Treatment of Suspected Giant Cell Arteritis with Tocilizumab

Diagnostic Considerations

The diagnosis of GCA requires confirmation through either temporal artery biopsy, cross-sectional imaging, or elevated acute-phase reactants (ESR/CRP), as recommended by the American College of Rheumatology 1, 2, 3
The American College of Rheumatology suggests that glucocorticoid responsiveness is a clinical feature of GCA, but it is not specific enough to establish the diagnosis in the absence of other confirmatory findings, with a strength of evidence rated as moderate 4, 5

The American College of Rheumatology conditionally recommends oral glucocorticoids with tocilizumab over oral glucocorticoids alone for confirmed GCA, with a strength of evidence rated as high 6, 7
The ACR/Vasculitis Foundation guidelines require confirmation of diagnosis through either temporal artery biopsy/cross-sectional imaging or elevated acute-phase reactants before initiating tocilizumab therapy, with a strength of evidence rated as moderate 1, 3

For patients with suspected but unconfirmed GCA, the American College of Rheumatology suggests continuing glucocorticoid taper as planned, with close clinical monitoring for disease activity during taper, and a strength of evidence rated as low 8, 9
The American College of Rheumatology recommends implementing close clinical monitoring for disease activity during taper, with a strength of evidence rated as moderate 8, 6
The American Academy of Ophthalmology recommends complete ophthalmology evaluation to assess optic neuropathy, with a strength of evidence rated as high 10

Patients with significant comorbidities (e.g., diabetes, osteoporosis, psychiatric disorders) in which prolonged glucocorticoid exposure carries substantial risk should receive tocilizumab at the time of GCA diagnosis. 11
Patients presenting with cranial GCA that includes visual involvement or a high risk of ischemic complications should be started on tocilizumab concurrently with glucocorticoids at diagnosis. 11
Patients who are unable to tolerate prolonged glucocorticoid therapy (e.g., due to intolerance or contraindications) should receive early tocilizumab addition. 11

Tocilizumab must not be initiated in individuals with active infection or untreated latent tuberculosis; appropriate screening for latent TB is required before therapy commencement. 11