August 2025
INTRODUCTION —
Giant cell arteritis (GCA, also known as temporal arteritis) is the most common systemic vasculitis in North America and Europe [1,2]. GCA affects only older adults, with a peak incidence between ages 70 and 79 [3]. Many of the clinical features of the disease result from vascular inflammation of the small extracranial branches of the carotid arteries. Visual loss is one of the most concerning potential complications of GCA; glucocorticoids ae initiated as soon as the diagnosis is suspected specifically to prevent this complication. However, the disease can be systemic; arterial involvement may lead to aortic aneurysm formation and/or stenosis of the major arteries.
The treatment and prognosis of GCA are reviewed here. The clinical manifestations and diagnosis of this disorder are discussed separately. (See "Clinical manifestations of giant cell arteritis" and "Diagnosis of giant cell arteritis".)
INITIAL MANAGEMENT —
The approach to the initial management of giant cell arteritis (GCA) depends on whether the patient presents with visual manifestations (eg, monocular or binocular visual loss, diplopia) or cerebrovascular events (eg, stroke, transient ischemic attack) potentially attributed to GCA.
No visual loss or cerebovascular events at diagnosis
Glucocorticoids — For patients without signs of ischemic organ damage (eg, visual loss) or cerebrovascular events (eg, stroke, transient ischemic attack), we initiate glucocorticoid therapy with prednisone 40 to 60 mg/day (or equivalent) administered in a single daily dose, with the goal of relieving symptoms and preventing visual loss (algorithm 1). If potentially reversible symptoms persist or worsen, the dose can be increased up to a maximum of prednisone 80 mg or equivalent until symptomatic control is achieved.
For all patients with GCA, we recommend initial treatment with high-dose glucocorticoids rather than a moderate dose of glucocorticoids. We do not use lower doses of glucocorticoids (ie, prednisone <40 mg/day) as initial therapy in any patients with newly diagnosed GCA. In patients at high risk of developing glucocorticoid toxicity, we still use high doses of glucocorticoids, but we add a glucocorticoid-sparing agent to facilitate glucocorticoid tapering. The approach to using a glucocorticoid-sparing agent and glucocorticoid tapering is discussed in detail below. (See 'Glucocorticoid-sparing agent in selected patients' below and 'Glucocorticoid tapering' below.)
●Clinical response – Patients usually report dramatic improvements of many GCA-related symptoms (eg, headache, fever, malaise) within 24 to 48 hours of glucocorticoid administration. The diagnosis of GCA should be reevaluated in patients who are resistant to adequate glucocorticoid therapy, especially in situations where temporal artery biopsy and imaging studies have not confirmed the diagnosis of GCA. (See "Diagnosis of giant cell arteritis", section on 'Diagnosis'.)
●Efficacy – Though never studied in a randomized trial, the role of glucocorticoids for the prevention of visual loss is supported by observational data and decades of clinical experience [4-6].
•In a retrospective study of 245 patients with biopsy-proven GCA, all of whom were treated with glucocorticoids, permanent visual loss was found in 34 patients (14 percent) [5]. However, vision loss occurred in 32 of the 34 patients before the initiation of glucocorticoids. Of the two cases of de novo visual loss that developed after glucocorticoids were started, one occurred eight days into treatment, and the other occurred three years after glucocorticoids were first administered and one year after their discontinuation when the erythrocyte sedimentation rate (ESR) was normal and was therefore unlikely related to GCA.
•In another study of 144 patients with biopsy-proven GCA described in the ophthalmologic literature, none of the 53 patients with normal vision at presentation lost vision after initiation of glucocorticoids [6]. Of the 91 patients with visual loss at presentation, nine experienced further visual loss after beginning glucocorticoids, all within five days of the start of treatment. Thus, if vision is intact at the time of the diagnosis of GCA, treatment with glucocorticoids appears to reduce the risk of visual loss to less than 1 percent.
●Data regarding initial dose – There are no clinical trials comparing different initial oral glucocorticoid doses for newly diagnosed GCA. However, clinical experience and observational data suggest that almost all patients with GCA respond symptomatically within one to seven days to a 40 to 60 mg of oral prednisone (or equivalent) [4,7-10]. As an example, a population-based study with 120 patients with GCA found that all patients responded rapidly to a median initial dose of 60 mg/day of prednisone [7].
Our approach to the initial glucocorticoid dose is consistent with the European Alliance of Associations for Rheumatology (EULAR; formerly European League Against Rheumatism) guidelines, which recommend a fixed starting dose of prednisone 40 to 60 mg/day (or equivalent) [11]. By contrast, the American College of Rheumatology (ACR) guidelines recommend a starting dose of 1 mg/kg of prednisone or equivalent, up to a maximum of 80 mg/day [12,13]. Our preference is based on the fact that the majority of clinical trials have used fixed starting doses of prednisone 60 mg/day, and that additional high-quality data on the optimal starting dose of glucocorticoids in GCA are lacking. We do not use starting doses of <40 mg/day, as the use of such doses have not been systematically studied.
There is insufficient evidence to justify the upfront use of intravenous pulse glucocorticoids in all patients with GCA, although they are recommended in patients with visual loss at presentation. (See 'Possible visual loss or cerebrovascular events' below.)
•A randomized trial with 164 patients with GCA (without ocular involvement at presentation) found no differences in the cumulative glucocorticoid doses or the number of GCA complications when comparing three different glucocorticoid protocols, two of which consisted of different pulse glucocorticoid regimens on a background of oral prednisone (240 mg intravenous pulse of methylprednisolone followed by 0.7 mg/kg/day oral prednisone or 240 mg intravenous pulse methylprednisolone followed by 0.5 mg/kg/day) and the other of which consisted of only oral prednisone (0.7 mg/kg/day) [14].
•Another small randomized study of 27 patients without ocular involvement found that adding initial pulse glucocorticoid therapy resulted in a reduced total exposure to glucocorticoids and a lower relapse rate [15].
Neither of these randomized trials, however, was designed to assess the outcome of ocular complications.
●No role for alternate-day dosing – Treatment of GCA requires daily glucocorticoid administration. The importance of daily dosing was demonstrated in the course of a study on the use of methotrexate for the management of GCA in which a rapid glucocorticoid taper to an alternate-day dose was associated with new visual loss in 8 of 98 patients [16]. In another study of regimens for glucocorticoid dosing, daily doses were more effective than alternate-day doses for symptomatic management [17].
