What is the appropriate management for temporal arteritis symptoms?

Management of Temporal Arteritis

Immediate high-dose glucocorticoid therapy is essential for temporal arteritis due to the imminent risk of permanent vision loss and should be initiated as soon as the diagnosis is suspected, without waiting for biopsy results. 1

Diagnostic Approach

• Clinical Presentation:

  • Age ≥50 years (essential criterion)
  • New-onset or changed headache pattern
  • Temporal artery abnormalities (thickening, tenderness, pulselessness)
  • Jaw claudication (highly specific, LR+ 4.90)
  • Visual symptoms (diplopia, amaurosis fugax)
  • Limb claudication (highest positive likelihood ratio, 6.01)
  • Polymyalgia rheumatica symptoms

• Laboratory Evaluation:

  • Elevated ESR (>50 mm/h, typically >100 mm/h)
  • Elevated CRP (≥2.5 mg/dL)
  • Thrombocytosis (platelet count >400 × 10³/μL)

Treatment Algorithm

1. Initial Management

• For patients without visual symptoms:

  • Oral prednisone 40-60 mg/day 1

• For patients with visual symptoms or threatened vision loss:

  • IV methylprednisolone 500-1000 mg/day 1
  • Urgent ophthalmology referral

2. Diagnostic Confirmation

• Temporal artery biopsy (gold standard)

  • Should be performed within 2 weeks of starting glucocorticoids
  • Long-segment specimen (>1 cm) to reduce false negatives
  • Continue treatment even if biopsy is pending 1

• If biopsy is negative but clinical suspicion remains high:

  • Proceed with noninvasive vascular imaging:
    • MRI/MRA
    • CT angiography
    • Ultrasonography
    • FDG-PET 1

3. Maintenance Therapy

• Gradual taper of glucocorticoids over at least 1 year 2
• Consider tocilizumab as a steroid-sparing agent to reduce glucocorticoid requirements and prevent relapses 1

4. Monitoring

• Regular assessment of clinical symptoms
• Serial inflammatory markers (ESR, CRP)
• Monitor for relapses (occur in 34-62% of patients) 1
• Baseline noninvasive vascular imaging to evaluate large vessel involvement 1

Prevention of Glucocorticoid-Induced Complications

• Bone protection therapy for all patients without contraindications
• Regular monitoring of:
  • Blood pressure
  • Blood glucose
  • Screening for cataracts
  • Other steroid-related complications 1

Important Considerations

• Temporal arteritis is considered a medical emergency due to the risk of permanent vision loss 2

• Only 15-20% of patients achieve sustained remission with glucocorticoids alone 1

• Steroid-related complications occur in approximately 58% of patients and are more common in:

  • Patients over 75 years of age
  • Those starting with doses >40 mg/day
  • Those requiring high maintenance doses 3

• Common steroid-related complications include:

  • Fractures
  • Severe infections
  • Bleeding ulcers 3

When to Refer

• Urgent referral for patients with:
  • Acute visual symptoms
  • Other high-risk features 1
• Consider referral to an experienced center for further workup, especially for patients with risk of ischemic complications 1

Remember that early recognition and prompt treatment are crucial to prevent permanent vision loss, which is the most devastating complication of temporal arteritis 4, 5.