Giant Cell Arteritis (Temporal Arteritis)

Referring to secondary care

Visual impairment requires urgent discussion with ophthalmology on call.

Background

GCA is the most common systemic vasculitis in people >50. It affects women more than men and 50% of patients have co-existing polymyalgia rheumatic (PMR). It is a critical ischaemic disease and should be considered a medical emergency.

When to suspect GCA

Patient aged >50 years with at least one of:

New onset localised headache

Usually unilateral in the temporal area
Occasionally diffuse or bilateral

Temporal artery abnormality such as tenderness or thickening (present in 45–75% of people with the condition)
Occasionally the overlying skin is red, and pulsation may be reduced or absent.

Other symptoms and signs suggestive of GCA include:

Systemic features (low grade fever, fatigue, anorexia, weight loss) affect most people
Features of PMR (bilateral upper arm stiffness, aching, and tenderness; pelvic girdle pain)
Scalp tenderness in ~50% of people, especially over the temporal and occipital arteries
Intermittent jaw claudication occurs in nearly 50% of people with GCA, causing pain in the jaw muscles while eating. Occasionally, intermittent claudication affects the arms, tongue, or the muscles involved in swallowing due to involvement of blood vessels which supply these areas.
Visual disturbances. Permanent partial or complete loss of vision in one or both eyes occurs in up to 20% of people and is a common early symptom. Typically it is described as painless with a feeling of a shade covering one eye, which can progress to total blindness. Double vision and visual field defects may occur. Untreated, the second eye is likely to become affected within 1–2 weeks, although it can be affected within 24 hours.

Investigations

C-reactive protein is typically elevated and is a more sensitive indicator of inflammation than plasma viscosity, which is more non-specific (see related guidance)

If inflammatory markers are normal, please consider an alternative cause for the patient's symptoms.

Differential diagnosis

Shingles
Migraine or other causes of headache
Serious intracranial pathology eg infiltrative retro-orbital or base of skull lesions
Other causes of acute visual loss eg TIA
Cervical spine disease
ENT pathology eg sinus, TMJ and ear disease
Systemic vasculitides
Connective tissue disease.

Management

Refer to secondary care as per GCA referral pathway above and start prednisolone along with gastric protection immediately:

Starting dose 1mg/kg daily, max 40mg (if visual symptoms/jaw claudication max 60mg) for 4 weeks
Reduce by 10mg every 2 weeks

Once a dose of 30mg reached:

30mg /day - 2 weeks
20mg /day - 2 weeks
15mg /day - 2 weeks
5mg /day - 2 weeks
10mg /day - 4 weeks
9mg /day - 4 weeks
8mg /day - 4 weeks
7mg /day - 4 weeks
6mg /day - 4 weeks
5mg /day - 8 weeks
4mg /day- 8 weeks
3mg /day - 8 weeks
2 mg/day - 8 weeks
1mg /day - 8 weeks

Always consider bone protection and calculate fracture risk using FRAX score.

Assess for hypertension and hyperglycaemia (blood glucose for acute changes and HbA1C to identify those at risk) within 2 weeks of commencing high dose steroids – BSR guidelines 2024

Review every 2-8 weeks in the first 6 months