Disease Relapses among Patients with Giant Cell Arteritis: A Prospective, Longitudinal Cohort Study

Abstract

Objective To evaluate the frequency, timing, and clinical features of relapses in giant cell arteritis (GCA). Methods Patients with GCA enrolled in a prospective, multicenter, longitudinal study were included in the analysis. Relapse was defined as either new disease activity after a period of remission or worsening disease activity. Results The study included 128 subjects: 102 women (80%) and 26 men (20%). Mean ± SD age at diagnosis of GCA was 69.9 ± 8.6 years. Mean followup for the cohort was 21.4 ± 13.9 months. Median (interquartile range) duration of disease at study enrollment was 4.6 months (1.2, 16.8). During followup, 59 relapses were observed in 44 patients (34%). Ten patients (8%) experienced 2 or more relapses. The most common symptoms at relapse were headache (42%) and polymyalgia rheumatica (51%), but ischemic (some transient) manifestations (visual symptoms, tongue or jaw claudication, and/or limb claudication) occurred in 29% of relapses (12% cohort). Forty-three relapses (73%) occurred while patients were taking glucocorticoid therapy at a median (range) prednisone dose of 7.5 (0–35) mg. In 21% of relapses, both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal. Among 69 patients enrolled in the cohort with newly diagnosed disease, 24% experienced a first relapse within 12 months after diagnosis. Conclusion Among patients with GCA, relapses are common, often occurring during treatment. ESR and CRP are frequently normal at times of clinical relapse, highlighting the need for better biomarkers to assess disease activity in GCA. There remains a need for effective therapeutic alternatives to glucocorticoids in GCA.

Glucocorticoid Dosages and Acute‐Phase Reactant Levels at Giant Cell Arteritis Flare in a Randomized Trial of Tocilizumab

“…Results from other trials with shorter prednisone tapers (12)(13)(14) and longitudinal studies using data from observational cohorts (15)(16)(17) have implied that the failure rate of glucocorticoid therapy for GCA is high. However, GiACTA is the first randomized clinical trial to use a prednisone-tapering regimen in GCA for as long as 1 year, and the first trial in any disease to use a variabledosage prednisone taper in which patients and investigators were blinded with regard to prednisone dosages.…”

Is vascular endothelial growth factor a useful biomarker in giant cell arteritis?

“…Despite early treatment with high-dose glucocorticoids, 34-79% relapse. [31][32][33][34] We cannot predict which patients are likely to relapse; identification of relapse is complicated by presentation with non-specific symptoms coupled with normal laboratory tests in up to 20%. 32 It is possible that VEGF may be a useful marker for the identification of relapsing patients, and this should be tested in future studies.…”

The Birmingham Vasculitis Activity Score as a Measure of Disease Activity in Patients with Giant Cell Arteritis

“…Previous clinical trials have used terms such as “relapses”, “recurrences”, “flares”, or “remission” to define disease activity and often take into consideration markers of inflammation (11–19). GCA is a chronic granulomatous vasculitis with observational cohorts reporting at least one disease relapse in 28–64% patients in (2–5, 7, 9, 10). While markers of inflammation such as sedimentation rate and C-reactive protein are neither sensitive nor specific in the assessment of disease activity (8, 26, 27), they are frequently used to assess disease activity in patients with GCA and may influence treatment decisions.…”

“…Glucocorticoids remain the mainstay of treatment for patients with GCA but treatment is associated with morbidity in the majority of patients (2). Additionally, relapses are common (2–10). Several randomized controlled trials have been conducted to evaluate other immunosuppressive therapy in patients with GCA (11–19).…”