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Seminars in Arthritis and Rheumatism Oct 2020Giant cell arteritis (GCA; sometimes referred to as temporal arteritis) and polymyalgia rheumatica (PMR) are common and interrelated inflammatory conditions that almost... (Review)
Review
BACKGROUND
Giant cell arteritis (GCA; sometimes referred to as temporal arteritis) and polymyalgia rheumatica (PMR) are common and interrelated inflammatory conditions that almost exclusively affect adults older than 50 years. There is a need for updated information on the epidemiology of these diseases.
OBJECTIVE
This systematic literature review (SLR) aims to summarize current evidence regarding the global incidence and prevalence of GCA and PMR.
METHODOLOGY
A systematic search of PubMed and Google Scholar databases from their inception dates to July 30, 2019 for relevant publications was performed. Studies that reported incidence and/or prevalence estimates for GCA and/or PMR were identified. When there were multiple studies of the same population, the most recent estimates were used. Details on source populations and case validation were systematically reviewed. Results were tabulated per region in the world.
RESULTS
Screening by 2 authors resulted in 2643 abstracts, of which 77 articles met the inclusion criteria. There were more studies on GCA compared to PMR, and more on incidence than on prevalence. Wide variations were found in study design and populations studied. Studies that included a thorough case validation tended to give lower estimates, in particular for PMR. The highest incidence per 100 000 aged ≥50 years of GCA was observed in studies from Scandinavia and the UK (14.6 to 43.6), and in Minnesota, USA (19.8 per 100 000). Corresponding estimates for Southern Europe were lower (1.1 to 11.1). Limited evidence indicates that GCA and PMR is less common in non-Caucasian populations. Prevalence estimates for PMR were ≥ 3 times higher than that of GCA in Caucasians.
CONCLUSION
This SLR provides up to date estimates of the occurrence of GCA and PMR in different populations around the world. The incidence of GCA is higher in populations of Northern European ancestry. Data on the epidemiology of PMR are more limited, with greater variation in incidence and prevalence estimates.
Topics: Databases, Factual; Giant Cell Arteritis; Humans; Incidence; Polymyalgia Rheumatica; Prevalence
PubMed: 32911281
DOI: 10.1016/j.semarthrit.2020.07.005 -
JAMA Internal Medicine Oct 2020Current clinical guidelines recommend selecting diagnostic tests for giant cell arteritis (GCA) based on pretest probability that the disease is present, but how pretest... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Current clinical guidelines recommend selecting diagnostic tests for giant cell arteritis (GCA) based on pretest probability that the disease is present, but how pretest probability should be estimated remains unclear.
OBJECTIVE
To evaluate the diagnostic accuracy of symptoms, physical signs, and laboratory tests for suspected GCA.
DATA SOURCES
PubMed, EMBASE, and the Cochrane Database of Systematic Reviews were searched from November 1940 through April 5, 2020.
STUDY SELECTION
Trials and observational studies describing patients with suspected GCA, using an appropriate reference standard for GCA (temporal artery biopsy, imaging test, or clinical diagnosis), and with available data for at least 1 symptom, physical sign, or laboratory test.
DATA EXTRACTION AND SYNTHESIS
Screening, full text review, quality assessment, and data extraction by 2 investigators. Diagnostic test meta-analysis used a bivariate model.
MAIN OUTCOME(S) AND MEASURES
Diagnostic accuracy parameters, including positive and negative likelihood ratios (LRs).
