Toxicity May Outweigh Treatment Benefit of IV Steroids in GCA
A recent systematic review that compared available treatments for patients with giant cell arteritis (GCA) and evaluated test accuracy of studies for diagnosis and monitoring of the disease found that intravenous glucocorticoids (IV GCs) did not provide benefit over tocilizumab combined with high-dose oral GCs in treating cranial ischemic symptoms of GCA.
These studies were used to inform evidence‐based recommendations for the American College of Rheumatology (ACR)/Vasculitis Foundation (VF) vasculitis management guidelines.
“A systematic review and search of articles in English in Ovid Medline, PubMed, Embase, and the Cochrane Library was conducted. Articles were screened for suitability, and studies presenting the highest level of evidence were given preference. Three hundred ninety‐nine full‐text articles addressing GCA questions were reviewed to inform 27 Population, Intervention, Comparison, and Outcome questions,” the authors reported.
While GCs remain a standard in GCA treatment, and are effective in preventing ischemic complications such as vision loss, they possess a high toxicity profile.
The investigators found significant variability in dosing regimens for IV GCs across the studies they analyzed. While 2 retrospective studies did not demonstrate overall improvement in vision among patients who presented with cranial ischemic symptoms who were treated with IV GCs, 1 study showed that patients treated with IV GCs were more likely to experience improved vision (40%) than with those who received oral GCs (13%).
“In light of the toxicities of GCs, especially in the elderly population primarily affected by GCA, we are consistently trying to minimize GC exposure,” the authors stated. “In two of the four arms of the study (by Stone, et al), a 26‐week GC taper was compared with a 52‐week taper, and there was no difference in patient ability to achieve remission of GCA, although remission rates were low in both arms (14% and 17.6%, respectively).”
They concluded, “Non‐GC immunosuppressive therapies with GCs compared with GCs alone showed no statistically significant in relapse at 1 year (OR 0.87 [95% CI 0.73‐1.04], [moderate certainty of evidence]) or serious adverse events (OR 0.81 [95% CI 0.54‐1.20]; [moderate certainty of evidence]). No benefit was found with intravenous glucocorticoids (GCs) compared with high‐dose oral GCs in patients with cranial ischemic symptoms (27.4% vs 12.3%; odds ratio [OR] 2.39 [95% confidence interval (CI) 0.75‐7.62], [very low certainty of evidence]). Weekly tocilizumab with a 26‐week GC taper was superior to a 52‐week GC taper in patients achieving remission (risk ratio 4.00 [95% CI 1.97‐8.12], [low certainty of evidence]).”
Dua A, Husainat N, Kalot M, et al. Giant cell arteritis: a systematic review and meta‐analysis of test accuracy and benefits and harms of common treatments. ACR Open Rheumatology Published online April 2, 2021