What is the initial treatment for temporal arthritis, particularly when associated with giant cell arteritis?

Initial Treatment for Temporal Arteritis (Giant Cell Arteritis)

High-dose oral glucocorticoids should be started immediately upon clinical suspicion of temporal arteritis/giant cell arteritis (GCA), with a recommended dose of prednisone 1 mg/kg/day (maximum 60 mg/day), even before biopsy confirmation. 1

Initial Treatment Approach

• For patients with newly diagnosed GCA without visual symptoms or cranial ischemia, high-dose oral glucocorticoids are the first-line treatment 2, 1
• For patients with threatened vision loss, intravenous pulse methylprednisolone (500-1000 mg/day for 3 days) should be administered immediately, followed by high-dose oral prednisone 1
• Adding tocilizumab to glucocorticoids is recommended as first-line therapy, especially for patients at high risk of steroid-related complications, to reduce relapse rates and minimize steroid exposure 1
• Daily dosing of glucocorticoids is preferred over alternate-day scheduling 2, 1

Diagnostic Confirmation

• Temporal artery biopsy should be arranged as soon as possible, ideally within 2 weeks of starting glucocorticoids, to confirm diagnosis 2, 1
• A long-segment biopsy specimen (>1 cm) is recommended to improve diagnostic yield 2, 1
• If temporal artery biopsy is negative but clinical suspicion remains high, noninvasive vascular imaging should be obtained to evaluate large vessel involvement 2

Glucocorticoid Tapering

• After 1 month of high-dose therapy, begin gradual taper of glucocorticoids, aiming for:
  • 10-15 mg/day by 3 months 1
  • ≤5 mg/day after 1 year 1
• Tapering should be guided by clinical symptoms and normalization of inflammatory markers (ESR, CRP) 1

Steroid-Sparing Agents

• Tocilizumab is the preferred steroid-sparing agent, with high-quality evidence supporting its efficacy 2, 1
• Methotrexate can be considered as an alternative if tocilizumab is contraindicated 1
• For patients with active extracranial large vessel involvement, oral glucocorticoids combined with a non-glucocorticoid immunosuppressive agent are recommended over oral glucocorticoids alone 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

Monitoring

• Implement long-term clinical monitoring for all patients, even those in apparent remission, to detect potential relapses and glucocorticoid-related adverse effects 1
• Monitor for glucocorticoid-related adverse effects and provide appropriate prophylaxis (e.g., bone protection) 1

Common Pitfalls and Caveats

• Delaying treatment while awaiting biopsy results can lead to irreversible vision loss; treatment should be initiated immediately upon clinical suspicion 1
• Visual loss occurs in 15-35% of patients with GCA, primarily before initiation of therapy 1
• Glucocorticoid-related adverse events are common (86% of patients) with long-term therapy 1, 3
• Without treatment, the risk of vision loss in the second eye is as high as 50% if one eye is already affected 1
• For patients with an increase in inflammation markers alone (without clinical symptoms), clinical observation and monitoring without escalation of immunosuppressive therapy is recommended 1