When to discontinue glucocorticoids in GCA? How to monitor disease activity?

Bhaskar Dasgupta, MD, is a professor of rheumatology at Southend University Hospital, UK, and honorary professor of Essex University, UK.

When to discontinue glucocorticoids in patients with giant cell arteritis (GCA)? How to monitor the disease activity?

The answer to that depends on the type of disease they have. I have been talking here at the MIRCIM about the urgent need to stratify GCA.

There are patients with GCA who have easy-to-treat disease, which we call remitting disease. These are patients who have cranial GCA overall. You start them on steroids and you can gradually taper off the steroids in ~18 months—18 months to 2-year time without any problems.

Unfortunately there is a group of patients with GCA when we do the disease stratification, [that is, those] who do not have remitting disease. These are who we call relapsing patients or refractory patients, or patients who have suffered ischemic sight loss, or patients who get side effects from the corticosteroids. We have a problem with this group of patients in continuing with the steroid treatment without controlling the disease or giving them more side effects. These are the patients where we really need to consider the addition of other medications, in addition to the steroids, like leflunomide; methotrexate; and biologic disease-modifying antirheumatic drugs (DMARDs), such as tocilizumab; and now new medications that are coming on stream, such as sarilumab.

Essentially the answer to your question is that if you have [patients with] remitting disease, you can get them off steroids in 18 months, whereas more difficult-to-treat patients may require longer treatment.

While we are doing that, we should be monitoring them with ultrasonography and other investigations such as a fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan or magnetic resonance imaging (MRI) scan for vascular damage. This is very, very important because many of these patients actually get aortic involvement. They get involvement of the segments of the aorta: the ascending aorta, the arch of the aorta, the descending aorta. You need to monitor these patients not only clinically but also using imaging such as echocardiography, large vessel vascular ultrasonography, FDG-PET, or MRI.