standard treatment for giant cell arteritis (GCA), even though they are associated with adverse side effects and high relapse rates. Tocilizumab (TCZ), an interleukin-6 receptor antagonist, has shown promise in sustaining remission and reducing the cumulative GC dosage, but it increases the risk of infections and is expensive. After discontinuation of TCZ, only about half of patients remain in remission. Additionally, only few studies have been conducted looking at remission maintenance, highlighting the need for alternative strategies to maintain remission in GCA. Methotrexate (MTX) has been shown to significantly decrease the risk of relapse in new-onset GCA and is already a proven safe drug in many rheumatologic diseases. METHODS This study aims to evaluate the efficacy and safety of MTX in maintaining remission in patients with GCA who have previously been treated with GC and at least 6 months with TCZ. We hypothesize that MTX can maintain remission in GCA patients, who have achieved stable remission after treatment with GC and TCZ, and prevent the occurrence of relapses. The study design is a monocentric, randomized, double-blind, placebo-controlled, parallel-group phase II trial randomizing 40 GCA patients 1:1 into a MTX or placebo arm. Patients will receive 17.5 mg MTX/matching placebo weekly by subcutaneous injection for 12 months, with the possibility of dose reduction if clinically needed. A 6-month follow-up will take place. The primary endpoint is the time to first relapse in the MTX group versus placebo during the 12-month treatment period. Secondary outcomes include patient- and investigator-reported outcomes and laboratory findings, as well as the prevalence of aortitis, number of vasculitic vessels, and change in intima-media thickness during the study. DISCUSSION This is the first clinical trial evaluating remission maintenance of GCA with MTX after a previous treatment cycle with TCZ. Following the discontinuation of TCZ in GCA, MTX could be a safe and inexpensive drug. TRIAL REGISTRATION ClinicalTrials.gov, NCT05623592. Registered on 21 November 2022. EU Clinical Trials Register, 2022-501058-12-00. German Clinical Trials Register DRKS00030571.
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Affiliation(s)
- Lena Kreis
- Department of Internal Medicine III, Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Nordrhein-Westfalen, Germany
| | - Christian Dejaco
- Department of Rheumatology, Medical University Graz, Auenbruggerplaz 15, 8036, Graz, Austria
| | - Wolfgang Andreas Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Krankenhaus Berlin, Lindenberger Weg 19, 13125, Berlin, Germany
| | - Robert Németh
- Institute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 55, 79106, Freiburg, Germany
| | - Valentin Sebastian Schäfer
- Department of Internal Medicine III, Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Nordrhein-Westfalen, Germany.
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Grazzini S, Conticini E, Falsetti P, D’Alessandro M, Sota J, Terribili R, Baldi C, Fabiani C, Bargagli E, Cantarini L, Frediani B. Tocilizumab Vs Methotrexate in a Cohort of Patients Affected by Active GCA: A Comparative Clinical and Ultrasonographic Study. Biologics 2023; 17:151-160. [PMID: 38059132 PMCID: PMC10697083 DOI: 10.2147/btt.s431818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/31/2023] [Indexed: 12/08/2023]
Abstract
Introduction No head-to-head study has assessed the superiority of tocilizumab versus methotrexate in giant cell arteritis (GCA), and few studies have demonstrated its effectiveness in terms of ultrasonographic findings, but without a control group. The primary endpoint was to assess whether tocilizumab was superior to methotrexate in inducing normalization of US findings, whereas the secondary endpoint was to assess the effectiveness of precocious withdrawal of glucocorticoids. Methods We prospectively enrolled all the patients with active GCA at our clinic. The inclusion criteria were clinical diagnosis of GCA; active disease; and clinical, laboratory, and US data, evaluated using the halo count (HC) and OMERACT GCA Ultrasonography Score (OGUS). Evaluations were repeated at 3, 6, and 12 months. Results Twenty patients were treated with Tocilizumab and 9 with Methotrexate. All but three tocilizumab-treated patients achieved remission at six months, whereas at 12 months, all patients were in glucocorticoid-free remission. Up to three of the nine methotrexate patients experienced a lack of efficacy or minor relapses. Tocilizumab-treated patients showed a statistically significant difference between baseline and all follow-ups in terms of OGUS and HC, whereas the difference in the Methotrexate group was significant after 1 year. The mean glucocorticoid dosage significantly decreased in both groups. No severe adverse events or major relapses were reported. Conclusion Our study demonstrates the superiority in terms of rapidity of a tocilizumab-based scheme over a methotrexate-based scheme in inducing clinical and US remission. Precocious withdrawal of glucocorticoids did not increase the risk of relapse.
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Affiliation(s)
- Silvia Grazzini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Paolo Falsetti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Miriana D’Alessandro
- Respiratory Diseases and Lung Transplant Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Jurgen Sota
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Riccardo Terribili
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Caterina Baldi
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases and Lung Transplant Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Mensch N, Hemmig AK, Aschwanden M, Imfeld S, Stegert M, Recher M, Staub D, Kyburz D, Berger CT, Daikeler T. Rapid glucocorticoid tapering regimen in patients with giant cell arteritis: a single centre cohort study. RMD Open 2023; 9:e003301. [PMID: 37460275 DOI: 10.1136/rmdopen-2023-003301] [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: 05/09/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES We evaluated the feasibility of a rapid glucocorticoid tapering regimen to reduce glucocorticoid exposure in patients with giant cell arteritis (GCA) treated with glucocorticoids only. METHODS Newly diagnosed patients with GCA treated with a planned 26-week glucocorticoid tapering regimen at the University Hospital Basel were included. Data on relapses, cumulative steroid doses (CSD) and therapy-related adverse effects were collected from patients' records. RESULTS Of 47 patients (64% women, median age 72 years), 32 patients (68%) had relapsed. Most relapses were minor (28/32) and 2/3 of those were isolated increased inflammatory markers (19/32). Among major relapses, one resulted in permanent vision loss. The median time until relapse was 99 days (IQR 71-127) and median glucocorticoid dose at relapse was 8 mg (IQR 5-16). Nine of 47 patients stopped glucocorticoids after a median duration of 35 weeks and did not relapse within 1 year. Median CSD at 12 months was 4164 mg which is lower compared with published data. Glucocorticoid-associated adverse effects occurred in 40% of patients, most frequently were new onset or worsening hypertension (19%), diabetes (11%) and severe infections (11%). CONCLUSION We could demonstrate that 32% of patients remained relapse-free and 19% off glucocorticoids at 1 year after treatment with a rapid glucocorticoid tapering regimen. Most relapses were minor and could be handled with temporarily increased glucocorticoid doses. Consequently, the CSD at 12 months was much lower than reported in published cohorts. Thus, further reducing treatment-associated damage in patients with GCA by decreasing CSD seems to be possible.
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Affiliation(s)
- Noemi Mensch
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | | | - Markus Aschwanden
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Stephan Imfeld
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Mihaela Stegert
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Mike Recher
- University Centre for Immunology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, Immunodeficiency, University of Basel, Basel, Switzerland
| | - Daniel Staub
- Department of Angiology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Basel, Basel, Switzerland
| | - Diego Kyburz
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Basel, Basel, Switzerland
| | - Christoph T Berger
- University Centre for Immunology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Basel, Basel, Switzerland
- Department of Biomedicine, Translational Immunology, University of Basel, Basel, Switzerland
| | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Basel, Basel, Switzerland
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Galli E, Pipitone N, Salvarani C. The role of PET/CT in disease activity assessment in patients with large vessel vasculitis. Curr Opin Rheumatol 2023; 35:194-200. [PMID: 36866659 DOI: 10.1097/bor.0000000000000931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW The aim of this article was to review the recent contributions on the role of PET in assessing disease activity in patients with large-vessel vasculitis (giant cell arteritis and Takayasu arteritis). RECENT FINDINGS 18 FDG (fluorodeoxyglucose) vascular uptake in large-vessel vasculitis at PET shows moderate correlation with clinical indices, laboratory markers and signs of arterial involvement at morphological imaging. Limited data may suggest that 18 FDG (fluorodeoxyglucose) vascular uptake could predict relapses and (in Takayasu arteritis) the development of new angiographic vascular lesions. PET appears to be in general sensitive to change after treatment. SUMMARY While the role of PET in diagnosis large-vessel vasculitis is established, its role in evaluating disease activity is less clear-cut. PET may be used as an ancillary technique, but a comprehensive assessment, including clinical, laboratory and morphological imaging is still required to monitor patients with large-vessel vasculitis over time.
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Affiliation(s)
- Elena Galli
- Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia
| | | | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia
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Lavrard-Meyer P, Gomes De Pinho Q, Daumas A, Benyamine A, Ebbo M, Schleinitz N, Harlé J, Jarrot P, Kaplanski G, Berbis J, Granel B. Hospitalisation pour infection chez les patients suivis pour une artérite à cellules géantes : étude monocentrique rétrospective. Rev Med Interne 2023; 44:212-217. [PMID: 37029032 DOI: 10.1016/j.revmed.2023.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Infections are associated with morbimortality of patients with giant cell arteritis (GCA). The aim of this work was twofold: the identification of factors predisposing to the risk of infection and the description of patients hospitalized with an infection occurring during the treatment period of CAG. METHODS A monocentric retrospective study was conducted in GCA patients, comparing patients hospitalized for infection with patients without infection. The analysis included 21/144 (14.6%) patients with 26 infections (cases) and 42 control matched on sex, age, and diagnosis of GCA. RESULTS Both groups were similar except for a higher frequency of seritis in cases (15% vs. 0%, p=0.03). Relapses of GCA were less common in cases (23.8% vs 50.0%, p=0.041). Hypogammaglobulinemia was present during infection. More than half of the infections (53.8%) occurred in the first year of follow-up with an average dose of 15mg/day of corticosteroids. Infections were mainly pulmonary (46.2%) and cutaneous (26.9%). CONCLUSION Factors associated with infectious risk were identified. This preliminary monocentric work will continue with a national multicentre study.
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Lavergne A, Dumont A, Deshayes S, Boutemy J, Maigné G, Silva NM, Nguyen A, Gallou S, Philip R, Aouba A, de Boysson H. Efficacy and tolerance of methotrexate in a real-life monocentric cohort of patients with giant cell arteritis. Semin Arthritis Rheum 2023; 60:152192. [PMID: 36963127 DOI: 10.1016/j.semarthrit.2023.152192] [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: 12/29/2022] [Revised: 02/28/2023] [Accepted: 03/15/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVES To assess the indications, efficiency and tolerance profiles of methotrexate (MTX) in patients with giant cell arteritis (GCA) in a real-life setting. METHODS From a monocentric database of >500 GCA patients, we retrospectively selected 49 patients who received MTX between 2010 and 2020. Cumulative glucocorticoid (GC) doses, the number of relapses and GC-related adverse events were recorded before, during and after MTX. We separately analyzed the 3 main indications of MTX, i.e., disease relapse, GC-sparing strategy, and GCA presentation. RESULTS With a median follow-up of 84 [10-255] months, 25 (51%) and 18/41 (44%) patients relapsed during MTX treatment and after its discontinuation, respectively. Among the 40 patients who relapsed before MTX, 26 (65%) experienced a new relapse after MTX introduction. Once MTX was introduced, 24 (49%) patients were able to discontinue GC after 20.5 [7-64] months. No significant difference in cumulative GC doses were noted before and after MTX introduction with a total GC dose of 14.7 [1.05-69.4] grams. At the last follow-up, MTX was discontinued in 41 patients, including 13 (32%) due to clinicobiological remission, 12 (30%) due to treatment failure and 15 (36%) due to side effects. CONCLUSION Our real-life study showed a modest beneficial effect of MTX on relapse in patients with GCA. However, we did not observe any GC-sparing effect in this study. Other studies are needed to assess the GC-sparing effect in patients in whom GC management is adapted from recent recommendations.