●Adverse effects – The risks of high-dose and chronic glucocorticoid therapy are well known and include cataracts, fractures, infections, hypertension, diabetes, osteoporosis, and osteonecrosis [7]. Other side effects of glucocorticoids include weight gain; hair loss; and capillary fragility, which can be especially problematic in older adults on antiplatelet or anticoagulant therapies. (See "Major adverse effects of systemic glucocorticoids".)
Glucocorticoid-sparing agent in selected patients
Indications and rationale — For patients with newly diagnosed GCA with increased risk of glucocorticoid-related adverse effects, we suggest the addition of tocilizumab to glucocorticoids (algorithm 1). Patients who are at increased risk of developing glucocorticoid-related side effects or complications include those with osteoporosis, diabetes, hypertension, or glaucoma. We also use tocilizumab for patients with relapsing disease, which is discussed further below. (See 'Tocilizumab' below and 'Management' below.)
Our approach to the use of a glucocorticoid-sparing agent is consistent with the EULAR guidelines [11] but differs from those of the ACR [12,13], which recommends tocilizumab for all newly diagnosed patients with GCA. Although tocilizumab is associated with a reduction in relapse and is glucocorticoid-sparing for patients with GCA, definitive data confirming the safety of long-term exposure of tocilizumab in an older adult population with multiple comorbidities are lacking. Furthermore, there are no definitive data showing that tocilizumab reduces glucocorticoid-related side effects, reduces tissue inflammation, or prevents vascular complications (eg, aneurysm or stenosis) in patients with large-vessel disease. (See 'Tocilizumab' below.)
Tocilizumab — Tocilizumab is administered as a 162 mg subcutaneous weekly injection or as a monthly intravenous infusion in combination with glucocorticoids. When tocilizumab is administered intravenously, we typically dose it at 8 mg/kg once every four weeks (with a maximum of 800 mg/infusion). However, in the United States, intravenous tocilizumab is administered at 6 mg/kg, which is the dose approved by the US Food and Drug Administration (FDA). Tocilizumab may be administered as monotherapy following discontinuation of glucocorticoids.
●Dose reduction for adverse events – In patients who develop an adverse event (eg, cytopenias or abnormal liver function tests) with the standard initial dose, the tocilizumab dose should be decreased. For patients receiving injections, the time between administrations can be increased to every other week; for patients receiving intravenous tocilizumab, the dose can be reduced to 4 mg/kg.
●Adverse events – The risks of tocilizumab include opportunistic infection, neutropenia, abnormal liver function tests, increased serum cholesterol, diverticulitis, and gastrointestinal perforation. Additional information regarding dose adjustments and adverse effects are described separately. Refer to the UpToDate Lexidrug monograph for tocilizumab. (See "Interleukin 6 inhibitors: Biology, principles of use, and adverse effects", section on 'Adverse effects'.)
●Duration of therapy – The optimal duration of therapy with tocilizumab is unknown.
•New-onset disease – We generally continue treatment for 12 to 18 months. If clinical remission is maintained, and glucocorticoids are successfully tapered off, we discontinue tocilizumab therapy.
•Relapsing disease – In some patients with relapsing disease who achieve sustained remission with tocilizumab, we try spacing out the tocilizumab injections to every other week (or reduce the dose of the intravenous infusion) for a period of 6 to 12 months before complete discontinuation.
●Monitoring disease activity – A pragmatic concern with the use of tocilizumab in the management of GCA pertains to its effects on the acute phase reactants. Interleukin 6 (IL-6) is a major driver of the acute phase response through its induction of hepatic synthesis of acute phase proteins (see "Acute phase reactants"). Blockade of IL-6 activity completely normalizes the ESR and C-reactive protein (CRP). Therefore, the assessment of GCA in a patient on tocilizumab must rely on clinical evaluation and, for patients with large-vessel involvement, periodic imaging studies. There continues to be an unfulfilled need for a reliable marker of active disease in GCA. (See 'Routine monitoring of disease activity' below and 'Imaging surveillance for patients with large-vessel involvement' below.)
●Efficacy – The beneficial effects of tocilizumab as a glucocorticoid-sparing intervention have been demonstrated in two randomized trials [18,19]. As an example, in an industry-sponsored Giant Cell Arteritis Actemra (GiACTA) trial, 251 patients with newly diagnosed or relapsing GCA were randomly assigned to receive either weekly or every-other-week subcutaneous tocilizumab injections, combined with a 26-week prednisone taper, or placebo combined with a prednisone taper over a period of either 26 or 52 weeks [19]. Patients with evidence of critical optic ischemia were not enrolled in the study. Sustained remission at 52 weeks occurred in 56 percent of the weekly tocilizumab group and in 53 percent of the every-other-week tocilizumab group compared with 14 percent of the placebo group, who tapered over 26 weeks, and 18 percent of the placebo (prednisone-only) group, who tapered over 52 weeks. When normalization of the CRP concentration was excluded from the definition, sustained remission at 52 weeks occurred in 59 percent of the weekly tocilizumab group and in 55 percent of the every-other-week tocilizumab group compared with 20 percent of the placebo group, who tapered over 26 weeks, and 33 percent of the placebo (prednisone-only) group, who tapered over 52 weeks. The cumulative median prednisone dose over the 52-week period in each tocilizumab group was 1862 mg, as compared with 3296 mg in the placebo group on the 26-week taper and 3818 mg in the placebo group on the 52-week taper. Serious adverse events were more common in the placebo groups, most of which were related to infection. One patient in the group receiving tocilizumab every other week had an episode of anterior ischemic optic neuropathy (AION) that resolved with glucocorticoid treatment.
Information about long-term effects of tocilizumab treatment on the disease course is limited [18,19]. In the two-year extension study of the GiACTA trial, after tocilizumab discontinuation, relapses were common, occurring in over half of patients enrolled [20]. Restarting tocilizumab (with or without glucocorticoids) was effective in restoring clinical remission in most patients. The glucocorticoid-sparing effect of tocilizumab demonstrated in the initial trial was maintained through year 3. Cumulative glucocorticoid doses over three years were significantly lower in patients originally randomized to tocilizumab compared with those originally randomized to placebo (median cumulative prednisone dose 2647 mg for tocilizumab once a week, 3948 mg for tocilizumab every other week, 5277 mg for placebo with a 26-week prednisone taper, and 5323 mg for placebo with a 52-week prednisone taper). No new or unexpected safety findings were reported over the full three years of the study.
