What is the typical treatment for arteritis?

Treatment of Arteritis

Initiate high-dose glucocorticoid therapy immediately upon clinical suspicion of arteritis—prednisolone 1 mg/kg/day (maximum 60 mg/day) for giant cell arteritis or 40-60 mg/day for Takayasu arteritis—without waiting for biopsy confirmation, as delay risks irreversible vision loss. 1, 2

Giant Cell Arteritis Treatment Algorithm

Step 1: Immediate Glucocorticoid Initiation

• Start oral prednisolone 40-60 mg daily as a single or divided dose for all patients with suspected giant cell arteritis 2, 3
• For patients presenting with visual symptoms, administer intravenous methylprednisolone 0.25-1 g daily for up to 3 days before transitioning to oral therapy 2
  • Visual loss occurs in 18% of patients at diagnosis and is usually irreversible 1
  • IV pulse therapy may benefit patients presenting early after onset of visual symptoms 1
• Do not delay treatment while awaiting temporal artery biopsy—glucocorticoids should be started on strong clinical suspicion 1
  • Biopsy should be performed within 1-2 weeks of starting glucocorticoids, as treatment prior to biopsy is unlikely to affect results 1

Step 2: Maintenance and Tapering

• Maintain the initial high dose for one month, then taper gradually 1
• Target 15-20 mg daily within 2-3 months of achieving remission 2, 4
• Aim for 10-15 mg/day at 3 months based on clinical trial data 1
• Never use alternate-day therapy, as this increases relapse risk 1
• Duration of therapy is variable and can extend to several years; some patients cannot tolerate complete discontinuation due to recurrent disease or secondary adrenal insufficiency 1

Step 3: Add Glucocorticoid-Sparing Agents

• Consider adding tocilizumab or methotrexate for patients with: 2
  • High risk of glucocorticoid-related adverse events (86% of patients experience these) 1
  • Relapsing disease
  • Inability to taper glucocorticoids according to schedule
• Methotrexate reduces relapse rates (45% vs. 84.2% with placebo) and cumulative prednisone dose by approximately 1,302 mg 5
• Tocilizumab is FDA-approved for giant cell arteritis treatment 6
• Evidence for immunosuppressive agents as adjunctive therapy has level 1A evidence with strength of recommendation B 1

Step 4: Adjunctive Measures

• Prescribe bone protection therapy to all patients unless contraindicated, given the prolonged glucocorticoid exposure 1
• Consider low-dose aspirin to decrease cranial ischemic complications 7, 3

Takayasu Arteritis Treatment Algorithm

Step 1: Initial High-Dose Glucocorticoids

• Start oral prednisone 40-60 mg daily (or equivalent) 2, 8
• Use daily dosing, not alternate-day schedules, for better disease control 8
• For patients with threatened vision loss or critical organ ischemia, consider IV pulse glucocorticoids (though less common than in giant cell arteritis) 8

Step 2: Early Addition of Immunosuppressive Agent

• Add a non-glucocorticoid immunosuppressive agent early in the treatment course for steroid-sparing effects 2, 8
• First-line options include: 2, 8
  • Methotrexate (often preferred initially due to efficacy and tolerability)
  • Azathioprine
  • Tumor necrosis factor inhibitors
• Tocilizumab (IL-6 inhibitor) is a second-line agent, not initial therapy 8
• Evidence level is 3 with strength of recommendation C for Takayasu arteritis 1

Step 3: Monitoring and Tapering

• Evaluate treatment success with physical examination and inflammatory markers (ESR/CRP) 2, 9, 8
• Target prednisone 15-20 mg/day within 2-3 months 2, 8
• Aim for ≤10 mg/day within 1 year 2
• Delay elective revascularization procedures until acute inflammation is controlled 2, 9, 8

Step 4: Long-Term Management

• Perform thorough clinical and imaging assessment of the arterial tree when diagnosis is suspected 1
• Manage at an expert center due to disease rarity, limited availability of specialist imaging, and treatment complexity 1
• Use MR angiography, CT angiography, or FDG-PET for disease activity assessment 9
• Schedule regular noninvasive imaging every 3-6 months or longer, as vascular changes can occur during clinically quiescent disease 9

Critical Pitfalls to Avoid

• Never delay treatment while awaiting biopsy results in giant cell arteritis—this can lead to irreversible vision loss 2
• Never use alternate-day glucocorticoid therapy—this significantly increases relapse risk 1, 8
• Do not fail to consider steroid-sparing agents in patients at high risk for glucocorticoid-related adverse events, as 86% of giant cell arteritis patients experience these complications 1, 2
• Do not perform revascularization procedures during active inflammation in Takayasu arteritis—wait until disease is controlled 2, 9, 8
• Do not rely solely on inflammatory markers (ESR/CRP) for monitoring, as these are imperfect indicators of disease activity 9
• Do not assess blood pressure in only one extremity during initial Takayasu arteritis evaluation—check all four extremities 9

Monitoring Requirements

• Regular clinical evaluation with inflammatory markers (ESR/CRP) for both types of arteritis 2, 9
• Assess for relapse during tapering, which may require temporary increase in glucocorticoid dose 2
• For Takayasu arteritis, perform long-term clinical monitoring even in apparent remission, given potential for catastrophic outcomes without surveillance 9
• Monitor for glucocorticoid-related adverse events including osteoporosis, infections, and metabolic complications 1