From the Guidelines
Temporal arteritis, also known as giant cell arteritis, is a serious inflammatory condition affecting the temporal arteries that requires immediate treatment with high-dose corticosteroids, with the recommended initial treatment being prednisone 40-60mg daily (or 1mg/kg/day), started immediately upon suspicion of the diagnosis, even before biopsy confirmation, as supported by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1.
Key Points
- The initial treatment should be maintained for 2-4 weeks until symptoms resolve and inflammatory markers normalize, followed by a slow taper over 12-18 months, as recommended by the 2021 guideline 1.
- Failure to treat promptly can result in permanent vision loss, emphasizing the importance of immediate treatment, as highlighted in the 2020 update of the EULAR recommendations for the management of large vessel vasculitis 1.
- Patients should also take calcium (1200mg daily) and vitamin D (800-1000 IU daily) supplements to prevent steroid-induced osteoporosis, along with a proton pump inhibitor for gastric protection, as part of comprehensive management.
- For long-term management, steroid-sparing agents like methotrexate or tocilizumab may be added, with the choice of agent depending on the individual patient's response and risk factors, as discussed in the guidelines 1.
- The disease typically affects adults over 50, with symptoms including new-onset headache, scalp tenderness, jaw claudication, and visual disturbances, which should prompt immediate referral to a specialist team for further diagnostic work-up and management, as recommended by the EULAR guidelines 1.
- Diagnosis is supported by elevated ESR/CRP, and temporal artery biopsy should be performed within 1-2 weeks of starting treatment, as part of the diagnostic work-up, with imaging and biopsy showing features of GCA even weeks after GC therapy, as noted in the guidelines 1.
- Regular monitoring of symptoms, inflammatory markers, and medication side effects is essential throughout the treatment course, to ensure optimal management and minimize the risk of complications, as emphasized in the guidelines 1.
From the Research
Definition and Diagnosis of Temporal Arteritis
- Temporal arteritis, also known as giant cell arteritis, is a systemic autoimmune vasculitis affecting patients over 50 years of age 2.
- It can cause rapid, irreversible bilateral vision loss in older adults and is therefore considered an ophthalmological emergency 2.
- The diagnosis of temporal arteritis can be difficult, especially in emergency department settings, but temporal artery ultrasound (TAUS) is a valuable tool for diagnosing giant cell arteritis 3.
- A temporal artery biopsy is also an important diagnostic tool, and high-dose steroids should be begun as soon as the diagnosis is considered 4.
Treatment and Management of Temporal Arteritis
- Corticosteroid treatment is the primary treatment for temporal arteritis, and the initial dose should be sufficient to control symptoms and signs 5.
- The optimal corticosteroid dose regimen is still debated, but a retrospective study found that a starting dose of 30-40 mg/d of prednisone was effective and less toxic than higher dose regimens 6.
- Treatment should be prolonged in the majority of patients, with a gradual tapering of the steroid dose over at least 1 year 5, 4.
- Careful monitoring of the response, both clinically and with serial inflammatory markers, is required to adjust the treatment regimen as needed 4.
Complications and Side Effects of Temporal Arteritis Treatment
- Serious corticosteroid side effects are uncommon, but can occur, especially with high-dose regimens 5, 6.
- Flare-up rates upon corticosteroid reduction are high, especially in the first 24 months of treatment, and can be more common in certain patient populations 5.
- The use of steroid-sparing agents should be considered if iatrogenic steroid complications occur 4.