Page 851 - Clinical Immunology_ Principles and Practice ( PDFDrive )
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CHaPtEr 59  Large-Vessel Vasculitides             823


           Calcium and vitamin D supplementation should be part of the   Please check your eBook at https://expertconsult.inkling.com/
           therapeutic regimen.                                   for self-assessment questions. See inside cover for registration
             In many, but not all, patients, immunosuppressive treatment   details.
           can be discontinued 18–24 months after diagnosis. Markers of
           systemic inflammation may remain elevated, and continuous   REFERENCES
           monitoring for aortic involvement and recurrence of cranial
           arteritis is recommended.                               1.  Weyand CM, Goronzy JJ. Medium- and large-vessel vasculitis. N Engl J
                                                                    Med 2003;349(2):160–9.
             Most patients with PMR are sufficiently treated with an initial   2.  Salvarani C, Cantini F, Boiardi L, et al. Polymyalgia rheumatica and
           dose of 20 mg of prednisone per day. In some patients, 10 mg   giant-cell arteritis. N Engl J Med 2002;347(4):261–71.
           of prednisone can induce and sustain a clinical response. Steroids   3.  Nordborg E, Nordborg C. Giant cell arteritis: epidemiological clues to its
           should be titrated to minimally needed doses to avoid side effects;   pathogenesis and an update on its treatment. Rheumatology (Oxford)
           tapering usually needs to be slow, over many months. In TA,   2003;42(3):413–21.
           long-term management should be tailored to individual patient   4.  Vanoli M, Bacchiani G, Origg L, et al. Takayasu’s arteritis: a changing
                   44
           conditions.  It has been argued that patients should be maintained   disease. J Nephrol 2001;14(6):497–505.
           on a low dose of corticosteroids, such as 5–7 mg prednisone   5.  Isobe M. Takayasu arteritis revisited: current diagnosis and treatment. Int
           daily, even after successful control of active disease.  J Cardiol 2013;168(1):3–10.
             Given the age at disease onset in TA, preventive measures to   6.  Numano F, Kishi Y, Tanaka A, et al. Inflammation and atherosclerosis.
           counteract accelerated atherosclerosis and optimize blood pressure   Atherosclerotic lesions in Takayasu arteritis. Ann N Y Acad Sci
                                                                    2000;902:65–76.
           control are important aspects of management.            7.  Wagner AD, Goronzy JJ, Weyand CM. Functional profile of tissue-
             It has been suggested that up to 50% of patients with TA may   infiltrating and circulating CD68+ cells in giant cell arteritis. Evidence for
                                               44
           require a second immunosuppressive agent.  Steroid-sparing   two components of the disease. J Clin Invest 1994;94(3):1134–40.
           effects of methotrexate have been reported for some patients.   8.  Baldini M, Maugeri N, Ramirez GA, et al. Selective up-regulation of the
           Similarly, mycophenolate mofetil may have clinical efficiency,   soluble pattern-recognition receptor pentraxin 3 and of vascular
           although only published data on a small patient cohort are   endothelial growth factor in giant cell arteritis: relevance for recent optic
           available. Empirically, azathioprine may have a place in main-  nerve ischemia. Arthritis Rheum 2012;64(3):854–65.
           tenance therapy of patients with TA. Finally, there may be a place   9.  Nadkarni S, Dalli J, Hollywood J, et al. Investigational analysis reveals a
           for agents blocking TNF-α in patients with persistent disease   potential role for neutrophils in giant-cell arteritis disease progression.
                                                                    Circ Res 2014;114(2):242–8.
           activity. Results from well-designed placebo-controlled treatment   10.  Roche NE, Fulbright JW, Wagner AD, et al. Correlation of interleukin-6
           trials testing the efficiency of such immunosuppressive drugs   production and disease activity in polymyalgia rheumatica and giant cell
           are awaited.                                             arteritis. Arthritis Rheum 1993;36(9):1286–94.
