What is the treatment for temporal arteritis (giant cell arteritis)?

From the Guidelines

Temporal arteritis, also known as giant cell arteritis, requires immediate treatment with high-dose corticosteroids to prevent vision loss and other complications, with the standard initial treatment being oral prednisone at 40-60mg daily, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1. The treatment should be started as soon as the diagnosis is suspected, even before biopsy confirmation. For severe cases with visual symptoms, intravenous methylprednisolone 500-1000mg daily for 3 days may be given before transitioning to oral therapy, as suggested by the 2018 update of the EULAR recommendations for the management of large vessel vasculitis 1. The high-dose corticosteroid should be maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize, then gradually tapered over 12-24 months to prevent relapse. Many rheumatologists now add methotrexate (10-25mg weekly) or tocilizumab (162mg subcutaneously weekly) as steroid-sparing agents to reduce the cumulative steroid dose and associated side effects, as recommended by the 2018 EULAR recommendations for the management of large vessel vasculitis 1. During treatment, patients should receive calcium (1200mg daily) and vitamin D (800-1000 IU daily) supplementation, along with a bisphosphonate if indicated, to prevent steroid-induced osteoporosis. Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential throughout the treatment course, as emphasized by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. The long treatment duration is necessary because temporal arteritis is a chronic vasculitis affecting medium and large arteries, and premature discontinuation of therapy often leads to disease recurrence. Some key points to consider in the treatment of temporal arteritis include:

• Early initiation of high-dose glucocorticoid therapy to induce remission, as recommended by the EULAR recommendations for the management of large vessel vasculitis 1
• The use of adjunctive therapy, such as methotrexate or tocilizumab, to reduce the cumulative steroid dose and associated side effects, as recommended by the 2018 EULAR recommendations for the management of large vessel vasculitis 1
• Regular monitoring of symptoms, inflammatory markers, and potential steroid side effects to adjust treatment as needed, as emphasized by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.

From the Research

Treatment Options for Temporal Arthritis

• The primary treatment for giant cell arteritis (GCA), also known as temporal arteritis, is high-dose corticosteroid therapy, which should be initiated without delay in patients with a suspected diagnosis 2.
• Patients with acute visual or neurologic symptoms require immediate therapy with high-dose intravenous methylprednisolone sodium succinate, followed by high-dose oral prednisone 2.
• For patients without visual or neurologic symptoms, treatment may begin directly with oral prednisone, with the same taper and duration based on laboratory values and clinical signs and symptoms 2.
• Corticosteroids are the drug of choice to treat GCA, and therapy is required for a long time, monitored by parameters of inflammation (ESR, CRP) 3.
• Additional agents like Tocilizumab have been proven to be effective steroid-sparing agents in the treatment of GCA 4.

Diagnosis and Management

• Temporal artery biopsy is the gold standard for diagnosis of GCA, but a negative result does not exclude the diagnosis due to skip lesions 3.
• Laboratory values such as erythrocyte sedimentation rate, CRP, fibrinogen, thrombocytes, and cardiolipin antibodies can indicate GCA, but none of these prove the diagnosis 3.
• C-reactive protein is more sensitive than the erythrocyte sedimentation rate in following the adequacy of corticosteroid dosages in temporal arteritis 5.
• The British Society for Rheumatology (BSR) and the British Health Professionals in Rheumatology (BHPR) have published guidelines on the management of GCA, emphasizing the prompt diagnosis and urgent management to prevent visual loss 6.

Complications and Prognosis

• The most important complication of GCA is visual loss in one or both eyes due to AION or retinal artery occlusion, which is usually irreversible even with therapy 3.
• GCA is a disease of variable duration, and the length of treatment differs from patient to patient 4.
• Patients with GCA require long-term monitoring of disease activity, complications, and relapse 6.