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Affiliation(s)
- Amandine Lavergne
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | | | - Alexandre Nguyen
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Rémi Philip
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France.
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Conticini E, Falsetti P, Baldi C, Fabiani C, Cantarini L, Frediani B. Routine color doppler ultrasonography for the early diagnosis of cranial giant cell arteritis relapses. Intern Emerg Med 2022; 17:2431-2435. [PMID: 36156190 DOI: 10.1007/s11739-022-03110-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Edoardo Conticini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Paolo Falsetti
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Caterina Baldi
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Claudia Fabiani
- Department of Medicine, Surgery and Neuroscience, Ophthalmology Unit, University of Siena, Siena, Italy
| | - Luca Cantarini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy.
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
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Utility of standard diffusion-weighted magnetic resonance imaging for the identification of ischemic optic neuropathy in giant cell arteritis. Sci Rep 2022; 12:16553. [PMID: 36192437 PMCID: PMC9530116 DOI: 10.1038/s41598-022-20916-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
This study assessed diffusion abnormalities of the optic nerve (ON) in giant cell arteritis (GCA) patients with acute onset of visual impairment (VI) using diffusion-weighted magnetic resonance imaging (DWI). DWI scans of GCA patients with acute VI were evaluated in a case-control study. Two blinded neuroradiologists assessed randomized DWI scans of GCA and controls for ON restricted diffusion. Statistical quality criteria and inter-rater reliability (IRR) were calculated. DWI findings were compared to ophthalmological assessments. 35 GCA patients (76.2 ± 6.4 years; 37 scans) and 35 controls (75.7 ± 7.6 years; 38 scans) were included. ON restricted diffusion was detected in 81.1% (Reader 1) of GCA scans. Localization of ON restricted diffusion was at the optic nerve head in 80.6%, intraorbital in 11.1% and affecting both segments in 8.3%. DWI discerned affected from unaffected ON with a sensitivity, specificity, positive and negative predictive value of 87%/99%/96%/96%. IRR for ON restricted diffusion was κinter = 0.72 (95% CI 0.59–0.86). DWI findings challenged ophthalmologic diagnoses in 4 cases (11.4%). DWI visualizes anterior and posterior ON ischemia in GCA patients with high sensitivity and specificity, as well as substantial IRR. DWI may complement the ophthalmological assessment in patients with acute VI.
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Bouffard MA, Prasad S, Unizony S, Costello F. Does Tocilizumab Influence Ophthalmic Outcomes in Giant Cell Arteritis? J Neuroophthalmol 2022; 42:173-179. [PMID: 35482901 DOI: 10.1097/wno.0000000000001514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite appropriate use of corticosteroids, an important minority of patients with giant cell arteritis (GCA) develop progressive vision loss during the initial stages of the disease or during corticosteroid tapering. Tocilizumab is the only clearly effective adjunctive treatment to corticosteroids in the management of GCA, but questions regarding its efficacy specifically in the neuro-ophthalmic population and its role in mitigating vision loss have not been broached until recently. EVIDENCE ACQUISITION The authors queried Pubmed using the search terms "GCA" and "tocilizumab" in order to identify English-language publications either explicitly designed to evaluate the influence of tocilizumab on the ophthalmic manifestations of GCA or those which reported, but were not primarily focused on, ophthalmic outcomes. RESULTS Recent retrospective analyses of populations similar to those encountered in neuro-ophthalmic practice suggest that tocilizumab is effective in decreasing the frequency of GCA relapse, the proportion of flares involving visual manifestations of GCA, and the likelihood of permanent vision loss. Data regarding the utility of tocilizumab to curtail vision loss at the time of diagnosis are limited to case reports. CONCLUSIONS Compared with conventional corticosteroid monotherapy, treatment of GCA with both corticosteroids and tocilizumab may decrease the likelihood of permanent vision loss. Further prospective, collaborative investigation between rheumatologists and neuro-ophthalmologists is required to clarify the ophthalmic and socioeconomic impact of tocilizumab on the treatment of GCA.
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Affiliation(s)
- Marc A Bouffard
- Department of Neurology (MAB), Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Neurology (SP), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine (SU), Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Dumain C, Broner J, Arnaud E, Dewavrin E, Holubar J, Fantone M, de Wazières B, Parreau S, Fesler P, Guilpain P, Roubille C, Goulabchand R. Patients' Baseline Characteristics, but Not Tocilizumab Exposure, Affect Severe Outcomes Onset in Giant Cell Arteritis: A Real-World Study. J Clin Med 2022; 11:jcm11113115. [PMID: 35683507 PMCID: PMC9181652 DOI: 10.3390/jcm11113115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/17/2022] [Accepted: 05/27/2022] [Indexed: 12/05/2022] Open
Abstract
Objectives: Giant cell arteritis (GCA) is associated with severe outcomes such as infections and cardiovascular diseases. We describe here the impact of GCA patients’ characteristics and treatment exposure on the occurrence of severe outcomes. Methods: Data were collected retrospectively from real-world GCA patients with a minimum of six-months follow-up. We recorded severe outcomes and treatment exposure. In the survival analysis, we studied the predictive factors of severe outcomes occurrence, including treatment exposure (major glucocorticoids (GCs) exposure (>10 g of the cumulative dose) and tocilizumab (TCZ) exposure), as time-dependent covariates. Results: Among the 77 included patients, 26% were overweight (BMI ≥ 25 kg/m2). The mean cumulative dose of GCs was 7977 ± 4585 mg, 18 patients (23%) had a major GCs exposure, and 40 (52%) received TCZ. Over the 48-month mean follow-up period, 114 severe outcomes occurred in 77% of the patients: infections—29%, cardiovascular diseases—18%, hypertension—15%, fractural osteoporosis—8%, and deaths—6%. Baseline diabetes and overweight were predictive factors of severe outcomes onset (HR, 2.41 [1.05−5.55], p = 0.039; HR, 2.08 [1.14−3.81], p = 0.018, respectively) independently of age, sex, hypertension, and treatment exposure. Conclusion: Diabetic and overweight GCA patients constitute an at-risk group requiring tailored treatment, including vaccination. The effect of TCZ exposure on the reduction of severe outcomes was not proved here.
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Affiliation(s)
- Cyril Dumain
- Internal Medicine Department, CHU Nîmes, University of Montpellier, 30029 Nîmes, France; (C.D.); (J.B.); (E.A.); (J.H.); (M.F.)
| | - Jonathan Broner
- Internal Medicine Department, CHU Nîmes, University of Montpellier, 30029 Nîmes, France; (C.D.); (J.B.); (E.A.); (J.H.); (M.F.)
| | - Erik Arnaud
- Internal Medicine Department, CHU Nîmes, University of Montpellier, 30029 Nîmes, France; (C.D.); (J.B.); (E.A.); (J.H.); (M.F.)
| | - Emmanuel Dewavrin
- Intensive Care Medicine Department, Lapeyronie Hospital, CHU Montpellier, 34090 Montpellier, France;
| | - Jan Holubar
- Internal Medicine Department, CHU Nîmes, University of Montpellier, 30029 Nîmes, France; (C.D.); (J.B.); (E.A.); (J.H.); (M.F.)
| | - Myriam Fantone
- Internal Medicine Department, CHU Nîmes, University of Montpellier, 30029 Nîmes, France; (C.D.); (J.B.); (E.A.); (J.H.); (M.F.)
| | - Benoit de Wazières
- Department of Internal Medicine and Geriatrics, CHU Nîmes, University of Montpellier, 30029 Nîmes, France;
| | - Simon Parreau
- Department of Internal Medicine, Limoges University Hospital Center, 87042 Limoges, France;
| | - Pierre Fesler
- Department of Internal Medicine, Lapeyronie Hospital, CHU Montpellier, 34090 Montpellier, France; (P.F.); (C.R.)
- PhyMedExp, INSERM U1046, CNRS UMR 9214, University of Montpellier, 34295 Montpellier, France
| | - Philippe Guilpain
- Department of Internal Medicine and Multi-Organic Diseases, St. Eloi Hospital, CHU Montpellier, 34295 Montpellier, France;
- Institute for Regenerative Medicine & Biotherapy, St. Eloi Hospital, University of Montpellier, INSERM, 34295 Montpellier, France
| | - Camille Roubille
- Department of Internal Medicine, Lapeyronie Hospital, CHU Montpellier, 34090 Montpellier, France; (P.F.); (C.R.)
- PhyMedExp, INSERM U1046, CNRS UMR 9214, University of Montpellier, 34295 Montpellier, France
| | - Radjiv Goulabchand
- Internal Medicine Department, CHU Nîmes, University of Montpellier, 30029 Nîmes, France; (C.D.); (J.B.); (E.A.); (J.H.); (M.F.)
- Institute for Regenerative Medicine & Biotherapy, St. Eloi Hospital, University of Montpellier, INSERM, 34295 Montpellier, France
- Correspondence: ; Tel.: +33-(0)4-66683241
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Conticini E, Hellmich B, Frediani B, Csernok E, Löffler C. Utility of serum complement factors C3 and C4 as biomarkers during therapeutic management of giant cell arteritis. Scand J Rheumatol 2022; 52:276-282. [PMID: 35383517 DOI: 10.1080/03009742.2022.2047311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE There is a strong unmet need for biomarkers in giant cell arteritis (GCA), as C-reactive protein (CRP) may be unreliable in patients treated with Tocilizumab (TCZ). We aimed to assess whether C3 and C4 are useful biomarkers in GCA patients, particularly in those treated with TCZ. METHOD We retrospectively enrolled all patients who underwent C3 and C4 measurement at baseline. All patients were evaluated at 3, 6, 12, and 24 months after diagnosis, as part of routine follow-up. Two assessments after the end of the observational period, in case of further relapses, were also included. RESULTS At baseline, mean ± sd levels (mg/dL) of C3 (133 ± 28.99) and C4 (25.9 ± 9.04) were within normal ranges. During follow-up, C3 and C4 decreased in patients attaining remission (107.07 ± 19.86, p = 0.0006; 19.86 ± 10.27, p = 0.01, respectively) and sustained remission (95.85 ± 18.04, p = 0.001; 15.61 ± 9.75, p = 0.006). In TCZ-treated patients, even stronger decreases in C3 (83.11 ± 19.66, p = 0.001) and C4 (8.26 ± 3.83, p < 0.0001) were observed, and their values were not correlated with CRP or erythrocyte sedimentation rate. CONCLUSION C3 and C4 do not seem useful in the diagnosis of GCA, as normal values do not rule out active vasculitis. However, C3 and C4 correlate with disease activity. As the low C4 levels found in TCZ-treated patients are not correlated with CRP, C4 should be evaluated as a potential biomarker of disease activity and treatment response.
