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Alba MA, Kermani TA, Unizony S, Murgia G, Prieto-González S, Salvarani C, Matteson EL. Relapses in giant cell arteritis: Updated review for clinical practice. Autoimmun Rev 2024; 23:103580. [PMID: 39048072 DOI: 10.1016/j.autrev.2024.103580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 07/20/2024] [Accepted: 07/20/2024] [Indexed: 07/27/2024]
Abstract
Giant cell arteritis (GCA), the most common primary vasculitis in adults, is a granulomatous systemic vasculitis usually affecting the aorta and its major branches, particularly the carotid and vertebral arteries. Although remission can be achieved in most patients with GCA using high-dose glucocorticoids (GC), relapses are frequent, occurring in >40% of GC-only treated patients, mostly during the first two years after diagnosis. Relapsing courses lead to high GC exposure, increasing the risk of treatment-related adverse effects. Although tocilizumab is an efficacious GC-sparing therapy that allows increased sustained remission and reduced cumulative GC doses, relapses are common after drug discontinuation. This narrative review examines the most relevant features of relapses in GCA, including its definition, classification, frequency, clinical, laboratory, and imaging characteristics, chronology, probable pathophysiology, and predictive factors. In addition, we discuss treatment options for relapsing patients and the effect of relapses on patient outcomes.
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Affiliation(s)
- Marco A Alba
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitari Mútua Terrassa, Terrassa, Spain.
| | - Tanaz A Kermani
- Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Sebastian Unizony
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Giuseppe Murgia
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Università di Modena e Reggio Emilia, Reggio Emilia, Italy
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Balogh L, Oláh K, Sánta S, Majerhoffer N, Németh T. Novel and potential future therapeutic options in systemic autoimmune diseases. Front Immunol 2024; 15:1249500. [PMID: 38558805 PMCID: PMC10978744 DOI: 10.3389/fimmu.2024.1249500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/17/2024] [Indexed: 04/04/2024] Open
Abstract
Autoimmune inflammation is caused by the loss of tolerance to specific self-antigens and can result in organ-specific or systemic disorders. Systemic autoimmune diseases affect a significant portion of the population with an increasing rate of incidence, which means that is essential to have effective therapies to control these chronic disorders. Unfortunately, several patients with systemic autoimmune diseases do not respond at all or just partially respond to available conventional synthetic disease-modifying antirheumatic drugs and targeted therapies. However, during the past few years, some new medications have been approved and can be used in real-life clinical settings. Meanwhile, several new candidates appeared and can offer promising novel treatment options in the future. Here, we summarize the newly available medications and the most encouraging drug candidates in the treatment of systemic lupus erythematosus, rheumatoid arthritis, Sjögren's disease, systemic sclerosis, systemic vasculitis, and autoimmune myositis.
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Affiliation(s)
- Lili Balogh
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Katalin Oláh
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Soma Sánta
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Nóra Majerhoffer
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Tamás Németh
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Semmelweis University, Budapest, Hungary
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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Paroli M, Caccavale R, Accapezzato D. Giant Cell Arteritis: Advances in Understanding Pathogenesis and Implications for Clinical Practice. Cells 2024; 13:267. [PMID: 38334659 PMCID: PMC10855045 DOI: 10.3390/cells13030267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
Giant cell arteritis (GCA) is a noninfectious granulomatous vasculitis of unknown etiology affecting individuals older than 50 years. Two forms of GCA have been identified: a cranial form involving the medium-caliber temporal artery causing temporal arteritis (TA) and an extracranial form involving the large vessels, mainly the thoracic aorta and its branches. GCA generally affects individuals with a genetic predisposition, but several epigenetic (micro)environmental factors are often critical for the onset of this vasculitis. A key role in the pathogenesis of GCA is played by cells of both the innate and adaptive immune systems, which contribute to the formation of granulomas that may include giant cells, a hallmark of the disease, and arterial tertiary follicular organs. Cells of the vessel wall cells, including vascular smooth muscle cells (VSMCs) and endothelial cells, actively contribute to vascular remodeling responsible for vascular stenosis and ischemic complications. This review will discuss new insights into the molecular and cellular pathogenetic mechanisms of GCA, as well as the implications of these findings for the development of new diagnostic biomarkers and targeted drugs that could hopefully replace glucocorticoids (GCs), still the backbone of therapy for this vasculitis.
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Affiliation(s)
- Marino Paroli
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Polo Pontino, 04100 Latina, Italy; (R.C.); (D.A.)
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Kaymakci MS, Warrington KJ, Kermani TA. New Therapeutic Approaches to Large-Vessel Vasculitis. Annu Rev Med 2024; 75:427-442. [PMID: 37683286 DOI: 10.1146/annurev-med-060622-100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Giant cell arteritis (GCA) and Takayasu arteritis (TAK) are large-vessel vasculitides affecting the aorta and its branches. Arterial damage from these diseases may result in ischemic complications, aneurysms, and dissections. Despite their similarities, the management of GCA and TAK differs. Glucocorticoids are used frequently but relapses are common, and glucocorticoid toxicity contributes to significant morbidity. Conventional immunosuppressive therapies can be beneficial in TAK, though their role in the management of GCA remains unclear. Tumor necrosis factor inhibitors improve remission rates and appear to limit vascular damage in TAK; these agents are not beneficial in GCA. Tocilizumab is the first biologic glucocorticoid-sparing agent approved for use in GCA and also appears to be effective in TAK. A better understanding of the pathogenesis of both conditions and the availability of targeted therapies hold much promise for future management.
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Affiliation(s)
- Mahmut S Kaymakci
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; ,
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; ,
| | - Tanaz A Kermani
- Division of Rheumatology, Department of Medicine, University of California Los Angeles, Santa Monica, California, USA;
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Zeisbrich M, Thiel J, Venhoff N. The IL-17 pathway as a target in giant cell arteritis. Front Immunol 2024; 14:1199059. [PMID: 38299156 PMCID: PMC10828953 DOI: 10.3389/fimmu.2023.1199059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 12/15/2023] [Indexed: 02/02/2024] Open
Abstract
The network of IL-17 cytokines is considered a key component of autoimmune and inflammatory processes. Blocking IL-17 showed great success in psoriasis as well as psoriatic arthritis, and in patients with axial spondyloarthritis. Secukinumab is one of the approved IL-17A inhibitors for these diseases and is now routinely used. In giant cell arteritis, a large vessel vasculitis, there is accumulating evidence for a pathogenic role of IL-17 and Th17 cells, which are part of the CD4+ T-cell subset. Giant cell arteritis occurs in individuals over 50 years of age and many have relative contraindications to glucocorticoid therapy, which today still represents the mainstay therapy. Despite the approval of tocilizumab, which targets the IL-6 receptor, a high demand for glucocorticoid-sparing agents remains that combine the effective suppression of the acute inflammation observed in giant cell arteritis with a safety profile that matches the needs of an older patient population. The first results from a phase II proof-of-principle study (TitAIN) support an optimistic outlook on a potential new treatment option with secukinumab in giant cell arteritis.
