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Non-ANCA Vasculitis: Practical Tidbits for TREATMENT
June 16 2017 12:16 PM ET — via RheumReports
The benefit of MTX in GCA is often thought to be mild. In a meta-analysis published years ago MTX was found to be steroid-sparing (Mahr AD, et al, Arthritis Rheum. 2007 Aug;56(8):2789-97). A study presented at EULAR from a large Madrid clinic (D Frietes, et al, #THU0309) reported results on 168 GCA patients. When relapsing, a third were on steroids. Relapses were cut in half if they were on MTX vs. not on MTX (on MTX 34% relapsed, not on MTX 65% relapsed). We know that future treatments for giant cell arteritis (GCA) will include tocilizumab (TCZ) after its recent approval by the FDA and with other countries presumed to follow soon. This makes me wonder if protocols will be tested where TCZ is used for induction and eventually MTX for maintenance therapy, but this approach currently has no evidence.
Take home: MTX can be steroid-sparing and also prevent relapses in GCA.
A study of Beçet's with ocular involvement (LC Dominguez-Casas, #THU0326) reported that half of patients with ocular involvement had panuveitis, nearly 70% were HLA-B51 positive, but most interesting to me was the varied treatment failures prior to the use of adalimumab. Treatments included steroids, cyclosporine, azathioprine and methotrexate, and sometimes in combination. Adalimumab was generally effective in these refractory patients.
Take home: The standard of care for Beçet's uveitis is rapidly evolving with TNFi (adalimumab) showing benefit in refractory patients. Whether it should be used in earlier lines therapy is uncertain.
Takayasu's vasculitis has a poorer prognosis if it occurs in males (very rare), diagnosis is delayed and if there is cardiac/aortic involvement and hypertension. This was more predictive than inflammatory markers and treatment type (K Matsumoto, #THU0325).
Take home: Try to clarify the degree of aortic and cardiac involvement, and treat hypertension, since following inflammatory markers is insufficient to predict the outcome in these patients. Of course, adequate immune suppression is needed for patients with serious vascular involvement. I wonder if many of the patients who smolder and are not in full remission as many have residual elevated inflammatory markers and/or on MRI/MRA imaging they have ongoing vasculitis in the aortic arch and in other areas.
Treatment of IgG4 disease was reported in a large Spanish case series (A Fernandez-Codina, #THU0550) and many patients did well with steroids, azathioprine and surgery although 1 in 5 relapsed and 1 in 4 were treatment failures.
Take home: Many patients with IgG4 will do well with steroids and azathioprine but in those who fail or relapse, other options are needed. There have been case reports / series with the use of rituximab with promising results and an RCT is underway.
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About the Author
Dr. Janet Pope
Dr. Janet Pope is Professor of Medicine at Western University and Division Head of Rheumatology. Dr. Pope's research interests include epidemiologic studies in scleroderma, classification criteria in systemic sclerosis, systemic lupus erythematosus and rheumatoid arthritis.
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