Takayasu Arteritis

11. Treatments for Takayasu arteritis
Rheumatologists are usually the specialists with the knowledge about Takayasu arteritis.
Other than that patients need consultation of a cardiologist, a vascular surgeon, a imaging/interventional radiologist and an obstetrician-gynecologist for pregnant patients.4 Patients with Takayasu arteritis requiring immunosuppressive drugs. Takayasu arteritis needs treatment to prevent further narrowing of affected arteries, controlling the inflammatory process and controlling hypertension. However, the narrowing that has already occurred often does not improve, even with drug treatment.6

Glucocorticoids (prednisone, prednisolone or others), often referred to as corticosteroids are usually the first line of treatment.
Therapeutic mediation includes corticosteroid therapy with or without cytotoxic agents.
The dose and length of treatment depends on the disease activity and the complications that develop and how long the patient has had it. Most of the time long-term, low-dose corticosteroid therapy may be required.4
But, Long-term use of corticosteroids can lead to infection, adrenal suppression, cataracts, hyperglycemia, hypertension (which complicates blood pressure control), aseptic necrosis, weight gain, osteoporosis, menstrual irregularities and slower wound healing11, Osteoporosis prevention when patients are started on corticosteroids should be seriously considered.

Doctors suggest immune-suppressing drugs (Cytotoxic agents) over glucocorticoids because their side effects less serious. This is called “steroid-sparing” treatment. These medicines include methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide and drugs that block tumor necrosis factor (such as etanercept, adalimumab or infliximab)

There isn’t sufficient evidence to prove these drugs are effective in treating Takayasu arteritis.6
Research studies are ongoing to find new drugs to treat Takayasu arteritis.4
• IL-6 receptor inhibitor
• B-cell depletion
• Anti-tumor necrosis factor agents
Therapy for Takayasu arteritis also includes strict management of traditional cardiovascular risk factors such as hypertension, dyslipidaemia, and lifestyle factors that increase the risk of cardiovascular disease and treatment if these problems are present. These complications are the major cause of death in Takayasu arteritis.
 Cardiovascular risk factors
Some experts advise routine use of low-dose aspirin which have a therapeutic effect in large vessel vasculitis. It helps to prevent blood clots forming in damaged arteries.
Also Antiplatelet agents and heparin may useful in preventing stroke. Warfarin also has been used.
Lasting damage to arteries sometimes needs a vascular procedure or surgical treatment.
This may involve angioplasty (widening a narrowed or blocked blood vessel), with or without placement of a stent, to prop open the vessel.
Indications for surgical repair or angioplasty:4
• Renovascular stenosis causing hypertension
• Cerebral ischemia and/or critical stenosis of 3 or more cerebral vessels
• Coronary artery stenosis leading to myocardial ischemia
• Extremity claudication induced by routine activity
• Thoracic or abdominal aneurysms larger than 5 cm in diameter
• Aortic regurgitation
• Severe coactation of the aorta

Another treatment option is cardiovascular procedures.
Bypass grafting, a surgery to reestablish blood flow around a blockage in a blood vessel in order to improve perfusion of affected areas. It is a procedure with the best long-term patency rate.8
As a general rule, both endovascular intervention and surgical procedures should be avoided during the active phase of the disease. Earlier diagnosis, better assessment of disease activity and future clinical trials will obviously improve the management of Takayasu arteritis.12

Most patients survive at least for 5 yrs.
Only a proportion of these patients respond to treatment and few patients make a complete recovery.13

12. Conclusion
At first, Takayasu arteritis was reported as an eye disease and soon after it was confirmed as a vasculitis.
Takayasu arteritis is an idiopathic chronic inflammatory disease which affects the aorta and its main branches. It spreads world-wide but rare, and most of the cases are seen in Asian countries, more commonly among women. This usually presenting with non-specific symptoms of malaise, fever, fatigue or visual problems.
American College of Rheumatology Classification Criteria is used in diagnosing Takayasu arteritis. There are no specific laboratory tests to diagnose. However, angiography is the investigation of choice when suspecting an individual suffering from Takayasu arteritis. Glucocorticoids (steroids) are the mainstay of treatment for Takayasu arteritis, but for addressing the refractory cases additional therapy becomes necessary. Surgical treatment is limited to irreversible stenotic lesions as Takayasu arteritis mainly involves centrally placed large
arteries.14