Therapeutic target
Avoidance of complications
Note: Clinical suspicion of giant cell arteritis is an immediate indication for treatment because of the imminent risk of irreversible visual loss (vision loss)!
Therapy recommendations
- Steroidal anti-inflammatory therapy (anti-inflammatory therapy with glucocorticoids):
- Giant cell arteritis: prednisolone (glucocorticoids), initially 1 mg/kg bw/d (max 60 mg), then reduction.
- Amaurosis fugax (transient visual disturbance): intravenous high-dose steroid therapy, ie, prednisolone (glucocorticoids): glucocorticoid pulse therapy with 500-1,000 mg methylprednisolone intravenously daily for 3 to 5 days.
- After initial therapy: reduction by 10 mg/week (up to 30 mg); if < 30 mg/d, then reduction by 2.5 mg/d (down to 10 mg); if < 10 mg/d, then reduction by 1 mg/month (minimum duration of therapy of approximately 2 years).
- Initial high-dose intravenous methyprednisolone therapy is recommended for patients with cerebral (“brain-related”) or ocular (“eye-related”) symptomatology.
- Methotrexate – 15-25 mg/week; lead to a lower steroid dose and decrease the relapse rate (recurrence of the disease); in case of contraindications (contraindications): alternatively: azathioprine (immunosuppressants/drugs that reduce the functions of the immune system) – 150 mg/d; decrease the steroid dose.
- Additive therapy:
- Acetylsalicylic acid (ASA) – 75-150 mg/d for platelet aggregation inhibition (protective effect on cardio- and cerebrovascular events/concerning heart and brain vessels).
- Vitamin D for osteoporosis prophylaxis (prevention of bone loss).
Further notes
- Dose reduction of prednisone should be accompanied by controls of inflammatory parameters inflammatory parameters (ESR and CRP). However, clinical response is paramount; laboratory parameters are for confirmation only.
- In off-label use (prescription of a finished drug outside the use approved by the drug authorities) methotrexate (MTX) is used.
- Biologicals are currently used only in trials: The monoclonal antibody tocilizumab, which blocks the receptor of interleukin-6 (IL-6), reduced glucocorticoid requirements in a phase III trial in patients with giant cell arteritis.Tocilizumab has been approved for the treatment of RZA since 2019.
- Administration of tocilizumab or MTX reduces glucocorticoid requirements and the risk of recurrence (risk of disease recurrence) in the long term compared with glucocorticoid monotherapy.