Treatment of giant cell (temporal) arteritis
- Gene G Hunder, MD
Gene G Hunder, MD
- Section Editor — Vasculitis
- Emeritus Consultant
- Professor Emeritus
- Mayo Clinic College of Medicine
- Section Editors
- Jonathan Trobe, MD
Jonathan Trobe, MD
- Section Editor — Ophthalmology
- Professor of Ophthalmology and Visual Sciences
- Professor of Neurology
- University of Michigan Kellogg Eye Center
- Eric L Matteson, MD, MPH
Eric L Matteson, MD, MPH
- Section Editor — Treatment Issues in Rheumatology
- Chair, Division of Rheumatology
- Professor of Medicine
- Mayo Clinic College of Medicine
Giant cell arteritis (GCA), also known as temporal arteritis, is a chronic vasculitis of medium and large vessels that occurs only in individuals older than 50 years of age . The mean age at diagnosis in patients with GCA is 72. Many of the most concerning features of the disease (eg, anterior ischemic optic neuropathy resulting in visual loss) result from vascular inflammation involving cranial branches of the arteries that originate from the aortic arch [2,3]. The disease is generalized, however, and may also involve the aorta itself, leading to aneurysms of the thoracic and abdominal aorta and also to ischemic symptoms (claudication) in the extremities.
The treatment and prognosis of giant cell arteritis (GCA) are reviewed here. The clinical manifestations and diagnosis of this disorder are discussed separately. (See "Clinical manifestations of giant cell (temporal) arteritis" and "Diagnosis of giant cell (temporal) arteritis".)
Glucocorticoid treatment should be instituted promptly once the diagnosis of GCA is suspected strongly, often even before it is confirmed. For patients in whom the diagnostic suspicion of GCA is high, especially those with recent or threatened vascular complications such as visual loss, therapy should be started immediately. A temporal artery biopsy should be obtained as soon as possible, but treatment should not be withheld while awaiting the performance or the results of the biopsy. (See 'Visual loss at diagnosis' below and "Diagnosis of giant cell (temporal) arteritis".)
If the temporal or other artery biopsies reveal no evidence of arteritis but if clinical suspicion of GCA remains strong, glucocorticoid treatment should be continued . Even with optimal bilateral temporal artery biopsy performance, false-negative results occur in at least 9 percent of GCA cases and probably in even higher percentages in most settings . The therapeutic regimen for GCA is somewhat different than that for patients who are believed to have only polymyalgia rheumatica (PMR). In general, the treatment of PMR requires lower doses of glucocorticoids. (See "Diagnosis of giant cell (temporal) arteritis", section on 'Temporal artery biopsy' and "Treatment of polymyalgia rheumatica" and 'Glucocorticoid tapering' below.)
Efficacy — Glucocorticoids have not been studied in a placebo-controlled manner in GCA. Their effectiveness in this disorder is so well-established, however, by years of use and knowledge of the consequences of untreated disease, that it would be unethical to conduct such a study at this time. Evidence for efficacy is based upon several series in which the use of glucocorticoids improved or resolved symptoms and decreased the risk of vascular complications when compared with the rates of such events in patients with the disease prior to the glucocorticoid era [5-8].
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- TREATMENT APPROACH
- INITIAL TREATMENT
- - Efficacy
- - Initial dose
- - Visual loss at diagnosis
- - Polymyalgia rheumatica
- - Adverse effects
- - Glucocorticoid tapering
- Monitoring and gauging disease activity
- Antiplatelet therapy
- Other measures
- RESISTANT DISEASE AND GLUCOCORTICOID-SPARING AGENTS
- Anti-TNF therapy
- IS REVASCULARIZATION INDICATED?
- Visual loss
- Cardiovascular disease
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS