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Home | Articles | Rheumatology | Giant Cell Arteritis

Giant Cell Arteritis

Last updated 23rd May 2022

Background

  1. Giant cell arteritis is a vasculitis of the extra-cranial arteries especially the branches of the carotid and ophthalmic arteries
  2. Virtually unheard of in under 50s, it is commonest in the elderly >70 years
  3. Serious compications such as partial or total irreversible blindness may result if not considered and treated urgently with high dose steroid

Core Inclusion Criteria (Primarily Used for Research)

  1. New headache
  2. Redness, tenderness and/or decreased pulsation temporal artery – note that temple tenderness per se is a non specific finding as may be found in tension headache, TMJ problems
  3. Age at disease onset >50 years
  4. ESR >50 mm/hr
  5. Abnormal temporal artery biopsy.
  6. Others include weight loss, fever and polymyalgia features

Complicated and Uncomplicated GCA

  1. BSR recognise two categories of GCA – complicated and uncomplicated
  2. Complicated – characterised by evolving or established visual loss, also patients with diplopia or jaw claudication who are at high risk of visual loss. Other rarer complications include stroke and inflammatory aortitis
  3. Uncomplicated – new headache with temporal artery tenderness and raised ESR/CRP only.

Temporal Artery Biopsy (TAB)

  1. Early TAB desirable in all patients with suspected GCA and should be performed within 2 weeks of starting steroid.
  2. Complicated – phone on call ophthalmologist
  3. Uncomplicated (inpatient) – phone and take referral letter to Mr Muir’s secretary on 33565
  4. Uncomplicated (outpatient) – urgent SCI referral to Rheumatology.  Referrals usually checked every weekday.  Team will aim to see urgently for temporal and axillary artery ultrasound and decision on whether or not to biopsy.
  5. Biopsy may be negative in some patients with GCA due to skip lesions
  6. Biopsy negative GCA should be treated as biopsy positive if clinical suspicion high or complications typical of GCA present

Management of GCA

  1. Uncomplicated GCA – initial dose Prednisolone should be 60mg daily for 4 weeks/until symptoms and laboratory abnormalities have resolved. Refer to High Dose Steroid Pre-Treatment Checklist
  2. Complicated GCA (visual symptoms, jaw or tongue claudication) – initial dose 60mg daily for 4 weeks as above, may get IV if inpatient.
  3. Then reduce by 10mg every 2 weeks until 20mg reached.
  4. Then by 2.5mg every 2-4 weeks until 10mg.
  5. Thereafter 1mg every 1-2 months providing there is no relapse
  6. Some patients benefit from more gradual taper, or a period of treatment at a stable dose eg 5mg daily for 3 months or from long term low dose therapy
  7. BSR suggest consider low dose aspirin to reduce visual loss and stroke in GCA though evidence for this is weak
  8. Bone and gastroprotection with alendronate and PPI also necessary
  9. Consider addition of Methotrexate for difficult to treat GCA and disease relapse

Follow Up

  1. Essentially this is clinical supported by inflammatory markers
  2. BSR recommend CXR every 2 years because of the increased incidence of thoracic aneurysm though evidence that this makes a difference is weak

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Content updated by Dr Richard Akintayo