Large vessel vasculitis (LVV) includes both giant cell arteritis (GCA) and Takayasu’s arteritis. Patients with LVV are occasionally treated with biological agents, but unfortunately, there is little evidence to support of the use of biological agents in this patient population, and current evidence is in the form of case series. In addition, both clinical trials and case studies are confounded by the variable definitions of disease remission used for LVV.
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Mohammed Osman, MD, a rheumatologist at the University of Alberta in Canada, and colleagues recently published a systematic review and meta-analysis of the subject in PLoS One.1 They identified 25 studies that reported on the use of five biological agents to treat patients with LVV. The studies included three randomized controlled trials (RCTs) and 22 case series of at least two cases. An evaluation of the case series revealed that eight were of good quality, 12 were of fair quality, and two were of poor quality.
The authors concluded that results from RCTs suggest that anti-tumor necrosis factor (anti-TNF) agents (infliximab, etanercept and adalimumab) are not effective in inducing remission of LVV or reducing corticosteroid (CS) use in patients with LVV.
However, some case series suggest that two biological agents may be beneficial for patients with LVV. For example, case series reported that 75 patients achieved remission following treatment with tocilizumab (anti-interleukin 6 receptor) and were able to reduce their CS dose. Case series also suggest that infliximab may be effective in the management of refractory Takayasu’s arteritis.
Published papers describe a total of 95 patients with GCA and 98 patients with Takayasu’s arteritis who have received biological agents. The publications include studies of patients with GCA who were treated with infliximab (35.6%), adalimumab (35.6%), tocilizumab (20%) and etanercept (8.4%). Patients with Takayasu’s arteritis were primarily treated with infliximab (76.5%), followed by tocilizumab (11.2%), etanercept (5.1%), rituximab (5.1%) and adalimumab (2.0%). Most of the patients (>75%) were female. Patients with GCA ranged in age from 58 to 85 years. As expected, patients with Takayasu’s arteritis were younger, ranging in age from 7 to 48 years.