RESULTS
In 68 unique studies (14 037 unique patients with suspected GCA; of 7798 patients with sex reported, 5193 were women [66.6%]), findings associated with a diagnosis of GCA included limb claudication (positive LR, 6.01; 95% CI, 1.38-26.16), jaw claudication (positive LR, 4.90; 95% CI, 3.74-6.41), temporal artery thickening (positive LR, 4.70; 95% CI, 2.65-8.33), temporal artery loss of pulse (positive LR, 3.25; 95% CI, 2.49-4.23), platelet count of greater than 400 × 103/μL (positive LR, 3.75; 95% CI, 2.12-6.64), temporal tenderness (positive LR, 3.14; 95% CI, 1.14-8.65), and erythrocyte sedimentation rate greater than 100 mm/h (positive LR, 3.11; 95% CI, 1.43-6.78). Findings that were associated with absence of GCA included the absence of erythrocyte sedimentation rate of greater than 40 mm/h (negative LR, 0.18; 95% CI, 0.08-0.44), absence of C-reactive protein level of 2.5 mg/dL or more (negative LR, 0.38; 95% CI, 0.25-0.59), and absence of age over 70 years (negative LR, 0.48; 95% CI, 0.27-0.86).
CONCLUSIONS AND RELEVANCE
This study identifies the clinical and laboratory features that are most informative for a diagnosis of GCA, although no single feature was strong enough to confirm or refute the diagnosis if taken alone. Combinations of these symptoms might help direct further investigation, such as vascular imaging, temporal artery biopsy, or seeking evaluation for alternative diagnoses.
Topics: Biopsy; Blood Sedimentation; Clinical Laboratory Techniques; Giant Cell Arteritis; Humans; Physical Examination; Positron-Emission Tomography; Temporal Arteries; Ultrasonography
PubMed: 32804186
DOI: 10.1001/jamainternmed.2020.3050 -
Reumatologia 2020Temporal arteritis (TA) is an inflammatory vascular disease common in the European population. It is mainly characterized by sudden onset headache. TA is rarely...
Temporal arteritis (TA) is an inflammatory vascular disease common in the European population. It is mainly characterized by sudden onset headache. TA is rarely associated with other autoimmune diseases, such as Sjögren's syndrome (SS). We present the case of a Peruvian 71 year-old man with SS history, who was admitted to the emergency department due to severe headache evolved in 4 days, periocular pain and right ptosis. The authors also performed a systematic review of case reports or case series of patients diagnosed with both TA and SS. This temporal arteritis case is an atypical presentation because headache was characterized by mixed nociceptive and neuropathic pain components. Despite the infrequency, new studies should be carried out to identify comorbidities in TA patients.
PubMed: 32684652
DOI: 10.5114/reum.2020.96684 -
Rheumatology International Aug 2020To describe the prevalence of depression among patients with primary systemic vasculitides (PSV); compare prevalence according to vasculitis type and against controls;... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To describe the prevalence of depression among patients with primary systemic vasculitides (PSV); compare prevalence according to vasculitis type and against controls; and examine the impact of depression on PSV outcomes.
METHODS
We searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with PRISMA guidelines. We included all studies that reported the prevalence or impact of depression in PSV. We also included polymyalgia rheumatica (PMR) given its association with giant cell arteritis (GCA). Meta-analyses of prevalence estimates were performed using random-effects models and reported as percentages (95% confidence interval).
RESULTS
We reviewed a total of 15 studies that described the prevalence of depression, categorised into small (n = 10) and large vessel vasculitis (n = 7). Pooled prevalence estimate for depression in a small vessel (predominantly ANCA-associated) vasculitis was 28% (95% CI 20-38%) with significant heterogeneity (I = 93%). Depression prevalence in large-vessel vasculitis (Takayasu and GCA/PMR) was 24% (95% CI 17-34%), again with significant heterogeneity (I = 96%). One study reported 56% prevalence of depression in medium vessel disease. The prevalence of depression in small vessel vasculitis was higher than healthy controls. In these patients, depression and depressive symptoms were associated with poorer quality of life, adherence, and work disability, but not disease activity or damage.
CONCLUSION
Depression is highly prevalent among patients with primary systemic vasculitis and associated with poorer outcomes across a range of measures in studies of small vessel disease. Further studies are needed for depression in medium and large vessel vasculitides.
