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Peron Filho F, Moreira ADS, Janes ALF, de Souza AWS. Effectiveness and safety of adalimumab compared with leflunomide in patients with Takayasu arteritis: a retrospective cohort study. RMD Open 2024; 10:e003992. [PMID: 38443091 PMCID: PMC11146362 DOI: 10.1136/rmdopen-2023-003992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE This study aims to evaluate the effectiveness and safety of adalimumab (ADA) compared with leflunomide (LEF) in patients with Takayasu arteritis (TAK). METHOD A retrospective cohort study was performed with the following inclusion criteria: the fulfilment of the 2022 American College Classification/European Alliance of Associations for Rheumatology criteria for TAK, age ≥18 years, and written informed consent. Forty-four patients were treated with LEF (n=28) or ADA (n=16) therapy due to relapsing/refractory disease or toxicity from previous therapy. Patients were evaluated at baseline (T0), at a median of 7.0 months (T1) and at 15.0 months of follow-up (T2). Data regarding disease activity, daily dose of prednisone, side effects and angiographic progression were analysed. RESULTS LEF and ADA groups had similar features on the baseline visit. However, intravenous methylprednisolone was more frequently prescribed for the ADA group (p=0.019). On T1 and T2 visits, complete response rates were similar for ADA and LEF groups (75.0% and 88.5%; p=0.397 and 62.5% vs 78.3%; p=0.307), respectively. The differences remained non-significant after adjusting for baseline variables by propensity score matching. Although the ADA group had a higher median daily prednisone on visit T1 (p=0.004), it was similar on visit T2 (p=0.595). Similar rates of angiographic progression were observed in ADA and LEF groups (40% vs 25%; p=0.467). Mild-to-moderate adverse events were observed only in the LEF group (17.9%). CONCLUSION LEF and ADA had comparable outcomes after a median of 15.0 months of follow-up. However, withdrawal from therapy and mild-to-moderate adverse events were only observed in the LEF group.
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Affiliation(s)
- Faustino Peron Filho
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Andressa de Souza Moreira
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Anna Larissa Faria Janes
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Alexandre W S de Souza
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
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Narváez J, Estrada P, LLop D, Vidal-Montal P, Brugarolas E, Maymó-Paituvi P, Palacios-Olid J, Nolla JM. Efficacy and safety of leflunomide in the management of large vessel vasculitis: A systematic review and metaanalysis of cohort studies. Semin Arthritis Rheum 2023; 59:152166. [PMID: 36645992 DOI: 10.1016/j.semarthrit.2023.152166] [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: 10/16/2022] [Revised: 12/06/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The search for new glucocorticoid-sparing disease-modifying anti-rheumatic drugs continues to be an unmet need in large vessel vasculitis (LVV). This report aims to assess the effectiveness and safety of leflunomide (LEF) in Takayasu arteritis (TA) and giant cell arteritis (GCA). METHODS We systematically reviewed the literature, searching for studies evaluating the efficacy of LEF in LVV. A meta-analysis was conducted using the random-effects method. RESULTS The literature search identified eight studies that assessed LEF in TAK and seven in GCA. All were uncontrolled observational studies with a high risk of bias, implying a low or very-low certainty of evidence. In TAK, the pooled proportion of patients achieving at least a partial remission was 75% (95% CI: 0.64-0.84), angiographic stabilization was observed in 86% (0.77-0.94) and relapses in 12% (0.05-0.21). The mean reduction in the prednisolone dose (MRPD) after LEF treatment was 15.7 mg/d (10.28-21.16). Adverse events were observed in 8% of patients (0.02-0.16). Comparison of LEF with methotrexate (MTX) or cyclophosphamide revealed LEF to be superior in terms of remission induction, relapse prevention, and tolerance. When compared with tofacitinib, both drugs demonstrated comparable efficacy. In GCA, the pooled proportion of patients achieving at least a partial remission was 60% (0.17-0.95). The MRPD after LEF treatment was 15.63 mg/d (1.29-32.55) and 53% of the patients were able to discontinue glucocorticoids (0.25 - 0.80). Relapses were observed in 21% of cases (0.14- 0.28) and adverse events in 28% (0.12-0.46). Comparison of LEF with MTX showed similar efficacy and tolerance. CONCLUSION LEF is well tolerated and might be effective for patients with TAK and GCA.
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Affiliation(s)
- Javier Narváez
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain.
| | - Paula Estrada
- Servicio de Reumatología. Hospital de Sant Joan Despí - Moisés Broggi. Barcelona, Spain
| | - Dídac LLop
- Unitat de Recerca de Lípids i Arteriosclerosi. Universitat Rovira i Virgili, Reus. Institut d'Investigació Sanitària Pere Virgili. Tarragona, Spain
| | - Paola Vidal-Montal
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Emma Brugarolas
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Pol Maymó-Paituvi
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Judith Palacios-Olid
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Joan Miquel Nolla
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
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Konen FF, Möhn N, Witte T, Schefzyk M, Wiestler M, Lovric S, Hufendiek K, Schwenkenbecher P, Sühs KW, Friese MA, Klotz L, Pul R, Pawlitzki M, Hagin D, Kleinschnitz C, Meuth SG, Skripuletz T. Treatment of autoimmunity: The impact of disease-modifying therapies in multiple sclerosis and comorbid autoimmune disorders. Autoimmun Rev 2023; 22:103312. [PMID: 36924922 DOI: 10.1016/j.autrev.2023.103312] [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: 02/15/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
More than 10 disease-modifying therapies (DMT) are approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) for the treatment of multiple sclerosis (MS) and new therapeutic options are on the horizon. Due to different underlying therapeutic mechanisms, a more individualized selection of DMTs in MS is possible, taking into account the patient's current situation. Therefore, concomitant treatment of various comorbid conditions, including autoimmune mediated disorders such as rheumatoid arthritis, should be considered in MS patients. Because the pathomechanisms of autoimmunity partially overlap, DMT could also treat concomitant inflammatory diseases and simplify the patient's treatment. In contrast, the exacerbation and even new occurrence of several autoimmune diseases have been reported as a result of immunomodulatory treatment of MS. To simplify treatment and avoid disease exacerbation, knowledge of the beneficial and adverse effects of DMT in other autoimmune disorders is critical. Therefore, we conducted a literature search and described the beneficial and adverse effects of approved and currently studied DMT in a large number of comorbid autoimmune diseases, including rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel diseases, cutaneous disorders including psoriasis, Sjögren´s syndrome, systemic lupus erythematosus, systemic vasculitis, autoimmune hepatitis, and ocular autoimmune disorders. Our review aims to facilitate the selection of an appropriate DMT in patients with MS and comorbid autoimmune diseases.
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Affiliation(s)
- Franz Felix Konen
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany..
| | - Nora Möhn
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany..
| | - Torsten Witte
- Department of Rheumatology and Clinical Immunology, Hannover Medical School, 30625 Hannover, Germany..
| | - Matthias Schefzyk
- Department of Dermatology, Allergology and Venerology, Hannover Medical School, 30625 Hannover, Germany..
| | - Miriam Wiestler
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany.
| | - Svjetlana Lovric
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany.
| | - Karsten Hufendiek
- University Eye Hospital, Hannover Medical School, 30625 Hannover, Germany.
| | | | - Kurt-Wolfram Sühs
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany..
| | - Manuel A Friese
- Institute of Neuroimmunology and Multiple Sclerosis, Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg 20251, Germany.
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany.
| | - Refik Pul
- Department of Neurology, University Medicine Essen, Essen, Germany; Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen 45147, Germany.
