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Corticosteroid monotherapy for the management of Takayasu arteritis—a systematic review and meta-analysis

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Abstract

We evaluated clinical response, normalization of inflammatory markers, angiographic stabilization (primary outcomes), relapses and adverse events (secondary outcomes) in Takayasu arteritis (TAK) patients following corticosteroid monotherapy. MEDLINE, EMBASE, Web of Science, Scopus, Pubmed Central, Cochrane library, clinical trial databases and major international Rheumatology conferences were searched for studies reporting outcomes in TAK following corticosteroid monotherapy (without language/date restrictions). Risk ratios were calculated for controlled studies. Proportions were pooled for uncontrolled studies. Heterogeneity was assessed using I2 statistic. Quality assessment of individual studies utilized the Newcastle–Ottawa scale. GRADE methodology ascertained certainty of individual outcomes across studies. Twenty-eight observational studies (1098 TAK) were identified. Twenty-three uncontrolled studies (580 TAK) were synthesized in meta-analysis. Clinical response was observed in 60% (95% CI 45–74%, 19 studies), normalization of inflammatory markers in 84% (95% CI 54–100%, 4 studies) and angiographic stabilization in 28% (95% CI 6–57%, 4 studies). Relapses occurred in 66% (95% CI 18–99%, 4 studies). Adverse events were reported in 51% (95% CI 2–99%, 4 studies). All pooled estimates had considerable heterogeneity, unexplained by subgroup analyses (time period, geographic location or number of patients). Two studies reported lesser restenosis following vascular surgery and fewer relapses when corticosteroids were combined with immunosuppressants compared with corticosteroid monotherapy. All outcomes had very low certainty. While corticosteroid monotherapy induces clinical response in most TAK patients, angiographic stabilization is observed in fewer than one-third. Most patients relapse following corticosteroid withdrawal. Preliminary evidence supports up-front addition of immunosuppressants to retard angiographic progression and reduce relapses (PROSPERO identifier CRD42021242910).

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Data availability

All the analyses performed for this systematic review have been reported in the main text or in the supplementary files. Data pertaining to the systematic review shall be shared on reasonable request to the corresponding author (Durga Prasanna Misra, durgapmisra@gmail.com).

Abbreviations

95% CI:

95% Confidence intervals

ACR:

American College of Rheumatology

APLAR:

Asia–Pacific League of Associations for Rheumatology

CENTRAL:

Cochrane Central Register of Clinical Trials

CRP:

C-reactive protein

DMARD:

Disease-modifying anti-rheumatic drug

ESR:

Erythrocyte sedimentation rate

EULAR:

European Alliance of Associations for Rheumatology

GRADE:

Grading of recommendations, assessment, development and evaluation

ICTRP:

International Clinical Trials Registry Platform

ITAS2010:

Indian Takayasu Clinical Activity Score

MOOSE:

Meta-analysis of observational studies in epidemiology

NIH:

National Institutes of Health

PET-CT:

Positron emission tomography computerized tomography

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

PRISMA-S:

PRISMA statement modified to include systematic searches across databases

PROSPERO:

International prospective register of systematic reviews

TAK:

Takayasu arteritis

Th1:

T helper 1

Th17:

T helper 17

Th17.1:

T helper 17.1

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Funding

Durga Prasanna Misra acknowledges support from Indian Council of Medical Research (Grant No 5/4/1-2/2019-NCD-II) for his research on Takayasu arteritis. The funding agency had no role in the actual conduct or reporting of this systematic review.

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Author notes

  1. Durga Prasanna Misra and Upendra Rathore are joint first authors.

Authors and Affiliations

  1. Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India

    Durga Prasanna Misra, Upendra Rathore & Vikas Agarwal

  2. School of Telemedicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India

    Pallavi Patro

  3. Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India

    Aman Sharma

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Contributions

The conception and design of the study: DPM, VA, AS; acquisition of data, analysis and interpretation of data: DPM, UR, PP; drafting the article: DPM, UR, PP; revising it critically for important intellectual content: VA, AS; final approval of the version to be submitted: DPM, UR, PP, VA, AS; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: DPM, UR, PP, VA, AS.

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Correspondence to Durga Prasanna Misra.

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Durga Prasanna Misra, Upendra Rathore, Pallavi Patro, Vikas Agarwal and Aman Sharma declares that they have no conflicts of interest, including no relationship with pharmaceutical companies.

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Misra, D.P., Rathore, U., Patro, P. et al. Corticosteroid monotherapy for the management of Takayasu arteritis—a systematic review and meta-analysis. Rheumatol Int 41, 1729–1742 (2021). https://doi.org/10.1007/s00296-021-04958-5

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