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• Authors' Response
  Lawrence M. Buono
  Published on: 29 November 2004
• Aspirin therapy for Giant Cell Arteritis
  Imran Masood
  Published on: 28 September 2004

• Published on: 29 November 2004

  Authors' Response

  • Lawrence M. Buono, Neuro-ophthalmology
  • Other Contributors:
    • Rod Foroozan, and Peter J. Savino

  Dear Editor

  We thank Dr Masood for his interest in our manuscript [1]. Clearly in some cases of giant cell arteritis (GCA), treatment with high dose corticosteroids alone is insufficient. The use of adjunctive heparin proved to be beneficial in our patient, although the reason is not clear [1]. Thrombocytosis has been shown to occur in a large percentage of patients with GCA [2, 3]. However, there is no convin...

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  Dear Editor

  We thank Dr Masood for his interest in our manuscript [1]. Clearly in some cases of giant cell arteritis (GCA), treatment with high dose corticosteroids alone is insufficient. The use of adjunctive heparin proved to be beneficial in our patient, although the reason is not clear [1]. Thrombocytosis has been shown to occur in a large percentage of patients with GCA [2, 3]. However, there is no convincing evidence that thrombocytosis plays a direct role in the ischemic complications of GCA [3].

  While anticoagulation may have been responsible for the improvement of blood flow in our patient, other biochemical activities of heparin such as prevention of inflammation may have also been at work. The value of adjunctive aspirin therapy may not lie with its anti-thromobotic effect, but rather with an interruption of the inflammatory cascade.

  While the preliminary data regarding the value of adjunctive aspirin use in the treatment of GCA is compelling [4], we believe that there is insufficient evidence at this time to place all patients on adjunctive aspirin therapy. We advocate further research to compare the effectiveness the combination of corticosteroid and aspirin treatment versus corticosteroid therapy alone.

  References

  (1) Buono LM, Foroozan R, de Virgiliis M, Savino PJ: Heparin therapy in giant cell arteritis. Br J Ophthalmol 2004, 88:298-301.

  (2) Foroozan R, Danesh-Meyer H, Savino PJ, et al.: Thrombocytosis in patients with biopsy-proven giant cell arteritis. Ophthalmology 2002, 109:1267-71.

  (3) Costello F, Zimmerman MB, Podhajsky PA, Hayreh SS: Role of thrombocytosis in diagnosis of giant cell arteritis and differentiation of arteritic from non-arteritic anterior ischemic optic neuropathy. Eur J Ophthalmol 2004, 14:245-57.

  (4) Nesher G, Berkun Y, Mates M, et al.: Low-dose aspirin and prevention of cranial ischemic complications in giant cell arteritis. Arthritis Rheum 2004, 50:1332-7.

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  Conflict of Interest:
  None declared.

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• Published on: 28 September 2004

  Aspirin therapy for Giant Cell Arteritis

  • Imran Masood, SHO Ophthalmology

  Dear Editor

  I read with interest Buono et al's paper [1]. They describe in detail the value of anti-coagulant therapy in the management of giant cell arteritis. The role of anti-platelet agents however is not considered. It has been known for a number of years that thrombocytosis [2] and platelet hyper-reactivity [3] are features of giant cell arteritis. Experimental studies have shown that aspirin effectively sup...

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  Dear Editor

  I read with interest Buono et al's paper [1]. They describe in detail the value of anti-coagulant therapy in the management of giant cell arteritis. The role of anti-platelet agents however is not considered. It has been known for a number of years that thrombocytosis [2] and platelet hyper-reactivity [3] are features of giant cell arteritis. Experimental studies have shown that aspirin effectively suppresses the production of interferon-gamma, essential for the development of an inflammatory infiltrate within the vessel wall [4]. Therefore in addition to an anti- platelet effect, aspirin therapy may reduce this infiltrate, and the consequent severe luminal narrowing that Buono et al. decribe in their patient. Moreover, a recent retrospective study of 166 patients has shown that cranial ischemic complications developed in only 3% of the aspirin- treated patients, compared with 13% of the patients treated with steroid alone [5]. Given this early evidence it makes intuitive sense to treat patients with giant cell arteritis using a combination of steroids and aspirin in the first instance. Clearly heparin therapy may still have a role to play in patients with severe complications but aspirin therapy should be considered as part of the initial therapy following diagnosis.

  References

  (1)Buono LM, Foroozan R, de Virgiliis M, Savino PJ. Heparin therapy in giant cell arteritis
  Br. J. Ophthalmol., Feb 2004; 88: 298 - 301.

  (2) Foroozan R, Danesh-Meyer H, Savino PJ, Gamble G, Mekari-Sabbagh ON, Sergott RC. Thrombocytosis in patients with biopsy-proven giant cell arteritis. Ophthalmology. 2002 Jul;109:1267-71.

  (3) Riddle JM, Bluhm GB, Pitchford WC et al. A comparative study of platelet reactivity in arthritis. Ann N Y Acad Sci. 1981;370:22-9.

  (4) Brack A, Rittner HL, Younge CK et al. Glucocorticoid-mediated repression of cytokine gene transcription in human arteritis-SCID chimeras. J. Clin Invest 1997;99:2842-2850.

  (5) Nesher G, Berkun Y, Mates M, Baras M, Rubinow A, Sonnenblick M. Low -dose aspirin and prevention of cranial ischemic complications in giant cell arteritis. Arthritis Rheum. 2004 Apr;50:1332-7.

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  Conflict of Interest:
  None declared.

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