From the Guidelines
Temporal arteritis (giant cell arteritis) requires prompt evaluation and treatment to prevent vision loss, and the most recent and highest quality study recommends starting treatment immediately with high-dose oral prednisone, typically 40-60 mg daily, as soon as the diagnosis is suspected 1.
Evaluation Approach
The evaluation of temporal arteritis begins with a clinical assessment for symptoms like headache, jaw claudication, and vision changes, followed by laboratory tests including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), which are typically elevated.
- Clinical assessment: symptoms like headache, jaw claudication, and vision changes
- Laboratory tests: ESR and CRP
Diagnostic Testing
Temporal artery biopsy remains the gold standard for diagnosis, though treatment should not be delayed while awaiting results.
- Temporal artery biopsy: gold standard for diagnosis
- Imaging tests: may be used to support diagnosis, but not recommended as a replacement for biopsy in the US 1
Treatment Approach
Treatment should start immediately with high-dose oral prednisone, typically 40-60 mg daily (or 1 mg/kg/day), which should be initiated as soon as the diagnosis is suspected.
- High-dose oral prednisone: 40-60 mg daily (or 1 mg/kg/day)
- Intravenous methylprednisolone: 500-1000 mg daily for 3 days may be given before transitioning to oral steroids for patients with visual symptoms
Monitoring and Adjunctive Therapy
The initial high-dose steroid should be maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize, then gradually tapered over 12-18 months to prevent relapse.
- Regular monitoring: symptoms, inflammatory markers, and steroid side effects
- Adjunctive therapy: tocilizumab (162 mg subcutaneously weekly) may allow faster steroid tapering and reduce relapse rates
- Bone protection: calcium, vitamin D, and often bisphosphonates while on long-term steroids
From the Research
Evaluation Approach
- The evaluation of temporal arteritis involves a combination of clinical suspicion, laboratory testing, and temporal artery biopsy 2
- Clinicians should be aware of the clinical signs and symptoms of temporal arteritis, including headache, scalp tenderness, jaw claudication, anemia, and an elevated sedimentation rate (ESR) 3
- A high index of suspicion is necessary to diagnose temporal arteritis, even in patients with a normal ESR or negative temporal artery biopsy 4, 5
- Historical features that substantially increase the likelihood of temporal arteritis include jaw claudication and diplopia, while the absence of any temporal artery abnormality modestly reduces the likelihood of disease 6
- Predictive physical findings include temporal artery beading, prominence, and tenderness 6
Laboratory Testing
- Erythrocyte sedimentation rate (ESR) is a commonly used laboratory test to evaluate temporal arteritis, with elevated values indicating a higher likelihood of disease 4, 6
- C-reactive protein (CRP) may also be used to evaluate temporal arteritis, although a normal CRP does not rule out the disease 5
- Anemia may be present in patients with temporal arteritis, and laboratory tests should include a complete blood count (CBC) 3
Temporal Artery Biopsy
- Temporal artery biopsy is the gold standard for diagnosis of temporal arteritis, although a negative biopsy does not rule out the disease 5
- Biopsy results should be interpreted in the context of clinical signs and symptoms, and a high index of suspicion should be maintained even in the presence of a negative biopsy 4, 5
Treatment Approach
- Temporal arteritis is a medical emergency and should be treated promptly with corticosteroids to prevent permanent loss of vision 4, 5
- Patients with clinical symptoms of temporal arteritis should be treated aggressively, even in the presence of a negative temporal artery biopsy or normal laboratory tests 5
- The treatment approach should involve a gradual tapering of corticosteroids to minimize side effects and prevent relapse of symptoms 4