Whether tocilizumab definitively resolves vessel inflammation (and consequently prevents the development of aortic aneurysm and large-vessel stenosis) is unclear. In a case report, a patient with GCA in apparent remission on tocilizumab died of a postoperative myocardial infarction and was found on postmortem examination to have active arteritis of the aorta, subclavian arteries, and right superficial temporal artery [21]. A cohort study investigating repeated temporal artery biopsies found persistent arterial inflammation in more than one-third of GCA patients who had been treated with tocilizumab and glucocorticoids for at least six months. Positron emission tomography (PET)/computed tomography (CT) and ultrasound performed at the time of the second biopsy supported these findings, revealing signs of ongoing vascular inflammation in approximately one-third of the patients [22].
Upadacitinib — We use upadacitinib 15 mg/day (administered orally) in patients with new or relapsing GCA who are at high risk of glucocorticoid-associated toxicity under the following circumstances:
●Contraindications to tocilizumab (eg, a history of gastrointestinal perforation or diverticulitis)
●History of tocilizumab-associated adverse events
●Disease relapse despite tocilizumab therapy
●Patient preference for an oral agent
Nevertheless, upadacitinib should be used with caution in patients with preexisting cardiovascular risk factors, such as ischemic heart disease, cerebrovascular events, or venous thromboembolism, due to the potential association of Janus kinase (JAK) inhibitors with an increased risk of cardiovascular events. (See 'Management' below and "Overview of the Janus kinase inhibitors for rheumatologic and other inflammatory disorders", section on 'Adverse effects'.)
In an industry-sponsored randomized trial (SELECT-GCA), 428 patients with either newly diagnosed or relapsing GCA were assigned, in a 2:1:1 ratio, to receive upadacitinib at a dose of 15 mg or 7.5 mg orally once daily plus a 26-week glucocorticoid taper or placebo plus a 52-week glucocorticoid taper [23]. Key observations from this study include the following:
●Upadacitinib 15 mg – Upadacitinib 15 mg/day was superior to placebo at achieving sustained remission, defined as the absence of signs or symptoms of GCA from week 12 through week 52 and adherence to the protocol-specified glucocorticoid taper, 46.4 (95% CI 39.6-53.2] versus 29.0 (95% CI 20.6-37.5) percent. Upadacitinib at a dose of 15 mg also demonstrated superiority over placebo in achieving sustained complete remission, delaying time to disease flare, reducing cumulative glucocorticoid exposure (1615 versus 2882 mg), and improving fatigue and quality of life.
●Upadacitinib 7.5 mg – Upadacitinib 7.5 mg/day was not clearly superior to placebo at achieving sustained remission (41.1 percent, 95% CI 31.8-50.4).
●Adverse events – Over the 52-week study period, the incidence of overall adverse events, serious adverse events, and most adverse events of special interest, including cancer and venous thromboembolism, was similar between the upadacitinib and placebo groups. However, a higher incidence of herpes zoster was observed in the 15 mg upadacitinib group compared with both placebo and the 7.5 mg group. While cardiovascular risk remains a potential concern with JAK inhibitors, no major adverse cardiovascular events were reported among patients treated with upadacitinib during the study.
However, real-world data are warranted to better characterize the long-term safety profile of upadacitinib in patients with GCA, who are typically diagnosed at a mean age above 65 years, a population inherently at increased cardiovascular risk. (See "Overview of the Janus kinase inhibitors for rheumatologic and other inflammatory disorders", section on 'Adverse effects'.)
Methotrexate — When used, methotrexate is typically initiated at a dose of 10 to 15 mg/week, with increases in dose every two to eight weeks of 5 mg/week up to 25 mg/week. We use the same regimen and approach to titration as that used in rheumatoid arthritis. (See "Use of methotrexate in the treatment of rheumatoid arthritis", section on 'Dosing and administration'.)
Methotrexate may be used as an alternative glucocorticoid-sparing agent for patients who are unable to use tocilizumab or upadacitinib due to factors such as availability, cost, or recurrent infections.
Limited data suggest that methotrexate is, at best, only moderately effective for reducing cumulative glucocorticoid dose and the rate of relapses [24]. Three randomized trials comparing methotrexate with placebo in patients with GCA treated with glucocorticoids reached divergent conclusions [16,25,26]. Of note, the doses of methotrexate used in the trials were low by contemporary standards (ie, only 10 to 15 mg/week). A meta-analysis of the individual patient-level data of 161 patients from these three trials suggested that the addition of methotrexate resulted in a statistically significant reduction in the cumulative dose of glucocorticoids over the 48 weeks following randomization (cumulative dose reduction of prednisone or equivalent of 842 mg), a decreased rate of first and second relapse, and a higher probability of achieving a glucocorticoid-free remission [27]. Adverse effects between the two treatment groups were similar. The superiority of methotrexate over placebo appeared only after 24 to 36 weeks.
There are no randomized trials comparing methotrexate with tocilizumab in GCA. In an observational study on patients with new-onset, active, large-vessel GCA starting treatment with either glucocorticoid monotherapy or combination with methotrexate or tocilizumab, all three treatment regimens controlled the clinical and biochemical signs of GCA and vascular inflammation evaluated by PET/CT [28]. Mean cumulative prednisone doses, however, were higher with glucocorticoid monotherapy (5637 mg), intermediate with methotrexate (4478 mg), and significantly lower with tocilizumab (2984 mg).
Possible visual loss or cerebrovascular events — Patients who present with visual manifestations (eg, monocular or binocular visual loss, diplopia) or with cerebrovascular events (eg, stroke, transient ischemic attack) potentially attributed to GCA require a higher initial dose of glucocorticoids. We use either 500 to 1000 mg/day of intravenous methylprednisolone daily for three days (followed by 40 to 60 mg/day of oral prednisone) or 1 mg/kg/day of oral prednisone (if intravenous pulse cannot be rapidly initiated). While the association between diplopia and visual loss in patients with GCA has not been confirmed in all studies, we also treat patients with GCA who present with diplopia with an initial course of intravenous glucocorticoids [29].
Glucocorticoids should be administered promptly. Though not validated in rigorous studies, this approach is used because of the crucial importance of preventing visual impairment due to GCA, which, once established, is rarely reversible [15]. Limited data suggest that the timing of glucocorticoid therapy may be more important than the route of administration for the prevention of future severe ischemic events [30]. A retrospective multicenter study of 29 patients with GCA with permanent visual loss is the only study that used a cutoff interval time of 24 hours from diagnosis to treatment onset to define early treatment. Early treatment was the only significant predictor of improvement of visual acuity (odds ratio [OR] 17.7); the therapeutic regimen (intravenous pulse versus oral prednisone) did not influence visual outcome [31].
