From the guideline—Recommendation: For patients with newly diagnosed GCA, we conditionally recommend the use of oral glucocorticoids with tocilizumab over oral glucocorticoids alone.
Q: The guideline recommends tocilizumab up front. That reflects my practice and many others. Yet it differs from what EULAR recommends, which is to use only tocilizumab in high-risk situations.3 What do you think led to the difference?
Dr. Maz: Just a reminder that this is also a conditional recommendation, and alternative approaches are still acceptable. Tocilizumab is the only FDA [U.S. Food & Drug Administration] approved therapy for GCA. Interestingly, even glucocorticoids, including prednisone, are not approved for GCA, but we’re quite aware of their efficacy for GCA.
The use of tocilizumab early on is based on data from GiACTA, which showed that tocilizumab has a significant steroid-sparing effect in GCA.4 It’s conditionally recommended for initial treatment to potentially reduce side effects of chronic glucocorticoid therapy. However, methotrexate with prednisone or prednisone alone can be used for newly diagnosed patients. The decision to treat with tocilizumab and glucocorticoids, methotrexate and glucocorticoids, or glucocorticoids alone as the initial therapy should be based on the physician’s experience, and the patient’s clinical condition, values, and preferences.
Also, cost may be a factor with tocilizumab. Its use is affected by other factors. For instance, patients with recurrent infections or diverticulitis may not be able to use this. So other options are valid and can be used.
From the guideline—Recommendation: For patients with GCA who have critical or flow-limiting involvement of the vertebral or carotid arteries, we conditionally recommend adding aspirin.
From the guideline—Recommendation: In patients with newly diagnosed GCA, we conditionally recommend against the use of a hydroxymethylglutaryl-coenzyme A reductase inhibitor (i.e., statin) specifically for the treatment of GCA.
Q: The guidelines gave a conditional recommendation against statins and in favor of aspirin for flow-limiting involvement. Why?
Dr. Maz: This recommendation was about whether statins could be used for the treatment of GCA. The guideline’s recommendations address whether they provide a significant therapeutic effect for GCA. The recommendation wasn’t to address if statins are useful for patients with risks for cardiovascular events, which is a different clinical question. We know aspirin may be beneficial in preventing ischemic events, but the efficacy of aspirin in preventing ischemic events without flow-limiting stenosis of the vertebral or carotid arteries is unclear.
Theoretically, it makes sense to reduce cardiovascular risk for the management of some patients using aspirin or statins, which is what we do for other patients with risk factors. Yet the available data didn’t show particular efficacy for those with this disease. Once again, being a conditional recommendation, this does not exclude their use based on the treating physician’s decision and individual patient’s clinical situation and risk factors.
