Giant cell arteritis

Written by Dr Badal Pal, consultant rheumatologist

Eye examination
Examination of the retina may show slight paleness or swelling of the optic disc - the point at which all the nerves of the retina come together - some fluffy spots of protein (cotton-wool exudates) or even tiny blood spots.

Are there other tests?
Other techniques have been tried and are still experimental, such as injection of a dye to look at the flow of the blood in the arteries (angiography) and isotope scanning. Ultrasound showing areas of blood vessel narrowing and so-called 'halos' due to local swelling, is being tried, as well as more sophisticated types of scanner such as magnetic resonance angiography and positron emission tomography (PET scans).

Thyroid function
Thyroid function is checked on a blood sample - occasionally patients with either PMR or GCA also have thyroid disorders. Occasionally liver blood tests are slightly abnormal.

Conditions that may be similar to GCA
Conditions that may sometimes look like GCA include:

dental problems

trigeminal neuralgia (neuralgia of the nerves to the face and forehead)

sinus disease

ear problems

diseases of the blood vessels in the eye or eye muscles and other causes of headaches.

How is GCA treated?
Prompt treatment with steroids such as prednisolone by mouth at a minimum dose of 40mg per day, but often 60mg per day is necessary. Occasionally intravenous steroids at around 250mg daily need to be given if patients present with visual complaints initially.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen can relieve some of the symptoms, but will not prevent the complications or reduce the risks of serious problems such as visual loss and therefore steroids are mandatory in GCA.

Bone disease risk
It is vital that the prevention of osteoporosis is considered from the start and where necessary such preventive measures as calcium and vitamin D supplements, hormone replacement therapy or even the bisphosphonate drugs such as alendronate or etidronate are prescribed. An assessment of bone strength should ideally be made usually by the DEXA scan.

Patients are advised to gradually increase their mobility and exercise levels, but to take adequate periods of rest whenever necessary.

How is GCA monitored and what is the outlook?
On average, treatment is necessary for at least two years, but many people require treatment for much longer periods, for example four or five years in at least 50 per cent of patients. Unfortunately, up to half of people are affected by the side effects of therapy.

The doctor will attempt to reduce the dosage of prednisolone after all symptoms have been controlled and this is usually after an initial one month of therapy. Initial reductions may be by instalments of 2.5mg or 5mg at a time (every week or so), but when the dosage has been reduced to 15mg daily further reductions should be achieved more slowly. This should be at no more than 1mg at a time every two or three weeks until a dose of 10mg is reached. After this, further reductions would be tailored according to the patient's condition and the ESR readings.

These are very much rough guides to the management of prednisolone therapy and individual patients may require personalised schemes depending on their progress.

Patients need to be monitored for relapse up to one year after stopping treatment. Relapses are likely if attempts are made to withdraw prednisolone treatment within one year. Temporal artery biopsy findings are not helpful in predicting relapse and often ESR readings are also not related to relapse. Some patients may relapse in the absence of a rising ESR others may show rises in ESR without actually showing a relapse in the condition itself.

Further information
Arthritis Research Campaign (ARC): www.arc.org.uk.

International League Against Rheumatism: www.ilar.org.

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