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Affiliation(s)
- E Conticini
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim unter Teck, Germany.,Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - B Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim unter Teck, Germany
| | - B Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - E Csernok
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim unter Teck, Germany
| | - C Löffler
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim unter Teck, Germany.,Department of Nephrology, Hypertensiology and Rheumatology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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12
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Stone JH, Spotswood H, Unizony SH, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Spiera R, Bao M. New-onset versus relapsing giant cell arteritis treated with tocilizumab: 3-year results from a randomized controlled trial and extension. Rheumatology (Oxford) 2021; 61:2915-2922. [PMID: 34718434 PMCID: PMC9258533 DOI: 10.1093/rheumatology/keab780] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/12/2021] [Indexed: 01/09/2023] Open
Abstract
Objective Tocilizumab plus prednisone induces sustained glucocorticoid-free remission in patients with GCA. However, its long-term benefits in new-onset vs relapsing disease are uncertain, and the value of weekly vs every-other-week dosing has not been evaluated. Methods In Giant-Cell Arteritis Actemra (GiACTA) part 1, patients with new-onset or relapsing GCA received blinded tocilizumab weekly (TCZ QW), tocilizumab every-other-week (TCZ Q2W) or placebo for 52 weeks, with a prednisone taper. In part 2 (open-label), patients were treated at investigator discretion for 104 weeks. In this analysis, patients were evaluated according to their original treatment assignments, and outcomes beyond 52 weeks were assessed. Outcomes of interest included time to first flare and cumulative glucocorticoid exposure over 3 years according to baseline disease status. Results Part 1 enrolled 250 patients; 215 entered part 2. At baseline, 48% had new-onset disease and 52% had relapsing disease. In patients with new-onset and relapsing disease, the median time to first flare in the TCZ QW group was 577 and 575 days, respectively, vs 479 and 428 days with TCZ Q2W and 179 and 224 days with placebo; the median cumulative glucocorticoid dose was 3068 mg and 2191 mg with TCZ QW, 4080 mg and 2353 mg with TCZ Q2W, and 4639 mg and 6178 mg with placebo. Conclusion TCZ QW delayed the time to flare and reduced the cumulative glucocorticoid dose in patients with relapsing GCA and new-onset GCA. These data support initiating TCZ QW as part of first-line therapy in all patients with active GCA. Trial registration ClinicalTrials.gov, https://clinicaltrials.gov, NCT01791153.
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Affiliation(s)
- John H Stone
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston, MA, USA
| | | | - Sebastian H Unizony
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston, MA, USA
| | - Martin Aringer
- University Medical Center and Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Bhaskar Dasgupta
- Mid and South Essex NHS Foundation Trust, Southend University Hospital, Westcliff-on-Sea, United Kingdom
| | - Juergen Rech
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Carlo Salvarani
- Division of Rheumatology, AUSL IRCCS Reggio Emilia and University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Robert Spiera
- Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Min Bao
- Genentech, South San Francisco, CA, USA
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13
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Kushimoto K, Ayano M, Nishimura K, Nakano M, Kimoto Y, Mitoma H, Ono N, Arinobu Y, Akashi K, Horiuchi T, Niiro H. HLA-B52 allele in giant cell arteritis may indicate diffuse large-vessel vasculitis formation: a retrospective study. Arthritis Res Ther 2021; 23:238. [PMID: 34517892 PMCID: PMC8436550 DOI: 10.1186/s13075-021-02618-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/28/2021] [Indexed: 02/05/2023] Open
Abstract
Background This study aimed to identify new characteristics of elderly onset large-vessel vasculitis (EOLVV) by focusing on human leucocyte antigen (HLA) genotype, polymyalgia rheumatica (PMR), and affected vascular lesions observed on positron emission tomography/computed tomography (PET/CT) imaging. Methods We retrospectively studied 65 consecutive Japanese patients with large-vessel vasculitis (LVV) who had extracranial vasculitis lesions and underwent PET/CT imaging. PET/CT images were assessed using the semi-quantitative PET visual score of each affected vessel, and the PET vascular activity score (PETVAS) and number of affected vessels were calculated. Subjects were subsequently grouped based on age at onset, superficial temporal artery (STA) involvement, and presence of PMR and compared each group according to HLA genotype. Unsupervised hierarchical cluster analysis was used to identify the patients with similar characteristics in terms of affected vascular lesions detected through PET/CT imaging. The clinical characteristics and PET/CT findings of the population newly identified in this study were examined. Results Twenty-seven patients with EOLVV did not meet the American College of Rheumatology 1990 criteria for giant cell arteritis (GCA) and Takayasu arteritis and were considered as unclassified EOLVV (UEOLVV). The unsupervised hierarchical cluster analysis revealed that UEOLVV with PMR and large-vessel GCA (LV-GCA) formed a cluster of LVV with GCA features (i.e., PMR and/or STA involvement) when restricted to patients who were HLA-B52-positive. Patients who were HLA-B52-positive with LVV and GCA features had similar clinical characteristics and patterns of affected vessels and presented with diffuse LVV lesions. HLA-B52-positive patients who had LVV with GCA features also presented with higher PETVAS, more affected vessels, and lower rates of biologics usage and relapse compared to HLA-B52-positive patients with TAK. Conclusions Patients who had UEOLVV with PMR had similar characteristics to patients with LV-GCA. Patients who were HLA-B52-positive and had LVV with GCA features presented with diffuse vascular lesions and may comprise a core population of Japanese patients with EOLVV. The findings of HLA-B52 positivity and diffusely affected vessels in patients with EOLVV can be considered as suspicious findings of LV-GCA. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02618-4.
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Affiliation(s)
- Kazuo Kushimoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Cancer Stem Cell Research, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.
| | - Keisuke Nishimura
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Miki Nakano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nobuyuki Ono
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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14
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Felten L, Leuchten N, Aringer M. Glucocorticoid dosing and relapses in giant cell arteritis-a single center cohort study. Rheumatology (Oxford) 2021; 61:1997-2005. [PMID: 34487149 DOI: 10.1093/rheumatology/keab677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To investigate the relationship between real life glucocorticoid (GC) dosing and relapse rates in patients with new onset giant cell arteritis (GCA) in a single center. METHODS Complete clinical data taken from the inpatient and outpatient records of consecutive GCA patients followed beyond stopping GC were retrospectively analyzed for GC doses, other immunomodulatory agents and relapses. RESULTS We included 54 patients with GCA confirmed by biopsy or imaging and followed over their complete GC course. In the 25% dose percentile, patients who needed no pulse therapy at onset reached a dose of 15 mg prednisolone or lower at day 40, of 7.5 mg prednisolone or lower on day 169 (after 24 weeks), and were off prednisolone on day 496 (70 weeks). They were below BSR-recommended doses between week 4 and week 12 and above these after week 14. The cumulative prednisolone dose reached in this 25% quartile was 3.74 g. Of the 54 patients, 24 (44%) relapsed, only 4 of whom had stopped GC clearly (17-58 weeks) earlier than the 25% dose quartile and one was distinctly (>10%) below the 25% GC percentile. Methotrexate treatment was not significantly associated with fewer relapses (p= 0.178). CONCLUSION Despite a long-term GC regimen with slow rates of reduction in the low dose range and high cumulative prednisolone doses, 44% of the patients relapsed. Only five (21%) of these relapses may have been prevented by adhering to the recommended GC regimen.
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Affiliation(s)
- Laura Felten
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Nicolai Leuchten
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
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15
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Venhoff N, Schmidt WA, Lamprecht P, Tony HP, App C, Sieder C, Legeler C, Jentzsch C, Thiel J. Efficacy and safety of secukinumab in patients with giant cell arteritis: study protocol for a randomized, parallel group, double-blind, placebo-controlled phase II trial. Trials 2021; 22:543. [PMID: 34404463 PMCID: PMC8369438 DOI: 10.1186/s13063-021-05520-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/06/2021] [Indexed: 12/03/2022] Open
Abstract
Background One key pathological finding in giant cell arteritis (GCA) is the presence of interferon-gamma and interleukin (IL)-17 producing T helper (Th) 1 and Th17 cells in affected arteries. There is anecdotal evidence of successful induction and maintenance of remission with the monoclonal anti-IL-17A antibody secukinumab. Inhibition of IL-17A could therefore represent a potential new therapeutic option for the treatment of GCA. Methods This is a randomized, parallel-group, double-blind, placebo-controlled, multi-center, phase II study in which patients, treating physicians, and the associated clinical staff as well as the sponsor clinical team are blinded. It is designed to evaluate efficacy and safety of secukinumab compared to placebo in combination with an open-label prednisolone taper regimen. Patients included are naïve to biological therapy and have newly diagnosed or relapsing GCA. Fifty patients are randomly assigned in a 1:1 ratio to receive either 300 mg secukinumab or placebo subcutaneously at baseline, weeks 1, 2 and 3, and every 4 weeks from week 4. Patients in both treatment arms receive a 26-week prednisolone taper regimen. The study consists of a maximum 6-week screening period, a 52-week treatment period (including the 26-week tapering), and an 8-week safety follow-up, with primary and secondary endpoint assessments at week 28. Patients who do not achieve remission by week 12 experience a flare after remission or cannot adhere to the prednisolone tapering will enter the escape arm and receive prednisolone at a dose determined by the investigator’s clinical judgment. The blinded treatment is continued. Two optional imaging sub-studies are included (ultrasound and contrast-media enhanced magnetic resonance angiography [MRA]) to assess vessel wall inflammation and occlusion before and after treatment. The primary endpoint is the proportion of patients in sustained remission until week 28 in the secukinumab group compared to the proportion of patients in the placebo group. A Bayesian approach is applied. Discussion The trial design allows the first placebo-controlled data collection on the efficacy and safety of secukinumab in patients with GCA. Trial registration ClinicalTrials.gov NCT03765788. Registration on 5 December 2018, prospective registration, EudraCT number 2018-002610-12; clinical trial protocol number CAIN457ADE11C.
