eMedicine Specialties > Neurology > Inflammatory and Demyelinating Diseases

Takayasu Arteritis: Treatment & Medication

Author: Gabriel Bucurescu, MD, MS, Staff Neurologist, Neurology Service, Philadelphia Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Sep 17, 2009

Treatment

Medical Care

Medical management of Takayasu arteritis (TA) depends on the disease activity and the complications that can develop. Some patients have only mild forms of TA; others deteriorate considerably. The two most important aspects of treatment are controlling the inflammatory process and controlling the hypertension. Corticosteroids are the most important therapeutic agents and are necessary in active disease. Therapy is continued until patients achieve remission.

  • For patients who do not achieve remission on corticosteroids, cytotoxic agents such as methotrexate (0.3 mg/kg/wk) or cyclophosphamide (1 mg/kg/d) may prove effective; azathioprine (1 mg/kg) is another possible option. For relapses, combinations of the above can be tried. Success has also been reported with mycophenolate mofetil and tacrolimus hydrate.9
  • Hypertension is treated with antihypertensive agents, and aggressive therapy is necessary to prevent complications.
  • Antiplatelet agents and heparin may prove useful in preventing stroke. Warfarin also has been used. The literature reports a case of improvement in renal and systemic function with low-dose intravenous (IV) heparin therapy (10,000 U/d) followed by oral anticoagulant and antiplatelet agents.
  • Anti–tumor necrosis factor (TNF) agents have recently shown encouraging results in a small number of patients with relapsing TA.10 Anti-TNF may be a useful adjunct to glucocorticoid therapy; however, to date, a controlled clinical trial is lacking.

Surgical Care

Bypass surgery has been performed on patients with critical thoracic aortic arch arterial stenosis, upper and lower extremity ischemia, cerebrovascular accidents, and renal artery stenosis. The procedures are generally case specific. Certain issues, such as the timing of surgery in relation to disease activity or the advisability of surgery in symptom-free patients, have not been resolved. Anastomotic stenoses or graft occlusion is a potential complication of surgery. Short lesions respond well to percutaneous transluminal angioplasty.

Consultations

  • Cardiologist
  • Rheumatologist
  • Obstetrician-gynecologist for pregnant patients
  • Vascular surgeon

Diet

Diet modification is necessary to manage hypertension or renal failure.

Activity

Any limitations depend on the severity of the disease and complications.

Medication

The goals of therapy are to reduce inflammation and suppress autoimmune disease. To treat the active disease, corticosteroids are used and gradually tapered. Cytotoxic agents are the main therapeutic agents when the response to steroids is unsatisfactory.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.


Prednisone (Deltasone, Orasone)

Used in treatment of various allergic and inflammatory diseases. Also used as an immunosuppressant to treat autoimmune disorders. Decreases inflammation by reversing increased capillary permeability and suppressing PMN activity.

Adult

0.05-2 mg/kg/d PO divided bid/qid for 1-3 mo; after obtaining a satisfactory response, taper slowly

Pediatric

4-5 mg/m2/d PO; alternatively, administer 1-2 mg/kg PO qd; taper over 2 wk as symptoms resolve

Clearance may decrease when used concurrently with estrogens; when used concurrently with digoxin, may increase digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin also may increase metabolism of glucocorticoids (consider increase in maintenance dose); monitor patients for hypokalemia when taking this medication concurrently with diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin lesions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Patients who receive glucocorticoids are at risk of multiple complications, including severe infections; abrupt discontinuation of glucocorticoids may cause an adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

Cytotoxic agents

In patients not responding to prednisone, cyclophosphamide or methotrexate—either in combination with prednisone or alone—can be used to suppress the active disease.


Cyclophosphamide (Cytoxan)

Alkylating agent chemically related to nitrogen mustards. Mechanism of action of active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells; used as second-line agent in treating exacerbations of immune-mediated processes.

