1
|
Harigai M, Miyamae T, Hashimoto H, Umetsu K, Yamashita K, Nakaoka Y. A multicentre, large-scale, observational study of tocilizumab in patients with giant cell arteritis in Japan. Mod Rheumatol 2024; 34:775-783. [PMID: 37522620 DOI: 10.1093/mr/road074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES In clinical trials, tocilizumab (TCZ) is efficacious in patients with giant cell arteritis (GCA). This study evaluated the real-world tolerability and effectiveness of TCZ in Japanese patients with GCA. METHODS In this multicentre, prospective, Phase 4, large-scale, observational study, patients with GCA (with no TCZ treatment 6 months before the study) were recruited from 71 centres across Japan. Patients received subcutaneous TCZ 162 mg weekly (observation period, 52 weeks). RESULTS Of the 117 patients [female, 70.1%; mean age, 74.2 years; mean disease duration, 1.4 years; treated for new-onset GCA, 71.8%; presence of large-vessel lesions (LVLs), 61.5%; previous immunosuppressant use, 28.2%; glucocorticoids at baseline, 95.7% (mean: 22.4 mg/day)], 38.5% reported adverse events. The most common adverse events of special interest were neutropaenia and leukopaenia (7.7%), followed by serious infection (6.0%). The relapse-free proportion was 85.0%; relapse after remission, 6.0%; and no remission, 9.0%. At the last observation, 94.2% of relapse-free patients received a concomitant glucocorticoid dose of <10 mg/day. Fatigue, headache, neck pain, and absence of LVLs were positively associated with the relapse. CONCLUSIONS TCZ was effective and well tolerated in Japanese patients with GCA and may be an effective treatment option combined with glucocorticoids.
Collapse
Affiliation(s)
- Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takako Miyamae
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Hideyuki Hashimoto
- Risk Communication Department, Drug Safety Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Kosei Umetsu
- Safety Science Department, Drug Safety Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Katsuhisa Yamashita
- Specialty Medical Science Department, Medical Affairs Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| |
Collapse
|
2
|
Nageswaran P, Ahmed S, Tahir H. Review of phase 2/3 trials in polymyalgia rheumatica and giant cell arteritis. Expert Opin Emerg Drugs 2024; 29:5-17. [PMID: 38180809 DOI: 10.1080/14728214.2024.2303093] [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: 10/20/2023] [Accepted: 01/04/2024] [Indexed: 01/07/2024]
Abstract
INTRODUCTION GCA (giant cell arteritis) and PMR (polymyalgia rheumatica) are two overlapping inflammatory rheumatic conditions that are seen exclusively in older adults, sharing some common features. GCA is a clinical syndrome characterized by inflammation of the medium and large arteries, with both cranial and extracranial symptoms. PMR is a clinical syndrome characterized by stiffness in the neck, shoulder, and pelvic girdle muscles. Both are associated with constitutional symptoms. AREAS COVERED In this review, we assess the established and upcoming treatments for GCA and PMR. We review the current treatment landscape, completed trials, and upcoming trials in these conditions, to identify new and promising therapies. EXPERT OPINION Early use of glucocorticoids (GC) remains integral to the immediate management of PMR and GCA but being aware of patient co-morbidities that may influence treatment toxicity is paramount. As such GC sparing agents are required in the treatment of PMR. Currently there are limited treatment options available for PMR and GCA, and significant unmet needs remain. Newer mechanisms of action, and hence therapeutic options being studied include CD4 T cell co-stimulation blockade, IL-17 inhibition, IL-12/23 inhibition, GM-CSF inhibition, IL-1β inhibition, TNF-α antagonist and Jak inhibition, among others, which will be discussed in this review.
Collapse
Affiliation(s)
| | - Saad Ahmed
- Department of Rheumatology, East Suffolk and North Essex Foundation Trust, Colchester, UK
| | - Hasan Tahir
- Department of Rheumatology, Royal Free London NHS Trust, London, UK
- Department of Medicine, University College London, London, UK
| |
Collapse
|
3
|
Hysa E, Bond M, Ehlers L, Camellino D, Falzon L, Dejaco C, Buttgereit F, Aletaha D, Kerschbaumer A. Evidence on treat to target strategies in polymyalgia rheumatica and giant cell arteritis: a systematic literature review. Rheumatology (Oxford) 2024; 63:285-297. [PMID: 37672017 PMCID: PMC10836985 DOI: 10.1093/rheumatology/kead471] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/10/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES To inform an international task force about current evidence on Treat to Target (T2T) strategies in PMR and GCA. METHODS A systematic literature research (SLR) was conducted in Medline, EMBASE, Cochrane Library, clinicaltrials.gov from their inception date to May 2022, and in the EULAR/ACR abstract database (2019-2021). Randomised clinical trials (RCTs) and non-randomised interventional studies published in English and answering at least one of the eleven PICO questions on T2T strategies, treatment targets and outcomes, framed by the taskforce, were identified. Study selection process, data extraction and risk of bias assessment were conducted independently by two investigators. RESULTS Of 7809 screened abstracts, 397 were selected for detailed review and 76 manuscripts were finally included (31 RCTs, eight subgroup/exploratory analyses of RCTs and 37 non-randomised interventional studies). No study comparing a T2T strategy against standard of care was identified. In PMR RCTs, the most frequently applied outcomes concerned treatment (90.9% of RCTs), particularly the cumulative glucocorticoids (GC) dose and GC tapering, followed by clinical, laboratory and safety outcomes (63.3% each). Conversely, the most commonly reported outcomes in RCTs in GCA were prevention of relapses (72.2%), remission as well as treatment-related and safety outcomes (67.0% each). CONCLUSIONS This SLR provides evidence and highlights the knowledge gaps on T2T strategies in PMR and GCA, informing the task force developing T2T recommendations for these diseases.
