Glucocorticoids ‘not absolutely evil,’ but difficult to taper in giant cell arteritis
Click Here to Manage Email Alerts
Glucocorticoids are an effective go-to treatment for giant cell arteritis, but discontinuing them can be difficult, according to a presenter at the 2024 AWIR annual conference.
“They’re not absolutely evil,” Peter A. Merkel, MD, PhD, chief of the rheumatology division at Penn Medicine, in Philadelphia, told attendees. “They work really well, but it’s always easier to keep them on, and it’s hard to dial back.”
Generally, glucocorticoids can be started “immediately” if a moderate-to-high probability of GCA is suspected. However, that directive can vary depending on the patient in front of you, Merkel said.
“If you don’t want to put an 82-year-old on glucocorticoids, you want to get a temporal artery biopsy first — that might be fine,” he said. “You’ve got to assess the situation, but we often do it.”
If the patient truly has GCA, a response to glucocorticoids can be expected in 1 to 7 days, according to Merkel. However, he noted that one should “strongly consider” stopping glucocorticoids after a negative temporal artery biopsy.
The patient should be carefully listened to throughout this process, Merkel said.
“They will tell you the story, and the story is everything,” he said. “You need to know what it is and what their response is. That’s going to set you up — both your pre-test probability and how you react.”
Ultimately, glucocorticoids should be tapered over a period of months, not years, Merkel said.
“Some of us were taught everyone needs 2 years — not true,” he said. “We definitely know from the trials that many patients can be tapered off more quickly.”
Merkel also advised not to overly worry about the risk for GCA relapse when tapering glucocorticoids.
“It is not the worst thing in the world to have a relapse under observation, when the patient and his or her family are closely monitoring, and you can jump on it quickly,” he said. “The chance of losing vision is very low, but the chance of glucocorticoid toxicity is very high.”
Merkel added that treating GCA with glucocorticoids, while effective, can invite some of the most common pitfalls in medicine.
“The hardest thing to do in medicine is to not treat, and the second hardest thing is to dial back treatment,” he said. “However, it’s often the right thing to do.”
Collapse
Merkel PA. Update on Treatment of Giant Cell Arteritis and Polymyalgia Rheumatica. Presented at: Association of Women in Rheumatology annual conference; July 25-27, 2024; Orlando, Florida (hybrid meeting).
Read more about
Click Here to Manage Email Alerts