             Detecting and treating hypertension is an essential component   11.  Weyand CM, Fulbright JW, Hunder GG, et al. Treatment of giant cell
           of caring for patients with TA. Untreated hypertension leads to   arteritis: interleukin-6 as a biologic marker of disease activity. Arthritis
           acceleration of atherosclerosis and cardiac insufficiency. In patients   Rheum 2000;43(5):1041–8.
           with upper-extremity involvement, obtaining accurate blood   12.  Stone JH, Tuckwell K, Dimonaco S, et al. Trial of tocilizumab in giant-cell
           pressure measurements is a challenge and requires education of   arteritis. N Engl J Med 2017;377:317–28.
           the patient and caregivers.                            13.  O’Neill L, Rooney P, Molloy D, et al. Regulation of inflammation and
                                                                    angiogenesis in giant cell arteritis by acute-phase serum amyloid A.
           Revascularization Procedures                             Arthritis Rheumatol 2015;67(9):2447–56.
                                                                  14.  Weyand CM, Goronzy JJ. Immune mechanisms in medium and
           Besides pharmacological therapy, revascularization procedures—  large-vessel vasculitis. Nat Rev Rheumatol 2013;9(12):731–40.
           including both surgical and endovascular interventions—have   15.  Pryshchep O, Ma-Krupa W, Younge BR, et al. Vessel-specific Toll-like
           vastly broadened therapeutic options in patients with TA and   receptor profiles in human medium and large arteries. Circulation
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           large-vessel GCA.  To minimize the risk of complications, such   2008;118(12):1276–84.
           as rapid reocclusion, an effort should be made to suppress vascular   16.  Ma-Krupa W, Jeon MS, Spoerl S, et al. Activation of arterial wall dendritic
           wall inflammation, ideally before subjecting the patients to   cells and breakdown of self-tolerance in giant cell arteritis. J Exp Med
           revascularization treatment. Conventional bypass grafts are still   2004;199(2):173–83.
           considered the method of choice. Percutaneous transluminal   17.  Krupa WM, Dewan M, Jeon MS, et al. Trapping of misdirected dendritic
           angioplasty can be useful in managing renal artery stenosis or   cells in the granulomatous lesions of giant cell arteritis. Am J Pathol
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           other short-segment lesions. Bypass surgery is needed in patients   18.  Weyand CM, Liao YJ, Goronzy JJ. The immunopathology of giant cell
           with cerebrovascular ischemia in whom catastrophic strokes may   arteritis: diagnostic and therapeutic implications. J Neuroophthalmol
           be prevented by bypassing critical stenosis of cervical vessels   2012;32(3):259–65.
           with grafts originating from the aortic arch. Reestablishing flow   19.  Weyand CM, Wagner AD, Bjornsson J, et al. Correlation of the
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           by multiple and long-segment stenosis, and arterial reconstruc-  tissue-infiltrating macrophages in giant cell arteritis. J Clin Invest
           tions with prosthetic graft materials or veins may be the only   1996;98(7):1642–9.
           alternative to obtain long-term patency. Placing of conventional   20.  Weyand CM, Schonberger J, Oppitz U, et al. Distinct vascular lesions in
           stents can be complicated by eliciting rapid restenosis, and it is   giant cell arteritis share identical T cell clonotypes. J Exp Med
           not known whether outcomes can be improved by drug-eluting   1994;179(3):951–60.
           stents. Occlusive disease of the coronary arteries usually represents   21.  Deng J, Younge BR, Olshen RA, et al. Th17 and Th1 T-cell responses in
                                                                    giant cell arteritis. Circulation 2010;121(7):906–15.
           a challenging clinical scenario, and most physicians opt for   22.  Watanabe R, Hosgur E, Zhang H, et al. Pro-inflammatory and
           conventional bypass surgery. Depending on symptoms, patients   anti-inflammatory T cells in giant cell arteritis. Joint Bone Spine 2016;pii:
           with aortic regurgitation may require repair of the weakened   S1297-319X(16)30124-5. doi:10.1016/j.jbspin.2016.07.005. [Epub ahead
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