From the Guidelines
The treatment for Giant Cell Arteritis (GCA) requires immediate high-dose corticosteroid therapy, typically starting with prednisone at 40-60mg daily, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and takayasu arteritis 1.
Key Considerations
- Treatment should begin as soon as GCA is suspected, even before biopsy confirmation, to prevent vision loss.
- This initial high dose is maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize, followed by a gradual taper over 12-18 months.
- For patients with visual symptoms or complications, methylprednisolone pulse therapy (500-1000mg IV daily for 3 days) may be used initially, as suggested by the 2018 update of the EULAR recommendations for the management of large vessel vasculitis 1.
Steroid-Sparing Agents
- Steroid-sparing agents like tocilizumab (162mg subcutaneously weekly) are often added to reduce corticosteroid exposure and prevent relapses, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and takayasu arteritis 1.
- Methotrexate (15-25mg weekly) or leflunomide may be alternatives.
Additional Recommendations
- Low-dose aspirin (81mg daily) is recommended to reduce the risk of ischemic complications.
- Regular monitoring of symptoms, inflammatory markers (ESR, CRP), and potential steroid side effects is essential throughout treatment.
- Bone protection with calcium, vitamin D supplements, and bisphosphonates should be initiated with steroid therapy to prevent osteoporosis, as suggested by the 2018 update of the EULAR recommendations for the management of large vessel vasculitis 1.
Important Considerations
- The decision to treat with tocilizumab and glucocorticoids, methotrexate and glucocorticoids, or glucocorticoid monotherapy for initial therapy should be made based on the physician’s experience and the patient’s clinical condition, values, and preferences, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and takayasu arteritis 1.
- The dosing and duration of oral glucocorticoid therapy can be variable depending on a patient’s manifestations and comorbidities and whether the use of a glucocorticoid-sparing agent was also initiated, as suggested by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and takayasu arteritis 1.
From the Research
Treatment Overview
- The treatment of Giant Cell Arteritis (GCA) is primarily based on glucocorticoids, which significantly reduce the risk of ischemic complications and rapidly relieve symptoms 2, 3, 4.
- The initial dose of prednisone or its equivalent should be at least 40-60mg per day, and the treatment course usually lasts for 1-2 years 3.
Initial Treatment
- For patients with suspected GCA and acute visual or neurologic signs or symptoms, therapy should be initiated immediately with high-dose intravenous methylprednisolone sodium succinate, followed by high-dose oral prednisone 2.
- For patients without visual or neurologic symptoms, therapy may begin directly with oral prednisone 2.
Tapering and Duration
- Prednisone should be tapered by 10 mg per day every month, and the taper and duration should be modified according to erythrocyte sedimentation rate, C-reactive protein, and signs and symptoms of GCA 2.
- Most patients require 1 year of therapy to avoid relapse, but some may need low doses of glucocorticosteroids for several years 3.
Alternative Treatments
- Methotrexate has been used as a glucocorticosteroid-sparing drug, and studies have shown that it can reduce the number of relapses and the cumulative dose of prednisone 5, 6.
- Tocilizumab is also being considered as a glucocorticoid-sparing treatment, and its efficacy is being discussed 4.
- Low-dose aspirin has been shown to decrease the rate of cranial ischemic complications secondary to GCA 3.