Clinical Pathways in Neuro-ophthalmology : An ... - E-Lib FK UWKS

106 Clinical Pathways in Neuro-Ophthalmology, second edition
What Is the Preferred Treatment Regimen
for GCA?
Untreated GCA may result in significant visual loss in one or both eyes. Therefore, it is
imperative that corticosteroid therapy begin immediately upon clinical suspicion of
GCA (class II, level B) to prevent visual loss (i.e., before TAB and laboratory confirmation).
Most authors have recommended an initial dose of oral prednisone of 1.0 mg=kg
to 1.5 mg=kg=d (60 to 100 mg per day) (Laidlaw, 1990; Lundberg, 1990; Myles, 1992;
Weisman, 1995) (class III, level C). Although some authors (Aiello, 1993) have reported
that an initial lower dose of 40 mg per day may be adequate to control clinical
symptoms (Myles, 1992), patients with visual loss probably require higher doses.
Some anecdotal cases of visual improvement have been reported following intravenous
(IV) corticosteroids for patients with visual loss and GCA (Diamond, 1991; Liu, 1994;
Matzkin, 1992; Postel, 1993). Many patients note improvement in symptoms within 1 to
2 days of starting steroid therapy, but other patients may continue to experience
symptoms of GCA including visual loss despite adequate corticosteroid therapy
(Aiello, 1993; Evans, 1994; Liu, 1994; Rauser, 1995). A rapid or premature reduction
of steroid therapy in GCA may also precipitate visual loss (Cullen, 1967). Occasionally
new AION may occur in patients on ‘‘adequate’’ doses of corticosteroids (Rauser, 1995).
Hwang et al reported a patient who developed bilateral ocular ischemic syndrome
despite corticosteroid treatment (Hwang, 1999).
Jover et al reported a randomized, double-blind, placebo-controlled study comparing
corticosteroids alone versus corticosteroids combined with methotrexate in 42 patients
with new-onset GCA (Jover, 2001). The prednisone plus methotrexate group experienced
fewer relapses than the prednisone with placebo group, whereas the rate and
severity of adverse events were similar in both groups. The authors suggested that
methotrexate plus corticosteroids is a safe alternative to corticosteroids alone for GCA
and is more effective in controlling disease ( Jover, 2001).
Stauton et al described a patient with GCA whose clinical condition deteriorated
steadily with signs suggesting an evolving vertebrobasilar stroke during corticosteroid
treatment (Stauton, 2000). The authors theorized that the clinical deterioration might
have actually been induced by the initiation of the corticosteroids.
Should Oral or IV Corticosteroids Be Used
for GCA?
Liu et al reported a 34% chance of visual improvement after corticosteroid therapy.
Additional visual loss occurred in 7 of 41 (17%) patients despite corticosteroids (Liu,
1994). Three patients experienced fellow-eye involvement after oral therapy, but none of
those treated with IV steroids developed fellow-eye involvement. Based on these
results, these authors recommended IV therapy (methylprednisolone 250 mg four
times daily for 3 to 5 days) in patients with visual loss due to GCA (Liu, 1994).
Matzkin et al reported visual recovery in two patients with central retinal artery
occlusions due to GCA after treatment with high-dose IV methylprednisolone (Matzkin,
1992). Other authors have described anecdotal cases of visual improvement following
IV corticosteroids for patients with visual loss and GCA (Aiello, 1993; Diamond, 1991;