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

Treatment of Giant Cell Arteritis (GCA)

For patients with newly diagnosed Giant Cell Arteritis, high-dose glucocorticoids should be initiated immediately, with tocilizumab added as adjunctive therapy, especially in high-risk patients or those with cranial ischemic manifestations. 1, 2, 3

Initial Treatment Algorithm

For GCA without visual symptoms:

• Start high-dose oral glucocorticoids (prednisone 40-60 mg/day) immediately 1, 2
• Consider adding tocilizumab 162 mg subcutaneously weekly as a steroid-sparing agent 2, 3
• Obtain temporal artery biopsy within 2 weeks of starting treatment 2
• Order noninvasive vascular imaging to evaluate large vessel involvement 1

For GCA with visual symptoms or cranial ischemia:

• Emergency treatment: Intravenous methylprednisolone 250-1000 mg/day for 3 days 2
• Follow with high-dose oral prednisone (40-60 mg/day) 1, 2
• Add tocilizumab as adjunctive therapy 1, 3
• Temporal artery biopsy should not delay treatment initiation 2

Glucocorticoid Tapering Schedule

• Maintain initial high dose until symptoms resolve and inflammatory markers normalize
• Taper to 15-20 mg/day within 2-3 months 2
• Further taper to ≤5 mg/day after 1 year 2
• Complete treatment typically requires about 2 years 2

Management of Disease Relapse

• For relapse with cranial ischemic symptoms: Add nonglucocorticoid immunosuppressive agent (tocilizumab or methotrexate) and increase glucocorticoid dose 1
• For relapse with polymyalgia rheumatica symptoms: Increasing glucocorticoid dose alone may be sufficient 1

Adjunctive Therapies

• Tocilizumab: FDA-approved for GCA, 162 mg subcutaneously weekly 2, 3
  • Significantly reduces relapse rates and allows for faster glucocorticoid tapering
• Methotrexate: Alternative steroid-sparing agent if tocilizumab is not tolerated 2
• Aspirin: Consider for patients with critical involvement of vertebral or carotid arteries 2

Monitoring

• Regular clinical assessment for disease activity and treatment-related adverse effects 1, 2
• Monitor inflammatory markers (ESR, CRP) 1, 2
• Long-term clinical monitoring is strongly recommended even during apparent remission 1
• Increases in inflammatory markers alone without clinical symptoms warrant closer monitoring but not necessarily treatment escalation 1

Special Considerations

• For patients requiring vascular surgical intervention, use high-dose glucocorticoids during the periprocedural period if active disease is present 1
• For severe GCA with worsening limb/organ ischemia, escalate immunosuppressive therapy before considering surgical intervention 1
• Immediate surgical intervention may be warranted for aortic aneurysms at high risk for rupture or impending tissue/organ infarction 1

Common Pitfalls to Avoid

• Delaying treatment while awaiting biopsy results - this is the strongest risk factor for permanent blindness 2
• Using a rapid taper protocol without steroid-sparing agents - significantly increases relapse risk 2
• Failing to monitor for glucocorticoid and tocilizumab-related adverse effects 2
• Escalating immunosuppressive therapy based solely on increased inflammatory markers without clinical symptoms 1

The treatment approach outlined above follows the most recent American College of Rheumatology/Vasculitis Foundation guidelines and prioritizes prevention of morbidity and mortality, particularly irreversible vision loss, while attempting to minimize glucocorticoid-related adverse effects through the use of steroid-sparing agents.