musculoskeletal and connective tissue disorders
Giant Cell Arteritis
Treatment of Giant Cell Arteritis
Corticosteroids Low-doseaspirin Tocilizumab Treatment should be started as soon as giant cell arteritis is suspected. Even if biopsy is delayed for up to 2 weeks, the pathology should still be evident. If patients > 55 have new-onset headache, jaw claudication, sudden visual disturbances, and/or temporal artery tenderness, consider immediate treatment with corticosteroids for giant cell arteritis. Corticosteroids are the cornerstone of treatment. Corticosteroids rapidly reduce symptoms and prevent vision loss in most patients. The optimal initial dose, tapering schedule, and total length of treatment are debated. For most patients, an initial dose ofprednisone40 to 60 mg orally once a day (or equivalent) for 4 weeks, followed by gradual tapering, is effective. If patients have visual disturbances, an initial dose of IVmethylprednisolone500 to 1000 mg once a day for 3 to 5 days can be tried in an attempt to help prevent further decline in vision, particularly in the contralateral eye. Saving vision probably depends more on how rapidly corticosteroid therapy is initiated rather than the dose. Optic nerve infarction, once started, cannot be reversed regardless of corticosteroid dose. If symptoms resolve after several weeks,prednisonecan be tapered gradually, decreasing from ~60 mg/day, based on the patient’s response, by 5 to 10 mg a day every week to 40 mg a day, by 2.5 to 5 mg a day every week to 10 to 20 mg a day, then further tapering until the drug is stopped. ESR alone should not be used to evaluate patient response (and disease activity). For example, in older patients, other factors, such as monoclonal gammopathies, can elevate ESR. Clinical symptoms must also be used. C-reactive protein can sometimes be more helpful than ESR. is an effective option that may reduce exposure to corticosteroids ( Treatment references ). When combined with corticosteroids, Older patients takingprednisonelong term should be given an antiresorptive drug to increase bone mass and prevent osteoporosis. had no benefit and potential harms were recognized ( Treatment references ). Low-doseaspirin(81 to 100 mg orally once a day) may help prevent ischemic events and should be prescribed for all patients unless contraindicated. 1.Adler S, Reichenbach S, Gloor A, et al: Risk of relapse after discontinuation oftocilizumabtherapy in giant cell arteritis.Rheumatology (Oxford)58(9):1639-1643, 2019. doi:10.1093/rheumatology/kez0913 2.Villiger PM, Adler S, Kuchen S, et al:Tocilizumabfor induction and maintenance of remission in giant cell arteritis: A phase 2, randomised, double-blind, placebo-controlled trial.Lancet387:1921–1927, 2016. doi: 10.1016/S0140-6736(16)00560-2 3.Stone JH, Tuckwell K, Dimonaco S, et al: Trial oftocilizumabin giant-cell arteritis.N Engl J Med377:317–328, 2017. doi: 10.1056/NEJMoa1613849 4.Hoffman GS, Cid MC, Rendt-Zagar KE, et al:Infliximabfor maintenance of glucocorticosteroid-induced remission of giant cell arteritis: a randomized trial.Ann Intern Med146(9):621-30, 2007. doi: 10.7326/0003-4819-146-9-200705010-00004. PMID: 17470830. 