What is the initial treatment for arteritis?

Initial Treatment for Arteritis

The initial treatment for arteritis is high-dose oral glucocorticoids, with prednisone 40-60 mg daily (or equivalent) recommended as first-line therapy for both giant cell arteritis (GCA) and Takayasu arteritis (TA). 1, 2

Giant Cell Arteritis Treatment

Initial Glucocorticoid Therapy

• Begin with oral prednisone 40-60 mg daily as a single or divided dose 1, 3
• For patients with GCA-related visual symptoms (acute vision loss or amaurosis fugax), consider intravenous methylprednisolone 0.25-1 g daily for up to 3 days before transitioning to oral therapy 1
• Do not delay oral glucocorticoid treatment while waiting for referral for intravenous therapy 1
• Obtain a temporal artery biopsy within 2 weeks of starting glucocorticoids, as longer delays may reduce diagnostic yield 1

Tapering Schedule

• Once remission is achieved, taper glucocorticoids to 15-20 mg daily within 2-3 months 1, 3
• Further taper to ≤5 mg daily by one year 1, 3
• Daily dosing is preferred over alternate-day schedules, which have been associated with higher relapse rates 1, 4

Steroid-Sparing Therapy

• Consider adding tocilizumab or methotrexate for patients with:
  • High risk of glucocorticoid-related adverse events 1, 3
  • Relapsing disease 1, 3
  • Inability to taper glucocorticoids according to schedule 1

Takayasu Arteritis Treatment

Initial Therapy

• Start with high-dose oral prednisone 40-60 mg daily 2, 5
• Add a non-glucocorticoid immunosuppressive agent early in the treatment course 2, 5
• Methotrexate is often used as the initial steroid-sparing agent due to efficacy and tolerability 2
• Other options include azathioprine or tumor necrosis factor inhibitors 2, 5

Monitoring and Dose Adjustment

• Evaluate treatment success with physical examination and inflammatory markers (ESR/CRP) 2, 5
• Aim to taper prednisone to 15-20 mg daily within 2-3 months, and to ≤10 mg daily within 1 year 2
• Delay any elective revascularization procedures until the acute inflammatory state is controlled 2, 5

Monitoring for Both Types of Arteritis

• Regular assessment of disease activity through clinical evaluation and measurement of inflammatory markers (ESR/CRP) 1, 2
• Monitor for glucocorticoid-related adverse events, which are common with prolonged use 6, 7
• Assess for relapse during tapering, which may require temporary increase in glucocorticoid dose 1

Common Pitfalls to Avoid

• Delaying treatment while waiting for biopsy results in GCA, which can lead to irreversible vision loss 1, 8
• Using alternate-day glucocorticoid therapy, which increases risk of relapse 1, 4
• Tapering glucocorticoids too rapidly, which can lead to disease flares 1, 3
• Failing to consider steroid-sparing agents in patients at high risk for glucocorticoid-related adverse events 1, 3
• Performing revascularization procedures during active inflammation in Takayasu arteritis 2, 5

Special Considerations

• For GCA with visual symptoms, immediate high-dose glucocorticoid therapy is critical to prevent permanent vision loss 1, 8
• Consider low-dose aspirin for GCA patients to decrease risk of ischemic complications, unless contraindicated 7
• Treatment duration is typically 1-2 years, but some patients may require low-dose glucocorticoids for several years 6, 8