What is the treatment for temporal arteritis?

Treatment for Temporal Arteritis

High-dose glucocorticoid therapy should be initiated immediately for temporal arteritis, with 40-60 mg/day oral prednisone for uncomplicated cases and 500-1000 mg/day IV methylprednisolone for cases with visual symptoms. 1

Initial Management

1. Immediate Glucocorticoid Therapy:

   • Start high-dose glucocorticoids without delay upon strong clinical suspicion
   • Dosing:
     • Uncomplicated GCA: 40-60 mg/day oral prednisone 1
     • GCA with visual symptoms: 500-1000 mg/day IV methylprednisolone 1
   • Do not delay treatment while awaiting biopsy results, as delayed treatment can result in permanent vision loss in 15-35% of untreated patients 1

2. Temporal Artery Biopsy:

   • Schedule within 1-2 weeks of starting glucocorticoids 1
   • Biopsy length should be at least 1 cm 2, 1
   • Unilateral biopsy is usually sufficient; contralateral biopsy is not routinely indicated 2
   • Treatment prior to biopsy is unlikely to affect results if biopsy is performed within 1-2 weeks 2

Maintenance Therapy

1. Glucocorticoid Continuation:

   • Maintain high-dose glucocorticoids for one month before tapering 1
   • Tapering should be gradual, not alternate-day dosing 2, 1
   • At 3 months, the glucocorticoid dose should be between 10-15 mg/day 2
   • Total duration of therapy may extend to several years 2

2. Adjunctive Immunosuppressive Therapy:

   • Add tocilizumab 162 mg subcutaneously weekly to reduce glucocorticoid requirements and prevent relapses 1
   • Consider immunosuppressive agents as adjunctive therapy to reduce glucocorticoid-related adverse events 2
   • For disease relapse with cranial ischemic symptoms, add a non-glucocorticoid immunosuppressive agent (preferably tocilizumab) rather than increasing glucocorticoids alone 1

Monitoring and Prevention of Complications

1. Disease Activity Monitoring:

   • Regular monitoring of ESR and CRP to guide glucocorticoid tapering 1
   • Clinical evaluation for symptoms and signs of disease activity 1

2. Prevention of Glucocorticoid-Induced Side Effects:

   • Calcium and vitamin D supplementation 1
   • Bisphosphonates for osteoporosis prevention 1
   • Monitor blood pressure and glucose levels 1
   • All patients should receive bone protection therapy in the absence of contraindications 2

Management of Complications

1. Visual Symptoms:

   • For patients presenting with visual symptoms, immediate high-dose IV methylprednisolone (500-1000 mg/day) is indicated 1
   • Visual loss is usually irreversible but pulsed IV methylprednisolone may benefit some patients who present early after onset of visual symptoms 2

2. Severe Disease:

   • For patients with severe GCA and worsening signs of limb/organ ischemia, escalate immunosuppressive therapy rather than proceeding directly to surgical intervention 1

Important Considerations

• Temporal arteritis is considered an ophthalmological emergency due to the risk of rapid, irreversible bilateral vision loss 3
• Visual loss in one eye occurs in approximately 18% of patients at diagnosis and is usually irreversible 2
• The American College of Rheumatology diagnostic criteria require at least 3 of 5 criteria: age ≥50 years, new-onset headache, temporal artery abnormalities, elevated ESR (≥50 mm/h), and abnormal temporal artery biopsy 1
• Ultrasound with "halo" sign has 88% sensitivity and 97% specificity for diagnosing GCA and may be used as a non-invasive diagnostic method 1, 4

Remember that early recognition and prompt treatment are crucial to prevent permanent vision loss, which is the most serious complication of temporal arteritis.