Treat-to-Target Guidelines for GCA and PMR Save

The Annals of Rheumatic Disease has published updated multinational, treat-to-target (T2T) recommendations for the treatment of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR).

The task force of 29 members from 10 countries developed five overarching principles and six recommendations based on systematic literature review of 1 key issues. The task force members consisted of rheumatologists, internists, a neuro-ophthalmologist, a patient representative, methodologists and a healthcare professional from each of 10 countries. 

Management is rooted in shared decision making and the need for urgency to avoid ischaemic complications. Overall, the targets are remission, prevention of tissue ischaemia and vascular damage. Comorbidities need to be considered when assessing disease activity and selecting treatment.

Overarching principles

• Clinical management of GCA and PMR should be driven by the awareness that they are closely interrelated conditions in a common spectrum of inflammatory diseases and can occur separately, simultaneously or in temporal sequence to each other
• GCA is a medical emergency because of the imminent risk of sight loss and other ischaemic events, and therefore, requires immediate treatment; management usually requires multidisciplinary collaboration.
• Patients should be offered access to information about GCA and PMR, including clinical disease features, patient-reported outcomes, potential complications, treatment-related benefits and risks, as well as relevant comorbidities.
• Management of GCA and PMR should be based on shared decision making between the informed patient and the physician.
• Treatment of GCA and PMR should aim at maximising health-related quality of life through control of symptoms, preventing disease-related damage and minimising treatment-related adverse consequences, taking relevant comorbidities into account.

Recommendations

1. The treatment target of GCA and PMR should be remission; remission is the absence of clinical symptoms and systemic inflammation
2. Treatment of GCA should also aim to prevent tissue ischaemia and vascular damage
3. Treatment selection in GCA and PMR should be based on disease severity and activity, presence of relevant comorbidities and potential predictors of outcome; treatment should be modified as needed during follow-up
4. Comorbidities may influence the assessment of the treatment target and should be considered before modifying treatment
5. Once remission is reached, it should be maintained with the minimal effective dose of medication#; drug-free remission may be achieved in a proportion of patients
6. Disease activity in GCA and PMR should be monitored regularly, as frequently as every 1–4 weeks until remission has been achieved, and at longer monitoring intervals (eg, between 3 and 6 months) in patients in stable remission on therapy; monitoring of patients off therapy should be discussed on an individual basis