Collapse
Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, San Martino Polyclinic, University of Genoa, Genoa, Italy
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Bruneck, Italy
| | - Lisa Ehlers
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dario Camellino
- Division of Rheumatology, Local Health Trust 3, Genoa, Italy
| | - Louise Falzon
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Bruneck, Italy
- Department of Rheumatology, Medical University Graz, Graz, Austria
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
4
|
Farisogullari B, Santos EJF, Dures E, Geenen R, Machado PM. Efficacy of pharmacological interventions: a systematic review informing the 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases. RMD Open 2023; 9:e003349. [PMID: 38056919 DOI: 10.1136/rmdopen-2023-003349] [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: 05/30/2023] [Accepted: 07/14/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE To identify the best evidence on the efficacy of pharmacological interventions in reducing fatigue in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and to summarise their safety in the identified studies to inform European Alliance of Associations for Rheumatology recommendations for the management of fatigue in people with I-RMDs. METHODS Systematic review of adults with I-RMDs conducted according to the Cochrane Handbook. Search strategy ran in Medline, Embase, Cochrane Library, CINAHL Complete, PEDro, OTseeker and PsycINFO. Only randomised controlled trials (RCTs) or controlled clinical trials were eligible. Assessment of risk of bias, data extraction and synthesis performed by two reviewers independently and in duplicate. Data pooled in statistical meta-analyses. RESULTS From 4151 records, 455 were selected for full-text review, 99 fulfilled the inclusion criteria and 19 RCTs were included in meta-analyses. Adalimumab was superior to placebo in reducing fatigue at 12 and 52 weeks in rheumatoid arthritis (RA) (n=3 and 2 RCTs; mean difference (MD)= -3.03, p<0.001; MD=-2.25, p=0.03, respectively). Golimumab (n=2 RCTs; 24 weeks: MD=-5.27, p<0.001), baricitinib (n=2 RCTs; 24 weeks: MD=-4.06, p<0.001), sarilumab (n=2 RCTs; 24 weeks: MD=-3.15, p<0.001), tocilizumab (n=3 RCTs; 24 weeks: MD=-3.69, p<0.001) and tofacitinib (n=3 RCTs; 12 weeks: MD=-4.44, p<0.001) were also superior to placebo in reducing fatigue in RA. A dose/effect relationship was observed for sarilumab, tocilizumab and tofacitinib. In spondyloarthritis (excluding psoriatic arthritis), secukinumab was superior to placebo in reducing fatigue at 16 weeks (n=2 RCTs; MD=-4.15, p<0.001), with a dose/effect relationship also observed. The narrative results of the RCTs not included in the meta-analysis indicated that several other pharmacological interventions were efficacious in reducing fatigue, with reassuring safety results. CONCLUSIONS Several pharmacological interventions are efficacious and generally safe for managing fatigue in people with I-RMDs.
Collapse
Affiliation(s)
| | - Eduardo José Ferreira Santos
- School of Health, Polytechnic University, Viseu, Portugal
- Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Emma Dures
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Rinie Geenen
- Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Pedro M Machado
- Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, UK
- National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| |
Collapse
|
5
|
Unizony S, Matza MA, Jarvie A, O'Dea D, Fernandes AD, Stone JH. Treatment for giant cell arteritis with 8 weeks of prednisone in combination with tocilizumab: a single-arm, open-label, proof-of-concept study. THE LANCET. RHEUMATOLOGY 2023; 5:e736-e742. [PMID: 38251564 DOI: 10.1016/s2665-9913(23)00265-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Even after the approval of tocilizumab, substantial glucocorticoid exposure (usually ≥6 months) and toxicity continue to be important problems for patients with giant cell arteritis. We aimed to assess the outcomes of a group of patients with giant cell arteritis treated with tocilizumab in combination with 8 weeks of prednisone. METHODS This prospective, single arm, proof-of-concept study was conducted at Massachusetts General Hospital (Boston, MA, USA). Individuals aged 50 years or older who had new-onset or relapsing giant cell arteritis with active disease were eligible for inclusion. Participants received 12 months of tocilizumab 162 mg weekly subcutaneously in combination with 8 weeks of prednisone. The primary endpoint was sustained prednisone-free remission at week 52. Adverse events were also evaluated. This trial is registered with ClinicalTrials.gov (NCT03726749), and is complete. FINDINGS Between Nov 28, 2018, and Nov 2, 2020, we enrolled 30 patients (mean age 73·7 years [SD 8·1], 18 [60%] women and 12 [40%] men, 30 [100%] White race, 15 [50%] new-onset disease, 23 [77%] temporal artery biopsy-proven, 14 [47%] imaging-proven). The initial prednisone doses were 60 mg (n=7), 50 mg (n=1), 40 mg (n=7), 30 mg (n=6), and 20 mg (n=9). All patients entered remission within 4 weeks from baseline. 23 (77%) of 30 patients were in sustained prednisone-free remission at week 52 and seven (23%) patients relapsed, with a mean time to relapse of 15·8 weeks (SD 14·7). Overall, four (13%) participants developed a serious adverse event, including one related or probably related to prednisone exclusively, two related or probably related to tocilizumab exclusively, and one related or probably related to prednisone, tocilizumab, or both. Two of the non-responder patients stopped tocilizumab and withdrew from the study prematurely after having a second disease relapse. No cases of giant cell arteritis-related permanent vision loss occurred during the study. INTERPRETATION These results suggest that 12 months of tocilizumab in combination with 8 weeks of prednisone could induce and maintain remission in patients with giant cell arteritis. Confirmation of these findings in a randomised controlled trial is required. FUNDING Genentech.
