Giant Cell Arteritis

Question 1

Define GCA.

Answer 1

granulomatous vasculitis of large and medium sized arteries aka temporal arteritis, cranial arteritis or granulomatous arteritis

Question 2

What is the most common serious consequence of GCA?

Answer 2

Irreversible loss of vision due to optic nerve ischaemia

Question 3

Define GCA.

Answer 3

= immune mediated vasculitis characterised by granulomatous inflammation of large and medium sized arteries aka temporal arteritis, cranial arteritis or granulomatous arteritis*aetiology is unknown

Question 4

What is the most common serious consequence of GCA?

Answer 4

Irreversible loss of vision due to optic nerve ischaemia

Question 5

Epidemiology

Answer 5

> 50 yo (highest between 70-80y)Females

Question 6

What arteries are preferentially involved?

Answer 6

• Extracranial arteries of carotid artery- Aorta and its major branches

Question 7

What are the cranial and extracranial Sx of GCA?

Answer 7

Key symptoms:Common - * Headache* Polymyalgia rheumatica symptoms: neck, shoulders, hips, proximal extremities that worsen after a period of inactivity and with movementExtremity claudication Other cranial artery abnormalities: occipital, postauricular, facialUncommon-* jaw claudication* loss of vision (sudden blindness typically in 1 eye - described as curtain coming down)* superficial temporal artery tenderness, thickening or nodularity* absent temporal artery pulse* abnormal fundoscopy* Amaurosis fugax (clot in eye artery)

Question 8

If you suspect GCA, what should you do?

Answer 8

Do ESR and start prednisolone 60mg/d PO immediately*risk is irreversible bilateral visual loss, which can occur suddenly if not treated

Question 9

What Ix should be done if suspect GCA?

Answer 9

1st tests to order (results if GCA):* ESR (ESR >/= 50mm/hour)* CRP (elevated)* Bloods: platelet increase; Hb decrease* LFTs: transaminases and ALP often elevated* Get temporal artery biospy done within 7 days of starting steroids (histo: granulomatous inflammation, multinucleated giant cells, inflammatory infiltrate)NB: skip lesions occur so do not be put off by negative biopsy * Temporal artery US (wall thickening)

Question 10

What is the main cause of death and morbidity in GCA?

Answer 10

Long term steroid treatment

Question 11

What is the treatment for GCA?

Answer 11

Pre

Question 12

What is the treatment for suspected GCA with no visual or neurological Sx?

Answer 12

Prednisolone - should be initiated immediately if index of suspicion for GCA is high* Rx should not be delayed if CRP, ESR or temporal artery biopsy are pending

Question 13

What are the DDx for GCA?

Answer 13

• Polymyalgia rheumatica (PMR) - cranial Sx often absent* Solid organ cancers and haematological malignancies esp multiple myeloma and lymphoma* Takayasu’s arteritis (TA) - TA onset 20-30, females and lack of involvement of cranial arteries

Question 14

What is the treatment for suspected GCA with no visual or neurological Sx?

Answer 14

Prednisolone 1mg/kg/day orally for 4 wks; gradually taper dose over 6-12 mths should be initiated immediately if index of suspicion for GCA is high Rx should not be delayed if CRP, ESR or temporal artery biopsy are pending

Question 15

What are the DDx for GCA?

Answer 15

• Polymyalgia rheumatica (PMR) - cranial Sx often absent* Solid organ cancers and haematological malignancies esp multiple myeloma and lymphoma* Takayasu’s arteritis (TA) - TA onset 20-30, females and lack of involvement of cranial arteries

Question 16

What is the treatment for suspected GCA with visual Sx?

Answer 16

Methylprednisolone pulse therapy 1g IV once daily for 3 days- IV pulse therapy at the outset of disease

Question 17

What is the treatment for confirmed GCA?

Answer 17

1st line: prednisolone 1mg/kg/day orally for 4 weeks; gradually taper dose over 6-12 mthsAdjunct: *aspirin: to lower risk of vision loss *osteoporosis prevention: bisphosphonates with Ca and vit D