What is the treatment for temporal arteritis (giant cell arteritis)?

From the Guidelines

Temporal arteritis, also known as giant cell arteritis, requires immediate treatment with high-dose corticosteroids to prevent vision loss and other complications. The standard initial treatment is oral prednisone at 40-60 mg daily (or 1 mg/kg/day), started as soon as the diagnosis is suspected, even before biopsy confirmation 1. For patients with visual symptoms, intravenous methylprednisolone 500-1000 mg daily for 3 days may be given before transitioning to oral therapy. The high-dose prednisone is typically maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize. Then, a slow taper begins, reducing by approximately 10% of the dose every 2-4 weeks. Most patients require 12-24 months of therapy, with careful monitoring for relapse during tapering. Low-dose aspirin (81 mg daily) is often added to reduce the risk of ischemic complications. Steroid-sparing agents like methotrexate or tocilizumab may be considered for patients who cannot tolerate steroids or have relapses 1. Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential throughout treatment. Calcium and vitamin D supplementation, along with bisphosphonates, should be prescribed to prevent steroid-induced osteoporosis. Prompt treatment is critical because inflammation of the temporal arteries can lead to permanent blindness if left untreated. Some key points to consider in the treatment of temporal arteritis include:

• The use of high-dose glucocorticoids as first-line treatment 1
• The potential benefits of adjunctive therapy with tocilizumab or methotrexate in selected patients 1
• The importance of regular monitoring and slow tapering of glucocorticoids to minimize the risk of relapse and steroid-related side effects 1
• The need for calcium and vitamin D supplementation to prevent steroid-induced osteoporosis. It is also important to note that the optimal duration of therapy with glucocorticoids for giant cell arteritis is not well established and should be guided by the patient’s values and preferences 1. In patients with suspected giant cell arteritis, temporal artery biopsy is conditionally recommended over magnetic resonance imaging (MRI) of the cranial arteries for establishing a diagnosis of giant cell arteritis 1. However, imaging modalities such as MRI may be helpful in establishing a diagnosis of giant cell arteritis, especially in patients with suspected large vessel involvement 1. Overall, the treatment of temporal arteritis requires a comprehensive approach that takes into account the patient’s individual needs and preferences, as well as the potential benefits and risks of different treatment strategies.

From the Research

Treatment Options for Temporal Arthritis

• Corticosteroids are the cornerstone of therapy for giant-cell arteritis, but relapse during dose tapering and corticosteroid-related adverse events often complicate management 2.
• Combined therapy with methotrexate and prednisone has been shown to reduce the proportion of patients who experience at least one relapse and the proportion of patients who experience multiple relapses 2.
• Methotrexate may be considered as adjunct therapy in patients with giant-cell arteritis to decrease the risk of further relapse events 3.
• Tumor necrosis factor alpha (TNF-alpha) inhibitors, such as adalimumab, may be effective in treating refractory or steroid-dependent temporal arteritis 4.

Diagnosis and Management

• Temporal artery biopsy is the gold standard for diagnosis of giant-cell arteritis, but a negative result does not exclude the diagnosis due to skip lesions 5.
• Laboratory values, such as erythrocyte sedimentation rate and CRP, can indicate giant-cell arteritis, but none of these values prove the diagnosis 5.
• Giant-cell arteritis is a critically ischaemic disease and should be treated as a medical emergency to prevent visual loss, which occurs in up to a fifth of patients 6.
• The British Society for Rheumatology and the British Health Professionals in Rheumatology have published guidelines on the management of polymyalgia rheumatica, which include recommendations for the prompt diagnosis and urgent management of giant-cell arteritis 6.

Complications and Monitoring

• Visual loss is a common complication of giant-cell arteritis and can be irreversible even with therapy 5.
• Monitoring of disease activity, complications, and relapse is crucial in the management of giant-cell arteritis 6.
• Parameters of inflammation, such as ESR and CRP, should be monitored to assess the effectiveness of treatment 5.