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty, Heinrich Heine University Dusseldorf, 40225 Dusseldorf, Germany.
| | - David Hagin
- Allergy and Clinical Immunology Unit, Department of Medicine, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St., Tel-Aviv 6423906, Israel.
| | - Christoph Kleinschnitz
- Department of Neurology, University Medicine Essen, Essen, Germany; Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen 45147, Germany.
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Dusseldorf, 40225 Dusseldorf, Germany.
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany..
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Sun Y, Wu B, Zhang W, Ma L, Kong X, Chen H, Jiang L. Comparison of the efficacy and safety of leflunomide versus placebo combined with basic prednisone therapy in patients with active disease phase of Takayasu arteritis: study protocol for a randomized, double-blinded controlled trial (Takayasu arteritis clinical trial in China: TACTIC). Ther Adv Chronic Dis 2023; 14:20406223231158567. [PMID: 36895331 PMCID: PMC9989417 DOI: 10.1177/20406223231158567] [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: 07/03/2022] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
Background Takayasu arteritis (TAK) is an immune-induced granulomatous vasculitis that occurs primarily in young Asian women. Our previous cohort studies have indicated that leflunomide (LEF), which can lead to rapid induction and might be a promising alternative treatment for TAK. Objectives To compare the efficacy and safety of LEF versus placebo combined with prednisone for active TAK in a Chinese population. Design This will be a multicenter, randomized, double-blinded controlled trial aiming to recruit 116 TAK patients with active disease. This study will last 52 weeks. Methods and analysis Participants will be assigned randomly to the LEF intervention arm or placebo control arm at a 1:1 ratio. Initially, LEF combined with prednisone will be given to the intervention arm and a placebo tablet combined with prednisone will be given to the placebo arm. At the end of week 24, subjects who achieved clinical remission or partial clinical remission will proceed to maintenance therapy with LEF to the end of week 52; those who did not achieve clinical remission or partial clinical remission in the LEF intervention arm will drop out from the study, and those in the placebo control arm will switch to LEF treatment to week 52. The primary endpoint will be the clinical remission rate of LEF versus placebo at the end of week 24. The secondary endpoints will be the time to clinical remission, mean dose of prednisone, disease recurrence, time to recurrence, adverse events, as well as clinical remission in subjects who switched from the placebo control arm to LEF therapy after week 24. Intention to treat will be the primary analysis. Discussion This is the first randomized double-blinded placebo-controlled trial to clarify the efficacy and safety of LEF in treating active TAK. The results will provide more evidence for TAK management. Registration ClinicalTrials.gov identifier: NCT02981979.
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Affiliation(s)
- Ying Sun
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Bingjie Wu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Wei Zhang
- Biomedical Information & Statistics Center, School of Public Health, Fudan University, Shanghai, P.R. China
| | - Lili Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Xiufang Kong
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Huiyong Chen
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, P.R. China
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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As C, Danda D. Current Diagnosis and Management of Takayasu Arteritis. Int Heart J 2023; 64:519-534. [PMID: 37518335 DOI: 10.1536/ihj.23-195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Takayasu arteritis (TA or TAK) is a chronic large vessel vasculitis with predilection to affect the aorta and its branches. The new 2022 ACR/EULAR classification criteria for Takayasu arteritis incorporated imaging characteristics as an absolute requirement. ESR and CRP fails in accuracy as disease activity markers. Pentraxin 3 appears to be a relatively superior biomarker, which correlates with ITAS 2010 as per several studies. PET-CT is also increasingly being studied for assessing disease activity with variable results. The management of TAK involves use of steroids with upfront steroid sparing immunosuppressive agents. MMF is one such conventional DMARD/immunosuppressant with good efficacy and better safety profile, as reported in various cohort studies. Tocilizumab is proved to be a rapid remission inducing agent in refractory Takayasu arteritis in observational studies. TNF inhibitors in many uncontrolled studies showed good responses, and there is a need for good RCTs for confirmation. JAK inhibitors have also been used with success in a few reports.
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Affiliation(s)
- Chandhu As
- Department of Clinical Immunology & Rheumatology, Christian Medical College & Hospital
| | - Debashish Danda
- Department of Clinical Immunology & Rheumatology, Christian Medical College & Hospital
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Szekeres D, Al Othman B. Current developments in the diagnosis and treatment of giant cell arteritis. Front Med (Lausanne) 2022; 9:1066503. [PMID: 36582285 PMCID: PMC9792614 DOI: 10.3389/fmed.2022.1066503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Giant cell arteritis is the most common vasculitis in adults above 50 years old. The disease is characterized by granulomatous inflammation of medium and large arteries, particularly the temporal artery, and is associated acutely with headache, claudication, and visual disturbances. Diagnosis of the disease is often complicated by its protean presentation and lack of consistently reliable testing. The utility of color doppler ultrasound at the point-of-care and FDG-PET in longitudinal evaluation remain under continued investigation. Novel techniques for risk assessment with Halo scoring and stratification through axillary vessel ultrasound are becoming commonplace. Moreover, the recent introduction of the biologic tocilizumab marks a paradigm shift toward using glucocorticoid-sparing strategies as the primary treatment modality. Notwithstanding these developments, patients continue to have substantial rates of relapse and biologic agents have their own side effect profile. Trials are underway to answer questions about optimal diagnostic modality, regiment choice, and duration.
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Affiliation(s)
- Denes Szekeres
- School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, United States
| | - Bayan Al Othman
- Department of Ophthalmology, University of Rochester Medical Center, Rochester, NY, United States,*Correspondence: Bayan Al Othman,
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Misra DP, Tomelleri A, Rathore U, Benanti G, Singh K, Behera MR, Jain N, Ora M, Bhadauria DS, Gambhir S, Kumar S, Baldissera E, Agarwal V, Campochiaro C, Dagna L. Impact of Geographic Location on Diagnosis and Initial Management of Takayasu Arteritis: A Tale of Two Cohorts from Italy and India. Diagnostics (Basel) 2022; 12:diagnostics12123102. [PMID: 36553110 PMCID: PMC9777621 DOI: 10.3390/diagnostics12123102] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/08/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
The present study compares disease characteristics, imaging modalities used, and patterns of treatment in two large cohorts of Takayasu arteritis (TAK) from Italy and India. Clinic files were retrospectively reviewed to retrieve information about initial choices of vascular imaging and immunosuppressive therapies. Unpaired t-tests compared means, and proportions were compared using Fisher’s exact test or Chi square test [Odds ratios (OR) with 95% confidence intervals (95%CI) calculated where appropriate]. The cohorts comprised 318 patients [Italy (n = 127), India (n = 191)] with similar delays to diagnosis. Ultrasound (OR Italy vs. India 9.25, 95%CI 5.02−17.07) was more frequently used in Italy and CT angiography in India (OR 0.32, 95%CI 0.20−0.51). Corticosteroid use was more prevalent and for longer duration in Italy. TAK from Italy had been more often treated with methotrexate, leflunomide or azathioprine, as opposed to tacrolimus in TAK from India (p < 0.05). Biologic or targeted synthetic disease-modifying agents were almost exclusively used in Italy. Survival on first immunosuppressive agent was longer from Italy than from India (log rank test p value 0.041). Considerable differences in the choice of initial vascular imaging modality and therapies for TAK from Italy and India could relate to prevalent socio-economic disparities. These should be considered while developing treatment recommendations for TAK.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
- Correspondence: (D.P.M.); (C.C.)
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Upendra Rathore
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Giovanni Benanti
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Kritika Singh
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Manas Ranjan Behera
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Neeraj Jain
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Manish Ora
- Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Dharmendra Singh Bhadauria
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Sanjay Gambhir
- Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Sudeep Kumar
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Elena Baldissera
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
- Correspondence: (D.P.M.); (C.C.)