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Affiliation(s)
- Markus Zeisbrich
- Department of Rheumatology and Clinical Immunology, Medical Center – University of Freiburg, Freiburg, Germany
| | - Jens Thiel
- Department of Rheumatology and Clinical Immunology, Medical Center – University of Freiburg, Freiburg, Germany
- Division of Rheumatology and Clinical Immunology, Medical University Graz, Graz, Austria
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center – University of Freiburg, Freiburg, Germany
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Chu CQ. Advances and challenges in management of large vessel vasculitis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:188-195. [PMID: 38125643 PMCID: PMC10729599 DOI: 10.2478/rir-2023-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 05/20/2023] [Indexed: 12/23/2023]
Abstract
Glucocorticoids (GC) remains the mainstay for management of large vessel vasculitis (LVV). Recent introduction of interleukin-6 signaling blocker, tocilizumab has substantially changed the practice in management of patients with LVV, in particular, giant cell arteritis (GCA). Benefit of tocilizumab to patients with Takayasu arteritis (TAK) is supported by observational studies, but randomized clinical trials are lacking. Addition of tocilizumab enables reduction of the total amount of GC in patients with GCA, but GC burden remains high and to be further reduced. Ongoing studies aim at minimal use of GC or even GC-free. Tumor necrosis factor inhibitors appear to be beneficial to TAK despite their ineffectiveness to GCA. Randomized clinical trials are undergoing to target other inflammatory cytokines in both GCA and TAK. Janus kinase inhibitors alone or in combination with conventional disease modifying anti-rheumatic drugs showed promising results in treatment of TAK.
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Affiliation(s)
- Cong-Qiu Chu
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, PortlandOregon 97239USA
- Rheumatology Section, Veterans Affairs Portland Health Care System, PortlandOregon 97239USA
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Andel PM, Diamantopoulos AP, Myklebust G, Haugeberg G. Vasculitis distribution and clinical characteristics in giant cell arteritis: a retrospective study using the new 2022 ACR/EULAR classification criteria. Front Med (Lausanne) 2023; 10:1286601. [PMID: 38020143 PMCID: PMC10681091 DOI: 10.3389/fmed.2023.1286601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Giant cell arteritis (GCA) is the most common vasculitis of the elderly. In recent years, advanced imaging has to a certain extent replaced temporal artery biopsy (TAB) to aid diagnosis in many institutions and helped to identify three major phenotypes of GCA, namely, cranial GCA (c-GCA), large-vessel non-cranial GCA (LV-GCA), and a combination of these two patterns called mixed-GCA, which all show different clinical patterns. Recent 2022 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria respect the changing conception and clinical practice during the last two decades. In this cohort study, we present vasculitis distribution and baseline characteristics using the 2022 ACR/EULAR classification criteria as well as the EULAR core data set. Methods In this retrospective study from Southern Norway, we identified all patients diagnosed with GCA between 2006 and 2019 in our single-center fast-track clinic (FTC). We included all patients who were examined using ultrasound (US) of cranial as well as non-cranial large vessels at diagnosis to depict vascular distribution. EULAR core data set, ACR 1990, and 2022 ACR/EULAR classification criteria were used to characterize the cohort. Results Seventy-seven patients were diagnosed with GCA at our institution in the aforementioned period. Seventy-one patients (92.2%) were diagnosed with the help of US and included in the further analysis. The 2022 ACR/EULAR classification criteria allocated 69 patients (97.2%), while the ACR 1990 classification criteria allocated 49 patients (69.0%) in our cohort as having GCA. Mixed-GCA was the most common type in 33 patients (46.5%). Weight loss was significantly more common in patients with large-vessel non-cranial vasculitis in LV-GCA and mixed-GCA. Headache, on the other hand, was significantly more common in patients with involvement of cranial vessels. Conclusion Mixed GCA was the most common form of GCA in our cohort. In our study, the 2022 ACR/EULAR classification criteria seem to be a more useful tool compared with the old ACR 1990 classification criteria to allocate GCA patients diagnosed and treated at our US-based FTC as having GCA.
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Affiliation(s)
- Peter M. Andel
- Division of Rheumatology, Department of Rheumatology, Surgery, Inflammation and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Department, Hospital of South East Norway, Kalnes, Norway
| | - Andreas P. Diamantopoulos
- Division of Internal Medicine, Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Glenn Haugeberg
- Division of Rheumatology, Department of Internal Medicine, Hospital of Southern Norway, Kristiansand, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Nepal D, Putman M, Unizony S. Giant Cell Arteritis and Polymyalgia Rheumatica: Treatment Approaches and New Targets. Rheum Dis Clin North Am 2023; 49:505-521. [PMID: 37331730 DOI: 10.1016/j.rdc.2023.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Prolonged glucocorticoid tapers have been the standard of care for giant cell arteritis (GCA) and polymyalgia rheumatica (PMR), but recent advancements have improved outcomes for patients with GCA while reducing glucocorticoid-related toxicities. Many patients with GCA and PMR still experience persistent or relapsing disease, and cumulative exposure to glucocorticoids for both diseases remains high. The objective of this review is to define current treatment approaches as well as new therapeutic targets and strategies. Studies investigating inhibition of cytokine pathways, including interleukin-6, interleukin-17, interleukin-23, granulocyte-macrophage colony-stimulating factor, Janus kinase-signal transduction and activator of transcription, and others, will be reviewed.
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Affiliation(s)
- Desh Nepal
- Department of Medicine, Division of Rheumatology, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Rheumatology, 6th Floor, Milwaukee, WI 53226, USA.