Topics: Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis; Case-Control Studies; Depression; Giant Cell Arteritis; Humans; Polymyalgia Rheumatica; Quality of Life
PubMed: 32494889
DOI: 10.1007/s00296-020-04611-7 -
Acta Neurologica Belgica Dec 2020Giant cell arteritis (GCA) may affect the brain-supplying arteries, resulting in ischemic stroke, whereby the vertebrobasilar territory is most often involved. Since...
Giant cell arteritis (GCA) may affect the brain-supplying arteries, resulting in ischemic stroke, whereby the vertebrobasilar territory is most often involved. Since etiology is unknown in 25% of stroke patients and GCA is hardly considered as a cause, we examined in a pilot study, whether screening for GCA after vertebrobasilar stroke might unmask an otherwise missed disease. Consecutive patients with vertebrobasilar stroke were prospectively screened for GCA using erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), hemoglobin, and halo sign of the temporal and vertebral artery on ultrasound. Furthermore, we conducted a systematic literature review for relevant studies. Sixty-five patients were included, and two patients (3.1%) were diagnosed with GCA. Patients with GCA were older in age (median 85 versus 69 years, p = 0.02). ESR and CRP were significantly increased and hemoglobin was significantly lower in GCA patients compared to non-GCA patients (median, 75 versus 11 mm in 1 h, p = 0.001; 3.84 versus 0.25 mg/dl, p = 0.01, 10.4 versus 14.6 mg/dl, p = 0.003, respectively). Multiple stenoses/occlusions in the vertebrobasilar territory affected our two GCA patients (100%), but only five (7.9%) non-GCA patients (p = 0.01). Our literature review identified 13 articles with 136 stroke patients with concomitant GCA. Those were old in age. Headache, increased inflammatory markers, and anemia were frequently reported. Multiple stenoses/occlusions in the vertebrobasilar territory affected around 70% of stroke patients with GCA. Increased inflammatory markers, older age, anemia, and multiple stenoses/occlusions in the vertebrobasilar territory may be regarded as red flags for GCA among patients with vertebrobasilar stroke.
Topics: Aged; Aged, 80 and over; Cross-Sectional Studies; Female; Giant Cell Arteritis; Humans; Incidence; Ischemic Stroke; Male; Pilot Projects; Vertebrobasilar Insufficiency
PubMed: 32323167
DOI: 10.1007/s13760-020-01344-z -
Chinese Medical Journal Apr 2020Takayasu arteritis-induced renal arteritis (TARA), commonly seen in Takayasu arteritis (TA), has become one of the main causes of poor prognosis and early mortality in...
BACKGROUND
Takayasu arteritis-induced renal arteritis (TARA), commonly seen in Takayasu arteritis (TA), has become one of the main causes of poor prognosis and early mortality in patients with TA. TARA progressing into Takayasu arteritis-induced renal artery stenosis (TARAS), could lead to severe complications including malignant hypertension, cardiac-cerebral vascular disease, and ischemic nephropathy. Since there existed no guidelines on treatments, this study aimed to review the comprehensive treatments for TARA.
METHODS
We searched systematically in databases including PubMed, Ovid-Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and SinoMed, from inception to May 2018. Literature selection, data extraction, and statistical analysis were performed.
RESULTS
Eighty-two literatures were recruited focusing on medical treatments (n = 34) and surgical treatments (n = 48). We found that combined medical treatments of glucocorticoids and conventional synthetic disease-modifying anti-rheumatic drugs could reach high rates of remission in patients with TARA, and biological disease-modifying anti-rheumatic drugs were preferred for refractory patients. After remission induction, surgical treatment could help reconstruct renal artery and recover renal function partly. Percutaneous transluminal angioplasty was the first choice for patients with TARAS, while open surgery showed a good long-term survival.
CONCLUSIONS
Patients with TARA should benefit both from medical treatments and from surgical treatments comprehensively and sequentially. Multidisciplinary team coordination is recommended especially in patients with severe complications.
