Successful treatment of refractory giant cell arteritis with etanercept

subclavian, left common carotid, and brachiocephalic arteries. Brain MRI revealed no major abnormalities in the cerebrovascular system. A biopsy of temporal arteries was denied by the patient. Positron emission tomography scanning showed increased uptake of 18F-fluorodeoxyglucose in the walls of aortic arch, left subclavian, left common carotid, and brachiocephalic arteries. The patient fulfilled the American College of Rheumatology 1990 criteria for the classification of giant cell arteritis (age of disease onset >50 years, new headache, and temporal artery abnormality) [2]. On the other hand, the patient did not meet the American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis (age of disease onset >50 years, absence of decreased pulsation of brachial arteries, blood pressure difference between arms, and bruit over subclavian arteries). Giant cell arteritis was diagnosed based on the clinical and radiological findings. The patient’s clinical course is shown in Fig. 1. As the patient denied the administration of high dose of prednisolone (PSL) at the time, initial treatment was started with low dose of PSL. Oral PSL 30 mg/day was started with a good initial response. However, the patient had relapsed five times in 1 year (Fig. 1). Relapse was defined as reappearance of clinical symptoms such as fever and/or neck pain associated with an elevated CRP (medications during first relapse: PSL 17.5 mg/day, second relapse: betamethasone 2.25 mg/day and methotrexate 6 mg/week, third relapse: betamethasone 1.75 mg/day, methotrexate 14 mg/week, and mizoribine 200 mg/day, fourth relapse: PSL 22.5 mg/day and cyclosporin 340 mg/day, and fifth relapse: PSL 20 mg/day and cyclosporin 340 mg/day). Thus, the steroid dose was never reduced below 17.5 mg/day. Therefore, in April 2015, etanercept (50 mg/week) was added to the treatment with PSL 20 mg/day and cyclosporin 340 mg/day. CRP became normal within 4 weeks. PSL was tapered to 5 mg after To the editor,