Adult

1 mg/kg/d IV

Pediatric

Administer as in adults

Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects of cyclophosphamide; also may potentiate doxorubicin-induced cardiotoxicity; conversely, digoxin serum levels may be reduced; antimicrobial effects of quinolones also may be reduced
May increase cyclophosphamide half-life while decreasing metabolite concentrations; may increase effects of anticoagulants
Rates of metabolism and leukopenic activity of cyclophosphamide are increased by long-term administration of high doses of phenobarbital; thiazide diuretics may prolong cyclophosphamide-induced leukopenia; also may prolong neuromuscular blockade by inhibiting cholinesterase activity

Documented hypersensitivity; severely depressed bone marrow function

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Regularly monitor patient's hematologic profile (particularly neutrophils and platelets) during treatment to determine degree of hematopoietic suppression; examine urine regularly for red cells, which may precede hemorrhagic cystitis


Methotrexate (Folex, Rheumatrex)

Mechanism of action in treatment of autoimmune diseases is unknown. May affect immune function. Effects can be observed as early as 3-6 wk following administration; used as second- or third-line drug to suppress active disease.

Adult

0.3 mg/kg/wk PO

Pediatric

Not established

Oral aminoglycosides may decrease absorption and blood levels of concurrent PO MTX; charcoal lowers plasma levels of both PO and IV MTX and may be particularly significant with high-dose therapies; etretinate may increase hepatotoxicity of MTX; folic acid or its derivatives (found in some vitamins) may decrease response
NSAIDs administered concurrently with MTX can cause a fatal interaction
Indomethacin and phenylbutazone can increase MTX plasma levels (mechanism of action is unknown but may involve inhibition of renal prostaglandin synthesis or competitive renal secretion)
Phenytoin serum concentrations may be decreased by MTX; probenecid, salicylates, and sulfonamides (including TMP-SMZ) may increase therapeutic and toxic effects of MTX; inhibition of renal tubular secretion, competition for a common elimination pathway, or protein displacement may be the mechanisms; if protein displacement is the mechanism, it may involve displacement of the highly bound metabolic 7-hydroxymethotrexate, since the parent drug is only 50% bound; procarbazine may increase nephrotoxicity of MTX; MTX may increase plasma levels of thiopurines

Documented hypersensitivity; alcoholism, alcoholic liver disease, or other chronic liver disease; patients with laboratory evidence of immunodeficiency syndromes or preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia) should not take this medication

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor hematology at least monthly and liver and renal function every 1-3 mo during therapy; during initial or changing doses or periods of increased risk of elevated MTX blood levels (eg, dehydration), more frequent monitoring may be indicated
Stop MTX immediately if significant drop in blood count; aspirin, NSAIDs, or low-dose steroids may be continued, although possibility of increased toxicity with concomitant use of NSAIDs (eg, salicylates) is unknown

Antihypertensive agents

Can be used to treat hypertension associated with arteritis. On occasion, combinations are required. Therapy can be individualized.


Nifedipine (Procardia)

One of the more common channel blockers used for hypertension associated with arteritis.

Adult

Immediate release dosage form: 10-30 mg PO tid; not to exceed 120-180 mg/d
Sustained-release dosage form: 30-60 mg PO qd; not to exceed 90-120 mg/d

Pediatric

0.25-0.5 mg/kg/dose PO tid/qid prn

May cause severe hypotension when taken concurrently with fentanyl; cimetidine may increase toxicity of nifedipine

Documented hypersensitivity to agent or adenosine

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Lower extremity edema has been associated; rare instances of allergic hepatitis have been reported

Antiplatelet agents

Help prevent CVAs and improve renal and systemic function. A formulation of extended-release dipyridamole and aspirin (Aggrenox) also recently has become available.


Ticlopidine hydrochloride (Ticlid)

Interferes with platelet membrane function by inhibiting ADP-induced platelet-fibrinogen binding and subsequent platelet-platelet interaction. Used as second-line antiplatelet therapy for patients who are intolerant to aspirin therapy or in whom such therapy fails.

Adult

250 mg PO bid

Pediatric

Not established

Corticosteroids and antacids may decrease effects; toxicity increases when taken concurrently with aspirin, theophylline, cimetidine, and NSAIDs

Documented hypersensitivity; caution in liver damage, neutropenia, or thrombocytopenia and with active bleeding disorders

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Discontinue if absolute neutrophil count falls to <1,200/µL or if platelet count falls to <80,000/µL


Clopidogrel (Plavix)

Thienopyridine derivative chemically related to ticlopidine that inhibits platelet aggregation; selectively inhibits ADP binding to its platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation.

