Treatment of Suspected Temporal Arteritis in Adults Over 50
Immediately initiate high-dose oral glucocorticoids (prednisone 40-60 mg daily) as soon as temporal arteritis is suspected based on clinical presentation, without waiting for biopsy or imaging confirmation. 1
Immediate Management Algorithm
Step 1: Assess for Visual Symptoms
- If visual symptoms present or threatened vision loss: Start IV pulse methylprednisolone 1000 mg daily for 3 days before transitioning to oral glucocorticoids 1
- If no visual symptoms: Begin oral prednisone 40-60 mg daily (maximum 60 mg/day) 2, 1
The rationale for immediate treatment is critical: visual loss occurs in 18% of patients at diagnosis and is usually irreversible 2. Untreated patients face 14-50% risk of vision loss 1. Treatment should never be delayed for diagnostic confirmation.
Step 2: Obtain Diagnostic Confirmation (Do Not Delay Treatment)
- Check inflammatory markers immediately: ESR and CRP are elevated in >95% of cases 1, 3
- Temporal artery biopsy: Should be performed within 1-2 weeks of starting glucocorticoids, with specimen length ≥1 cm 2, 1
- Alternative imaging: Temporal artery ultrasound showing "halo sign" supports diagnosis (88% sensitive, 97% specific) 2, 1
- Baseline vascular imaging: Obtain MR or CT angiography of neck/chest/abdomen/pelvis to evaluate large vessel involvement 1
Step 3: Add Adjunctive Immunosuppressive Therapy
Add tocilizumab as adjunctive therapy to reduce glucocorticoid requirements and prevent disease relapse. 1 This recommendation is based on level 1A evidence with strength of recommendation B 2. Tocilizumab has demonstrated efficacy in reducing glucocorticoid requirements and flare rates 1.
Alternative steroid-sparing agents if tocilizumab unavailable:
Step 4: Glucocorticoid Tapering Strategy
- Month 1: Maintain initial high dose (40-60 mg daily) 2, 1
- Month 3: Target dose 10-15 mg daily 2, 1
- Year 1: Target ≤5 mg/day if disease controlled 1
- Do NOT use alternate-day therapy: This increases relapse risk 2
- Guide tapering by: Clinical symptoms and inflammatory markers (ESR/CRP), not IL-6 levels 1
Duration of therapy is variable and can extend to several years; some patients cannot tolerate complete discontinuation due to recurrent disease or secondary adrenal insufficiency 2.
Supportive Care
Bone Protection (Mandatory)
Initiate bone protection therapy for all patients unless contraindicated: calcium, vitamin D, and bisphosphonates 2, 1. This is critical as 86% of patients suffer glucocorticoid-related adverse events 2.
Cardiovascular Protection
Low-dose aspirin (75-150 mg/day) is recommended for all patients to protect against cardiovascular and cerebrovascular events 1.
Monitoring and Follow-up
Clinical Monitoring
- Primary monitoring: Clinical symptoms and ESR/CRP levels throughout disease course 1
- Periodic vascular imaging: For patients with known large-vessel involvement to assess for aneurysms, stenoses, and stability of existing lesions 1
- Patients without large vessel involvement: May not require routine repeated imaging 1
Management of Relapse
- Escalate glucocorticoid dose if disease relapse occurs 1
- Add or change immunosuppressive agent (e.g., switch from methotrexate to tocilizumab or add abatacept) if relapse occurs despite adequate glucocorticoid therapy 1
Common Pitfalls to Avoid
- Never delay treatment waiting for biopsy results: The risk of irreversible vision loss outweighs diagnostic uncertainty 2, 1
- Do not use alternate-day glucocorticoid therapy: This significantly increases relapse risk 2
- Do not taper too quickly: Maintain high dose for full month before beginning taper 2, 1
- Do not forget bone protection: Start immediately with glucocorticoids 2, 1
- Do not dismiss diagnosis with normal inflammatory markers: While rare (<5% of cases), temporal arteritis can occur with normal ESR/CRP, but this should prompt consideration of alternative diagnoses 2