Preexisting sight loss can progress, despite initiation of glucocorticoid therapy, in approximately 10 percent of patients, usually within the first week of treatment [6]. If untreated, the second eye is likely to become affected in up to 30 percent of patients, and more than half of these patients develop bilateral loss of vision within the first two weeks [32].
The stark reality of such visual loss is that patients seldom recover useful vision in an affected eye [33-35]. In a retrospective review of 84 patients (114 eyes) with variable degrees of GCA-associated visual loss (due to AION in over 90 percent of patients), there were no differences in improvement in visual acuity when comparing patients who received intravenous glucocorticoids followed by oral therapy (41 patients) with patients who received only oral glucocorticoids (43 patients). Improvement in visual acuity was only observed in 4 percent of eyes (three patients treated with intravenous glucocorticoids and two with oral glucocorticoids), as judged by improvement in both visual acuity and central visual field (by kinetic perimetry and Amsler grid) [33]. Of note, improvement perceived by patients and noted on visual acuity tests may not reflect true recovery of retinal or optic nerve function but rather eccentric compensation for acquired, permanent visual deficits.
Patients with large-vessel involvement — Large-vessel GCA involves the aorta and the great vessels, most commonly the subclavian arteries and distally to the axillary and brachial arteries. Patients with large-vessel GCA are managed in a manner similar to those without large-vessel involvement.
It remains uncertain whether large-vessel involvement may require more protracted or intensive treatment. In one retrospective cohort study comparing 120 patients with large-vessel GCA with 240 patients with cranial GCA, the patients with large-vessel GCA had a higher cumulative glucocorticoid dose after one year of treatment, relapsed more frequently, and received more adjunctive immunosuppressant therapies [36]. Additional information regarding the clinical features of large-vessel involvement is presented separately. (See "Clinical manifestations of giant cell arteritis", section on 'Large vessel involvement'.)
Additional management considerations for patients with large-vessel involvement include the following:
●Antiplatelet therapy for selected patients – For patients who have critical or flow-limiting involvement of the cerebral or carotid arteries, we add low-dose aspirin to glucocorticoid and glucocorticoid-sparing therapy. If low-dose aspirin is used, a proton pump inhibitor should also be administered as aspirin, age, and high-dose glucocorticoids are all risk factors for gastrointestinal bleeding (see "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity", section on 'Proton pump inhibitors'). The rationale for low-dose aspirin use in this setting is for prevention of ischemic events in patients with vascular narrowing resulting in decreased cerebral flow. However, there are limited data supporting the role of antiplatelet therapy for the prevention of ischemic events in patients with GCA [37-41].
●Vascular complications – For patients with vascular complications such as aortic aneurysms or stenosis resulting in limb or organ ischemia, management decisions regarding potential surgical intervention should involve collaboration of the vascular surgeon and the rheumatologist.
For patients with GCA who require vascular surgical intervention and have clinical evidence of active disease, we typically use high-dose glucocorticoids in the periprocedural period. Clinical studies that would inform the management of complications such as limb ischemia or aortic aneurysms in GCA are lacking, and the approach to management is largely based on clinical experience and extrapolated from experience with Takayasu arteritis.
Additional considerations regarding specific vascular complications include:
•Ischemic limb symptoms – Most ischemic limb symptoms from stenosis improve or stabilize with medical management in GCA, and revascularization of arteries to the extremities (eg, angioplasty, stent placement, or bypass surgery) is seldom required. Vasculitic narrowing of large arteries, such as the subclavian artery, is usually gradual and accompanied by the development of an extensive web of collateral vessels (image 1). With treatment of the underlying inflammatory process, the collateral circulation is commonly adequate to maintain the viability of distal tissues, even though there is some incident limb ischemia or diminished or absent peripheral arterial pulsations (brachial, radial, and ulnar). In one report of 53 treated patients with subclavian involvement due to GCA, symptoms and signs of ischemia resolved in 15 (27 percent), improved in 30 (55 percent), and were unchanged in 8 (15 percent) [42].
If indicated, stenting or angioplasty should be undertaken when clinical evidence for inflammation has been suppressed with treatment. Restenosis is not uncommon [42].
•Aortic aneurysms – Patients with aortic aneurysms related to GCA should be carefully evaluated for the presence of ongoing active vascular inflammation with laboratory (ESR, CRP) and imaging studies (magnetic resonance angiography [MRA], PET). Patients with active disease are treated with resumption or an increase in glucocorticoid therapy and the addition of a glucocorticoid-sparing agent, as with any disease relapse. (See 'Glucocorticoid-sparing agent in selected patients' above and 'Management' below.)
The use of imaging studies to evaluate large-vessel vasculitis is discussed in detail elsewhere. (See "Treatment of Takayasu arteritis", section on 'Imaging'.)
Additional information regarding medical and surgical management of thoracic aortic aneurysm and dissections is presented separately. (See "Management of thoracic aortic aneurysm in adults" and "Management of acute type B aortic dissection".)
SUBSEQUENT MANAGEMENT
Glucocorticoid tapering — Symptoms and signs of giant cell arteritis (GCA) usually respond quickly to glucocorticoids. After two to four weeks of therapy, the dose can be gradually tapered. The approach to glucocorticoid tapering generally depends on whether patients are also receiving tocilizumab or upadacitinib.
●Glucocorticoid monotherapy – For patients who are not on tocilizumab or upadacitinib, we use the following approach:
•The initial dose of prednisone 60 mg/day can generally be reduced to 50 mg/day after two weeks and to 40 mg/day at the end of four weeks, assuming symptoms and signs have receded and the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have declined to normal or near-normal ranges.
•Subsequently, the dose can gradually be reduced by 5 mg every two weeks to 20 mg/day and then by 2.5 mg every two weeks to 10 mg/day if there are no flares of disease activity.
•After achieving a daily dose of 10 mg, the prednisone taper should be slowed, such that patients remain on progressively decreasing doses over the ensuing 6 to 12 months. Tapering by 1 mg decrements each month once the daily dose is less than 10 mg can be considered, particularly in patients with concomitant polymyalgia rheumatica.
Alternatively, the 52-week tapering protocol utilized in the placebo arms of the Giant Cell Arteritis Actemra (GiACTA) and SELECT-GCA trials may be followed (table 1).
