Induction therapy with an intravenous pulse of methylprednisolone shortens patients' response time to oral glucocorticoids for giant cell arteritis, enabling the use of lower total dose, earlier tapering of the drug, and longer remission, Dr. Mehrdad Mazlumzadeh of the Mayo Clinic, Scottsdale, Ariz., and his associates reported.
The investigators conducted a double-blind, placebo-controlled study in which 27 patients (19 women; mean age of 74 years) all had biopsy-confirmed, newly diagnosed giant cell arteritis.
They were randomized to intravenous pulse of either methylprednisolone or saline once daily for the first 3 days of treatment, and then switched to a regimen of 40 mg/day of oral prednisone.
The dose was tapered over the course of 9 months in patients with controlled disease. Specifically, the dosage regimen was lowered every 2 weeks to 30 mg/day, 25 mg/day, 20 mg/day, 17.5 mg/day, 15 mg/day, 12.5 mg/day, and 10 mg/day. At the 10-mg/day dosing period, the dosage was lowered 1 mg per day every 2 weeks.
Although both groups responded well to daily oral prednisone, patients who received the initial intravenous pulse methylprednisolone had faster tapering.
Compared with controls, patients treated with pulsed methylprednisolone used lower doses of oral prednisone (5 mg or less daily) without disease recurrence—a difference that persisted at 52− and 78-week follow-up visits (Arthritis Rheum. 2006;54:3310–8).
Of the 27 patients, 14 were randomized to 3-day pulsed intravenous methylprednisolone followed by oral prednisone and 13 randomized controls had saline infusions and oral prednisone.
Only 12 patients (6 in each group) had 10 mg/day or more of prednisone for 10 days before enrollment.
At 36 weeks, 10 of 14 patients who had intravenous glucocorticoids were on 5 mg/day or less of prednisone, compared with only 2 of the 13 controls.
“Possibly more importantly, this difference was maintained at the 52-week and 78-week follow-up visits, thereby documenting the long-term benefits of the initial pulse in controlling the vascular inflammation,” the researchers wrote.
Those who had intravenous pulse glucocorticoids took lower median doses than did the controls at all follow-up exams, and their total cumulative glucocorticoid dose (5,636 mg) was significantly lower than that of the controls (7,860 mg). Compared with controls, intravenous pulse patients also had fewer relapses.