| | - Michael Putman
- Department of Medicine, Division of Rheumatology, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Rheumatology, 6th Floor, Milwaukee, WI 53226, USA
| | - Sebastian Unizony
- Massachusetts General Hospital, Vasculitis and Glomerulonephritis Center, Harvard Medical School, 55 Fruit Street, Yawkey 4B, Boston, MA 02114, USA
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Tian X, Li M, Jiang N, Zhao Y, Li J, Zhou Y, Wang Y, Wang Y, Li T, Yang Y, Wang Y, Merkel PA, Zeng X. Comparative Efficacy of Secukinumab Versus Tumor Necrosis Factor Inhibitors for the Treatment of Takayasu Arteritis. Arthritis Rheumatol 2023; 75:1415-1423. [PMID: 36916777 DOI: 10.1002/art.42496] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Tumor necrosis factor (TNF) alpha and interleukin-17 (IL-17) are thought to be involved in the pathogenesis of Takayasu arteritis (TAK), and TNF inhibitors (TNFi) are recommended for the treatment of TAK. The present study was undertaken to investigate the efficacy of secukinumab, an IL-17A monoclonal antibody, compared to treatment with TNFi. METHODS This was a prospective, single-center, open-label cohort study. Patients with active TAK who did not respond to treatment with glucocorticoids combined with 2 immunosuppressive agents were treated with either secukinumab or TNFi as an add-on therapy without an increased dosage of glucocorticoids. A complete response was defined as complete resolution of signs and symptoms of active disease, normal values of inflammatory markers, no progression on imaging of involved arteries, and dose of glucocorticoid <15 mg/day. A partial response was similarly defined as a complete response except with an erythrocyte sedimentation rate <40 mm/hour and C-reactive protein level of <20 mg/liter. RESULTS Nineteen patients in the secukinumab group and 34 patients in the TNFi group were enrolled. The demographic data and inflammatory markers of the 2 groups were comparable at baseline. Complete response and partial response for patients treated with secukinumab and TNFi were 31.6% and 58.8% (P = 0.057), respectively, at 3 months and 52.6% and 64.7%, respectively, at 6 months (P = 0.389). CONCLUSION Our findings suggest that secukinumab and TNFi are effective for patients with TAK who do not respond to oral glucocorticoids and conventional immunosuppressive agents, with similar response rates at 3 and 6 months.
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Affiliation(s)
- Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Nan Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Yang Zhao
- Department of Rheumatology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, China
| | - Jing Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Yahong Wang
- Department of Ultrasonography, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ying Wang
- Department of Ultrasonography, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Taotao Li
- Department of Rheumatology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yunjiao Yang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Yanhong Wang
- Department of Epidemiology and Bio-statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine; and Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
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Tomelleri A, van der Geest KSM, Khurshid MA, Sebastian A, Coath F, Robbins D, Pierscionek B, Dejaco C, Matteson E, van Sleen Y, Dasgupta B. Disease stratification in GCA and PMR: state of the art and future perspectives. Nat Rev Rheumatol 2023:10.1038/s41584-023-00976-8. [PMID: 37308659 DOI: 10.1038/s41584-023-00976-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature, an excellent response to glucocorticoids, a tendency to a chronic and relapsing course, and older age of the affected population. This Review highlights the emerging view that these diseases should be approached as linked conditions, unified under the term GCA-PMR spectrum disease (GPSD). In addition, GCA and PMR should be seen as non-monolithic conditions, with different risks of developing acute ischaemic complications and chronic vascular and tissue damage, different responses to available therapies and disparate relapse rates. A comprehensive stratification strategy for GPSD, guided by clinical findings, imaging and laboratory data, facilitates appropriate therapy and cost-effective use of health-economic resources. Patients presenting with predominant cranial symptoms and vascular involvement, who usually have a borderline elevation of inflammatory markers, are at an increased risk of sight loss in early disease but have fewer relapses in the long term, whereas the opposite is observed in patients with predominant large-vessel vasculitis. How the involvement of peripheral joint structures affects disease outcomes remains uncertain and understudied. In the future, all cases of new-onset GPSD should undergo early disease stratification, with their management adapted accordingly.
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Affiliation(s)
- Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Alwin Sebastian
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Fiona Coath
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK
| | - Daniel Robbins
- Medical Technology Research Centre, School of Allied Health, Anglia Ruskin University, Chelmsford, UK
| | - Barbara Pierscionek
- Faculty of Health Education Medicine and Social Care, Medical Technology Research Centre, Anglia Ruskin University, Chelmsford Campus, Chelmsford, UK
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Eric Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK.
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Venhoff N, Schmidt WA, Bergner R, Rech J, Unger L, Tony HP, Finzel S, Andreica I, Kofler DM, Weiner SM, Lamprecht P, Schulze-Koops H, App C, Pournara E, Mendelson MH, Sieder C, Maricos M, Thiel J. Safety and efficacy of secukinumab in patients with giant cell arteritis (TitAIN): a randomised, double-blind, placebo-controlled, phase 2 trial. THE LANCET. RHEUMATOLOGY 2023; 5:e341-e350. [PMID: 38251601 DOI: 10.1016/s2665-9913(23)00101-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/20/2023] [Accepted: 03/30/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The treatment of giant cell arteritis with glucocorticoid-sparing agents is an unmet medical need. We evaluated the efficacy and safety of secukinumab, an anti-interleukin-17A monoclonal antibody, in patients with giant cell arteritis. METHODS We conducted a Bayesian randomised, parallel-group, double-blind, placebo-controlled, multicentre, phase 2 study at 11 clinics or hospitals in Germany. Patients aged 50 years or older with new-onset or relapsing giant cell arteritis who were naive to biological therapy and already receiving glucocorticoids with a prednisolone equivalent dose of 25-60 mg/day were eligible for inclusion. Participants were assigned (1:1) to receive 300 mg secukinumab or placebo subcutaneously once a week up to week 4 and every 4 weeks thereafter. In both treatment groups, prednisolone dose was tapered down to 0 mg over a 26-week period. Patients, investigator staff, and clinical trial team were masked to the treatment assignment. The primary endpoint was the median proportion (Bayesian analysis) of patients with sustained remission until week 28 in the full analysis set (ie, all patients who received at least one dose of assigned treatment, analysed according to treatment assigned at randomisation). Sustained remission rate of the placebo group from a previous trial of tocilizumab in patients with giant cell arteritis was used to derive the prior distribution of placebo sustained remission rate for the primary endpoint. The safety of secukinumab was assessed in the safety set (ie, all patients who received at least one dose of study treatment, analysed according to study treatment received). This trial is completed and is registered with ClinicalTrials.gov, NCT03765788. FINDINGS Of the 65 patients who were assessed for eligibility, 52 patients (median age 75 years [IQR 69-79]; 35 [67%] female and 17 [33%] male, 52 [100%] White) were enrolled between Jan 30, 2019 and March 30, 2020 and were randomly assigned to receive secukinumab (n=27) or placebo (n=25). Four of 27 patients in the secukinumab group and eight of 25 patients in the placebo group discontinued treatment by week 28 of the study. On the basis of the Bayesian analysis, the median proportion of patients in sustained remission until week 28 was 70% (95% credibility interval 52-85) in the secukinumab group versus 20% (12-30) in the placebo group. The incidence of adverse events was similar in the secukinumab (27 [100%] of 27 patients had any adverse event) and placebo groups (24 [96%] of 25 patients had any adverse event); the most common adverse events were hypertension (six [22%] of 27 patients in the secukinumab group and eight [32%] of 25 patients in the placebo group) and nasopharyngitis (five [19%] of 27 patients in the secukinumab group and five [20%] of 25 patients in the placebo group). Two patients (one in each group) died during the study, neither of which was considered to be related to study treatment. INTERPRETATION Patients with active giant cell arteritis had a higher sustained remission rate in the secukinumab group than in the placebo group at week 28, in combination with glucocorticoid taper regimen. Secukinumab was tolerated well with no new safety concerns. This proof-of-concept phase 2 study further supports the development of secukinumab as a treatment option for people with giant cell arteritis. FUNDING Novartis Pharma.