Topics: Angioplasty; Antirheumatic Agents; Glucocorticoids; Humans; Renal Artery; Renal Artery Obstruction; Takayasu Arteritis
PubMed: 32187045
DOI: 10.1097/CM9.0000000000000704 -
The Journal of Headache and Pain Mar 2020Giant cell arteritis (GCA) remains a medical emergency because of the risk of sudden irreversible sight loss and rarely stroke along with other complications. Because...
BACKGROUND AND AIM
Giant cell arteritis (GCA) remains a medical emergency because of the risk of sudden irreversible sight loss and rarely stroke along with other complications. Because headache is one of the cardinal symptoms of cranial GCA, neurologists need to be up to date with the advances in investigation and management of this condition. The aim of this document by the European Headache Federation (EHF) is to provide an evidence-based and expert-based recommendations on GCA.
METHODS
The working group identified relevant questions, performed systematic literature review and assessed the quality of available evidence, and wrote recommendations. Where there was not a high level of evidence, the multidisciplinary (neurology, ophthalmology and rheumatology) group recommended best practice based on their clinical experience.
RESULTS
Across Europe, fast track pathways and the utility of advanced imaging techniques are helping to reduce diagnostic delay and uncertainty, with improved clinical outcomes for patients. GCA is treated with high dose glucocorticoids (GC) as a first line agent however long-term GC toxicity is one of the key concerns for clinicians and patients. The first phase 2 and phase 3 randomised controlled trials of Tocilizumab, an IL-6 receptor antagonist, have been published. It is now been approved as the first ever licensed drug to be used in GCA.
CONCLUSION
The present article will outline recent advances made in the diagnosis and management of GCA.
Topics: Antibodies, Monoclonal, Humanized; Delayed Diagnosis; Europe; Giant Cell Arteritis; Glucocorticoids; Headache; Humans; Neurologists; Polymyalgia Rheumatica; Practice Guidelines as Topic
PubMed: 32183689
DOI: 10.1186/s10194-020-01093-7 -
ACR Open Rheumatology Feb 2020To assess the current state of knowledge for the utility of coronary calcium scoring (CCS) in connective tissue disorders (CTDs) as it relates to the presence and...
OBJECTIVE
To assess the current state of knowledge for the utility of coronary calcium scoring (CCS) in connective tissue disorders (CTDs) as it relates to the presence and quantification of coronary atherosclerosis.
METHODS
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search via PubMed, Embase, Scopus, Web of Science Core Collection, CINAHL, and Cochrane Database of Systematic Review retrieved 1019 studies (since database inception on May 7, 2018) from which 121 manuscripts were eligible for review. Inclusion criteria consisted of studies that investigated CCS in adults with respective CTDs. Studies were excluded if a complete manuscript was not written in English or was a case report.
RESULTS
Thirty-one studies were included (27 with healthy age-/gender-matched control group for comparison and 4 without). CTDs analyzed in articles with control group: 11 rheumatoid arthritis (RA), 14 systemic lupus erythematosus (SLE), 4 systemic sclerosis (SSc), 1 idiopathic inflammatory myopathies (IIM), 1 Takayasu arteritis, and 1 psoriasis. Nine out of 11 RA studies, 12 out of 14 SLE studies, and 2 out of 4 SSc studies showed statistically significant increased CCS when compared with the control group. CTDs analyzed in studies without control group: two Kawasaki disease, one juvenile idiopathic arthritis (JIA), and one antiphospholipid syndrome (APS) article, which demonstrated increased coronary arterial calcium burden, however, without statistically significant data.
CONCLUSION
CTDs, especially SLE and RA, are associated with higher CCS compared with the control group, indicating increased risk of coronary atherosclerosis. Our search did not elicit sufficient publications or statistically significant results in many other CTDs.
PubMed: 32043830
DOI: 10.1002/acr2.11107 -
RMD Open 2019To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations.
