What is the management of temporal arteritis?

From the Guidelines

The management of temporal arteritis requires immediate high-dose corticosteroid therapy, typically starting with oral prednisone 40-60mg daily, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline 1.

Key Points

• Treatment should begin as soon as temporal arteritis is suspected, even before biopsy confirmation, to prevent vision loss.
• After 2-4 weeks at the initial dose, a slow taper can begin, typically reducing by 10% every 2 weeks until reaching 10mg daily, then more gradually thereafter.
• Most patients require treatment for 1-2 years, though some may need longer therapy.
• Methotrexate or tocilizumab may be added as steroid-sparing agents in patients who cannot tolerate steroids or have relapses during tapering.
• Low-dose aspirin (81mg daily) is often recommended to reduce the risk of ischemic complications.
• Patients should be monitored regularly for disease activity with clinical assessments and inflammatory markers (ESR, CRP).
• Bone density screening and prophylaxis against osteoporosis with calcium, vitamin D, and bisphosphonates is essential due to prolonged steroid use.
• Steroid-related side effects including diabetes, hypertension, and infection risk should be monitored.

Diagnosis and Monitoring

• Temporal artery biopsy is recommended for establishing a diagnosis of GCA, although it may not be necessary in all cases 1.
• Imaging studies, such as MRI or ultrasound, may be used to support the diagnosis, but are not a replacement for biopsy.
• Regular monitoring of disease activity and adjustment of treatment as needed is crucial to prevent relapses and minimize steroid-related side effects.

Treatment Goals

• The primary goal of treatment is to prevent vision loss and other complications of temporal arteritis.
• Secondary goals include minimizing steroid-related side effects and improving quality of life.
• Treatment should be individualized based on patient factors, such as age, comorbidities, and preferences.

From the FDA Drug Label

Although controlled clinical trials have shown corticosteroids to be effective in speeding the resolution of acute exacerbations of multiple sclerosis, they do not show that corticosteroids affect the ultimate outcome or natural history of the disease. The management of temporal arteritis is not directly addressed in the provided drug label. Key points:

• The label discusses the use of corticosteroids in various conditions, but does not specifically mention temporal arteritis.
• The label provides general precautions and guidelines for the use of corticosteroids, but does not offer specific guidance on the management of temporal arteritis. 2

From the Research

Temporal Arteritis Management

• The management of temporal arteritis is primarily based on steroid therapy, which is sufficient in most cases 3.
• High-dosage oral prednisone or intravenous prednisolone is often used to treat temporal arteritis, especially in cases where there is a risk of blindness due to anterior ischemic optic neuropathy (AION) or closure of the central artery of the retina 4.
• The initial corticosteroid dosage may vary depending on the severity of the disease, with higher dosages (1 mg/kg/d) recommended for cases involving large arteries 3.
• Some studies suggest that a lower initial prednisone dosage (15 mg/day) may be sufficient for patients with a relatively benign subgroup of temporal arteritis, characterized by a lower erythrocyte sedimentation rate and higher level of haemoglobin at presentation 5.
• The efficacy and adverse effects of different corticosteroid dose regimens have been evaluated, with one study suggesting that a regimen starting at 30-40 mg/d of prednisone and tapering to 10 mg/d within 6 months and to 5-7.5 mg/d within 1 year may be effective and less toxic 6.
• Temporal arteritis can present atypically, and primary physicians should be aware of the potential complications of treatment, including diabetes mellitus, osteoporosis, and compression fracture of lumbar vertebrae 7.
• Steroid-sparing strategies, such as alternate-day steroid administration or adding a second drug (methylprednisolone, dapsone, azathioprine, methotrexate), have been evaluated, but their efficacy has not been proven 3.
• Vascular surgery is seldom necessary, but may be considered in certain cases, although it should not be done in the active phase of the disease 3.
• Anticoagulant therapy may be useful to reduce excess vascular mortality, but its benefit has not been demonstrated 3.