Conventional approach. In most patients with GCA, the current standard approach to therapy is prednisone(Drug information on prednisone) starting at a dosage of about 1 mg/kg/d and not exceeding 80 mg/d. Selection of the starting dosage is highly empirical, and clinicians’ practices vary. There also is no standard corticosteroid tapering regimen. We recommend the following guidelines:
• Use of 60 mg/d for 1 month is appropriate for initial suppression of disease activity.
• Tapering to 20 mg/d by the end of month 2 helps avoid excessive prednisone toxicity.
• A long “tail” to the prednisone taper is required, such that patients continue to take the medication for at least 1 year but spend most of that time taking less than 10 mg/d.
• Tapering in 1-mg decrements every 2 to 4 weeks (or even longer) at the end of the prednisone taper is appropriate.
Relapses are common in patients with GCA. About 50% experience a relapse during the first year of treatment, usually when their prednisone dosage goes below 10 mg/d.12,13 Disease flares require reinstitution of prednisone at a dosage that previously was effective in maintaining disease remission. Once the disease is controlled, a slower prednisone taper is recommended. Although many patients can discontinue prednisone in time, a few will require a low dosage of prednisone (5 to 10 mg/d) indefinitely to maintain disease quiescence.
All patients who take prolonged corticosteroid courses should receive 1.5 g/d of elemental calcium and 800 IU/d of vitamin D to prevent osteoporosis. Patients who take 7.5 mg/d or more of prednisone for more than 6 months also are candidates for bisphosphonate therapy. Bone mineral density studies are recommended at baseline and then every other year to monitor the development of osteoporosis.
Threatened or completed vision loss. Patients who present with threatened vision loss (eg, symptoms of amaurosis fugax or transient monocular blindness or other visual symptoms of concern) make up a special group among those who have GCA. They require the most aggressive possible treatment approach from the outset because vision loss in 1 or both eyes has disastrous implications.
We suggest hospitalizing these patients for administration of “pulse” methylprednisolone(Drug information on methylprednisolone), 1 g/d for 3 days. Limited data suggest that if high-dose corticosteroids are used in this manner, patients who present with completed vision loss have a small chance of recovering some useful vision in the affected eye. In both threatened and completed vision loss, the use of low-dose aspirin(Drug information on aspirin) is also suggested.