Diagnosis and treatment of giant cell arteritis: BSR guidelines

British Society for Rheumatology has released its guideline on diagnosis and treatment of giant cell arteritis. It is an update of the 2010 British Society for Rheumatology (BSR) guideline. The aim of the guideline is to provide guidance for clinicians in the diagnosis and treatment of giant cell arteritis, supported by evidence where possible. The guidelines have been published in the Journal Rheumatology.

Giant cell arteritis, or temporal arteritis, is a large-vessel vasculitis affecting older people. Without high-dose glucocorticoid treatment, GCA can lead to occlusion of cranial blood vessels, which may result in blindness or stroke. Most occurrences of blindness or stroke happen either before treatment or during the first week of treatment. Giant cell arteritis is, therefore, a medical emergency requiring immediate treatment. Many patients with Giant cell arteritis have inflammation of the aorta and its proximal branches (extracranial large-vessel involvement), which can lead to aortic aneurysm, dissection or rupture. 

Major Recommendations are -

Diagnostic tests for GCA

Which additional confirmatory diagnostic tests should be performed in all patients with suspected GCA?

• Strong recommendation: Patients with suspected GCA should have a confirmatory diagnostic test. This could be either a temporal artery biopsy at least 1 cm in length or an ultrasound of the temporal and axillary arteries, or both.

Which tests can be used to evaluate involvement of the aorta and its proximal branches in GCA?

• Conditional recommendation: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), magnetic resonance angiography (MRA), computed tomography angiography (CTA) or axillary artery ultrasound may be used to evaluate involvement of the aorta and its proximal branches.

Treatment of GCA

What is the best dose and route of initial glucocorticoid therapy for GCA in the absence of ischaemic visual manifestations?

• Conditional recommendation: The standard initial glucocorticoid dose for GCA is 40–60 mg oral prednis(ol)one per day.

What is the best dose and route of initial glucocorticoid therapy for GCA in the presence of ischaemic visual manifestations?

• Conditional recommendation: GCA patients with acute or intermittent visual loss may initially be given 500 mg–1 g intravenous methylprednisolone daily for up to 3 consecutive days before commencing oral prednisone therapy. If intravenous therapy is not immediately possible, this should not delay initiation of oral prednis(ol)one.

How should glucocorticoid dose be tapered in GCA?

• Conditional recommendation: Glucocorticoid dose should be tapered to zero over 12–18 months, providing there is no return of GCA symptoms, signs or laboratory markers of inflammation. A more rapid dose reduction is appropriate for patients at high risk of glucocorticoid toxicity and/or those receiving concomitant glucocorticoid-sparing therapy.

What dosing frequency of oral glucocorticoid should be used in GCA?

• Conditional recommendation: Patients should be prescribed a single daily dose of glucocorticoid rather than alternate-day dosing or divided daily dosing.

Should modified-release prednisone be used in place of standard therapy?

• No recommendation can be made for the use of modified-release prednisone in the treatment of GCA. 
  

When should further, non-biologic immunosuppression be added to glucocorticoid therapy for GCA?

• Conditional recommendation: Methotrexate might be considered for GCA, in combination with a glucocorticoid taper, in patients at high risk of glucocorticoid toxicity or who relapse. There is insufficient evidence to recommend any other oral immunosuppressive agent in GCA, including azathioprine, leflunomide or mycophenolate mofetil.

Which biologic agents can be used for GCA in addition to standard therapy?

• Strong recommendation: Tocilizumab can be considered for GCA in combination with a glucocorticoid taper, especially in patients at high risk of glucocorticoid toxicity or who relapse. TNF inhibitors are not recommended in GCA.

Should anticoagulant or antiplatelet agents be given for GCA?

• The routine use of antiplatelet or anticoagulant agents for GCA is not recommended.

Should cholesterol-lowering agents be given for GCA?

• The routine use of cholesterol-lowering agents such as statins for GCA is not recommended.

 For more details click on the link: https://doi.org/10.1093/rheumatology/kez664