Collapse
Affiliation(s)
- Sebastian Unizony
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mark A Matza
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam Jarvie
- Emory University School of Medicine, Atlanta, GA, USA
| | - David O'Dea
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ana D Fernandes
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
Coath FL, Bukhari M, Ducker G, Griffiths B, Hamdulay S, Hingorani M, Horsburgh C, Jones C, Lanyon P, Mackie S, Mollan S, Mooney J, Nair J, Patil A, Robson J, Saravanan V, O'Sullivan EP, Whitlock M, Mukhtyar CB. Quality standards for the care of people with giant cell arteritis in secondary care. Rheumatology (Oxford) 2023; 62:3075-3083. [PMID: 36692142 DOI: 10.1093/rheumatology/kead025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/28/2022] [Accepted: 01/06/2023] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE GCA is the commonest primary systemic vasculitis in adults, with significant health economic costs and societal burden. There is wide variation in access to secondary care GCA services, with 34% of hospitals in England not having any formal clinical pathway. Quality standards provide levers for change to improve services. METHODS The multidisciplinary steering committee were asked to anonymously put forward up to five aspects of service essential for best practice. Responses were qualitatively analysed to identify common themes, subsequently condensed into domain headings, and ranked in order of importance. Quality standards and metrics for each domain were drafted, requiring a minimum 75% agreement. RESULTS 13 themes were identified from the initial suggestions. Nine quality standards with auditable metrics were developed from the top 10 themes. Patient Access, glucocorticoid use, pathways, ultrasonography, temporal artery biopsy, PET scan access, rheumatology/ophthalmology expertise, education, multidisciplinary working have all been covered in these quality standards. Access to care is a strand that has run through each of the developed standards. An audit tool was developed as part of this exercise. CONCLUSION These are the first consensus auditable quality standards developed by clinicians from rheumatology and ophthalmology, nursing representatives and involvement of a patient charity. We hope that these standards will be adopted by commissioning bodies to provide levers for change from the improvement of patient care of individuals with GCA.
Collapse
Affiliation(s)
- Fiona L Coath
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich Hospital, Norfolk, UK
| | - Marwan Bukhari
- Rheumatology Department, University Hospitals of Morecambe Bay NHS Foundation Trust, Royal Lancaster Infirmary, Lancaster, UK
- Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, UK
| | - Georgina Ducker
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich Hospital, Norfolk, UK
| | - Bridget Griffiths
- Rheumatology Department, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Chair of the Specialised Rheumatology Clinical Reference Group, NHS England, London, UK
| | - Shahir Hamdulay
- Rheumatology Department, London Northwest University Healthcare NHS Trust, London, UK
| | | | | | - Colin Jones
- Department of Ophthalmology, Norfolk and Norwich Hospital, Norfolk, UK
| | - Peter Lanyon
- Rheumatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
- National Clinical Co-Lead for Rheumatology, NHS Improvement, London, UK
| | - Sarah Mackie
- Rheumatology Department, University of Leeds, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Susan Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Janice Mooney
- School of Health and Social Care, University of Staffordshire, Stafford, UK
| | - Jagdish Nair
- Department of Rheumatology, Liverpool University Hospitals, Liverpool, UK
| | - Ajay Patil
- Ophthalmology Department, University Hospitals Birmingham, Birmingham, UK
| | - Joanna Robson
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | | | - Madeline Whitlock
- Rheumatology Department, Southend Hospital, Mid and South Essex NHS Foundation Trust, Essex, UK
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich Hospital, Norfolk, UK
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Crawshaw H, Janagan S, Austin K, Baker C, Day J, Robson JC. Patient-reported outcomes in vasculitis. Best Pract Res Clin Rheumatol 2023; 37:101829. [PMID: 37277246 DOI: 10.1016/j.berh.2023.101829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 06/07/2023]
Abstract
Systemic vasculitis encompasses a group of multisystem disorders; both the diseases and the treatment strategies can have a significant impact on a patient's health-related quality of life (HRQoL). Using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) to evaluate the patient's view of their condition, treatments, and healthcare journey is essential to the patient-centered care approach. In this paper, we discuss the use of generic, disease-specific, and treatment-specific PROMs and PREMs in systemic vasculitis and future research goals.
Collapse
Affiliation(s)
- Helena Crawshaw
- Rheumatology Department Gloucestershire Royal Hospital NHS Trust, Great Western Road, Gloucester, Gloucestershire, GL1 3NN, UK.
| | - Shalini Janagan
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK.
| | - Keziah Austin
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK; Rheumatology Department, Royal National Hospital for Rheumatic Diseases, Combe Park, Bath, BA1 3NG, UK.
| | - Charlotte Baker
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK.
| | - Julia Day
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK.
| | - Joanna C Robson
- Centre for Health and Clinical Research, University of the West of England, Bristol, Room 5-054, Rheumatology Research B502, Bristol Royal Infirmary, Bristol, BS2 8HW, UK.
| |
Collapse
|
11
|
Scolnik M, Brance ML, Fernández-Ávila DG, Inoue Sato E, de Souza AWS, Magri SJ, Saldarriaga-Rivera LM, Ugarte-Gil MF, Flores-Suarez LF, Babini A, Zamora NV, Acosta Felquer ML, Vergara F, Carlevaris L, Scarafia S, Soriano Guppy ER, Unizony S. Pan American League of Associations for Rheumatology guidelines for the treatment of giant cell arteritis. THE LANCET. RHEUMATOLOGY 2022; 4:e864-e872. [PMID: 38261393 DOI: 10.1016/s2665-9913(22)00260-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/20/2022] [Accepted: 08/30/2022] [Indexed: 11/27/2022]
Abstract
Considerable variability exists in the way that health-care providers treat patients with giant cell arteritis in Latin America, with patients commonly exposed to excessive amounts of glucocorticoids. In addition, large health disparities prevail in this region due to socioeconomic factors, which influence access to care, including biological treatments. For these reasons, the Pan American League of Associations for Rheumatology developed the first evidence-based giant cell arteritis treatment guidelines tailored for Latin America. A panel of vasculitis experts from Mexico, Colombia, Peru, Brazil, and Argentina generated clinically meaningful questions related to the treatment of giant cell arteritis in the population, intervention, comparator, and outcome (PICO) format. Following the grading of recommendations, assessment, development, and evaluation methodology, a team of methodologists did a systematic literature search, extracted and summarised the effects of the interventions, and graded the quality of the evidence. The panel of vasculitis experts voted on each PICO question and made recommendations, which required at least 70% agreement among the voting members to be included in the guidelines. Nine recommendations and one expert opinion statement for the treatment of giant cell arteritis were developed considering the most up-to-date evidence and the socioeconomic characteristics of Latin America. These recommendations include guidance for the use of glucocorticoids, tocilizumab, methotrexate, and aspirin for patients with giant cell arteritis.