In selected patients with significant risk for severe glucocorticoid toxicity and contraindications to tocilizumab and upadacitinib, we use an accelerated taper regimen consistent with the taper used for patients on tocilizumab or upadacitinib.
●Glucocorticoids plus tocilizumab or upadacitinib – For most patients with GCA receiving glucocorticoids in combination with tocilizumab or upadacitinib, we use an accelerated glucocorticoid-tapering regimen (table 2).
This accelerated tapering regimen was used in the two trials demonstrating the glucocorticoid-sparing effect of tocilizumab and upadacitinib (GiACTA and SELECT-GCA) [19,23]. Patients are initiated on prednisone 60 mg/day and complete the prednisone taper in 26 weeks. The details of these studies presented above. (See 'Tocilizumab' above and 'Upadacitinib' above.)
Routine monitoring of disease activity — Monthly follow-up visits for the first six months of treatment are ideal, though their frequency will be subject to the exigencies of logistical issues. In stable patients, subsequent follow-up visits can be spaced out to every three months. Ultimately, all matters of follow-up (the interval between clinician visits, the frequency of laboratory monitoring, and the speed of the glucocorticoid taper) are governed by the clinical course of the given patient and must be individualized accordingly.
The goal of these visits is to evaluate the patient's response to therapy and assess for toxicity of the treatment regimen. Patients should be counseled to be watchful for symptoms of polymyalgia rheumatica (PMR) or GCA and should be encouraged to seek medical attention immediately if any symptoms are noted.
The following data are obtained during follow-up visits:
●History and physical examination – At each visit, patients should routinely be asked about cranial symptoms (eg, headache, visual symptoms, jaw claudication) and PMR symptoms (eg, proximal musculoskeletal symptoms and/or signs), as well as any new or worsening symptoms and signs of large-vessel involvement (eg, limb claudication, aortic murmur, peripheral loss of pulses).
Patients should also be monitored for adverse effects from glucocorticoids (eg, osteoporosis, infection, diabetes, cataracts, and glaucoma) [7] and tocilizumab or upadacitinib. (See "Major adverse effects of systemic glucocorticoids" and "Interleukin 6 inhibitors: Biology, principles of use, and adverse effects", section on 'Adverse effects'.)
●ESR and CRP – For patients who are not on tocilizumab, the ESR and CRP can be useful adjuncts to clinical decision-making. Blockade of interleukin 6 (IL-6) activity with tocilizumab completely normalizes the ESR and CRP levels, with the result that these inflammatory makers are not useful for monitoring disease activity. Unfortunately, there are no useful alternative markers for monitoring disease activity in patients on tocilizumab, and clinicians must rely on clinical evaluation and, in the case of large-vessel involvement, periodic imaging studies.
For most patients on glucocorticoid monotherapy, the ESR and CRP usually improve substantially within a few days of the institution of therapy; the CRP declines much more rapidly than the ESR. Elevations of the ESR and CRP should be accompanied by other clinical findings suggestive of recrudescent GCA if changes in glucocorticoid doses are to be made. As markers of disease activity for large-vessel GCA, the ESR and CRP have the same value and are accompanied by the same caveats as they do for the cranial phenotype.
Both the ESR and CRP, however, are imperfect biomarkers in GCA. The ESR usually rises with age (a value of 40 mm/hour may be normal for an 80-year-old), and, in some patients, abnormalities of serum proteins unrelated to GCA can spuriously elevate the ESR. Examples include monoclonal gammopathies and hypergammaglobulinemia secondary to liver disease. Though the ESR and CRP have not been directly compared for the assessment of disease activity in GCA, clinical experience suggests that the CRP is more useful. (See "Clinical manifestations of giant cell arteritis", section on 'Erythrocyte sedimentation rate and C-reactive protein' and "Acute phase reactants", section on 'Laboratory evaluation'.)
Imaging surveillance for patients with large-vessel involvement — Different imaging modalities (CT, CT angiography [CTA], magnetic resonance imaging [MRI], MR angiography [MRA], and ultrasound) may be used for long-term monitoring of structural damage, particularly to detect stenosis, occlusion, dilatation, and/or aneurysms.
●Frequency – The frequency of surveillance should be decided on an individual basis. Repeat imaging of a newly discovered or enlarging aortic aneurysm should be considered at six months of follow-up; if stable, the interval between imaging studies can be lengthened to an annual basis.
●Modality – The choice of an imaging modality will vary by institution and individual patient (see "Diagnosis of giant cell arteritis", section on 'Imaging modalities'). There are not enough data to recommend the routine use of any of the different imaging modalities for monitoring disease activity during follow-up of patients with large-vessel GCA. As an example, in a large retrospective cohort study of patients diagnosed with large-vessel GCA, PET/CT grading showed moderate accuracy in distinguishing between clinically active and inactive disease, with a sensitivity of 51 and specificity of 83 percent [43]. Furthermore, PET/CT was not able to predict subsequent relapse. However, in selected cases in which a flare is suspected, imaging might be helpful to confirm or exclude it.
The use of imaging studies to evaluate large-vessel vasculitis is discussed in detail elsewhere. (See "Treatment of Takayasu arteritis", section on 'Imaging'.)
Prevention of treatment-associated toxicity — Immunosuppressive therapy with high-dose glucocorticoids with or without a glucocorticoid-sparing agent has both infectious and noninfectious toxicities that warrant additional prophylactic measures. The specific regimens are discussed in detail separately:
●Prevention of opportunistic infections – Reports of Pneumocystis jirovecii pneumonia (PCP) in GCA are rare [44,45]. In a retrospective cohort study of 1168 patients with GCA, no cases of PCP were identified over 547 patient-years of follow-up [46]. However, prednisone use at 16 mg/day or more for eight weeks has been shown to be associated with an increased risk of PCP [47], and the risk of PCP in patients on prednisone and tocilizumab or upadacitinib is still unknown.
While the absolute risk of PCP in GCA is small, some experts recommend PCP prophylaxis for patients with GCA given the risk of morbidity and mortality associated with PCP. Ultimately, the decision to prescribe PCP prophylaxis should be individualized based on patient risk factors and preference and following a careful discussion of risks and benefit. (See "Treatment and prevention of Pneumocystis pneumonia in patients without HIV", section on 'Indications'.)
