From the Guidelines
Temporal arteritis, also known as giant cell arteritis, presents with several key symptoms including severe headaches, scalp tenderness, jaw pain when chewing (jaw claudication), vision changes or sudden vision loss, fatigue, fever, and weight loss.
Symptoms of Temporal Arteritis
Some patients may also experience pain and stiffness in the shoulders and hips.
- Severe headaches
- Scalp tenderness
- Jaw pain when chewing (jaw claudication)
- Vision changes or sudden vision loss
- Fatigue
- Fever
- Weight loss
- Pain and stiffness in the shoulders and hips
Treatment Options
Treatment should begin immediately with high-dose corticosteroids, typically prednisone at 40-60mg daily, even before confirming diagnosis if temporal arteritis is strongly suspected, as delays can lead to permanent vision loss 1. The diagnosis is confirmed through blood tests showing elevated inflammatory markers (ESR and CRP) and a temporal artery biopsy. Once started, steroid therapy typically continues at high doses for 2-4 weeks before gradually tapering over many months, often 12-24 months total. Some patients may require steroid-sparing agents like methotrexate or tocilizumab to reduce steroid side effects during long-term treatment. Regular monitoring of symptoms and inflammatory markers is essential to guide treatment adjustments. Patients should be aware that steroid therapy can cause side effects including weight gain, mood changes, increased blood sugar, osteoporosis, and increased infection risk, so calcium and vitamin D supplements are often recommended to protect bone health 1.
Important Considerations
It is crucial to initiate treatment promptly to prevent complications such as vision loss. The use of low-dose aspirin is also recommended in all patients with giant cell arteritis 1. Reconstructive surgery for Takayasu arteritis should be performed in the quiescent phase of disease and should be undertaken at expert centres 1. Elective procedures should be performed when disease is in remission, and these patients will need long-term follow-up. High-dose GC therapy (40–60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active GCA or TAK 1. Induction treatment with a starting GC dose of 40–60 mg per day leads to remission in the majority of patients with LVV 1. A suspected diagnosis of LVV should be confirmed by imaging (ultrasound or MRI for temporal or other cranial arteries, ultrasound, CT, positron-emission-tomography (PET)-CT or MRI for the aorta/extracranial arteries) or histology (TAB) 1. Every effort should be made to confirm a suspected diagnosis of LVV. In rare cases, both imaging and biopsy are negative. If the clinical probability in such cases is high, a provisional diagnosis of GCA may be made, which needs to be confirmed or revised during follow-up 1. The original recommendations advised TAB in every case of suspected GCA. Since then, a large amount of good-quality data demonstrated that imaging and biopsy have similar diagnostic value if assessors are proficient in these techniques 1. Ultrasound guidance appears not to improve the diagnostic yield of TAB. Biopsies should be at least 1 cm in length, which corresponds to a postfixation length of at least 0.7 cm. Biopsy quality is crucial for accurate diagnosis 1. In patients with GCA with acute visual loss or amaurosis fugax, the administration of 0.25–1 g intravenous methylprednisolone for up to 3 days should be considered, because these high doses have both genomic and rapid non-genomic effects 1. However, there are only low-quality retrospective clinical data supporting this recommendation. Referral for intravenous GC therapy should not delay treatment with oral GC. The SLR revealed quality issues in both randomised controlled clinical trials (RCTs) of high dose pulse intravenous GC therapy in patients with visual symptoms. In view of the limited quality of evidence, the task force recommends limiting the use of intravenous pulse GC therapy to patients with complicated GCA such as those with GCA-related visual symptoms 1. We recommend tapering the GC dose, once remission has been achieved. A GC taper regimen must weigh the risk of relapse against the risk of GC-related adverse events. In GCA, relapses are infrequent (<3%) that both are normal 1. Hellmich B, et al. Ann Rheum Dis 2020;79:19–30. doi:10.1136/annrheumdis-2019-215672 1.
From the Research
Temporal Arteritis Symptoms
- Classic symptoms of temporal arteritis include:
- Polymyalgia rheumatica
- New-onset headache
- Jaw claudication
- Visual symptoms such as diplopia and amaurosis fugax 2
- Other symptoms may include:
- Dry cough
- Toothache
- Tongue infarction
- Vision loss 3
- Atypical manifestations may occur in about 40% of patients, including:
- Fever of unknown origin
- Respiratory tract symptoms
- Large artery involvement 3
Treatment Options
- High-dose corticosteroids are the mainstay of treatment for temporal arteritis 2, 4, 5
- Rapid treatment with steroids can prevent permanent vision loss 2
- A gradual tapering of the steroid dose should occur over at least 1 year, with the consideration of the use of steroid-sparing agents if iatrogenic steroid complications occur 4
- TNF-alpha inhibitors, such as adalimumab, may be effective in treating refractory or steroid-dependent temporal arteritis 5