Adult

75 mg PO qd

Pediatric

Not established

Concomitant administration of clopidogrel with naproxen associated with increased occult GI blood loss; administer NSAIDs and clopidogrel with caution
Prolongs bleeding time; safety of coadministration with warfarin has not been established, thus administer these 2 agents with caution

Documented hypersensitivity; active pathologic bleeding (eg, peptic ulcer, intracranial hemorrhage)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients who may be at risk of increased bleeding from trauma, surgery, or other pathologic conditions; caution in patients who have lesions with a propensity to bleed (eg, ulcers)
Cautiously use drugs such as aspirin and other NSAIDs that may increase such lesions in patients who are taking clopidogrel


Aspirin and extended-release dipyridamole (Aggrenox)

Drug combination with antithrombotic action.
Aspirin inhibits prostaglandin synthesis, preventing formation of platelet-aggregating thromboxane A2. May be used in low dose to inhibit platelet aggregation and improve complications of venous stases and thrombosis.
Dipyridamole is a platelet adhesion inhibitor that possibly inhibits RBC uptake of adenosine, itself an inhibitor of platelet reactivity. In addition, may inhibit phosphodiesterase activity leading to increased cyclic-3', 5'-adenosine monophosphate within platelets and formation of the potent platelet activator thromboxane A2.

Adult

25/200 mg PO bid

Pediatric

Not established

Theophylline may decrease hypotensive effects of dipyridamole; antiplatelet activity of dipyridamole may increase heparin toxicity
Aspirin effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs

Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; due to association of aspirin with Reye syndrome, do not use in children ( <16 y) with flu

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Aspirin may cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or who are taking anticoagulants
Caution in hypotension; dipyridamole has peripheral vasodilating effects

Anticoagulants

In patients with renal failure due to crescentic glomerulonephritis and nephrotic syndrome, low-dose heparin followed by oral anticoagulation leads to improved renal and systemic function. It probably reduces the destructive effects of fibrin thrombi in the small vessels of the kidney.


Warfarin (Coumadin)

Interferes with hepatic synthesis of vitamin K-dependent coagulation factors. Used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders.
Tailor dose to maintain an INR in the range of 2-3.

Adult

5-10 mg/d PO qd for 2-3 d; adjust dose according to desired INR

Pediatric

Not established

Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate
Medications that may increase anticoagulant effects of warfarin include oral antibiotics, capecitabine, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac

Documented hypersensitivity; severe liver or kidney disease; open wounds or GI ulcers

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis


Heparin

Augments activity of antithrombin III; does not actively lyse but is able to block further thrombogenesis; prevents reaccumulation of a clot after a spontaneous fibrinolysis.

Adult

Loading dose: 40-170 U/kg IV
Maintenance infusion: 18 U/kg/h IV
Alternatively, start with 50 U/kg/h IV, followed by a continuous infusion of 15-25 U/kg/h; increase dose by 5 U/kg/h q4h prn using aPTT results

Pediatric

Loading dose: 50 U/kg/h IV
Maintenance infusion: 15-25 U/kg/h IV; increase dose by 2-4 U/kg/h IV q6-8h prn using aPTT results

Digoxin, tetracycline, nicotine, and antihistamines may decrease effects; NSAIDs, aspirin, dipyridamole, dextran, and hydroxychloroquine may increase toxicity

Documented hypersensitivity; active bleeding and subacute bacterial endocarditis; history of heparin-induced thrombocytopenia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Some preparations contain the preservative benzyl alcohol; when used in large amounts, benzyl alcohol has been associated with fetal toxicity (gasping syndrome); preservative-free heparin is recommended in neonates; use with caution in patients who are diagnosed with shock or severe hypotension

Immunosuppressant agents

Inhibit key factors responsible for immune reactions.


Mycophenolate (Cellcept, Myfortic)

Inhibits inosine monophosphate dehydrogenase (IMPDH) and suppresses denovo purine synthesis by lymphocytes, thereby inhibiting their proliferation. Inhibits antibody production.
Two formulations are available and are not interchangeable. The original formulation, mycophenolate mofetil (MMF, Cellcept) is a prodrug that once hydrolyzed in vivo, releases the active moiety mycophenolic acid. A newer formulation, mycophenolic acid (MPA, Myfortic) is an enteric-coated product that delivers the active moiety.

