What is the initial management of temporal arteritis?

From the Guidelines

The initial management of temporal arteritis involves immediate high-dose corticosteroid therapy, typically prednisone 40-60 mg daily (or 1 mg/kg/day), which should be started as soon as the diagnosis is suspected, even before confirmatory testing. This prompt treatment is crucial to prevent vision loss, which can occur rapidly and become permanent 1. A temporal artery biopsy should be performed within 1-2 weeks of starting treatment to confirm the diagnosis, but treatment should not be delayed while awaiting biopsy results 1.

Key Considerations

• The diagnosis of temporal arteritis is based on clinical presentation, pathologic abnormalities on temporal artery biopsy, and/or evidence of large vessel involvement on vascular imaging 1.
• Glucocorticoids are the mainstay treatment for giant cell arteritis, but tocilizumab has been approved by the US Food and Drug Administration for the treatment of GCA 1.
• Patients should also receive calcium and vitamin D supplementation to prevent steroid-induced osteoporosis, and consideration should be given to prophylaxis against Pneumocystis pneumonia for those on prolonged high-dose steroids.
• Steroid-sparing agents like methotrexate or tocilizumab may be added in cases of relapse or steroid-related complications 1.
• Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential throughout treatment 1.

Treatment Approach

• High-dose corticosteroid therapy should be initiated immediately, with a typical dose of prednisone 40-60 mg daily (or 1 mg/kg/day) 1.
• The prednisone dose can be gradually tapered once symptoms improve and inflammatory markers normalize, usually within 2-4 weeks, but most patients require at least 1-2 years of therapy 1.
• A temporal artery biopsy should be performed within 1-2 weeks of starting treatment to confirm the diagnosis, but treatment should not be delayed while awaiting biopsy results 1.

From the Research

Initial Management of Temporal Arteritis

The initial management of temporal arteritis involves the use of high-dosage oral prednisone or intravenous prednisolone to prevent complications such as unilateral or total blindness due to anterior ischemic optic neuropathy (AION) or closure of the central artery of the retina 2.

Diagnosis and Treatment

• Diagnosis of temporal arteritis is based on clinical signs and symptoms, including severe pain in the temporal region, scalp tenderness, and a feeling of malaise or depression, with or without episodes of transient loss of vision 2.
• A diagnostic work-up should include an erythrocyte sedimentation rate and a temporal artery biopsy 2.
• Treatment with high-dosage prednisone can be effective in relieving symptoms and lowering the sedimentation rate, even in cases with a negative temporal artery biopsy 2.

Corticosteroid Dosage Regimens

• Different corticosteroid dose regimens have been evaluated in the treatment of temporal arteritis, including starting doses of 30-40 mg/d, 40-60 mg/d, and > 60 mg/d 3.
• A starting dose of 30-40 mg/d and tapering to 10 mg/d within 6 months and to 5-7.5 mg/d within 1 year was found to be effective and less toxic than higher dose regimens 3.
• A lower initial prednisone dosage of 15 mg/day may be suggested for patients with a relatively benign subgroup of temporal arteritis, characterized by a lower erythrocyte sedimentation rate and higher level of haemoglobin at presentation 4.

Importance of Prompt Treatment

• Delayed initiation or discontinuation of corticosteroid therapy can result in profound, irreversible visual loss 5.
• Systemic corticosteroid therapy should be initiated as soon as the diagnosis of temporal arteritis is made clinically, without waiting for the results of the temporal artery biopsy specimen 5.

Potential Complications of Steroid Treatment

• Steroid-related complications, such as fractures and severe infections, can occur in patients with temporal arteritis, particularly in those older than 75 years and those taking high maintenance doses 6.
• The therapeutic regimen in temporal arteritis should be individualized, taking into account the patient's age, severity of the disease, and coexistent medical conditions 6.