Len - you smartly focus on the problem that will confront many.
1. We have FDA guidance and package inserts that state use a TNFi before JAKi
2. We know from Oral surveillance - CV/CA risks are greater in those over 65, who are smokers and w/ hx of MI/CVE
3. We have great news with a new JAKi approval in GCA, but while the PI states UPA is is indicated for the treatment of adults with giant cell arteritis - 5 time before that it says after a TNFi
4. But TNFi are not indicated in GCA.
Thus is a JAKi equal to or less safe than and IL-6 inhibitor in an older GCA patient? We dont know as IL-6 was not studied for safety as the JAKi were. My opinion is to use which ever drug would be safer based on patient comorbidities or preference. If the GCA pt was a a smoker or has a past hx of Zoster, VTE, MACE, MI -- I would use the IL-6 inhibitor. If the patient had a hx of diverticulitis or bowel perforation, significant liver issues or problems with IL-6i I would consider a JAKi. I hate waffle, but you asked a waffle house question!