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Affiliation(s)
- Nils Venhoff
- Department Innere Medizin, Klinik für Rheumatologie und Klinische Immunologie, Vaskulitiszentrum Freiburg, Universitätsklinikum Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Klinik für Innere Medizin, Abteilung Rheumatologie und Klinische Immunologie in Berlin-Buch, Lindenberger Weg 19, D-13125, Berlin, Germany
| | - Peter Lamprecht
- Universität zu Lübeck, Klinik für Rheumatologie und klinische Immunologie, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Hans-Peter Tony
- Medizinische Klinik II, Universitätsklinik, Rheumatology/Immunology, Oberduerrbacher Strasse 6, D-97080, Wuerzburg, Germany
| | - Christine App
- Department of Immunology, Hepatology & Dermatology, Novartis Pharma GmbH, Roonstrasse 25, D-90429, Nuremberg, Germany
| | - Christian Sieder
- Department of Immunology, Hepatology & Dermatology, Novartis Pharma GmbH, Roonstrasse 25, D-90429, Nuremberg, Germany
| | - Carolin Legeler
- Department of Immunology, Hepatology & Dermatology, Novartis Pharma GmbH, Roonstrasse 25, D-90429, Nuremberg, Germany.
| | | | - Jens Thiel
- Department Innere Medizin, Klinik für Rheumatologie und Klinische Immunologie, Vaskulitiszentrum Freiburg, Universitätsklinikum Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
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16
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Coath FL, Mukhtyar C. Ultrasonography in the diagnosis and follow-up of giant cell arteritis. Rheumatology (Oxford) 2021; 60:2528-2536. [PMID: 33599253 DOI: 10.1093/rheumatology/keab179] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 12/22/2022] Open
Abstract
Colour Doppler ultrasonography is the first measure to allow objective bedside assessment of GCA. This article discusses the evidence using the OMERACT filter. Consensus definitions for ultrasonographic changes were agreed upon by a Delphi process, with the 'halo' and 'compression' signs being characteristic. The halo is sensitive to change, disappearing within 2-4 weeks of starting glucocorticoids. Ultrasonography has moderate convergent validity with temporal artery biopsy in a pooled analysis of 12 studies including 965 participants [κ = 0.44 (95% CI 0.38, 0.50)]. The interobserver and intra-observer reliabilities are good (κ = 0.6 and κ = 0.76-0.78, respectively) in live exercises and excellent when assessing acquired images and videos (κ = 0.83-0.87 and κ = 0.88, respectively). Discriminant validity has been tested against stroke and diabetes mellitus (κ=-0.16 for diabetes). Machine familiarity and adequate examination time improves performance. Ultrasonography in follow-up is not yet adequately defined. Some patients have persistent changes in the larger arteries but these do not necessarily imply treatment failure or predict relapses.
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Affiliation(s)
- Fiona L Coath
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Chetan Mukhtyar
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
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17
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Unizony SH, Bao M, Han J, Luder Y, Pavlov A, Stone JH. Treatment failure in giant cell arteritis. Ann Rheum Dis 2021; 80:1467-1474. [PMID: 34049857 PMCID: PMC8522464 DOI: 10.1136/annrheumdis-2021-220347] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/24/2021] [Indexed: 11/19/2022]
Abstract
Objective Identify predictors of treatment failure in patients with giant cell arteritis (GCA) receiving tocilizumab in combination with glucocorticoids and in patients with GCA receiving only glucocorticoids. Methods Posthoc analysis of the Giant-Cell Arteritis Actemra trial including 250 patients who received tocilizumab every week plus a 26-week prednisone taper (n=100), tocilizumab every-other-week plus a 26-week prednisone taper (n=49) or placebo plus a 26-week (n=50) or 52-week (n=51) prednisone taper in the intention-to-treat population. Responders for this analysis were patients who maintained remission (no GCA signs/symptoms and no erythrocyte sedimentation rate elevation) through week 52. Treatment failure was defined as inability to achieve remission by week 12 or relapse between weeks 12 and 52. Predictors investigated in univariate and multivariable analyses included patient characteristics, disease-related and treatment-related factors and patient-reported outcomes (PROs). Results 149 patients received tocilizumab plus prednisone (TCZ/PDN) and 101 received placebo plus prednisone (PBO+PDN). After adjustment for confounders, treatment failure was significantly less likely in the TCZ/PDN group than the PBO/PDN group (OR, 0.2; 95% CI, 0.1 to 0.3; p<0.0001). Risk for treatment failure was significantly higher in women than men in the PBO/PDN group (OR, 5.2; 95% CI, 1.6 to 17.2; p=0.007) but not in the TCZ/PDN group. Predictors of treatment failure in the TCZ/PDN group included lower baseline prednisone doses and worse PROs at baseline. Conclusion The strongest risk factors for treatment failure in GCA are treatment with prednisone alone and female sex. Lower starting prednisone doses and impaired PROs are associated with failure to respond to tocilizumab. Trial registration number NCT01791153.
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Affiliation(s)
- Sebastian H Unizony
- Vasculitis and Glomerulonephritis Center, Rheumatology, Immunology and Allergy Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Min Bao
- Genentech Inc, South San Francisco, California, USA
| | - Jian Han
- Genentech Inc, South San Francisco, California, USA
| | - Yves Luder
- F Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | - John H Stone
- Vasculitis and Glomerulonephritis Center, Rheumatology, Immunology and Allergy Division, Massachusetts General Hospital, Boston, Massachusetts, USA
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18
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Stone JH, Han J, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Spiera R, Unizony SH, Bao M. Long-term effect of tocilizumab in patients with giant cell arteritis: open-label extension phase of the Giant Cell Arteritis Actemra (GiACTA) trial. THE LANCET. RHEUMATOLOGY 2021; 3:e328-e336. [PMID: 38279390 DOI: 10.1016/s2665-9913(21)00038-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The combination of tocilizumab plus a glucocorticoid taper is effective in maintaining clinical remission without requiring additional glucocorticoid therapy in patients with giant cell arteritis, as shown in part one of the Giant Cell Arteritis Actemra (GiACTA) trial. However, the duration of the tocilizumab effect after discontinuation is unknown. Here, we explored the maintenance of efficacy 1 year after discontinuation of tocilizumab treatment, the effectiveness of retreatment with tocilizumab after relapse, and the long-term glucocorticoid-sparing effect of tocilizumab. METHODS In part one of the GiACTA trial, 251 patients were randomly assigned (2:1:1:1) to receive subcutaneous tocilizumab (162 mg) once a week or every other week, combined with a 26-week prednisone taper, or placebo combined with a prednisone taper over a period of either 26 weeks or 52 weeks. Patients in clinical remission stopped masked injections at 1 year (the conclusion of part one). In part two, treatment was at the investigators' discretion and could consist of no treatment, tocilizumab, glucocorticoids, methotrexate, or combinations of these, for two years. Maintenance of efficacy as assessed by clinical remission (defined as absence of relapse determined by the investigator), cumulative glucocorticoid dose, and long-term safety were exploratory objectives in part two of the trial. This trial is registered at ClinicalTrials.gov, NCT01791153. FINDINGS 215 patients participated in part two of the trial; 81 patients who were randomly assigned to tocilizumab once a week in part one were in clinical remission after 1 year, of whom 59 started part two on no treatment. 25 of these 59 patients (42%) maintained tocilizumab-free and glucocorticoid-free clinical remission throughout part two. Median (95% CI) cumulative glucocorticoid doses over 3 years were 2647 mg (1987-3507) for tocilizumab once a week, 3948 mg (2352-5186) for tocilizumab-every-other-week, 5277 mg (3944-6685) for placebo with a 26-week prednisone taper, and 5323 mg (3900-6951) for placebo with a 52-week prednisone taper (van Elteren p≤0·001, tocilizumab once a week vs placebo groups; p<0·05, tocilizumab-every-other-week vs placebo groups). Tocilizumab-based regimens restored clinical remission among patients who experienced relapse in part two and were treated (median time to remission: 15 days for tocilizumab alone [n=17]; 16 days for tocilizumab plus glucocorticoids [n=36]; and 54 days for glucocorticoids alone [n=27]). No new or unexpected safety findings were reported over the full 3 years of the study. INTERPRETATION Giant cell arteritis remains a chronic disease that entails ongoing management and careful vigilance for disease relapse, but continuous indefinite treatment with immunosuppressive drugs is not required for all patients. A substantial proportion of patients treated with tocilizumab for one year maintain drug-free remission during the two years after tocilizumab cessation. For patients who experience relapse, tocilizumab can be used to manage relapses, but it remains prudent to include prednisone for patients who experience relapse because of the risk for vision loss. FUNDING F Hoffmann-La Roche.
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Affiliation(s)
- John H Stone
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston, MA, USA.
| | - Jian Han
- Genentech, South San Francisco, CA, USA
| | - Martin Aringer
- University Medical Center and Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, Netherlands
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Bhaskar Dasgupta
- Southend University Hospital, NHS Foundation Trust, Westcliff-on-Sea, UK
| | - Juergen Rech
- Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia and University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | | | - Sebastian H Unizony
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston, MA, USA
| | - Min Bao
- Genentech, South San Francisco, CA, USA
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Burg LC, Schmidt WA, Brossart P, Reinking KI, Schützeichel FM, Finger RP, Schäfer VS. A 78-year-old female with severe tongue pain: benefit of modern ultrasound. BMC Med Imaging 2021; 21:55. [PMID: 33743613 PMCID: PMC7981810 DOI: 10.1186/s12880-021-00585-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background Giant cell arteritis (GCA) is the most common form of systemic vasculitis in persons aged 50 years and older. Medium and large vessels, like the temporal and axillary arteries, are commonly affected. Typical symptoms are headache, scalp tenderness, jaw claudication and ophthalmological symptoms as loss of visual field, diplopia or amaurosis due to optic nerve ischemia. Tongue pain due to vasculitic affection of the deep lingual artery can occur and has so far not been visualized and followed up by modern ultrasound.
Case presentation We report the case of a 78-year-old woman with typical symptoms of GCA, such as scalp tenderness, jaw claudication and loss of visual field, as well as severe tongue pain. Broad vasculitic affection of the extracranial arteries, vasculitis of the central retinal artery and the deep lingual artery could be visualized by ultrasound. Further did we observe a relevant decrease of intima-media thickness (IMT) values of all arteries assessed by ultrasound during follow-up. Especially the left common superficial temporal artery showed a relevant decrease of IMT from 0.49 mm at time of diagnosis to 0.23 mm on 6-months follow-up. This is the first GCA case described in literature, in which vasculitis of the central retinal artery and the lingual artery could be visualized at diagnosis and during follow-up using high-resolution ultrasound. Conclusion High-resolution ultrasound can be a useful diagnostic imaging modality in diagnosis and follow-up of GCA, even in small arteries like the lingual artery or central retinal artery. Ultrasound of the central retinal artery could be an important imaging tool in identifying suspected vasculitic affection of the central retinal artery.
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Affiliation(s)
- Lara Clarissa Burg
- Clinic of Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Peter Brossart
- Clinic of Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | | | | | - Valentin Sebastian Schäfer
- Clinic of Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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20
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Spiera R, Unizony SH, Bao M, Luder Y, Han J, Pavlov A, Stone JH. Tocilizumab vs placebo for the treatment of giant cell arteritis with polymyalgia rheumatica symptoms, cranial symptoms or both in a randomized trial. Semin Arthritis Rheum 2021; 51:469-476. [PMID: 33784598 DOI: 10.1016/j.semarthrit.2021.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The randomized, placebo (PBO)-controlled GiACTA trial demonstrated the efficacy and safety of tocilizumab (TCZ) in patients with giant cell arteritis (GCA). The present study evaluated the efficacy of TCZ in patients with GCA presenting with polymyalgia rheumatica (PMR) symptoms only, cranial symptoms only or both PMR and cranial symptoms in the GiACTA trial. METHODS In GiACTA, 250 patients with GCA received either TCZ weekly or every other week plus a 26-week prednisone taper or PBO plus a 26- or 52-week prednisone taper. This post hoc analysis assessed baseline characteristics, sustained remission rate, number of flares, annualized flare rate, time to flare, cumulative prednisone dose, methotrexate use and safety in patients with PMR symptoms only, cranial symptoms only or both at baseline. RESULTS Overall, 52 patients had PMR symptoms only, 94 had cranial symptoms only and 104 had both symptoms at baseline. At Week 52, rates of sustained remission were significantly higher with TCZ vs PBO in all 3 groups (PMR only, 45.2% vs 19.0%, P = 0.0446; cranial only, 60.3% vs 19.4%, P = 0.0001; PMR and cranial, 55.0% vs 11.4%, P < 0.0001). Smaller proportions of TCZ-treated patients experienced disease flare than PBO-treated patients across all groups (PMR only, 41.9% vs 57.1%; cranial only, 20.7% vs 47.2%; PMR and cranial, 31.7% vs 81.8%). Annualized flare rate and risk of flare were significantly lower with TCZ vs PBO for patients with cranial symptoms only and both symptoms; they were numerically lower, but did not reach statistical significance, in the smaller group of patients with PMR symptoms only. CONCLUSIONS TCZ improved clinical outcomes in patients who presented with PMR symptoms only, cranial symptoms only or both at baseline, suggesting that TCZ is effective in patients with GCA regardless of the presenting clinical phenotype.
