What is the treatment for temporal arteritis (giant cell arteritis)?

Treatment for Temporal Arteritis (Giant Cell Arteritis)

Immediate initiation of high-dose oral glucocorticoids (40-60 mg/day prednisone or equivalent) is the first-line treatment for suspected giant cell arteritis (GCA) and should not be delayed for diagnostic confirmation. 1

Initial Management

Immediate Treatment

• Start high-dose oral glucocorticoids immediately upon clinical suspicion:
  • Prednisone 1 mg/kg/day (maximum 80 mg/day) 1
  • For patients with visual symptoms: Consider IV methylprednisolone 500-1000 mg/day for 3 days before transitioning to oral therapy 1
• Do not delay treatment for biopsy results when GCA is strongly suspected, as this can lead to irreversible vision loss 2
• Add low-dose aspirin (75-150 mg/day) for patients with critical or flow-limiting involvement of vertebral or carotid arteries 1

Diagnostic Confirmation

• Temporal artery biopsy should be performed within 2 weeks of starting glucocorticoids 1
  • Specimen length should be >1 cm 1, 3
  • Biopsy results are not affected if performed within 7-10 days of starting therapy 2
• Temporal artery ultrasound may be used in centers with appropriate expertise (sensitivity 88%, specificity 97%) 1, 4
• Additional imaging (MRI, PET, CT) may be needed for extracranial disease 3

Treatment Phases

Initial Phase (2-4 weeks)

• Maintain high-dose glucocorticoids until symptoms resolve and inflammatory markers normalize 1
• Monitor ESR, CRP, and CBC regularly 5

Tapering Phase

• Reduce dose to 15-20 mg/day within 2-3 months 1
• Target dose of ≤10 mg/day by 6 months 1
• Aim for ≤5 mg/day after one year 1
• Complete tapering based on clinical response and laboratory parameters 1

Adjunctive Therapy

Steroid-Sparing Agents

• Consider tocilizumab (162 mg subcutaneously weekly) in combination with glucocorticoids for: 1, 3
  • Patients at high risk for glucocorticoid-related adverse events
  • Refractory or relapsing disease
  • Active extracranial large vessel involvement
• Methotrexate is an alternative when tocilizumab is contraindicated 1, 3
• Do not use infliximab as it is associated with recurrent ocular symptoms and increased disease activity 3

Relapse Management

• Increase glucocorticoid dose (5-15 mg/day above the last effective dose) 1
• Add tocilizumab (preferred) or methotrexate if not already on immunosuppressive therapy 1

Monitoring and Follow-up

• Regular assessment of symptoms, physical examination, and inflammatory markers (ESR, CRP) 1
• For isolated increases in inflammatory markers without clinical symptoms, clinical observation without therapy escalation is recommended 1
• Monitor for steroid-related adverse effects and provide bone protection therapy 1

Special Considerations

• GCA is a medical emergency due to risk of permanent vision loss 3, 6
• Up to 60% of patients will experience one or more relapses during glucocorticoid tapering 3
• Multidisciplinary management may be needed, especially for patients with extracranial manifestations 3

Common Pitfalls to Avoid

• Delaying treatment while awaiting biopsy results can lead to irreversible vision loss 2
• Assuming a negative biopsy rules out GCA (false negatives can occur) 1
• Tapering steroids too quickly, which can lead to disease relapse 3
• Failing to provide prophylaxis against steroid-related complications 1

Giant cell arteritis requires prompt recognition and treatment to prevent serious complications, particularly irreversible vision loss. The cornerstone of therapy remains high-dose glucocorticoids with careful tapering, with newer biologic agents offering steroid-sparing benefits.