Biological therapy in polymyalgia rheumatica.

INTRODUCTION: Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease of the elderly, treated mainly with systemic corticosteroids. The frequency of side effects of steroids is high in this aged population and increased due to comorbidities. The use of biological treatments could be of interest in this condition. AREAS COVERED: This review takes into account literature data from the PubMed and clinical trial databases concerning the results of the use of biological treatments in PMR, in terms of efficacy and safety of these treatments. EXPERT OPINION: Current data do not allow us to identify any particular efficacy of the various anti-TNF agents used in the treatment of PMR. Anti-interleukin 6 agents (tocilizumab, sarilumab) have shown consistent efficacy results, suggesting a particularly interesting steroid-sparing effect in the population under consideration. The safety profile appears acceptable. Other biologic targeted treatments are currently being evaluated. Anti-interleukin-6 agents may well have a place in the therapeutic strategy for PMR, particularly for patients with steroid-resistant disease or at high risk of complications of corticosteroid therapy.

Endovascular Therapy for Intracranial Giant Cell Arteritis : Systematic Review, Technical Considerations and the Effect of Intra-arterial Calcium Channel Blockers.

BACKGROUND: Giant cell arteritis (GCA) is a systemic vasculitis that may cause ischemic stroke. Rarely, GCA can present with aggressive intracranial stenoses, which are refractory to medical therapy. Endovascular treatment (EVT) is a possible rescue strategy to prevent ischemic complications in intracranial GCA but the safety and efficacy of EVT in this setting are not well-described. METHODS: A systematic literature review was performed to identify case reports and series with individual patient-level data describing EVT for intracranial GCA. The clinical course, therapeutic considerations, and technique of seven endovascular treatments in a single patient from the authors' experience are presented. RESULTS: The literature review identified 9 reports of 19 treatments, including percutaneous transluminal angioplasty (PTA) with or without stenting, in 14 patients (mean age 69.6 ± 6.3 years). Out of 12 patients 8 (66.7%) with sufficient data had > 1 pre-existing cardiovascular risk factor. All patients had infarction on MRI while on glucocorticoids and 7/14 (50%) progressed despite adjuvant immunosuppressive agents. Treatment was PTA alone in 15/19 (78.9%) cases and PTA + stent in 4/19 (21.1%). Repeat treatments were performed in 4/14 (28.6%) of patients (PTA-only). Non-flow limiting dissection was reported in 2/19 (10.5%) of treatments. The indications, technical details, and results of PTA are discussed in a single illustrative case. We report the novel use of intra-arterial calcium channel blocker infusion (verapamil) as adjuvant to PTA and as monotherapy, resulting in immediate improvement in cerebral blood flow. CONCLUSION: Endovascular treatment, including PTA with or without stenting or calcium channel blocker infusion, may be effective therapies in medically refractory GCA with intracranial stenosis.

Glucocorticoids Are Not Associated with Bone Mineral Density in Patients with Polymyalgia Rheumatica, Giant Cell Arteritis and Other Vasculitides-Cross-Sectional Baseline Analysis of the Prospective Rh-GIOP Cohort.

