Giant Cell Arteritis

Question 1

What is Giant Cell Arteritis?

Answer 1

a systemic vasculitis of the medium and large arteries. It typically presents with symptoms affecting the temporal arteries and is also known as temporal arteritis.

Question 2

Giant cell arteritis has a strong link with which other condition?

Answer 2

Polymyalgia rheumatica

Question 3

Patients high at risk of giant cell arteritis?

Answer 3

white females over 50

Question 4

Key complication of giant cell arteritis?

Answer 4

vision loss

This is often irreversible. high dose steroids are used immediately once a diagnosis is suspected to prevent the development of progression of vision loss

Question 5

Symptoms of giant cell arteritis?

Answer 5

The main presenting feature is a headache:

Severe unilateral headache typically around temple and forehead
Scalp tenderness my be noticed when brushing hair
Jaw claudication
Blurred or double vision
Irreversible painless complete sight loss can occur rapidly

There may be associated systemic symptoms such as:

Fever
Muscle aches
Fatigue
Weight loss
Loss of appetite
Peripheral oedema

Question 6

Diagnosis of giant cell arteritis?

Answer 6

A definitive diagnosis is based on:

Clinical presentation
Raised ESR: usually 50 mm/hour or more
Temporal artery biopsy findings

Question 7

What is found on a biopsy of the temporal artery?

Answer 7

Multinucleated giant cells - what gives rise to the giant cell arteritis name

Question 8

Additional investigations for giant cell arteritis?

Answer 8

Full blood count may show a normocytic anaemia and thrombocytosis (raised platelets)

Liver function tests can show a raised alkaline phosphatase

C reactive protein is usually raised

Duplex ultrasound of the temporal artery shows the hypoechoic halo sign

Question 9

Initial medication for Giant Cell Arteritis?

Answer 9

Steroids:

Start steroids immediately before confirming the diagnosis to reduce the risk of permanent sight loss. Start 40-60mg prednisolone per day. 60mg is given depending where there are jaw claudication or visual symptoms. Review the response to steroids within 48 hours. There is usually a rapid and significant response to treatment.

Question 10

Other medications apart from steroids?

Answer 10

Aspirin 75mg daily decreases visual loss and strokes

Proton pump inhibitor (e.g. omeprazole) for gastric prevention while on steroids

Question 11

Ongoing management points for patients with giant cell arteritis?

Answer 11

Once the diagnosis is confirmed they will need to continue high dose steroids (40-60mg) until the symptoms have resolved. They then need to slowly wean off the steroids. This can take several years. This is a similar process to managing polymyalgia rheumatica.

There are additional measures for patients on steroids that can be remembered by the mnemonic “Don’t STOP”:

DON’T – Don’t stop taking steroids abruptly. There is a risk of adrenal crisis.
S – Sick Day Rules.
T – Treatment Card.
O – Osteoporosis prevention with bisphosphonates and supplemental calcium and vitamin D.
P – Proton pump inhibitor for gastric protection.

Question 12

Early complications?

Answer 12

Early neuro-ophthalmic complications:

Vision loss
Cerebrovascular accident (stroke)

Question 13

Late complications

Answer 13

Relapses of the condition are common

Steroid related side effects and complications

Cerebrovascular accident (stroke)

Aortitis leading to aortic aneurysm and aortic dissection