Rule out giant cell arteritis (GCA) (temporal arteritis)

From the Guidelines

To rule out temporal arteritis, I recommend obtaining an erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as initial screening tests, followed by a temporal artery biopsy if clinical suspicion remains high, as suggested by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1. Patients typically present with new-onset headache, scalp tenderness, jaw claudication, visual disturbances, and constitutional symptoms like fever and weight loss. Some key points to consider when evaluating a patient for temporal arteritis include:

• Physical examination should include palpation of the temporal arteries for tenderness or decreased pulsation.
• If clinical suspicion is high, start prednisone 40-60mg daily immediately, even before biopsy results, to prevent vision loss, as recommended by the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease 1.
• The biopsy should be performed within 1-2 weeks of starting steroids, as histological findings remain present during this period, according to the EULAR recommendations for the management of large vessel vasculitis 1.
• Temporal artery ultrasound may be used as a supplementary diagnostic tool, with a sensitivity of 88% and specificity of 97% for diagnosing temporal arteritis, as reported in the 2009 EULAR recommendations 1. Some important considerations when diagnosing temporal arteritis include:
• Remember that a negative biopsy doesn't completely exclude the diagnosis if clinical suspicion is high.
• Prompt diagnosis and treatment are crucial as untreated temporal arteritis can lead to permanent blindness.
• The disease typically affects adults over 50 years of age, with women being more commonly affected than men, as noted in the 2021 American College of Rheumatology/Vasculitis Foundation guideline 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Ruling Out Temporal Arteritis

To rule out temporal arteritis, the following steps can be taken:

• Clinical assessment: This includes evaluating symptoms such as new-onset headache, jaw claudication, proximal myalgia, weight loss, and fever 2, 3.
• Laboratory tests: These may include erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, thrombocytes, and cardiolipin antibodies, although none of these can definitively prove the diagnosis 2.
• Temporal artery biopsy: This is considered the gold standard for diagnosis, but a negative result does not exclude the disease due to the possibility of skip lesions 2, 3.
• Imaging studies: Angiography, magnetic resonance angiography, positron emission tomography, or ultrasound can be used to confirm the diagnosis of large-vessel giant cell arteritis 4.

Considerations in Ruling Out Temporal Arteritis

• A negative temporal artery biopsy does not rule out the disease, and patients with classic clinical manifestations but negative biopsy results should still be treated aggressively 3.
• The diagnosis of temporal arteritis is primarily clinical, and treatment should not be withheld based on negative laboratory or biopsy results alone 3.
• Corticosteroid treatment is the mainstay of treatment for temporal arteritis, and prolonged treatment may be necessary to control symptoms and prevent complications 5, 4.

Treatment and Management

• Corticosteroid treatment should be started promptly after suspected diagnosis, with an initial dose of 40 to 70 mg/d of prednisolone, and reduced gradually based on symptoms and laboratory results 4.
• Low-dose aspirin may be used to reduce the risk of ophthalmologic and cardiovascular complications 4.
• In cases of refractory temporal arteritis, treatment with tumor necrosis factor alpha (TNF-alpha) inhibitors such as adalimumab may be considered 6.