From the Guidelines
Giant cell arteritis (GCA) should be treated immediately with high-dose corticosteroids, typically prednisone 40-60mg daily, to prevent vision loss and other complications, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1.
Key Recommendations
- High-dose glucocorticoid therapy (40–60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active GCA, as stated in the 2018 update of the EULAR recommendations for the management of large vessel vasculitis 2, 3.
- Tocilizumab may be added as a steroid-sparing agent in refractory cases or to reduce steroid-related side effects, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1, 4.
- Diagnosis requires prompt temporal artery biopsy, ideally within 1-2 weeks of starting steroids, as suggested by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1.
Important Considerations
- Patients with visual symptoms may require methylprednisolone 500-1000mg IV daily for 3 days before transitioning to oral prednisone 1.
- Low-dose aspirin (81mg daily) may be recommended to reduce ischemic complications, but its use should be individualized based on patient risk factors and preferences 1.
- Regular monitoring of symptoms, inflammatory markers (ESR, CRP), and potential steroid side effects, including blood glucose, blood pressure, and bone density, is essential for optimal management of GCA 1.
Treatment Goals
- Prevent vision loss and other complications
- Induce remission with high-dose glucocorticoids
- Reduce steroid-related side effects with steroid-sparing agents like tocilizumab
- Monitor disease activity and adjust treatment as needed to achieve and maintain remission.
From the FDA Drug Label
1.2 Giant Cell Arteritis (GCA) ACTEMRA® (tocilizumab) is indicated for the treatment of giant cell arteritis (GCA) in adult patients. The treatment of giant cell arteritis (GCA) in adult patients is an indication for tocilizumab (IV), as stated in the drug label 5.
- Key points: + Giant cell arteritis (GCA): an indication for tocilizumab (IV) + Adult patients: the specified patient population for this indication The information provided in the drug label directly supports the use of tocilizumab (IV) for the treatment of GCA in adult patients 5.
From the Research
Diagnosis of Giant Cell Arteritis
- Giant cell arteritis (GCA) is a systemic inflammatory vasculitis affecting medium and large vessels with potentially sight and life-threatening complications 6.
- Early diagnosis and prompt treatment are imperative in order to prevent vision loss and progression of the disease 6.
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are inflammatory markers which are elevated in the majority of patients and support the diagnosis of GCA among patients who present with typical symptoms 6.
- GCA is confirmed with superficial temporal artery biopsy which demonstrates characteristic pathological findings 6.
Treatment of Giant Cell Arteritis
- High dose corticosteroid therapy is the mainstay of treatment and is administered either intravenously or orally to prevent further vision loss and treat systemic vasculitis 6, 7.
- Oral corticosteroid therapy is required for months to years with careful follow-up and periodic laboratory evaluations with ESR and CRP 6.
- Corticosteroids are tapered gradually over months and may be associated with complications such as hypertension, diabetes mellitus, osteoporosis, psychosis, peptic ulcer disease, and infection 6.
- Supplementation with calcium, vitamin D, bisphosphonate therapy, antimicrobial prophylaxis, and initiation of a proton pump inhibitor or Histamine H2-receptor antagonist should be considered 6, 7, 8.
- Adjunctive immunomodulatory therapy may be considered in patients experiencing relapsing inflammation despite high doses of corticosteroids or those with corticosteroid-induced complications 6, 9, 10, 8.
Adjunctive Therapies
- Emerging evidence for adjunctive therapy with tocilizumab, methotrexate, aspirin, angiotensin receptor blockers, and statins is encouraging and may lead to a more mainstream role for these therapies among patients with GCA 6, 9, 10, 8.
- 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 10.
- Tocilizumab is very promising but its benefit-to-risk ratio in old people is largely unknown 10, 8.
- Aspirin may benefit patients suffering ischemic complications or with multiple cardiovascular risk factors 10, 8.