Treatment for Temporal Arteritis (Giant Cell Arteritis)
The recommended first-line treatment for temporal arteritis is immediate initiation of high-dose oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day), with the addition of tocilizumab as a steroid-sparing agent, especially for patients at high risk of steroid-related complications. 1
Initial Treatment Approach
- Start high-dose oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day) immediately upon clinical suspicion of GCA, even before biopsy confirmation, to prevent ischemic complications 1
- For patients with threatened vision loss or cranial ischemic symptoms, administer intravenous pulse methylprednisolone (500-1000 mg/day for 3 days) immediately, followed by high-dose oral prednisone 2
- Do not delay treatment while awaiting biopsy results, as vision loss can be permanent 2
Treatment Based on Disease Presentation
For GCA without visual symptoms/loss or critical cranial ischemia:
- High-dose daily oral glucocorticoids with tocilizumab is strongly recommended 3
- In some instances, glucocorticoids with methotrexate or glucocorticoids alone can be considered 3
For GCA with visual symptoms/loss or critical cranial ischemia:
- Immediate IV pulse glucocorticoids (methylprednisolone 0.25-1g/day for 3 days) followed by high-dose oral glucocorticoids 2
- Add tocilizumab as the preferred steroid-sparing agent 1
Glucocorticoid Tapering Strategy
- Maintain initial high-dose glucocorticoids for approximately one month 4
- Begin gradual taper after symptoms are controlled, aiming for 15-20 mg/day within 2-3 months 4
- Guide tapering by monitoring clinical symptoms and normalization of inflammatory markers (ESR, CRP) 4
- Avoid alternate-day therapy as this increases risk of relapse 4
- Aim for a dose of ≤5 mg/day after 1 year 1
Adjunctive Therapy
- Add tocilizumab to glucocorticoids as first-line therapy to reduce relapse rates and minimize steroid exposure 1
- Consider methotrexate as an alternative steroid-sparing agent if tocilizumab is contraindicated 1
- IL-6 antagonists may be particularly effective for patients with polymyalgia rheumatica symptoms (shoulder/hip girdle pain) 4
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 symptoms 4
- Monitor for recurrence of headache, scalp tenderness, jaw claudication, and other pain symptoms that may indicate relapse 4
Monitoring and Follow-up
- Implement long-term clinical monitoring for all patients, even those in apparent remission 1
- Monitor for glucocorticoid-related adverse effects and provide appropriate prophylaxis (e.g., bone protection) 1
- For patients with an increase in inflammation markers alone (without clinical symptoms), clinical observation and monitoring without escalation of immunosuppressive therapy is recommended 3
Potential Complications and Cautions
- Without treatment, the risk of vision loss in the second eye is as high as 50% if one eye is already affected 1
- Steroid-related complications occur in approximately 58% of patients, with fractures and severe infections being most common 5
- Complications are age-related, occurring twice as often in patients older than 75 years compared to younger patients 5
- Steroid-related side effects are dose-related, occurring more commonly in patients starting with doses >40 mg/day and in patients taking high maintenance dosage 5
- Lower maintenance doses of prednisone (around 13 mg/day vs 26.3 mg/day) have been associated with fewer serious corticosteroid-related complications 6
Warning Signs Requiring Immediate Attention
- New or worsening headache despite treatment may indicate inadequate disease control 4
- Visual symptoms (amaurosis fugax, diplopia) accompanying pain require emergency treatment with IV pulse glucocorticoids 4
- Jaw claudication with pain is a high-risk symptom that may precede cranial ischemic complications 4