Giant Cell Arteritis

Temporal arteritis is large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR). Histology shows changes which characteristically 'skips' certain sections of affected artery whilst damaging others.

Features
typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
headache (found in 85%)
jaw claudication (65%)
visual disturbances secondary to anterior ischemic optic neuropathy
tender, palpable temporal artery
features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
also lethargy, depression, low-grade fever, anorexia, night sweats

Investigations
raised inflammatory markers: ESR > 50 mm/hr (note ESR < 30 in 10% of patients). CRP may also be elevated
temporal artery biopsy: skip lesions may be present
note creatine kinase and EMG normal

Treatment
high-dose prednisolone - there should be a dramatic response, if not the diagnosis should be reconsidered
urgent ophthalmology review. Patients with visual symptoms should be seen the same-day by an ophthalmologist. Visual damage is often irreversible

Management

Uncomplicated GCA

(no visual involvement and/or jaw/tongue claudication) should be treated with oral prednisolone 40-60mg daily until symptoms and investigations normalise.

Complicated GCA

(with visual involvement and/or jaw/tongue claudication)
IV methylprednisolone 500-1000mg for 3 days before starting oral prednisolone.

As GCA requires long-term steroid therapy bone sparing agents (a bisphosphonate and vitamin D) and a gastroprotective drug (e.g omeprazole) should be prescribed. Also, low dose aspirin should be considered as it has been shown to reduce the rate of visual loss and cerebrovascular accidents in GCA.

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