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Giant cell / Temporal arteritis

 

 

Giant Cell Arteritis / Temporal Arteritis is a medical emergency but rarely requires hospital admission.

  • GCA is the commonest vasculitis in the UK

  • Can be associated with irreversible neuro-ophthalmic complications and large artery involvement e.g. aortic aneurysm

  • Mean age onset=  70

  • Female : male         3 : 1

Patient info available here (patient.co.uk article)

Press here for full guideline (Clinical Knowledge Summary)

 

Key diagnostic points

  • Usually age over 50 (almost never seen in patients aged under 50)

  • Constitutional Symptoms (fatigue, weight loss) (present in 90% of patients)

  • Headache May be transient, not always temporal. (present in 66% of patients).

  • Jaw/Tongue Claudication (pain worsens on chewing). The most specific symptom.

  • Temporal Artery Abnormalities (prominent artery/tender to palpation/absent pulse)

  • Visual Changes (especially diplopia, blurring or amaurosis fugax)

  • Unexplained raised CRP

  • Sudden onset

  • 40% associated PMR symptoms

 

Diagnostic criteria

American College of Rheumatology guidelines state three or more of:

  • onset at or over age 50 years

  • new type of headache

  • thickened, tender, or nodular temporal artery with decreased pulsation

  • ESR / CRP > 50

  • abnormal arterial biopsy showing necrotising arteritis

 

The presence of any three of more of the above criteria is reported as having sensitivity and specificity above 90% for GCA [2].

However temporal arteritis can be present with two or less criteria

 

Treatment

If Giant Cell Arteritis is suspected do not delay treatment:

Uncomplicated GCA without jaw claudication/visual symptoms=Prednisolone 40mg daily

Complicated GCA with jaw claudication*/visual symptoms* =Prednisolone 60mg daily

(*=strong predictors of neuro-opthalmic complications requiring higher steroid doses).

In patients with a high BMI doses may need to be higher aiming for an initial dose of prednisolone of not less than 0.75mg/kg daily if weight > 80kg, no more than 100mg.

 

 

Urgent Referral

All GCA need specialist management in secondary care (Rheumatology /Ophtalmology)  therefore please refer after starting treatment:

 

Uncomplicated GCA

Outpatient management under the Rheumatology team is appropriate, unless there are any concerning features.

9am-5pm Monday to Friday commence treatment then contact the Rheumatology Registrar bleep 2292 or the Rheumatology Consultant on call through RCH switchboard 01872 250000 to arrange further assessment.

Out of hours commence treatment and contact rheumatology team between 9am-5pm on the next working weekday to arrange further assessment.

 

 

Complicated GCA 

If visual loss or visual symptoms contact eye casualty, arrange urgent same day Ophthalmological assessment (01872 253788), refer to Rheumatology as well, bleep 2292 

 

Investigations

Temporal artery biopsy is the cornerstone of diagnosis and will be arranged by the rheumatology department unless there is visual involvement, in which case it will be performed acutely by the ophthalmology department.

 

The GP should arrange the following investigations but treatment should not be delayed pending the results if GCA is suspected:

  • ESR, CRP, FBC, U&Es, LFTs

  • Urine Dipstick

  • CXR (looking for mediastinal widening)

The upper limit of normal for the ESR is [age in years (+ 10 if female)] divided by 2.

BEWARE: in patients taking statins or non-steroidal anti-inflamatory drugs the ESR may not be raised (or not as high) in temporal arteritis.

The CRP however is unaffected.

 

Dose reduction – guide only – should be tailored to the patient

Continue starting dose for 4 weeks or until symptoms have resolved and inflammatory markers returned to normal; then

  • reduce by 10mg every 2 weeks until dose is 20mg daily; then

  • reduce by 2.5mg every 4 weeks until dose is 10mg; then

  • reduce by 1mg every 1-2 months unless patient relapses

CAVE: for different Dose reduction scheme for enteric-coted Prednisolone and further recommendations see Summary below [3]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References – adapted from BSR / BHPR guidelines 2010 [2]

[1] Clinical Knowledge Summaries (CKS). Giant cell arteritis. Version 1.1. Newcastle upon Tyne: CKS; 2009.

[2] Dasgupta B, Borg FA, Hassan N et al on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR Guidelines for the management of giant cell arteritis. Oxford: British Society for Rheumatology; 2010

[3] RCGP Guideline. Diagnosis and management of Giant Cell Arteritis, Concise guidance to good practice series, August 2010