BACKGROUND: Glucocorticoids (GCs) can cause osteoporosis (OP). Prior observational research on bone density and the effects of GCs in polymyalgia rheumatica (PMR) and vasculitides is scarce and inconclusive. METHODS: Rh-GIOP is a prospective cohort study of bone health in patients with inflammatory rheumatic diseases. In this cross-sectional baseline analysis, we focused on patients with PMR and different forms of vasculitides. Multivariable linear regression was used to model the effect of current and cumulative GC intake on the minimum T-score at any site (mTs; at either lumbar spine or hip), with comprehensive adjustment for confounders. In separate models, GCs were modelled both as continuous and categorical predictors. Sensitivity analyses, stratifying by measurement site and disease, were conducted. RESULTS: A total of 198 patients, with a mean age of 67.7 ± 11.4 years and a mean disease duration of 5.3 ± 6.3 years, were included. Most patients suffered from PMR (36%), giant cell arteritis (26%) or granulomatosis with polyangiitis (17%). Women comprised 66.7% of the patients, and 87.4% were currently taking GCs. The mean CRP was 13.2 ± 26.1 mg/L. OP diagnosed by dual energy X-ray absorptiometry (DXA) (T-score ≤ -2.5) was present in 19.7% of the patients. While 88% were taking vitamin D supplements, calcium supplementation (4%) and treatment with anti-resorptive agents (17%) were relatively infrequent. Only 7% had a vitamin D deficit. Neither current (ß(continuous model) = -0.01, 97.5% CI -0.02 to 0.01; p(all models) ≥ 0.49) nor cumulative (ß(continuous model) = 0.01, 97.5% CI -0.04 to 0.07; p(all models) ≥ 0.35) GC doses were associated with mTs in any model. CRP was not associated with mTs in any model (p(all models) ≥ 0.56), and no interaction between CRP and GC intake was observed (p for interaction(all models) ≥ 0.32). Across all analyses, lower body mass index (p(all models) ≤ 0.01), history of vertebral fractures (p(all models) ≤ 0.02) and proton-pump inhibitor intake (p(all models) ≤ 0.04) were associated with bone loss. Sensitivity analyses with femoral neck and lumbar spine T-scores as dependent variables led to similar results as the analysis that excluded patients with PMR. CONCLUSIONS: In this cohort of PMR and vasculitides, we found a similar prevalence of OP by DXA to the overall elderly German population. Vitamin D supplementation was very common, and vitamin D insufficiency was less frequent than expected in Germans. There was no association between current or cumulative GC intake, CRP and impaired bone density. Proton-pump inhibitors seem to be a major, but somewhat neglected, risk factor for OP and should be given more attention. Our findings require confirmation from longitudinal analyses of the Rh-GIOP and other cohorts.

Efficacy and safety of biological agents in patients with giant cell arteritis: A meta-analysis of randomized trials.

OBJECTIVE: This study assessed the efficacy and safety of biological agents in patients with giant cell arteritis (GCA). MATERIALS AND METHODS: A meta-analysis of 6 randomized clinical trials (RCTs) (260 patients and 193 controls) to examine the efficacy and safety of tocilizumab, tumor necrosis factor (TNF) inhibitors, and abatacept relative to that of placebo in GCA patients was performed. RESULTS: The remission rate was significantly higher for tocilizumab-treated patients than that for placebo-treated controls (odds ratio (OR) 7.009, 95% confidence interval (CI) 3.854 - 12.75, p < 0.001). In addition, the relapse rate was significantly lower for the tocilizumab group than that for the placebo group (OR 0.222, 95% CI 0.129 - 0.381, p < 0.001). Further, no significant difference in remission and relapse was observed between groups treated with TNF inhibitors, abatacept, and placebo. The number of serious adverse events (SAEs) was significantly lower in tocilizumab-treated patients than that in placebo-treated controls (OR 0.539, 95% CI 0.296 - 0.982, p = 0.044). However, there was no significant difference in SAEs among patients treated with TNF inhibitors, abatacept, and placebo. The infection rate was significantly higher in TNF inhibitor-treated patients than in those treated with placebo (OR 2.407, 95% CI 1.168 - 4.960, p = 0.017), while there was no significant difference in infection rate between individuals treated with tocilizumab, abatacept, and placebo. CONCLUSION: Tocilizumab was found to be more effective than placebo in GCA patients, but TNF inhibitors and abatacept were not. Further, TNF inhibitors were associated with a higher risk of infection.

Characteristics and management of giant cell arteritis in France: a study based on national health insurance claims data.

OBJECTIVE: Few data are available on the epidemiology and management of GCA in real life. We aimed to address this situation by using health insurance claims data for France. METHODS: This retrospective study used the Echantillon Généraliste de Bénéficiaires (EGB) database, a 1% representative sample of the French national health insurance system. The EGB contains anonymous data on long-term disease status, hospitalizations and reimbursement claims for 752 717 people. Data were collected between 2007 and 2015. The index date was defined as the date of the first occurrence of a GCA code. Demographics, comorbidities, diagnostic tests and therapies were analysed. Annual incidence rates were calculated, and incident and overall GCA cases were studied. RESULTS: We identified 241 patients with GCA. The annual incidence was 7-10/100 000 people ⩾50 years old. Among the 117 patients with incident GCA, 74.4% were females, with mean age 77.6 years and mean follow-up 2.2 years. After the index date, 51.3% underwent temporal artery biopsy and 29.1% high-resolution Doppler ultrasonography. Among the whole cohort, 84.3% used only glucocorticoids. The most-prescribed glucocorticoid-sparing agent was methotrexate (12.0%). CONCLUSION: The incidence of GCA in France is 7-10/100 000 people ⩾ 50 years old. Adjunct agents, mainly methotrexate, are given to only a few patients. The use of temporal artery biopsy in only half of the patients might reflect a shift toward the use of imaging techniques to diagnose GCA.