●Osteoporosis prevention – Because of the length of the course of glucocorticoid treatment for GCA, osteoporosis prevention should be aggressively pursued at the start of therapy. Adequate dietary calcium and vitamin D intake should be encouraged. Determination of bone mineral density near the time that treatment is begun is essential for guiding management of bone loss. (See "Prevention and treatment of glucocorticoid-induced osteoporosis".)
●Age-appropriate vaccinations – Age-appropriate vaccinations should be up to date in immunosuppressed patients. (See "Immunizations in autoimmune inflammatory rheumatic disease in adults".)
●Screening for latent tuberculosis – Screening tests of latent tuberculosis should be performed at the start of therapy. (See "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)
DISEASE RELAPSE
Incidence — Reports on the incidence of relapses in giant cell arteritis (GCA) vary widely, from 34 to 74 percent [48-52]. This range is due in part to a lack of consensus regarding the definition of what constitutes a relapse. In some analyses, asymptomatic rises in the acute phase reactants were counted as a flare of GCA, and in others, a recrudescence of symptoms only, unaccompanied by rises in the acute phase reactants, was included. All studies construed the appearance of polymyalgia rheumatica (PMR) as a relapse of GCA.
Clinical features — The majority of relapses in GCA occur at doses of prednisone below 20 mg/day and are most prevalent during the first year of treatment. Headache and PMR are the most common symptomatic expressions of relapse. Other symptoms include jaw claudication, the development of ischemic limb symptoms, and the recurrence of constitutional symptoms.
Elevations of the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) do not always indicate a disease flare, but their occurrence should trigger close clinical follow-up and questioning of patients about symptoms of recurring disease. In addition, if elevations in ESR and CRP are accompanied by constitutional symptoms, diagnostic imaging for underlying large-vessel vasculitis may be considered.
Late relapses (and recurrences) of GCA are described, leading to protracted glucocorticoid treatment. In one study, one-half of patients were still on treatment after five years [51]. Other estimates of the total duration of glucocorticoid treatment are in the range of one to two years [53,54], which is more consonant with clinical practice.
Management
●Increase glucocorticoid dose – For patients who experience a relapse of GCA, we increase the glucocorticoid dose appropriate to the nature of the relapse. For visual symptoms attributable to GCA (generally occurring within the first weeks of the initial diagnosis of disease), we use either 500 to 1000 mg/day of intravenous methylprednisolone daily for three days (followed by 40 to 60 mg/day of oral prednisone) or 1 mg/kg/day of oral prednisone (if intravenous pulse cannot be rapidly initiated). For other symptoms, an increase of the daily dose of glucocorticoids to the last effective dose or 5 to 15 mg above this dose is appropriate. Smaller increments in the daily dose of prednisone, between 5 to 7.5 mg/day, are usually appropriate for PMR symptoms.
●Addition of a glucocorticoid-sparing agent – For patients who are not already on a glucocorticoid-sparing agent at the time of relapse, we add a glucocorticoid-sparing agent, preferably tocilizumab. The rationale for this approach is based on data from the clinical trials of tocilizumab for GCA that included patients with relapsing disease. These trials are discussed in detail above. (See 'Tocilizumab' above.)
For patients with relapsing disease while already on tocilizumab, in addition to increasing the glucocorticoid dose, some experts may modify the tocilizumab dose or route of administration when possible. This approach is based on clinical experience, as there are no data to support this approach. As an example, if a patient relapses while on tocilizumab subcutaneous injections every other week, the dosing frequency may be increased to weekly injections. As another example, if a patient relapses while receiving tocilizumab 6 mg/kg intravenously once every four weeks, they may have their dose increased to 8 mg/kg once every four weeks. Additionally, switching from subcutaneous administration to intravenous administration may be attempted.
Upadacitinib may represent a viable glucocorticoid-sparing alternative for patients preferring oral therapy, those who are unable to receive tocilizumab due to contraindications, or those who experience adverse events or disease relapse despite tocilizumab therapy. However, its use requires careful consideration, particularly given that the majority of patients with GCA are over 65 years of age, an age group inherently more vulnerable to treatment-related risks. This highlights the importance of a thorough risk–benefit evaluation, especially in individuals with additional risk factors such as smoking, preexisting cardiovascular disease, or a history of malignancy. In such cases, alternative therapeutic strategies, including participation in investigational clinical trials, should be considered. (See "Overview of the Janus kinase inhibitors for rheumatologic and other inflammatory disorders", section on 'Adverse effects'.)
Our approach to these issues is outlined in the algorithm (algorithm 2).
UNPROVEN OR INEFFECTIVE AGENTS —
Several other glucocorticoid-sparing agents have been reported as having efficacy as adjunctive treatment for giant cell arteritis (GCA), but their use cannot be endorsed because of small effect, potential toxicity, lack of controls, or small numbers of patients studied.
●Tocilizumab plus ultra-short glucocorticoid therapy – Three proof-of-concept studies evaluated the efficacy and safety of tocilizumab monotherapy after ultra-short-term glucocorticoid treatment:
•In the first study, 18 patients with newly diagnosed GCA received 500 mg methylprednisolone intravenously for three consecutive days. Thereafter, glucocorticoid treatment was discontinued, and a single infusion of tocilizumab (8 mg/kg bodyweight) was administered intravenously, followed by weekly subcutaneous tocilizumab injections (162 mg) until week 52 [55]. Only 22 percent of patients achieved remission within 31 days and had no relapse at week 24 (primary endpoint). However, 78 percent of the enrolled patients achieved remission within 24 weeks, and 72 percent remained relapse-free until 52 weeks. One patient developed unilateral arteritic anterior ischemic optic neuropathy 15 days after the third glucocorticoid infusion.
•In the second study, 18 patients with newly diagnosed or relapsing active large-vessel GCA received 500 mg methylprednisolone intravenously for three consecutive days followed by weekly subcutaneous tocilizumab injections (162 mg) from day 4 until week 52 [56]. The proportion of patients with relapse-free clinical remission at weeks 24 and 52 was 83 and 76 percent, respectively. Compared with baseline, there was a significant reduction of vascular inflammation evaluated by positron emission tomography (PET)/CT at weeks 24 and 52. No patient showed new aortic dilation. However, four patients who had shown aortic dilation at baseline showed a significant increase in aortic diameter (≥5 mm) at week 52.
•In the third study, 30 patients with newly diagnosed or relapsing GCA were treated with 52 weeks of subcutaneous tocilizumab (162 mg/week) and an eight-week prednisone taper (starting with 60 mg/day) [57]. All patients entered remission after four weeks of therapy; 77 percent of patients remained in a glucocorticoid-free remission by week 52. Among the patients who relapsed, the mean time to relapse was 16 weeks.
