From the Guidelines
Temporal arteritis (giant cell arteritis) treatment requires immediate high-dose corticosteroids to prevent vision loss and other complications, with the most recent and highest quality study 1 supporting the use of high-dose oral glucocorticoids (GCs) over IV pulse GCs for patients without manifestations of cranial ischemia.
Treatment Options
- Treatment typically begins with prednisone 40-60mg daily (or equivalent), started as soon as the diagnosis is suspected, even before biopsy confirmation, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1.
- This initial high dose is maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize, after which the dose is gradually tapered over 12-24 months to prevent relapse, with some patients requiring treatment for several years 1.
- Low-dose aspirin (81mg daily) is often added to reduce the risk of ischemic complications, as conditionally recommended for patients with GCA who have critical or flow-limiting involvement of the vertebral or carotid arteries 1.
- For patients who cannot tolerate steroids or require steroid-sparing therapy, tocilizumab (a biologic agent that blocks IL-6) may be used, as conditionally recommended for patients with newly diagnosed GCA, with the use of oral GCs with tocilizumab over oral GCs alone supported by low to high level of evidence 1.
- Methotrexate is sometimes added as a steroid-sparing agent, although the level of evidence for this recommendation is lower, with some studies suggesting its use in patients with GCA who experience disease relapse while receiving moderate-to-high–dose GCs 1.
Monitoring and Prevention
- Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential throughout treatment, with long-term clinical monitoring strongly recommended for patients with GCA in apparent clinical remission 1.
- Bone protection with calcium, vitamin D supplements, and sometimes bisphosphonates is important to prevent steroid-induced osteoporosis, as supported by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1.
- Prompt treatment is crucial because temporal arteritis can cause permanent blindness if left untreated, as steroids prevent further inflammation but cannot reverse existing damage to the optic nerve, highlighting the importance of immediate high-dose corticosteroids to prevent vision loss and other complications 1.
From the Research
Treatment Options for Temporal Arteritis
- The mainstay of treatment for temporal arteritis is high-dose corticosteroids (CS) 2, 3, 4, 5.
- Treatment with CS can last from 1 to 5 years or more, and may lead to serious side effects in about 60% of patients 2.
- There is no conclusive evidence about the role of immunosuppressive agents like methotrexate and azathioprine in the treatment of temporal arteritis 2.
- Tumor necrosis factor alpha (TNF-alpha) inhibitors, such as adalimumab, infliximab, and etanercept, have been used to treat refractory or steroid-dependent temporal arteritis 2.
- Early recognition and treatment of temporal arteritis is essential to prevent permanent visual loss, which can occur in up to 50% of patients if left untreated 3, 4, 5.
- Temporal artery biopsy is used to confirm the diagnosis, and the timing of the biopsy is important, as the duration of corticosteroid treatment can affect the positivity of the biopsy results 6.
- Patients with temporal arteritis may require ongoing ophthalmologic evaluation to monitor the effectiveness of treatment and detect any ocular complications 4.
- Careful attention must be given to early detection and prevention of systemic side effects of corticosteroid treatment, such as gastrointestinal problems, osteoporosis, and diabetes 4.