A family physician presented a medical case:
75 year-old woman with temporal arteritis. How long should corticosteroids be used, and how should the tapering be done.....?
Healthy 75 year-old lady presenting with headaches, mainly temporal. Severe. Known smoker with Hypertension and GERD. She takes Pantoprazole, Lisinopril, Verapamil SR. Exam revealed tender and hard temporal arteries, BP 190/80. Bloods revealed: CRP 44, ESR 41. Cortisone started on first consultation. Imediate improved clinical response. Temporal artery biopsy confirmed Giant cell / Temporal arteritis. Dose of 30mg Prednisone per day. (small lady) . After 3 months ESR normalised to 7. BP normalised without addition of more meds. When do we start tapering Prednisone and how fast and till when to stop? (Bear in mind she has Osteopenia)
Close details
Patient demographics
Gender
female
Age
75
Ethnicity
Occupation
Chief complaint or problem to solve
75 year-old woman with temporal arteritis. How long should corticosteroids be used, and how should the tapering be done.....?
Case history
Healthy 75 year-old lady presenting with headaches, mainly temporal. Severe. Known smoker with Hypertension and GERD. She takes Pantoprazole, Lisinopril, Verapamil SR. Exam revealed tender and hard temporal arteries, BP 190/80. Bloods revealed: CRP 44, ESR 41. Cortisone started on first consultation. Imediate improved clinical response. Temporal artery biopsy confirmed Giant cell / Temporal arteritis. Dose of 30mg Prednisone per day. (small lady) . After 3 months ESR normalised to 7. BP normalised without addition of more meds. When do we start tapering Prednisone and how fast and till when to stop? (Bear in mind she has Osteopenia)
Purpose of case discussion
What's the next step in her treatment? How long to use Cortisone, and when to taper and stop?
Supplemental Materials

Dr. Geoffrey Rutledge
Internal Medicine
6 doctors agree

In brief: Lifelong treatment

The confirmed diagnosis of TA means ongoing steroid treatment may be required, and it can be difficult to taper without relapse.
Recent literature suggests that "the addition of tocilizumab (TCZ), intravenous or subcutaneous, may provide additional benefit for both inducing and maintaining remission... TCZ appears to be quick in onset, and helps to minimize glucocorticoid exposure over time." http://journals.sagepub.com/doi/10.1177/2040622317700089
TCZ is a humanized monoclonal antibody directed against the IL-6 receptor. TCZ is not without side effects (esp infections) but studies show often results in significantly lower steroid requirement. See Regent et al: https://www.ncbi.nlm.nih.gov/pubmed/27182063

In brief: Lifelong treatment

The confirmed diagnosis of TA means ongoing steroid treatment may be required, and it can be difficult to taper without relapse.
Recent literature suggests that "the addition of tocilizumab (TCZ), intravenous or subcutaneous, may provide additional benefit for both inducing and maintaining remission... TCZ appears to be quick in onset, and helps to minimize glucocorticoid exposure over time." http://journals.sagepub.com/doi/10.1177/2040622317700089
TCZ is a humanized monoclonal antibody directed against the IL-6 receptor. TCZ is not without side effects (esp infections) but studies show often results in significantly lower steroid requirement. See Regent et al: https://www.ncbi.nlm.nih.gov/pubmed/27182063
Dr. Geoffrey Rutledge
Dr. Geoffrey Rutledge
Thank
1 comment
Dr. Yale Kanter
Until sed rate returns to normal and symptoms have cleared.
Dr. John Goldman
Internal Medicine - Rheumatology
6 doctors agree

In brief: Now

Use a slow taper - as slow as 1 mg/ week.
follow freshly done sed rate (nit sent to central labs) with eat taper. You can try 5 mg drops every few weeks until 15 mg/day and then 1 mg drops.

The goal is to get off and later if not taper off can try anti-IL-6 inhibitors - if insuracne apptoval.

Be certain she is on osteoprosis treat ment including calcium Vitamin D in high dose 1000 to 4000 day.

treat the osteoporosis risk with a bisphosphonate

In brief: Now

Use a slow taper - as slow as 1 mg/ week.
follow freshly done sed rate (nit sent to central labs) with eat taper. You can try 5 mg drops every few weeks until 15 mg/day and then 1 mg drops.

The goal is to get off and later if not taper off can try anti-IL-6 inhibitors - if insuracne apptoval.

Be certain she is on osteoprosis treat ment including calcium Vitamin D in high dose 1000 to 4000 day.

treat the osteoporosis risk with a bisphosphonate
Dr. John Goldman
Dr. John Goldman
Thank
1 comment
Dr. Ronald Krauser
Calcium and vitamin D have little or no benefit for improving bone density or preventing bone lose. Individuals on chronic systemic corticosteroids should be treated with concurrent oral bisphosphonates.
Dr. Matt Wachsman
Internal Medicine
5 doctors agree

In brief: Not a very

good answer but you play it by ear. Certainly months.
but then there is going to be a gradual taper off of prednisone anyway, so you see about the symptoms and sed rate at each level of tapering to see if you can go lower.

