PassFinals
Musculoskeletal

Giant Cell Arteritis

A large- and medium-vessel vasculitis in people over 50 that can cause irreversible visual loss, requiring immediate glucocorticoid treatment when strongly suspected and urgent specialist confirmation.

In a nutshell

Giant cell arteritis is a time-critical vasculitis in people over 50. New headache, scalp tenderness, jaw or tongue claudication, PMR symptoms or systemic upset should trigger urgent assessment. Start high-dose glucocorticoids immediately when suspicion is strong; visual loss, transient visual loss or diplopia requires same-day ophthalmology or acute assessment. Confirm with fast-track ultrasound and/or temporal artery biopsy without delaying treatment.

Classic presentation

A person over 50 develops a new temporal headache, scalp tenderness and jaw claudication with raised inflammatory markers, with or without shoulder and hip girdle stiffness.

Key points

  • Visual loss, transient visual loss, visual-field change or diplopia is an emergency because cranial ischaemia can become irreversible.
  • Start high-dose glucocorticoids as soon as GCA is strongly suspected; take blood first only if this does not delay treatment.
  • Temporal or axillary ultrasound and temporal artery biopsy support confirmation but neither should delay initial treatment; a negative result does not automatically exclude GCA.
  • Jaw or tongue claudication and visual or neurological symptoms suggest ischaemic disease and require urgent escalation.
  • Taper glucocorticoids gradually with clinical and inflammatory-marker monitoring; there is no universal taper that fits every patient.
  • Consider tocilizumab with rheumatology for relapsing or refractory disease within NICE TA518 criteria.
  • Assess fracture, cardiovascular, metabolic, infection, mood, ocular and gastrointestinal risks caused by prolonged glucocorticoids.
  • Clinical symptoms remain important during tocilizumab treatment because CRP may be suppressed.

First-line investigation

Immediate clinical and visual assessment with FBC, CRP and ESR or plasma viscosity, followed by fast-track temporal or axillary ultrasound and/or temporal artery biopsy according to local expertise.

Management

Treat suspected GCA immediately

  • Start high-dose glucocorticoids on strong clinical suspicion; obtain FBC, CRP and ESR or plasma viscosity first only when this does not delay treatment.2,1,3

Escalate threatened vision

  • Arrange same-day ophthalmology or acute medical assessment for visual loss, transient visual loss, visual-field change, colour-vision change, diplopia, stroke or other focal neurological symptoms.2,1

Confirm rapidly without delaying treatment

  • Use fast-track temporal or axillary ultrasound and/or temporal artery biopsy according to local expertise, and interpret results with clinical probability because neither test is perfect.2,1

Taper and prevent steroid harm

  • Taper glucocorticoids gradually with symptom and inflammatory-marker review, assess fracture and cardiovascular risk, and provide individualised bone, metabolic, infection, ocular and gastrointestinal protection.2,1,6

Use specialist steroid-sparing treatment

  • Consider tocilizumab with rheumatology for relapsing or refractory GCA within NICE TA518 criteria, with specialist monitoring for infection, laboratory abnormalities and interactions.5,2,6

Safety-net relapse and visual symptoms

  • Provide a written plan for same-day help with any visual or neurological change and urgent review of recurrent headache, jaw claudication or systemic symptoms during steroid tapering.1,3,2

Exam traps

  • Do not wait for biopsy or ultrasound before starting steroids.
  • Normal inflammatory markers do not safely exclude GCA when the clinical picture is convincing.
  • A negative temporal artery biopsy does not automatically exclude disease because arterial inflammation can be segmental.
  • Visual disturbance or diplopia changes the urgency and requires same-day ophthalmology or acute assessment.
  • Tocilizumab is not routine first-line treatment for every new presentation; NICE TA518 limits the NHS recommendation to defined relapsing or refractory disease.
  • Do not use a rigid steroid taper or routine aspirin and bone medication without individual risk assessment and specialist or guideline-based prescribing.

Illustrations

Prominent, tortuous superficial temporal artery over the scalpClinical photograph demonstrating a thickened, tender or nodular temporal artery, with a note that examination can be normal despite GCA.Opzwartbeek, Wikimedia Commons · CC-BY-SA-4.0
Temporal artery biopsy in giant cell arteritisHistology of a temporal artery showing granulomatous inflammation and disruption of the internal elastic lamina, with a reminder about skip lesions.Nephron, Wikimedia Commons · CC-BY-SA-3.0
Ischaemic pathway to visual lossDiagram tracing arterial inflammation to ocular or optic-nerve ischaemia, with the immediate steroid and ophthalmology escalation point.PassFinals · original

Key sources

  1. NICE CKS: Giant cell arteritis (UK primary-care knowledge summary on recognition, immediate treatment, referral, confirmation and follow-up of suspected giant cell arteritis)
  2. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis (UK specialist guideline on immediate treatment, inflammatory tests, imaging or biopsy, visual complications, relapse and steroid-sparing therapy; published 2020)Published 23 Jan 2020
  3. NHS: Temporal arteritis (NHS information on symptoms, urgent treatment and the risk of visual loss in giant cell arteritis)
  4. NICE CG150: Headaches in over 12s: diagnosis and management (NICE headache guidance describing symptoms suggestive of giant cell arteritis and current headache referral context)
  5. NICE TA518: Tocilizumab for treating giant cell arteritis (NICE technology appraisal recommending tocilizumab within defined NHS criteria for relapsing or refractory disease; procurement wording updated June 2024)Published 18 Apr 2018 | Updated 1 Jun 2024
  6. BNF online (Check current glucocorticoid, tocilizumab, bisphosphonate, gastroprotection and aspirin monographs for dose, contraindication, interaction, monitoring and adverse-effect details)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.