From the Guidelines
Management of giant cell arteritis (GCA) requires prompt initiation of high-dose corticosteroids, typically prednisone 40-60mg daily, to prevent vision loss and other complications, as recommended by the 2018 EULAR guidelines 1.
Key Principles of Management
- Treatment should begin immediately upon clinical suspicion, even before biopsy confirmation, to minimize the risk of vision loss and other complications.
- The initial high dose should be maintained for 2-4 weeks, followed by a gradual taper over 12-18 months, guided by symptom resolution and normalization of inflammatory markers (ESR/CRP) 1.
- For patients with visual symptoms, methylprednisolone 0.25-1g IV daily for up to 3 days may be given before transitioning to oral prednisone, although the evidence for this is limited to low-quality retrospective clinical data 1.
Adjunctive Therapy
- Tocilizumab (162mg subcutaneously weekly) can be added as a steroid-sparing agent, particularly in patients at high risk for steroid complications, as recommended by the 2018 EULAR guidelines 1.
- Methotrexate may be used as an alternative adjunctive therapy, with a modest role in reducing relapse rate and lowering the cumulative dose of glucocorticoid therapy, as demonstrated in a meta-analysis of three randomized controlled trials 1.
Monitoring and Prevention
- Regular monitoring includes clinical assessment for symptom recurrence, inflammatory marker testing, and vigilance for steroid-related complications.
- Low-dose aspirin (75-150mg daily) is recommended to reduce the risk of cardiovascular and cerebrovascular events, with gastroduodenal mucosal protection considered when commencing aspirin 1.
- Bone protection with calcium, vitamin D, and bisphosphonates should be initiated concurrently with steroids to prevent osteoporosis.
From the Research
Management of Giant Cell Arteritis
- The primary treatment for giant cell arteritis (GCA) is glucocorticoid (GC) therapy, which is effective but requires prolonged administration, resulting in adverse side effects 2.
- Induction treatment with high-dose pulse intravenous (IV) methylprednisolone has been shown to permit a shorter course of therapy and have long-term benefits, with a higher frequency of patients experiencing sustained remission of their disease after discontinuation of treatment 2.
- The choice of initial prednisone dosage takes into account the disease severity and comorbidities in order to reduce the drug side effects, and low-dose aspirin may benefit patients suffering ischemic complications or with multiple cardiovascular risk factors 3.
- Methotrexate has a moderate corticosteroid sparing effect, but it does not prevent cephalic complications and there is no evidence of a reduced frequency of CS adverse effects with this drug 3.
- Tocilizumab is an effective glucocorticoid-sparing therapy, demonstrating sustained glucocorticoid-free remission in 56% of patients receiving weekly tocilizumab compared with 18% of patients receiving a 52-week prednisone taper 4.
Treatment Options
- Corticosteroids remain the main treatment for GCA, but new therapies are helping to reduce their dosage and duration of use 5.
- Noninvasive imaging techniques, such as temporal artery ultrasound and positron emission tomography/computed tomography (PET/CT), are increasingly used in the diagnosis and monitoring of GCA 4.
- The duration of corticosteroid treatment seems to affect the positivity of temporal artery biopsy in patients with suspected GCA, with a more than 7 days' duration of steroid treatment linked with lower rates of positive biopsy 6.
Ongoing Research
- Further studies are needed to determine the role of imaging in monitoring longitudinal disease activity and to develop new biomarkers for disease flares 4.
- Ongoing efforts are directed towards new methods to identify disease flares and to reduce the long-term rate of cardiovascular events and the burden of CS adverse effects 3, 4.