Development of an evidence-based regimen of prednisolone to treat giant cell arteritis – the Norwich regimen

Mukhtyar, Chetan; Cate, Heidi; Graham, Conor; Merry, P; Mills, Karen; Misra, Aseema; Jones, Colin

doi:10.1093/rap/rkz001

Cited by 13 publications

(9 citation statements)

References 48 publications

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“…GCA is a primary systemic vasculitis, which most commonly affects women in the eighth decade of life [ 1 ]. High-dose glucocorticoid therapy remains the cornerstone of treatment and is typically tapered over ∼2 years [ 2 , 3 ]. EULAR recommends that the core dataset for observational studies and routine clinical care should include the laboratory markers of haemoglobin, ESR and CRP [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

“…Individuals referred from primary care are assessed clinically within 48 h, and an US examination is performed within 7 days of starting prednisolone. All individuals in whom the clinical suspicion of GCA is retained are commenced on the Norwich regimen of prednisolone, as published previously [ 3 ]. While waiting for the US examination, as part of the routine baseline laboratory tests and in line with national guidance, it is standard of care at our institution to include HbA 1c as a method of glycaemic stratification for individuals who might find themselves on long-term prednisolone [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

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The relationship between glycated haemoglobin levels and the risk of giant cell arteritis – a case–control study

Mukhtyar

Myers

Jones

et al. 2020

Rheumatology Advances in Practice

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Objectives The EULAR core dataset for observational studies in giant cell arteritis (GCA) does not include glycated haemoglobin (HbA1c). A multivariable score to stratify pre-test probability of GCA also does not include HbA1c. There have been contradictory reports about Diabetes Mellitus (DM) being a risk factor for GCA. We report the first study analysing the relationship of pre-diagnosis HbA1c with the risk of GCA. Methods This was a single centre retrospective case-control study conducted in Norfolk, UK. All GCA cases were diagnosed with imaging or biopsy. Each case was assigned 2 age and gender-matched controls. The primary outcome measure was the glycaemic status (HbA1c categorised into euglycaemia, pre-diabetes, DM) at diagnosis between cases and controls. HbA1c between two groups was compared using the Mann-Whitney U test. The glycaemic categorisation was compared using the Chi-squared test. Results 112 cases and 224 controls were included. The median (IQR) of HbA1c of cases and controls was 40 (37, 43) and 41 (39, 47) (p < 0.001) respectively. 10/112 cases and 52/224 controls had DM. Chi-square test demonstrates significant interaction between glycaemic state and GCA (p = 0.006). Individuals with DM had an odds ratio (95% CI) of 0.32 (0.13,0.74) (p = 0.008) of having GCA compared to euglycaemic individuals. Conclusion HbA1c in the diabetic range reduces probability of GCA. HbA1c should be considered in any multivariable score to calculate risk of GCA, and in future development of diagnostic and classification criteria. There is need for an epidemiological study looking at the possibility of a protective nature of DM against GCA or whether it is just a mimic.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The relationship between glycated haemoglobin levels and the risk of giant cell arteritis – a case–control study

Mukhtyar

Myers

Jones

et al. 2020

Rheumatology Advances in Practice

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“…We have published our developments and continue to endeavour to improve the body of knowledge in this area. 2,5,6,15…”

Section: Discussionmentioning

confidence: 99%

“…We called it the 'Norwich prednisolone regimen', and presented it locally, nationally and in a peer-reviewed publication. 5 Since March 2011, all newly diagnosed patients with GCA were treated using that regimen. Improving care for GCA…”

Section: Improving the Patient Journeymentioning

confidence: 99%

Improving the quality of care for people with giant cell arteritis

et al. 2021

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Giant cell arteritis (GCA) is a systemic vasculitis with numerous potential complications and societal costs. After the publication of international guidelines, we found a number of deficiencies in the local care pathway of patients suspected to have GCA. These included poor referral and management pathways, and absence of dedicated monitoring and followup. In this paper, we describe a 10-year transformation which led to our service being nominated for a national award.A comprehensive consensus pathway saw referral numbers rise from 19 to 135 from 2012 to 2019. A consensus management pathway has meant that patients are assessed within 2 days of referral and glucocorticoids started at point of referral. All patients with suspected GCA are clerked and managed according to this agreed pathway which is available on the hospital intranet. The introduction of diagnostic ultrasonography has meant that the need for biopsies has dropped by >80% reducing the annual cost of diagnostics by >£140,000. The introduction of a vasculitis specialist nurse has resulted in improving education, contact and speed of access to our service. The improvements in the service resulted in our service becoming a finalist in the Royal College of Physicians Excellence in Patient Care Award in 2020.

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“…Historically, GCs have been the mainstay of treatment. A recent review identified a number of CS regimens, although these have not yet been validated, and variability in CS protocols in clinical practice remains an issue [ 6 ]. Moreover, GC toxicity is an increasing concern, with data attributing a significant proportion of morbidity to their adverse effects [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Stratified glucocorticoid monotherapy is safe and effective for most cases of giant cell arteritis

Karabayas

Dospinescu²,

Locherty³

et al. 2020

Rheumatology Advances in Practice

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Objectives High dose glucocorticoids anchor standard care in giant cell arteritis (GCA) but are associated with significant toxicity. We aimed to evaluate the safety and effectiveness of a stratified approach to glucocorticoid tapering. The strategy aggressively reduced glucocorticoid doses in those manifesting an adequate early response to treatment with view to minimising glucocorticoid complications. Methods A retrospective, population-based study of GCA was performed. All cases were confirmed by temporal artery biopsy between November 2010 and November 2015. Baseline and outcome data were extracted from secondary and primary care records at diagnosis and 1 year. The primary outcome was loss of vision. Secondary outcomes included remission and relapse rates as well as corticosteroid related complications. Results The cohort consisted of 73 patients (76% female; mean age 73.5, SD 7.6). At presentation reduction in visual acuity (VA) was recorded in n = 17 (22.3%). Median CRP at diagnosis was 69.5mg/L (IQR 40.5-101mg/L) with median ESR 80mm/h (IQR 60-91mm/hr). At 1 year, remission was achieved in n = 64 (87.7%) and n = 10 (13.7%) relapsed. A single patient sustained visual loss following initiation of therapy. Median CRP at 1 year was 4mg/L (IQR 4-9.5mg/L) and mean Prednisolone dose was 5.4mg (0-15mg). Steroid related complications were observed in n = 10(13.7%). Conclusion A stratified approach to corticosteroid tapering appeared safe and effective in GCA. It was associated with high rate of remission and promisingly low rates of relapse following 1 year follow up. This real-world data indicates glucocorticoid exposure can be safely minimised in some patients with GCA.

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Development of an evidence-based regimen of prednisolone to treat giant cell arteritis – the Norwich regimen

Cited by 13 publications

References 48 publications

The relationship between glycated haemoglobin levels and the risk of giant cell arteritis – a case–control study

The relationship between glycated haemoglobin levels and the risk of giant cell arteritis – a case–control study

Improving the quality of care for people with giant cell arteritis

Stratified glucocorticoid monotherapy is safe and effective for most cases of giant cell arteritis

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