What is the treatment approach for temporal arteritis vs vasculitis?

Treatment Approach for Temporal Arteritis vs Vasculitis

For temporal arteritis (giant cell arteritis), immediate initiation of high-dose glucocorticoid therapy (prednisone 40-60 mg/day or 1 mg/kg/day up to 80 mg) is recommended upon clinical suspicion, with consideration of IV methylprednisolone (500-1000 mg/day for 3-5 days) for patients with visual symptoms. 1, 2

Temporal Arteritis (Giant Cell Arteritis) Treatment

Initial Management

• Start high-dose oral glucocorticoids immediately upon clinical suspicion, do not wait for biopsy results 1, 2
• For patients with threatened vision loss, consider IV pulse glucocorticoids (methylprednisolone 500-1000 mg/day for 3-5 days) 1, 2
• Temporal artery biopsy should be performed within 2 weeks of starting glucocorticoids to confirm diagnosis 2, 1
  • Long-segment biopsy (>1 cm) is preferred 2
  • Unilateral biopsy is generally sufficient 2

Adjunctive Therapy

• Consider adding tocilizumab (162 mg subcutaneously weekly) to glucocorticoids, especially for:
  • Patients at high risk for glucocorticoid-related adverse events
  • Refractory or relapsing disease
  • Patients with active extracranial large vessel involvement 1, 2
• Methotrexate is an alternative when tocilizumab is contraindicated 1, 2
• Add low-dose aspirin (75-150 mg/day) for patients with critical or flow-limiting involvement of vertebral or carotid arteries 1

Glucocorticoid Tapering

1. Maintain high-dose glucocorticoids for 2-4 weeks until symptoms resolve and inflammatory markers normalize
2. Taper to 15-20 mg/day within 2-3 months
3. Aim for ≤10 mg/day by 6 months
4. Target ≤5 mg/day after one year 1

Monitoring

• Regular assessment of symptoms, physical examination, and inflammatory markers (ESR, CRP)
• Monitor for steroid-related adverse effects and provide bone protection therapy 1, 2
• In case of relapse, increase glucocorticoid dose (5-15 mg/day above the last effective dose) or add immunosuppressive therapy 1

Other Systemic Vasculitides

The treatment approach for other systemic vasculitides differs from temporal arteritis:

• Treatment is specific to the type of vasculitis 2
• General approach includes immunosuppressants and antiplatelets 2
• Management should occur at expert centers for rare vasculitides like Takayasu arteritis 2

Common Pitfalls to Avoid

• Delayed treatment: Do not wait for biopsy results before starting glucocorticoids, as this can lead to irreversible vision loss 1, 3
• Inadequate initial dosing: Starting with doses below 40 mg/day may be insufficient to control disease activity 1
• Overly rapid tapering: Can lead to disease relapse with 60% of patients experiencing one or more relapses during glucocorticoid tapering 1
• Neglecting steroid-related complications: Provide prophylaxis against complications such as osteoporosis 1, 4
• Assuming a negative biopsy rules out GCA: False negatives can occur due to skip lesions 1, 5

Diagnostic Considerations

• Temporal artery biopsy remains the gold standard for diagnosis 2, 5
• In centers with appropriate expertise, temporal artery ultrasound may be used (sensitivity 88%, specificity 97%) 1, 2
• Noninvasive vascular imaging with clinical assessment is recommended for patients with suspected GCA and negative biopsy results 1, 2
• Laboratory findings typically include elevated ESR and CRP, though atypical presentations with normal ESR have been reported 5, 6

The treatment of temporal arteritis requires prompt intervention with high-dose glucocorticoids to prevent vision loss, with careful monitoring and tapering, while other vasculitides require specific immunosuppressive regimens based on the type of vasculitis involved.