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
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Danda D, Manikuppam P, Tian X, Harigai M. Advances in Takayasu arteritis: An Asia Pacific perspective. Front Med (Lausanne) 2022; 9:952972. [PMID: 36045929 PMCID: PMC9423100 DOI: 10.3389/fmed.2022.952972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
Abstract
Takayasu Arteritis (TA) is a rare form of chronic granulomatous large vessel vasculitis that is more common in Asia compared to other parts of the world. There have been several developments in the field of Takayasu arteritis in relation to genetics, classification, clinical features, imaging, disease activity assessment and management and much of these works have been done in the Asia Pacific region. We will be discussing selected few in the current review.
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Affiliation(s)
- Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore, India
| | - Prathyusha Manikuppam
- Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore, India
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Masayoshi Harigai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the recent advances in Takayasu arteritis (TAK), mainly focusing on pathogenesis, imaging modalities, and management. RECENT FINDINGS Three novel clusters based on angiographic findings were identified in the Indian cohort and replicated in the North American cohorts. Different new imaging modalities have been tried in the assessment of arterial inflammation with promising results. There is more evidence on the long-term use of tocilizumab, but relapses are common. In light of the recent findings on the pathogenesis of TAK, Janus kinase inhibitors seem to be promising. SUMMARY Improvement in imaging modalities and in our understanding of the disease pathogenesis will allow us to better assess the disease activity and identify effective therapeutic agents.
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Affiliation(s)
| | - Gulen Hatemi
- Department of Medicine, Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Misra DP, Rathore U, Patro P, Agarwal V, Sharma A. Disease-modifying anti-rheumatic drugs for the management of Takayasu arteritis-a systematic review and meta-analysis. Clin Rheumatol 2021; 40:4391-4416. [PMID: 33932173 PMCID: PMC8087890 DOI: 10.1007/s10067-021-05743-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 01/17/2023]
Abstract
The pharmacotherapy of Takayasu arteritis (TAK) with disease-modifying anti-rheumatic drugs (DMARDs) is an evolving area. A systematic review of Scopus, Web of Science, Pubmed Central, clinical trial databases and recent international rheumatology conferences for interventional and observational studies reporting the effectiveness of DMARDs in TAK identified four randomized controlled trials (RCTs, with another longer-term follow-up of one RCT) and 63 observational studies. The identified trials had some concern or high risk of bias. Most observational studies were downgraded on the Newcastle-Ottawa scale due to lack of appropriate comparator groups. Studies used heterogenous outcomes of clinical responses, angiographic stabilization, normalization of inflammatory markers, reduction in vascular uptake on positron emission tomography, reduction in prednisolone doses and relapses. Tocilizumab showed benefit in a RCT compared to placebo in a secondary per-protocol analysis but not the primary intention-to-treat analysis. Abatacept failed to demonstrate benefit compared to placebo for preventing relapses in another RCT. Pooled data from uncontrolled observational studies demonstrated beneficial clinical responses and angiographic stabilization in nearly 80% patients treated with tumour necrosis factor alpha inhibitors, tocilizumab or leflunomide. Certainty of evidence for outcomes from RCTs ranged from moderate to very low and was low to very low for all observational studies. There is a paucity of high-quality evidence to guide the pharmacotherapy of TAK. Future observational studies should attempt to include appropriate comparator arms. Multicentric, adequately powered RCTs assessing both clinical and angiographic responses are necessary in TAK.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Upendra Rathore
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Pallavi Patro
- School of Telemedicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), -226014, Lucknow, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), -160012, Chandigarh, India
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Alobo G, Nahurira V, Omona V, Bayo P, Olum S. Refractory convulsive syncope in pregnancy: a rare presentation of Takayasu's arteritis - a case report and literature review. Afr Health Sci 2021; 21:852-857. [PMID: 34795744 PMCID: PMC8568231 DOI: 10.4314/ahs.v21i2.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neurological manifestation of Takayasu's Arteritis (TA) in pregnancy presenting as convulsive syncope is extremely rare, and poses a serious diagnostic dilemma due to other vast causes of fits in pregnancy. OBJECTIVE We aimed to present and shed more light on a case of TA with convulsive syncope in pregnancy refractory to anticonvulsants for seven weeks, and review the literature on the management of TA in pregnancy. CASE PRESENTATION A gravida 4 para 3+0 at 28 weeks of amenorrhea presented with repeated episodes of the sudden loss of consciousness, followed by a fall and jerking of the limbs. These were refractory to anticonvulsants that she had used for seven weeks. Physical examination revealed undetectable pulse and blood pressure (BP) in the upper limbs but elevated BP in the lower limbs. Further investigations confirmed TA and she improved on steroids and antihypertensives. CONCLUSION This case typically describes the unexpected presentation of TA with convulsive syncope. It calls for meticulous clinical assessment of epileptic seizures in pregnancy to avoid a late diagnosis of TA and its potential poor outcomes.
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Affiliation(s)
- Gasthony Alobo
- Department of Obstetrics and Gynecology, Lacor Hospital, Gulu, Uganda
- Department of Obstetrics and Gynecology, Lira University, Lira Uganda
| | - Violah Nahurira
- Department of Obstetrics and Gynecology, Lacor Hospital, Gulu, Uganda
| | - Venice Omona
- Department of Pediatrics and Neurology, Lacor Hospital, Gulu, Uganda
| | - Pontius Bayo
- Department of Obstetrics and Gynecology, Lacor Hospital, Gulu, Uganda
| | - Sam Olum
- Department of Internal Medicine, Gulu University, Gulu, Uganda
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Advancements in medical and surgical treatments of Takayasu arteritis-induced renal arteritis: a systematic review. Chin Med J (Engl) 2021; 133:975-981. [PMID: 32187045 PMCID: PMC7176450 DOI: 10.1097/cm9.0000000000000704] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Takayasu arteritis-induced renal arteritis (TARA), commonly seen in Takayasu arteritis (TA), has become one of the main causes of poor prognosis and early mortality in patients with TA. TARA progressing into Takayasu arteritis-induced renal artery stenosis (TARAS), could lead to severe complications including malignant hypertension, cardiac-cerebral vascular disease, and ischemic nephropathy. Since there existed no guidelines on treatments, this study aimed to review the comprehensive treatments for TARA. Methods We searched systematically in databases including PubMed, Ovid-Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and SinoMed, from inception to May 2018. Literature selection, data extraction, and statistical analysis were performed. Results Eighty-two literatures were recruited focusing on medical treatments (n = 34) and surgical treatments (n = 48). We found that combined medical treatments of glucocorticoids and conventional synthetic disease-modifying anti-rheumatic drugs could reach high rates of remission in patients with TARA, and biological disease-modifying anti-rheumatic drugs were preferred for refractory patients. After remission induction, surgical treatment could help reconstruct renal artery and recover renal function partly. Percutaneous transluminal angioplasty was the first choice for patients with TARAS, while open surgery showed a good long-term survival. Conclusions Patients with TARA should benefit both from medical treatments and from surgical treatments comprehensively and sequentially. Multidisciplinary team coordination is recommended especially in patients with severe complications.