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Affiliation(s)
- Robert Spiera
- Hospital for Special Surgery, Department of Medicine, New York, NY, USA.
| | - Sebastian H Unizony
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Min Bao
- Genentech, Inc., South San Francisco, California, USA
| | - Yves Luder
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Jian Han
- Genentech, Inc., South San Francisco, California, USA
| | | | - John H Stone
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Abstract
Purpose of Review Guidelines for the management of large vessel vasculitides have been recently updated by several scientific societies. We have evaluated the current recommendations for treatment of giant cell arteritis (GCA) and Takayasu arteritis (TA) and addressed potential future therapeutic strategies. Recent Findings While glucocorticoids (GCs) remain the gold standard for induction of remission, many patients relapse and acquire high cumulative GC exposure. Thus, GC-sparing therapies such as methotrexate are recommended for selected patients with GCA and all patients with TA. Recent high-quality evidence shows that tocilizumab is an effective GC-sparing agent in GCA. Non-biologic and biologic immunomodulators also appear to have GC-sparing properties in TA. Summary Tocilizumab is now considered to be part of the standard treatment for GCA, particularly with relapsing disease, but questions on its use such as length of treatment and monitoring of disease activity remain open. High-quality evidence to guide treatment of TA is still lacking.
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22
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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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23
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Nielsen BD, Gormsen LC. 18F-Fluorodeoxyglucose PET/Computed Tomography in the Diagnosis and Monitoring of Giant Cell Arteritis. PET Clin 2020; 15:135-145. [PMID: 32145884 DOI: 10.1016/j.cpet.2019.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
18F-Fluorodeoxyglucose (FDG) PET/computed tomography (CT) is a highly accurate diagnostic tool for large vessel vasculitis (LVV) and is one of the recommended imaging modalities for confirmation of the diagnosis. This article focuses on the role of FDG-PET/CT in LVV diagnosis and disease monitoring, mainly focusing on giant cell arteritis; in particular, the diagnostic accuracy, diagnostic criteria, the potential pitfalls in the interpretation of large vessel FDG uptake, and the clinical indication compared with other imaging modalities are discussed.
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Affiliation(s)
- Berit Dalsgaard Nielsen
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 59, Entrance E, Aarhus, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, Entrance J, Aarhus 8200, Denmark; Diagnostic Centre, Silkeborg Regional Hospital, Falkevej 1A, 8600 Silkeborg, Denmark.
| | - Lars Christian Gormsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, Entrance J, Aarhus 8200, Denmark
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24
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Views on glucocorticoid therapy in rheumatology: the age of convergence. Nat Rev Rheumatol 2020; 16:239-246. [PMID: 32076129 DOI: 10.1038/s41584-020-0370-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
After decades of sometimes fierce debate about the advantages and disadvantages of glucocorticoids, an age of convergence has been reached. Current recommendations for the management of diseases such as rheumatoid arthritis (RA), polymyalgia rheumatica and large vessel vasculitis reflect the current consensus that as much glucocorticoid as necessary, but as little as possible, should be used. Over the past few years, a range of glucocorticoid-sparing strategies have been developed, as have tools to improve the management of this therapy. A comprehensive view of glucocorticoid-induced osteoporosis has also emerged that recognizes that bone fragility is not solely determined by the dose and duration of glucocorticoid treatment. Nevertheless, open questions remain around whether long-term use of very low doses of glucocorticoids is a realistic option for patients with RA and whether the search for innovative glucocorticoids or glucocorticoid receptor ligands with improved benefit-to-risk ratios will ultimately be successful.
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25
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Isobe M, Amano K, Arimura Y, Ishizu A, Ito S, Kaname S, Kobayashi S, Komagata Y, Komuro I, Komori K, Takahashi K, Tanemoto K, Hasegawa H, Harigai M, Fujimoto S, Miyazaki T, Miyata T, Yamada H, Yoshida A, Wada T, Inoue Y, Uchida HA, Ota H, Okazaki T, Onimaru M, Kawakami T, Kinouchi R, Kurata A, Kosuge H, Sada KE, Shigematsu K, Suematsu E, Sueyoshi E, Sugihara T, Sugiyama H, Takeno M, Tamura N, Tsutsumino M, Dobashi H, Nakaoka Y, Nagasaka K, Maejima Y, Yoshifuji H, Watanabe Y, Ozaki S, Kimura T, Shigematsu H, Yamauchi-Takihara K, Murohara T, Momomura SI. JCS 2017 Guideline on Management of Vasculitis Syndrome - Digest Version. Circ J 2020; 84:299-359. [PMID: 31956163 DOI: 10.1253/circj.cj-19-0773] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University
| | - Yoshihiro Arimura
- Department of Rheumatology and Nephrology, Kyorin University School of Medicine.,Internal Medicine, Kichijoji Asahi Hospital
| | - Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | | | - Yoshinori Komagata
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Graduate School of Medicine
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Kei Takahashi
- Department of Pathology, Toho University Ohashi Medical Center
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology, and Infectious Diseases, Ehime University Graduate School of Medicine
| | - Masayoshi Harigai
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki
| | | | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center
| | - Hidehiro Yamada
- Medical Center for Rheumatic Diseases, Seirei Yokohama Hospital
| | | | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Graduate School of Medical Sciences, Kanazawa University
| | | | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hideki Ota
- Department of Advanced MRI Collaboration Research, Tohoku University Graduate School of Medicine
| | - Takahiro Okazaki
- Vice-Director, Shizuoka Medical Center, National Hospital Organization
| | - Mitsuho Onimaru
- Division of Pathophysiological and Experimental Pathology, Department of Pathology, Graduate School of Medical Sciences, Kyushu University
| | - Tamihiro Kawakami
- Division of Dermatology, Tohoku Medical and Pharmaceutical University
| | - Reiko Kinouchi
- Medicine and Engineering Combined Research Institute, Asahikawa Medical University.,Department of Ophthalmology, Asahikawa Medical University
| | - Atsushi Kurata
- Department of Molecular Pathology, Tokyo Medical University
| | | | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Eiichi Suematsu
- Division of Internal Medicine and Rheumatology, National Hospital Organization, Kyushu Medical Center
| | - Eijun Sueyoshi
- Department of Radiological Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine
| | | | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine Department of Internal Medicine, Faculty of Medicine, Kagawa University
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University
| | | | - Shoichi Ozaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hiroshi Shigematsu
- Clinical Research Center for Medicine, International University of Health and Welfare
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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26
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Hellmich B, Agueda A, Monti S, Buttgereit F, de Boysson H, Brouwer E, Cassie R, Cid MC, Dasgupta B, Dejaco C, Hatemi G, Hollinger N, Mahr A, Mollan SP, Mukhtyar C, Ponte C, Salvarani C, Sivakumar R, Tian X, Tomasson G, Turesson C, Schmidt W, Villiger PM, Watts R, Young C, Luqmani RA. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis 2019; 79:19-30. [PMID: 31270110 DOI: 10.1136/annrheumdis-2019-215672] [Citation(s) in RCA: 550] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Since the publication of the European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis (LVV) in 2009, several relevant randomised clinical trials and cohort analyses have been published, which have the potential to change clinical care and therefore supporting the need to update the original recommendations. METHODS Using EULAR standardised operating procedures for EULAR-endorsed recommendations, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 13 countries. We modified existing recommendations and created new recommendations. RESULTS Three overarching principles and 10 recommendations were formulated. We recommend that a suspected diagnosis of LVV should be confirmed by imaging or histology. High dose glucocorticoid therapy (40-60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active giant cell arteritis (GCA) or Takayasu arteritis (TAK). We recommend adjunctive therapy in selected patients with GCA (refractory or relapsing disease, presence of an increased risk for glucocorticoid-related adverse events or complications) using tocilizumab. Methotrexate may be used as an alternative. Non-biological glucocorticoid-sparing agents should be given in combination with glucocorticoids in all patients with TAK and biological agents may be used in refractory or relapsing patients. We no longer recommend the routine use of antiplatelet or anticoagulant therapy for treatment of LVV unless it is indicated for other reasons. CONCLUSIONS We have updated the recommendations for the management of LVV to facilitate the translation of current scientific evidence and expert opinion into better management and improved outcome of patients in clinical practice.
