All patients with large-vessel vasculitis should be screened for treatment-related cardiovascular comorbidities, with prophylaxis and life-style counseling administered to mitigate the risk for complications, according to updated EULAR recommendations published in the Annals of the Rheumatic Diseases.
“In April 2008, the first recommendations of the European League against Rheumatism (EULAR) for managing [large-vessel vasculitis] were published,” Bernhard Hellmich, MD, of the Eberhard Karls University of Tübingen, Germany, and colleagues wrote. “These recommendations have provided guidance to clinicians and researchers and have been widely cited. Since then, the results of several randomized clinical trials and cohort analyses have become available and the EULAR recommendations on imaging in [large-vessel vasculitis] have been published recently.”
To update the original recommendations on the management of large-vessel vasculitis, considering new information that could change clinical care, Hellmich and colleagues formed a task force of 20 experts. This task force included rheumatologists, internists, immunologists, a neurologist, a neuro-ophthalmologist and an epidemiologist from 11 European countries, India and China. The group also included two fellows, one health professional and two patients.
Patients with large-vessel vasculitis should be screened for treatment-related cardiovascular comorbidities, according to updated EULAR recommendations.
Members of the task force used a Delphi survey to define eight key research questions, which in turn informed two systematic literature reviews, one focusing on general management of the disease and the other on treatment. After reviewing the results of the literature search, task force members met face-to-face to vote on each recommendation and overarching principle. Agreement on each point was ranked on a 0 to 10 scale via email following the meeting. The EULAR executive committee ultimately approved the final manuscript.
The task force drafted and approved three overarching principles and 10 recommendations. The overarching principles are:
- Care for patients with large-vessel vasculitis should be based on shared decision making between the patient and rheumatologist;
- Patients should have access to education regarding the disease’s impact, symptoms and treatment, as well as all possible treatment-related complications; and
- Patients with large-vessel vasculitis should be screened for cardiovascular comorbidities, and should receive prophylaxis and lifestyle counseling to reduce the risk for treatment-related complications.
In its recommendations, the task force urged that any suspected diagnosis of large-vessel vasculitis be confirmed by imaging or histology. In addition, high-dose glucocorticoid therapy — defined as 40 mg to 60mg per day prednisone-equivalent — should be administered immediately to induce remission in active giant cell arteritis or Takayasu arteritis. Adjunctive therapy with tocilizumab (Actemra, Genentech) in selected patients with giant cell arteritis, including those with refractory or relapsing disease, and those with an increased risk for glucocorticoid-related adverse events or complications, is also recommended. However, methotrexate could be used as an alternative.
According to the recommendations, nonbiological glucocorticoid-sparing drugs should be used in combination with glucocorticoids in all patients with Takayasu arteritis, and biological agents may be used in refractory patients or cases of relapse.
In a departure from the previous recommendations, EULAR no longer recommends the routine use of antiplatelet or anticoagulant therapy for large-vessel vasculitis, unless it is indicated for other reasons.
“We substantially revised the original recommendations for the management of [large-vessel vasculitis],” Hellmich and colleagues wrote. “Despite progress over the past 10 years, we acknowledge that many recommendations are still consensus-based. However, despite the low [level of evidence], the level of agreement for each recommendation was consistently high among the task force members. We encourage clinicians to implement these recommendations into their clinical practice in order to effectively manage [large-vessel vasculitis] and to improve the patients’ quality of care.” – by Jason Laday
Disclosure: Hellmich reports speaking and/or consulting fees from Abbvie, Boehringer, Chugai, Celgene, MSD, Pfizer, Novartis and Roche. Please see the full study for additional authors’ disclosures.