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

Stone, John H.; Tuckwell, Katie; Dimonaco, Sophie; Klearman, Micki; Aringer, Martin; Blockmans, Daniel Engelbert; Brouwer, Elisabeth; Cid, María C.; Dasgupta, Bhaskar; Rech, Juergen; Salvarani, Carlo; Schulze‐Koops, Hendrik; Schett, Georg; Spiera, Robert; Unizony, Sebastian; Collinson, Neil

doi:10.1002/art.40876

Cited by 75 publications

(60 citation statements)

References 26 publications

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“…Active LVLs of GCA without clinical signs and symptoms were demonstrated by PET-CT [47,48]. Previous studies also showed CRP elevation without clinical signs and symptoms was a common finding during tapering of PSL dose [42] or at relapse of the disease in GCA cohorts [13,17]. The present study also showed that elevation or re- elevation of CRP without clinical signs and symptoms was a common finding in the active GCA with LVLs at baseline or relapse.…”

Section: Discussionsupporting

confidence: 72%

“…Differential treatment response and discrepancy of the results in each cohort may be influenced by the definition of clinical remission and relapse, prevalence of LVLs, and severity of LVLs at baseline. CRP elevation without clinical signs and symptoms was not a reliable indicator of relapse of cranial lesions and PMR [42], while clinical signs and symptoms of active GCA were not necessarily observed in patients with progression of LVLs [22,36,[43][44][45][46]. Active LVLs of GCA without clinical signs and symptoms were demonstrated by PET-CT [47,48].…”

Section: Discussionmentioning

confidence: 99%

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Associated factors of poor treatment outcomes in patients with giant cell arteritis: clinical implication of large vessel lesions

et al. 2020

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Background: Relapses frequently occur in giant cell arteritis (GCA), and long-term glucocorticoid therapy is required. The identification of associated factors with poor treatment outcomes is important to decide the treatment algorithm of GCA. Methods: We enrolled 139 newly diagnosed GCA patients treated with glucocorticoids between 2007 and 2014 in a retrospective, multi-center registry. Patients were diagnosed with temporal artery biopsy, 1990 American College of Rheumatology classification criteria, or large vessel lesions (LVLs) detected by imaging based on the modified classification criteria. Poor treatment outcomes (non-achievement of clinical remission by week 24 or relapse during 52 weeks) were evaluated. Clinical remission was defined as the absence of clinical signs and symptoms in cranial and large vessel areas, polymyalgia rheumatica (PMR), and elevation of C-reactive protein (CRP) levels. A patient was determined to have a relapse if he/she had either one of the signs and symptoms that newly appeared or worsened after achieving clinical remission. Re-elevation of CRP without clinical manifestations was considered as a relapse if other causes such as infection were excluded and the treatment was intensified. Associated factors with poor treatment outcomes were analyzed by using the Cox proportional hazard model.

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Section: Discussionsupporting

confidence: 72%

Section: Discussionmentioning

confidence: 99%

Associated factors of poor treatment outcomes in patients with giant cell arteritis: clinical implication of large vessel lesions

et al. 2020

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“…The assessment of possible relapse in the face of normal levels of acute phase reactants might be hampered in patients treated with anti-IL-6 receptor drugs, which can cause an apparent normalization of inflammatory markers even in the presence of active inflammation. In a sub-analysis of the GiACTA trial, almost all flares (92%) in tocilizumab-treated groups occurred with a normal level of CRP, whereas 34% of flares occurred with normal CRP levels in patients receiving prednisone alone 46 . On the other hand, many patients receiving prednisone alone presented with elevated CRP levels without experiencing a clinical relapse.…”

Section: Wwwnaturecom/nrrheummentioning

confidence: 96%

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 this context, CRP is no indicator for the detection of flare in the treatment with prednisone plus tocilizumab. 3 The assessment of clinical symptoms in combination with imaging (eg, PET-CT) seems to be potential markers for the detection of a disease flare. Further studies were required to verify this finding.…”

Section: Descriptionmentioning

confidence: 99%

Refractory giant cell arteritis: the value of clinical symptoms and imaging

et al. 2020

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

Cited by 75 publications

References 26 publications

Associated factors of poor treatment outcomes in patients with giant cell arteritis: clinical implication of large vessel lesions

Associated factors of poor treatment outcomes in patients with giant cell arteritis: clinical implication of large vessel lesions

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

Refractory giant cell arteritis: the value of clinical symptoms and imaging

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