What is the treatment for giant cell arteritis?

Treatment of Giant Cell Arteritis

High-dose glucocorticoids combined with tocilizumab should be the initial treatment for giant cell arteritis (GCA), with glucocorticoids tapered gradually over time to minimize toxicity while maintaining disease control. 1

Initial Treatment

Glucocorticoid Therapy

• Start with high-dose oral glucocorticoids: 40-60 mg/day prednisone (or 1 mg/kg/day, maximum 60 mg) 1
• Administer daily rather than alternate-day dosing 1
• For patients with threatened vision loss or cranial ischemia:
  • Consider IV pulse methylprednisolone (250 mg-1 g/day for 1-3 days) before transitioning to oral therapy 1
• Maintain initial high dose for approximately 1 month, then begin gradual taper 1
  • At 3 months, aim for 10-15 mg/day 1
  • By 1 year, aim for ≤5 mg/day or complete discontinuation if possible

Adjunctive Therapy

• First-line adjunctive agent: Tocilizumab 1, 2

  • FDA-approved for GCA
  • Significantly reduces glucocorticoid requirements
  • Dosing: 162 mg subcutaneously weekly
  • Particularly beneficial for patients with:
    • Extracranial large vessel involvement
    • High risk for glucocorticoid toxicity
    • Relapsing disease

• Alternative adjunctive agent: Methotrexate 1

  • Consider when tocilizumab is contraindicated or unavailable
  • Dosing: 15-25 mg weekly
  • Less robust evidence compared to tocilizumab

Additional Therapy

• Low-dose aspirin (75-150 mg/day) should be prescribed to all patients without contraindications 1
  • Reduces risk of cardiovascular and cerebrovascular events
  • Consider gastric protection when initiating

Management of Relapses

1. For patients with disease relapse and cranial ischemic symptoms:

   • Add a non-glucocorticoid immunosuppressive agent (tocilizumab preferred)
   • Increase glucocorticoid dose 1

2. For patients with relapse while on moderate-to-high dose glucocorticoids:

   • Add a non-glucocorticoid immunosuppressive agent 1

3. For polymyalgia rheumatica symptoms:

   • May be controlled by increasing glucocorticoid dose alone 1

Monitoring

• Clinical monitoring is mandatory for all patients, even those in apparent remission 1

• Frequency depends on:

  • Disease duration and activity
  • Treatment regimen
  • Patient risk factors

• Include regular assessment of:

  • Clinical symptoms
  • Inflammatory markers (ESR, CRP)
  • Potential glucocorticoid adverse effects

• Important caveat: Isolated elevation of inflammatory markers without clinical symptoms warrants closer monitoring but not immediate treatment escalation 1

Duration of Therapy

• Most patients require at least 1-2 years of glucocorticoid therapy
• Some patients may need low-dose therapy for several years
• Tocilizumab may allow for more rapid glucocorticoid tapering and discontinuation

Common Pitfalls to Avoid

1. Delaying treatment while awaiting temporal artery biopsy results

   • Start treatment immediately upon clinical suspicion
   • Biopsy remains valuable even after 1-2 weeks of treatment 1

2. Tapering glucocorticoids too rapidly

   • Increases risk of relapse and vision loss
   • Follow a structured, gradual taper schedule

3. Failing to provide bone protection

   • All patients on glucocorticoids should receive calcium, vitamin D, and consider bisphosphonates

4. Overlooking large vessel involvement

   • Consider vascular imaging at diagnosis to evaluate extent of disease 1

5. Relying solely on inflammatory markers

   • Clinical assessment remains essential
   • Isolated marker elevation without symptoms requires monitoring, not treatment escalation 1