TA Temporal Arteritis/ GCA Giant Cell Arteritis Pathway and Guidelines ***

Temporal Arteritis /Giant Cell Arteritis Pathway

click on the above link to see the acute management of TA.

PMR Polymyalgia Rheumatica has a separate pathway

BEST talk - Dr.Sharlala March 2017 - discusses TA management as well as PMR Management

GIANT CELL ARTERITIS MANAGEMENT GUIDELINES

Temporal Arteritis

Diagnosis

GCA is a large vessel vasculitis and the commonest of all the vasculitides.

Patients typically present at age over 50 with new-onset headache and a raised inflammatory response and may also have scalp pain, jaw claudication, visual, constitutional or girdle (polymyalgia) symptoms.

Management

1.Glucocorticoids upon suspicion of GCA:

  • Prednisolone EC 40-60 mg/day. At least 0.75 mg/kg/day
  • 60 mg daily if visual symptoms, 40 mg daily if no visual symptoms 

2.Glucocorticoid dose reduction

  • Reduction should start on normalisation of inflammatory markers.
  • The British Society for Rheumatology recommends:-
  • one month of 40-60 mg/day,
  • then initial reduction by 5 mg/week until 20 mg/day.

However, this needs to be tailored to each patient’s case.

  • Most patients will be off glucocorticoids within 2 years.

    (Just as a guide, a recent patient had the following steroid reduction regime prescribed by the The Consultant Rheumatologist)
    40 mg/ day for 1 week
    35 mg/day  for 1 week
    30 mg/day  for 1 week
    20 mg/day  for 1 week
    15 mg/day  for 6 week
    12.5 mg/day  for 6 week
    10 mg/day  for 6 week
    9 mg/day  for 6 week
    8 mg/day  for 6 week
  • HOWEVER remember that this regime may need to be altered on a case to case basis. This is just a guidance)

3.Bone protection:

  • ALL patients require calcium and vitamin D supplements

AND

  • in patients over 65 years (or under 65 but with fractures),

an oral bisphosphonate should be prescribed.

  • In patients under 65 years without fractures,

DXA scan can guide the need for bisphosphonates (required if osteopenia or osteoporosis).

4. Gastric protection:

  • a PPI is needed particularly with the higher Prednisolone doses.

5. Aspirin 75 mg/day

6. Regular check for Steroid induced Diabetes Mellitus.

Important points

  • A clinical response of resolution of symptoms is expected within the first few days of therapy with glucocorticoids.
  • Inflammatory markers may take up to a month to normalise.
  • A temporal artery biopsy should be performed in all cases unless there is a contraindication. Ideally this should take place within the first 2 weeks of glucocorticoid treatment to optimise the diagnostic yield.
  • THERAPY WITH GLUCOCORTICOIDS SHOULD NOT BE DELAYED TO OBTAIN A BIOPSY.
  • If ophthalmological symptoms are present, an urgent Ophthalmology review is required, over the phone to the on-call doctor, either through switchboard or through secretaries (Michelle Gorst on 2782 or Tanya Sanderson on 2009).
  • Upon clinical suspicion of GCA, please commence glucocorticoids and fax an urgent letter to barnsleyopdcentralreferral@nhs.net
  • If there is a need to discuss a patient, please contact the Rheumatology secretaries on x2387 or x2421.
  • If no resolution of symptoms or significant constitutional symptoms are present, an alternative aetiology ought to be suspected.

 Based on the BSR and BHPR guidelines for the management of giant cellarteritis. Rheumatology 2010;49:1594-7

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