What is the initial treatment for temporal arteritis diagnosis?

Initial Treatment for Temporal Arteritis (Giant Cell Arteritis)

High-dose glucocorticoids should be started immediately upon clinical suspicion of temporal arteritis, even before biopsy confirmation, to prevent vision loss and other ischemic complications. 1

Immediate Treatment Based on Clinical Presentation

• For patients without visual symptoms or critical cranial ischemia:

  • Start high-dose daily oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day) with tocilizumab as first-line therapy 2, 1
  • In some instances, glucocorticoids with methotrexate or glucocorticoids alone can be considered as alternatives 2, 1

• For patients with threatened vision loss or critical cranial ischemia:

  • Administer intravenous pulse methylprednisolone (500-1000 mg/day for 3 days) immediately 2, 1
  • Follow with high-dose oral prednisone (1 mg/kg/day) 1
  • This approach is critical as visual loss occurs in 15-35% of patients with GCA, primarily before initiation of therapy 1

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, 1
• If temporal artery biopsy is negative but clinical suspicion remains high, consider noninvasive vascular imaging of large vessels to aid in diagnosis 2

Glucocorticoid Administration

• Daily oral glucocorticoids are conditionally recommended over alternate-day schedules 2
• Begin gradual taper after 1 month of high-dose therapy, aiming for:
  • 10-15 mg/day by 3 months
  • ≤5 mg/day after 1 year 1
• Guide tapering by monitoring clinical symptoms and normalization of inflammatory markers (ESR, CRP) 1

Adjunctive Therapy

• Adding tocilizumab to glucocorticoids is recommended as first-line therapy to:
  • Reduce relapse rates
  • Minimize steroid exposure
  • Particularly beneficial for patients at high risk of steroid-related complications 1
• Consider methotrexate as an alternative steroid-sparing agent if tocilizumab is contraindicated 1

Management of Relapses

• For disease relapse with cranial ischemic symptoms:
  • Add a non-glucocorticoid immunosuppressive agent
  • Increase glucocorticoid dose
  • Tocilizumab is preferred over methotrexate for relapsing disease with cranial ischemia 1

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
• For patients with increased inflammatory markers alone (without clinical symptoms), clinical observation and monitoring without escalation of immunosuppressive therapy is recommended 1

Important Clinical Considerations

• Without treatment, the risk of vision loss in the second eye is as high as 50% if one eye is already affected 1
• Glucocorticoid-related adverse events are common (86% of patients) with long-term therapy 1
• NSAIDs may provide temporary symptomatic relief for mild pain but should not replace or delay glucocorticoid therapy 3