Collapse
Affiliation(s)
- Marina Scolnik
- Rheumatology Unit, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Maria L Brance
- School of Medicine, National Rosario University, Santa Fe, Argentina
| | | | - Emilia Inoue Sato
- Medicine Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Sebastián J Magri
- Rheumatology Unit, Hospital Italiano de La Plata, La Plata, Argentina
| | | | | | - Luis F Flores-Suarez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Alejandra Babini
- Rheumatology Unit, Hospital Italiano de Cordoba, Cordoba, Argentina
| | | | - María L Acosta Felquer
- Rheumatology Unit, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Santiago Scarafia
- Rheumatology Unit, Hospital Municipal San Cayetano, Virreyes, Argentina
| | - Enrique R Soriano Guppy
- Rheumatology Unit, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sebastian Unizony
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
12
|
Kastrati K, Aletaha D, Burmester GR, Chwala E, Dejaco C, Dougados M, McInnes IB, Ravelli A, Sattar N, Stamm TA, Takeuchi T, Trauner M, van der Heijde D, Voshaar MJH, Winthrop K, Smolen JS, Kerschbaumer A. A systematic literature review informing the consensus statement on efficacy and safety of pharmacological treatment with interleukin-6 pathway inhibition with biological DMARDs in immune-mediated inflammatory diseases. RMD Open 2022; 8:rmdopen-2022-002359. [PMID: 36260501 PMCID: PMC9462104 DOI: 10.1136/rmdopen-2022-002359] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/30/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively targeting interleukin-6 (IL-6) pathway in the context of immune-mediated inflammatory diseases. Methods A systematic literature research of all publications on IL-6 axis inhibition with bDMARDs published between January 2012 and December 2020 was performed using MEDLINE, EMBASE and Cochrane CENTRAL databases. Efficacy and safety outcomes were assessed in clinical trials including their long-term extensions and observational studies. Meeting abstracts from ACR, EULAR conferences and results on clinicaltrials.gov were taken into consideration. Results 187 articles fulfilled the inclusion criteria. Evidence for positive effect of IL-6 inhibition was available in various inflammatory diseases such as rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still’s disease, cytokine release syndrome due to chimeric antigen receptor T cell therapy and systemic sclerosis-associated interstitial lung disease. Newcomers like satralizumab and anti-IL-6 ligand antibody siltuximab have expanded therapeutic approaches for Castleman’s disease and neuromyelitis optica, respectively. IL-6 inhibition did not provide therapeutic benefits in psoriatic arthritis, ankylosing spondylitis and certain connective tissue diseases. In COVID-19, tocilizumab (TCZ) has proven to be therapeutic in advanced disease. Safety outcomes did not differ from other bDMARDs, except higher risks of diverticulitis and lower gastrointestinal perforations. Inconsistent results were observed in several studies investigating the risk for infections when comparing TCZ to TNF-inhibitors. Conclusion IL-6 inhibition is effective for treatment of several inflammatory diseases with a safety profile that is widely comparable to other bDMARDs.
Collapse
Affiliation(s)
- Kastriot Kastrati
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Gerd R Burmester
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Eva Chwala
- University Library, Medical University of Vienna, Wien, Austria
| | - Christian Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria
- Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Maxime Dougados
- Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
| | - Iain B McInnes
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Angelo Ravelli
- UO Pediatria II-Reumatologia, Istituto Giannina Gaslini, Genova, Italy
| | - Naveed Sattar
- Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, UK
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna Department of Medicine III, Wien, Austria
| | | | - Marieke J H Voshaar
- Department of Pharmacy and Department of Research & Innovation, Sint Maartenskliniek, Ubbergen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kevin Winthrop
- Schools of Medicine and Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| |
Collapse
|
13
|
van Eeden C, Osman MS, Cohen Tervaert JW. Fatigue in ANCA-associated vasculitis (AAV) and systemic sclerosis (SSc): similarities with Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). A critical review of the literature. Expert Rev Clin Immunol 2022; 18:1049-1070. [PMID: 36045606 DOI: 10.1080/1744666x.2022.2116002] [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 Persistent debilitating fatigue is a frequent complaint in patients with systemic autoimmune rheumatic diseases (SARDs). Fatigue is, however, frequently overlooked in the clinic, and patients who successfully achieve remission of their disease, often still have a lowered quality of life due to its persistence. How similar is this fatigue to Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), what is this fatigue associated with, and what tools/approaches (if any), have resulted in the improvement of fatigue in these patients is poorly defined. AREAS COVERED Similarities between the pathophysiology of ME/CFS, systemic sclerosis (SSc) and primary systemic vasculitides (PSV) are discussed, followed by an in-depth review of the prevalence and correlates of fatigue in these diseases. The authors reviewed literature from MEDLINE, APA PsycInfo, Embase, and CINAHL. EXPERT OPINION Persistent fatigue is a prominent feature in SARDs and may not be associated with components commonly associated with disease activity and/or progression. Immune and metabolic commonalities exist between ME/CFS, SSc, and PSVs - suggesting that common pathways inherent to the diseases and fatigue may be present. We suggest that patients with features of ME/CFS need to be identified by treating physicians, as they may require alternative approaches to therapy to improve their quality of life.
