Suspected Giant Cell Arteritis - Northern locality

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 (PMR)
• 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.

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

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

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:

• Aspirin 75mg, unless contraindications (for prevention of ischaemic complications)
• Proton Pump inhibitor: omeprazole or lansoprazole for GI protection section 1.3.5 Proton pump inhibitors
• Bone protection
  • if aged over 65: see formulary section 6.6.2 bisphosphonates and calcium / vitamin D see formulary section 9.6.4 Vitamin D.
  • For patients aged below 65 please assess the risk of fracture first including DEXA scan and treat accordingly.

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 Criteria

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

Referral Instructions

Please call the on call consultant Rheumatologist (Urgent fax is requested by the consultant and patient is booked into next available urgent slot)

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.

Evidence

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

Pathway Group

Consultant Rheumatologists:

Dr Kyle, Dr Manhas

Publication date: January 18