A Pilot Study in Severe Patients With Takayasu Arteritis.
A Pilot Study in Severe Patients With Takayasu Arteritis.
Takayasu arteritis (TAK) is a rare chronic inflammatory arteritis, which lacks an effective
 well-accepted intervention strategy. We classify TAK patients into 3 levels, including mild,
 moderate, and severe. And the biological agents tocilizumab and adalimumab are randomly
 prescribed in severe patients, to find out the relatively better treatment strategy,
 facilitating better intervention strategy in severe TAK patients.
The Takayasu arteritis (TAK) is a rare chronic inflammatory arteritis, which lacks an
 effective well-accepted intervention strategy. Previous studies have revealed that
 methotrexate, tofacitinib, adalimumab, and tocilizumab were effective in controlling disease
 activity and preventing disease relapse in some TAK patients, especially the latter two
 biological agents. However, we believed that different patients should be prescribed
 different drug combinations, i.e. personalized medicine, to obtain the optimal intervention
 effect.

 Here we tried to classify the TAK patients into three levels including mild, moderate, and
 severe, and prescribe different drug interventions to discover which biological agent is
 better in severe TAK patients.

 1. Patients were classified as mild, moderate, and severe groups according to the disease
 severity of TAK patients.

 1.1 Severe

 1. Severe hypertension

 1. Continuously upper limb systolic blood pressure ≥180mmHg or diastolic blood
 pressure ≥110mmHg;

 2. OR upper limb blood pressure cannot be measured if lower limb systolic blood
 pressure ≥200mmHg or diastolic blood pressure ≥120mmHg;

 3. With target organ damage due to hypertension;

 2. Aortic arch and its branches involved

 a. Multiple branches involved (two or more) and severe stenosis (stenosis rate ≥70%); b.
 stenosis rate ≥50%, accompanied by nervous system ischemic symptoms and/or signs; c.
 stenosis rate ≥50%, accompanied by a recent history of cerebrovascular events;

 3. The carotid artery and its branches involved

 1. Multiple branches (two or more) involved and severe stenosis (stenosis rate ≥70%);

 2. stenosis rate ≥50%, accompanied by nervous system ischemic symptoms and/or signs;

 3. stenosis rate ≥50%, accompanied by the recent history of cerebrovascular events;

 4. Pulmonary artery involvement

 a. Chest tightness, hemoptysis, dyspnea, radionuclide pulmonary ventilation/blood
 perfusion imaging or CTA suggesting pulmonary artery thrombosis with respiratory failure
 (type I); b. Chest tightness, shortness of breath, and cardiac ultrasound suggesting
 severe pulmonary artery hypertension with cardiac function abnormality (NYHA class III
 and above);

 5. The coronary artery involved

 1. The onset of unstable angina pectoris or myocardial infarction;

 2. Cardiac ultrasound indicating ischemic cardiomyopathy, NYHA class III and above;

 6. The aortic valve and aortic root involved

 1. Severe reflux of the aortic valve;

 2. OR aortic valve leakage, annulus tearing;

 3. OR aneurysm in the aortic root and/or ascending aortic (≥2 times in diameter);

 4. OR dilation of the aortic root and/or ascending aorta (≥5cm in diameter);

 5. OR dissection of the aortic root and/or ascending aorta; Any item of the above a -
 e is accompanied by abnormal cardiac function (NYHA III and above);

 7. Renal artery involved a. Severe stenosis of renal artery secondary to malignant
 hypertension (blood pressure is still 180 / 120mmHg after treatment with three or more
 antihypertensive drugs) b. Severe renal artery stenosis accompanied by a progressive
 increase in serum creatinine or a reduction in glomerular filtration rate (GFR) of ≥25%;

 8. Glucocorticoids and the traditional synthetic chemical immunosuppressants were of no
 use. And the disease is not well controlled with the severe injury of the organs.

 1.2 Moderate

 1. Hypertension

 a. Upper limb systolic blood pressure ≥160-180mmHg or / and diastolic blood pressure
 ≥100-110mmHg; b. OR upper limb blood pressure is unmeasurable or lower limb systolic
 blood pressure is ≥180mmHg or diastolic blood pressure is ≥100-110mmHg;

 2. Aortic arch and its branches involved

 a. 1-2 vessels are involved with moderate stenosis (stenosis rate ≥50%-<70%); b.
 Dizziness occurs during physical activity, and symptoms disappear in the resting state;

 3. The carotid artery and its branches involved

 a. Unilateral or bilateral vascular stenosis rate ≥50% -70%, with dizziness during light
 physical activity;

 4. Pulmonary artery involved

 a. Radionuclide pulmonary ventilation/blood perfusion imaging or CTA indicates pulmonary
 vascular disease; chest tightness after activity; Cardiac ultrasound indicates moderate
 pulmonary artery hypertension (pressure> 40-60mmHg), with abnormal cardiac function
 (NYHA class Ⅱ);