Current and emerging diagnosis tools and therapeutics for giant cell arteritis.

INTRODUCTION: Giant cell arteritis (GCA) is the most common large-vessel vasculitis in individuals older than 50 years from Western countries. The goal of the treatment is to achieve improvement of symptoms and clinical remission as well as decrease the risk of severe vascular complications. Areas covered: The review summarizes the main epidemiological and clinical features of GCA and discusses in depth both the classic and the new therapies used in the management of GCA. Expert commentary: Prednisone/prednisolone of 40-60 mg/day is the mainstay in GCA therapy. It yields improvement of clinical features and reduces the risk of permanent visual loss in patients with GCA. Other drugs are used in patients who experience relapses (flares of the disease) or side effects related to glucocorticoids. Methotrexate is the most common conventional immunosuppressive drug used as a glucocorticoid sparing agent. Among the new biologic agents, the most frequently used is the recombinant humanized anti-IL-6 receptor antibody, which is effective to improve clinical symptoms, decrease the cumulative prednisone dose, and reduce the frequency of relapses in these patients. Antitumor necrosis factor-α therapy is not useful in GCA. Experience with other biologic agents, such as abatacept or ustekinumab, looks promising but it is still scarce.

Sustained remission after long-term biological therapy in patients with large vessel vasculitis: an analysis of ten cases.

OBJECTIVES: To describe the results obtained in clinical practice with the use of biological therapy (BT) in patients diagnosed with Takayasu arteritis (TA) and giant cell arteritis (GCA). METHODS: Retrospective single center study of TA/GCA patients who received BT (infliximab [IFX], etanercept [ETN] and tocilizumab [TCZ]). In TA, active disease was defined according to a previous National Institutes of Health study. In GCA, active disease was defined with a modified criteria and clinical manifestations secondary to temporal artery involvement or polymyalgia rheumatica symptoms. Clinical data and outcomes are reported using descriptive statistics. RESULTS: Five patients with TA and 5 with GCA were included. The main reason for starting BT was lack of response to prior therapy and/or ≥2 relapses during GC tapering. Five patients started IFX, four TCZ and 1 ETN. Remission was observed before 6 months in all cases. Only one patient had a relapse during long-term follow-up and the overall GC daily dose was reduced by 70%. Two AEs were considered attributable to IFX and one to TCZ. CONCLUSION: A favorable and sustained response to BT was observed in our patients with TA and GCA. Thus, BT might be considered as an alternative in patients with large vessel arteritis refractory to conventional treatment or with GC related comorbidities.

Biotherapies in large vessel vasculitis.

Giant cell arteritis (GCA) and Takayasu's arteritis (TA) are large vessel vasculitis (LVV) and aortic involvement is not uncommon in Behcet's disease (BD) and relapsing polychondritis (RP). Glucocorticosteroids are the mainstay of therapy in LVV. However, a significant proportion of patients have glucocorticoid dependance, serious side effects or refractory disease to steroids and other immunosuppressive treatments such as cyclophosphamide, azathioprine, mycophenolate mofetil and methotrexate. Recent advances in the understanding of the pathogenesis have resulted in the use of biological agents in patients with LVV. Anti-tumor necrosis factor-α drugs seem effective in patients with refractory Takayasu arteritis and vascular BD but have failed to do so in giant cell arteritis. Preliminary reports on the use of the anti-IL6-receptor antibody (tocilizumab), in LVV have been encouraging. The development of new biologic targeted therapies will probably open a promising future for patients with LVV.

MRI parametric monitoring of biological therapies in primary large vessel vasculitides: a pilot study.

