Intravenous or Oral Glucocorticoids as Initial Therapy for Transient and Permanent Visual Changes in Giant Cell Arteritis: A Retrospective Cohort Study

Objectives Guidelines for the treatment of giant cell arteritis-associated vision changes (GCAVCs) recommend the use of intravenous over oral glucocorticoids to improve visual outcomes. These recommendations are based on limited data. We assessed the impact of oral or intravenous glucocorticoids on visual outcomes in a real-world cohort of individuals with GCAVCs. Methods We conducted a retrospective cohort study of individuals from a tertiary healthcare facility in Ontario, Canada between December 2017 and November 2023. Individuals included in the cohort were aged 50 or older and assigned a validated diagnostic code for GCA during an inpatient, outpatient, or emergency department visit. Diagnoses of GCA were based on the final diagnosis of the treating clinician and were required to be supported by histology, imaging findings suggestive of inflammatory vasculopathy, and/or the presence of increased inflammatory markers. GCAVCs were confirmed by the treating rheumatologist, ophthalmologist, or internist. Results were described using summary statistics. The impact of intravenous (IV) or oral glucocorticoids on visual improvement as documented by either the patient’s rheumatologist or ophthalmologist visual outcomes was assessed using multivariable logistic regression (adjusted for age, sex, and time from symptom onset to treatment). A subgroup analysis was performed in patients who had GCAVCs associated with permanent visual loss (ischemic optic neuropathy and retinal artery occlusion). Results The cohort included 289 patients with a diagnosis of GCA, of whom 77 (26.6%) experienced GCAVCs. GCAVCs included 51 cases of ischemic optic neuropathy, 6 of amaurosis fugax, 5 retinal artery occlusions, and 15 others. Individuals with transient and permanent GCAVCs were treated with oral (72.7% and 50.0% respectively) or intravenous and oral (25.0% and 50.0% respectively) glucocorticoids. Eight individuals with ischemic optic neuropathy or retinal artery occlusion had visual improvement including 5 of 27 (18.5%) who received oral glucocorticoids and 3 of 25 (12.0%) who received intravenous glucocorticoids. Complete data was available for 31 of 77 (40.3%) of cohort participants due to lack of data concerning date of glucocorticoid initiation; logistic regression was performed both including and excluding time from symptom to glucocorticoid initiation. Neither analysis demonstrated an association between the use of IV glucocorticoids and improved visual outcomes (p values 0.12-0.99) (Table). Table: results of multivariable logistic regression assessing intravenous versus oral glucocorticoids for visual improvement as judged by the treating ophthalmologist and/or rheumatologist. Results are expressed as odds ratios with their corresponding 95% confidence intervals, n reflects the sample size either including or excluding data concerning the interval between symptom onset and treatment. Conclusion Our cohort demonstrated that IV glucocorticoids, compared to oral glucocorticoids, were not associated with visual improvement in individuals who experienced GCAVCs. Conclusions are limited by the small number of events and observational nature of the data.