An update on the clinical approach to giant cell arteritis

Abstract

Recent national and international guidance from rheumatology societies have reflected the advances in evidence for both the investigation and management of giant cell arteritis. Cranial ultrasound reduces diagnostic delay and improves clinical outcomes. Immediate high-dose glucocorticoids remain the standard treatment for giant cell arteritis. Randomised controlled trial evidence using tocilizumab, an interleukin-6 receptor antagonist, has been shown to have good clinical efficacy with glucocorticoid sparing effects. Overall patient outcomes appear to be improved by formalising pathways for diagnosis to include clinical experts' opinion early in decision making.

Keywords: giant cell arteritis; temporal arteritis; temporal artery biopsy; tocilizumab; ultrasound.

Fig 1.

Fundus photography of optic discs showing pale optic disc oedema. a) Left eye. b) Right eye.

Fig 2.

Colour Doppler ultrasound of the temporal arteries showing halo sign. a) Left temporal artery. b) Right temporal artery. Image courtesy of Dr Viktoria Fana.

Fig 3.

Temporal artery biopsy showing thickened intima and a narrowed lumen (thin arrow); the elastic lamina is fragmented with transmural inflammation and giant cells (thick arrow).

Fig 4.

Panels a, b and c show increased 2-¹⁸ fluorine-fluorodeoxyglucose (F-FDG) uptake in the right vertebral artery where it enters the foramen magnum through the right suboccipital triangle (arrow). Panels d, e and f show increased 2-¹⁸ F-FDG uptake in the left vertebral artery where it enters the foramen magnum through the left suboccipital triangle (arrow). Panels g, h and i show increased 2-¹⁸ F-FDG uptake in the right and left vertebral artery in the transverse foramina of the C2 (arrows). a, d and g) Axial 2-¹⁸F-FDG positron emission tomography. b, e and h) Axial low-dose computed tomography (ldCT). c, f and i) Axial fused 2-¹⁸F-FDG PET-ldCT. Images and description courtesy of by Dr Jane Maestri Brittain.