What is the recommended treatment for temporal arteritis?

From the Guidelines

The recommended treatment for temporal arteritis is high-dose corticosteroid therapy, typically starting with prednisone at 40-60 mg daily, as suggested by the most recent guidelines 1.

Key Considerations

• Treatment should begin immediately upon suspicion of the diagnosis, even before biopsy confirmation, to prevent vision loss, as emphasized in the 2021 guideline for the management of giant cell arteritis and Takayasu arteritis 1.
• This initial high dose is usually maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize.
• Then, a slow taper begins, typically reducing by 10% of the dose every 2-4 weeks, with the entire course lasting 12-24 months.

Adjunctive Therapy

• Adjunctive therapy with methotrexate (10-25 mg weekly) or tocilizumab (162 mg subcutaneously weekly) may be added as steroid-sparing agents, as recommended in the 2020 update of the EULAR recommendations for the management of large vessel vasculitis 1.
• Patients should also receive calcium (1200-1500 mg daily) and vitamin D (800-1000 IU daily) supplementation to prevent steroid-induced osteoporosis, and often a proton pump inhibitor for gastric protection.

Additional Measures

• Low-dose aspirin (81 mg daily) is frequently recommended to reduce the risk of ischemic complications, although its use is not universally agreed upon, as noted in the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.
• Corticosteroids are effective because they suppress the granulomatous inflammation of the arterial walls that characterizes temporal arteritis, thereby preventing the dangerous complications of this vasculitis, particularly permanent blindness.

Diagnostic Approach

• A temporal artery biopsy should be performed whenever a diagnosis of giant cell arteritis is suspected, but this should not delay the treatment, as stated in the EULAR recommendations for the management of large vessel vasculitis 1.
• Ultrasonography of the temporal artery may be a useful diagnostic tool, with a sensitivity of 88% and specificity of 97% for diagnosing temporal arteritis, as reported in the 2009 EULAR recommendations 1.

From the FDA Drug Label

For the treatment of dermatomyositis, temporal arteritis, polymyositis, and systemic lupus erythematosus. The recommended treatment for temporal arteritis is methylprednisolone (IV), as it is indicated for the treatment of this condition 2.

• The use of methylprednisolone is recommended as an adjunctive therapy for short-term administration to tide the patient over an acute episode or exacerbation.
• Methylprednisolone can be used to treat various conditions, including rheumatic disorders such as temporal arteritis.

From the Research

Temporal Arteritis Diagnosis and Treatment

• Temporal arteritis, also known as giant cell arteritis, is a systemic autoimmune vasculitis that can cause rapid, irreversible bilateral vision loss in older adults, making it an ophthalmological emergency 3.
• The diagnosis of temporal arteritis is typically made based on a combination of clinical presentation, laboratory findings, and temporal artery biopsy results 4.
• Classic symptoms of temporal arteritis include polymyalgia rheumatica, new-onset headache, jaw claudication, and visual symptoms such as diplopia and amaurosis fugax 4.
• Elevated erythrocyte sedimentation rate is a common laboratory finding in temporal arteritis, and abnormalities on temporal artery biopsy are the gold standard for diagnosis 4.

Treatment of Temporal Arteritis

• Rapid treatment with steroids can prevent permanent vision loss, which is the worst ischemic complication of the disease 4, 5.
• The performance of temporal artery biopsy should not delay the prompt institution of steroid therapy on diagnosis of giant cell arteritis, since the diagnostic yield of biopsy seems valuable within 4 weeks of starting high-dose steroid treatment 6.
• Steroids given to suppress the inflammatory involvement of the arterial wall safeguard the blood supply to the eye, and immediate hospitalization is recommended when the diagnosis is made and steroid therapy is begun, along with measures for symptomatic relief of headaches 5.
• The duration of corticosteroid treatment seems to affect the positivity of temporal artery biopsy in patients with suspected giant cell arteritis, with a more than 7 days' duration of steroid treatment being independently linked with lower rates of positive biopsy 7.