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Affiliation(s)
- Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim-Teck, Germany
| | - Ana Agueda
- Rheumatology Department, Centro Hospitalar do Baixo Vouga E.P.E, Aveiro, Portugal
| | - Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Frank Buttgereit
- Department of Rheumatology and Immunology, University Hospital Charité, Berlin, Germany
| | - Hubert de Boysson
- Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen, Basse-Normandie, France
| | - Elisabeth Brouwer
- Rheumatology and Clinical Immunology, UMCG, Groningen, The Netherlands
| | | | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Christian Dejaco
- Rheumatology, Medical University Graz, Graz, Austria.,Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Nicole Hollinger
- Department of Internal Medicine, Rheumatology and Immunology, Medus Klinken, Karl-Albrechts-Universität Tübingen, Kirchheim-Teck, Germany
| | - Alfred Mahr
- Hospital Saint-Louis, University Paris Diderot, Paris, France
| | - Susan P Mollan
- Ophthalmology, University Hospitals Birmingham, Birmingham, UK.,Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Chetan Mukhtyar
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Cristina Ponte
- Rheumatology, Hospital de Santa Maria - CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal.,Rheumatology Research Unit; Instituto de Medicina Molecular, Instituto de Medicina Molecular, Lisboa, Portugal
| | | | - Rajappa Sivakumar
- Stroke and Neurocritical Care, GLB Hospitals and Acute Stroke Centers, Chennai, India
| | - Xinping Tian
- Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | | | - Carl Turesson
- Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - Wolfgang Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Krankenhaus Berlin, Berlin, Germany
| | - Peter M Villiger
- Rheumatology and Clinical Immunology / Allerg, University Hospital (Inselspital), Bern, Switzerland
| | - Richard Watts
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
| | | | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
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27
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Stone JH, Tuckwell K, Dimonaco S, Klearman M, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Schulze-Koops H, Schett G, Spiera R, Unizony SH, Collinson N. Glucocorticoid Dosages and Acute-Phase Reactant Levels at Giant Cell Arteritis Flare in a Randomized Trial of Tocilizumab. Arthritis Rheumatol 2019; 71:1329-1338. [PMID: 30835950 PMCID: PMC6772126 DOI: 10.1002/art.40876] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/28/2019] [Indexed: 12/04/2022]
Abstract
Objective This study was undertaken to evaluate glucocorticoid dosages and serologic findings in patients with giant cell arteritis (GCA) flares. Methods Patients with GCA were randomly assigned to receive double‐blind dosing with either subcutaneous tocilizumab (TCZ) 162 mg weekly plus 26‐week prednisone taper (TCZ‐QW + Pred‐26), every‐other‐week TCZ plus 26‐week prednisone taper (TCZ‐Q2W + Pred‐26), placebo plus 26‐week prednisone taper (PBO + Pred‐26), or placebo plus 52‐week prednisone taper (PBO + Pred‐52). Outcome measures were prednisone dosage, C‐reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) at the time of flare. Results One hundred patients received TCZ‐QW + Pred‐26, 49 received TCZ‐Q2W + Pred‐26, 50 received PBO + Pred‐26, and 51 received PBO + Pred‐52. Of the 149 TCZ‐treated patients, 36 (24%) experienced flare, 23 (64%) of whom were still receiving prednisone (median dosage 2.0 mg/day). Among 101 PBO + Pred–treated patients, 59 (58%) experienced flare, 45 (76%) of whom were receiving prednisone (median dosage 5.0 mg/day). Many flares occurred while patients were taking >10 mg/day prednisone: 9 (25%) in the TCZ groups and 13 (22%) in the placebo groups. Thirty‐three flares (92%) in TCZ‐treated groups and 20 (34%) in PBO + Pred–treated groups occurred with normal CRP levels. More than half of the PBO + Pred–treated patients had elevated CRP levels without flares. Benefits of the TCZ and prednisone combination over prednisone alone for remission induction were apparent by 8 weeks. Conclusion Most GCA flares occurred while patients were still receiving prednisone. Acute‐phase reactant levels were not reliable indicators of flare in patients treated with TCZ plus prednisone or with prednisone alone. The addition of TCZ to prednisone facilitates earlier GCA control.
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Affiliation(s)
- John H Stone
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Martin Aringer
- University Medical Center and Technische Universität Dresden, Dresden, Germany
| | | | - Elisabeth Brouwer
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Maria C Cid
- University Hospital Clínic de Barcelona and University of Barcelona, Barcelona, Spain
| | - Bhaskar Dasgupta
- Southend University Hospital, NHS Foundation Trust, Southend, UK
| | - Juergen Rech
- Universitätsklinikum Erlangen, Erlangen, Germany
| | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia and Università di Modena and Reggio Emilia, Reggio Emilia, Italy
| | | | - Georg Schett
- Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Sebastian H Unizony
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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O'Neill L, McCormick J, Gao W, Veale DJ, McCarthy GM, Murphy CC, Fearon U, Molloy ES. Interleukin-6 does not upregulate pro-inflammatory cytokine expression in an ex vivo model of giant cell arteritis. Rheumatol Adv Pract 2019; 3:rkz011. [PMID: 31431999 PMCID: PMC6649906 DOI: 10.1093/rap/rkz011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/17/2019] [Indexed: 11/14/2022] Open
Abstract
Objective The aim of this study was to examine the pro-inflammatory effects of IL-6 in ex vivo temporal artery explant cultures. Methods Patients meeting 1990 ACR classification criteria for GCA were prospectively recruited. Temporal artery biopsies were obtained and temporal artery explants cultured ex vivo with IL-6 (10-40 ng/ml) in the presence or absence of its soluble receptor (sIL-6R; 20 ng/ml) for 24 h. Explant supernatants were harvested after 24 h and assayed for IFN-γ, TNF-α, Serum amyloid A, IL-1β, IL-17, IL-8, angiotensin II and VEGF by ELISA. Myofibroblast outgrowths, cytoskeletal rearrangement and wound repair assays were performed. Results IL-6 augmented production of VEGF, but not of any of the other pro-inflammatory mediators assayed. No differences were observed in the explants cultured in the presence or absence of the sIL-6R or between those with a positive (n = 11) or negative (n = 17) temporal artery biopsy. IL-6 did not enhance myofibroblast proliferation or migration. Western blot analysis confirmed signalling activation, with increased expression of pSTAT3 in response to IL-6+sIL-6R. Conclusion IL-6 stimulation of temporal artery explants from patients with GCA neither increased expression of key pro-inflammatory mediators nor influenced myofibroblast proliferation or migration.
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Affiliation(s)
- Lorraine O'Neill
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Jennifer McCormick
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Wei Gao
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Douglas J Veale
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Geraldine M McCarthy
- Mater Misericordiae University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Conor C Murphy
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Royal College of Surgeons, Ireland
| | - Ursula Fearon
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
| | - Eamonn S Molloy
- Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Royal College of Surgeons, Ireland
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Identification of an activated neutrophil phenotype in polymyalgia rheumatica during steroid treatment: a potential involvement of immune cell cross-talk. Clin Sci (Lond) 2019; 133:839-851. [PMID: 30898854 PMCID: PMC6449535 DOI: 10.1042/cs20180415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 01/16/2019] [Accepted: 03/20/2019] [Indexed: 01/24/2023]
Abstract
We have reported the existence of a distinct neutrophil phenotype in giant cell arteritis (GCA) patients arising at week 24 of steroid treatment. In the present study, we investigated whether longitudinal analysis of neutrophil phenotype in patients with polymyalgia rheumatica (PMR) could reveal a novel association with disease status and immune cell cross-talk. Thus, we monitored PMR patient neutrophil phenotype and plasma microvesicle (MV) profiles in blood aliquots collected pre-steroid, and then at weeks 1, 4, 12 and 24 post-steroid treatment. Using flow cytometric and flow chamber analyses, we identified 12-week post-steroid as a pivotal time-point for a marked degree of neutrophil activation, correlating with disease activity. Analyses of plasma MVs indicated elevated AnxA1+ neutrophil-derived vesicles which, in vitro, modulated T-cell reactivity, suggesting distinct neutrophil phenotypic and cross-talk changes at 24 weeks, but not at 12-week post-steroid. Together, these data indicate a clear distinction from GCA patient neutrophil and MV signatures, and provide an opportunity for further investigations on how to ‘stratify’ PMR patients and monitor their clinical responses through novel use of blood biomarkers.
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Turesson C, Börjesson O, Larsson K, Mohammad AJ, Knight A. Swedish Society of Rheumatology 2018 guidelines for investigation, treatment, and follow-up of giant cell arteritis. Scand J Rheumatol 2019; 48:259-265. [DOI: 10.1080/03009742.2019.1571223] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- C Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
- Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - O Börjesson
- Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - K Larsson
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - AJ Mohammad
- Rheumatology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden
| | - A Knight
- Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Strand V, Dimonaco S, Tuckwell K, Klearman M, Collinson N, Stone JH. Health-related quality of life in patients with giant cell arteritis treated with tocilizumab in a phase 3 randomised controlled trial. Arthritis Res Ther 2019; 21:64. [PMID: 30786937 PMCID: PMC6381622 DOI: 10.1186/s13075-019-1837-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/30/2019] [Indexed: 02/04/2023] Open
Abstract
Background Patients with giant cell arteritis (GCA) treated with tocilizumab (TCZ) every week or every other week and prednisone tapering achieved superior rates of sustained remission to patients treated with placebo and prednisone tapering in a randomised controlled trial. Health-related quality of life (HRQOL) in patients from this trial is now reported. Methods Exploratory analyses of SF-36 PCS and MCS and domain scores, PtGA and FACIT-Fatigue were performed in patients treated with weekly subcutaneous TCZ 162 mg plus 26-week prednisone taper (TCZ-QW + Pred-26) or placebo plus 26-week or 52-week prednisone tapers (PBO + Pred-26 or PBO + Pred-52). These analyses were performed on responder and non-responder patients, including those who achieved the primary outcome and those who experienced flare and received escape prednisone doses. Results Baseline SF-36 PCS, MCS and domain scores were low, indicating impaired HRQOL related to GCA. At week 52, least squares mean (LSM) changes in PCS scores improved with TCZ-QW + Pred-26 but worsened in both PBO + Pred groups (p < 0.001). LSM changes in MCS scores increased with TCZ-QW + Pred-26 versus PBO + Pred-52 (p < 0.001). Treatment with TCZ-QW + Pred-26 resulted in significantly greater improvement in four of eight SF-36 domains compared with PBO + Pred-26 and six of eight domains compared with PBO + Pred-52 (p < 0.01). Improvement with TCZ-QW + Pred-26 met or exceeded minimum clinically important differences (MCID) in all eight domains compared with five domains with PBO + Pred-26 and none with PBO + Pred-52. Domain scores in the TCZ-QW + Pred-26 group at week 52 met or exceeded age- and gender-matched normative values (A/G norms). LSM changes from baseline in FACIT-Fatigue scores increased significantly with TCZ-QW + Pred-26, exceeding MCID and A/G norms (p < 0.001). Conclusions Patients with GCA receiving TCZ-QW + Pred-26 reported statistically significant and clinically meaningful improvement in SF-36 and FACIT-Fatigue scores compared with those receiving prednisone only. Improvements in the TCZ-QW + Pred-26 group led to recovery of HRQOL to levels at least comparable to those of A/G-matched normative values at week 52 and exceeded normative values in five of eight domains. Trial registration ClinicalTrials.gov, NCT01791153. Date of registration: February 13, 2013.
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Affiliation(s)
- Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, CA, USA
| | | | | | | | | | - John H Stone
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Yawkey 2, 55 Fruit Street, Boston, MA, 02114, USA.
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Abstract
Giant cell arteritis (GCA) is an inflammatory vasculitis typically affecting elderly that can potentially cause vision loss. Studies have demonstrated that early recognition and initiation of treatment can improve visual prognosis in patients with GCA. This review addresses the benefits of early diagnosis and treatment, and discusses the available treatment options to manage the disease.
