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Introduction of a fracture risk assessment service incorporating VFA and a one-stop pathway has enhanced vertebral fracture identification and targeting of treatment and management.

Data availabilityThe data that support the findings of this study are available from the corresponding author upon reasonable request.

BackgroundPrimary large vessel vasculitides encompass giant cell arteritis and Takayasu's arteritis. The mainstay of treatment is glucocorticoids, with immuno-suppressants such as methotrexate and azathioprine being used as steroid-sparing agents (1). In the Rheumatology Department at the Royal Hallamshire Hospital, Sheffield, UK mycophenolate mofetil (MMF), a reversible inhibitor of inosine monophosphate dehydrogenase necessary for the growth of B and T cells, has been used as an alternative immuno-suppressant. There is limited data supporting its effectiveness in patients with large vessel vasculitis (2), but anecdotal evidence from clinical practice in Sheffield has shown it to be effective. The aim of this retrospective study is to evaluate the effectiveness of MMF in the treatment of patients with large vessel vasculitis in terms of reduction in steroid dose, reduction in inflammation (C-reactive protein) and overall tolerability of the drug.MethodsA retrospective review of 35 patients with large vessel vasculitis (23 large vessel vasculitis, 5 temporal arteritis, 4 Takayasu's arteritis, 2 aortitis and 1 giant cell arteritis) taking MMF between January 2008 and December 2013 was undertaken. The patient list was created by searching electronically saved clinic letters for the keywords large vessel vasculitis, aortitis, Takayasu's, giant cell arteritis, temporal arteritis and mycophenolate mofetil. Reductions in steroid dose and CRP and adverse effects to MMF were assessed.ResultsThe patients, 29 women and 6 men with a mean age of 64, had been taking MMF in doses of between 1.5g once daily to 1.5g twice daily for between 1 and 10 years. MMF had a steroid sparing effect in 34 patients (97%) and in 6 cases the steroids were discontinued. 28 patients (80%) experienced a reduction in their CRP over the study period, and 21 (60%) had a CRP of less than 5 at the end of December 2013. The mean CRP at initiation of MMF was 24.1 and at the end of the study period it was 7.6. 28 patients continued taking MMF, 25 (71%) at the highest doses prescribed. 13 patients (37%) experienced adverse events whilst taking MMF, but these led to the termination of treatment in only 3 cases (9%). 4 patients (11%) had additional medications added in to the mycophenolate.ConclusionsMMF is an effective and well tolerated treatment for large vessel vasculitis. This retrospective review showed it to have a steroid sparing effect in 97% of patients and to lead to a reduction in CRP in 80%. 37% of patients experienced adverse events but these led to the discontinuation of MMF in only 9%. The results are comparable with those from previous studies demonstrating the effectiveness of MMF in the treatment of large vessel vasculitis, but they augment the evidence by incorporating larger patient numbers over a longer follow-up period.ReferencesMukhtyar C, Guillevin L, Cid M, et al. EULAR recommendations for the manangement of large vessel vasculitis. Annals of the Rheumatic Diseases 2009:68: 318-323.Kotter I, Henes J, Wagner A, et al. Does glucocorti...

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BackgroundThe mainstay of treatment for large vessel vasculitis is glucocorticoids. Immuno-suppressants, including mycophenolate mofetil (MMF) and methotrexate (MTX) are used as steroid-sparing agents.1 A previous study at our centre showed MMF to have a steroid sparing effect in 97% of patients and to reduce C-reactive protein (CRP) in 80%.2 ObjectivesThis study was undertaken to compare the efficacy of MMF or MTX combined with prednisolone or prednisolone alone in the treatment of large vessel vasculitis.MethodsPatients with large vessel vasculitis (LVV) confirmed on positron emission tomography (PET) scan and those meeting ACR criteria for a diagnosis of giant cell arteritis (GCA), treated with prednisolone alone, prednisolone with MMF or prednisolone with MTX started within 3 months of prednisolone being commenced and with a minimum follow up of 24 months were included in a retrospective single centre study. CRP and prednisolone doses were recorded at baseline, after 3, 6, 9, 12, 18 and 24 months of treatment and area under the curve (AOC) calculated for CRP and prednisolone doses. Median AOC prednisolone dose for patients treated with MMF or MTX was then compared with that of patients treated with prednisolone alone. A quantile regression model was also constructed to compare prednisolone dose between the 3 treatment groups, adjusted for CRP. StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP was used for all statistical calculations.Results65 patients were included in the study, 41 with GCA and 24 LVV. 49 were female and 16 male. Mean age at diagnosis was 68; range 21 to 87. 37 patients were treated with prednisolone alone; 35 had GCA and 2 LVV. 20 were treated with MMF and prednisolone; 4 with GCA and 16 LVV. 8 were treated with MTX and prednisolone; 2 had GCA and 6 LVV. The AOC for prednisolone and CRP were not normally distributed across the cohort, and non-parametric methods were therefore used for comparisons. Median AOC prednisolone dose for the prednisolone only group was 68.0, (interquartile range (IQR) 17.7, n=37), for the MMF treated group 70.8 (IQR 28.7, n=20) and for the MTX treated group 67.8 (IQR 20.4 n=8). Median AOC CRP was highest in the group treated with prednisolone alone (58.9, IQR 34.5) compared to MMF (43.8, IQR 26.5) and MTX (49.3 IQR 67.5) but there were no statistical differences between median AOC prednisolone dose or CRP in either the unadjusted or regression models.ConclusionsNo significant difference was shown between the groups. MMF is as effective as MTX and prednisolone alone in the treatment of LVV. However, there are limitations to the study. The patient group was small. There was no randomisation to treatment group; treatment choice was based on clinician preference. There was potential bias in that patients perceived to be more difficult to treat may have been given MMF or MTX in addition to prednisolone, and there was a higher proportion of patients with LVV compared to GCA in the MMF and MTX treated groups.References[1] Mukhtyar C...