What is the treatment for temporal arteritis?

Treatment of Temporal Arteritis (Giant Cell Arteritis)

For patients with temporal arteritis, high-dose oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day) should be initiated immediately upon clinical suspicion, even before biopsy confirmation, with the addition of tocilizumab as first-line therapy to reduce relapse rates and minimize steroid exposure. 1, 2

Initial Treatment Approach

• Start high-dose oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day) immediately upon clinical suspicion of GCA to prevent vision loss and other ischemic complications 1
• For patients with threatened vision loss or other cranial ischemic symptoms, administer intravenous pulse methylprednisolone (500-1000 mg/day for 3 days) immediately, followed by high-dose oral prednisone 1, 2
• Daily dosing of glucocorticoids is preferred over alternate-day schedules to maintain disease control 3, 2
• Consider adding tocilizumab to glucocorticoids as first-line therapy, especially for patients at high risk of steroid-related complications 1, 3

Diagnostic Confirmation

• Arrange temporal artery biopsy as soon as possible, ideally within 2 weeks of starting glucocorticoids 3
• Obtain a long-segment biopsy specimen (>1 cm) to improve diagnostic yield 3
• If temporal artery biopsy is negative but clinical suspicion remains high, consider noninvasive vascular imaging to evaluate large vessel involvement 3

Glucocorticoid Tapering Strategy

• Maintain initial high-dose glucocorticoids for approximately one month to ensure adequate disease control 2
• Begin gradual taper after symptoms are controlled, aiming for 15-20 mg/day within 2-3 months 2, 1
• Guide tapering by monitoring clinical symptoms and normalization of inflammatory markers (ESR, CRP) 2, 1
• Aim for a dose of ≤5 mg/day after 1 year, but continue monitoring for relapses 1

Adjunctive Therapy

• Tocilizumab is recommended as the preferred steroid-sparing agent to reduce relapse rates and minimize glucocorticoid exposure 1, 3
• Consider methotrexate as an alternative steroid-sparing agent if tocilizumab is contraindicated 1, 2
• NSAIDs may provide temporary symptomatic relief for mild pain but should not replace or delay glucocorticoid therapy 2

Management of Relapses

• For disease relapse with cranial ischemic symptoms, increase glucocorticoid dose and add or optimize non-glucocorticoid immunosuppressive therapy 2, 1
• Tocilizumab is preferred over methotrexate for relapsing disease with cranial symptoms 2, 1
• Monitor for recurrence of headache, scalp tenderness, jaw claudication, and other symptoms that may indicate relapse 2

Monitoring

• Implement long-term clinical monitoring for all patients, even those in apparent remission, to detect potential relapses 1
• Monitor for glucocorticoid-related adverse effects and provide appropriate prophylaxis (e.g., bone protection) 1
• New or worsening headache despite treatment may indicate inadequate disease control and requires immediate attention 2
• Visual symptoms (amaurosis fugax, diplopia) accompanying pain require emergency treatment with IV pulse glucocorticoids to prevent permanent vision loss 2, 4

Prognosis and Complications

• Without treatment, the risk of vision loss in the second eye is as high as 50% if one eye is already affected 1
• Visual loss occurs in 15-35% of patients with GCA, primarily before initiation of therapy 1, 4
• Glucocorticoid-related adverse events are common (86% of patients) with long-term therapy, highlighting the importance of steroid-sparing agents 1, 3