To the Editor:

We read with great interest the article by Mazlumzadeh et al (1), in which it is reported that treatment of giant cell arteritis (GCA) using induction therapy with high-dose glucocorticoids optimizes therapeutic benefit, allowing a shorter duration of glucocorticoid treatment. In that study, 27 patients with biopsy-proven GCA were randomized to receive induction therapy with intravenous (IV) methylprednisolone (15 mg/kg ideal body weight/day) or IV saline for 3 consecutive days. All patients were started on 40 mg/day prednisone and treated according to the same tapering schedule. The authors concluded that induction therapy with high-dose pulse IV methylprednisolone confers the long-term benefit of allowing a lower total oral prednisone dose.

The median total cumulative oral prednisone dose received by the IV glucocorticoid–treated patients at week 78 was 5,636 mg (interquartile range [IQR] 4,050–6,690), while the median total cumulative oral prednisone dose received by the placebo-treated group at week 78 was 7,860 mg (IQR 7,373–9,005) (P = 0.001). The initial high-dose IV methylprednisolone received (15 mg/kg ideal body weight daily for 3 days, which can translate to as much as 1,000 mg/day for an average 70-kg patient) was not included in the latter calculation. Obviously this exclusion could underestimate the cumulative dose of glucocorticoid received by the end of the treatment period. Although the oral dose received may have been lower in the methylprednisolone-treated group, the total dose received may have been equal or higher in this group.

In addition, small sample size could have affected the final outcomes. Although the patients in Mazlumzadeh and colleagues' study were randomized, the numbers were limited (13 in the placebo group and 14 in the methylprednisolone-treated group). The mean C-reactive protein level at baseline was lower in the methylprednisolone-treated group (3.43 mg/dl versus 5.16 mg/dl), and fewer patients in this group had weight loss, fever, or scalp tenderness. Although these differences were not statistically significant, they may represent a real difference in the severity of the disease. A study of 164 patients showed that pulse methylprednisolone (at a dosage lower than that used in the study by Mazlumzadeh et al) had no significant long-term corticosteroid-sparing effects in patients with simple forms of GCA (2). A larger multicenter study could clarify the role of high-dose pulse IV methylprednisolone in the treatment of GCA.

  • 1
    Mazlumzadeh M, Hunder GG, Easley KA, Calamia KT, Matteson EL, Griffing WL, et al. Treatment of giant cell arteritis using induction therapy with high-dose glucocorticoids: a double-blind, placebo-controlled, randomized prospective clinical trial. Arthritis Rheum 2006; 54: 33108.
  • 2
    Chevalet P, Barrier JH, Pottier P, Magadur-Joly G, Pottier MA, Hamidou M, et al. A randomized, multicenter, controlled trial using intravenous pulses of methylprednisolone in the initial treatment of simple forms of giant cell arteritis: a one year followup study of 164 patients. J Rheumatol 2000; 27: 148491.

Kayvan Arashvand MD*, * Wrexham Maelor Hospital, Wrexham, UK.