What is the treatment for temporal arteritis?

Treatment of Temporal Arteritis (Giant Cell Arteritis)

Start high-dose oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day) immediately upon clinical suspicion—even before biopsy confirmation—and add tocilizumab as first-line combination therapy to reduce relapse rates and minimize steroid exposure. 1, 2, 3

Immediate Treatment Initiation

For Patients WITHOUT Visual Symptoms or Critical Cranial Ischemia

• Begin prednisone 1 mg/kg/day (maximum 60 mg/day) orally as soon as temporal arteritis is suspected 1, 2, 3
• Use daily dosing rather than alternate-day schedules, as alternate-day therapy increases relapse risk 1, 4, 3
• Add tocilizumab to glucocorticoids as first-line combination therapy, particularly for patients at high risk of steroid complications 1, 2, 3
• If tocilizumab is contraindicated or unavailable, consider methotrexate as an alternative steroid-sparing agent 1, 2, 3
• Prescribe low-dose aspirin (75-150 mg/day) unless contraindicated to protect against cardiovascular and cerebrovascular events 3

For Patients WITH Threatened Vision Loss or Critical Cranial Ischemia

• Administer intravenous pulse methylprednisolone 500-1000 mg/day for 3 days immediately 1, 2, 4, 3
• Follow IV therapy with high-dose oral prednisone 1 mg/kg/day 1, 2, 3
• Add tocilizumab to the regimen 3

Critical pitfall: Do not delay treatment while awaiting biopsy results—vision loss can be permanent and occurs in 15-35% of patients, primarily before treatment initiation. 2, 3 Without treatment, the risk of vision loss in the second eye reaches 50% if one eye is already affected. 2, 3

Diagnostic Confirmation

• Arrange temporal artery biopsy as soon as possible, ideally within 2 weeks of starting glucocorticoids 1, 2
• Obtain a long-segment biopsy specimen (>1 cm) to improve diagnostic yield, as GCA is a focal and segmental disease 1, 2
• Initially perform unilateral biopsy; proceed with contralateral biopsy only if the first is negative and clinical suspicion remains high 1
• If temporal artery biopsy is negative but clinical suspicion persists, obtain noninvasive vascular imaging to evaluate large vessel involvement 2, 3

Glucocorticoid Tapering Strategy

• Maintain initial high-dose glucocorticoids for approximately one month to ensure adequate disease control 4, 3
• Begin gradual taper after symptoms are controlled and inflammatory markers (ESR, CRP) have normalized 1, 2, 4, 3
• Target 10-15 mg/day by 3 months and ≤5 mg/day after 1 year 2, 4
• Guide tapering by monitoring clinical symptoms and normalization of inflammatory markers 1, 2, 4, 3

Critical pitfall: Avoid rapid steroid withdrawal as it can lead to disease exacerbation. 3

Management of Disease Relapses

Relapse with Cranial Ischemic Symptoms

• Add a non-glucocorticoid immunosuppressive agent (preferably tocilizumab over methotrexate) 1, 2, 4, 3
• Increase glucocorticoid dose 1, 2, 4, 3

Relapse with Polymyalgia Rheumatica Symptoms Only

• Increasing glucocorticoid dose alone may be sufficient 3

Elevated Inflammatory Markers WITHOUT Clinical Symptoms

• Use clinical observation and monitoring without escalating immunosuppressive therapy 2, 3

Special Considerations for Large Vessel Involvement

• Obtain noninvasive vascular imaging to evaluate large vessel involvement in all newly diagnosed GCA patients 3
• For active extracranial large vessel involvement, combine oral glucocorticoids with a non-glucocorticoid immunosuppressive agent rather than using glucocorticoids alone 2, 3
• For severe GCA with worsening limb/organ ischemia, escalate immunosuppressive therapy rather than proceeding immediately to surgery 3
• Consider immediate surgical intervention only for aortic aneurysms at high risk for rupture or impending/progressive tissue or organ infarction 3

Long-Term Monitoring

• Implement long-term clinical monitoring for all patients, even those in apparent remission, to detect relapses 2, 3
• Monitor inflammatory markers (ESR, CRP) regularly to guide treatment decisions 4, 3
• Provide appropriate prophylaxis for glucocorticoid-related adverse effects, particularly bone protection 2
• Watch for recurrence of headache, scalp tenderness, jaw claudication, and visual symptoms that may indicate relapse 4

Important caveat: Glucocorticoid-related adverse events occur in 86% of patients with long-term therapy, making the addition of steroid-sparing agents like tocilizumab particularly valuable. 1, 2, 3