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Wang Y, Zhao Z, Gao D, Wang H, Liao S, Dong C, Luo G, Ji X, Li Y, Wang X, Zhao Y, Li K, Zhang J, Jin J, Zhang Y, Zhu J, Zhang J, Huang F. Additive effect of leflunomide and glucocorticoids compared with glucocorticoids monotherapy in preventing relapse of IgG4-related disease: A randomized clinical trial. Semin Arthritis Rheum 2020; 50:1513-1520. [DOI: 10.1016/j.semarthrit.2020.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 02/08/2023]
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Wu C, Sun Y, Cui X, Wu S, Ma L, Chen H, Yan Y, Ji Z, Liu Y, Lin J, Lv P, Chen R, Yang P, Jiang L. Effectiveness and safety of methotrexate versus leflunomide in 12-month treatment for Takayasu arteritis. Ther Adv Chronic Dis 2020; 11:2040622320975233. [PMID: 33294149 PMCID: PMC7705767 DOI: 10.1177/2040622320975233] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/29/2020] [Indexed: 12/31/2022] Open
Abstract
Aims: The study investigates the effectiveness and safety of methotrexate (MTX)
versus leflunomide (LEF) in 12-month treatment of
Takayasu arteritis (TAK). Methods: This was a cohort study. Patients diagnosed with TAK between 1 January 2013
and 1 January 2019 were enrolled from First Hospital of China Medical
University and Zhongshan Hospital of Fudan University. Patients had active
disease and were treated with glucocorticoid combined with LEF or MTX.
Treatment response, imaging assessment and side-effects were evaluated
during 12-month follow-up. Results: In total, 68 patients were enrolled (40 cases treated with LEF and 28 treated
with MTX). At baseline, age, sex, disease duration and disease activity
index showed no significant differences between groups. Prevalence of
complete remission (CR) at 6 months was significantly higher in the LEF
group than that in the MTX group (LEF versus MTX: 72.50%
versus 53.57%, p = 0.04), though the
CR prevalence at 9 months and 12 months showed no significant differences
between groups. At 9 months, the prevalence of treatment resistance was much
lower in the LEF group compared with MTX group (5.41%
versus 11.54%, p = 0.03). Furthermore,
prevalence of disease relapse in the LEF group was lower than that in MTX
group at 12 months (7.24% versus 16.67%,
p = 0.03). Patients with high baseline C-reactive protein
levels (⩾15 mg/L) carried a higher risk of treatment resistance (OR = 1.36,
95% CI 1.07–13.41, p = 0.06) and disease relapse
(HR = 2.51, 95% CI 1.36–12.98, p = 0.04). Conclusion: LEF might provide a quicker treatment response with lower prevalence of
disease relapse compared with that elicited in MTX during 12 months
follow-up for TAK.
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Affiliation(s)
- Chunling Wu
- Department of Rheumatology and Immunology, The First Hospital of China Medical University, Shenyang, P. R. China
| | - Ying Sun
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Xiaomeng Cui
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Sifan Wu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lili Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Huiyong Chen
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Yan Yan
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Zongfei Ji
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Yun Liu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Peng Lv
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Rongyi Chen
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Pingting Yang
- Department of Rheumatology and Immunology, The First Hospital of China Medical University, Shenyang, Liaoning, P. R. China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Xuhui District, Shanghai, 200032, P. R. China Centre of Evidence-based Medicine, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
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Intervention in Takayasu Aortitis: When, Where and How? HEARTS 2020. [DOI: 10.3390/hearts1020008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Takayasu arteritis is a large vessel vasculitis which commonly affects the aorta and its major branches. Active arterial inflammation is characterised by the presence of T and B lymphocytes, natural killer cells, macrophages and occasional multinucleate giant cells. Uncontrolled vascular inflammation can progress to cause arterial stenosis, occlusion or aneurysmal dilatation. Medical treatment involves combination immunosuppression and more recently biologic therapies targeting TNF-α and IL-6. Due to the typical delays in diagnosis and accumulation of arterial injury, open and endovascular surgical intervention are important and potentially life-saving treatment options for Takayasu arteritis. Common indications for surgery include aortic coarctation and ascending aortic dilatation ± aortic valve regurgitation, renal artery stenosis, ischaemic heart disease, supra-aortic disease, mesenteric ischaemia, severe limb-threatening claudication and aneurysm repair. Surgical outcomes are markedly improved in patients with clinically inactive disease and those who receive adequate periprocedural immunosuppression. Decisions regarding surgical approaches are best made as part of a multi-disciplinary team.
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Breen TJ, Osborn TG, Kleinman Sween J. Untreated Takayasu arteritis: an unusual case of widespread disease. BMJ Case Rep 2020; 13:13/8/e234825. [DOI: 10.1136/bcr-2020-234825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 38-year-old man with no medical history presented with bilateral flank and epigastric abdominal pain. CT abdomen and pelvis demonstrated diffuse nodules and lymphadenopathy, which were biopsied and showed chronic inflammatory changes. He later presented with pleuritic chest pain and was sent for a CT chest angiogram, which revealed perivascular inflammation involving the thoracic aortic arch, supra-aortic branch vessels and descending thoracic aorta. Further work-up showed vasculitic involvement of the coeliac, superior mesenteric and femoral arteries with heavy collateralisation. These findings were most consistent with widespread Takayasu arteritis that had been untreated for nearly 20 years. It was necessary to define the degree of active inflammation and need for immediate therapy, as the patient had a concomitant latent tuberculosis infection that precluded the use of immunosuppressive medications. This report illustrates an unusual case of Takayasu arteritis and highlights the presentation, diagnosis and work-up of suspected cases.
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Dai X, Cui X, Sun Y, Ma L, Jiang L. Effectiveness and safety of leflunomide compared with cyclophosphamide as induction therapy in Takayasu's arteritis: an observational study. Ther Adv Chronic Dis 2020; 11:2040622320922019. [PMID: 32551033 PMCID: PMC7278326 DOI: 10.1177/2040622320922019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 03/31/2020] [Indexed: 01/09/2023] Open
Abstract
Aims The objective of this study was to investigate the outcomes of leflunomide (LEF) compared with those of cyclophosphamide (CYC) as induction against active Takayasu's arteritis (TA) in Chinese patients. Methods This was an observational study based on a prospective cohort that included TA patients diagnosed in large third-level first-class general hospitals in East China from January 2009 to September 2018. LEF- or CYC-induced active patients were enrolled for comparative effectiveness analysis. One-to-more paired cohorts of LEF versus CYC were derived by propensity-score matching (PSM). The primary outcome was complete remission (CR) at 9-month follow up, and secondary endpoints included partial remission (PR) and effectiveness rate (ER). Multivariable logistic regression was used to identify statistical significance. Results A total of 131 enrolled patients with at least 3-months treatment included 53 receiving a regimen of glucocorticoid (GC) and LEF and 78 receiving GC and CYC. Compared with the CYC group, the LEF group showed higher CR rate {LEF versus CYC: 84.6% [95% confidence interval (CI) 74.5-94.8%] versus 59.0% (47.8-70.1%); relative risk (RR) = 0.3 (0.1-0.6), p = 0.002} and lower daily GC dose [10.0 (5.0-12.5) versus 12.5 (10.0-15.0) mg, p = 0.043] at the end of the 9-month induction. In the matched analysis, the LEF group (n = 23) still indicated a higher CR rate than the CYC group (n = 54) after PSM [RR = 0.1 (0.0-0.6), p = 0.003]. Four LEF-treated patients had mild side effects, and one died unrelated to LEF. Conclusion LEF could be an alternative induction therapy against TA, showing good effectiveness and tolerance compared with CYC.
