What is the treatment for temporal arteritis?

Treatment for Temporal Arteritis

The treatment for temporal arteritis requires immediate initiation of high-dose glucocorticoids (prednisone 40-60 mg/day or 1 mg/kg/day up to 80 mg) upon clinical suspicion to prevent permanent vision loss and treat symptoms. 1

Initial Treatment Approach

Immediate Glucocorticoid Therapy

• Start prednisone 40-60 mg/day orally as soon as temporal arteritis is suspected
• For patients with visual symptoms, consider IV methylprednisolone 500-1000 mg/day for 3-5 days before transitioning to oral therapy 1
• Do not delay treatment while awaiting biopsy results, as this can lead to irreversible vision loss 1

Adjunctive Therapy

• Add aspirin (75-150 mg/day) for patients with critical or flow-limiting involvement of vertebral or carotid arteries 1
• Consider tocilizumab (162 mg subcutaneously weekly) in combination with glucocorticoids for:
  • Patients at high risk for glucocorticoid-related adverse events
  • Refractory or relapsing disease
  • Active extracranial large vessel involvement 1
• Methotrexate is an alternative when tocilizumab is contraindicated 1

Diagnostic Confirmation

• Perform temporal artery biopsy within 2 weeks of starting glucocorticoids (specimen length >1 cm) 1
• Temporal artery ultrasound may be used in centers with appropriate expertise (sensitivity 88%, specificity 97%) 1, 2
• Consider noninvasive vascular imaging with clinical assessment for patients with negative biopsy results 1

Treatment Duration and Tapering

1. Initial phase (2-4 weeks): Maintain high-dose glucocorticoids until symptoms resolve and inflammatory markers normalize 1
2. Early tapering phase: Reduce dose to 15-20 mg/day within 2-3 months 1
3. Intermediate tapering phase: Target dose of ≤10 mg/day by 6 months 1
4. Long-term tapering: Aim for ≤5 mg/day after one year, with complete tapering based on clinical response and laboratory parameters 1

Monitoring and Follow-up

• Monitor for clinical response (headache typically responds dramatically within a short period) 1
• Regular assessment of symptoms, physical examination, and inflammatory markers (ESR, CRP) 1
• Watch for steroid-related adverse effects and provide bone protection therapy 1

Management of Relapse

• 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

Common Pitfalls to Avoid

• Inadequate initial dosing: Starting with doses below 40 mg/day may be insufficient to control disease activity and prevent complications 1
• Delayed treatment: Waiting for biopsy results before starting treatment can result in permanent vision loss 1, 3
• Rapid steroid tapering: Can lead to disease relapse 1
• Assuming negative biopsy rules out GCA: False negatives can occur 1
• Failure to recognize the emergency: Temporal arteritis is a medical emergency due to the risk of permanent vision loss 1, 4, 3

Remember that temporal arteritis is an ophthalmological emergency requiring prompt treatment to prevent irreversible vision loss. Up to 60% of patients may experience one or more relapses during glucocorticoid tapering, necessitating vigilant monitoring and appropriate adjustments to therapy 1.