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Recent data suggest a pathophysiological role of aging and immuno-senescence during polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), by definition rheumatic disease of the elderly. During aging, there is a decline in major physiological functions (immune system, muscle, cognitive, endocrine, cardiovascular, respiratory and renal functions), which combined with multi-morbidity, environmental factors and polypharmacy can lead to frailty. Frailty is a clinical syndrome and dynamic concept including a pre-frailty stage; it reflects a reduction in physiological reserve capacities which alters the mechanisms of adaptation to stress. It results in the inability of a vulnerable subject to return to baseline homoeostasis after minor stress, increasing the risk of hospitalization, loss of autonomy and death. To date, there are no consensual criteria for frailty and its assessment in clinical practice remains difficult, based either on physical criteria including weight loss, fatigue, reduction in muscular strength and walking, inactivity or on a multidimensional geriatric assessment. The impact on morbidity and mortality and quality of life, the possibility of detecting reversible stages of pre-frailty and of implementing preventive measures justify interest in rheumatology as the number of patients aged 65 years and older with inflammatory rheumatic diseases is increasing. If there are no specific recommendations for the management of frailty or pre-frailty, recommendations for exercises, physical activity and nutrition to limit sarcopenia and comorbidities can be applied. The association with multi-morbidity and its additive effect reinforces the need for screening, prevention and specific management of comorbidities, particularly infections, osteoporosis, cardiovascular diseases, during chronic inflammatory rheumatic diseases, PMR and GCA.

Apart from life-threatening and/or functional emergencies, treatment of vascular lesions in giant cell arteritis (GCA) is medical. Revascularization may be considered if the lesion remains symptomatic or progressive despite optimal medical treatment, provided that there is no disease-related inflammation, and always managed by a team of trained experts. The main risk associated with aortic involvement (aortitis) is the development of an aneurysm, most often in the thoracic aorta, after several years of progression. Indications and surgical techniques used to manage these aneurysms follow the recommendations for the general population. In peripheral artery disease, lesions are characterized by parietal thickening, stenosis and sometimes occlusion, which can lead to exertional claudication or chronic permanent ischemia. Open or endovascular surgical management of these stenotic lesions is frequently complicated by restenosis. The role of endovascular techniques in the management of inflammatory lesions is debated, but there is a preference for open surgery, particularly in the lower limbs. Cervical and cerebral arteries also present a risk of stenosis leading to stroke. Balloon dilation and/or stenting of cervical or cerebral arteries during GCA carries a high risk of rupture and restenosis, and remains a rescue treatment limited to certain specific cases of stroke where there are concerns about patient prognosis in the absence of intervention.

Background/purpose: Combination therapy with methotrexate (MTX) has shown to improve biologic Disease Modifying Rheumatic Drugs (bDMARD) survival in rheumatoid arthritis, but interest in MTX combination therapy in Psoriatic Arthritis (PsA) remains controversial. We conducted a systematic literature review and meta-analysis to study whether a combination therapy bDMARD and MTX improves bDMARD drug survival in PsA.

Methods: We performed a systematic literature review to identify all pertinent articles studying ts/bDMARDs drugs survival (TNF inhibitors (TNFi), IL-17, IL-23, IL-12/23 and JAK inhibitors) and MTX in PsA up until December 2023. Hazard ratio's (HR) were extracted. A random-effect model and inverse-variance method were used. Sensitivity and subgroup analyses were performed to identify sources of heterogeneity and to confirm the robustness of the results.

Results: 2,299 records were identified, and twenty studies were included, with a total of 30,634 patients with PsA. All studies were observational. Two studies involved bDMARDs other than TNFi. Combination therapy with MTX was found to be associated with a superior bDMARDs drug survival (HR = 0.82 [CI95%, 0.75, 0.89], p-value < 0.001, I²=45%) and TNFi drug survival (HR=0.79 [CI95%, 0.73, 0.86], p-value < 0.001, I²=27%). A meta-analysis for non-TNFi was not possible due to the limited number of publications.

Conclusion: This meta-analysis shows the positive association between combination therapy bDMARD with MTX and a better bDMARDs drug survival, especially with TNFi. Further studies are needed to confirm this hypothesis with robust evidence such as randomised controlled trials.