What is the treatment for temporal arteritis?

Treatment of Temporal Arteritis

Immediate high-dose glucocorticoid therapy (40-60 mg/day prednisone) is the cornerstone treatment for temporal arteritis and should be initiated immediately upon clinical suspicion to prevent permanent vision loss. 1

Initial Treatment Approach

Glucocorticoid Therapy

• For patients without visual symptoms:

  • Oral prednisone 40-60 mg/day 2, 1
  • Do not delay treatment while awaiting biopsy results 1

• For patients with threatened vision loss:

  • IV pulse methylprednisolone 500-1000 mg/day for 3 days 1
  • Followed by oral prednisone 40-60 mg/day 1

Diagnostic Confirmation

• Arrange temporal artery biopsy within a reasonable timeframe after starting treatment
• Long-segment biopsy (>1 cm) is preferred 1
• Noninvasive vascular imaging (ultrasound, MRI, CT angiography) may be considered if biopsy is negative 1

Glucocorticoid Tapering Schedule

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

Caution: Rapid tapering increases risk of disease relapse and complications 1, 3

Adjunctive Therapy

For high-risk patients or refractory/relapsing disease:

• First-line adjunctive agent:

  • Tocilizumab 162 mg subcutaneously weekly 2, 1

• Alternative adjunctive agent:

  • Methotrexate (if tocilizumab is not suitable) 2, 1

• Consider for critical vascular involvement:

  • Aspirin 75-150 mg/day (for critical or flow-limiting involvement of vertebral or carotid arteries) 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 2, 1

Monitoring

• Regular assessment of symptoms, physical examination, and inflammatory markers (ESR, CRP) 1
• Monitor for steroid-related adverse effects 1, 4
• Provide bone protection therapy 1

Important Considerations and Pitfalls

Complications to Watch For

• Vision loss occurs in 15-35% of untreated patients and is often permanent 1
• Up to 60% of patients experience relapses during glucocorticoid tapering 1
• Steroid-related complications (fractures, infections) occur in up to 58% of patients and are more common in those:
  • Over 75 years of age 4
  • Taking initial doses >40 mg/day 4, 3
  • On high maintenance doses 4

Evidence-Based Insights

• Lower initial prednisone doses (30-40 mg/day) may be equally effective with significantly fewer side effects compared to higher doses (>40-60 mg/day or >60 mg/day) 3
• The European League Against Rheumatism (EULAR) recommends sustained remission for at least 6 months and achievement of individual target glucocorticoid dose 2
• Glucocorticoid-free remission is defined as discontinued glucocorticoid therapy (though patients may still receive other immunosuppressive therapy) 2

Remember that temporal arteritis is a medical emergency, and treatment should never be delayed when clinically suspected, as delaying treatment while awaiting biopsy results can increase the risk of permanent vision loss 1.