Adult

Mycophenolate mofetil: 1 g/d PO/IV q12h
Mycophenolic acid: 720 mg PO bid; administer on empty stomach 1 h before or 2 h after meals

Pediatric

Not established

In combination with either acyclovir or ganciclovir may result in higher levels for both interacting drugs due to competition for renal tubular excretion; aluminum/magnesium present in some antacids, and cholestyramine containing products may decrease absorption, reducing levels (do not administer together); probenecid may increase levels of mycophenolate; salicylates and azathioprine may increase toxicity; may decrease levonorgestrel AUC; may decrease live virus vaccine immune response; when administered in combination with theophylline may increase free fraction levels of theophylline; may reduce blood levels hormones contained in oral contraceptives and could reduce effectiveness

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Increases risk for infection (monitor blood count); severe renal impairment (CrCl <25 mL/min) may have increased adverse effects due to increased free MPA; caution in active peptic ulcer disease; incidence of malignancies and lymphoma consistent with that reported for other immunosuppressants (0.9%); commonly causes constipation, nausea, diarrhea, urinary tract infection, and nasopharyngitis; rare reports include interstitial lung disorders, colitis, pancreatitis, intestinal perforation, GI hemorrhage, gastric ulcers, duodenal ulcers, and ileus; do not chew, crush, or cut Myfortic tab; women of childbearing potential must have a negative serum or urine pregnancy test must be completed within one week of beginning MMF and must receive contraceptive counseling and use effective contraception; continue contraception for 6 wk following discontinuing


Tacrolimus (Prograf)

Suppresses humoral (T-lymphocyte) immunity.

Adult

0.05 mg/kg/d IV or 0.15-0.3 mg/kg/d PO divided bid

Pediatric

0.1 mg/kg/d IV or 0.3 mg/kg/d PO

Caution with drugs associated with renal dysfunction, including aminoglycoside, amphotericin B, cisplatin, and others (can enhance nephrotoxicity); concentrations may be increased in presence of diltiazem, nicardipine, nifedipine, verapamil, clotrimazole, fluconazole, itraconazole, ketoconazole, clarithromycin, erythromycin, troleandomycin, cisapride, metoclopramide, bromocriptine, cimetidine, cyclosporine, danazol, methylprednisolone, and protease inhibitors; concentrations may decrease when administered with carbamazepine, phenobarbital, phenytoin, rifabutin, and rifampin

Documented hypersensitivity (including hypersensitivity reactions to tacrolimus or HCO-60 [polyoxyl 60 hydrogenated castor oil])

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Insulin-dependent diabetes reported in 20% of patients using tacrolimus for transplants, which is reversible in 15% after 1 year and in 50% after 2 years; increased risk for African American and Hispanic patients; nephrotoxicity, neurotoxicity, hyperglycemia, hyperkalemia, tremor, headache, and increased risk of lymphomas and other malignancies (especially skin tumors) may occur; anaphylaxis, hypertension, myocardial hypertrophy, gastrointestinal abnormalities, arthralgias, cramps, asthma, and bronchitis have been reported with its use


Azathioprine (Imuran)

Antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. May decrease proliferation of immune cells, which results in lower autoimmune activity.

Adult

1 mg/kg/d PO for 6-8 wk; increase by 0.5 mg/kg q4wk until response or dose reaches 2.5 mg/kg/d

Pediatric

Initial dose: 2-5 mg/kg/d PO/IV
Maintenance dose: 1-2 mg/kg/d PO/IV

Toxicity increases with allopurinol; concurrent use with ACE inhibitors may induce severe leukopenia; may increase levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine

Documented hypersensitivity; low levels of serum thiopurine methyltransferase (TPMT)

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Increases risk of neoplasia; caution with liver disease and renal impairment; hematologic toxicities may occur; check TPMT level prior to therapy and monitor liver, renal, and hematologic function; pancreatitis rarely associated

More on Takayasu Arteritis

Overview: Takayasu Arteritis
Differential Diagnoses & Workup: Takayasu Arteritis
Treatment & Medication: Takayasu Arteritis
Follow-up: Takayasu Arteritis
References
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Further Reading

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Keywords

aortic arch arteritis, aortitis syndrome, pulseless disease, brachiocephalic arteritis, occlusive thromboarteritis, nonspecific arteritis, occlusive thromboaortopathy, TA

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Contributor Information and Disclosures

Author

Gabriel Bucurescu, MD, MS, Staff Neurologist, Neurology Service, Philadelphia Veterans Affairs Medical Center
Gabriel Bucurescu, MD, MS is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, and American Epilepsy Society
Disclosure: Nothing to disclose.

Medical Editor

Sydney Louis, MB, BCh, MD, Emeritus Professor, Department of Neurology, Brown University School of Medicine
Sydney Louis, MB, BCh, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

,, Kathy Roarty Placeholder
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

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