What is the recommended treatment for an older adult over 50 years old suspected of having temporal arteritis?

Recommended Treatment for Temporal Arteritis in Adults Over 50

Start high-dose oral glucocorticoids (prednisone 40-60 mg daily or 1 mg/kg/day, maximum 60 mg) immediately upon clinical suspicion, without waiting for biopsy confirmation, and strongly consider adding tocilizumab as first-line adjunctive therapy to reduce relapse rates and minimize steroid exposure. 1

Immediate Treatment Algorithm

For Patients WITHOUT Visual Symptoms or Threatened Vision Loss

• Initiate oral prednisone 40-60 mg daily (or 1 mg/kg/day, maximum 60 mg) as a single morning dose immediately upon clinical suspicion, even before obtaining temporal artery biopsy confirmation 1
• The American College of Rheumatology strongly recommends adding tocilizumab (162 mg subcutaneously weekly) to glucocorticoids as first-line therapy, particularly for patients at high risk of steroid-related complications 1
• Daily dosing is preferred over alternate-day scheduling 1

For Patients WITH Visual Symptoms or Threatened Vision Loss

• Administer intravenous methylprednisolone 500-1000 mg daily for 3 consecutive days immediately, followed by high-dose oral prednisone (1 mg/kg/day, maximum 60 mg) 1
• This aggressive approach is critical because vision loss is often irreversible, and without treatment, the risk of vision loss in the second eye approaches 50% if one eye is already affected 1

Diagnostic Confirmation While on Treatment

Do not delay treatment while awaiting biopsy confirmation - this is a critical pitfall to avoid, as vision loss can occur rapidly and is typically permanent 1

• Arrange temporal artery biopsy as soon as possible, ideally within 2 weeks of starting glucocorticoids 2, 1
• Obtain a long-segment biopsy specimen (>1 cm) to improve diagnostic yield, as skip lesions may render shorter specimens falsely negative 2, 1
• Treatment prior to biopsy is unlikely to affect histopathological results if performed within this 1-2 week window 2
• If temporal artery biopsy is negative but clinical suspicion remains high, obtain noninvasive vascular imaging (CT or MRI of thoracic aorta and branch vessels) to evaluate for large vessel involvement 1

Glucocorticoid Tapering Strategy

Maintain the initial high dose for approximately 1 month until symptoms resolve and inflammatory markers (ESR/CRP) normalize 1

Structured Tapering Timeline:

• At 1 month: Begin gradual taper after symptom resolution and ESR/CRP normalization 2, 1
• At 2-3 months: Target dose of 10-15 mg/day 2, 1
• At 12 months: Target dose of ≤5 mg/day 2, 1
• Total duration: Typically 1-2 years to avoid recurrence, though some patients may require longer therapy 1

Guide tapering by clinical symptoms and normalization of inflammatory markers, not by a fixed timeline alone 2, 1. The taper should not be in the form of alternate-day therapy, as this increases relapse risk 2.

Adjunctive Steroid-Sparing Therapy

First-Line Steroid-Sparing Agent:

• Tocilizumab (162 mg subcutaneously weekly) is the preferred steroid-sparing agent, as it reduces relapse rates from 34-75% and allows faster steroid tapering 1
• The American College of Rheumatology recommends tocilizumab particularly for patients at high risk of steroid-related complications or those with refractory/relapsing disease 1

Alternative Steroid-Sparing Agents:

• Methotrexate can be considered if tocilizumab is contraindicated or unavailable, though evidence is less robust 2, 1
• Abatacept is reasonable as adjunctive therapy 1

Management of Disease Relapse

Relapses occur in 34-75% of GCA patients during steroid tapering 1

For Major Relapse (Cranial Ischemic Symptoms):

• Increase prednisone to 40-60 mg/day immediately 1
• Add tocilizumab as a steroid-sparing agent (preferred over methotrexate for relapsing disease with cranial symptoms) 1

For Minor Relapse (Isolated Elevation of ESR/CRP Without Clinical Symptoms):

• Clinical observation and monitoring without escalation of immunosuppressive therapy is recommended 1
• Clinical assessment takes priority over laboratory values alone 1

Monitoring and Follow-Up

• Assess clinical symptoms (headache, jaw claudication, visual changes) and inflammatory markers (ESR, CRP) regularly 1
• Physical examination should include temporal artery palpation and assessment for new ischemic symptoms 1
• Implement long-term clinical monitoring for all patients, even those in apparent remission, to detect potential relapses 1
• For patients with known large-vessel involvement, obtain periodic vascular imaging to assess for aneurysms, stenoses, and stability of lesions 1
• Patients without large vessel involvement may not require routine repeated imaging 1

Glucocorticoid Complication Prevention

All patients should receive bone protection therapy in the absence of contraindications, as 86% of patients suffer glucocorticoid-related adverse events with long-term therapy 2, 1

• Initiate calcium, vitamin D, and bisphosphonates for all patients unless contraindicated 1
• Monitor for other steroid-related complications including hyperglycemia, hypertension, weight gain, and mood changes 1

Additional Protective Therapy

• Low-dose aspirin (75-150 mg/day) is recommended for all GCA patients to protect against cardiovascular and cerebrovascular events 3

Critical Pitfalls to Avoid

1. Never delay treatment while awaiting biopsy confirmation - vision loss is often irreversible 1
2. Do not perform elective revascularization procedures until the acute inflammatory state is controlled and quiescent 1
3. Do not rely solely on inflammatory markers for treatment decisions - clinical symptoms take priority 1
4. Avoid alternate-day steroid dosing during tapering, as this increases relapse risk 2
5. Do not assume normal ESR/CRP rules out GCA - while elevated markers are present in >95% of cases, rare patients may have normal values 2, 3