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Affiliation(s)
- Iyza F Baig
- McGovern Medical School, The University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Alexis R Pascoe
- McGovern Medical School, The University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Ashwini Kini
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA,
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA, .,Department of Ophthalmology, Baylor College of Medicine,Houston, TX, USA, .,Department of Ophthalmology, .,Department of Neurology, .,Department of Neurosurgery, Weill Cornell Medical College, Houston, TX, USA, .,The University of Texas Medical Branch, Galveston, TX, USA, .,The Universityof Texas MD Anderson Cancer Center, Houston, TX, USA, .,Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA,
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Koster MJ, Yeruva K, Crowson CS, Muratore F, Labarca C, Warrington KJ. Efficacy of Methotrexate in Real-world Management of Giant Cell Arteritis: A Case-control Study. J Rheumatol 2019; 46:501-508. [DOI: 10.3899/jrheum.180429] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2018] [Indexed: 10/27/2022]
Abstract
Objective.To determine the effect of methotrexate (MTX) on relapse risk and glucocorticoid (GC) use in a large single-institution cohort of patients with giant cell arteritis (GCA).Methods.Patients diagnosed with GCA from 1998 to 2013 with confirmed evidence of temporal artery biopsy and/or radiographic evidence of large vessel vasculitis were identified. Each patient with GCA treated with adjunct MTX (case) was matched to a similar patient with GCA treated only with GC (control). GC requirements and relapse events before and after MTX initiation (or corresponding index date) were compared using rate ratios (RR).Results.Eighty-three cases and 83 controls were identified and compared. No significant differences in age, demographics, laboratory variables, baseline disease characteristics, or mean initial prednisone doses were observed. Median [interquartile range (IQR)] time from GCA diagnosis to MTX initiation in cases was 39 (13–80) weeks and the median (IQR) starting dose was 13.5 (10–15) mg/week. RR comparing relapse rates before and after MTX initiation/index date were significantly reduced in both cases (RR 0.32, 95% CI 0.24–0.41) and controls (RR 0.60, 95% CI 0.43–0.86). The decrease in relapse rate was significantly greater in patients taking MTX than in those taking GC alone (p = 0.004). Rates of GC discontinuation did not differ between groups.Conclusion.In this large single-institution cohort, the addition of MTX to GC decreased the rate of subsequent relapse by nearly 2-fold compared to patients taking GC alone. MTX may be considered as adjunct therapy in patients with GCA to decrease the risk of further relapse events.
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Aschwanden M, Schegk E, Imfeld S, Staub D, Rottenburger C, Berger CT, Daikeler T. Vessel wall plasticity in large vessel giant cell arteritis: an ultrasound follow-up study. Rheumatology (Oxford) 2018; 58:792-797. [DOI: 10.1093/rheumatology/key383] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 11/01/2018] [Indexed: 01/18/2023] Open
Abstract
Abstract
Objectives
To assess changes of arterial vessel wall morphology in large vessel GCA patients (LV-GCA) by repeated US.
Methods
Patients with LV-GCA on US examination were followed up 6, 12 and 24 months after diagnosis by US of the temporal, vertebral, carotid (common, internal, external), subclavian, axillary, femoral (deep, superficial and common) and popliteal arteries. Clinical and laboratory data were assessed at each visit. Vessel wall thickening was classified as moderate, marked or arteriosclerotic.
Results
A total of 42 patients (26 female) with a median age of 75 years at diagnosis had in median 2 (range 1–3) US follow-up exams. Twenty-eight had both LV and temporal artery involvement and 14 had LV-GCA only. The common carotid, subclavian, axillary, popliteal and/or superficial femoral artery were most commonly involved. Reduction of LV wall thickening occurred in 45% of patients during follow-up, corresponding to 71 of the 284 (25%) initially ‘vasculitic’ LV segments. In contrast, a reduction of vessel wall thickening in the temporal artery was found in 85% of patients. Of the LVs, the vertebral, axillary, subclavian and deep femoral arteries were most likely to improve. There was no difference in relapses or the received cumulative steroid dose between patients with or without a reduction of vessel wall thickening (temporal artery or LV) during follow-up.
Conclusion
Regression of wall thickening within the LV is significantly less common than in the temporal artery and irrespective of clinical remission. Morphological regression does not seem to be a useful predictor for relapses.
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Affiliation(s)
- Markus Aschwanden
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Elke Schegk
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Stephan Imfeld
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Daniel Staub
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | | | - Christoph T Berger
- Departments of Biomedicine and Internal Medicine, Translational Immunology and Medical Outpatient Clinic, University Hospital Basel, Basel, Switzerland
| | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
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Abstract
Giant cell arteritis is a granulomatous immune-mediated vasculitis of medium and large vessels. It most commonly affects white females over the age of 50 and is the most common primary vasculitis in the United States. Treatment of this disease has classically been with high-dose corticosteroids, but this therapy has been associated with severe morbidity and mortality. Tocilizumab, a humanized monoclonal antibody targeting the interleukin-6 receptor, has been used with great efficacy and safety in rheumatoid arthritis and systemic-onset juvenile idiopathic arthritis. As interleukin-6 has been shown to be a key cytokine in giant cell arteritis, the use of an inhibiting agent has been explored. In the 15 case reports/series that were reviewed, most patients were given tocilizumab due to refractory giant cell arteritis and/or intolerance to glucocorticoid therapy, and most experienced remission of symptoms. At this time, there are only 2 randomized control trials to evaluate the efficacy and safety of tocilizumab use in giant cell arteritis. The phase II trial by Villiger et al and the GiACTA trial both showed that tocilizumab greatly increased the rate of sustained remission in giant cell arteritis over the course of 1 year. The most common adverse events were similar to those seen with use in rheumatoid arthritis: infections, neutropenia, and increases in lipids and liver function test enzymes. Based on the results of numerous case studies and the 2 randomized control trials, tocilizumab is the first agent to be approved by the Food and Drug Administration for treatment of giant cell arteritis.
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Kermani TA, Dasgupta B. Current and emerging therapies in large-vessel vasculitis. Rheumatology (Oxford) 2018; 57:1513-1524. [PMID: 29069518 DOI: 10.1093/rheumatology/kex385] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 11/14/2022] Open
Abstract
GCA shares many clinical features with PMR and Takayasu arteritis. The current mainstay of therapy for all three conditions is glucocorticoid therapy. Given the chronic, relapsing nature of these conditions and the morbidity associated with glucocorticoid therapy, there is a need for better treatment options to induce and sustain remission with fewer adverse effects. Conventional immunosuppressive treatments have been studied and have a modest effect. There is a keen interest in biologic therapies with studies showing the efficacy of IL-6 antagonists in PMR and GCA. Recently the first two randomized clinical trials in Takayasu arteritis have been completed. A major challenge for all of these conditions is the lack of standardized measures to assess disease activity. Long-term studies are needed to evaluate the impact of biologic therapies showing potential on important clinical outcomes such as vascular damage, cost-effectiveness and quality of life. The optimal duration of treatment also needs to be assessed.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital & Anglia Ruskin University, Westcliff-on-sea, UK
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Ninan JV, Lester S, Hill CL. Giant cell arteritis: beyond temporal artery biopsy and steroids. Intern Med J 2018; 47:1228-1240. [PMID: 28485026 DOI: 10.1111/imj.13483] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/25/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
Giant cell arteritis is the most common primary vasculitis of the elderly. The acute complications of untreated giant cell arteritis, such as vision loss or occasionally stroke, can be devastating. The diagnosis is, however, not altogether straightforward due to variable sensitivities of the temporal artery biopsy as a reference diagnostic test. In this review, we discuss the increasing role of imaging in the diagnosis of giant cell arteritis. Glucocorticoid treatment is the backbone of therapy, but it is associated with significant adverse effects. A less toxic alternative is required. Conventional and novel immunosuppressive agents have only demonstrated modest effects in a subgroup of steroid refractory Giant cell arteritis due to the different arms of the immune system at play. However, recently a study of interleukin-6 blockade demonstrated benefits of giant cell arteritis. The current status of these immunosuppressive agents and novel therapies are also discussed in this review.
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Affiliation(s)
- Jem V Ninan
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, Modbury Hospital, Adelaide, South Australia, Australia
| | - Susan Lester
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Catherine L Hill
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Three days of high-dose glucocorticoid treatment attenuates large-vessel 18F-FDG uptake in large-vessel giant cell arteritis but with a limited impact on diagnostic accuracy. Eur J Nucl Med Mol Imaging 2018; 45:1119-1128. [DOI: 10.1007/s00259-018-4021-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/11/2018] [Indexed: 10/17/2022]
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40
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Schett G. Physiological effects of modulating the interleukin-6 axis. Rheumatology (Oxford) 2018; 57:ii43-ii50. [DOI: 10.1093/rheumatology/kex513] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Indexed: 12/18/2022] Open
Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3 – Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
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Sreih AG, Alibaz-Oner F, Kermani TA, Aydin SZ, Cronholm PF, Davis T, Easley E, Gul A, Mahr A, McAlear CA, Milman N, Robson JC, Tomasson G, Direskeneli H, Merkel PA. Development of a Core Set of Outcome Measures for Large-vessel Vasculitis: Report from OMERACT 2016. J Rheumatol 2017; 44:1933-1937. [PMID: 28864646 DOI: 10.3899/jrheum.161467] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Among the challenges in conducting clinical trials in large-vessel vasculitis (LVV), including both giant cell arteritis (GCA) and Takayasu arteritis (TA), is the lack of standardized and meaningful outcome measures. The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group initiated an international effort to develop and validate data-driven outcome tools for clinical investigation in LVV. METHODS An international Delphi exercise was completed to gather opinions from clinical experts on LVV-related domains considered important to measure in trials. Patient interviews and focus groups were completed to identify outcomes of importance to patients. The results of these activities were presented and discussed in a "Virtual Special Interest Group" using telephone- and Internet-based conferences, discussions through electronic mail, and an in-person session at the 2016 OMERACT meeting. A preliminary core set of domains common for all forms of LVV with disease-specific elements was proposed. RESULTS The majority of experts agree with using common outcome measures for GCA and TA, with the option of supplementation with disease-specific items. Following interviews and focus groups, pain, fatigue, and emotional effect emerged as health-related quality of life domains important to patients. Current disease assessment tools, including the Birmingham Vasculitis Activity Score, were found to be inadequate to assess disease activity in GCA and standardized assessment of imaging tests were felt crucial to study LVV, especially TA. CONCLUSION Initial data from a clinician Delphi exercise and structured patient interviews have provided themes toward an OMERACT-endorsed core set of domains and outcome measures.
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Affiliation(s)
- Antoine G Sreih
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Fatma Alibaz-Oner
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Tanaz A Kermani
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Sibel Z Aydin
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Peter F Cronholm
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Trocon Davis
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Ebony Easley
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Ahmet Gul
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Alfred Mahr
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Carol A McAlear
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Nataliya Milman
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Joanna C Robson
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Gunnar Tomasson
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Haner Direskeneli
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Peter A Merkel
- From the Division of Rheumatology, and Department of Family Medicine and Community Health, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA; Fatih Sultan Mehmet Training and Research Hospital; Division of Rheumatology, Department of Internal Medicine, Istanbul University Faculty of Medicine; Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey; Division of Rheumatology, University of Ottawa; Division of Rheumatology, The Ottawa Hospital; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Internal Medicine, University Paris Diderot, Paris, France; University of the West of England; University of Bristol; University Hospitals Bristol National Health Service (NHS) Trust, Bristol, UK; Department of Public Health Sciences, University of Iceland, Reykjavik, Iceland. .,A.G. Sreih, MD, Assistant Professor of Medicine, Division of Rheumatology, University of Pennsylvania; F. Alibaz-Oner, MD, Associate Professor of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital; T.A. Kermani, MD, MS, Assistant Professor of Medicine, Division of Rheumatology, University of California at Los Angeles; S.Z. Aydin, Associate Professor in Rheumatology, Division of Rheumatology, University of Ottawa; P.F. Cronholm, MD, MSCE, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, University of Pennsylvania; T. Davis, Department of Family Medicine and Community Health, University of Pennsylvania; E. Easley, MPH, Department of Family Medicine and Community Health, University of Pennsylvania; A. Gul, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, Istanbul University, Faculty of Medicine; A. Mahr, MD, PhD, Professor of Internal Medicine, Department of Internal Medicine, University Paris Diderot; C.A. McAlear, MA, Division of Rheumatology, University of Pennsylvania; N. Milman, MD, Assistant Professor, Division of Rheumatology, University of Ottawa, and Division of Rheumatology, The Ottawa Hospital, and Department of Clinical Epidemiology, Ottawa Hospital Research Institute; J.C. Robson, MRCP, PhD, Consultant Senior Lecturer, University of the West of England, and Honorary Senior Lecturer, University of Bristol, and Honorary Consultant in Rheumatology, University Hospitals Bristol NHS Trust; G. Tomasson, MD, PhD, Assistant Professor of Epidemiology, Department of Public Health Sciences, University of Iceland; H. Direskeneli, MD, Professor of Rheumatology, Division of Rheumatology, Marmara University, School of Medicine; P.A. Merkel, MD, MPH, Professor of Medicine and Epidemiology, Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania.
