What is the recommended treatment approach for a suspected diagnosis of temporal arteritis?

From the Guidelines

The recommended treatment approach for suspected temporal arteritis (giant cell arteritis) begins with immediate high-dose corticosteroid therapy, typically prednisone 40-60mg daily, which should be started without waiting for biopsy confirmation, as recommended by the 2020 EULAR guidelines for the management of large vessel vasculitis 1. This urgency is due to the risk of permanent vision loss if treatment is delayed.

• A temporal artery biopsy should be performed within 1-2 weeks of starting steroids to confirm the diagnosis, as steroids do not immediately affect biopsy results, and a long-segment temporal artery biopsy specimen (>1 cm) is preferred, as suggested by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1.
• Once the diagnosis is confirmed, prednisone is typically continued at the initial dose for 2-4 weeks until symptoms resolve and inflammatory markers normalize, then gradually tapered over 12-18 months, with the goal of tapering the GC dose to a target dose of 15–20 mg/day within 2–3 months and after 1 year to ≤5 mg/day, as recommended by the 2020 EULAR guidelines 1.
• During treatment, patients should receive calcium and vitamin D supplementation to prevent osteoporosis, and may need a proton pump inhibitor for gastric protection.
• Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential, as recommended by the 2009 EULAR recommendations for the management of large vessel vasculitis 1.
• In some cases, steroid-sparing agents like methotrexate or tocilizumab may be added to reduce steroid dependence, as suggested by the 2020 EULAR guidelines and the 2021 American College of Rheumatology/Vasculitis Foundation guideline 1. The aggressive initial treatment is justified by the inflammatory nature of the disease, which causes granulomatous inflammation of medium and large arteries, particularly the branches of the carotid artery.
• The use of low-dose aspirin in all patients with giant cell arteritis is also recommended, as suggested by the 2009 EULAR recommendations 1.
• Additionally, patients with symptoms of giant cell arteritis should be treated urgently, and high-dose steroids should be initiated quickly within the first 24 hours after symptoms onset to reduce the risk of permanent blindness and to increase the chance of visual recovery, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.

From the Research

Temporal Arteritis Diagnosis and Treatment

• Temporal arteritis is a serious condition that requires immediate treatment to prevent complications, including unilateral or total blindness due to anterior ischemic optic neuropathy (AION) or closure of the central artery of the retina 2.
• The symptoms and clinical signs of temporal arteritis can mimic those of other conditions, making diagnosis challenging 2.
• A diagnostic work-up for temporal arteritis should include an erythrocyte sedimentation rate and a temporal artery biopsy 2.
• Temporal artery ultrasound (TAUS) is a valuable tool for diagnosing giant cell arteritis (GCA) in the emergency department, allowing for quick ruling out of GCA and avoidance of unindicated steroid treatment 3.
• Corticosteroids are the recommended treatment for temporal arteritis, with high-dosage oral prednisone or intravenous prednisolone typically used 2, 4.
• The timing of temporal artery biopsy is important, with a suggested performance within 2 weeks from the initiation of corticosteroids 4.
• The duration of corticosteroid treatment can affect the positivity of temporal artery biopsy, with a trend toward shorter duration of treatment in biopsy-positive patients 4.

Treatment Approach

• Patients with suspected temporal arteritis should be referred for a diagnostic work-up and started on high-dosage corticosteroids if diagnosis is confirmed 2, 5.
• The initial prednisone dosage may vary depending on the histological subtype, with a suggested lower dosage (15 mg/day) for patients with the "healed arteritis" subgroup 6.
• Patients with biopsy-proven temporal arteritis should be continued on steroid therapy until the active disease is quiescent, with careful monitoring of the erythrocyte sedimentation rate (ESR) while steroids are being tapered 5.
• If the ESR remains elevated for a year or more despite continuation of high steroid levels, consideration should be given to repeating the temporal artery biopsy 5.