What is the treatment for temporal arteritis?

Treatment for Temporal Arteritis

Immediate high-dose glucocorticoid therapy (prednisone 40-60 mg/day) is the cornerstone treatment for temporal arteritis and should be initiated promptly when clinical suspicion is high, without waiting for biopsy results, to prevent permanent vision loss. 1

Initial Management

• First-line treatment:

  • Oral prednisone 40-60 mg/day for standard cases 1
  • IV methylprednisolone 500-1000 mg/day for cases with visual symptoms 1
  • Treatment should begin immediately upon suspicion, without waiting for biopsy confirmation 1

• Urgent referral:

  • Patients with new-onset persistent localized headache, constitutional symptoms, jaw/tongue claudication, acute visual symptoms should be urgently referred to specialists 1
  • "Fast-track" referral within 24 hours reduces the rate of permanent visual impairment 1
  • Patients with new onset visual symptoms require immediate ophthalmological evaluation 1

Diagnostic Approach

• Key diagnostic criteria (American College of Rheumatology) 1:

  • Age ≥50 years at disease onset
  • New-onset or change in headache pattern
  • Temporal artery abnormalities (thickening, tenderness, pulselessness)
  • Elevated ESR (>50 mm/h)
  • Abnormal temporal artery biopsy

• Confirmatory testing:

  • Temporal artery biopsy remains the gold standard (sample length ≥1 cm) 1
  • Elevated inflammatory markers (ESR, CRP) strongly support diagnosis 1
  • Temporal artery ultrasound can be useful in emergency settings to expedite diagnosis 2

Advanced Treatment Options

• Adjunctive therapy:

  • Tocilizumab is recommended to reduce glucocorticoid requirements and prevent relapses 1
  • Low-dose aspirin (75-150 mg/day) is recommended to protect against cardiovascular and cerebrovascular events 1
  • Gastroduodenal protection should be considered when starting aspirin 1

• Steroid-sparing options:

  • Tocilizumab has the strongest evidence for glucocorticoid-sparing effects 1
  • Limited evidence exists for adalimumab in refractory cases 3, but this is not part of standard guidelines

Monitoring and Follow-up

• Regular monitoring of clinical symptoms and inflammatory markers is essential 1
• Relapses occur in 34-62% of patients, with only 15-20% achieving sustained remission with glucocorticoids alone 1
• Prevention of glucocorticoid-induced side effects:
  • Bone protection therapy
  • Blood pressure and glucose monitoring
  • Regular screening for cataracts and other complications 1

Common Pitfalls and Caveats

• Delayed treatment risks:

  • Permanent vision loss is the most serious complication of untreated temporal arteritis 4
  • Do not wait for biopsy results if clinical suspicion is high 1

• Diagnostic challenges:

  • Symptoms can mimic other conditions (angle-closure glaucoma, hypertension, migraine, etc.) 5
  • Some patients may have negative temporal artery biopsies but still respond to treatment 5
  • Symptoms can be vague, non-specific, and gradual in onset 6

• Treatment duration:

  • Long-term corticosteroid treatment (1-5 years or more) is often required 3
  • Serious side effects occur in approximately 60% of patients on prolonged steroid therapy 3
  • Tapering should be guided by clinical symptoms and inflammatory markers 1

Remember that temporal arteritis is an ophthalmological emergency, and prompt recognition and treatment are essential to prevent irreversible vision loss.