What is the treatment for temporal arteritis?

Treatment of Temporal Arteritis

The treatment for temporal arteritis requires immediate initiation of high-dose glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day) upon clinical suspicion, even before biopsy confirmation, to prevent vision loss and other ischemic complications. 1, 2

Initial Management

• Start high-dose oral glucocorticoids immediately upon clinical suspicion of temporal arteritis (giant cell arteritis) 3, 1, 2
• For patients with threatened or recent vision loss, administer intravenous pulse methylprednisolone (500-1000 mg/day for 3 days) followed by high-dose oral prednisone 1, 4
• Do not delay treatment while awaiting temporal artery biopsy results, as vision loss can be permanent 2, 4
• Arrange temporal artery biopsy as soon as possible, ideally within 1-2 weeks of starting glucocorticoids 3, 2
• Obtain a long-segment biopsy specimen (>1 cm) to improve diagnostic yield 3, 2

Glucocorticoid Tapering Strategy

• Maintain initial high-dose glucocorticoids for approximately one month to ensure adequate disease control 1
• Begin gradual taper after symptoms are controlled, aiming for 15-20 mg/day within 2-3 months 1, 2
• Guide tapering by monitoring clinical symptoms and normalization of inflammatory markers (ESR, CRP) 1, 2
• Avoid alternate-day therapy as this increases risk of relapse 1
• Aim for ≤5 mg/day after 1 year of treatment 2, 4

Adjunctive Therapy

• Consider adding tocilizumab as a first-line steroid-sparing agent, especially for patients at high risk of steroid-related complications 1, 2
• Tocilizumab reduces relapse rates and minimizes steroid exposure 2
• Consider methotrexate as an alternative steroid-sparing agent if tocilizumab is contraindicated 1, 2

Management of Relapses

• For disease relapse with cranial ischemic symptoms, increase glucocorticoid dose and add or optimize non-glucocorticoid immunosuppressive therapy 1, 2
• Tocilizumab is preferred over methotrexate for relapsing disease with cranial symptoms 1, 2

Monitoring

• Implement long-term clinical monitoring for all patients, even those in apparent remission 2
• Monitor for recurrence of headache, scalp tenderness, jaw claudication, and other symptoms that may indicate relapse 1
• Monitor for glucocorticoid-related adverse effects and provide appropriate prophylaxis (e.g., bone protection) 2
• New or worsening headache despite treatment may indicate inadequate disease control 1

Warning Signs Requiring Immediate Attention

• Visual symptoms (amaurosis fugax, diplopia) accompanying pain require emergency treatment with IV pulse glucocorticoids 1, 4
• Jaw claudication with pain is a high-risk symptom that may precede cranial ischemic complications 1
• Without treatment, the risk of vision loss in the second eye is as high as 50% if one eye is already affected 2, 4

Diagnostic Considerations

• Temporal artery ultrasound can be a valuable tool for diagnosing GCA, especially in emergency settings 5
• Raised inflammatory markers (ESR, CRP) are highly sensitive for the diagnosis of giant cell arteritis 3
• A normal ESR or CRP should raise suspicion for an alternative diagnosis 3