From the Guidelines
Temporal arteritis, also known as giant cell arteritis, should be treated immediately with high-dose corticosteroids (prednisone 40-60 mg daily) as soon as it is suspected, even before confirming the diagnosis, to prevent vision loss. This condition presents with new-onset headache, scalp tenderness, jaw claudication, and visual disturbances in patients typically over 50 years old. Diagnosis requires a temporal artery biopsy, which should be performed within 1-2 weeks of starting steroids, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1. Laboratory tests typically show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
Key Considerations
- Once diagnosed, continue prednisone at the initial dose for 2-4 weeks, then gradually taper over 12-24 months based on symptom resolution and normalization of inflammatory markers, as suggested by the 2018 update of the EULAR recommendations for the management of large vessel vasculitis 2, 3.
- Add calcium and vitamin D supplementation to prevent steroid-induced osteoporosis.
- Consider adding methotrexate or tocilizumab as steroid-sparing agents for patients who cannot tolerate steroids or have relapses during tapering, as recommended by the 2018 EULAR guidelines 2, 3.
- Monitor patients regularly for steroid side effects and disease recurrence, checking ESR and CRP levels.
Importance of Prompt Treatment
Prompt treatment is crucial because inflammation of the temporal arteries can lead to irreversible blindness if the ophthalmic artery becomes occluded, making this a true medical emergency requiring immediate intervention. The 2021 American College of Rheumatology/Vasculitis Foundation guideline and the 2018 EULAR recommendations emphasize the importance of early diagnosis and treatment to prevent complications and improve outcomes in patients with giant cell arteritis 1, 2, 3.
From the Research
Presentation of Temporal Arteritis
- Temporal arteritis, also known as giant cell arteritis, is a systemic autoimmune vasculitis that affects patients over 50 years of age 4
- It can cause rapid, irreversible bilateral vision loss in older adults and is therefore considered an ophthalmological emergency 4
- Symptoms and signs of temporal arteritis can be vague, non-specific, and gradual in onset, often leading to a delayed or inaccurate diagnosis 4
Treatment of Temporal Arteritis
- High-dose corticosteroids are the mainstay of treatment for temporal arteritis 5
- The initial dose of corticosteroids can vary, with some studies suggesting a starting dose of 30-40 mg/day of prednisone 6 and others using higher doses 6
- Corticosteroid treatment should be prolonged in the majority of patients, with some studies showing that treatment can be withdrawn after 5 years in some cases, but with a risk of flare-ups 7
- Steroid-sparing medications, such as dapsone or methotrexate, may be used to taper steroid dosage and reduce side effects, but their effectiveness is not well established and more studies are needed 8
- TNF-alpha inhibitors, such as adalimumab, have been used to treat refractory or steroid-dependent temporal arteritis, but more studies are needed to confirm their efficacy 5
Management and Monitoring
- Early initiation of treatment for temporal arteritis is crucial to prevent vision loss and other complications 4
- Patients with temporal arteritis should be monitored closely for signs of flare-ups and side effects of treatment, and adjustments to treatment should be made as needed 7, 6
- The optimal corticosteroid dose regimen and the role of steroid-sparing agents and TNF-alpha inhibitors in the treatment of temporal arteritis require further study 6, 5, 8