Polymyalgia rheumatica und Riesenzellarteriitis: Steroidsparende Therapie mit Immunsuppressiva und Biologika

Zusammenfassung

Glukokortikoide (GC) sind hochwirksame Medikamente zur Behandlung der Polymyalgia rheumatica (PMR) und der Riesenzellarteriitis (RZA), haben aber auch eine hohe Rate an unerwünschten Wirkungen. Gleichzeitig kommt es im Behandlungsverlauf häufig zu Rezidiven der Erkrankung. Der Einsatz von immunsuppressiven Substanzen zur GC-Einsparung und besserer Kontrolle der Entzündung ist deswegen häufig notwendig. Die beste Evidenz gibt es für Methotrexat (MTX), welches in mehreren kontrollierten Studien bei PMR einen guten GC-sparenden Effekt gezeigt hat. MTX wird auch für die RZA eingesetzt, bei dieser Erkrankung sind die Daten jedoch uneinheitlich. Als Reservemedikament mit der Evidenz aus einer sehr kleinen kontrollierten Studie bei PMR und RZA gilt Azathioprin, während Leflunomid und verschiedene andere Immunsuppressiva nur in Einzelfallberichten als wirksam beschrieben wurden. Neu ist der Einsatz von Biologika in dieser Indikation. Fallsammlungen berichten von einer guten Wirkung von TNF-Inhibitoren und dem IL-6-Rezeptor-Hemmstoff Tocilizumab bei therapierefraktären Fällen der RZA. Für Tocilizumab läuft derzeit eine prospektive, randomisierte Studie bei RZA. Der Einsatz von TNF-Inhibitoren primär zur ­GC-Einsparung bei RZA hat sich dagegen in prospektiven randomisierten Studien nicht bewährt.

Abstract

Treatment of polymyalgia rheumatica (PMR) and giant cell arteriitis (GZA) with glucocorticoids (GC) is associated with a high rate of adverse events. At the same time flares of the disease are frequent. Therefore, immunosuppressive drugs which help to reduce GC doses and improve control of inflammation are frequently needed. The best evidence exists for methotrexate (MTX), which has shown favourable effects as a GC-sparing agent in PMR. MTX is used for GCA as well. However, for this indication the data are heterogeneous. A second-line drug with evidence from a small controlled clinical trial is azathioprine, while leflunomide and different other immunosuppressive drugs were shown to be effective only in case reports. A novel approach is the use of biological drugs in this indication. Case series report about good effects of TNF-inhibitors and the inhibitor of IL-6-receptor tocilizumab in refractory cases of GCA. Tocilzumab is currently being investigated in a prospective, randomised clinical trial in GCA. The primary use of TNF-inhibitors as a GC-sparing agent in GCA however has not been shown to be effective in prospective randomised trials.

Schlüsselwörter

Immunsuppressiva - Biologika - Polymyalgia rheumatica - Riesenzellarteriitis

Key words

immunosuppression - biologics - polymyalgia rheumatica - giant-cell arteriitis

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