Clinical Rheumatology

, Volume 33, Issue 2, pp 227–236

Prednisolone combined with adjunctive immunosuppression is not superior to prednisolone alone in terms of efficacy and safety in giant cell arteritis: meta-analysis

  • M. Yates
  • Y. K. Loke
  • R. A. Watts
  • A. J. MacGregor
Original Article

Abstract

To conduct a meta-analysis of published data of the effectiveness of drug treatment in giant cell arteritis (GCA) to provide evidence to support the optimal use of glucocorticoids (GCs) and adjunct therapy. MEDLINE, CENTRAL and EMBASE searches were used to identify randomised control trials on the treatment of GCA. Studies included were trials in which: (1) the participants were classified as having GCA by the 1990 ACR criteria or biopsy proven disease; (2) parallel-group randomised control of at least 16 weeks duration had been conducted with at least 20 participants; (3) the design included either alternative adjunct immunosuppressant regimens, alternative GCs dosing or routes of administration; and (4) outcome data was included on either relapse rates or rates of infection. One thousand eight hundred thirty-six articles were retrieved, of which only 37 met the primary inclusion criteria. Sixteen of these studies reported some information about the GCs or adjuvant regimen used. Only ten studies were of sufficient quality to be included in the meta-analysis. Together these comprised 638 participants of which 72 % were female. Three studies compared various GCs regimens, with two comparing IV GCs, the latter showing a marginal benefit with respect to relapse (risk ratio (RR) = 0.78, 95 % CI = 0.54 to 1.12) but a greater risk of infection (RR = 1.58, 95 % CI = 0.90 to 2.78). Another three used methotrexate as an adjunctive agent and showed marginal benefit with respect to relapse (RR = 0.85, 95 % CI = 0.66 to 1.11). The remaining four trials compared prednisolone to dapsone, infliximab, adalimumab and hydroxychloroquine, respectively. There are various clinical trials of varying quality. The results from this meta-analysis show that the use of adjunct agents is not associated with improved outcome.

Keywords

Giant cell arteritis Glucocorticoids Immunosuppression Meta-analysis Treatment Vasculitis 