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Affiliation(s)
- Xiaomin Dai
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaomeng Cui
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Sun
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lili Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, No. 180, Road Fenglin, Xuhui District, Shanghai 200032, P. R. China Evidence-Based Medicine Center, Fudan University, Shanghai, China
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Ying S, Xiaomeng C, Xiaomin D, Jiang L, Peng L, Lili M, Rongyi C, Zongfei J, Huiyong C, Lindi J. Efficacy and safety of leflunomide versus cyclophosphamide for initial-onset Takayasu arteritis: a prospective cohort study. Ther Adv Musculoskelet Dis 2020; 12:1759720X20930114. [PMID: 32536986 PMCID: PMC7268110 DOI: 10.1177/1759720x20930114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/07/2020] [Indexed: 01/24/2023] Open
Abstract
Background Leflunomide (LEF) has been considered as an alternative treatment for Takayasu arteritis (TA); however, data on its efficacy are still scanty. Objective To investigate the efficacy and safety of LEF versus cyclophosphamide (CYC) for initial-onset TA. Methods Initial-onset TA patients with active disease were enrolled in this research. Patients enrolled from 1 January 2009 to 31 December 2015 were treated with glucocorticoids and CYC, while patients enrolled from 1 January 2016 to 31 October 2018 received glucocorticoids and LEF. Treatment response including complete remission (CR), partial remission (PR), and effectiveness rate (ER) and side effects were evaluated at 6 and 12 months. Results and conclusion In total, 92 patients were enrolled. A total of 47 patients were treated with LEF, while 45 patients were treated with CYC. The CR and ER rates were 75.55%, and 88.89% at 6 months, and 85.37% and 95.12% at 12 months in the LEF group. The CR and ER rates were 39.02% and 70.73% at 6 months, and 56.41% and 82.05% at 12 months in the CYC group. The CR rate was significantly higher in the LEF group than in the CYC group both at 6 months (75.61% versus 38.24%, p < 0.01) and 12 months (77.42% versus 53.33%, p < 0.05) after adjustment for propensity scores. The incidence of side effects in the LEF group was much lower than that in the CYC group (21.28% versus 44.44%). In conclusion, LEF provided a better treatment response, along with lower reproductive toxicity, compared with CYC in initial-onset TA.
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Affiliation(s)
- Sun Ying
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Cui Xiaomeng
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Dai Xiaomin
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lin Jiang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Lv Peng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Ma Lili
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Chen Rongyi
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Ji Zongfei
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Chen Huiyong
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Jiang Lindi
- Department of Rheumatology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road Shanghai, 200032, P. R. China Centre of Evidence-based Medicine, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
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Cui X, Dai X, Ma L, Yang C, Tan W, Zhang L, Zhang Z, Feng X, Wu R, Zou Y, Zhou Z, Lu Y, Wang Y, Wu M, Li S, Wang L, Lin H, Dong Z, Fu W, Sun X, Wang C, Ding J, Lv P, Lin J, Jiang L. Efficacy and safety of leflunomide treatment in Takayasu arteritis: Case series from the East China cohort. Semin Arthritis Rheum 2020; 50:59-65. [DOI: 10.1016/j.semarthrit.2019.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/05/2019] [Accepted: 06/10/2019] [Indexed: 12/26/2022]
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Campochiaro C, Tomelleri A, Sartorelli S, Cavalli G, De Luca G, Baldissera E, Dagna L. Drug retention and discontinuation reasons between seven biologics in patients with Takayasu arteritis. Semin Arthritis Rheum 2020; 50:509-514. [PMID: 32088012 DOI: 10.1016/j.semarthrit.2020.01.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We retrospectively investigated drug retention rate (DRR) and reasons for discontinuation of seven biologic disease-modifying anti-rheumatic drugs (bDMARDs) in Takayasu's arteritis (TA) in a real-world setting. METHODS TA patients followed-up in our center fulfilling the 1990 ACR criteria and treated with ≥1 bDMARD were selected. Data about disease duration, number of bDMARDs, reasons for bDMARDs discontinuation, and concomitant conventional synthetic (cs)DMARDs were collected. Survival curves were examined by the Kaplan-Meier method and compared using a stratified log-rank test. 24-month DRR was calculated. Hazard ratio (HR) for concomitant csDMARDs and for previous bDMARDs was evaluated. A comparative sub-analysis between anti-TNFα drugs and tocilizumab was performed. RESULTS We identified 50 patients and 86 bDMARD-courses. No significant differences were observed in age and disease duration between the seven groups. Infliximab was the most frequent first-line bDMARD (78.6%). At bDMARDs initiation, all patients were prescribed prednisone (mean dose, 13.5 ± 10.3 mg/day) and 85.2% concomitant csDMARD therapy. 43% of treatment courses were stopped by 24 months. Golimumab had the highest DRR (71.4%), followed by infliximab (69%), adalimumab (56.3%), abatacept (50%), tocilizumab (41.1%), anakinra (0%) and rituximab (0%), p = 0.016. Concomitant csDMARDs therapy showed positive effects on DRR (HR=2.87, 95% CI=1.19-6.92, p = 0.019). Anti-TNFα drugs had significantly higher DRR compared to tocilizumab (67.2% vs 41.1%, p = 0.028). Even in these subgroups, csDMARDs showed positive effects on DRR (HR=3.79, 95% CI=1.49-9.6, p = 0.005). CONCLUSIONS Anti-TNFα agents had the highest DRR overall and a higher DRR in a head-to-head comparison with tocilizumab. Concomitant csDMARDs had a significant positive effect on bDMARDs DRR.
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Affiliation(s)
- Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy.
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Silvia Sartorelli
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Elena Baldissera
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
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Abstract
Childhood-onset Takayasu arteritis (c-TA) is the third most common systemic vasculitic disorder in children. Vascular stenosis is the main complication, and aneurysms are reported in 19-65% of cases, often in combination with stenotic lesions. Management of patients with c-TA is largely based on studies involving predominantly patients with adult-onset TA (a-TA). More widely used criteria for patients with c-TA have been devised by the joint European League Against Rheumatism, Pediatric Rheumatology International Trials Organization, and Pediatric Rheumatology European Society. Of the available imaging modalities, those that do not use radiation (color Doppler ultrasound and magnetic resonance angiogram) are preferred over 18F-labeled fluoro-2-deoxyglucose (18F-FDG) positron-emission tomography, computed tomography (CT), and CT angiogram in children. Remission rates have been reported to be lower in c-TA than in a-TA, and published mortality rates in c-TA range from 16 to 40%, which is much higher than reported in patients with a-TA. The usual drug therapy options include steroids plus steroid-sparing second-line immunosuppressants, such as mycophenolate, azathioprine, methotrexate, cyclophosphamide, and cyclosporine, along with antiplatelet agents. Interleukin-6 inhibitors such as tocilizumab, as well as the tumor necrosis factor inhibitors, are other aggressive therapeutic options. As yet, no randomized controlled trials have been conducted in c-TA.
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Affiliation(s)
- Ruchika Goel
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - T Sathish Kumar
- Department of Child Health, Christian Medical College, Vellore, India
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India.
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Abstract
The diagnosis of primary central and peripheral nerve vasculitides should be established with certainty if suspected before commencing potent immunosuppressive therapy. The aim of induction therapy is to rapidly control the underlying inflammatory response and stabilize the blood-brain and blood-nerve barriers, followed by maintenance immunosuppression tailored to the likeliest humoral and cell-mediated autoimmune inflammatory vasculitic processes.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY, USA; School of Public Health, City University of New York, New York, NY, USA.
