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Biological-Targeted Treatments in Takayasu Arteritis
Study Questions:
What are the safety and efficacy of biologics (e.g., tumor necrosis factor-alpha [TNA-α] antagonists and tocilizumab) in patients with Takayasu arteritis (TA)?
Methods:
This was a retrospective, nationwide, multicenter analysis of 49 TA patients (80% female, median age 42) treated with TNF-α antagonists (80%) or tocilizumab (20%). All patients fulfilled either American College of Rheumatology and/or Ishikawa criteria for TA. Factors associated with complete response were assessed.
Results:
The main vascular signs included upper extremity claudication (30%), lower limb claudication (19%), vascular bruit (70%), decrease or absent radial pulse (48%), blood pressure difference >10 mm Hg (45%), carotidodynia (33%), and aortic regurgitation (16%). Eighty-eight percent of TA patients were either inadequately controlled with or intolerant to conventional immunosuppressive therapy. Overall response (complete or partial) to biological-targeted treatments at 6 and 12 months was 75% and 83%, respectively. C-reactive protein levels were lower at the time of biologic drug initiation in responders versus nonresponders (22 [10-46] mg/L vs. 58 [26-76] mg/L, p = 0.006). Responders also had a trend toward lower immunosuppressive drugs prior to starting biologics (p = 0.054). After 12 months of biologic therapy, C-reactive protein levels (30 vs. 6 mg/L, p < 0.005) and daily prednisone dosage (15 vs. 7.5 mg, p < 0.005) significantly decreased. The 3-year relapse-free survival was higher with biologic treatment versus disease-modifying antirheumatic drugs (DMARDs) (90.0% vs. 58.7%, p = 0.0025). There was no efficacy difference between TNF-α antagonists and tocilizumab. Over a median follow-up of 24 months, 21% of patients experienced adverse events, with biological-targeted treatment discontinuation in 6.6% of cases.
Conclusions:
The authors concluded that biological-targeted treatments are highly effective and acceptably safe for patients with refractory TA.
Perspective:
The authors used a nationwide registry of TA patients to describe the efficacy and safety of biological-targeted treatments in patients refractory to DMARDs. Most notable is that 93% of patients experienced either complete or partial resolution with biologic therapies, and that steroid doses were 50% lower in responders. The authors also describe the diverse array of vascular signs associated with TA. Clinicians need a high index of suspicion for TA among patients with vague symptoms and any number of vascular findings. After a systematic workup and diagnostic approach, clinicians have data to suggest that biologic agents are safe and effective for TA patients in whom DMARDs are not highly effective.
Keywords: Antirheumatic Agents, Aortic Valve Insufficiency, Biomarkers, Biological Therapy, Blood Pressure, C-Reactive Protein, Immunosuppressive Agents, Prednisone, Primary Prevention, Rheumatology, Takayasu Arteritis, Tumor Necrosis Factor-alpha, Vasculitis, Vascular Diseases
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