From the Guidelines
The recommended next step for an elderly woman with left-sided headache, jaw claudication, left eye vision loss, and a tender left temporal artery is immediate initiation of high-dose corticosteroids, specifically prednisone 60mg daily or methylprednisolone 1000mg IV daily for 3 days, while simultaneously arranging for a temporal artery biopsy. This clinical presentation strongly suggests giant cell arteritis (GCA), a medical emergency that requires prompt treatment to prevent permanent blindness in both eyes, as highlighted in the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1. The biopsy should be performed within 1-2 weeks of starting steroids, as histological findings remain present during this period despite treatment.
After initiating high-dose steroids, the dose should be maintained for 2-4 weeks before gradually tapering over months based on symptom resolution and normalization of inflammatory markers (ESR and CRP), as recommended by the 2021 guideline 1. Additional workup should include:
- Complete blood count
- ESR
- CRP
- Ophthalmologic evaluation
Low-dose aspirin (81mg daily) should also be started to reduce the risk of ischemic complications, as suggested by the 2020 EULAR recommendations for the management of large vessel vasculitis 1. Prompt treatment is critical as vision loss from GCA is often irreversible, and delay in therapy increases the risk of blindness in the contralateral eye, emphasizing the need for immediate action as stated in the 2024 treat-to-target recommendations in giant cell arteritis and polymyalgia rheumatica 1. The pathophysiology involves granulomatous inflammation of medium and large arteries, particularly the temporal artery, causing vascular occlusion and ischemia to affected tissues.
Given the high risk of permanent vision loss and other ischemic events, immediate initiation of treatment without waiting for diagnostic confirmation is supported by recent guidelines, including the 2021 American Heart Association/American Stroke Association guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1, underscoring the urgency of initiating high-dose corticosteroids promptly.
From the Research
Recommended Next Steps
The patient's symptoms, including left-sided headache, jaw claudication, left eye vision loss, and a tender left temporal artery, are suggestive of Giant Cell Arteritis (GCA) 2, 3, 4, 5.
Diagnostic Considerations
- The presence of vision loss, headache, and jaw claudication are common symptoms of GCA 3, 4, 5.
- A tender temporal artery is also a characteristic finding in GCA 3, 5.
- The erythrocyte sedimentation rate (ESR) is often elevated in GCA, but a normal ESR does not rule out the diagnosis 5.
Treatment Options
- High-dose corticosteroids are the mainstay of treatment for GCA to prevent visual loss 3, 6.
- Intravenous (IV) methylprednisolone may be used for patients with acute visual loss, with a dose of 500 to 1000 mg commonly prescribed 6.
- Oral prednisone may be used for patients without acute visual loss, with a dose of 1.0 to 1.5 mg/kg commonly prescribed 6.
- Temporal artery biopsy can confirm the diagnosis of GCA, but treatment should not be delayed while waiting for biopsy results 3, 4, 5.