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Podgorska D, Podgorski R, Aebisher D, Dabrowski P. Takayasu arteritis - epidemiology, pathogenesis, diagnosis and treatment. J Appl Biomed 2019; 17:20. [PMID: 34907753 DOI: 10.32725/jab.2018.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 11/05/2022] Open
Abstract
Takayasu disease belongs to the group of autoimmune vasculitis which most often affects the aorta and its branches. It is rare, and it mainly affects young women. Recent epidemiologic studies suggest that Takayasu arteritis is being increasingly recognized in Europe. The first symptoms are non-specific and an early diagnosis is difficult and requires clinical awareness and suspicion. Patients with Takayasu arteritis often present increased inflammatory markers, including C-reactive protein and erythrocyte sedimentation rate, but systemic inflammatory response does not always show a positive correlation with inflammatory activity in the vessel wall. Therefore, imaging studies play a principal role in diagnosis and control of the disease. Glucocorticoids remain the most effective and serve as a cornerstone first line treatment. Immunosuppressive drugs play an important role as well, and biological therapy is increasingly being included in the treatment. This article describes the epidemiology, pathophysiology, diagnostics and treatment of this rare disease, so as to alert clinicians because disease left untreated can lead to narrowing and even closure of vital blood vessels. The most common Takayasu arteritis complications include pulmonary thrombosis, aortic regurgitation, congestive heart failure, cerebrovascular events, vision degeneration or blindness, and hearing problems.
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Affiliation(s)
- Dominika Podgorska
- Clinical Provincial Hospital No. 2, Department of Rheumatology, Rzeszow, Poland
| | - Rafal Podgorski
- University of Rzeszow, Centre for Medical and Natural Sciences Research and Innovation, Rzeszow, Poland.,University of Rzeszow, Faculty of Medicine, Department of Biochemistry, Rzeszow, Poland
| | - David Aebisher
- University of Rzeszow, Faculty of Medicine, Department of Human Immunology, Rzeszow, Poland
| | - Piotr Dabrowski
- Clinical Provincial Hospital No. 2, Department of Rheumatology, Rzeszow, Poland
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26
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Misra DP, Wakhlu A, Agarwal V, Danda D. Recent advances in the management of Takayasu arteritis. Int J Rheum Dis 2019; 22 Suppl 1:60-68. [PMID: 30698358 DOI: 10.1111/1756-185x.13285] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS); Lucknow India
| | - Anupam Wakhlu
- Department of Rheumatology; King George's Medical University; Lucknow India
| | - Vikas Agarwal
- Department of Clinical Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS); Lucknow India
| | - Debashish Danda
- Department of Clinical Immunology & Rheumatology; Christian Medical College Hospital; Vellore India
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Transcranial Doppler Evaluation in Takayasu Arteritis With Oculo-Cerebrovascular Complications. Neurologist 2018; 24:17-21. [PMID: 30586029 DOI: 10.1097/nrl.0000000000000202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Takayasu arteritis is a large-vessel vasculitis that may cause oculo-cerebral ischemia. We report a patient with visual loss as initial manifestation, and discuss transcranial Doppler (TCD) findings before and after surgical revascularization. CASE DESCRIPTION A 19-year-old female developed episodes of transient positional right vision loss, progressing to permanent right vision loss and bright light-induced left amaurosis. Examination demonstrated subclavian bruits, palpable epigastrium aortic pulsation, faint radial pulses, right retinal pallor, arteriolar narrowing, and bilateral boxcarring. Head and neck computed tomography angiogram demonstrated left subclavian origin and right common carotid artery occlusion, and severe innominate and left common carotid artery stenosis. TCD demonstrated right ophthalmic artery flow reversal and nonpulsatile waveforms with dampened spectra in the right anterior circulation. Corticosteroids, methotrexate, infliximab, and dual-antiplatelet therapy were initiated. Eleven weeks later, the patient underwent ascending aortic aneurysm repair and bilateral carotid artery bypass with an aortic graft. Pathology was consistent with chronic active Takayasu arteritis. Two weeks postoperatively, left eye visual symptoms resolved; right visual loss persisted. Postoperative TCD showed marked improvement in cerebral perfusion. CONCLUSIONS Retinal ischemia in young women should prompt emergent inflammatory and systemic vascular evaluation. In our subject, prolonged right retinal ischemia had dismal prognosis despite carotid-aortic revascularization, whereas left retinal boxcarring reversed. Surgical revascularization is recommended for severely symptomatic oculo-cerebrovascular disease, once inflammation is better controlled with immunosuppressive therapy. TCD documented the presence and monitored the subsequent resolution of blood flow changes causing retinal and brain hypoxia.
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Adams TN, Zhang D, Batra K, Fitzgerald JE. Pulmonary manifestations of large, medium, and variable vessel vasculitis. Respir Med 2018; 145:182-191. [PMID: 30509707 DOI: 10.1016/j.rmed.2018.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/14/2018] [Accepted: 11/06/2018] [Indexed: 02/01/2023]
Abstract
The hallmark of vasculitis is autoimmune inflammation of blood vessels and surrounding tissues, resulting in an array of constitutional symptoms and organ damage. The lung is commonly targeted in the more familiar ANCA-associated small vessel vasculitidies, but large and medium vessel vasculitides, including Takayasu arteritis, giant cell arteritis, polyarteritis nodosa, Behcet's disease, and necrotizing sarcoid granulomatosis, may also feature prominent pulmonary involvement. Pulmonary manifestations of these conditions include pulmonary arterial aneurysms, pulmonary hypertension, diffuse alveolar hemorrhage, pulmonary nodules, and parenchymal infiltrates. An understanding of the diverse manifestations of vasculitis and a high index of clinical suspicion are essential to avoid delays in disease recognition that may result in permanent or life threatening morbidity. In this review, we outline the general clinical manifestations, pulmonary manifestations, diagnostic workup, imaging findings, and treatment of medium, large, and variable vessel vasculitides.
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Affiliation(s)
- Traci N Adams
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States.
| | - Da Zhang
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States
| | - Kiran Batra
- University of Texas Southwestern Medical Center, Department of Radiology, United States
| | - John E Fitzgerald
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States
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Kermani TA, Dasgupta B. Current and emerging therapies in large-vessel vasculitis. Rheumatology (Oxford) 2018; 57:1513-1524. [PMID: 29069518 DOI: 10.1093/rheumatology/kex385] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 11/14/2022] Open
Abstract
GCA shares many clinical features with PMR and Takayasu arteritis. The current mainstay of therapy for all three conditions is glucocorticoid therapy. Given the chronic, relapsing nature of these conditions and the morbidity associated with glucocorticoid therapy, there is a need for better treatment options to induce and sustain remission with fewer adverse effects. Conventional immunosuppressive treatments have been studied and have a modest effect. There is a keen interest in biologic therapies with studies showing the efficacy of IL-6 antagonists in PMR and GCA. Recently the first two randomized clinical trials in Takayasu arteritis have been completed. A major challenge for all of these conditions is the lack of standardized measures to assess disease activity. Long-term studies are needed to evaluate the impact of biologic therapies showing potential on important clinical outcomes such as vascular damage, cost-effectiveness and quality of life. The optimal duration of treatment also needs to be assessed.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital & Anglia Ruskin University, Westcliff-on-sea, UK
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Does leflunomide have a role in giant cell arteritis? An open-label study. Clin Rheumatol 2018; 38:291-296. [DOI: 10.1007/s10067-018-4232-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/11/2018] [Accepted: 07/23/2018] [Indexed: 01/26/2023]
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31
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Barra L, Yang G, Pagnoux C. Non-glucocorticoid drugs for the treatment of Takayasu's arteritis: A systematic review and meta-analysis. Autoimmun Rev 2018; 17:683-693. [DOI: 10.1016/j.autrev.2018.01.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 02/05/2023]
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32
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Analysis of predictive factors for treatment resistance and disease relapse in Takayasu’s arteritis. Clin Rheumatol 2018; 37:2789-2795. [DOI: 10.1007/s10067-018-4094-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022]
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Tombetti E, Mason JC. Takayasu arteritis: advanced understanding is leading to new horizons. Rheumatology (Oxford) 2018; 58:206-219. [DOI: 10.1093/rheumatology/key040] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Indexed: 12/27/2022] Open
Affiliation(s)
- Enrico Tombetti
- Department of Immunology, Transplantation and Infections Disease, Vita-Salute San Raffaele University and San Raffaele Scientific Institute, Milan, Italy
- Vascular Sciences and Rheumatology, Imperial Centre for Translational and Experimental Medicine, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Justin C Mason
- Vascular Sciences and Rheumatology, Imperial Centre for Translational and Experimental Medicine, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
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Abstract
Takayasu arteritis is an idiopathic granulomatous vasculitis of the aorta and its main branches and it constitutes one of the more common vasculitides in children. Inflammation and intimal proliferation lead to wall thickening, stenotic or occlusive lesions, and thrombosis, while destruction of the elastica and muscularis layers originates aneurysms and dissection. Carotid artery tenderness, claudication, ocular disturbances, central nervous system abnormalities, and weakening of pulses are the most frequent clinical features. The diagnosis is usually confirmed by the observation of large vessel wall abnormalities: stenosis, aneurysms, occlusion, and evidence of increased collateral circulation in angiography, MRA or CTA imaging. The purpose of this revision is to address the current knowledge on pathogenesis, investigations, classification, outcome measures and management, and to emphasize the need for timely diagnosis, effective therapeutic intervention, and close monitoring of this severe condition.
