Giant cell arteritis (GCA) and Takayasu arteritis carry substantial risk of vascular complications and chronic disability, and their treatment has traditionally meant prolonged high-dose glucocorticoids. The direction of modern therapy is targeted immunomodulation that reduces both relapse and steroid exposure — and GCA now has a second approved targeted therapy.
Tocilizumab: the first targeted therapy for GCA
Tocilizumab, an IL-6 receptor inhibitor, was the first biologic approved for GCA. It reduces relapse rates and enables successful glucocorticoid tapering (superior to taper alone in the GiACTA trial), and also shows benefit in relapsing or refractory Takayasu arteritis. Its risks include infection, gastrointestinal perforation (particularly with underlying diverticulitis), and cytopenias.
Upadacitinib: a new oral option for GCA
The significant recent development is upadacitinib, an oral JAK inhibitor. In the Phase 3 SELECT-GCA trial, upadacitinib 15 mg (but not 7.5 mg) combined with a 26-week glucocorticoid taper achieved significantly higher sustained remission at 52 weeks than placebo with a longer taper (46.4% vs 29.0%). On this basis, upadacitinib was approved for GCA in 2025 — the second targeted therapy for the condition after tocilizumab, and the first oral one. As with the JAK class generally, monitoring for infection (including herpes zoster), thromboembolism, and cardiovascular events is warranted.
Takayasu and refractory disease
TNF inhibitors (infliximab, adalimumab) are effective and widely used off-label in Takayasu arteritis — improving remission and reducing vascular damage in glucocorticoid- or cyclophosphamide-refractory disease — but are not effective in GCA. Rituximab and abatacept have more limited, emerging roles in refractory large-vessel vasculitis, and JAK inhibitors are being explored in Takayasu as well.
| Agent | Main indication | Role | Key risks |
|---|---|---|---|
| Tocilizumab | GCA, Takayasu | Reduces relapse, steroid-sparing; approved in GCA | Infection, GI perforation, cytopenias |
| Upadacitinib | GCA | Sustained remission 46.4% vs 29.0%; approved 2025 | Infection, VTE, cardiovascular |
| TNF inhibitors | Takayasu (not GCA) | Improve remission in refractory disease | Infection, TB, malignancy |
| Rituximab / abatacept | Refractory LVV | Emerging, limited evidence | Infection, infusion reactions |
Further reading: GiACTA tocilizumab; SELECT-GCA upadacitinib (Blockmans et al., NEJM 2025); reviews of biologics and JAK inhibitors in large-vessel vasculitis (2022–2025).