What is the treatment for temporal arteritis?

Treatment for Temporal Arteritis

The treatment for temporal arteritis (giant cell arteritis) should begin immediately with high-dose glucocorticoid therapy (40-60 mg/day prednisone-equivalent), even before diagnostic confirmation, to minimize the risk of permanent vision loss. 1

Initial Treatment

Immediate Glucocorticoid Therapy

• First-line treatment: Prednisone 40-60 mg/day orally 1
• For patients with visual symptoms: Intravenous methylprednisolone 500-1000 mg/day 1
• Treatment should not be delayed for diagnostic testing when clinical suspicion is high
• Therapy can be initiated before temporal artery biopsy, which can still yield accurate results within 7-10 days of starting glucocorticoids 1

Adjunctive Therapy

• Tocilizumab is recommended in combination with glucocorticoids to:
  • Reduce glucocorticoid requirements
  • Prevent relapses
  • Improve outcomes 1, 2
• FDA-approved specifically for the treatment of giant cell arteritis in adults 2

Diagnostic Confirmation

While treatment is being initiated, diagnostic confirmation should proceed with:

1. Laboratory testing:

   • Erythrocyte sedimentation rate (ESR) - typically >50 mm/hr
   • C-reactive protein (CRP) 1

2. Imaging:

   • Temporal artery ultrasound - 88% sensitivity, 97% specificity for "halo" sign
   • Alternative: MRI of cranial arteries 1

3. Temporal artery biopsy:

   • Gold standard for diagnosis
   • Should be at least 1 cm in length
   • Can be performed within 7-10 days of starting glucocorticoids without affecting results 1

Treatment Course and Monitoring

Glucocorticoid Tapering

• After initial high-dose therapy and symptom control (usually 2-4 weeks)
• Gradual tapering over at least 1 year 3
• Regular monitoring of clinical symptoms and inflammatory markers

Prevention of Glucocorticoid-Induced Side Effects

• Bone protection therapy for all patients without contraindications
• Regular monitoring of blood pressure and glucose
• Screening for cataracts and other complications 1

Special Considerations

Visual Symptoms

• Visual symptoms represent a medical emergency requiring immediate intervention
• Higher doses of glucocorticoids (IV methylprednisolone) are indicated 1
• Urgent referral to ophthalmology is recommended 1

Relapse Management

• Relapses occur in 34-62% of patients
• Only 15-20% of patients achieve sustained remission with glucocorticoids alone
• Tocilizumab is particularly valuable in reducing relapse rates 1, 2

Common Pitfalls to Avoid

1. Delaying treatment while awaiting diagnostic confirmation - this can lead to irreversible vision loss 1, 4
2. Inadequate initial dosing of glucocorticoids - underdosing may not adequately control inflammation
3. Tapering glucocorticoids too quickly - can lead to disease flares
4. Failure to monitor for and prevent steroid-related complications - bone protection therapy is essential 1
5. Missing the diagnosis due to vague or nonspecific symptoms - maintain high clinical suspicion in patients over 50 with new-onset headache, jaw claudication, or visual symptoms 5, 4

Temporal arteritis should always be considered a medical emergency due to the risk of permanent vision loss and other serious complications. The benefits of immediate high-dose glucocorticoid therapy outweigh the risks when clinical suspicion is high.