Shifting GCA Management Toward Targeted Therapies by Minimizing Glucocorticoid Toxicity

Hey, welcome. I’m Dr. Len Calabrese. I’m the Vice Chairman of Rheumatology at the Cleveland Clinic Foundation, and I’m the co-director of the Center for Vasculitis Care and Research here at our institution. And I’m very pleased to be here today to talk about some implications of long-term glucocorticoid use in giant cell arteritis and some recent advances that I think are really moving the needle to help our patients get more effective outcomes and less severe toxicities. So giant cell arteritis is a disease that all rheumatologists love to see. It is the most common form of inflammatory vasculitis that we have. We know it epidemiologically to be a condition that affects the older population, and it is one of the few diseases than when it presents, particularly with head and neck. Ischemia represents a medical emergency for years now, for a generation giant cell arteritis has been treated with glucocorticoids and done so effectively, prompt initiation of high dose glucocorticoids generally at a dose of one milligram per kilogram a day.

You give it over a period of two to four weeks and then you start this very slow taper. Some people feel that aspirin and ischemic risk may be indicated, but the evidence is weak, but that is really the standard of care. Up until fairly recently, the prednisone is ultimately tapered by 10 or 20% per month, and optimally at the end of a year, a patient is on either a really low dose or off of this. But as rheumatologists, we recognize this is really actually the exception. And steroid free remission is only seen in the minority of patients the issues that we have. While this is an effective therapy and prompt initiation decreases ischemic complications, the toxicities of glucocorticoids in this population are formidable in the field of rheumatology and other allied specialties. Over the past five years, there has been a movement recognizing that even low dose glucocorticoids are attended by significant toxicity.

Guidelines in rheumatoid arthritis and lupus have pushed for lower and lower and even no glucocorticoid regimens in the elderly population. Glucocorticoids pose a risk because of concomitant osteopenia, cataracts, increased cardiovascular risk and infections, all the things that we as rheumatologists are so familiar with. In 2017, the introduction of Tocilizumab, the IL-6 inhibitor, really transformed the treatment and gave us a steroid sparing option This past year and pause over the past year, we’ve seen the results of the pivotal phase three trial of upadacitinib, a selective JAK one inhibitor as a steroid searing agent in giant cell arteritis, which showed that the use of this drug at 15 milligrams per day with a steroid taper of 26 weeks, something unheard of in the pre biologic era, was effective at increasing the rates of remission and decreasing many of the glucocorticoid adverse events that we are so used to seeing.

So this adds to our armamentarium for the treatment of this disease. And as I’ll discuss in future videos, the earlier use of steroid sparing medications, I believe in my own practice and experience as well as supported by the data offer the patient the greatest likelihood of disease, remission, sustained remission, and lower toxicity. I’ll go on in subsequent discussions to talk about the toxicities of biologic therapies in this population, but for now, I think that this is a transformative step in the treatment of giant cell arteritis, and I’m very excited to be here to use them.

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This video was created in collaboration with AbbVie.