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Giant Cell Arteritis: Current and Future Treatment Options. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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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Koster MJ, Warrington KJ. Classification of large vessel vasculitis: Can we separate giant cell arteritis from Takayasu arteritis? Presse Med 2017; 46:e205-e213. [PMID: 28774474 DOI: 10.1016/j.lpm.2016.11.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/14/2016] [Indexed: 11/27/2022] Open
Abstract
The two main variants of large vessel vasculitis include Takayasu arteritis and giant cell arteritis. While these two conditions have historically been considered different conditions, recent evidence questions whether they are a spectrum of the same disease. Classification criteria are limited in distinguishing between cases with phenotypic overlap. The limitations of the current criteria and directions of future research are reviewed.
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Affiliation(s)
- Matthew J Koster
- Mayo Clinic College of Medicine, Division of Rheumatology, Rochester, Minnesota, USA.
| | - Kenneth J Warrington
- Mayo Clinic College of Medicine, Division of Rheumatology, Rochester, Minnesota, USA
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Stone JH, Tuckwell K, Dimonaco S, Klearman M, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Schett G, Schulze-Koops H, Spiera R, Unizony SH, Collinson N. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med 2017; 377:317-328. [PMID: 28745999 DOI: 10.1056/nejmoa1613849] [Citation(s) in RCA: 757] [Impact Index Per Article: 108.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Giant-cell arteritis commonly relapses when glucocorticoids are tapered, and the prolonged use of glucocorticoids is associated with side effects. The effect of the interleukin-6 receptor alpha inhibitor tocilizumab on the rates of relapse during glucocorticoid tapering was studied in patients with giant-cell arteritis. METHODS In this 1-year trial, we randomly assigned 251 patients, in a 2:1:1:1 ratio, to receive subcutaneous tocilizumab (at a dose of 162 mg) weekly or every other week, combined with a 26-week prednisone taper, or placebo combined with a prednisone taper over a period of either 26 weeks or 52 weeks. The primary outcome was the rate of sustained glucocorticoid-free remission at week 52 in each tocilizumab group as compared with the rate in the placebo group that underwent the 26-week prednisone taper. The key secondary outcome was the rate of remission in each tocilizumab group as compared with the placebo group that underwent the 52-week prednisone taper. Dosing of prednisone and safety were also assessed. RESULTS Sustained remission at week 52 occurred in 56% of the patients treated with tocilizumab weekly and in 53% of those treated with tocilizumab every other week, as compared with 14% of those in the placebo group that underwent the 26-week prednisone taper and 18% of those in the placebo group that underwent the 52-week prednisone taper (P<0.001 for the comparisons of either active treatment with placebo). The cumulative median prednisone dose over the 52-week period was 1862 mg in each tocilizumab group, as compared with 3296 mg in the placebo group that underwent the 26-week taper (P<0.001 for both comparisons) and 3818 mg in the placebo group that underwent the 52-week taper (P<0.001 for both comparisons). Serious adverse events occurred in 15% of the patients in the group that received tocilizumab weekly, 14% of those in the group that received tocilizumab every other week, 22% of those in the placebo group that underwent the 26-week taper, and 25% of those in the placebo group that underwent the 52-week taper. Anterior ischemic optic neuropathy developed in one patient in the group that received tocilizumab every other week. CONCLUSIONS Tocilizumab, received weekly or every other week, combined with a 26-week prednisone taper was superior to either 26-week or 52-week prednisone tapering plus placebo with regard to sustained glucocorticoid-free remission in patients with giant-cell arteritis. Longer follow-up is necessary to determine the durability of remission and safety of tocilizumab. (Funded by F. Hoffmann-La Roche; ClinicalTrials.gov number, NCT01791153 .).
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Affiliation(s)
- John H Stone
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Katie Tuckwell
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Sophie Dimonaco
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Micki Klearman
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Martin Aringer
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Daniel Blockmans
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Elisabeth Brouwer
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Maria C Cid
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Bhaskar Dasgupta
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Juergen Rech
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Carlo Salvarani
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Georg Schett
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Hendrik Schulze-Koops
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Robert Spiera
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Sebastian H Unizony
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
| | - Neil Collinson
- From the Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Boston (J.H.S., S.H.U.); Roche Products, Welwyn Garden City (K.T., S.D., N.C.), and Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea (B.D.) - both in the United Kingdom; Genentech, South San Francisco, CA (M.K.); the Department of Rheumatology, Medicine III, University Medical Center and Faculty of Medicine Technische Universität Dresden, Dresden (M.A.), Friedrich-Alexander-University Erlangen-Nürnberg, Department of Internal Medicine 3-Rheumatology and Immunology (J.R.), and Institute of Clinical Immunology (G.S.), Universitätsklinikum Erlangen, Erlangen, and the Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich (H.S.-K.) - all in Germany; the Department of General Internal Medicine, University Hospitals Gasthuisberg, Leuven, Belgium (D.B.); the Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Groningen, the Netherlands (E.B.); the Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Division of Internal Medicine, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy (C.S.); and Hospital for Special Surgery, New York (R.S.)
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Henes JC, Schulze-Koops H, Witt M, Tony HP, Mueller F, Grunke M, Czihal M, Dörner T, Proft F. Off-label-Biologikatherapie bei Patienten mit Großgefäßvaskulitiden und/oder Polymyalgia rheumatica. Z Rheumatol 2017; 77:12-20. [DOI: 10.1007/s00393-017-0325-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Tuckwell K, Collinson N, Dimonaco S, Klearman M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Unizony SH, Stone JH. Newly diagnosed vs. relapsing giant cell arteritis: Baseline data from the GiACTA trial. Semin Arthritis Rheum 2017; 46:657-664. [DOI: 10.1016/j.semarthrit.2016.11.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/02/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
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Langford CA, Cuthbertson D, Ytterberg SR, Khalidi N, Monach PA, Carette S, Seo P, Moreland LW, Weisman M, Koening CL, Sreih AG, Spiera R, McAlear CA, Warrington KJ, Pagnoux C, McKinnon K, Forbess LJ, Hoffman GS, Borchin R, Krischer JP, Merkel PA. A Randomized, Double-Blind Trial of Abatacept (CTLA-4Ig) for the Treatment of Giant Cell Arteritis. Arthritis Rheumatol 2017; 69:837-845. [PMID: 28133925 DOI: 10.1002/art.40044] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 01/10/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare the efficacy of abatacept to that of placebo for the treatment of giant cell arteritis (GCA). METHODS In this multicenter trial, patients with newly diagnosed or relapsing GCA were treated with abatacept 10 mg/kg intravenously on days 1, 15, and 29 and week 8, together with prednisone administered daily. At week 12, patients in remission underwent a double-blinded randomization to continue to receive abatacept monthly or switch to placebo. Patients in both study arms received a standardized prednisone taper, with discontinuation of prednisone at week 28. All patients remained on their randomized assignment until meeting criteria for early termination or until 12 months after enrollment of the last patient. The primary end point was duration of remission (relapse-free survival rate). RESULTS Forty-nine eligible patients with GCA were enrolled and treated with prednisone and abatacept; of these, 41 reached the week 12 randomization and underwent a blinded randomization to receive abatacept or placebo. Prednisone was tapered using a standardized schedule, reaching a daily dosage of 20 mg at week 12 with discontinuation in all patients at week 28. The relapse-free survival rate at 12 months was 48% for those receiving abatacept and 31% for those receiving placebo (P = 0.049). A longer median duration of remission was seen in those receiving abatacept compared to those receiving placebo (median duration 9.9 months versus 3.9 months; P = 0.023). There was no difference in the frequency or severity of adverse events, including infection, between the treatment arms. CONCLUSION In patients with GCA, the addition of abatacept to a treatment regimen with prednisone reduced the risk of relapse and was not associated with a higher rate of toxicity compared to prednisone alone.
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Affiliation(s)
| | | | | | - Nader Khalidi
- St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
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49
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Watelet B, Samson M, de Boysson H, Bienvenu B. Treatment of giant-cell arteritis, a literature review. Mod Rheumatol 2017; 27:747-754. [PMID: 27919193 DOI: 10.1080/14397595.2016.1266070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Giant-cell arteritis (GCA) is the most common vasculitis in people aged more than 50 years. Despite the frequency of this disease, there is currently no international consensus on its therapeutic modalities. The aim of this study was to conduct a review on an international literature about the treatment of GCA, whatever the clinical pattern might be. Oral corticosteroids remain the cornerstone treatment, possibly preceded by intravenous bolus in complicated forms. In cases of glucocorticoid (GC) dependence or GC-related side effects, a GC-sparing agent may be necessary. Methotrexate is one of the most used treatments despite its low level of evidence and mild efficacy. Cyclophosphamide and tocilizumab look promising but require validation in further studies. The results for TNF-α blockers and azathioprine are disappointing. Preventing complications of prolonged corticosteroid therapy is a world challenge and the management of GC-induced osteoporosis is not the same from one country to another. There is a significant risk of arterial thrombosis, mainly at treatment onset, which may encourage to associate an antiplatelet therapy, especially in patients with other cardiovascular risk factors. Place of statins in the treatment of the disease is uncertain.
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Affiliation(s)
- Bénédicte Watelet
- a Department of Vascular Medicine , Centre Hospitalier Universitaire de Caen , Caen , Basse Normandie , France
| | - Maxime Samson
- b Department of Internal Medicine and Clinical Immunology , Hôpital François Mitterrand, CHU de Dijon; INSERM UMR1098, University of Bourgogne Franche-Comté, FHU INCREASE , Dijon , France , and
| | - Hubert de Boysson
- c Department of Internal Medicine , Centre Hospitalier Universitaire de Caen , Caen , Basse Normandie , France
| | - Boris Bienvenu
- c Department of Internal Medicine , Centre Hospitalier Universitaire de Caen , Caen , Basse Normandie , France
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50
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Pflugfelder J. [Tocilizumab in giant cell arteritis]. Z Rheumatol 2016; 76:87-88. [PMID: 27904995 DOI: 10.1007/s00393-016-0243-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J Pflugfelder
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Klinik Kirchheim, Akademisches Lehrkrankenhaus der Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
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