Treatment of Temporal Arteritis
Immediate initiation of high-dose glucocorticoid therapy is the cornerstone of temporal arteritis treatment, with prednisone 40-60 mg/day recommended as initial therapy to prevent permanent vision loss, which occurs in 14-35% of untreated patients. 1
Initial Treatment Algorithm
Emergency Treatment
- Oral prednisone: 40-60 mg/day for patients without visual symptoms 1
- IV methylprednisolone: 500-1000 mg/day for patients presenting with visual symptoms 1
- Treatment should begin immediately upon suspicion of temporal arteritis, without waiting for biopsy results 1
Adjunctive Therapy
- Tocilizumab: 162 mg subcutaneously weekly - FDA-approved for giant cell arteritis (GCA) to reduce glucocorticoid requirements and flare rates 1
- Aspirin: 75-150 mg/day may be considered for patients with critical or flow-limiting involvement of vertebral or carotid arteries 1
Monitoring and Maintenance
- Regular assessment of:
- Clinical symptoms
- Physical examination findings
- Inflammatory markers (ESR and CRP)
- Steroid-related adverse effects 1
Steroid Tapering Considerations
Research shows that lower initial 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) 2. The lower dose regimen resulted in only 36% of patients developing steroid-related side effects compared to 78-88% with higher doses, while maintaining similar efficacy 2.
Complications of Treatment
Steroid-related complications are common and potentially serious:
- 58% of patients may develop major steroid-related complications 3
- Most common complications include fractures and severe infections 3
- Complications are age-related (twice as common in patients >75 years) 3
- Complications are dose-related (more common with initial doses >40 mg/day) 3
Special Considerations
A subgroup of patients with "healed arteritis" histological pattern may represent a milder form of the disease that could potentially be treated with lower initial prednisone doses (15 mg/day) 4. These patients typically present with lower ESR and higher hemoglobin levels compared to classical GCA patients.
Clinical Pearls and Pitfalls
- Critical pitfall: Delaying treatment while awaiting biopsy results can lead to permanent vision loss 1
- Important caveat: Temporal artery biopsy should be performed within 2 weeks of starting glucocorticoids to maintain diagnostic accuracy 1
- Treatment duration: Most patients require 1-2 years of therapy, with cumulative cure rates (off steroids without exacerbation for 6+ months) of 29-35% at 2 years and 48-50% at 3 years 2
- Mortality risk: Steroid treatment may increase mortality (SMR 2.12), particularly in the first year of treatment, primarily due to infections and gastrointestinal bleeding 3
The evidence strongly supports immediate initiation of glucocorticoid therapy as the primary intervention for temporal arteritis, with the addition of tocilizumab as a steroid-sparing agent to reduce cumulative steroid exposure and associated complications.