Table 1.

Treatment for giant cell arteritis

Treatment	Dosing	Mechanism	Strength of evidence	Cost-effective	Risks	Special points
Current treatments
Corticosteroids	Methylprednisolone 1 g followed by 100 mg/day of prednisone. Taper over 6–12 months, depending on symptoms and serum markers	Binds with corticosteroid receptor promoting synthesis of anti-inflammatory proteins and inhibiting synthesis of pro-inflammatory proteins (including IL-6)	Level III	Cheap $1/10 mg tablet	Weight gain, hypertension, diabetes, osteoporosis, insomnia, mania, immune suppression Relative contraindications: diabetes mellitus, mania	In the era of the covid-19 pandemic, attention should be paid to the potential immune suppression associated with corticosteroids. Patients should be alerted to this and extra vigilant.
Methotrexate	0.15 mg/kg/week MTX (increased to 0.25 mg/kg/week, for a maximum weekly dosage of 15 mg	Multiple. Inhibits dihydrofolate reductase, inhibits T cell adhesion molecules.	Level II	Moderate $63/g	Fatigue, dizziness, myelosuppression. Contraindications: chronic renal disease	As above
Tocilizumab	162 mg/week	Inhibition of IL-6	Level II	Expensive $1060/week	Immunosuppression, neutropenia, infusion reaction, tuberculosis, sepsis	As above
Emerging or experimental therapies
Abatacept	10 mg/kg intravenously on days 1, 15, and 29 and week 8	Inhibits interaction of dendritic cells with CD4+ T cells, preventing their activation and IL-6 production	Level II	Expensive $3000/injection	Immunosuppression, infection, malignancy	As above
Ustekinumab	90 mg subcutaneously every 12 weeks.	Monoclonal antibody inhibits IL-12 and IL23,	Level VI	Extremely expensive $21,000 every 12 weeks	Infection, alopecia	As above
Aspirin	81 mg/day	Platelet inhibition to theoretically reduce thrombotic effects of GCA	Level V	Cheap $10/month	Bleeding, gastritis, may potentiate gastric effects of steroids	Reduction in mortality may not be specific to GCA
Leflunomide	10 mg/day	Pyrimidine synthesis inhibitor that blocks T cell expansion	Level IV	Moderate $120/month	Hepatotoxicity, bone marrow toxicity/immunosuppression, hypersensitivity reactions, hypertension, peripheral neuropathy
Acyclovir/valacyclovir	Intravenous acyclovir, 15 mg/kg 3 times daily for 2 weeks, followed by oral valacyclovir, 1 g 3 times daily	Antiviral to treat varicella-zoster virus (VZV)	Anecdotal only	Moderate $40/day	Renal failure, infusion reactions	Predicated on controversial notion that GCA is caused by VZV

Note that all non-steroidal treatments are utilized as adjunctive therapy with steroids, not in its stead