What is the diagnosis and treatment approach for temporal arteritis?

From the Guidelines

Temporal arteritis, also known as giant cell arteritis, is a serious inflammatory condition that requires immediate treatment with high-dose corticosteroids, typically prednisone 40-60mg daily, to prevent vision loss, and a temporal artery biopsy should be performed within 1-2 weeks of starting steroids. The diagnosis of temporal arteritis involves a combination of clinical assessment, laboratory tests, and often a temporal artery biopsy, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1. Patients typically present with new-onset headache, scalp tenderness, jaw claudication, and sometimes vision changes, and laboratory markers including elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) support the diagnosis. Some key points to consider in the diagnosis and treatment approach include:

• The use of temporal artery biopsy as the diagnostic test of choice, although imaging studies such as temporal artery ultrasound or MRI of the cranial vessels may be helpful in establishing a diagnosis of GCA 1.
• The importance of starting high-dose corticosteroids immediately upon suspicion of the diagnosis, even before biopsy confirmation, to prevent vision loss 1.
• The need for regular monitoring of disease activity, including clinical and laboratory assessments, to guide treatment decisions and minimize treatment toxicities 1.
• The potential use of steroid-sparing agents, such as methotrexate or tocilizumab, in cases of relapse or to reduce steroid-related complications 1. Overall, the management of temporal arteritis requires a comprehensive approach that incorporates clinical assessment, laboratory testing, and imaging studies, as well as careful consideration of treatment options and potential complications, as outlined in the 2021 American College of Rheumatology/Vasculitis Foundation guideline 1.

From the Research

Diagnosis of Temporal Arteritis

• The diagnosis of temporal arteritis, also known as giant cell arteritis (GCA), is primarily clinical and should not be discarded by a negative temporal artery biopsy (TABx) 2.
• TABx is considered the gold standard for diagnosis, but a negative result does not rule out the disease 2.
• Clinical manifestations such as jaw claudication and diplopia can substantially increase the likelihood of temporal arteritis 3.
• Predictive physical findings include temporal artery beading, prominence, and tenderness 3.
• A normal erythrocyte sedimentation rate (ESR) can indicate a lower likelihood of disease, but does not rule it out 3.

Treatment Approach

• Patients with classic clinical manifestations of temporal arteritis but with a negative TABx should be treated aggressively with corticosteroids 2.
• The duration of corticosteroid treatment can affect the positivity of TABx, with a trend towards shorter duration of treatment in TABx-positive patients 4.
• Corticosteroid treatment should not be delayed, as the diagnostic yield of TABx seems valuable within 4 weeks of starting high-dose steroid treatment 5.
• A new protocol that includes enhanced clinical evaluation and color duplex ultrasonography can improve patient evaluation and reduce the number of temporal artery biopsies performed 6.

Temporal Artery Biopsy

• TABx should be performed within 2 weeks from the initiation of corticosteroids for optimal diagnostic yield 4.
• The performance of TABx should not delay the prompt institution of steroid therapy on diagnosis of GCA 5.
• A late TABx can still be informative despite long-term treatment with low doses of corticosteroids, especially in patients with a prior history of polymyalgia rheumatica (PMR) 5.