Giant Cell Arteritis: Current and Future Treatment Options

Giant cell arteritis (GCA) is the most common vasculitis affecting patients over the age of 50. Glucocorticoids have been the mainstay of GCA treatment for nearly 70 years. While prompt treatment with prednisone at a dose of at least 40 mg is effective in preventing severe ischemic complications such as visual loss, frequent relapses and treatment-related morbidity remain significant challenges. New insights into disease pathogenesis have led to recent approval of tocilizumab for the treatment of GCA in conjunction with prednisone. While tocilizumab was studied in patients with new-onset disease, it is not yet clear whether it will be used routinely as initial therapy or will be primarily used in patients with relapsing disease or those intolerant to glucocorticoids. Prior to tocilizumab approval, methotrexate was the first-line steroidsparing agent and will likely continue to have a role in the treatment of GCA due to its modest steroidsparing effect. Other biologics such as abatacept and ustekinumab may have efficacy in GCA but require further study. Experience with cyclophosphamide, azathioprine, leflunomide, and mycophenolate mofetil is limited to small studies and their efficacy in GCA is uncertain. The use of intravenous glucocorticoids for patients with ocular symptoms and duration of glucocorticoid therapy in patients with GCA also require further study. Aspirin may help prevent ischemic complications in GCA; however, prospective studies of this agent are lacking.