In brief: Not a very

good answer but you play it by ear. Certainly months.
but then there is going to be a gradual taper off of prednisone anyway, so you see about the symptoms and sed rate at each level of tapering to see if you can go lower.
Dr. Matt Wachsman
Dr. Matt Wachsman
Thank
2 comments
Dr. Thomas Namey
No longer Rx of choice. Use initially but start MTX quickly sc at 25mg/wk! The start steroid taper!
Dr. Thomas Namey
Also CRP is a much better marker then Sed Rate!
Dr. Hamid Sajjadi
Ophthalmology
4 doctors agree

In brief: Reconsider diagnosis

CRP of 44 nmol/l; is not too high for this age group.
ESR being 41 is almost normal for a 75-year-old. Just having headaches & hard felt areas on temples does not make diagnosis of TA. TA is a serious DX & they need to be on Steroids lifelong. She needs a rheumatic workup ANA, RA, RPR, etc. Rule out other rheumatic disease. Because in TA you cannot even go to every other day steroids. You can taper the steroids by ESR & go to 5 mg daily if possible. But with other rheumatic diseases there are many other choices than steroids & also you can go to steroids every other day with less system responses. Steroids make GERD&BP worse. Palpable hard arteries should get temporal artery biopsy. She needs a Neuro-Ophthalmologist & a Rheumatologist & a General surgeon for biopsy of Temporal lobe. After all the tests the neuro-ophthalmologist & Rheumatologist need to make a diagnosis based on her VF, OCT, & complete lab workup.

In brief: Reconsider diagnosis

CRP of 44 nmol/l; is not too high for this age group.
ESR being 41 is almost normal for a 75-year-old. Just having headaches & hard felt areas on temples does not make diagnosis of TA. TA is a serious DX & they need to be on Steroids lifelong. She needs a rheumatic workup ANA, RA, RPR, etc. Rule out other rheumatic disease. Because in TA you cannot even go to every other day steroids. You can taper the steroids by ESR & go to 5 mg daily if possible. But with other rheumatic diseases there are many other choices than steroids & also you can go to steroids every other day with less system responses. Steroids make GERD&BP worse. Palpable hard arteries should get temporal artery biopsy. She needs a Neuro-Ophthalmologist & a Rheumatologist & a General surgeon for biopsy of Temporal lobe. After all the tests the neuro-ophthalmologist & Rheumatologist need to make a diagnosis based on her VF, OCT, & complete lab workup.
Dr. Hamid Sajjadi
Dr. Hamid Sajjadi
Thank
2 comments
Dr. Geoffrey Rutledge
While I agree that we should be sure of this diagnosis, the case history does include "Temporal artery biopsy confirmed Giant cell / Temporal arteritis" which is enough for me!
Dr. Hamid Sajjadi
Actually I agree with Dr. Rutledge I missed the "temporal artery biopsy confirmed Giant cell temproral arteritis". I don't know but I missed it. May be because I have quiet a few TA cases, mainly referred to me, & I have never seen such low ESR. That is why I mentioned you need to do a temporal artery biopsy. So I completely agree with Dr. Rutledge.
Dr. Alvin Wells
Internal Medicine - Rheumatology
4 doctors agree

In brief: GCA

Recent data shows that the use of subcutaneous Actemra allows tapering of prednisone with less chance of relapse (Lancet 2016; 387:1921-1927).

In brief: GCA

Recent data shows that the use of subcutaneous Actemra allows tapering of prednisone with less chance of relapse (Lancet 2016; 387:1921-1927).
Dr. Alvin Wells
Dr. Alvin Wells
Thank
2 comments
Dr. Yale Kanter
or until sed rate returns to normal range if it is a proven biopsy diagnosis
Dr. Ronald Krauser
I have also found that methotrexate can be effective as a steroid sparing agent in giant cell arteritis. It is also considerably cheaper than Actemra.
Dr. Al Hegab
Internal Medicine - Allergy & Immunology
3 doctors agree

In brief: This is case

specific, and should be monitored by the treating physician(s), wish you well

In brief: This is case

specific, and should be monitored by the treating physician(s), wish you well
Dr. Al Hegab
Dr. Al Hegab
Thank
Dr. Thomas Namey
Internal Medicine - Rheumatology
3 doctors agree

In brief: No more pred!

Quickly taper. Use sc MTX instead! Start with 50 mg sc 4 weeks and then 25 therafter. per week.
Pfizers drug
TOFACITINIB CITRATE will receive approval soon. Prednisone is now archaic with more potential for harm!

In brief: No more pred!

Quickly taper. Use sc MTX instead! Start with 50 mg sc 4 weeks and then 25 therafter. per week.
Pfizers drug
TOFACITINIB CITRATE will receive approval soon. Prednisone is now archaic with more potential for harm!
Dr. Thomas Namey
Dr. Thomas Namey
Thank
Dr. Jovita Anyanwu
Internal Medicine
2 doctors agree

In brief: When

Constitutional symptoms resolve and inflammatory markers are controlled steroids can be tapered over a 1 year to 2 years period.
Discuss with treating Rheumatologist or Neurologist

In brief: When

Constitutional symptoms resolve and inflammatory markers are controlled steroids can be tapered over a 1 year to 2 years period.
Discuss with treating Rheumatologist or Neurologist
Dr. Jovita Anyanwu
Dr. Jovita Anyanwu
Thank
Dr. Peter Ihle
Orthopedic Surgery
2 doctors agree

In brief: There is no 1-

-answer as everyone is different, as well as their response to meds.
Be sure to ask this of your treating physician.

In brief: There is no 1-

-answer as everyone is different, as well as their response to meds.
Be sure to ask this of your treating physician.
Dr. Peter Ihle
Dr. Peter Ihle
Thank
2 comments
Dr. Thomas Namey
Use MTX 25mg sc and decrease steroids after two weeks!
Dr. Ronald Krauser
Agree with early addition of methotrexate and fairly rapid tapering of prednisone using symptoms and results of acute phase reactants as guides.
Get help from a real doctor now
Dr. Dennis Higginbotham
Board Certified, Obstetrics & Gynecology
27 years in practice
49M people helped
Continue
111,000 doctors available
Read more answers from doctors