CLEVELAND — Kenneth J. Warrington, MD, professor of medicine at the Mayo Clinic College of Medicine, reviewed the current treatment for giant cell arteritis, the chronicity of the disease, treatment-related morbidity and vascular complications at the Primary Vasculitides Pre-symposium of the Biologic Therapies VII Summit.
“Giant cell arteritis is a chronic and systemic vasculopathy with potentially devastating complications,” Warrington said. “Our current treatment strategy — ie, glucocorticoid — certainly has some advantages, particularly with regard to loss of vision, but many significant limitations and morbidity.”
Kenneth J. Warrington
Warrington reviewed primary treatment with glucocorticoids, which includes either 1 gram per day of IV methylprednisolone for 3 days or between 40 mg and 60 mg of daily prednisone for 4 weeks followed by a 10% approximate taper for every 2 weeks to 4 weeks. He cited a study of a referral cohort that showed 24% of users continued glucocorticoids after 2 years and 54% discontinued after 5 years.
A benefit of glucocorticoids is less vision loss; however, the limitations include chronic vasculopathy, relapse, treatment-related morbidity and vascular complications, Warrington noted. He cited studies that found relapses in about 41% of a Spanish cohort, in 37% of a Reggio Emilia Italian cohort and in 34% of patients in a third study. In the third study, the median prednisone dose at time of relapse was 7.5 mg. Relapse symptoms include polymyalgia rheumatic, headache, constitutional symptoms and no vision loss. In the management of relapses, Warrington said to exclude mimics, increase glucocorticoids — depending on the relapse — and to use imaging if there are new vascular signs or symptoms.
He reviewed alternative treatment with methotrexate, which — according to a study published in Arthritis & Rheumatology — reduced the risk for first relapse by 35% and the risk for second relapse by 51%. However, Warrington noted that with methotrexate, there was no reduction of glucocorticoid-associated adverse events.
For adjunctive therapy, Warrington mentioned low-dose aspirin. He said this treatment has been controversial as there have been retrospective data, but has decreased the risk for ischemic events. He also mentioned statins; although, Warrington said these do not have a glucocorticoid-sparing effect.
Warrington also discussed glucocorticoid-related morbidity, as this treatment has an adverse event rate of up to 86% and may increase the risk for osteoporosis, glaucoma, hospitalization, serious infection, diabetes and fracture. In addition, Warrington talked about vascular complications — where large-vessel vasculitis is under-recognized — and thoracic aortic aneurysms, a late complication when the disease is clinically in remission.
“There is a great unmet need in giant cell arteritis or just vasculitis in general,” Warrington said. “We certainly await a more targeted and effective therapy with less toxicity.” – by Will Offit
Warrington KJ. “Giant cell arteritis: How do I take care of my patient?” Presented at: Biologic Therapies VII Summit; April 4-8, 2017; Cleveland.
Disclosure: Warrington reports he is an independent contractor, which includes contracted research, for GlaxoSmithKline.