What is the treatment for temporal arthritis, specifically giant cell arteritis?

Treatment of Giant Cell Arteritis (Temporal Arteritis)

Initiate high-dose oral glucocorticoids (prednisone 1 mg/kg/day, maximum 60 mg/day) immediately upon clinical suspicion—do not wait for biopsy confirmation—and add tocilizumab as first-line combination therapy to reduce relapse rates and minimize steroid exposure. 1, 2, 3

Immediate Treatment Based on Clinical Presentation

For Patients WITHOUT Threatened Vision Loss

• Start high-dose oral prednisone 1 mg/kg/day (maximum 60 mg/day) immediately upon clinical suspicion 1, 2, 3
• Dose daily, not alternate-day, as alternate-day dosing increases relapse risk 1, 2, 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, consider methotrexate as an alternative steroid-sparing agent 1, 2, 3

For Patients WITH Threatened Vision Loss or Visual Symptoms

• Administer intravenous pulse methylprednisolone 500-1000 mg/day for 3 days immediately 1, 2, 4, 3
• Follow with high-dose oral prednisone 1 mg/kg/day after IV pulse therapy 1, 2, 3
• Without treatment, the risk of losing the second eye is 50% if one eye is already affected 2, 3
• Vision loss occurs in 15-35% of patients, almost exclusively before treatment initiation 1, 2, 3

Diagnostic Confirmation (Do Not Delay Treatment)

• Arrange temporal artery biopsy within 2 weeks of starting glucocorticoids 1, 2
• Obtain a long-segment biopsy specimen (>1 cm) to improve diagnostic yield 1, 2
• If biopsy is negative but clinical suspicion remains high, obtain noninvasive vascular imaging to evaluate large vessel involvement 1, 3
• Temporal artery biopsy remains the optimal diagnostic approach in the US, as ultrasound is operator-dependent and results are influenced by glucocorticoid treatment 1

Adjunctive Therapies

• Prescribe low-dose aspirin (75-150 mg/day) for all patients unless contraindicated, to protect against cardiovascular and cerebrovascular events 3
• For patients with critical or flow-limiting involvement of vertebral or carotid arteries, add aspirin 1
• Do not use statins specifically for GCA treatment, as evidence does not support their use for this indication 1

Glucocorticoid Tapering Strategy

• Maintain initial high-dose glucocorticoids for approximately 1 month to ensure adequate disease control 2, 4, 3
• Begin gradual taper after symptoms are controlled and inflammatory markers normalize 2, 4, 3
• Target 10-15 mg/day by 3 months and ≤5 mg/day after 1 year 1, 2, 3
• Guide tapering by clinical symptoms and normalization of ESR/CRP, not by inflammatory markers alone 1, 2, 4, 3
• Avoid rapid steroid withdrawal as it leads to disease exacerbation 3

Management of Disease Relapse

Relapse WITH Cranial Ischemic Symptoms

• Add a non-glucocorticoid immunosuppressive agent (preferably tocilizumab) and increase glucocorticoid dose 1, 2, 3
• Tocilizumab is preferred over methotrexate for relapsing disease with cranial ischemia 2, 4, 3

Relapse WITH Polymyalgia Rheumatica Symptoms Only

• Increasing glucocorticoid dose alone may be sufficient 2, 3

Elevated Inflammatory Markers WITHOUT Clinical Symptoms

• Clinical observation and monitoring without escalation of immunosuppressive therapy is recommended 2, 3

Special Considerations for Large Vessel Involvement

• Obtain noninvasive vascular imaging in all newly diagnosed GCA patients to evaluate large vessel involvement 1, 3
• For patients with active extracranial large vessel involvement, use oral glucocorticoids combined with a non-glucocorticoid immunosuppressive agent over glucocorticoids alone 1, 2, 3

Monitoring Strategy

• Monitor as frequently as every 1-4 weeks until remission is achieved 1
• Once in stable remission, monitor every 3-6 months 1
• Implement long-term clinical monitoring even in apparent remission to detect relapses 2, 3
• Monitor for glucocorticoid-related adverse effects (occur in 86% of patients) and provide appropriate prophylaxis including bone protection 2, 3
• Track ESR and CRP regularly to guide treatment decisions 1, 2, 4, 3

Critical Pitfalls to Avoid

• Never delay treatment while awaiting biopsy results—vision loss can be permanent 2, 3
• Do not use alternate-day glucocorticoid dosing—it increases relapse risk 1, 2, 3
• Do not use infliximab for GCA—it is associated with recurrent ocular symptoms and disease activity 3
• Recognize that flare occurs in 34-62% of patients, and only 15-20% achieve sustained remission with glucocorticoids alone 1
• Be aware that sight loss has become less common but still occurs in 14-18% of patients 1