Giant cell arteritis (GCA)
Questionnaire/history:
Headache (~75%)?
- Dull severe headache?
- In the temporal region (although can present with parietal or occipital pain)?
- Insidious in onset (usually)?
Visual symptoms?
- Partial?
- Complete loss of vision?
- Diplopia?
Scalp tenderness?
Jaw/tongue claudication (2-4%)?
- Pain in the jaw/tongue on chewing?
(Note: usually happens after minutes of chewing in the masseter muscles, due to ischaemia)
Systemic symptoms (common)?
- Fatigue?
- Weight loss?
- Anorexia?
- Sweats?
- Fevers?
PMR symptoms?
- Proximal muscle pain?
- Early morning stiffness?
Past medical history?
Current medication?
Known drug allergies?
Examination:
Temporal arteries?
- Tenderness?
- Hard lumps?
- Lack of pulsation?
Vascular exam?
- BP in both arms?
- Carotid bruits?
Eyes?
- Visual acuity and fields?
--- Fundoscopy?
--- Cotton wool spots?
--- Oedema?
--- Pale discs?
--- Haemorrhage?
Investigations:
Bloods (FBC, U&E, LFT, Ca, ESR, CRP; ESR/CRP rarely normal (ESR elevated out of proportion to CRP, ESR normal in 4% and > 50 in > 80%); other typical findings inc. ↑ ALP and thrombocytosis)
CXR?
Urine dip?
Management:
Prednisolone 40-60 mg daily
PPI cover
No aspirin
Visual involvement:
Immediate referral (same day) for an ophthalmology review
If no visual involvement:
Urgent rheumatology review within 3 days for further investigation (temporal artery biopsy used to be the gold standard but increasing evidence now supports temporal artery ultrasound to rule out low-risk cases, and rule in high-risk cases, thus reducing need for biopsy)
Relapses common (>40%):
Returning to the previous effective steroid dose if headache returns
Prednisolone 40-60 mg if jaw/tongue claudication
Prednisolone 60mg or IV Methylprednisolone if eye symptoms
Resource(s):