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Affiliation(s)
- Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
| | - Raoul Bergner
- Medizinische Klinik A, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany
| | - Jürgen Rech
- Department of Internal Medicine 3 - Rheumatology and Immunology, Deutsches Zentrum Immuntherapie, Friedrich-Alexander-University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Leonore Unger
- Medical Department 1, Städtisches Klinikum Dresden, Dresden, Germany
| | - Hans-Peter Tony
- Department of Medicine 2, Rheumatology and Clinical Immunology, University of Wuerzburg, Wuerzburg, Germany
| | - Stephanie Finzel
- Department of Rheumatology and Clinical Immunology, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ioana Andreica
- Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Bochum, Germany
| | - David M Kofler
- Division of Clinical Immunology and Rheumatology, Department I of Internal Medicine, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Stefan M Weiner
- Medical Department 2, Krankenhaus der Barmherzigen Brüder Trier, Medical Campus of the Johannes Gutenberg-University Mainz, Trier, Germany
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig-Maximilians-University of Munich, Munich, Germany
| | | | | | | | | | | | - Jens Thiel
- Department of Rheumatology and Clinical Immunology, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
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12
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Ford JA, Gewurz D, Gewurz-Singer O. Tocilizumab in giant cell arteritis: an update for the clinician. Curr Opin Rheumatol 2023; 35:135-140. [PMID: 36912060 DOI: 10.1097/bor.0000000000000937] [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: 03/14/2023]
Abstract
PURPOSE OF REVIEW The recent approval of tocilizumab (TCZ) for the treatment of giant cell arteritis (GCA) has changed the landscape for management of this disease. Herein, we review recent literature addressing practical questions for the clinician regarding the use of TCZ in GCA. We evaluate efficacy of TCZ across different disease phenotypes, optimal dosing and formulation, treatment-related toxicity, recommendations for monitoring disease, and duration of therapy. RECENT FINDINGS Post-hoc analyses of a large clinical trial and real-world data suggest efficacy of TCZ across various disease phenotypes in GCA, and support use of weekly subcutaneous dosing over every-other-week dosing. More data are needed to guide duration of TCZ therapy, optimal disease activity monitoring in patients treated with TCZ, and to speak to efficacy in GCA with large vessel involvement. SUMMARY TCZ has added valuably to the treatment arsenal in GCA, though more data are needed to guide optimal use of the drug.
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Affiliation(s)
- Julia A Ford
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Ora Gewurz-Singer
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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13
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Iudici M, Hemmig AK, Stegert M, Courvoisier C, Adler S, Becker MO, Berger CT, Dan D, Finckh A, Mahr A, Neumann T, Reichenbach S, Ribi C, Seitz L, Villiger P, Wildi L, Daikeler T. Management of giant-cell arteritis in Switzerland: an online national survey. Swiss Med Wkly 2023; 153:40051. [PMID: 37011593 DOI: 10.57187/smw.2023.40051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
AIMS OF THE STUDY To assess current practices in diagnosing, treating, and following-up giant-cell arteritis by specialists in Switzerland and to identify the main barriers to using diagnostic tools. METHODS We performed a national survey of specialists potentially caring for patients with giant-cell arteritis. The survey was sent by email to all members of the Swiss Societies of Rheumatology and for Allergy and Immunology. A reminder was sent to nonresponders after 4 and 12 weeks. Its questions covered the following dimensions: respondents' main characteristics, diagnosis, treatment, and imaging's role during follow-up. The main study results were summarized using descriptive statistics. RESULTS Ninety-one specialists, primarily aged 46-65 years (n = 53/89; 59%), working in academic or nonacademic hospitals or private practice, and treating a median of 7.5 (interquartile range [IQR]: 3-12) patients with giant-cell arteritis per year participated in this survey. Ultrasound of temporal arteries/large vessels (n = 75/90; 83%) and positron-emission-tomography-computed tomography (n = 52/91; 57%) or magnetic resonance imaging (n = 46/90; 51%) of the aorta/extracranial arteries were the most common techniques used to diagnose giant-cell arteritis with cranial or large vessel involvement, respectively. Most participants reported a short time to obtain imaging tests or arterial biopsy. The glucocorticoid tapering scheme, glucocorticoid-sparing agent, and glucocorticoid-sparing treatment duration varied among the participants. Most physicians did not follow a predefined repeat imaging scheme for follow-up and mainly relied on structural changes (vascular thickening, stenosis, or dilatation) to drive treatment choice. CONCLUSIONS This survey indicates that imaging and temporal biopsy are rapidly accessible for diagnosing giant-cell arteritis in Switzerland but highlights heterogeneous practice in many disease management areas.
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Affiliation(s)
- Michele Iudici
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Mihaela Stegert
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Courvoisier Courvoisier
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sabine Adler
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Bern, Switzerland
| | - Mike Oliver Becker
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph T Berger
- University Center for Immunology, University Hospital Basel, Basel, Switzerland
- Department Biomedicine, Translational Immunology, University of Basel, Basel, Switzerland
| | - Diana Dan
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Axel Finckh
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Alfred Mahr
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Thomas Neumann
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Stephan Reichenbach
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Camillo Ribi
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Luca Seitz
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Peter Villiger
- Department of Rheumatology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Lukas Wildi
- Department of Rheumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
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14
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Jivraj I. Treatment of Giant Cell Arteritis. Int Ophthalmol Clin 2023; 63:39-54. [PMID: 36963826 DOI: 10.1097/iio.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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15
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Matza MA, Dagincourt N, Mohan SV, Pavlov A, Han J, Stone JH, Unizony SH. Outcomes during and after long-term tocilizumab treatment in patients with giant cell arteritis. RMD Open 2023; 9:rmdopen-2022-002923. [PMID: 37024237 PMCID: PMC10083869 DOI: 10.1136/rmdopen-2022-002923] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/08/2023] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVE To assess outcomes in giant cell arteritis (GCA) patients during and after long-term tocilizumab (TCZ) treatment. METHODS Retrospective analysis of GCA patients treated with TCZ at a single centre (2010-2022). Time to relapse and annualised relapse rate during and after TCZ treatment, prednisone use, and safety were assessed. Relapse was defined as reappearance of any GCA clinical manifestation that required treatment intensification, regardless of C reactive protein levels and erythrocyte sedimentation rate. RESULTS Sixty-five GCA patients were followed for a mean (SD) of 3.1 (1.6) years. The mean duration of the initial TCZ course was 1.9 (1.1) years. The Kaplan-Meier (KM)-estimated relapse rate at 18 months on TCZ was 15.5%. The first TCZ course was discontinued due to satisfactory remission achievement in 45 (69.2%) patients and adverse events in 6 (9.2%) patients. KM-estimated relapse rate at 18 months after TCZ discontinuation was 47.3%. Compared with patients stopping TCZ at or before 12 months of treatment, the multivariable adjusted HR (95% CI) for relapse in patients on TCZ beyond 12 months was 0.01 (0.00 to 0.28; p=0.005). Thirteen patients received >1 TCZ course. Multivariable adjusted annualised relapse rates (95% CI) in all periods on and off TCZ aggregated were 0.1 (0.1 to 0.2) and 0.4 (0.3 to 0.7), respectively (p=0.0004). Prednisone was discontinued in 76.9% of patients. During the study, 13 serious adverse events occurred in 11 (16.9%) patients. CONCLUSION Long-term TCZ treatment was associated with remission maintenance in most patients with GCA. The estimated relapse rate by 18 months after TCZ discontinuation was 47.3%.
