From the Guidelines
Giant cell arteritis (GCA) should be treated immediately with high-dose corticosteroids, such as prednisone 40-60 mg/day, and consideration of adjunctive tocilizumab to reduce steroid requirements and relapses, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline 1.
Symptoms and Physical Exam Findings
Key symptoms of GCA include:
- New-onset headache (typically temporal)
- Scalp tenderness
- Jaw claudication
- Visual disturbances (including vision loss)
- Fatigue
- Fever
- Weight loss Physical examination may reveal:
- Temporal artery tenderness
- Reduced or absent temporal artery pulse
- Scalp tenderness
- Occasionally fundoscopic changes showing arteritic anterior ischemic optic neuropathy
Diagnostics
Diagnostic workup includes:
- Elevated inflammatory markers (ESR typically >50 mm/hr, CRP)
- Temporal artery biopsy showing granulomatous inflammation
- Vascular imaging (ultrasound, MRA, or CTA) demonstrating arterial wall thickening or stenosis
Treatment
Treatment should begin immediately with high-dose corticosteroids:
- Prednisone 40-60 mg/day
- Consider IV methylprednisolone 0.25-1 g/day for 3 days in cases with visual symptoms, as recommended by the 2018 EULAR guidelines 1 After 2-4 weeks of high-dose therapy, begin a slow taper over 12-18 months, guided by symptoms and inflammatory markers. Consider adjunctive tocilizumab (162 mg subcutaneously weekly) to reduce steroid requirements and relapses. Add calcium, vitamin D, and bisphosphonates for osteoporosis prophylaxis during steroid therapy. Monitor patients closely for steroid side effects and disease recurrence, particularly during dose reduction.
Management
The 2021 American College of Rheumatology/Vasculitis Foundation guideline recommends limiting the use of adjunctive therapy to patients who have already developed, or have an increased risk of developing, glucocorticoid-related side effects or complications 1. The decision to use adjunctive immunosuppressive therapy in the individual patient should be balanced against potential risks for treatment-related complications.
From the Research
Symptoms of Giant Cell Arteritis (GCA)
- Cranial manifestations are typical clinical features of GCA, including visual complications and the risk of blindness 2
- Polymyalgia rheumatica is a frequent manifestation that in some cases may be the presenting symptom of GCA 2
- Nonspecific symptoms may be present, and large-vessel involvement may prevail in some cases 2
- Visual symptoms, such as unilateral vision loss, can occur and may be treated with pulse glucocorticoid treatment to prevent involvement of the fellow eye 3
Physical Exam Findings
- No specific physical exam findings are mentioned in the provided studies, but it is recommended to perform a temporal artery biopsy to confirm the diagnosis of GCA 4, 5
Diagnostics
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are inflammatory markers that are elevated in the majority of patients and support the diagnosis of GCA 4
- Temporal artery biopsy demonstrates characteristic pathological findings and is used to confirm the diagnosis of GCA 4, 5
- Treatment should be initiated urgently, even when diagnostic studies are pending, in cases of suspected ophthalmic involvement 4
Treatment
- High-dose corticosteroid therapy is the mainstay of treatment and is administered either intravenously or orally to prevent further vision loss and treat systemic vasculitis 2, 4, 5
- Oral corticosteroid therapy is required for months to years with careful follow-up and periodic laboratory evaluations with ESR and CRP 4
- Adjunctive immunomodulatory therapy, such as methotrexate or tocilizumab, may be considered in patients experiencing relapsing inflammation despite high doses of corticosteroids or those with corticosteroid-induced complications 2, 4
- Supplementation with calcium, vitamin D, bisphosphonate therapy, antimicrobial prophylaxis, and initiation of a proton pump inhibitor or Histamine H2-receptor antagonist should be considered to prevent complications associated with corticosteroid therapy 4, 5