OBJECTIVE: To evaluate the development of characteristic MRI changes in patients with primary large-vessel vasculitis (LVV) when treated with biological therapies. METHODS: 12 patients with primary LVV (8 patients with Takayasu arteritis and 4 patients with giant-cell arteritis) received biological therapy with tumour necrosis factor-α blockers (n = 9) or an interleukin-6 inhibitor (n = 3). MRI investigations were performed at baseline (pre-treatment) and follow-up. All patients underwent the same MRI/MR angiography (MRA) protocol. Laboratory parameters (C-reactive protein and erythrocyte sedimentation rate) and clinical response (Birmingham Vasculitis Activity Score) were assessed. RESULTS: Wall thickness was 4.2 ± 0.3 mm pre-treatment and significantly decreased to 3.2 ± 0.3 mm post treatment in 9/12 patients. Mural enhancement was increased in all 12/12 patients with LVV, and subsided with therapy in 5/12 patients. Mural oedema or ill-defined contour were less prevalent but also improved with biological treatment. C-reactive protein and erythrocyte sedimentation rate levels decreased, and clinical assessment revealed a significant improvement from pre-treatment to post-treatment. However, the course of imaging characteristics often did not parallel that of laboratory or clinical parameters. In all three patients receiving interleukin-6 blockade, laboratory markers and clinical scores normalized despite persistent vascular inflammation in one patient which was disclosed by MRI. CONCLUSION: Contrast-enhanced MRI/MRA may be useful when evaluating the development of disease activity in primary LVV under biological therapies. A high degree of suspicion and regular imaging follow-up is needed to detect persistent inflammation. ADVANCES IN KNOWLEDGE: This is the first study investigating the applicability of different MRI/MRA parameters for monitoring biological therapy in patients with primary LVV.

Fast track pathway reduces sight loss in giant cell arteritis: results of a longitudinal observational cohort study.

OBJECTIVES: To investigate the effectiveness of a fast track pathway (FTP) on sight loss in patients with suspected giant cell arteritis (GCA). METHODS: A longitudinal observational cohort study was conducted in the secondary care rheumatology department. One hundred and thirty-five newly referred suspected GCA patients seen via the FTP (Jan. 2012-Dec. 2013) were compared to 81 patients seen through the conventional referral and review system (Jan. 2009-Dec. 2011). RESULTS: The FTP resulted in significant reduction in irreversible sight loss from 37.0% (as seen in the historical cohort 2009-2011) to 9.0 % (2012-2013, OR 0.17, p=0.001). Adjustment for clinical and demographic parameters including known risk factors for GCA associated blindness did not significantly change the primary result (OR 0.08, p=0.001). FTP resulted in a reduction of time from symptom onset to diagnosis, particularly by reduction of time from general practitioner's (GP) referral to the rheumatology review (79% of FTP patients were seen within one working day compared to 64.6 % in the conventional pathway, p=0.023). The FTP has seen a reduction in number of GP appointments. CONCLUSIONS: There was a significant reduction of permanent sight loss with a fast track GCA pathway. The effect may be due to multiple factors including better GP education and reduction in delayed diagnosis. These results need verification at other sites.

[Treatment of large vessel vasculitis]. / Tratamiento de las vasculitis de grandes vasos.

Large vessels vasculitis: Giant cells arteritis (GCA), and Takayasu's arteritis (TA) are a pair of systemic chronic inflammatory diseases characterized by specific involvement of large caliber, elastic-layered arteries. Presently, and derived from the paucity of clinical controlled trials approaching the issue, the management of GCA and TA is largely based on the clinical judgment of the treating physician. Glucocorticoids and immunosuppressive drugs are used when clear evidence of inflammatory activity is observed. The traditional management approach is to start with systemic glucocorticoid therapy at immunosuppressive dose, followed by cytotoxic immunosuppressive drugs (methotrexate, azatioprine, cyclophosphamide or mycofenolate mofetil) aimed at maintaining remission and decreasing corticosteroid therapy time. Recently, based on the potential pathogenic role of tumor necrosis factor α in these diseases, a series of reports addressing the benefic effect of αTNF-blockers in patients who have been resistant to the traditional management approach have been published. Non- reversible vascular lesions (such as occlusion or stenosis) may require surgical treatment (stent or bypass), however this must be done only when a complete control of the inflammatory activity has been reached.

[Biologic therapies in the systemic vasculitides]. / Terapia biológica en las vasculitis sistémicas.

Several biological therapies have been evaluated in systemic vasculitis. Anti TNF-α agents may have a role in the treatment of Takayasu's arteritis and probably in giant cell arteritis. In Kawasaki's disease, infliximab is an option in subjects with intravenous immunoglobulin-resistant disease. Anti TNF-α cannot be recommended to treat ANCA-associated vasculitis. Anti-T lymphocyte globulin and alemtuzumab could have a role in the treatment of ANCA associated vasculitis, although current information about these two biological treatments comes from conventional resistant treatment cases, so the high incidence of complications and relapses observed with these treatment may be intrinsic to the severity of the disease and not related to the biological agents.