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Affiliation(s)
- Mark A Matza
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Andrey Pavlov
- Everest Clinical Research Corporation, Markham, Ontario, Canada
| | - Jian Han
- Genentech Inc, South San Francisco, California, USA
| | - John H Stone
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian H Unizony
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Molina-Collada J, Castrejón I, Monjo I, Fernández-Fernández E, Torres Ortiz G, Álvaro-Gracia JM, de Miguel E. Performance of the 2022 ACR/EULAR giant cell arteritis classification criteria for diagnosis in patients with suspected giant cell arteritis in routine clinical care. RMD Open 2023; 9:rmdopen-2022-002970. [PMID: 37094980 PMCID: PMC10151996 DOI: 10.1136/rmdopen-2022-002970] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/03/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE To examine the performance of the new 2022 American College of Rheumatology (ACR)/EULAR giant cell arteritis (GCA) classification criteria for diagnosis in routine clinical care. METHODS Multicentric retrospective observational study of patients referred to two ultrasound (US) fast track clinics. Patients with GCA were compared with unselected controls with suspected GCA. The gold standard for GCA diagnosis has been clinical confirmation after 6 months of follow-up. All patients underwent an US exam of temporal and extracranial arteries (carotid, subclavian and axillary) at baseline. Fluorodeoxyglucose-positron emission tomography/CT was performed according to standard clinician criteria. The performance of the new 2022 ACR/EULAR GCA classification criteria was evaluated in all patients with GCA across different subsets of the disease. RESULTS A total of 319 patients (188 cases, 131 controls) were included for analysis (mean age 76 years, 58.9% females). Overall, the 2022 EULAR/ACR GCA classification criteria had a sensitivity of 92.6% and a specificity of 71.8%, using GCA clinical diagnosis as external criterion and the area under the curve (AUC) was 0.928 (95% CI 0.899 to 0.957). Isolated large vessel-GCA showed a sensitivity of 62.2% and a specificity of 71.8% (AUC 0.691 (0.592 to 0.790)), while biopsy-proven GCA showed a sensitivity of 100% and a specificity of 71.8% (AUC 0.989 (0.976 to 1)). Overall sensitivity and specificity of the 1990 ACR criteria was 53.2% and 80.2%, respectively. CONCLUSIONS The new 2022 ACR/EULAR GCA classification criteria showed adequate diagnostic accuracy in patients with suspected GCA under routine care, and an improvement on the sensitivity and specificity of the 1990 ACR classification criteria in all patient subsets.
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Affiliation(s)
- Juan Molina-Collada
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Isabel Castrejón
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
| | - Irene Monjo
- Department of Rheumatology, Hospital Universitario La Paz, Madrid, Spain
| | | | | | - Jose María Álvaro-Gracia
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
| | - Eugenio de Miguel
- Department of Rheumatology, Hospital Universitario La Paz, Madrid, Spain
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17
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Unmet need in the treatment of polymyalgia rheumatica and giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 36:101822. [PMID: 36907732 DOI: 10.1016/j.berh.2023.101822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
For decades, aside from prednisone and the occasional use of immune suppressive drugs such as methotrexate, there was little to offer patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). However, there is a great interest in various steroid sparing treatments in both these conditions. This paper aims to provide an overview of our current knowledge of PMR and GCA, examining their similarities and distinctions in terms of clinical presentation, diagnosis, and treatment, with emphasis placed on reviewing recent and ongoing research efforts on emerging treatment. Multiple recent and ongoing clinical trials are demonstrating new therapeutics that will provide benefit and contribute to the evolution of clinical guidelines and standard of care for patients with GCA and/or PMR.
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18
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Springer JM, Kermani TA. Recent advances in the treatment of giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 37:101830. [PMID: 37328409 DOI: 10.1016/j.berh.2023.101830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 06/18/2023]
Abstract
Giant cell arteritis (GCA) is a systemic, granulomatous, large-vessel vasculitis that affects individuals over the age of 50 years. Morbidity from disease includes cranial manifestations which can cause irreversible blindness, while extra-cranial manifestations can cause vascular damage with large-artery stenosis, occlusions, aortitis, aneurysms, and dissections. Glucocorticoids while efficacious are associated with significant adverse effects. Furthermore, despite treatment with glucocorticoids, relapses are common. An understanding of the pathogenesis of GCA has led to the discovery of tocilizumab as an efficacious steroid-sparing therapy while additional therapeutic targets affecting different inflammatory pathways are under investigation. Surgical treatment may be indicated in cases of refractory ischemia or aortic complications but data on surgical outcomes are limited. Despite the recent advances, many unmet needs exist, including the identification of patients or subsets of GCA who would benefit from earlier initiation of adjunctive therapies, patients who may warrant long-term immunosuppression and medications that sustain permanent remission. The impact of medications like tocilizumab on long-term outcomes, including the development of aortic aneurysms and vascular damage also warrants investigation.