 5. Coronary artery involvement

 a. Chest tightness and chest pain after moderate activities, CTA showed 50% or more in
 coronary artery stenosis, abnormal cardiac function (NYHA class Ⅱ);

 6. The aortic valve and aortic root involved

 1. Moderate aortic regurgitation;

 2. Aortic root and/or ascending aortic aneurysm (diameter <2 times);

 3. Dilation of the aortic root and/or ascending aorta (diameter <5cm); Each item of a
 - c is accompanied by abnormal cardiac function (NYHA Class II);

 7. Renal artery involvement a. Renal artery stenosis rate ≥50%, and blood pressure 160-180
 / 110-120 (excluding 120) mmHg after treatment, or with left ventricular myocardial
 hypertrophy, hypertension and heart disease, CKD-II;

 1.3 Mild

 1. Hypertension

 1. Upper limb systolic blood pressure ≥140mmHg or diastolic blood pressure ≥90mmHg;

 2. OR upper limb blood pressure is unmeasurable or lower limb systolic blood pressure
 is ≥140mmHg or diastolic blood pressure is ≥90mmHg;

 2. Aortic arch and its branches involved a. Single or multiple lesions with mild stenosis
 (stenosis rate <50%), and without neurological ischemic symptoms and/or signs in daily
 activities;

 3. The carotid artery and its branches involved

 a. Single or multiple lesions with mild stenosis (stenosis rate <50%) and no
 neurological ischemic symptoms and/or signs during daily activities;

 4. The pulmonary artery involved

 1. Cardiac ultrasound indicates mild or normal pulmonary artery pressure (pressure
 30-40mmHg);

 2. Imaging shows pulmonary arteritis or pulmonary artery stenosis, occlusion a and b,
 with chest tightness, shortness of breath, and hemoptysis without activity; cardiac
 function (NYHA I), normal blood gas analysis;

 5. The coronary artery involved

 a. Chest tightness, shortness of breath, chest pain after inactivity; cardiac function
 (NYHA I);

 6. The aortic valve and aortic root involved

 1. Mild aortic regurgitation;

 2. Aortic root and / or ascending aortic aneurysm-like expansion (diameter <1.5
 times); a and b, each with cardiac function (NYHA I);

 7. Renal artery involved a. Renal artery stenosis rate <50%, without/with mild hypertension
 (see 1), or normal serum creatinine, normal or slightly impaired glomerular filtration
 rate (GFR);

 1.2. Based on the TAK patients in the ECTA cohort (Clinical trials. No: NCT03893136), we
 tried to compare the treatment efficacy of biological agents between tocilizumab (TCZ) and
 adalimumab (ADA) in severe TAK patients, with a pilot study.

 Other important detailed description of the study are listed as follows:

 1. Basic treatment of prednisone:

 The initial prednisone dose is 40mg.qd.po, and maintained for 1 month. After 1 month's
 treatment, the dose is gradually tapered to 15mg by 5mg per 2 weeks. Subsequently, the
 dose is decreased to 5mg by 2.5mg per 3 months. The 5mg is the final target maintained
 dose. In the treatment, if the relapse occurs, the dose of prednisone returned to the
 last dosage. For example, if the patient gets a relapse at the dose of 15mg of
 prednisone, then the dose of prednisone returned to 20mg.

 The relapse of TAK is defined according to the "2018 Update of the EULAR recommendations
 for the management of large vessel vasculitis". Relapse includes major relapse or minor
 relapse. Major relapse: Recurrence of active disease with either of the following: a.
 Clinical features of ischemia* (including jaw claudication, visual symptoms, the visual
 loss attributable to TAK, scalp necrosis, stroke, limb claudication). b. Evidence of
 active aortic inflammation resulting in progressive aortic or large vessel dilatation,
 stenosis or dissection. Minor relapse Recurrence of active disease, not fulfilling the
 criteria for the major relapse.

 2. ADA: 40mg bim IH.

 3. TCZ: 8mg/kg qm ivgtt.

 4. Treatment shift: if the TAK patients in ADA group failed to reach clinical remission at
 the end of 24th week, they would be shifted to TCZ group starting a new round of
 induction and complete the rest 24-week follow-up; and vice versa;

 In the follow-up, the disease remission and related markers are monitored.
Inclusion Criteria:

 1. age≥14 years old;

 2. active: Kerr score≥ 2;

 3. severe:

 1. Blood pressure > 180/110mmHg;

 2. ≥ 3 branches with the stenotic rate > 70% involved;

 3. high degree of organ insufficiency: NYHF III~IV; eGFR (MRDR) 15~ 60ml/min;

 Exclusion Criteria:

 1. Severe organ insufficiency;

 2. Acute or chronic active infections including tuberculosis, hepatitis virus, etc.;

 3. Other autoimmune diseases including systemic lupus erythematosus, Behcet disease, IgG4
 relative disease;

 4. malignant tumors;

 5. history of severe drug allergy;

 6. successive twice relapse occurs even after the intervention adjustment ( for the
 benefits of patients)