Treatment of Temporal Arteritis
Immediate high-dose glucocorticoid therapy is essential for treating temporal arteritis due to the imminent risk of permanent vision loss. 1
Initial Treatment
First-Line Therapy
- Oral glucocorticoids:
Adjunctive Therapy
- Tocilizumab is recommended to reduce glucocorticoid requirements and prevent relapses 1
- Low-dose aspirin (75-150 mg/day) should be prescribed to all patients without contraindications to protect against cardiovascular and cerebrovascular events 3
- Consider gastroduodenal mucosal protection when starting aspirin 3
Glucocorticoid Tapering
- After initial control of symptoms (usually 2-4 weeks), begin gradual tapering:
- Aim to reduce to 10 mg/day within 6 months
- Further reduce to 5-7.5 mg/day within 1 year 4
- This moderate-dose regimen (starting with 30-40 mg/day) has been shown to be as effective as higher doses while causing significantly fewer side effects (36% vs 78-88% for higher doses) 4
Monitoring
- Regular clinical assessment combined with inflammatory markers (ESR, CRP)
- Relapses are common (34-62% of patients) and typically associated with rising ESR 3, 1
- Only 15-20% of patients achieve sustained remission with glucocorticoids alone 1
Prevention of Glucocorticoid-Induced Side Effects
- Bone protection therapy for all patients without contraindications
- Regular monitoring of:
- Blood pressure
- Blood glucose
- Screening for cataracts and other complications 1
Important Considerations
Risk of Complications
- Higher starting doses (>40 mg/day) and higher maintenance doses are associated with increased risk of steroid-related complications 4, 5
- Complications are age-related, occurring twice as often in patients older than 75 years 5
- Major complications include:
Treatment Duration
- Long-term therapy is often required
- Cumulative cure rates (patients off steroids without exacerbation for 6+ months):
- 11-13% after 1 year
- 29-35% after 2 years
- 48-50% after 3 years 4
Referral Recommendations
- Urgent referral for patients with acute visual symptoms or other high-risk features 1
- Consider referral to experienced centers for further workup, including large-vessel imaging 1
Diagnostic Reminders
- Key diagnostic criteria include:
- Age ≥50 years
- New-onset headache or change in headache pattern
- Temporal artery abnormalities (thickening, tenderness, pulselessness)
- Elevated ESR (>50 mm/h)
- Abnormal temporal artery biopsy 1
- Note that atypical presentations can occur, including cases with normal ESR 6
The treatment approach should balance effective disease control with minimizing steroid-related complications, particularly in elderly patients who are at higher risk for adverse effects.