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Affiliation(s)
- Jason M Springer
- Vanderbilt University Medical Center, 1161 21st Avenue Sound, T3113 Medical Center North, Nashville, TN, 37232, USA.
| | - Tanaz A Kermani
- University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
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19
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Abstract
T helper 17 (Th17) cells are IL-17-producing CD4 T cells that play a crucial role in autoimmune diseases. IL-17 is a key cytokine for host protection against mucosal and skin infection but is also one of the major pathogenic cytokines. IL-1 and IL-23 are requisite for stimulating pathogenic Th17 cell differentiation and proliferation. Therapeutics targeting the IL-17/IL-23 pathway are widely used clinically for the treatment of autoimmune diseases. Besides IL-17, pathogenic Th17 cells produce granulocyte-macrophage colony-stimulating factor, tumor necrosis factor α, interferon γ, IL-21 and IL-22. However, Th17-targeted therapy has not yet been established. T cell metabolism orchestrates T cell survival, cell differentiation, epigenetic change and function and each T cell subset favors a particular metabolic pathway. Recent studies have provided novel insights into the role of T cell metabolism in the pathogenesis of autoimmune diseases. The current review focuses on the role of Th17 cell metabolism in autoimmune diseases, particularly glycolysis, amino acid metabolism, lipid metabolism, as well as the regulators of these processes, including mTORC1. Therapeutics targeting T cell metabolism in autoimmune diseases could serve as a possible treatment option for patients who are refractory to or unresponsive to conventional therapy.
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Affiliation(s)
- Michihito Kono
- Faculty of Medicine, Department of Rheumatology, Endocrinology and Nephrology, Hokkaido University, Sapporo, Japan
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20
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Schmidt WA. Vascular ultrasound in rheumatology practice. Best Pract Res Clin Rheumatol 2023; 37:101847. [PMID: 37419758 DOI: 10.1016/j.berh.2023.101847] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/09/2023]
Abstract
Rheumatologists are increasingly using vascular ultrasound. Several guidelines now recommend ultrasound as the first diagnostic modality in giant cell arteritis (GCA). The German curriculum for rheumatology training has recently included ultrasound for the acute diagnosis of vasculitis. Recent studies have shown that ultrasound of temporal, axillary, subclavian, and vertebral arteries has sensitivities and specificities of >90%. Vascular ultrasound detects subclinical GCA in approximately 20% of patients with "pure" polymyalgia rheumatica. GCA fast-track clinics might regularly include these patients. A new score based on the intima-media thickness of the temporal and axillary arteries allows the monitoring of structural changes with treatment. The score decreases faster for the temporal arteries than it does for the axillary arteries. Measuring the diameter of the ascending aorta and the aortic arch might become a fast and cost-effective tool for the long-term monitoring of aortic aneurysms in extracranial GCA. Vascular ultrasound also has a role for Takayasu arteritis, thrombosis, Behçet's syndrome, and Raynaud's phenomenon.
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Affiliation(s)
- Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Center for Rheumatology Berlin-Buch, Lindenberger Weg 19, 13125 Berlin, Germany.
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21
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Soysal Gündüz Ö, Armağan Alptürker K, Güler Şen M, Can F, Erdal S, Ulman C, Pırıldar T. The Relationship of Carotid Intima-Media Thickness with Cell Adhesion
Molecules and Pentraxin-3 in Patients with Psoriatic Arthritis. AKTUEL RHEUMATOL 2023. [DOI: 10.1055/a-1942-6311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Abstract
Aim Cardiovascular morbidity is increased in patients with psoriatic
arthritis (PsA) compared to the general population. Several recent studies have
indicated that pentraxin 3 (PTX-3) and cell adhesion molecules (CAMs) might be
independent biomarkers of subclinical atherosclerosis. In this study, we aimed
to determine the relationship of CAMs and PTX-3 with carotid intima media
thickness (CIMT) in patients with PsA and to compare CIMT and serum levels of
these biomarkers in patients with healthy controls (HCs).
Method PsA patients fulfilling the CASPAR (Classification criteria for
Psoriatic Arthritis) criteria without traditional cardiovascular (CV)
comorbidity and HCs without autoimmune and/or CV disease were included
in this cross-sectional study. Carotid artery Doppler ultrasound examinations
were conducted by a single radiologist blinded to the participants’
clinical characteristics. Serum vascular adhesion molecule 1 (VCAM-1),
intercellular adhesion molecule 1 (ICAM-1), E-selectin, and PTX-3 concentrations
were analized.
Results 43 PsA patients (27 females, mean age 42.49±11.70 years,
and a mean disease duration of 9.37±7.96 years) and 37 HCs (28 females,
mean age 42.16±11.38 years) were included. In regression analyses, age
and PTX-3 were found to be the best predictors of CIMT in patients with PsA.
CIMT was significantly higher in PsA patients compared with HCs
(0.63±0.18 vs. 0.49±0.10 mm, p<0.01). In te PsA
group, serum levels of PTX-3, ICAM-1, and VCAM-1 were also significantly higher
than HCs. CIMT correlated positively with age, disease duration, PTX-3, ICAM-1,
and VCAM-1 (p<0.05).
Conclusion In our study, age and serum level of PTX-3 were found to be the
predictors of CIMT in patients with PsA without CV comorbidity. This outcome
highlights the importance of monitoring CIMT and serum level of PTX-3 as CV risk
factors in PsA patients.
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Affiliation(s)
- Özgü Soysal Gündüz
- Faculty of Medicine, Department of Internal Medicine, Division of
Rheumatology, Manisa Celal Bayar University, Manisa, Turkey
| | - Kezban Armağan Alptürker
- Faculty of Medicine, Department of Physical Medicine and
Rehabilitation, Division of Rheumatology, Manisa Celal Bayar University, Manisa,
Turkey
| | - Menice Güler Şen
- Faculty of Medicine, Department of Internal Medicine, Division of
Rheumatology, Manisa Celal Bayar University, Manisa, Turkey
| | - Fatma Can
- Faculty of Medicine, Department of Radiology, Manisa Celal Bayar
University, Manisa, Turkey
| | - Serkan Erdal
- Faculty of Medicine, Department of Medical Biochemistry, Manisa Celal
Bayar University, Manisa, Turkey
| | - Cevval Ulman
- Faculty of Medicine, Department of Medical Biochemistry, Manisa Celal
Bayar University, Manisa, Turkey
| | - Timur Pırıldar
- Faculty of Medicine, Department of Internal Medicine, Division of
Rheumatology, Manisa Celal Bayar University, Manisa, Turkey
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22
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Samson M, Genet C, Corbera-Bellalta M, Greigert H, Espígol-Frigolé G, Gérard C, Cladière C, Alba-Rovira R, Ciudad M, Gabrielle PH, Creuzot-Garcher C, Tarris G, Martin L, Saas P, Audia S, Bonnotte B, Cid MC. Human monocyte-derived suppressive cells (HuMoSC) for cell therapy in giant cell arteritis. Front Immunol 2023; 14:1137794. [PMID: 36895571 PMCID: PMC9989212 DOI: 10.3389/fimmu.2023.1137794] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction The pathogenesis of Giant Cell Arteritis (GCA) relies on vascular inflammation and vascular remodeling, the latter being poorly controlled by current treatments. Methods This study aimed to evaluate the effect of a novel cell therapy, Human Monocyte-derived Suppressor Cells (HuMoSC), on inflammation and vascular remodeling to improve GCA treatment. Fragments of temporal arteries (TAs) from GCA patients were cultured alone or in the presence of HuMoSCs or their supernatant. After five days, mRNA expression was measured in the TAs and proteins were measured in culture supernatant. The proliferation and migration capacity of vascular smooth muscle cells (VSMCs) were also analyzed with or without HuMoSC supernatant. Results Transcripts of genes implicated in vascular inflammation (CCL2, CCR2, CXCR3, HLADR), vascular remodeling (PDGF, PDGFR), angiogenesis (VEGF) and extracellular matrix composition (COL1A1, COL3A1 and FN1) were decreased in arteries treated with HuMoSCs or their supernatant. Likewise, concentrations of collagen-1 and VEGF were lower in the supernatants of TAs cultivated with HuMoSCs. In the presence of PDGF, the proliferation and migration of VSMCs were both decreased after treatment with HuMoSC supernatant. Study of the PDGF pathway suggests that HuMoSCs act through inhibition of mTOR activity. Finally, we show that HuMoSCs could be recruited in the arterial wall through the implication of CCR5 and its ligands. Conclusion Altogether, our results suggest that HuMoSCs or their supernatant could be useful to decrease vascular in flammation and remodeling in GCA, the latter being an unmet need in GCA treatment.