Tratamiento de las vasculitis de grandes vasos / Treatment of large vessel vasculitis

Las vasculitis primarias de grandes vasos: la arteritis de células gigantes (ACG) y la arteritis de Takayasu (AT) son enfermedades inflamatorias crónicas que afectan principalmente las arterias elásticas de gran calibre. En la actualidad hay escasas evidencias que permitan conocer cuál es el mejor tratamiento en cuanto a eficacia y seguridad, así como la mejor estrategia para mantener la remisión y mejorar el pronóstico debido a que casi no hay estudios controlados sobre el tópico, por lo que en la mayoría de los casos el tratamiento se basa en el juicio del clínico. Los glucocorticoides e inmunosupresores están indicados si hay una clara evidencia de actividad. El enfoque tradicional consiste en el uso de glucocorticoides a dosis inmunosupresoras para el manejo de los episodios de actividad inflamatoria, seguido de inmunosupresores citotóxicos (metotrexato, azatioprina, ciclofosfamida o micofenolato de mofetilo) para mantener la remisión y disminuir el tiempo en corticoterapia. En fechas recientes, y dado el papel patogénico potencial del factor de necrosis tumoral en estos padecimientos, hay reportes alentadores del uso de inhibidores de esta citocina en el tratamiento de pacientes refractarios al enfoque tradicional. Las lesiones que dejan como secuela oclusión o estenosis vascular habitualmente no son reversibles con el tratamiento médico, por lo que en ocasiones requieren de tratamiento quirúrgico (angioplastia o bypass), el cual debe realizarse solo cuando la actividad de la enfermedad esté controlada de forma adecuada (AU)

Large vessels vasculitis: Giant cells arteritis (GCA), and Takayasu’s arteritis (TA) are a pair of systemic chronic inflammatory diseases characterized by specific involvement of large caliber, elastic-layered arteries. Presently, and derived from the paucity of clinical controlled trials approaching the issue, the management of GCA and TA is largely based on the clinical judgment of the treating physician. Glucocorticoids and immunosuppressive drugs are used when clear evidence of inflammatory activity is observed. The traditional management approach is to start with systemic glucocorticoid therapy at immunosuppressive dose, followed by cytotoxic immunosuppressive drugs (methotrexate, azatioprine, cyclophosphamide or mycofenolate mofetil) aimed at maintaining remission and decreasing corticosteroid therapy time. Recently, based on the potential pathogenic role of tumor necrosis factor in these diseases, a series of reports addressing the benefic effect of TNF-blockers in patients who have been resistant to the traditional management approach have been published. Non- reversible vascular lesions (such as occlusion or stenosis) may require surgical treatment (stent or bypass), however this must be done only when a complete control of the inflammatory activity has been reached (AU)

Terapia biológica en las vasculitis sistémicas / Biologic therapies in the systemic vasculitides

Varias terapias biológicas se han probado en las vasculitis sistémicas. Los anti-TNF- pudieran tener un papel en el tratamiento de la arteritis de Takayasu y probablemente en la arteritis de células gigantes. En el caso de la enfermedad de Kawasaki, existe información de que el infliximab puede ser usado como una alternativa a la gammaglobulina por vía intravenosa en pacientes sin respuesta a una primera dosis de ésta. No se puede recomendar el uso de anti TNF- en las vasculitis asociadas a ANCA. La gammaglobulina antitimocito y el alemtuzumab pudieran tener algún papel en el tratamiento de las vasculitis asociadas a ANCA. La información existente acerca de la utilidad de estos dos fármacos proviene de casos refractarios al tratamiento convencional, por lo que la alta incidencia de complicaciones y recaídas observadas en los casos tratados con estos fármacos pudiera ser más bien intrínseca a la gravedad de la enfermedad y no debida a los agentes biológicos (AU)

Several biological therapies have been evaluated in systemic vasculitis. Anti TNF- agents may have a role in the treatment of Takayasu’s arteritis and probably in giant cell arteritis. In Kawasaki’s disease, infliximab is an option in subjects with intravenous immunoglobulin-resistant disease. Anti TNF- cannot be recommended to treat ANCA-associated vasculitis. Anti-T lymphocyte globulin and alemtuzumab could have a role in the treatment of ANCA associated vasculitis, although current information about these two biological treatments comes from conventional resistant treatment cases, so the high incidence of complications and relapses observed with these treatment may be intrinsic to the severity of the disease and not related to the biological agents (AU)

Vasculitis working group: selected unanswered questions related to giant cell arteritis and anti-neutrophil cytoplasmic antibody-associated vasculitis.