Collapse
Affiliation(s)
- Charmaine van Eeden
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammed S Osman
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School for Mental Health and Neurosciences (MHeNs), Maastricht University, Maastricht, Netherlands
| |
Collapse
|
14
|
Corbera-Bellalta M, Alba-Rovira R, Muralidharan S, Espígol-Frigolé G, Ríos-Garcés R, Marco-Hernández J, Denuc A, Kamberovic F, Pérez-Galán P, Joseph A, D'Andrea A, Bondensgaard K, Cid MC, Paolini JF. Blocking GM-CSF receptor α with mavrilimumab reduces infiltrating cells, pro-inflammatory markers and neoangiogenesis in ex vivo cultured arteries from patients with giant cell arteritis. Ann Rheum Dis 2022; 81:524-536. [PMID: 35045965 PMCID: PMC8921590 DOI: 10.1136/annrheumdis-2021-220873] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/08/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Effective and safe therapies are needed for the treatment of patients with giant cell arteritis (GCA). Emerging as a key cytokine in inflammation, granulocyte-macrophage colony stimulating factor (GM-CSF) may play a role in promoting inflammation in GCA. OBJECTIVES To investigate expression of GM-CSF and its receptor in arterial lesions from patients with GCA. To analyse activation of GM-CSF receptor-associated signalling pathways and expression of target genes. To evaluate the effects of blocking GM-CSF receptor α with mavrilimumab in ex vivo cultured arteries from patients with GCA. METHODS Quantitative real time PCR, in situ RNA hybridisation, immunohistochemistry, immunofluorescence and confocal microscopy, immunoassay, western blot and ex vivo temporal artery culture. RESULTS GM-CSF and GM-CSF receptor α mRNA and protein were increased in GCA lesions; enhanced JAK2/STAT5A expression/phosphorylation as well as increased expression of target genes CD83 and Spi1/PU.1 were observed. Treatment of ex vivo cultured GCA arteries with mavrilimumab resulted in decreased transcripts of CD3ε, CD20, CD14 and CD16 cell markers, and reduction of infiltrating CD16 and CD3ε cells was observed by immunofluorescence. Mavrilimumab reduced expression of molecules relevant to T cell activation (human leukocyte antigen-DR [HLA-DR]) and Th1 differentiation (interferon-γ), the pro-inflammatory cytokines: interleukin 6 (IL-6), tumour necrosis factor α (TNFα) and IL-1β, as well as molecules related to vascular injury (matrix metalloprotease 9, lipid peroxidation products and inducible nitric oxide synthase [iNOS]). Mavrilimumab reduced CD34 + cells and neoangiogenesis in GCA lesions. CONCLUSION The inhibitory effects of mavrilimumab on multiple steps in the GCA pathogenesis cascade in vitro are consistent with the clinical observation of reduced GCA flares in a phase 2 trial and support its development as a therapeutic option for patients with GCA.
Collapse
Affiliation(s)
- Marc Corbera-Bellalta
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Roser Alba-Rovira
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Georgina Espígol-Frigolé
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Roberto Ríos-Garcés
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Javier Marco-Hernández
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Farah Kamberovic
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | | | | | - Maria C Cid
- Vasculitis Research Group, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - John F Paolini
- Kiniksa Pharmaceuticals Corp, Lexington, Massachusetts, USA
| |
Collapse
|
15
|
Treatment of Giant Cell Arteritis (GCA). J Clin Med 2022; 11:jcm11071799. [PMID: 35407411 PMCID: PMC8999932 DOI: 10.3390/jcm11071799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 01/27/2023] Open
Abstract
Giant cell arteritis (GCA) is the most frequent primary large-vessel vasculitis in individuals older than 50. Glucocorticoids (GCs) are considered the cornerstone of treatment. GC therapy is usually tapered over months according to clinical symptoms and inflammatory marker levels. Considering the high rate of GC-related adverse events in these older individuals, immunosuppressive treatments and biologic agents have been proposed as add-on therapies. Methotrexate was considered an alternative option, but its clinical impact was limited. Other immunosuppressants failed to demonstrate a significant favourable benefit/risk ratio. The approval of tocilizumab, an anti-interleukin 6 (IL-6) receptor inhibitor brought significant improvement. Indeed, tocilizumab had a noticeable effect on cumulative GCs’ dose and relapse prevention. After the improvement in pathophysiological knowledge, other targeted therapies have been proposed, with anti-IL-12/23, anti-IL-17, anti-IL-1, anti-cytotoxic T-lymphocyte antigen 4, Janus kinase inhibitors or anti-granulocyte/macrophage colony stimulating factor therapies. These therapies are currently under evaluation. Interestingly, mavrilimumab, ustekinumab and, to a lesser extent, abatacept have shown promising results in phase 2 randomised controlled trials. Despite this recent progress, the value, specific condition and optimal application of each treatment remain undecided. In this review, we discuss the scientific rationale for each treatment and the therapeutic strategy.
