Ep 155 – Temporal arteritis

Temporal arteritis, also known as giant cell arteritis, is an inflammatory condition that affects the large- and medium-sized arteries, primarily those in the head. It most commonly occurs in adults over 50, particularly women. The exact cause is unknown, but it is believed to be an autoimmune response that leads to inflammation and narrowing of the arteries, reducing blood flow. Symptoms include severe headaches, scalp tenderness, jaw pain when chewing and, in severe cases, sudden vision loss. Diagnosis typically involves blood tests, imaging and a temporal artery biopsy. Early detection is crucial to avoid permanent damage and blindness. In this episode, Dr Roger Henderson looks at how to diagnose this condition promptly and accurately, why urgent referral is crucial and the treatment options now available in primary care.

Key take-home points

• Temporal arteritis is the most common form of vasculitis in adults over the age of 50, with a peak incidence in patients over the age of 70.
• Typical symptoms include headaches, scalp tenderness and jaw claudication. Constitutional symptoms include malaise, fatigue, weight loss, anorexia and low-grade fever.
• The headaches are typically severe, may be unilateral or bilateral, and are usually located in the temporal area. Scalp tenderness usually precedes these headaches by a few weeks.
• Temporal arteritis is a medical emergency. Due to the urgency of the situation, a same-day referral to secondary care – often to a rheumatology specialist – is required to obtain an expert opinion and evaluate if further testing is warranted.
• Glucocorticoid therapy should be started immediately if there is a clinical suspicion of temporal arteritis and should not be delayed while waiting for investigations to be done.
• Fewer than 5% of patients with temporal arteritis have normal inflammatory markers.
• Usually considered the gold standard for diagnosis, a temporal artery biopsy should be performed on the most symptomatic or tender side.
• Ultrasound of the temporal artery is now viewed as a diagnostic alternative to temporal artery biopsies since it is a non-invasive test that can often be performed more quickly and easily.
• High-dose glucocorticoids are the mainstay of treatment; once the diagnosis is suspected, treat with high doses immediately.
• Typically, symptoms will show swift improvement once corticosteroid treatment begins; a lack of such improvement should prompt consideration of an alternative diagnosis.
• The aim is then to gradually taper the steroids down over 6–12 months, based on symptom resolution and inflammatory markers.
• Adjunctive therapies may be considered by a specialist in combination with the glucocorticoid taper in patients with arteritis who relapse, have refractory disease or who are at high risk of glucocorticoid toxicity.
• Antiplatelet agents or anticoagulants should not be given routinely to patients with temporal arteritis.
• With prompt treatment, most patients achieve remission, but relapses are common, occurring in up to 50% despite appropriate treatment.
• Early intervention is critical to prevent irreversible blindness, which occurs in approximately 15–20% of untreated cases.
• Overall survival is similar to that of the general population.

Key references

1. Mackie SL, et al. Rheumatology (Oxford). 2020;59(3):e1-e23. doi: 10.1093/rheumatology/kez672.
2. Lyons HS, et al. Eye (Lond). 2020;34(6):1013-1026. doi: 10.1038/s41433-019-0608-7.
3. Ponte C, et al. Ann Rheum Dis. 2022;81(12):1647-1653. doi: 10.1136/ard-2022-223480.
4. Dejaco C, et al. Ann Rheum Dis. 2024;83(6):741-751. doi: 10.1136/ard-2023-224543.
5. Farina N, et al. Eur J Intern Med. 2023;107:17-26. doi: 10.1016/j.ejim.2022.10.025.
6. NICE. 2018. https://www.nice.org.uk/guidance/ta518.
7. Coath FL, Mukhtyar C. Rheumatology (Oxford). 2021;60(6):2528-2536. doi: 10.1093/rheumatology/keab179.