Background/Purpose: Relapses in patients with giant cell arteritis (GCA) are common and often lead to higher cumulative use of glucocorticoids. This study aims to evaluate the relapse characteristics and glucocorticoid use among a large single-institution cohort of patients with biopsy-proven GCA. 

Methods: A retrospective review was performed to identify all patients with biopsy-proven GCA from January 1998 to December 2013. Demographic, clinical, laboratory and treatment data at baseline and subsequent follow visits were collected. Relapse was defined as recurrence of clinical manifestations compatible with spectrum of GCA and/or increase in inflammatory markers (ESR/CRP), not otherwise explainable, which required reintroduction or increased dose of glucocorticoid therapy. Comparisons between relapse groups were performed using Chi-square and Kruskal-Wallis tests. Time to daily dose of <5 mg and 0 mg of prednisone as well as glucocorticoid-associated adverse events were assessed using Kaplan-Meier methods. Patients with initial oral prednisone dose of >40 mg and ≤40 mg were compared using Cox models.

Results: The cohort included 286 patients with biopsy-proven GCA (213 females and 73 males, mean [±SD] age 75.0 [±7.6] years) with a mean (±SD) followup of 6.0 (±3.9) years. During followup 213 patients (75%) had one or more relapses. In patients experiencing a relapse, 50% of relapses occurred during the first year, 68% during the first two years and 79% during the first five years of follow up. The median relapse rate observed was 0.4 [Interquartile range (IQR) 0.21, 0.64] relapses per year.  We further evaluated patients in three groups; no relapse, low relapse rate (<0.5 relapses/yr), and high relapse rate (≥ 0.5 relapses/yr). A higher proportion of patients with hypertension (p=0.007), diabetes (p=0.04) and prior history of venous thrombosis (p=0.04) were present in the ≥0.5 relapse/yr group compared to the no relapse and <0.5 relapse/yr groups.

Twenty-two patients (8%) received pulse dose steroids at diagnosis. Of the remaining 264 patients, 155 (59%) initially received >40 mg and 109 (41%) ≤40 mg of daily oral prednisone. Comparing patients treated with an initial oral prednisone dose of >40mg/day with patients receiving ≤40mg/day, the mean (±SD) prednisone dose was higher at the following intervals: one year [7.4 (±2.3) g vs. 5.8 (±2.1) g; p<0.001], during the first two years [9.6 (±3.5) g vs. 7.7 (±2.7) g; p=0.01] and total follow up duration [10.0 (±4.9) g vs. 8.2 (±5.2) g; p=0.03]. Patients started on >40 mg/day reached <5 mg/day [HR 1.46 (1.09, 1.96); p=0.01] and 0 mg [HR 1.56 (1.09, 2.23); p=0.02] earlier than those started on ≤40 mg/day. Time to first relapse based on initial oral prednisone dose did not differ [HR 1.18 (0.88, 1.57); p=0.27].No difference in glucocorticoid-associated adverse events was seen between the two groups.

Conclusion: In our biopsy-proven GCA cohort, female sex, hypertension, diabetes and history of venous thrombosis were associated with increased risk of relapse. An initial prednisone dose of >40mg/day led to earlier steroid discontinuation without increase in glucocorticoid-associated adverse events.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/relapse-characteristics-and-glucocorticoid-use-in-patients-with-biopsy-proven-giant-cell-arteritis/