Suspected Giant Cell Arteritis - Eastern locality

GCA is a vasculitis of large vessels. It commonly presents when cranial arteries are affected but it is a systemic vasculitis and vascular involvement might be widespread. Mean age of onset is about 70; it is very rare before 50 years of age.

Scope

Referral and diagnostic protocol for suspected GCA

Out of Scope

Any other acute Rheumatology condition

Assessment

Signs and Symptoms

  • Aged over 50
  • New headache (usually unilateral, temporal but can be diffuse or bilateral)
  • Scalp pain (diffuse or localised, typically pain on brushing the hair)
  • Temporal artery abnormalities (tender, thickened or beaded with reduced or absent pulsation)
  • Jaw and tongue claudication
    • Claudication is defined by ischaemic masseter pain on chewing
    • Pain on jaw opening only is more suggestive of TMJ pathology
  • Visual symptoms, e.g. Transient or permanent reduction in visual acuity, ischaemic optic neuropathy or diplopia
  • Unexplained fever
  • Weight loss, loss of appetite or tiredness; often generally unwell
  • Symptoms of polymyalgia rheumatica
  • Limb claudication
  • Raised CRP, plasma viscosity or ESR greater than 50
  • Normocytic anaemia, thrombocytosis

History and Examination

  • Full history including systems review.
  • Full examination, in particular temporal arteries, and scalp palpation, BP in both arms, peripheral pulses including listening for bruits and cranial nerve examination including fundoscopy.

Malignancy and infection must be excluded if prominent systemic symptoms such as weight loss or fevers.

Red Flags

Malignancy and infection must be excluded if prominent systemic symptoms such as weight loss or fevers

Investigations

Investigations in primary care should not delay referral if GCA is suspected clinically.

  • inflammatory markers should be performed before patient commences steroid treatment
  • CRP, Plasma viscosity, FBC, U&E, LFTs,
  • Urine dipstick – systemic vasculitis can cause glomerulonephritis/renal vasculitis and proteinuria

​Management

1. Steroid Therapy

  • Do not delay treatment awaiting results – initiate steroid therapy if there is a high index of clinical suspicion:
    • Uncomplicated GCA
      • without jaw claudication or visual symptoms: prednisolone 40mg daily;
    • Complicated GCA
      • with jaw claudication or visual symptoms: prednisolone 60mg daily.

2. Please ensure additional prescription of the following if diagnosis confirmed:

Patient Information

  • Inform patient of working diagnosis
  • Explain importance of diagnosis and treatment;
    • 1 in 20 lose vision in 1 eye
    • 1 in 40 have a stroke of some sort.
  • Discuss risks from steroids including the dangers of sudden cessation. Please provide the patient with a steroid card.
  • Long term nature of follow up and steroid treatment. Most patients are on a steroid for couple of years, about half experience a relapse requiring an increase in steroid dose.

​Referral

Referral Criteria

  • If GCA is suspected, please initiate therapy & request initial investigation as above
  • Urgent referral should be requested as below:

Referral Instructions

  • If visual loss or visual symptoms please arrange urgent, same day ophthalmology assessment via the on-call ophthalmologist.
  • We are happy to discuss cases with a degree of diagnostic uncertainty via the Rheumatology consultant mobile phone 07920 781631 answered between 12.30-1.30; or Rheumatology SpR via switchboard, or by directly contacting the Rheumatology consultants. Rheumatology service operates Mon- Fri 9-5.
  • Please send urgent referral by email rde-tr.rheumatologygca@nhs.net – this will be reviewed on a daily basis Mon – Fri 9-5. An automatic reply will be generated to confirm that you have sent the referral to the correct email address. If you do not receive this, please check the address is correct. Please do not use DRSS for possible GCA referrals.
  • Out of Hours please contact AMU or Ophthalmology as appropriate
  • Complicated elderly patients with multiple comorbidities may be appropriate for referral to an On Call Healthcare for Older People team

Referral of suspected cases of GCA with a high index of suspicion should not be delayed pending discussion

Patient Information

  • Inform patient of working diagnosis
  • Explain importance of diagnosis and treatment;
    • 1 in 20 lose vision in 1 eye
    • 1 in 40 have a stroke of some sort.
  • Discuss risks from steroids including the dangers of sudden cessation. Please provide the patient with a steroid card.
  • Long term nature of follow up and steroid treatment. Most patients are on a steroid for couple of years, about half experience a relapse requiring an increase in steroid dose.

Supporting Information​

Evidence

Adapted from 2010 BSR/BHPR guidelines for the management of giant cell arteritis

Pathway Group

RD&E Consultant Rheumatologists:

Dr Haigh , Dr Mascarenhas, Dr Murphy, Dr Brown, Dr Cates, Dr Earl, Dr Abusalameh

Publication date: January 2018

 

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