Factors Associated with Relapse and Dependence on Glucocorticoids in Giant Cell Arteritis

Dumont, Anaël; Parienti, Jean‐Jacques; Delmas, Claire; Boutémy, Jonathan; Maigné, G.; Silva, Nicolas Martin; Sultan, Audrey; Planchard, G.; Aouba, Achille; Boysson, Hubert de

doi:10.3899/jrheum.181127

Cited by 59 publications

(45 citation statements)

References 33 publications

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“…Predictors of relapse in LVV are poorly understood. Our data confirm that markers of inflammation, baseline anemia, and LV-GCA are associated with a higher risk of relapse (27)(28)(29)(30). Increasing interest is emerging to find different predictors of relapse or future disease complications as part of the FTA approach, including quantitative analysis of CDS findings suggestive of more extensive or more severe vascular involvement at disease onset (31).…”

Section: Discussionsupporting

confidence: 76%

Fast-Track Ultrasound Clinic for the Diagnosis of Giant Cell Arteritis Changes the Prognosis of the Disease but Not the Risk of Future Relapse

et al. 2020

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Background: Color Duplex sonography (CDS) of temporal arteries and large vessels (LV) is a recently validated diagnostic methodology for Giant Cell Arteritis (GCA). CDS combined with a fast-track approach (FTA) has improved the early diagnosis of the disease.Objectives: To assess FTA effects on the prevention of permanent visual loss (PVL), relapse and late complications of GCA compared to conventional practice. To assess the impact of COVID-19 pandemic on outcomes of GCA patients assessed with FTA.Methods: GCA patients diagnosed up to June 2020 at the Rheumatology Department, University of Pavia, were included. FTA was implemented since October 2016. FTA consists in the referral within 1 working day of a suspected GCA case to an expert rheumatologist who performs clinical evaluation and CDS.Results: One hundred sixty patients were recruited [female 120 (75%), mean age 72.4 ± 8.2 years]. Sixty-three (39.4%) evaluated with FTA, 97 (60.6%) with conventional approach. FTA patients were older (75.1 ± 7.6 vs. 70.6 ± 8.2 years old; p < 0.001). Median follow-up duration was shorter in the FTA group compared to the conventional one (0.9 vs. 5.0 years; p < 0.001). There was no difference between the two cohorts regarding major vessel district involvement (LV-GCA 17.5% vs. 22.7%; p = 0.4). PVL occurred in 8 (12.7%) FTA patients and 26 (26.8%) conventional ones (p = 0.03). The relative risk of blindness in the conventional group was 2.11 (95% C.I. 1.02–4.36; P = 0.04) as compared to FTA. Median symptom latency of patients experiencing PVL was higher in the conventional group (23 days IQR 12–96 vs. 7 days IQR 4–10, p = 0.02). During COVID-19 there was a significant increase in the occurrence of PVL (40%) including bilateral blindness despite a regularly operating FTA clinic. Cumulative incidence of relapses and time to first relapse did not change after FTA introduction (P = 0.2). No difference in late complications (stenosis/aneurysms) was detected.Conclusions: FTA including CDS evaluation contributed to a substantial reduction of PVL in GCA by shortening the time to diagnosis and treatment initiation. Relapse rate did not change upon FTA introduction, highlighting the need for better disease activity monitoring and treatment strategies optimization based on risk stratification that would predict the occurrence of relapse during glucocorticoid de-escalation.

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Section: Discussionsupporting

confidence: 76%

Fast-Track Ultrasound Clinic for the Diagnosis of Giant Cell Arteritis Changes the Prognosis of the Disease but Not the Risk of Future Relapse

et al. 2020

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“…Female sex and a worse FACIT-Fatigue (a short self-reported questionnaire that measures the level of fatigue) score at baseline were also linked with an incomplete treatment response. The presence of LVV, determined either by CT angiography or PET-CT, has also been associated with an increased relapse rate 111 .…”

Section: Long-term Management Predictors Of Disease Coursementioning

confidence: 99%

Monitoring and long-term management of giant cell arteritis and polymyalgia rheumatica

