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 1. This urgency is due to the risk of irreversible 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.
• Once the diagnosis is confirmed and symptoms improve, prednisone is gradually tapered over 12-24 months, with dose reductions of about 10% every 2-4 weeks, while monitoring for symptom recurrence.
• Laboratory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be followed to assess treatment response.
• For patients requiring long-term steroids, bone protection with calcium, vitamin D, and bisphosphonates should be considered, along with gastric protection.
• In steroid-resistant cases or to reduce steroid exposure, methotrexate or tocilizumab may be added as steroid-sparing agents, as suggested by the 2021 American College of Rheumatology/Vasculitis Foundation guideline 1. Regular monitoring for steroid side effects and disease activity is essential throughout treatment, and the use of low-dose aspirin may also be considered in all patients with giant cell arteritis, as recommended by the 2009 EULAR guidelines 1. The 2021 guideline for the prevention of stroke also supports the urgent treatment of giant cell arteritis with high-dose steroids to reduce the risk of permanent blindness and increase the chance of visual recovery 1. Additionally, the 2020 EULAR guidelines recommend adjunctive therapy in selected patients with GCA using tocilizumab, and methotrexate may be used as an alternative 1. Overall, the treatment approach should prioritize the prevention of morbidity, mortality, and improvement of quality of life, and should be guided by the most recent and highest quality evidence available 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.