## Management of Giant Cell Arteritis ### First-Line Treatment **Key Point:** Corticosteroids (prednisolone/prednisone) are the gold standard and only proven effective first-line therapy for giant cell arteritis (GCA). ### Dosing Strategy 1. **Induction phase:** High-dose corticosteroids (prednisolone 40–60 mg/day orally or IV methylprednisolone 500–1000 mg daily for 3 days if vision-threatening) 2. **Taper:** Gradual reduction over 12–24 months based on clinical response and ESR/CRP normalization 3. **Duration:** Typically 1–2 years of therapy ### Rationale for Prednisolone as First-Line - **Rapid anti-inflammatory effect:** Prevents irreversible vision loss (amaurosis fugax, anterior ischemic optic neuropathy) within days - **Evidence-based:** Only agent with proven efficacy in randomized trials - **Symptom resolution:** Headache and constitutional symptoms resolve within 24–48 hours - **Marker normalization:** ESR and CRP normalize within 1–2 weeks ### Adjunctive Agents (Not First-Line) | Agent | Role | Timing | |-------|------|--------| | Methotrexate | Corticosteroid-sparing; reduces relapse risk | Added after 2–4 weeks if high relapse risk or steroid intolerance | | Azathioprine | Alternative steroid-sparing agent | Second-line if MTX contraindicated | | TNF-α inhibitors (infliximab) | Experimental; not standard induction | Reserved for refractory cases or steroid-dependent disease | **High-Yield:** Vision loss in GCA is irreversible and a medical emergency—corticosteroids must be started immediately, even before biopsy confirmation if clinical suspicion is high. **Clinical Pearl:** Temporal artery biopsy should ideally be performed within 1–2 weeks of starting steroids; biopsy remains positive for several weeks despite treatment initiation. [cite:Harrison 21e Ch 297]
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