EULAR recommendations for giant cell arteritis, PMR prioritize remission as target
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The treatment target for patients with giant cell arteritis or polymyalgia rheumatica should be remission, with vascular damage prevention taking priority in patients with GCA, according to treat-to-target recommendations from EULAR.
“Treatment targets have already been defined in several areas of rheumatology, including rheumatoid arthritis (RA), spondyloarthritis (SpA), gout and systemic lupus erythematosus (SLE),” Christian Dejaco, MD, of the division of rheumatology and clinical immunology at Medical University of Graz, in Austria, and colleagues wrote in the Annals of the Rheumatic Diseases. “Moreover, studies have demonstrated that a targeted management approach yields superior outcomes than conventional care in terms of clinical course, long-term damage and functional status.
“Up to now, [treat to target (T2T)] is not a recognized treatment approach in GCA and PMR, and to this point there has not been a systematic evaluation and consensus finding process on this topic,” they added. “The development of T2T recommendations for GCA/PMR, therefore, addresses a current unmet medical need.”
To draft and approve new EULAR recommendations for treatment targets in patients with GCA and PMR, Dejaco and colleagues formed an international, multidisciplinary task force. This 29-member task force included rheumatologists, internal medical doctors, a neuro-ophthalmologist, a patient representative and methodologists, representing 10 countries.
Following a virtual meeting to determine questions that the new recommendations should answer, the group conducted a systematic literature review of the MEDLINE, EMBASE and COCHRANE library databases. The searches included papers published through May 2022. To be included in the final analysis, records were required to have a sample size of more than 20 patients, be published in English, and be qualitative. Review findings were presented at a second virtual meeting, where attendees voted on individual statements for inclusion, which required a 75% or higher consensus on the first ballot.
The new recommendations include five overarching principles and six specific recommendations.
The overarching principles are:
- Management of GCA and PMR should include an awareness that the conditions overlap.
- Patients with GCA are considered to be in the midst of a medical emergency due to the possibility of vision loss.
- Patients should be able to receive detailed information regarding GCA and PMR.
- Disease management should be based on shared decision-making between the patient and physician.
- GCA and PMR management should focus on helping patients achieve maximum-possible quality of life while minimizing potential of damage.
The recommendations follow:
- The primary treatment target for GCA and PMR is remission, defined as the absence of clinical symptoms and systemic inflammation.
- Additionally, GCA therapy should focus on preventing tissue ischemia and vascular damage.
- Therapy selection for patients with both diseases should account for disease severity and the presence of any comorbidities.
- The presence of comorbidities may impact how physicians examine the achievability of remission.
- Remission should be maintained using the smallest, effective possible doses of medication.
- Patients should have their disease severity and activity monitored regularly.
“Despite the limited evidence, we expect these T2T recommendations contribute to high-quality clinical care in GCA and PMR,” Dejaco and colleagues wrote. “We anticipate that new developments in the management and assessment of disease states and outcomes will take place in the coming years, which will affect these recommendations and necessitate amending them.”
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