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Langzeitkomplikationen, Monitoring und interventionelle Therapien bei Großgefäßvaskulitiden

Long-term complications, monitoring and interventional treatment of large vessel vasculitis

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Zusammenfassung

Die Riesenzellarteriitis (RZA) und die Takayasu-Arteriitis (TAK) zählen zu den Großgefäßvaskulitiden und erfordern eine langfristige medikamentöse Therapie. Bei beiden Erkrankungen ist die Behandlung mit Glukokortikoiden (GC) erste Wahl, bei der RZA werden in therapieresistenten Fällen, bei Rezidiven oder bei erhöhtem Risiko für GC-Nebenwirkungen Immunsuppressiva wie Tocilizumab oder Methotrexat eingesetzt. Bei TAK-Patienten sollte bei allen Patienten eine Therapie mit Immunsuppressiva in Betracht gezogen werden. Im Verlauf der Erkrankung können sowohl krankheits- als auch therapieassoziierte Komplikationen auftreten. Zu den häufigsten krankheitsbezogenen Komplikationen gehören Visuseinschränkungen bis hin zur Erblindung bei der RZA sowie Gefäßstenosen, Aortenaneurysmata mit möglicher Dissektion bei RZA und TAK. Die perkutane transluminale Angioplastie (PTA) und die Stentimplantation sind minimal-invasive interventionelle Verfahren, die trotz einer Tendenz zu Restenosen eine risikoarme Therapieoption bei der TAK und der RZA darstellen. Abhängig von der Lokalisation und der klinischen Gesamtsituation sind interventionelle Verfahren gegenüber dem gefäßchirurgischen Vorgehen abzuwägen. Sämtliche Eingriffe sollten, wenn möglich, in einer Phase der stabilen Remission erfolgen. Für das Monitoring von Patienten mit RZA und TAK sind neben der Erfassung klinischer Erscheinungen v. a. das C‑reaktive Protein (CRP) und die Blutkörperchensenkungsgeschwindigkeit (BSG) geeignete Verlaufsparameter. Beide sind jedoch unter Interleukin-6-Blockade mit Tocilizumab nicht aussagekräftig. Der Wert von neuen Interleukin-6-unabhängigen Biomarkern ebenso wie die Bedeutung der Bildgebung (Sonographie, Magnetresonanzangiographie, Computertomographie, PET-CT [Positronenemissionstomographie-Computertomographie]) in der Verlaufsbeurteilung der RZA und TAK müssen noch weiter untersucht werden.

Abstract

Giant cell arteritis (GCA) and Takayasuʼs arteritis (TAK) both belong to the group of large vessel vasculitides and require long-term drug treatment. Glucocorticoids (GC) are the first choice for the treatment of both diseases. For GCA immunosuppressants, such as tocilizumab or methotrexate should be considered in cases of treatment refractory and relapses or if there is a high risk for GC-related adverse events. In TAK patients the use of immunosuppressive agents should be considered for all patients. In the course of the disease, severe disease-associated and treatment-associated complications can occur. The most frequent disease-associated complications include visual impairment up to blindness in GCA, as well as vascular stenoses with ischemia and aortic aneurysms with possible dissection in GCA and TAK. Percutaneous transluminal angioplasty (PTA) and stenting are minimally invasive, low-risk interventional procedures for GCA and TAK patients with clinically significant vascular stenoses, despite a tendency to restenosis. Interventional procedures should be weighed up against vascular surgical approaches depending on the localization and the total clinical situation. All interventions should be conducted in a phase of stable remission when possible. For monitoring of disease activity in patients with GCA and TAK, assessment of clinical manifestations as well as C‑reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) are useful; however, both are unreliable under interleukin‑6 block with tocilizumab. The value of new biomarkers independent from interleukin‑6 and the importance of imaging (sonography, magnetic resonance angiography, computed tomography and positron emission tomography-CT) for monitoring GCA and TAK still have to be investigated in future studies.

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Authors and Affiliations

  1. Rheumatologische Spezialambulanz, Krankenhaus der Barmherzigen Brüder Graz-Eggenberg, Bergstr. 27, 8010, Graz, Österreich

    E. Wipfler-Freißmuth

  2. Landesweiter Dienst für Rheumatologie, Südtiroler Sanitätsbetrieb, Krankenhaus Bruneck, Bruneck, Italien

    C. Dejaco

  3. Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland

    M. Both

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Correspondence to E. Wipfler-Freißmuth.

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E. Wipfler-Freißmuth, C. Dejaco und M. Both geben an, dass kein Interessenkonflikt besteht.

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B. Hellmich, Kirchheim-Teck

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Wipfler-Freißmuth, E., Dejaco, C. & Both, M. Langzeitkomplikationen, Monitoring und interventionelle Therapien bei Großgefäßvaskulitiden. Z Rheumatol 79, 523–531 (2020). https://doi.org/10.1007/s00393-020-00807-1

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