Treatment of Temporal Arteritis (Giant Cell Arteritis)
High-dose glucocorticoids should be initiated immediately upon clinical suspicion of temporal arteritis, even before biopsy confirmation, with prednisone 1 mg/kg/day (maximum 60 mg/day) as the standard initial treatment to prevent vision loss and other complications. 1, 2
Initial Treatment
- Start high-dose oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg daily) immediately upon suspicion of GCA, without waiting for biopsy results 1, 2
- For patients with threatened vision loss, administer intravenous pulse methylprednisolone (500-1000 mg/day for 3 days) immediately, followed by high-dose oral prednisone 3, 1
- Do not delay treatment while arranging for diagnostic confirmation, as vision loss can be permanent and occurs in 15-35% of patients with GCA 3, 1
- Without treatment, the risk of vision loss in the second eye is as high as 50% if one eye is already affected 3
Diagnostic Confirmation
- Arrange temporal artery biopsy as soon as possible, ideally within 2 weeks of starting glucocorticoids 2, 1
- Obtain a long-segment biopsy specimen (>1 cm) to improve diagnostic yield 2
- A unilateral temporal artery biopsy is initially recommended, though bilateral biopsies may be appropriate if symptoms are not clearly localized 2
- In centers with appropriate expertise, temporal artery ultrasound may be considered as a complementary diagnostic tool 2, 4
Glucocorticoid Tapering
- Maintain initial high-dose therapy for 1 month before beginning gradual taper 2, 1
- Aim for a prednisone dose of 10-15 mg/day by 3 months 2, 1
- Target a dose of ≤5 mg/day after 1 year 1, 3
- Guide tapering by clinical symptoms and normalization of inflammatory markers (ESR, CRP) 1
Adjunctive Therapy
- Add tocilizumab to glucocorticoids as first-line therapy, especially for patients at high risk of steroid-related complications 1, 2
- Consider methotrexate as an alternative steroid-sparing agent if tocilizumab is contraindicated 1
- For refractory cases, other immunosuppressive agents such as azathioprine, leflunomide, or mycophenolate mofetil may be considered 2
Management of Relapses
- For disease relapse with cranial ischemic symptoms, add a non-glucocorticoid immunosuppressive agent and increase glucocorticoid dose 1
- Tocilizumab is preferred over methotrexate for relapsing disease with cranial ischemia 1
- TNF-alpha inhibitors like adalimumab may be considered in treatment-resistant cases, though evidence is limited 5
Monitoring
- Implement long-term clinical monitoring for all patients, even those in apparent remission 1
- Monitor for glucocorticoid-related adverse effects, which occur in up to 86% of patients with long-term therapy 1
- Provide appropriate prophylaxis for steroid-related complications (e.g., bone protection) 1
- Follow inflammatory markers (ESR, CRP) regularly to assess disease activity 2, 6
Prognosis and Complications
- Visual loss is the most feared complication, occurring primarily before initiation of therapy 1, 3
- Once vision is lost due to GCA, recovery is uncommon, emphasizing the importance of prompt treatment 3
- Glucocorticoid-related adverse events are common with long-term therapy 1
- Without treatment, GCA can lead to other serious complications including stroke and cranial nerve palsies 2
Important Considerations
- Temporal arteritis is considered an ophthalmological emergency due to the risk of irreversible vision loss 6
- Early recognition of symptoms such as new-onset headache, jaw claudication, and visual disturbances is crucial for timely intervention 7
- Treatment duration typically ranges from 1-5 years, with many patients requiring long-term monitoring 5