METHODS
Two independent systematic literature reviews were performed, one on diagnosis and monitoring and the other on drugs and surgical treatments. Using a predefined PICO (population, intervention, comparator and outcome) strategy, Medline, Embase and Cochrane databases were accessed. Eligible papers were reviewed and results condensed into a summary of findings table. This paper reports the main results for Takayasu arteritis (TAK).
RESULTS
A total of 287 articles were selected. Relevant heterogeneity precluded meta-analysis. Males appear to have more complications than females. The presence of major complications, older age, a progressive disease course and a weaker inflammatory response are associated with a more unfavourable prognosis. Evidence for details on the best disease monitoring scheme was not found. High-quality evidence to guide the treatment of TAK was not found. Glucocorticoids are widely accepted as first-line treatment. Conventional immunosuppressive drugs and tumour necrosis factor inhibitors were beneficial in case series and uncontrolled studies. Tocilizumab failed the primary endpoint (time to relapse) in a randomised controlled clinical trial; however, results still favoured tocilizumab over placebo. Vascular procedures may be required, and outcome is better when performed during inactive disease.
CONCLUSIONS
Evidence to guide monitoring and treatment of patients with TAK is predominantly derived from observational studies with low level of evidence. Therefore, higher-quality studies are needed in the future.
Topics: Biomarkers; Combined Modality Therapy; Comorbidity; Diagnosis, Differential; Disease Management; Disease Susceptibility; Giant Cell Arteritis; Humans; Patient-Centered Care; Prognosis; Severity of Illness Index; Symptom Assessment; Takayasu Arteritis; Treatment Outcome
PubMed: 31673416
DOI: 10.1136/rmdopen-2019-001020 -
RMD Open 2019To analyse the current evidence for the management of large vessel vasculitis (LVV) to inform the 2018 update of the EULAR recommendations. (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVES
To analyse the current evidence for the management of large vessel vasculitis (LVV) to inform the 2018 update of the EULAR recommendations.
METHODS
Two systematic literature reviews (SLRs) dealing with diagnosis/monitoring and treatment strategies for LVV, respectively, were performed. Medline, Embase and Cochrane databases were searched from inception to 31 December 2017. Evidence on imaging was excluded as recently published in dedicated EULAR recommendations. This paper focuses on the data relevant to giant cell arteritis (GCA).
RESULTS
We identified 287 eligible articles (122 studies focused on diagnosis/monitoring, 165 on treatment). The implementation of a fast-track approach to diagnosis significantly lowers the risk of permanent visual loss compared with historical cohorts (level of evidence, LoE 2b). Reliable diagnostic or prognostic biomarkers for GCA are still not available (LoE 3b).The SLR confirms the efficacy of prompt initiation of glucocorticoids (GC). There is no high-quality evidence on the most appropriate starting dose, route of administration, tapering and duration of GC (LoE 4). Patients with GCA are at increased risk of dose-dependent GC-related adverse events (LoE 3b). The addition of methotrexate or tocilizumab reduces relapse rates and GC requirements (LoE 1b). There is no consistent evidence that initiating antiplatelet agents at diagnosis would prevent future ischaemic events (LoE 2a). There is little evidence to guide monitoring of patients with GCA.
CONCLUSIONS
Results from two SLRs identified novel evidence on the management of GCA to guide the 2018 update of the EULAR recommendations on the management of LVV.
Topics: Antibodies, Monoclonal, Humanized; Antirheumatic Agents; Biomarkers; Blindness; Drug Therapy, Combination; Female; Giant Cell Arteritis; Glucocorticoids; Humans; Male; Methotrexate; Observational Studies as Topic; Outcome Assessment, Health Care; Randomized Controlled Trials as Topic; Recurrence; Risk Management; Systemic Vasculitis; Takayasu Arteritis
PubMed: 31673411
DOI: 10.1136/rmdopen-2019-001003