Collapse
|
16
|
Putman M, Sattui S, Conway R. Where do we go after GiACTA? Rheumatology (Oxford) 2022; 61:2720-2721. [PMID: 35020808 DOI: 10.1093/rheumatology/keac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/20/2021] [Accepted: 01/04/2022] [Indexed: 11/14/2022] Open
|
17
|
Abstract
Large-vessel vasculitis (LVV) manifests as inflammation of the aorta and its major branches and is the most common primary vasculitis in adults. LVV comprises two distinct conditions, giant cell arteritis and Takayasu arteritis, although the phenotypic spectrum of primary LVV is complex. Non-specific symptoms often predominate and so patients with LVV present to a range of health-care providers and settings. Rapid diagnosis, specialist referral and early treatment are key to good patient outcomes. Unfortunately, disease relapse remains common and chronic vascular complications are a source of considerable morbidity. Although accurate monitoring of disease activity is challenging, progress in vascular imaging techniques and the measurement of laboratory biomarkers may facilitate better matching of treatment intensity with disease activity. Further, advances in our understanding of disease pathophysiology have paved the way for novel biologic treatments that target important mediators of disease in both giant cell arteritis and Takayasu arteritis. This work has highlighted the substantial heterogeneity present within LVV and the importance of an individualized therapeutic approach. Future work will focus on understanding the mechanisms of persisting vascular inflammation, which will inform the development of increasingly sophisticated imaging technologies. Together, these will enable better disease prognostication, limit treatment-associated adverse effects, and facilitate targeted development and use of novel therapies.
Collapse
|
18
|
Robson JC, Almeida C, Dawson J, Bromhead A, Dures E, Guly C, Hoon E, Mackie S, Ndosi M, Pauling J, Hill C. Patient perceptions of health-related quality of life in giant cell arteritis: international development of a disease-specific patient-reported outcome measure. Rheumatology (Oxford) 2021; 60:4671-4680. [PMID: 33528002 PMCID: PMC8487303 DOI: 10.1093/rheumatology/keab076] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/13/2021] [Indexed: 11/12/2022] Open
Abstract
Objectives GCA is a large vessel vasculitis (LVV) presenting with headache, jaw claudication, musculoskeletal and visual involvement. Current treatment is glucocorticoids and anti-IL-6 tocilizumab in refractory disease. The objective of this study was to explore the impact of GCA and its treatment on people’s health-related quality of life (HRQoL), to inform the development of a disease-specific patient-reported outcome measure (PROM) for use in clinical trials and practice. Methods Participants from the UK and Australia, with biopsy- or imaging-confirmed GCA, were interviewed to identify salient aspects of HRQoL in relation to GCA and its treatment. Purposive sampling included a range of demographic and disease features (cranial, LVV-GCA and visual involvement). Inductive analysis identified individual themes of importance, then domains. Candidate questionnaire items were developed from the individual themes, refined by piloting, cognitive interviews and a linguistic translatability assessment. Results Thirty-six interviews were conducted to saturation with participants with GCA from the UK (25) and Australia (11). Mean age was 74 years, 23 (63.9%) were female, 13 (36.1%) had visual loss and 5 (13.9%) had LVV-GCA. Thirty-nine individual themes within five domains were identified: physical symptoms; activity of daily living and function; participation; psychological impact; and impact on sense of self and perception of health. Sixty-nine candidate items were developed from individual themes; piloting and refinement resulted in a 40-item draft questionnaire. Conclusion This international qualitative study underpins the development of candidate items for a disease-specific PROM for GCA. The draft questionnaire is now ready for psychometric testing.
Collapse
Affiliation(s)
- Joanna C Robson
- Centre for Health and Clinical Research, University of the West of England.,Bristol Royal Infirmary, University Hospitals and Weston Bristol NHS Foundation Trust, Bristol
| | - Celia Almeida
- Centre for Health and Clinical Research, University of the West of England.,Bristol Royal Infirmary, University Hospitals and Weston Bristol NHS Foundation Trust, Bristol
| | - Jill Dawson
- Nuffield Department of Population Health (HSRU), University of Oxford, Oxford, UK
| | - Alison Bromhead
- Bristol Royal Infirmary, University Hospitals and Weston Bristol NHS Foundation Trust, Bristol
| | - Emma Dures
- Centre for Health and Clinical Research, University of the West of England.,Bristol Royal Infirmary, University Hospitals and Weston Bristol NHS Foundation Trust, Bristol
| | - Catherine Guly
- Bristol Royal Infirmary, University Hospitals and Weston Bristol NHS Foundation Trust, Bristol
| | - Elizabeth Hoon
- School of Public Health, University of Adelaide, Adelaide, SA, Australia
| | - Sarah Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR (National Institute for Health Research) Leeds Biomedical Research Centre, University of Leeds.,Leeds Teaching Hospitals NHS (National Health Service) Trust, Leeds
| | - Mwidimi Ndosi
- Centre for Health and Clinical Research, University of the West of England.,Bristol Royal Infirmary, University Hospitals and Weston Bristol NHS Foundation Trust, Bristol
| | - John Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases.,Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Catherine Hill
- School of Public Health, University of Adelaide, Adelaide, SA, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville.,Rheumatology Unit, The Royal Adelaide Hospital, Adelaide, SA, Australia
| |
Collapse
|
19
|
Abstract