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Affiliation(s)
- Ricardo A G Russo
- Service of Immunology & Rheumatology, Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - María M Katsicas
- Service of Immunology & Rheumatology, Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
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Abstract
Takayasu arteritis (TA) is a rare disease affecting chiefly young women, although it can affect both men and women and persons of many different ethnicities. TA carries a high morbidity rate, but importantly, overall mortality has declined over time such that the 15-year survival rate has increased from 82.9% for patients diagnosed between 1957 and 1975 to 96.5% for those diagnosed from 1976 to 1990. Severity of presenting arterial complications and delay to diagnosis have also decreased over the past decade owing to advances in non-invasive diagnostic imaging and the development of medical therapies. Despite these advances, there still remain significant gaps in the diagnosis and management of these complex patients. These gaps encompass the basic, yet extremely complex, tasks of defining a universally accepted diagnostic criterion, accurate assessment of disease activity and development of clinically meaningful and accurate outcome measures to guide necessary clinical trials for the management of these complex patients.
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Pacheco RL, Latorraca CDOC, de Souza AWS, Pachito DV, Riera R. Clinical interventions for Takayasu arteritis: A systematic review. Int J Clin Pract 2017; 71. [PMID: 28895653 DOI: 10.1111/ijcp.12993] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/30/2017] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Takayasu arteritis (TA) is a rare systemic vasculitis that affects large vessels often resistant to treatment and associated with high morbidity and mortality. Treatment is defied by the relapsing nature of the disease and frequent adverse effects of corticosteroids and immunosuppressors, rendering failure of treatment in a significant portion of patients. Considering the low quantity and quality of published studies focusing on treatment of TA, synthesis and critical assessment of the available evidence is fundamental to establish recommendations for clinical practice. OBJECTIVE To evaluate the effectiveness and safety of clinical interventions for TA. METHODS Systematic review conducted in accordance to recommendations stated in the Cochrane Handbook, with inclusion of all comparative studies focusing on any type of clinical intervention for TA. RESULTS Five comparative studies were included (one randomised clinical trial, two non-randomised clinical trials, and two historical cohorts) totalling 342 patients, aiming at the assessment of effectiveness of corticosteroids, immunosuppressors, biologics and other types of pharmacological treatment for distinct clinical presentations of TA. The quality of studies, assessed by the use of instruments developed specifically for each study design, was considered low. Data scarcity and clinical heterogeneity prevented quantitative synthesis (meta-analysis). CONCLUSION Despite an extensive literature search, few comparative studies with small sample sizes were retrieved. The quality of these studies was considered low, preventing recommendations on effectiveness and safety of the studied interventions for clinical practice. Until new comparative studies with more robust sample sizes are conducted, treatment of TA should be guided individually taking into account the severity of disease and the availability of treatment options.
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Affiliation(s)
- Rafael L Pacheco
- Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | | | - Alexandre Wagner Silva de Souza
- Discipline of Rheumatology, Vasculitis Outpatient Clinic, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Daniela V Pachito
- Evidence Based Health Program, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Cochrane Brazil, Rua Borges Lagoa, São Paulo, Brazil
| | - Rachel Riera
- Cochrane Brazil, Rua Borges Lagoa, São Paulo, Brazil
- Discipline of Evidence Based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
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Sun Y, Ma L, Ma L, Kong X, Chen H, Lv P, Lin J, Liu H, Yan Y, Ji Z, Yang C, Dai S, Wan W, Zou Y, Jin X, Jiang L. Cyclophosphamide could be a better choice than methotrexate as induction treatment for patients with more severe Takayasu’s arteritis. Rheumatol Int 2017; 37:2019-2026. [DOI: 10.1007/s00296-017-3847-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 10/03/2017] [Indexed: 11/28/2022]
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Keser G, Aksu K. What is new in management of Takayasu arteritis? Presse Med 2017; 46:e229-e235. [PMID: 28774475 DOI: 10.1016/j.lpm.2016.11.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/14/2016] [Indexed: 10/19/2022] Open
Abstract
Management of Takayasu arteritis (TAK) is challenging mostly due to difficulties in assessing actual disease activity. The rational of medical treatment is to suppress both vascular and systemic inflammation with appropriate systemic immunosuppression, including corticosteroids and conventional immunosuppressive (IS) agents. In case of refractory disease activity, biologic agents such as TNF inhibitors and tocilizumab may be tried. In selected cases, endovascular interventions and surgical procedures may be indicated and should be performed during inactive disease. Among conventional IS agents, new data is available for leflunomide. On the other hand, most of the new information in the management of TAK arises from the growing experience with biologic agents used in resistant cases. Besides, there are potential new therapeutic targets which may be promising in the future for medical treatment of TAK. Finally, new trends in endovascular interventions for management of TAK deserve attention.
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Affiliation(s)
- Gokhan Keser
- Ege University School of Medicine, Department of Internal Medicine, Division of Rheumatology, Bornova, Izmir, Turkey.
| | - Kenan Aksu
- Ege University School of Medicine, Department of Internal Medicine, Division of Rheumatology, Bornova, Izmir, Turkey
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Naidu GSRSNK, Misra DP, Sharma A. Current and Future Treatment Options for Takayasu Arteritis and Persistent Therapeutic Challenges. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Muratore F, Pipitone N, Salvarani C. Standard and biological treatment in large vessel vasculitis: guidelines and current approaches. Expert Rev Clin Immunol 2017; 13:345-360. [PMID: 28116918 DOI: 10.1080/1744666x.2017.1285699] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Giant cell arteritis and Takayasu arteritis are the two major forms of idiopathic large vessel vasculitis. High doses of glucocorticoids are effective in inducing remission in both conditions, but relapses and recurrences are common, requiring prolonged glucocorticoid treatment with the risk of the related adverse events. Areas covered: In this article, we will review the standard and biological treatment strategies in large vessel vasculitis, and we will focus on the current approaches to these diseases. Expert commentary: The results of treatment trials with conventional immunosuppressive agents such as methotrexate, azathioprine, mycophenolate mofetil, and cyclophosphamide have overall been disappointing. TNF-α blockers are ineffective in giant cell arteritis, while observational evidence and a phase 2 randomized trial support the use of tocilizumab in relapsing giant cell arteritis. Observational evidence strongly supports the use of anti-TNF-α agents and tocilizumab in Takayasu patients with relapsing disease. However biological agents are not curative, and relapses remain common.
