Large-vessel vasculitis guidelines receive substantial overhaul

EULAR guidelines on large-vessel vasculitis (LVV) have received a ‘substantial overhaul’ to reflect several shifts in the evidence base in treating the disease since the guidelines were last published in 2009.

Professor Bernhard Hellmich, chair of the Department for Internal Medicine, Rheumatology and Immunology at Medius Kliniken in Germany, who led the guideline task force of clinical experts, health professionals and two patients, said the update represented a new set of recommendations rather than just a simple revision.

“Whilst the majority of the original recommendations addressed LVV in general, new data allowed us to offer separate recommendations for GCA and [Takayasu arteritis] for some key areas of management including the role of conventional immunosuppressants and biologic therapies.”

The new guidelines advise that a suspected diagnosis of LVV should be confirmed by imaging – whether ultrasound, MRI, CT or PET CT, replacing the routine use of biopsy.

And patients with LVV should be screened for treatment-related and cardiovascular comorbidities with prophylaxis and lifestyle advice given where necessary, state the guidelines published in the Annals of Rheumatic Diseases.

The routine use of antiplatelet or anticoagulant therapy for large-vessel vasculitis is no longer recommended unless it is indicated for other reasons.

Clinical trials done since the advice was last reviewed a decade ago have also prompted the updated recommendation of tociluzimab as an adjunctive treatment in some patients with giant cell arteritis including in refractory or relapsing disease or those at risk of complications or adverse effects from the condition.

The guidelines committee acknowledged that despite progress over the past 10 years,  many of the recommendations were still consensus-based.

“However, despite the low-LoE, the level of agreement for each recommendation was consistently high among the task force members. We encourage clinicians to implement these recommendations into their clinical practice in order to effectively manage LVV and to improve the patients’ quality of care,” they concluded.

Dr Chetan Mukhtyar, a consultant rheumatologist at the Norfolk and Norwich University Hospital and taskforce member said the recommendation on imaging for diagnosis was important because you could save a frail, elderly patient from having to undergo an invasive procedure and get them a faster diagnosis.

“In our centre we use ultrasound and only if that is negative and you still suspect the diagnosis will they have a biopsy.”

He said the evidence base had moved on a great deal since the last guidance was published and that includes the better understanding of cardiovascular risk in these patients.

Dr Mukhtyar added that there was a ‘caveat’ in the use of tociluzimab in England where the NHS only allowed its use for one year so it was reserved for the most needy patients.

“There are efforts to form a national register of tociluzimab so we can get real world data,” he added.

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