BACKGROUND Giant cell arteritis (GCA) is the most common form of systemic vasculitis in people older than 50 years of age. It causes granulomatous inflammation of medium- to large-sized vessels. Tocilizumab is a recombinant monoclonal antibody directed against interleukin-6 receptors (IL-6R). OBJECTIVES To assess the effectiveness and safety of tocilizumab, given alone or with corticosteroids, compared with therapy without tocilizumab for treatment of GCA. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 1); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Science Information database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). There were no date or language restrictions in the electronic search for trials. We last searched the electronic databases on 3 January 2020. SELECTION CRITERIA We included only randomized controlled trials (RCTs) that compared tocilizumab of any dosage regimen (alone or with corticosteroids) with therapy without tocilizumab that had a minimum follow-up of six months. Participants were at least 50 years of age, with biopsy-proven GCA or by large-vessel vasculitis by angiography, and met the American College of Rheumatology 1990 guidelines for GCA. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. MAIN RESULTS Main results We included two RCTs in the review. The studies were conducted in the USA, Canada, and Europe and enrolled a total of 281 participants with GCA, of whom 74% were women. The mean age of participants was 70 years, with new-onset or relapsing GCA, and fulfilled the 1990 American College of Rheumatology criteria with no uncontrolled comorbidities. Both studies were funded by F. Hoffmann-La Roche AG, the manufacturer of tocilizumab. Findings One RCT (30 participants) compared tocilizumab administered every four weeks versus placebo. Point estimates at 12 months and beyond favored tocilizumab over placebo in terms of sustained remission (risk ratio (RR) 4.25, 95% confidence interval (CI) 1.21 to 14.88; moderate-certainty evidence). Point estimates suggest no evidence of a difference for all-cause mortality at 12 months or more (RR 0.17, 95% CI 0.01 to 3.94; moderate-certainty evidence). At 12 months, mean time to first relapse after induction of remission was 25 weeks in favor of participants receiving tocilizumab compared to placebo (mean difference (MD) 25, 95% CI 11.4 to 38.6; moderate-certainty evidence). The second RCT (251 participants) randomized participants into two intervention and two comparator groups to receive tocilizumab weekly (100 participants), bi-weekly (49 participants), weekly placebo + 26-week taper (50 participants), or weekly placebo + 52-week taper (51 participants). At 12 months, point estimates from this study on proportion of participants with sustained remission favored participants who received tocilizumab weekly versus placebo + 52-week taper (RR 3.17, 95% CI 1.71 to 5.89; 151 participants); tocilizumab weekly versus placebo + 26-week taper (RR 4.00, 95% CI 1.97 to 8.12; 150 participants); tocilizumab every other week versus placebo + 52-week taper (RR 3.01, 95% CI 1.57 to 5.75; 100 participants); tocilizumab every other week versus placebo + 26-week taper (RR 3.79, 95% CI 1.82 to 7.91; 99 participants) (moderate-certainty evidence). Point estimates on proportion of participants who did not need escape therapy (defined by the study as the inability to keep to the protocol-defined prednisone taper) favored participants who received tocilizumab weekly versus placebo + 52-week taper (RR 1.71, 95% CI 1.24 to 2.35; 151 participants); tocilizumab weekly versus placebo + 26-week taper (RR 2.96, 95% CI 1.83 to 4.78; 150 participants); tocilizumab every other week versus placebo + 52-week taper (RR 1.49, 95% CI 1.04 to 2.14; 100 participants); tocilizumab every other week versus placebo + 26-week taper (RR 0.65, 95% CI 0.27 to 1.54; 99 participants) (moderate-certainty evidence). This study did not report mean time to first relapse after induction of remission or all-cause mortality. The same study found no evidence of a difference between groups with regard to vision changes and quality of life, except for the assessment of quality of life with the physical component score of the 36-Item Short Form Health Survey (SF-36), which favored weekly tocilizumab versus placebo + 52-week taper (MD 8.17, 95% CI 4.44 to 11.90; moderate-certainty evidence). Adverse events One RCT reported a lower percentage of participants who experienced serious adverse events when receiving tocilizumab every four weeks versus placebo. The second RCT reported no evidence of a difference among groups with regard to adverse events; however, fewer participants reported serious adverse events in the tocilizumab weekly and tocilizumab biweekly interventions compared with the placebo + 26-week taper and placebo + 52-week taper comparators. Investigators in both studies reported that infection was the most frequently reported adverse event. AUTHORS' CONCLUSIONS This review indicates that tocilizumab therapy may be beneficial in terms of proportion of participants with sustained remission, relapse-free survival, and the need for escape therapy. While the evidence was of moderate certainty, only two studies were included in the review, suggesting that further research is required to corroborate these findings. Future trials should address issues related to the required duration of therapy, patient-reported outcomes such as quality of life and economic outcomes, as well as the clinical outcomes evaluated in this review.
Collapse
Affiliation(s)
- Aileen A Antonio
- Hauenstein Neurosciences, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | - Ronel N Santos
- Hauenstein Neurosciences, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | - Samuel A Abariga
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| |
Collapse
|
20
|
Should Tocilizumab Be Used Routinely in New Patients With a Diagnosis of Giant Cell Arteritis? J Neuroophthalmol 2021; 40:117-121. [PMID: 31834197 DOI: 10.1097/wno.0000000000000869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Abstract
Purpose of Review The goal of this paper is to review current and future uses of patient-reported outcomes in large vessel vasculitis. The large vessel vasculitides comprise Giant Cell Arteritis and Takayasu arteritis; both are types of systemic vasculitis which affect the larger blood vessels. Patient-reported outcomes (PROs) capture the impact of these diseases on health-related quality of life. Recent Findings Generic PROs such as the SF-36 are currently used to compare HRQOL of people with GCA and TAK within clinical trials and observational studies and to make comparisons with the general population and HRQoL in other diseases. The development of a disease-specific PRO for GCA is currently underway. Beyond clinical trials, there is much interest in the use of PROs within routine clinical care, particularly E-PROs for remote use. Summary Further work will be needed to complete the development of disease-specific PROs for people with large vessel vasculitis and to establish feasibility, acceptability, and utility of E-PROs.
Collapse
Affiliation(s)
- Joanna Robson
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK. .,Rheumatology Department, University Hospitals Bristol and Weston NHF Foundation Trust, Bristol, UK.