et al. 2020

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Giant cell arteritis (GCA) is the most common type of primary vasculitis in Western countries 1,2. Polymyalgia rheumatica (PMR) is the second most common inflammatory rheumatic disease of the elderly after rheumatoid arthritis (RA) 3. The two diseases are interrelated: 40-60% of patients with GCA have symptoms of PMR 3 , and histological features consistent with GCA have been found in 16-21% of temporal artery biopsy samples from patients with PMR 3. Most of these patients with PMR, however, presented with additional features of GCA, whereas the prevalence of positive histology in unselected patients with PMR is unknown. Both GCA and PMR are heterogeneous diseases. Although systemic manifestations (such as fever, malaise and weight loss) are common in both diseases, they are not present in all patients 4-6. Up to 1 in 5 patients with GCA with ocular involvement can present without systemic manifestations of the disease 7. GCA is the most common form of large-vessel vasculitis (LVV) and has a broad spectrum of disease manifestations, which are frequently overlapping. In the majority of cases, cranial and extracranial large arteries are involved to varying degrees, leading to different clinical phenotypes 8,9. Isolated cranial or extracranial GCA, which are at either end of this continuum, are relatively uncommon 10. Predominant cranial GCA is characterized by headache, jaw claudication and visual manifestations (representing the prototypical clinical picture of temporal arteritis). By contrast, predominant large-vessel GCA is characterized by more pronounced systemic manifestations, PMR, vascular bruits, limb claudication and imaging signs of inflammation in the aorta and its major branches 10. In some of these patients, vascular stenoses or aneurysms in association with other GCA features are the presenting clinical manifestations 9,11. PMR is characterized by pain and stiffness in the shoulder and pelvic girdles, which can have an abrupt or a subtle onset 3. Up to 20% of patients with PMR can present with a normal erythrocyte sedimentation rate (ESR) 12 , although the presence of both normal ESR and C-reactive protein (CRP) levels is rare 13-15. Glucocorticoids are the cornerstone of treatment for GCA and PMR. They are effective, but glucocorticoidrelated adverse effects occur in up to 85% of patients with GCA and 65% of patients with PMR, respectively 16-22. The IL-6 receptor inhibitor tocilizumab has become available as a glucocorticoid-sparing strategy in patients with GCA 23,24 , an approach that is also being evaluated for PMR 25,26. Management of both GCA and PMR is hampered by the lack of universally accepted definitions of remission and other disease states (such as low disease activity or vessel damage without active disease). Many questions about monitoring and long-term management are still unanswered (Box 1).

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“…In contrast, in a cohort study of 204 GCA patients with large vessel involvement, survival was impaired in patients with aortic aneurysm or dissection [12]. Moreover, large vessel impairment was reported to be associated to higher GCA relapse rates [11,13,14].…”

Section: Introductionmentioning

confidence: 90%

Symptomatic Aortitis at Giant Cell Arteritis Diagnosis: A Prognostic Factor of Aortic Event.

Espitia

Blonz

Urbanski

et al. 2020

Preprint

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Background Giant cell arteritis (GCA) is frequently associated with aortic involvement that is likely to cause life-threatening structural complications (aneurysm, dissection). Few studies have investigated the occurrence of these complications and no predictive factor has been identified so far. The aim of this study was to investigate factors associated with the risk of aortic complications in a cohort of GCA aortitis.Methods Data of all patients managed with aortitis (CT or 18 FDG PET) at the diagnosis of GCA in five hospitals from May 1998 and April 2019 were retrospectively collected. Clinical features were compared according to the presence of aortitis symptoms. The predictive factors of occurrence or aggravation of aortic structural abnormalities were investigated. Results One hundred and seventy-one patients with GCA aortitis were included; 55 patients (32 %) had symptoms of aortitis (dorsal/lumbar/abdominal pain, aortic insufficiency) at diagnosis. The median follow-up was 38 months. Aortic complications occurred after a median time of 32 months. There were 19 new aortic aneurysms or complications of aneurysm, and 5 dissections. Survival without aortic complication was significantly different between the symptomatic and non-symptomatic groups (Log rank, p=0.0003). In multivariate analysis the presence of aortitis symptoms at diagnosis (HR 15.1 [1.4; 158.1] p=0.02) was a predictive factor associated with the occurrence of aortic complications. Conclusion In this study, the presence of aortitis symptoms at the diagnosis of GCA aortitis was an independent predictive factor of occurrence of aortic complications during follow-up.

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Factors Associated with Relapse and Dependence on Glucocorticoids in Giant Cell Arteritis

Cited by 59 publications

References 33 publications

Fast-Track Ultrasound Clinic for the Diagnosis of Giant Cell Arteritis Changes the Prognosis of the Disease but Not the Risk of Future Relapse

Fast-Track Ultrasound Clinic for the Diagnosis of Giant Cell Arteritis Changes the Prognosis of the Disease but Not the Risk of Future Relapse

Monitoring and long-term management of giant cell arteritis and polymyalgia rheumatica

Symptomatic Aortitis at Giant Cell Arteritis Diagnosis: A Prognostic Factor of Aortic Event.

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