As proof-of-concept studies, these data are insufficient to guide changes in clinical practice. An ultra-short course of glucocorticoids in combination with tocilizumab may be an option for a subset of patients with GCA; however, randomized controlled trials and longer-term longitudinal studies will be necessary to fully understand the efficacy and safety of this treatment regimen.
●Secukinumab – In a randomized trial of 52 patients with either newly diagnosed or relapsing GCA, subcutaneous secukinumab (300 mg/week for the first four weeks and every four weeks thereafter) improved the rate of sustained remission through 28 weeks compared with placebo (70 versus 20 percent) when each was given in addition to a 26-week glucocorticoid taper [58]. There was no difference in adverse events between the two groups. One patient died in each arm of the study; neither death was attributed to the study treatment. Further study is needed to determine a possible role for secukinumab as adjunctive treatment for GCA.
●Mavrilimumab – Preclinical research has implicated granulocyte-macrophage colony-stimulating factor (GM-CSF) in the pathogenesis of GCA. Mavrilimumab, an immunoglobulin G4 (IgG4) monoclonal antibody, blocks GM-CSF signaling by binding to the alpha chain of the receptor. In a phase 2 trial enrolling patients with GCA, mavrilimumab plus 26 weeks of prednisone was superior to placebo for time to flare by week 26 and sustained remission [59]. Further studies are needed to define the potential role of mavrilimumab in the treatment of GCA.
●Abatacept – A trial of abatacept, a blocker of T-cell costimulation, was proposed on the basis of the presence of activated CD4+ T cells in the typical inflammatory infiltrate of the temporal artery in GCA [60]. (See "Pathogenesis of giant cell arteritis".)
In a phase 2 randomized, double-blind study of patients with newly diagnosed or relapsing GCA, 49 patients were enrolled and treated with prednisone and intravenous abatacept, administered on days 1, 15, 29, and 56. At week 12, 41 patients were in remission and were randomized to continue treatment with monthly abatacept or placebo. Prednisone was tapered by a standardized schedule and discontinued by week 28. The rate of sustained remission at 12 months in patients treated with abatacept compared with placebo was of borderline statistical significance (48 versus 31 percent). There was no difference in adverse events, including infection, between the two groups. Further study is needed to determine a possible role for abatacept as adjunctive treatment for GCA.
●Baricitinib – Preclinical findings and case reports have demonstrated the biologic plausibility that agents selectively targeting Janus kinase 1 (JAK1)/JAK2 hold potential promise in GCA. In a prospective, open-label, proof-of-concept study with a tiered glucocorticoid entry and accelerated taper in patients with relapsing GCA, the oral selective JAK1/JAK2 inhibitor baricitinib at 4 mg/day was well tolerated and allowed discontinuation of glucocorticoids in most patients [61]. Larger randomized clinical trials are needed to determine the safety and efficacy of JAK inhibition in GCA.
●Azathioprine – In a study from a single center of 31 patients with GCA, polymyalgia rheumatica (PMR), or both, a double-blind randomized controlled study of azathioprine, 150 mg/day, versus placebo showed a small but statistically significant reduction in mean prednisolone dose at 52 weeks (1.9 mg/day±0.84 versus 4.2 mg/day±0.58) [62]. However, only 20 patients completed the study.
●Ustekinumab – T helper 1 (Th1) and Th17 cells are believed to play key roles in the pathogenesis of GCA [63] (see "Pathogenesis of giant cell arteritis"). Ustekinumab blocks interleukin 12 (IL-12), a Th1-promoting cytokine, and IL-23, a Th17-promoting cytokine, providing a theoretical basis for its use in the treatment of GCA. In an open-label study of ustekinumab in 14 patients with refractory GCA, the prednisolone dose was decreased from a median of 20 to 5 mg/day; four patients discontinued glucocorticoid therapy entirely [64]. However, a subsequent prospective, open-label trial of ustekinumab in patients with active new-onset or relapsing GCA was closed prematurely after 7 of the initial 10 patients relapsed [65].
●Cyclophosphamide – Cyclophosphamide has been widely used in the treatment of systemic vasculitis. A few small, uncontrolled studies have suggested that it may be useful in GCA in patients at high risk of glucocorticoid-related adverse effects who have not responded adequately to other immunosuppressive or immunomodulatory glucocorticoid-sparing treatments [66-68]. A systematic review identified 103 published cases for analysis [68]. The major indications for cyclophosphamide, administered either orally or intravenously, included glucocorticoid dependency or relapsing disease. Most of the reported patients (86 percent) responded, but 22 percent relapsed despite maintenance immunosuppressive therapy. Adverse effects were described in one-third of the patients, and 12.5 percent discontinued the therapy because of infections and cytopenias. One death due to hepatitis was reported.
●Others – Small, uncontrolled, retrospective series have proposed benefit for dapsone [69], leflunomide [70], and IL-1 blockade [71] for the management of GCA.
●Lack of benefit of anti-TNF therapy – Because GCA is characterized by granulomatous inflammation, tumor necrosis factor (TNF) inhibition would appear to be an appropriate approach to treatment. However, several small randomized trials of TNF inhibition have found that infliximab, etanercept, and adalimumab are ineffective in patients with GCA [72-74].
As an example, 44 patients were studied in a multicenter, randomized, placebo-controlled trial of infliximab for the maintenance of remission [72]. After prednisone-induced remission, patients were randomly assigned in a 2:1 ratio to infliximab 5 mg/kg or placebo. An interim analysis at week 22 demonstrated that infliximab did not reduce the proportion of patients with relapses (43 versus 50 percent on placebo). In addition, infliximab did not increase the proportion of patients whose prednisone dose could be tapered to 10 mg/day without relapse (61 versus 75 percent). Consequently, the trial was stopped early. Through the follow-up period, no differences between the treatment groups were observed in the proportion of relapse-free patients, the cumulative dose of prednisone, or the incidence of adverse events.
PROGNOSIS —
Giant cell arteritis (GCA) is a disease of variable duration. In some, it may have a course of one to two years, while in many others, the disease is more chronic. The glucocorticoid dose can eventually be reduced and discontinued in the majority of patients, although some patients require low doses of prednisone for a number of years to control symptoms.
GCA does not adversely affect overall survival, excepting the subset of patients with aortic aneurysm and dissection [75-77].