| | - Sarah Mackie
- Vascular Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Rheumatology Department, Leeds Teaching Hospital NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Catherine Hill
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Division of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
24
|
Nakaoka Y, Isobe M, Tanaka Y, Ishii T, Ooka S, Niiro H, Tamura N, Banno S, Yoshifuji H, Sakata Y, Kawakami A, Atsumi T, Furuta S, Kohsaka H, Suzuki K, Hara R, Maejima Y, Tsukamoto H, Takasaki Y, Yamashita K, Okada N, Yamakido S, Takei S, Yokota S, Nishimoto N. Long-term efficacy and safety of tocilizumab in refractory Takayasu arteritis: final results of the randomized controlled phase 3 TAKT study. Rheumatology (Oxford) 2021; 59:2427-2434. [PMID: 31951279 PMCID: PMC7449811 DOI: 10.1093/rheumatology/kez630] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/25/2019] [Indexed: 11/27/2022] Open
Abstract
Objective To investigate the long-term efficacy and safety of the IL-6 receptor antibody tocilizumab in patients with Takayasu arteritis (TAK). Methods Patients completing the randomized, double-blind, placebo-controlled period of the TAKT (Takayasu arteritis Treated with Tocilizumab) trial were followed up during open-label extended treatment with weekly s.c. tocilizumab 162 mg for up to 96 weeks or longer, with oral glucocorticoid tapering performed at the investigators’ discretion. Endpoints of the extension analysis included steroid-sparing effects of tocilizumab, imaging data, patient-reported outcomes (36-Item Short Form Health Survey) and safety. Results All 36 patients enrolled in the double-blind period entered the open-label extension; 28 patients received tocilizumab for 96 weeks. The median glucocorticoid dose was 0.223 mg/kg/day at the time of relapse before study entry, 0.131 mg/kg/day (interquartile range 0.099, 0.207) after 48 weeks and 0.105 mg/kg/day (interquartile range 0.039, 0.153) after 96 weeks. Overall, 46.4% of patients reduced their dose to <0.1 mg/kg/day, which was less than half the dose administered at relapse before study entry (mean difference –0.120 mg/kg/day; 95% CI −0.154, −0.087). Imaging evaluations indicated that most patients’ disease was improved (17.9%) or stable (67.9%) after 96 weeks compared with baseline. Mean 36-Item Short Form Health Survey physical and mental component summary scores and 7 of 8 domain scores were clinically improved from baseline and maintained over 96 weeks of tocilizumab treatment. No unexpected safety issues were reported. Conclusion These results in patients with Takayasu arteritis provide evidence of a steroid-sparing effect and improvements in well-being during long-term treatment with once-weekly tocilizumab 162 mg, with no new safety concerns. Trial registration JAPIC Clinical Trials Information, http://www.clinicaltrials.jp/user/cteSearch_e.jsp, JapicCTI-142616.
Collapse
Affiliation(s)
- Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita Japan.,Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka Japan
| | | | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu Japan
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai Japan
| | - Seido Ooka
- Division of Rheumatology and Allergology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki Japan
| | - Hiroaki Niiro
- Department of Medical Education, Faculty of Medical Sciences, Kyushu University, Fukuoka Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo Japan
| | - Shogo Banno
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto Kyoto, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki Japan
| | - Tatsuya Atsumi
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo Japan
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo Japan
| | - Ryoki Hara
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo Japan
| | | | - Yoshinari Takasaki
- Juntendo University Koshigaya Hospital, Juntendo University Faculty of Medicine, Saitama Japan
| | | | | | | | - Syuji Takei
- Pediatrics and Developmental Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima Japan
| | - Shumpei Yokota
- Pediatric Rheumatology, Fuji Toranomon Orthopedics Hospital, Shizuoka, Japan
| | - Norihiro Nishimoto
- Department of Molecular Regulation for Intractable Diseases, Institute of Medical Science, Tokyo Medical University, Tokyo, Japan
| |
Collapse
|
25
|
Simon S, Ninan J, Hissaria P. Diagnosis and management of giant cell arteritis: Major review. Clin Exp Ophthalmol 2021; 49:169-185. [PMID: 33426764 DOI: 10.1111/ceo.13897] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/06/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
Giant cell arteritis is a medical emergency because of the high risk of irreversible blindness and cerebrovascular accidents. While elevated inflammatory markers, temporal artery biopsy and modern imaging modalities are useful diagnostic aids, thorough history taking and clinical acumen still remain key elements in establishing a timely diagnosis. Glucocorticoids are the cornerstone of treatment but are associated with high relapse rates and side effects. Targeted biologic agents may open up new treatment approaches in the future.
Collapse
Affiliation(s)
- Sumu Simon
- Department of Ophthalmology and South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jem Ninan
- Department of Rheumatology, Modbury Public Hospital, Modbury, South Australia, Australia
| | - Pravin Hissaria
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
26
|
Smith TJ, Bartalena L. Will biological agents supplant systemic glucocorticoids as the first-line treatment for thyroid-associated ophthalmopathy? Eur J Endocrinol 2019; 181:D27-D43. [PMID: 31370005 PMCID: PMC7398270 DOI: 10.1530/eje-19-0389] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
Abstract
In this article, the two authors present their opposing points of view concerning the likelihood that glucocorticoids will be replaced by newly developed biological agents in the treatment of active, moderate-to-severe thyroid-associated ophthalmopathy (TAO). TAO is a vexing, disfiguring and potentially blinding autoimmune manifestation of thyroid autoimmunity. One author expresses the opinion that steroids are nonspecific, frequently fail to improve the disease and can cause sometimes serious side effects. He suggests that glucocorticoids should be replaced as soon as possible by more specific and safer drugs, once they become available. The most promising of these are biological agents. The other author argues that glucocorticoids are proven effective and are unlikely to be replaced by biologicals. He reasons that while they may not uniformly result in optimal benefit, they have been proven effective in many reports. He remains open minded about alternative therapies such as biologicals but remains skeptical that they will replace steroids as the first-line therapy for active, moderate-to-severe TAO without head-to-head comparative clinical trials demonstrating superiority. Despite these very different points of view, both authors are optimistic about the availability of improved medical therapies for TAO, either as single agents or in combination. Further, both agree that better treatment options are needed to improve the care of our patients with active moderate-to-severe TAO.
Collapse
Affiliation(s)
- Terry J. Smith
- Department of Ophthalmology and Visual Sciences, Division of metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA
| | - Luigi Bartalena
- Department of Medicine & Surgery,University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100 Varese, Italy
| |
Collapse
|
27
|
|