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Affiliation(s)
- Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France.,Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France.,Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Coraline Genet
- Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Marc Corbera-Bellalta
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Hélène Greigert
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France.,Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Georgina Espígol-Frigolé
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Claire Gérard
- Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Claudie Cladière
- Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Roser Alba-Rovira
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Marion Ciudad
- Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | | | | | - Georges Tarris
- Department of Pathology, Dijon University Hospital, Dijon, France
| | - Laurent Martin
- Department of Pathology, Dijon University Hospital, Dijon, France
| | - Philippe Saas
- Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France.,Centre d'investigation clinique (CIC)-1431, INSERM, Besançon University Hospital, Etablissement Français du Sang (EFS), Besançon, France
| | - Sylvain Audia
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France.,Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Bernard Bonnotte
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France.,Université Bourgogne Franche-Comté, INSERM, Etablissement Français du Sang, Bourgogne Franche-Comté (EFS BFC), UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Maria C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
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23
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Henes JC, Saur S. Diagnostik und Therapie der
Großgefäßvaskulitiden – Wo stehen wir
aktuell? AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1931-3989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ZusammenfassungDie beiden Großgefäßvaskulitiden unterscheiden sich in
mehrfacher Hinsicht, vor allem aber durch das Alter der betroffenen Patienten
bei Erstmanifestation. Die Riesenzellarteriitis (RZA) ist eine Erkrankung des
älteren Patienten wohingegen die Takayasu Arteriitis per definitionem
vor dem 40 Lebensjahr auftritt. Die Diagnosen sind in den letzten Jahren durch
verbesserte Bildgebung und Therapieoptionen mehr ins Bewusstsein
gerückt. Neben der klassischen Steroidtherapie – welche bis
heute Mittel der ersten Wahl ist – steht uns mit Tocilizumab, einem
monoklonalen Antikörper gegen IL6-Rezeptor, zumindest für die
RZA, eine zusätzliche hocheffektive Therapie zur Verfügung.
Andere vielversprechende Substanzen befinden sich derzeit in Erprobung. Dieser
Artikel soll einen Überblick zu Diagnostik und Therapie, aber auch einen
Ausblick zu möglicherweise kommenden medikamentösen Optionen
bieten.
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Affiliation(s)
- Joerg Christoph Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and
Auto-inflammatory Diseases and Internal Medicine II, University Hospital
Tuebingen, Tuebingen, Germany
| | - Sebastian Saur
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and
Auto-inflammatory Diseases and Internal Medicine II, University Hospital
Tuebingen, Tuebingen, Germany
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24
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Macaluso F, Marvisi C, Castrignanò P, Pipitone N, Salvarani C. Comparing treatment options for large vessel vasculitis. Expert Rev Clin Immunol 2022; 18:793-805. [PMID: 35714219 DOI: 10.1080/1744666x.2022.2092098] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Giant cell arteritis (GCA) and Takayasu arteritis (TAK) are the major forms of large vessel vasculitis (LVV).Glucocorticoids represent the cornerstone of LVV treatment, however, relapses and recurrences frequently occur when they are tapered or stopped, determining a prolonged exposure to glucocorticoids and a subsequent increased risk of glucocorticoid-related side effects. Therefore, conventional and biologic immunosuppressive drugs have been proposed to obtain a glucocorticoid-sparing effect. AREAS COVERED We searched PubMed® using the keywords "giant cell arteritis/drug therapy" and "Takayasu Arteritis/drug therapy" OR "Takayasu Arteritis/surgery". This review focuses on the management of LVV, based on the current evidence while highlighting the differences in terms of therapeutic management of TAK and GCA. EXPERT OPINION Conventional disease modifying anti-rheumatic drugs, such as methotrexate or azathioprine, are recommended in association to glucocorticoids for selected GCA and all TAK patients. Two randomized placebo-controlled trials recently demonstrated the efficacy of tocilizumab in reducing relapses and cumulative prednisone dosage in GCA patients with newly diagnosed or relapsing disease. Observational evidence and two small randomized controlled trials support the use of TNF-alpha inhibitors and tocilizumab as glucocorticoid-sparing agents in relapsing TAK, albeit high-quality evidence regarding the management of TAK is still lacking.
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Affiliation(s)
- Federica Macaluso
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Department of Precision Medicine, Section of Rheumatology, Università della Campania L Vanvitelli, Naples, Italy
| | - Chiara Marvisi
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Paola Castrignanò
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
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25
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Watanabe R, Hashimoto M. Vasculitogenic T Cells in Large Vessel Vasculitis. Front Immunol 2022; 13:923582. [PMID: 35784327 PMCID: PMC9240193 DOI: 10.3389/fimmu.2022.923582] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Vasculitis is an autoimmune disease of unknown etiology that causes inflammation of the blood vessels. Large vessel vasculitis is classified as either giant cell arteritis (GCA), which occurs exclusively in the elderly, or Takayasu arteritis (TAK), which mainly affects young women. Various cell types are involved in the pathogenesis of large vessel vasculitis. Among these, dendritic cells located between the adventitia and the media initiate the inflammatory cascade as antigen-presenting cells, followed by activation of macrophages and T cells contributing to vessel wall destruction. In both diseases, naive CD4+ T cells are polarized to differentiate into Th1 or Th17 cells, whereas differentiation into regulatory T cells, which suppress vascular inflammation, is inhibited. Skewed T cell differentiation is the result of aberrant intracellular signaling, such as the mechanistic target of rapamycin (mTOR) or the Janus kinase signal transducer and activator of transcription (JAK-STAT) pathways. It has also become clear that tissue niches in the vasculature fuel activated T cells and maintain tissue-resident memory T cells. In this review, we outline the most recent understanding of the pathophysiology of large vessel vasculitis. Then, we provide a summary of skewed T cell differentiation in the vasculature and peripheral blood. Finally, new therapeutic strategies for correcting skewed T cell differentiation as well as aberrant intracellular signaling are discussed.
