EULAR recommendations: Vasculitis (Large vessel vasculitis)

Large vessel vasculitis (LVV)- Takayasu and GCA:-

1. Thorough clinical and imaging assessment of the arterial tree when a diagnosis of Takayasu is suspected-
• MRA/PET could assist in diagnosis and document of extent of involvement but has its limitations (not widely available, operator dependant).
• Conventional angiogram is gold standard

2. In Giant cell arteritis,
• Temporal artery biopsy should be performed
• 1cm tissue length is required
• skip lesions may lead to false negative HPE
• Don’t delay treatment while waiting for biopsy. Treat first.
• If CRP/ESR is not elevated, think of another diagnosis
• USG of the temporal artery looking for vessel wall oedema was 88% sensitive and 97% specific in diagnosing GCA

3. Start steroids early and at high dose for induction of remission of LVV
• Prednisolone- 1mg/kg (max 60mg) daily
• Maintain for 1 month then taper
• Taper should not be in the form of EOD therapy which is a/w higher relapse rate
• At 3 months, steroid dose should be at 10-15mg/d
• Steroid duration could be for several years
• Must give bone protection during this period

4. Immunosuppressive agents should be considered in LVV as adjunctive therapy
• Methotrexate (20-25mg weekly)
• Azathioprine (2mg/kg/d)
• Cyclophosphamide (in steroid resistant Takayasu)

5. Monitoring of LVV- clinical and inflammatory markers

6. Use low dose aspirin in all GCA pt

7. Reconstructive surgery for Takayasu should be performed during the quiescent phase at expert centres