Managing of giant cell arteritis and polymyalgia rheumatica

ABSTRACT

Introduction: Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are relatively common and often overlapping conditions in individuals older than 50 years from Western countries. Treatment yields improvement of symptoms in both conditions and reduction of the risk of permanent visual loss in GCA. Relapses constitute an important point of concern in these patients.

Areas covered: This review focuses on the main therapeutic strategies for the management of both conditions. The use of conventional immunosuppressive drugs and the new biologic agents for the management of the disease are discussed.

Expert opinion: An initial dose of prednisone of 40–60 mg/day is useful to improve symptoms and to reduce the risk of blindness in GCA. In turn, 10–20 mg/prednisone a day is generally sufficient to yield clinical improvement in most patients with PMR. A condition different from isolated PMR must be considered when resolution of PMR features is not achieved within 7 days after the onset of corticosteroids. Relapses are common − generally when the dose of prednisone is below than 7.5–10 mg/day. Methotrexate is the most commonly used corticosteroid sparing agent. Biologic agents, such as the recombinant humanized anti-IL-6 receptor antibody tocilizumab, have been incorporated into the management of these conditions, in particular of GCA. Osteoporosis prophylaxis is also recommended.

KEYWORDS:

• Giant cell arteritis
• polymyalgia rheumatica
• relapses
• prednisone
• methotrexate
• infliximab
• tocilizumab

Article highlights

• Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) have become two diseases (often overlapping conditions) relatively common in Western countries in patients older than 50 years.

• The main purpose of the treatment of GCA is to improve the symptoms and reduce the risk of severe ischemic complications, in particular the risk of blindness. Rapid resolution of polymyalgia symptoms is the objective of the treatment in patients with PMR.

• Glucocorticoids are the mainstay of treatment for patients with GCA and PMR.

• The absence of response to corticosteroids should be considered as a red flag to consider the presence of other condition mimicking PMR or presenting with PMR features.

• Patients with GCA or PMR who experience severe corticosteroid-related side effects and/or in those patients who require prolonged corticosteroid therapy due to relapses of the disease can use alternative-corticosteroid sparing drugs.

• Methotrexate (MTX) is the most commonly conventional immunosuppressive drug used as a corticosteroid sparing agent.

• In patients with GCA refractory to corticosteroids and other drugs, including MTX, anti-IL6 tocilizumab has proved to improve clinical features, normalize ESR and CRP and reduce the dose of prednisone.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This paper was not funded.