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Do we need treatment with tumour necrosis factor blockers for giant cell arteritis?
  1. Carlo Salvarani1,
  2. Nicolò Pipitone1,
  3. Luigi Boiardi1,
  4. Gene G Hunder2
  1. 1
    Unit of Rheumatology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
  2. 2
    Mayo Clinic College of Medicine, Rochester, Minnesota, USA
  1. Dr Carlo Salvarani, Unit of Rheumatology, Arcispedale S. Maria Nuova, V. le Risorgimento N80, 42100 Reggio Emilia, Italy; salvarani.carlo{at}

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For many years glucocorticoids (GCs) have been known to effectively suppress the clinical manifestations of giant cell arteritis (GCA), and prevent its ischaemic complications. GCs are still the treatment of choice for this disease. It is recommended that GC therapy be commenced as soon as the diagnosis of GCA is established. An initial dose of 40–60 mg/daily of prednisone (or equivalent) as a single or divided dose is generally found to be adequate in the vast majority of the cases.1 2 Higher-dose pulse GC therapy has been advocated by some for patients with recent or pending visual disturbances, but an observational study and a randomised controlled trial (RCT) failed to demonstrate superiority of pulse over oral GC therapy in preventing ischaemic complications.3 4

The initial dose of GCs is usually given for 2 to 4 weeks until all reversible signs and symptoms have resolved and acute phase reactants are back to normal. Subsequently, the dose can be gradually reduced every 1–2 weeks by a maximum of 10% of the total daily dose. Because of the variability of the course of GCA, no fixed rules have been established regarding treatment duration. Most patients are treated for 1–2 years, but some with a prolonged or relapsing course may require low doses of GCs for several years.57 Clinical flares usually occur when the prednisone (or equivalent) dose is reduced to approximately 5–10 mg/daily.79 The benefit conferred by GCs needs to be balanced against the common and well recognised complications related to long-term GC use. In a population-based study of 120 patients with GCA, 86% of patients had adverse events including bone fractures, avascular necrosis of the hip, diabetes mellitus, infections, gastrointestinal bleeding, and cataract.7 Adverse events were related to the age of patients and …

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