References

  1. 1.
    Smeeth L (2006) Incidence of diagnosed polymyalgia rheumatica and temporal arteritis in the UK, 1990–2001. Ann Rheum Dis 65(8):1093–1098. doi:10.1136/ard.2005.046912, published Online First: Epub DatePubMedCrossRefGoogle Scholar
  2. 2.
    Birkhead NC, Wagener HP, Shick RM (1957) Treatment of temporal arteritis with adrenal corticosteroids; results in fifty-five cases in which lesion was proved at biopsy. JAMA 163(10):821–827CrossRefGoogle Scholar
  3. 3.
    Shick RM, Baggenstoss AH, Fuller BF et al (1950) Effects of cortisone and ACTH on periarteritis nodosa and cranial arteritis. Proc Staff Meet Mayo Clin 25(17):492–494PubMedGoogle Scholar
  4. 4.
    Loddenkemper T, Sharma P, Katzan I et al (2007) Risk factors for early visual deterioration in temporal arteritis. J Neurol Neurosurg Psychiatry 78(11):1255–1259PubMedCrossRefGoogle Scholar
  5. 5.
    Gonzalez-Gay MA, Blanco R, Rodriguez-Valverde V et al (1998) Permanent visual loss and cerebrovascular accidents in giant cell arteritis: predictors and response to treatment. Arthritis Rheum 41(8):1497–1504. doi:10.1002/1529-0131(199808)41:8<1497::aid-art22>3.0.co;2-z, published Online First: Epub DatePubMedCrossRefGoogle Scholar
  6. 6.
    Proven A, Gabriel SE, Orces C et al (2003) Glucocorticoid therapy in giant cell arteritis: duration and adverse outcomes. Arthritis Rheum 49(5):703–708PubMedCrossRefGoogle Scholar
  7. 7.
    Mukhtyar C, Guillevin L, Cid MC et al (2009) EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis 68(3):318–323. doi:10.1136/ard.2008.088351, published Online First: Epub DatePubMedCrossRefGoogle Scholar
  8. 8.
    Dasgupta B, Borg FA, Hassan N et al (2010) BSR and BHPR Guidelines for the management of giant cell arteritis. Rheumatology. doi:10.1093/rheumatology/keq039b, published Online First: Epub DateGoogle Scholar
  9. 9.
    Matteson EL, Gold KN, Bloch DA et al (1996) Long-term survival of patients with giant cell arteritis in the American College of Rheumatology giant cell arteritis classification criteria cohort. Am J Med 100(2):193–196PubMedCrossRefGoogle Scholar
  10. 10.
    Gran JT, Myklebust G, Wilsgaard T et al (2001) Survival in polymyalgia rheumatica and temporal arteritis: a study of 398 cases and matched population controls. Rheumatology 40(11):1238–1242PubMedCrossRefGoogle Scholar
  11. 11.
    Narvaez J, Vives LL, Estrada P, et al (2010) Severe and opportunistic infections during giant cell arteritis course: A case–control study. Arthritis Rheum;Conference: American College of Rheumatology/Association of Rheumatology Health Professionals Annual Scientific Meeting, ACR/ARHP 10 Philadelphia, PA United States. Conference Start: 20091016 Conference End: 20091021. Conference Publication: (var.pagings). 62:1310Google Scholar
  12. 12.
    Mahr AD, Jover JA, Spiera RF et al (2007) Adjunctive methotrexate for treatment of giant cell arteritis: an individual patient data meta-analysis. Arthritis Rheum 56(8):2789–2797. doi:10.1002/art.22754, published Online First: Epub DatePubMedCrossRefGoogle Scholar
  13. 13.
    Public, Health, Resource, et al (2006) Critical appraisal skills programme (CASP): Making Sense of Evidence 10 Questions to Help You Make Sense of Randomised Controlled TrialsGoogle Scholar
  14. 14.
    Furukawa TA, Barbui C, Cipriani A et al (2006) Imputing missing standard deviations in meta-analyses can provide accurate results. J Clin Epidemiol 59(1):7–10. doi:10.1016/j.jclinepi.2005.06.006, published Online First: Epub DatePubMedCrossRefGoogle Scholar
  15. 15.
    Bengtsson BA, Malmvall BE (1981) An alternate-day corticosteroid regimen in maintenance therapy of giant cell arteritis. Acta Med Scand 209(5):347–50 Google Scholar
  16. 16.
    De Silva M, Hazleman BL (1986) Azathioprine in giant cell arteritis/polymyalgia rheumatica: a double-blind study. Annals of the rheumatic diseases 45(2):136–8 Google Scholar
  17. 17.
    Liozon F, Barrier J, Vidal E, et al (1990) Treatment of giant cell arteritis with dapsone: Effectiveness and side-effects. [French]. Revue de Medecine Interne 11(5):364–70 Google Scholar
  18. 18.
    Mariette X, Baron G, Hachulla E, et al (2011) Results of a randomized controlled study of adalimumab for steroid sparing in patients with giant-cell arteritis. Arthritis and Rheumatism 1) Google Scholar
  19. 19.
    Martinez-Taboada VM, Rodriguez-Valverde V, Carreno L, et al (2008) A double-blind placebo controlled trial of etanercept in patients with giant cell arteritis and corticosteroid side effects. Annals of the Rheumatic Diseases 67(5):625–30 Google Scholar
  20. 20.
    Schaufelberger C, Andersson R, Nordborg E (1998) No additive effect of cyclosporin a compared with glucocorticoid treatment alone in giant cell arteritis: Results of an open, controlled, randomized study [4]. British Journal of Rheumatology 37(4):464–65 Google Scholar
  21. 21.
    Hunder GG, Sheps SG, Allen GL et al (1975) Daily and alternate-day corticosteroid regimens in treatment of giant cell arteritis: comparison in a prospective study. Annals Intern Med 82(5):613–618CrossRefGoogle Scholar