The occurrence of visual loss after an initial course of high-dose glucocorticoid treatment, administered daily, is unusual.
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Giant cell arteritis and polymyalgia rheumatica".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Polymyalgia rheumatica and giant cell arteritis (The Basics)")
●Beyond the Basics topics (see "Patient education: Vasculitis (Beyond the Basics)" and "Patient education: Polymyalgia rheumatica and giant cell arteritis (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Initial management
•Systemic glucocorticoids – For all patients with giant cell arteritis (GCA), we recommend initial treatment with high-dose systemic glucocorticoids (algorithm 1) to preserve vision (Grade 1C) as well as to treat other clinical symptoms associated with GCA (Grade 2B). Treatment should be initiated promptly once the diagnosis is confirmed or there is a high index of suspicion for GCA. Our practice regarding the specific dose and route of administration of glucocorticoids for newly diagnosed GCA is as follows (see 'Glucocorticoids' above):
-No visual loss at diagnosis – Prednisone 40 to 60 mg/day or equivalent, given in a single daily dose.
-Threatened or established visual loss at diagnosis – Methylprednisolone 500 to 1000 mg/day intravenous for three days (followed by 40 to 60 mg/day of oral prednisone).
•Glucocorticoid-sparing agent in selected patients
-Tocilizumab – For patients who have an increased risk of glucocorticoid-related adverse effects, we suggest the addition of tocilizumab to glucocorticoid therapy rather than glucocorticoid therapy alone (Grade 2B). Patients who are at increased risk of developing glucocorticoid-related side effects or complications include those with osteoporosis, diabetes, cardiovascular disease, or glaucoma. However, the American College of Rheumatology (ACR) recommends the use of adjunctive tocilizumab for all patients with GCA.
-Upadacitinib – Upadacitinib may represent a viable glucocorticoid-sparing alternative for patients who are unable to receive tocilizumab due to contraindications. However, its use should be approached with caution in patients with preexisting cardiovascular risk factors, given the potential cardiovascular safety concerns associated with Janus kinase (JAK) inhibitors. Both tocilizumab and upadacitinib have demonstrated a glucocorticoid-sparing effect in clinical trials. (See 'Glucocorticoid-sparing agent in selected patients' above and 'Indications and rationale' above and 'Tocilizumab' above and 'Upadacitinib' above.)
-Methotrexate – Methotrexate may be used as an alternative to tocilizumab and upadacitinib for patients who are unable to use the medication due to factors such as availability, cost, recurrent infections, or contraindications; however, limited available data and clinical experience suggest methotrexate is less effective than tocilizumab. (See 'Methotrexate' above.)
•Patients with large-vessel involvement – Patients with large-vessel GCA are managed using the same approach outlined above. In addition, for patients who have critical or flow-limiting involvement of the cerebral or carotid arteries, we add low-dose aspirin to glucocorticoid and glucocorticoid-sparing therapy. For patients with vascular complications such as aortic aneurysms or stenosis resulting in limb or organ ischemia, management decisions regarding potential surgical intervention should involve collaboration of the vascular surgeon and the rheumatologist. (See 'Patients with large-vessel involvement' above.)
●Subsequent management
•Glucocorticoid tapering – Symptoms and signs of GCA usually respond quickly to glucocorticoids; taper can generally be initiated after one to two weeks. The approach to glucocorticoid tapering varies generally depends on whether patients are also receiving tocilizumab. (See 'Glucocorticoid tapering' above.)
-Patients on glucocorticoid monotherapy – For patients with GCA receiving monotherapy with glucocorticoids, we use a standard glucocorticoid tapering regimen (table 1).
-Patients on glucocorticoids plus tocilizumab – For most patients with GCA receiving glucocorticoids in combination with tocilizumab or upadacitinib, we use an accelerated glucocorticoid-tapering regimen (table 2).
•Routine monitoring of disease activity – Monitoring of disease activity requires careful clinical follow-up to evaluate the patient's response to therapy and assess for toxicity of the treatment regimen.
For patients who are not on tocilizumab, the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) can be useful adjuncts to clinical decision-making. However, tocilizumab completely normalizes the ESR and CRP levels, and they are thus not useful for monitoring disease activity in such patients. Clinicians must rely on clinical evaluation and, for patients with large-vessel involvement, periodic imaging studies for patients on tocilizumab. (See 'Routine monitoring of disease activity' above.)
•Imaging surveillance for patients with large-vessel involvement – Different imaging modalities (CT, CT angiography [CTA], MRI, MR angiography [MRA], and ultrasound) may be used for long-term monitoring of structural damage, particularly to detect stenosis, occlusion, dilatation, and/or aneurysms. The frequency of surveillance, as well as the imaging method applied, should be decided on an individual basis. (See 'Imaging surveillance for patients with large-vessel involvement' above.)
•Prevention of treatment-associated toxicity – Immunosuppressive therapy with high-dose glucocorticoids with or without a glucocorticoid-sparing agent has both infectious and noninfectious toxicities that warrant additional prophylactic measures including prevention of opportunistic infections, osteoporosis prevention, age-appropriate vaccinations, and screening for latent tuberculosis. (See 'Prevention of treatment-associated toxicity' above.)
●Disease relapse
•Incidence and clinical features – Relapses of disease activity are most common at prednisone doses less than 20 mg/day and are most prevalent during the first year of treatment. Headache and polymyalgia rheumatica (PMR) are the most common symptomatic expressions of relapse. Relapses usually do not result in major adverse events (eg, visual loss). (See 'Incidence' above.)
•Management of relapse
-For patients who experience a relapse of GCA, we increase the glucocorticoid dose appropriate to the nature of the relapse similar to the approach that we use for initial therapy (algorithm 2).
-For patients who are not already on a glucocorticoid-sparing agent at the time of relapse, we suggest adding tocilizumab rather than continuing glucocorticoids alone (Grade 2B). Upadacitinib may represent a viable glucocorticoid-sparing alternative for patients without cardiovascular risk factors who are unable to receive tocilizumab due to contraindications, or for those who experience adverse events or disease relapse despite tocilizumab therapy. (See 'Management' above.)
●Prognosis – GCA is a disease of variable duration. Length of treatment may extend from one to multiple years. Glucocorticoid treatment can eventually be discontinued in the majority of patients. (See 'Prognosis' above.)
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges Gene G Hunder, MD and William P Docken, MD, who contributed to earlier versions of this topic review.
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