Takayasu Arteritis is a chronic inflammatory disease that affects large blood vessels. The document discusses challenges in managing the disease course and activity over time. It summarizes guidelines for determining disease activity versus remission using clinical features, biomarkers and imaging. Medical management focuses on controlling inflammation with steroids, DMARDs and biologics. Surgery is indicated for complications like aortic aneurysms or critical stenosis when disease is inactive.
2. Scenarios
• Among patients in “clinical remission” and on stable
medical therapy, what do we do if there is disease
progression?
• Among patients with fixed stenosis not amenable to
medical treatment, when do we send for intervention?
7. TAK Disease Course
• Control Inflammation
• Relieve symptoms
• Limit extent of vessel involvement
DISEASE ACTIVITY
80%
20%
• Monitor disease activity
• Corrective vascular interventions
TIME COURSE
Ma J, et al. J Vasc Surg 2010; 51: 700-6. Subramanyan R, et al. Circulation 1989, 80: 429-37
8. Biomarkers of Activity
Useful in Monitoring Not Useful
• ESR • Fibrinogen, Haptoglobin
• CRP (>2050ng/ml) • CRP
• Serum Amyloid A (SAA) • -Acid glycoprotein
• C4 Binding Protein (C4BP) • Serum Amyloid P
• Pentraxin3 (PTX3) • C4a, C3c
• Matrix Metalloproteinase-9 • Transthyretin
(MMP-9) • 1-microglobin
• MMP-2, MMP-3
Ishihara T, et al. Circulation J 2012: doi: 10.1253/circj.CJ-12-0131. Ma J, et al. J Vasc Surg 2010; 51: 700-6.
9. Biomarkers of Activity
Biomarker Active TA Inactive TA Controls P-value
ESR 39.1 + 24.8 15.2 + 9.6 11.3 + 5.1 <0.05
Elevated ESR (%) 83 28 0
SAA 95.9 (51.9) 49.2 (82) 23.9 (50.1) <0.005
C4BP 88.5 (72.6) 61.7 (57.7) 32.6 (32.1) <0.005
CRP 6.65 (18.1) 2.3 (5.75) 2.28 (1.58) 0.116
C4a 13.3 (13.6) 14.9 (10.4) 16 (23.9) 0.784
C3c 689.8 + 263 780.8 + 231 793 + 225 0.513
Values listed as Mean + SD or Median (Interquartile range)
Ma J, et al. J Vasc Surg 2010; 51: 700-6.
10. The IDEAL Imaging Modality in TAK
• Facilitate early diagnosis
• Provide assessment of disease extent
• Provide assessment of inflammatory activity
• Demonstrate response to treatment
• Distinguish vs. atherosclerotic plaques
Mason J. Nature Rev Rheum 2010.
11. Performance of Imaging Modalities
CT/ MR High Resolution 18F-FDG PET
Angiography Ultrasound Scan
Early diagnosis
Disease extent
Disease activity
Evaluate response
Differentiate vs.
atherosclerosis
Monitor every No SINGLE modality
6 MONTHS
for evidence of provides all the
progressive
vascular disease
information required.
Modalities may have distinct or
complementary roles in care.
Mason J. Nature Rev Rheum 2010.
12. Determining TAK Activity
National Institutes of Health (NIH) Criteria
• Systemic Features
• Elevated ESR or CRP
• Symptoms of Vascular Ischemia
• Typical Angiographic Features
New onset OR Worsening of any two of the
above criteria reflects disease activity.
Kerr GS, et al. Ann Int Med 1994.
13. Determining TAK Activity
REMISSION SUSTAINED REMISSION
• Absence of symptoms • Remission criteria for AT
• Normal inflammatory LEAST 6 months
markers • Steroid dose <10mg/day
• No new imaging findings
14. Controlling Disease Activity
Prednisone DMARDs
BIOLOGICS
Japan Guidelines MTX
• Starting dose: 20-30 mg/d AZA Infliximab*
• Maximum dose: 60 mg/d CsA Etanercept*
CYC
American College of Rheumatology Tocilizumab
• Max starting dose: 60 mg/d MMF
* Open-label trials
JCS Joint Working Group. Circ J 2011; 75: 474-503. Mukhtyar C, et al. Ann Rheum Dis 2008; doi:
10.1136/ard.2008.088351. Johnston SL, et al. J Clin Path 2002; 55: 481-486
15. Medical Management of TAK
Prednisone 0.5 – 1 mkd
Difficult to taper
Is disease
MTX 7.5 – 25mg/wk
AZA 2 mkd INACTIVE?
CsA 3 mkd (Can taper steroids)
CYC PO 50-100 mg/d
(IV 300-750 mg/m2 /mo)
Ineffective
MMF 1.5 – 3 mg/d
Ineffective
Infliximab 5mg/kg/dose Ineffective
Etanercept 25 mg 2/wk Tocilizumab 8 mg/kg/mo
JCS Joint Working Group. Circ J 2011; 75: 474-503. Johnston SL, et al. J Clin Path 2002; 55: 481-486
16. TAK Surgery
Best done during Inactive Phase
• Prevent restenosis, anastomotic failure, thrombosis,
hemorrhage and infection
If Urgent surgery during Active Phase
• ESR <30mm/hr
• CRP <1mg/dl
JCS Joint Working Group. Circ J 2011; 75: 474-503. Johnston SL, et al. J Clin Path 2002; 55: 481-486
17. Indications for TAK Surgery
• Aortic root dilation >50mm on CT
• Aortic coarctation
• Aortic valve regurgitation >75% EF
• Dilatation of branches of aorta >30mm
• Symptomatic cerebral ischemia
• Critical stenosis of >3 cerebral vessels
• Cardiac ischemia w/ confirmed CAD
• Renal artery lesions – esp those with HF, unstable angina,
renovascular HPN, decreased renal function
JCS Joint Working Group. Circ J 2011; 75: 474-503. Johnston SL, et al. J Clin Path 2002; 55: 481-486
18. Summary
• Reviewed the course of Takayasu Arteritis
• Discussed definitions of disease activity and remission
– Role of biomarkers
– Role of imaging studies
• Presented the medical management of Takayasu Arteritis
• Enumerated indications for surgical intervention