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26
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New Insights into the Pathogenesis of Giant Cell Arteritis: Mechanisms Involved in Maintaining Vascular Inflammation. J Clin Med 2022; 11:jcm11102905. [PMID: 35629030 PMCID: PMC9143803 DOI: 10.3390/jcm11102905] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 02/04/2023] Open
Abstract
The giant cell arteritis (GCA) pathophysiology is complex and multifactorial, involving a predisposing genetic background, the role of immune aging and the activation of vascular dendritic cells by an unknown trigger. Once activated, dendritic cells recruit CD4 T cells and induce their activation, proliferation and polarization into Th1 and Th17, which produce interferon-gamma (IFN-γ) and interleukin-17 (IL-17), respectively. IFN-γ triggers the production of chemokines by vascular smooth muscle cells, which leads to the recruitment of additional CD4 and CD8 T cells and also monocytes that differentiate into macrophages. Recent data have shown that IL-17, IFN-γ and GM-CSF induce the differentiation of macrophage subpopulations, which play a role in the destruction of the arterial wall, in neoangiogenesis or intimal hyperplasia. Under the influence of different mediators, mainly endothelin-1 and PDGF, vascular smooth muscle cells migrate to the intima, proliferate and change their phenotype to become myofibroblasts that further proliferate and produce extracellular matrix proteins, increasing the vascular stenosis. In addition, several defects in the immune regulatory mechanisms probably contribute to chronic vascular inflammation in GCA: a defect in the PD-1/PD-L1 pathway, a quantitative and qualitative Treg deficiency, the implication of resident cells, the role of GM-CSF and IL-6, the implication of the NOTCH pathway and the role of mucosal‑associated invariant T cells and tissue‑resident memory T cells.
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27
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Robert M, Miossec P, Hot A. The Th17 Pathway in Vascular Inflammation: Culprit or Consort? Front Immunol 2022; 13:888763. [PMID: 35479069 PMCID: PMC9035791 DOI: 10.3389/fimmu.2022.888763] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
The involvement of IL-17A in autoimmune and inflammatory diseases has prompted the development of therapeutic strategies to block the Th17 pathway. Promising results came from their use in psoriasis and in ankylosing spondylitis. IL-17A acts on various cell types and has both local and systemic effects. Considering the premature mortality observed during chronic inflammatory diseases, IL-17A action on vascular cells was studied. Both in vitro and in vivo results suggest that this cytokine favors inflammation, coagulation and thrombosis and promotes the occurrence of cardiovascular events. These observations led to study the role of IL-17A in diseases characterized by vascular inflammation, namely allograft rejection and vasculitis. Increased circulating levels of IL-17A and histological staining reveal that the Th17 pathway is involved in the pathogenesis of these diseases. Vasculitis treatment faces challenges while the use of steroids has many side effects. Regarding results obtained in giant cell arteritis with IL-6 inhibitors, a cytokine involved in Th17 differentiation, the use of anti-IL-17 is a promising strategy. However, lessons from rheumatoid arthritis and multiple sclerosis must be learnt before targeting IL-17 in vasculitis, which may be culprit, consort or both of them.
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Affiliation(s)
- Marie Robert
- Department of Clinical Immunology and Rheumatology, and Immunogenomics and Inflammation Research Unit, University of Lyon, Hôpital Edouard Herriot, Lyon, France
- Department of Internal Medicine, University of Lyon, Hôpital Edouard Herriot, Lyon, France
- *Correspondence: Marie Robert,
| | - Pierre Miossec
- Department of Clinical Immunology and Rheumatology, and Immunogenomics and Inflammation Research Unit, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Arnaud Hot
- Department of Internal Medicine, University of Lyon, Hôpital Edouard Herriot, Lyon, France
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28
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Advances in the Treatment of Giant Cell Arteritis. J Clin Med 2022; 11:jcm11061588. [PMID: 35329914 PMCID: PMC8954453 DOI: 10.3390/jcm11061588] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/25/2022] Open
Abstract
Giant cell arteritis (GCA) is the most common vasculitis among elderly people. The clinical spectrum of the disease is heterogeneous, with a classic/cranial phenotype, and another extracranial or large vessel phenotype as the two more characteristic patterns. Permanent visual loss is the main short-term complication. Glucocorticoids (GC) remain the cornerstone of treatment. However, the percentage of relapses with GC alone is high, and the rate of adverse events affects more than 80% of patients, so it is necessary to have alternative therapeutic options, especially in patients with worse prognostic factors or high comorbidity. MTX is the only DMARD that has shown to reduce the cumulative dose of GC, while tocilizumab is the first biologic agent approved due to its ability to decrease the relapse rate and lower the cumulative GC doses. However, apart from the IL-6 pathway, there are other pro-inflammatory cytokines and growth factors involved in the typical intima hyperplasia and vascular remodeling of GCA. Among them, the more promising targets in GCA treatment are the IL12/IL23 axis antagonists, IL17 inhibitors, modulators of T lymphocytes, and inhibitors of either the JAK/STAT pathway, the granulocyte-macrophage colony-stimulating factor, or the endothelin, all of which are updated in this review.
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29
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Sandovici M, van der Geest N, van Sleen Y, Brouwer E. Need and value of targeted immunosuppressive therapy in giant cell arteritis. RMD Open 2022; 8:rmdopen-2021-001652. [PMID: 35149602 PMCID: PMC8845325 DOI: 10.1136/rmdopen-2021-001652] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
Despite the heterogeneity of the giant cell arteritis (GCA) at the level of clinical manifestations and the cellular and molecular players involved in its pathogenesis, GCA is still treated with standardised regimens largely based on glucocorticoids (GC). Long-term use of high dosages of GC as required in GCA are associated with many clinically relevant side effects. In the recent years, the interleukin-6 receptor blocker tocilizumab has become available as the only registered targeted immunosuppressive agent in GCA. However, immunological heterogeneity may require different pathways to be targeted in order to achieve a clinical, immunological and vascular remission in GCA. The advances in the targeted blockade of various molecular pathways involved in other inflammatory and autoimmune diseases have catalyzed the research on targeted therapy in GCA. This article gives an overview of the studies with targeted immunosuppressive treatments in GCA, with a focus on their clinical value, including their effects at the level of vascular inflammation.
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Affiliation(s)
- Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - Niels van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
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