The authors of recent European guidelines on giant cell arteritis have stressed the importance of fast specialist diagnosis and treatment.
Speaking at a session on large vessel vasculitis at the British Society for Rheumatology (BSR) annual conference, the authors of EULAR and BSR updated recommendations also flagged up the latest evidence on imaging, tapering of steroid dose and the use of tocilizumab.
Dr Sarah Mackie, Associate Professor and Consultant Rheumatologist at the University of Leeds and author of the revised BSR giant cell arteritis guidelines published in 2020, said high-dose steroids should be started in any patient with a high suspicion of the condition before diagnosis has been confirmed.
Anyone with double vision or vision loss should be seen by an ophthalmologist on the same day and other patients seen by a specialist – most likely a rheumatologist – within three days, she said.
No longer is it the case that all patients must have the giant cell arteritis confirmed with a biopsy, she added, but it can be confirmed with what is available, including ultrasound.
The preferred test depends on the patient: for example, in those with a high pre-test probability for giant cell arteritis – more than 50% – a positive temporal artery ultrasound is likely to be enough to confirm the condition, Dr Mackie explained.
Once the patient has achieved remission we would recommend tapering the dose under careful monitoring, she told the virtual meeting. And in the event of relapse or in a patient with a high risk of steroid toxicity, the guidelines strongly recommend the use of tocilizumab, which she described as an “important advance”.
“There are three take-home messages for clinical practice,” she said. “The role of ultrasound in the diagnosis for giant cell arteritis is well established. For relapse we would generally recommend escalating the steroid dose, and consider adding in immunosuppression with a strong recommendation for tocilizumab.”
She added that it was vital to check for hyperglycaemia early after starting high-dose steroids.
When asked whether the condition should always be diagnosed and managed by a rheumatologist, Dr Mackie said it would depend on local circumstances. But given the complexities in diagnosis, the patient should at least be seen initially by someone with substantial experience of giant cell arteritis.
In an update on the latest evidence on imaging in large vessel vasculitis, Dr Christina Duftner from Medical University Innsbruck reiterated that waiting for imaging should not delay the start of treatment.
“In patients in whom there is a high clinical suspicion of giant cell arteritis and a positive imaging test, diagnosis may be made without a biopsy or further imaging and this is really unique,” she said.
In the early phase of treatment of patients with suspicion of giant cell arteritis we have to confirm the disease or rule it out as soon as possible, she added.
“I really have to clearly state, we do not recommend against biopsy but we have to clearly outline that in the case when there is high quality imaging provided it should be suggested as a first test,” she said.
In a presentation on the 2018 update of EULAR guidance on large vessel vasculitis, delegates also heard about changes to advice on use of antiplatelet or anticoagulant therapy, which is no longer routinely recommended for the treatment of large vessel vasculitis unless indicated for other reasons, such as coronary heart disease.