  22. 22.
    Chevalet P, Barrier JH, Pottier P et al (2000) A randomized, multicenter, controlled trial using intravenous pulses of methylprednisolone in the initial treatment of simple forms of giant cell arteritis: a one-year follow up study of 164 patients. J Rheumatol 27(6):1484–1491PubMedGoogle Scholar
  23. 23.
    Mazlumzadeh M, Hunder GG, Easley KA et al (2006) Treatment of giant cell arteritis using induction therapy with high-dose glucocorticoids: a double-blind, placebo-controlled, randomized prospective clinical trial. Arthritis Rheum 54(10):3310–3318PubMedCrossRefGoogle Scholar
  24. 24.
    Spiera RF, Mitnick HJ, Kupersmith M et al (2001) A prospective, double-blind, randomized, placebo controlled trial of methotrexate in the treatment of giant cell arteritis (GCA). Clin Exp Rheumatol 19(5):495–501PubMedGoogle Scholar
  25. 25.
    Jover JA, Hernandez-Garcia C, Morado IC et al (2001) Combined treatment of giant-cell arteritis with methotrexate and prednisone: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 134(2):106–114PubMedCrossRefGoogle Scholar
  26. 26.
    Hoffman GS, Cid MC, Hellmann DB et al (2002) A multicenter, randomized, double-blind, placebo-controlled trial of adjuvant methotrexate treatment for giant cell arteritis. Arthritis Rheum 46(5):1309–1318PubMedCrossRefGoogle Scholar
  27. 27.
    Liozon F, Vidal E, Barrier JH (1993) Dapsone in giant cell arteritis treatment. Eur J Intern Med 4(3):207–214Google Scholar
  28. 28.
    Hoffman GS, Cid MC, Rendt-Zagar KE et al (2007) Infliximab for maintenance of glucocorticosteroid-induced remission of giant cell arteritis a randomized trial. Ann Internal Med 146(9):621–630CrossRefGoogle Scholar
  29. 29.
    Seror R, Baron G, Hachulla E et al (2013) Adalimumab for steroid sparing in patients with giant-cell arteritis: results of a multicentre randomised controlled trial. Ann Rheum Dis. doi:10.1136/annrheumdis-2013-203586, published Online First: Epub DateGoogle Scholar
  30. 30.
    Sailler L, Lapeyre-Mestre M, Geffray L, et al (2009) Adding hydroxychloroquine to prednisone does not improve the outcome in giant cell arteritis: A double blind randomized controlled trial. Arthritis Rheum;Conference: American College of Rheumatology/Association of Rheumatology Health Professionals Annual Scientific Meeting, ACR/ARHP 09 Atlanta, GA United States. Conference Start: 20101106 Conference End: 20101111. Conference Publication: (var.pagings). 60:1972Google Scholar
  31. 31.
    Seitz M, Reichenbach S, Bonel HM et al (2011) Rapid induction of remission in large vessel vasculitis by IL-6 blockade. A case series. Swiss Med Wkly 141:w13156. doi:10.4414/smw.2011.13156, published Online First: Epub DatePubMedGoogle Scholar
  32. 32.
    Christidis D, Jain S, Gupta BD (2011) Successful use of tocilizumab in polymyalgic onset biopsy positive GCA with large vessel involvement. BMJ Case Rep. doi:10.1136/bcr.04.2011.4135, published Online First: Epub DatePubMedGoogle Scholar
  33. 33.
    Salvarani C, Magnani L, Catanoso M et al (2012) Tocilizumab: a novel therapy for patients with large-vessel vasculitis. Rheumatology 51(1):151–156. doi:10.1093/rheumatology/ker296, published Online First: Epub DatePubMedCrossRefGoogle Scholar
  34. 34.
    Terrier B, Geri G, Chaara W et al (2011) IL-21 modulates Th1 and Th17 responses in giant cell arteritis. Arthritis Rheum. doi:10.1002/art.34327, published Online First: Epub DateGoogle Scholar
  35. 35.
    Deng J, Younge BR, Olshen RA et al (2010) Th17 and Th1 T-cell responses in giant cell arteritis. Circulation 121(7):906–915. doi:10.1161/circulationaha.109.872903, published Online First: Epub DatePubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Samson M, Audia S, Fraszczak J et al (2012) Th1 and Th17 lymphocytes expressing CD161 are implicated in giant cell arteritis and polymyalgia rheumatica pathogenesis. Arthritis Rheum 64(11):3788–3798. doi:10.1002/art.34647, published Online First: Epub DatePubMedCrossRefGoogle Scholar
  37. 37.
    Espígol-Frigolé G, Corbera-Bellalta M, Planas-Rigol E et al (2012) Increased IL-17A expression in temporal artery lesions is a predictor of sustained response to glucocorticoid treatment in patients with giant-cell arteritis. Ann Rheum Dis. doi:10.1136/annrheumdis-2012-201836, published Online First: Epub DatePubMedCentralGoogle Scholar
  38. 38.
    Direskeneli H, Aydin SZ, Kermani TA et al (2011) Development of outcome measures for large-vessel vasculitis for use in clinical trials: opportunities, challenges, and research agenda. J Rheum 38(7):1471–1479. doi:10.3899/jrheum.110275, published Online First: Epub DatePubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2013

Authors and Affiliations

  • M. Yates
    • 1
    • 2
  • Y. K. Loke
    • 3
  • R. A. Watts
    • 3
  • A. J. MacGregor
    • 1
    • 2
    • 3
  1. 1.Department of RheumatologyNorfolk and Norwich University HospitalColney LaneUK
  2. 2.University of East AngliaNorwich, NorfolkUK
  3. 3.Norwich Medical SchoolUniversity of East AngliaNorwichUK

Personalised recommendations