Giant Cell Arteritis

Print

  • Giant cell arteritis (GCA) is a medical emergency
  • Urgently refer all people with suspected GCA using a local GCA pathway for specialist evaluation (usually by a rheumatologist) on the same working day if possible, and in all cases within 3 working days.
    • If there is visual loss (transient or permanent) — arrange an urgent (same day) assessment by an ophthalmologist
  • Document the person's symptoms, signs, and level of function both before and after the onset of the condition to use as a baseline to compare response to treatment

Glucocorticosteroid treatment

Starting dosage regimes  
Uncomplicated GCA

No jaw/tongue claudication or visual symptoms

  • prednisolone 40–60 mg (not less than 0.75 mg/kg) daily until resolution of symptoms and laboratory abnormalities
Complicated GCA

Evolving visual loss or history of amaurosis fugax

  • intravenous methylprednisolone 500 mg to 1 g daily for three days before oral prednisolone

Established vision loss

  • at least 60 mg oral prednisolone daily
  • they should be seen by an ophthalmologist the same day
Bone protection (prevention of steroid-induced osteoporosis)
Individuals with high fracture risk e.g. aged ⩾65 years or prior fragility fracture
  • Bisphosphonate eg. alendronic acid 70mg weekly
  • calcium (1,200 - 1,500 mg daily) and vitamin D (800-1,000 IU)
  • DEXA not required

Other individuals

  • calcium (1,200 - 1,500 mg daily) and vitamin D (800-1,000 IU) when starting steroid therapy
  • DEXA scan recommended
  • A bone-sparing agent may be indicated if T-score is −1.5 or lower eg. alendronic acid 70mg weekly 

Individuals requiring higher initial steroid dose

  • Bisphosphonate eg. alendronic acid 70mg weekly with calcium (1,200 - 1,500 mg daily) and vitamin D (800-1,000 IU)   

 

GI protection

Protein pump inhibitors

  • omeprazole 20mg od
  • or lanzoprazole 15mg od
Dose reduction  
Standard regimen 
  • 40–60 mg prednisolone (not less than 0.75 mg/kg) continued for four weeks (or until resolution of symptoms and lab abnormalities)
  • then dose is reduced by 10 mg every two weeks to 20 mg
  • then by 2.5 mg every two to four weeks to 10 mg
  • then by 1 mg every one to two months, provided there is no relapse.
 For enteric coated prednisolone 
  • As above down to 10 mg per day. For doses below this
  • 10 mg/7.5 mg alternating for two months
  • then 7.5 mg daily for one to two months
  • then 7.5/5 mg alternating for one to two months
Monitoring of treatment  
Review
  • Assess the person's response to prednisolone within 48 hours (the response of symptoms to corticosteroids is usually rapid)
  • If response to prednisolone is poor, seek specialist advice and consider an alternative diagnosis
  • Review at weeks 0, 1, 3, 6 then months 3, 6, 9, 12 in the first year
  • Extra unscheduled visits may be necessary in the event of relapse or adverse events
At eash visit

Liver function tests

  • about a third of people have mildly elevated liver function test results, particularly for alkaline phosphatase (discontinue monitoring if normal at baseline)

Full blood count

  • normochromic normocytic anaemia and an elevated platelet count are common.

C-reactive protein (CRP)

  • the CRP level is typically elevated and may be a more sensitive indicator of inflammation in some people with giant cell arteritis.

Erythrocyte sedimentation rate (ESR)

  • the ESR is often greater than 50 mm/hour. However, the ESR may be normal at presentation and even during a flare of disease activity.

Urea and electrolytes

Glucose

Every two years
  • Chest radiograph to monitor for aortic aneurysm (echocardiography, PET and MRI may also be appropriate)
  • Bone mineral density
Treatment relapse  
Headache only Treat with the previous higher glucocorticosteroid dosage
Headache and jaw claudication Treat with 40–60 mg daily prednisolone
Eye symptoms Treat with either 60 mg prednisolone or intravenous methylprednisolone
Large vessel GCA
  • Investigate with imaging techniques (PET, MRI scanning)
  • Consider treatment using systemic vasculitis protocols

Omeprazole prednisolone methylprednisolone Alendronic acid Lanzoprazole

© 2023 AskShilpa.com | WellBN Ltd

Press enter to search

If you are involved in the prescribing process, then AskShilpa has been created for you!

01273 772020
contact@askshilpa.com
18-19 Western Rd, Hove BN3 1AE

Shilpa's Words

We love askshilpa.com