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Affiliation(s)
- Francesco Muratore
- a Rheumatology Unit, Department of Internal Medicine , Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico , Reggio Emilia , Italy
| | - Nicolò Pipitone
- a Rheumatology Unit, Department of Internal Medicine , Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico , Reggio Emilia , Italy
| | - Carlo Salvarani
- a Rheumatology Unit, Department of Internal Medicine , Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico , Reggio Emilia , Italy
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Misra DP, Sharma A, Kadhiravan T, Negi VS. A scoping review of the use of non-biologic disease modifying anti-rheumatic drugs in the management of large vessel vasculitis. Autoimmun Rev 2017; 16:179-191. [DOI: 10.1016/j.autrev.2016.12.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/21/2016] [Indexed: 01/04/2023]
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Updates in Pathophysiology, Diagnosis and Management of Takayasu Arteritis. Ann Vasc Surg 2016; 35:210-25. [PMID: 27238990 DOI: 10.1016/j.avsg.2016.02.011] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 02/18/2016] [Accepted: 02/19/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Takayasu arteritis (TA) is a rare, systemic, inflammatory vasculitis of granulomatous nature, and still of unknown etiology. It mainly involves the aorta and its major branches and is more commonly seen in women of childbearing age and Asians. TA leads to stenosis, occlusion, or aneurysmal degeneration of large arteries, and its pathogenesis seems to be mainly due to an abnormal cell-mediated immunity, although other molecular and genetic abnormalities may contribute. The diagnosis and treatments lie on clinical and arteriographic findings. Because of its fluctuating course, both clinical scores and biomarkers are currently evaluated. The aim of this review is to report a comprehensive and methodologically robust state of the art about Takayasu arteritis, including the latest data and evidences in the definition, epidemiology, pathogenesis and etiology, clinical manifestations and classification, diagnosis, assessment of disease activity and progression, biomarkers, and treatment. METHODS We searched all publications addressing definition, epidemiology, pathogenesis, etiology, classification, diagnosis, biomarkers, and treatment of TA. Randomized trials, cohort studies, and reviews were contemplated to give a breadth of clinical data. PubMed and Scopus were searched from August 2010 to November 2015. RESULTS Of the 3,056 records found, 267 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 169 articles because of the following reasons: (1) no innovative or important content; (2) no multivariable analysis; (3) insufficient data; (4) no clear potential biases or strategies to solve them; (5) no clear end-points; and (6) inconsistent or arbitrary conclusions. The final set included 98 articles. CONCLUSIONS This review presents the last updates in all fields of Takayasu arteritis. Still today, large areas of TA pathogenesis and disease-activity assessment need to be further investigated to better treat patients with TA.
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de Souza AWS, de Almeida Agustinelli R, de Cinque Almeida H, Oliveira PB, Pinheiro FAG, Oliveira ACD, Sato EI. Leflunomide in Takayasu arteritis - A long term observational study. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:371-5. [PMID: 27476631 DOI: 10.1016/j.rbre.2016.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/25/2015] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate the extended follow-up data on efficacy and toxicity of leflunomide therapy in Takayasu arteritis (TA) patients previously enrolled in the original open-label study of short-term effects of leflunomide in TA. METHODS An open-label long-term longitudinal study was performed in TA patients who fulfilled the 1990 American College of Rheumatology criteria for TA and had participated in a previous study that evaluated short-term efficacy of leflunomide in TA. Complete follow-up information could be retrieved from 12 out of 15 patients enrolled in the original study. Disease activity was evaluated by Kerr's criteria and by the Indian Takayasu Activity Score 2010 (ITAS2010). RESULTS The mean follow up time was 43.0±7.6 months and 5 (41.6%) TA patients remained on leflunomide therapy while 7 (58.3%) TA patients had to change to another therapy due to failure to prevent relapses in 6 patients and toxicity in one patient. No significant differences were found between patients who remained on leflunomide therapy and those who changed to another agent regarding age at study entry, time since diagnosis, prednisone daily dose at study entry, baseline ITAS2010, mean or maximum ESR and CRP, and cumulative prednisone dose at study end. Among TA patients who had changed leflunomide to another agent, two had an additional clinical relapse and needed to change therapy. CONCLUSION Leflunomide led to sustained remission in approximately half of patients at a mean time of 12 months and was well tolerated by TA patients.
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Affiliation(s)
| | | | - Hemerli de Cinque Almeida
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Patrícia Bermudes Oliveira
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Ana Cecilia Diniz Oliveira
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Emilia Inoue Sato
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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de Souza AWS, de Almeida Agustinelli R, de Cinque Almeida H, Oliveira PB, Pinheiro FAG, Oliveira ACD, Sato EI. Leflunomide in Takayasu arteritis - A long term observational study. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:S0482-5004(16)00005-X. [PMID: 26924006 DOI: 10.1016/j.rbr.2015.09.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/31/2015] [Accepted: 09/25/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the extended follow-up data on efficacy and toxicity of leflunomide therapy in Takayasu arteritis (TA) patients previously enrolled in the original open-label study of short-term effects of leflunomide in TA. METHODS An open-label long-term longitudinal study was performed in TA patients who fulfilled the 1990 American College of Rheumatology criteria for TA and had participated in a previous study that evaluated short-term efficacy of leflunomide in TA. Complete follow-up information could be retrieved from 12 out of 15 patients enrolled in the original study. Disease activity was evaluated by Kerr's criteria and by the Indian Takayasu Activity Score 2010 (ITAS2010). RESULTS The mean follow up time was 43.0±7.6 months and 5 (41.6%) TA patients remained on leflunomide therapy while 7 (58.3%) TA patients had to change to another therapy due to failure to prevent relapses in 6 patients and toxicity in one patient. No significant differences were found between patients who remained on leflunomide therapy and those who changed to another agent regarding age at study entry, time since diagnosis, prednisone daily dose at study entry, baseline ITAS2010, mean or maximum ESR and CRP, and cumulative prednisone dose at study end. Among two TA patients who had changed laflunomide to another agent, two had a clinical relapse and needed to change therapy. CONCLUSION Leflunomide led to sustained remission in approximately half of patients at a mean time of 12 months and was well tolerated by TA patients.
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Affiliation(s)
| | | | - Hemerli de Cinque Almeida
- Divisão de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Patrícia Bermudes Oliveira
- Divisão de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | - Ana Cecilia Diniz Oliveira
- Divisão de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Emilia Inoue Sato
- Divisão de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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O'Neill L, Ponte C, Sznajd J, Rodrigues AP, Seeliger B, Luqmani RA. Giant Cell Arteritis and Takayasu Arteritis: Are they a different spectrum of the same disease? INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Ryan C, Barbour A, Burke L, Sheppard MN. Non-infectious aortitis of the ascending aorta: a histological and clinical correlation of 71 cases including overlap with medial degeneration and atheroma—a challenge for the pathologist. J Clin Pathol 2015; 68:898-904. [DOI: 10.1136/jclinpath-2015-203061] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/11/2015] [Indexed: 12/15/2022]
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Alibaz-Oner F, Direskeneli H. Update on Takayasu's arteritis. Presse Med 2015; 44:e259-65. [DOI: 10.1016/j.lpm.2015.01.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 01/02/2015] [Indexed: 01/17/2023] Open
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Chatterjee S, Flamm SD, Tan CD, Rodriguez ER. Clinical Diagnosis and Management of Large Vessel Vasculitis: Takayasu Arteritis. Curr Cardiol Rep 2014; 16:499. [DOI: 10.1007/s11886-014-0499-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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50
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Keser G, Direskeneli H, Aksu K. Management of Takayasu arteritis: a systematic review. Rheumatology (Oxford) 2013; 53:793-801. [DOI: 10.1093/rheumatology/ket320] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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