Efficacy and safety of steroid-sparing treatments in giant cell arteritis according to the glucocorticoids tapering regimen: A systematic review and meta-analysis

Efficacy of leflunomide as a steroid‐sparing agent in treatment of Indian giant cell arteritis patients: A 2‐year follow‐up study

“…Major challenges in the effective treatment of GCA are relapses, which is reported to occur in up to 75% of patients, 16 and the risk associated with continued glucocorticoid therapy 14 . Tocilizumab, an interleukin‐6 receptor inhibitor, is highly effective as a steroid‐sparing agent in GCA 17 . However, treatment with tocilizumab is expensive and its use is limited, especially in resource‐poor settings.…”

“…Among the csDMARDs, only methotrexate has been sufficiently studied. But efficacy of methotrexate as a steroid‐sparing agent has not been very encouraging and at best a modest result has been reported in most literature 17,18 . Leflunomide, another csDMARD, exerts its immunomodulatory effect by reversibly inhibiting the enzyme dihydro‐orotate dehydrogenase and as a consequence dendritic cells and activated T‐lymphocytes are inhibited resulting in impaired production of various cytokines including tumor necrosis factor alpha (TNF‐α) and interleukins 2, 6 and 12 14 …”

“…14 Tocilizumab, an interleukin-6 receptor inhibitor, is highly effective as a steroidsparing agent in GCA. 17 However, treatment with tocilizumab is expensive and its use is limited, especially in resource-poor settings. The risk of infection is also undeniable.…”

“…But efficacy of methotrexate as a steroid-sparing agent has not been very encouraging and at best a modest result has been reported in most literature. 17,18 Leflunomide, another csDMARD, exerts its immunomodulatory effect by reversibly inhibiting the enzyme dihydro-orotate dehydrogenase and as a consequence dendritic cells and activated T-lymphocytes are inhibited resulting in impaired production of various cytokines including tumor necrosis factor alpha (TNFα) and interleukins 2, 6 and 12. 14 Our cohort primarily represents cranial GCA, and we cannot comment on extra-cranial large vessel involvement among them, as positron emission tomography (PET) scan was not done in any of these patients because of unavailability of the same in our center.…”

Treatment of Giant Cell Arteritis (GCA)

“…Following these conflicting results, an individual patient data analysis suggested hazard ratios for a first and second relapse of 0.65 ( p = 0.04) and 0.49 ( p = 0.02), respectively [ 9 ]. The real impact of MTX in real life is still debated [ 30 ], and a large multicentric RCT evaluating MTX versus TCZ (NCT03892785) is attempting to answer this delicate question. Findings from a small series of patients with relapsing GCA ( n = 11) or polymyalgia rheumatica ( n = 12) treated with leflunomide (LEF) showed a reduction in C-reactive protein level and GC daily dose [ 31 ].…”