Evidence to guide assessment and management of patients with vasculitis is lacking for many important clinical questions. The evidence surrounding several common questions about management of vasculitis was reviewed. Patients with giant cell arteritis (GCA) are at risk for developing extra-cranial large vessel inflammation. Clinicians should be aware of this complication and search for large vessel involvement in patients with GCA who have ischemic symptoms. Research is needed to define optimal strategies to identify patients with such complications. Because of the hazards of chronic corticosteroid use, alternative therapies for patients with GCA have been sought but thus far no clear alternatives have been identified. Anti-neutrophil cytoplasmic antibodies (ANCA) are associated with small-vessel vasculitis, including Wegener's granulomatosis and microscopic polyangiitis, but changes in ANCA titers should not be used as a surrogate biomarker for disease activity. Several immunosuppressive agents can be used for maintenance therapy after induction of remission in patients with ANCA-associated vasculitis, with no firm evidence that one agent is superior to others. Collectively, this review shows that more research is needed to provide a firmer body of evidence to support clinical decision-making for patients with vasculitis.

Treatment of chronic inflammatory diseases with biologic agents: opportunities and risks for the elderly.

The treatment armamentarium in rheumatic inflammatory diseases has drastically increased in the last years. Earlier uses of conventional disease-modifying antirheumatic drugs (DMARDs), along with the arrival of newer therapies including the so-called "biologic" agents, have provided better long-term outcomes for patients suffering from these illnesses. Biologic agents have shown efficacy for several diseases and failed in others. Due to a high prevalence of some of these diseases in the elderly population, this age group may also benefit, although treatment will have to be tailored to its special needs. In this mini review, we will discuss the use of these medications in rheumatic diseases with a significant prevalence in the elderly, their proven and potential uses, and the considerations that need to be taken into account when using them in this population.

[Skin lesions from the application of suction cups for therapeutic purposes]. / Lesiones cutáneas por aplicación de ventosas con fines terapéuticos.

The application of suction cups or cupping is a medicinal practice that is very widespread in Asian countries. The presence of circular areas of erythema, ecchymosis or blood blisters symmetrically distributed on the shoulders, back, thorax or lumbar area should suggest the use of this technique. The number of followers of traditional Chinese medicine is increasing in the Western world, so we should be familiar with these practices in order to prevent social and/or legal conflicts that may arise from mistaken diagnoses of abuse. We present the case of a 65-year-old male with multiple circular, erythematous, bullous lesions, symmetrically distributed, which occurred after the application of suction cups in the context of polymyalgia rheumatica.

[Polymyalgia rheumatica and temporal arteritis]. / Polymyalgia rheumatica en arteriitis temporalis.

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are closely related and frequently occurring inflammatory diseases with an incidence of 50 and 18 per 100,000 per year, respectively, in people aged 50 years or over. The most frequent symptom of PMR is aching and morning stiffness lasting more than 1 month and exacerbated by movement, occurring in the shoulder and pelvic girdles and in the neck region. GCA is vasculitis of the large and medium-sized arteries that originate from the aortic arch, causing new and marked headache localised over the temporal or occipital areas, jaw claudication, visual impairment or claudication of the arms. GCA is characterised by histopathological panarteritis with a predominantly lymphohistiocytic cell infiltrate. Activation of macrophages is central to the arteritis. Standard treatment for PMR and GCA is glucocorticoids, which may consist of prednisone 10-20 mg/day or its equivalent for PMR patients and prednisone 30-40 mg to 1 mg/kg body weight for GCA patients. For GCA patients with recently impaired vision, treatment should start with high doses of intravenously administered glucocorticoids, such as methylprednisolone 1 g/day for 3 consecutive days. A treatment duration of 1-2 years is often required for patients with PMR or GCA; because of the side effects associated with long-term use of glucocorticoids, osteoporosis prophylaxis with oral calcium supplementation, vitamin D and bisphosphonates is appropriate.