What is the treatment for Giant Cell Arteritis (GCA)?

From the Guidelines

The treatment for giant cell arteritis (GCA) primarily involves high-dose corticosteroids, typically starting with prednisone at 40-60mg daily, as recommended by the most recent guidelines 1.

Key Considerations

• Treatment should begin immediately upon suspicion of GCA to prevent vision loss.
• This initial high dose is maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize, then gradually tapered over 12-18 months.
• For severe cases or those with visual symptoms, initial IV methylprednisolone pulse therapy (500-1000mg daily for 3 days) may be used.
• Tocilizumab, an IL-6 receptor antagonist, is now approved as a steroid-sparing agent, typically given as 162mg subcutaneously weekly, for patients with refractory or relapsing disease, or those at increased risk for glucocorticoid-related adverse events 1.
• Low-dose aspirin (81mg daily) is often added to reduce the risk of ischemic complications, although its use is not universally recommended 1.

Monitoring and Adjunctive Therapy

• Patients should be monitored regularly for disease activity and steroid side effects, including bone density assessment and prophylaxis against osteoporosis and Pneumocystis pneumonia for those on prolonged high-dose steroids.
• The decision to use adjunctive immunosuppressive therapy should be balanced against potential risks for treatment-related complications, and limited to patients who have already developed, or have an increased risk of developing glucocorticoid-related side effects or complications 1.

Evidence-Based Recommendations

• The 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of GCA and Takayasu arteritis provides evidence-based recommendations for the evaluation and management of these conditions 1.
• The guideline emphasizes the importance of prompt treatment with high-dose corticosteroids, and the use of tocilizumab as a steroid-sparing agent in selected patients.

From the Research

Treatment Overview

The treatment for Giant Cell Arteritis (GCA) primarily involves the use of corticosteroids, with the goal of reducing inflammation and preventing complications 2, 3, 4, 5, 6.

Corticosteroid Treatment

• The initial dosage of prednisone is typically between 0.5 to 1 mg/kg/d, taking into account the severity of the disease and comorbidities to minimize side effects 2.
• High-dose glucocorticoids are effective in controlling the inflammatory activity of GCA, but long-term use can lead to significant cumulative exposure and increased risk of glucocorticoid-associated diseases 4, 6.
• The duration of corticosteroid treatment varies, with some patients requiring treatment for several years, and decisions on treatment duration and intensity must be made individually for each patient 6.

Alternative and Adjunctive Treatments

• Methotrexate has been shown to have a moderate corticosteroid-sparing effect and can be used as an alternative to corticosteroid therapy alone in patients with GCA 3.
• Low-dose aspirin may benefit patients with ischemic complications or multiple cardiovascular risk factors, and is recommended in all patients unless contraindicated 2, 5.
• Tocilizumab has shown promise in reducing the cumulative exposure to glucocorticoids and is recommended as a GC-sparing treatment for patients with GC-associated comorbidities or increased risk of developing them 6.
• Other treatments, such as azathioprine and tumor necrosis factor-alpha inhibitors, may be considered in patients with longstanding, recalcitrant disease 5.

Treatment Challenges

• Finding a well-tolerated corticosteroid-sparing drug remains a challenge, and further studies are necessary to reduce the long-term rate of cardiovascular events and the burden of corticosteroid adverse effects 2.
• The optimal schedule of glucocorticoid administration and the use of other treatments as glucocorticoid-sparing agents require further research to establish the best treatment strategies for patients with GCA 5.