GCA

Please contact Rheumatology On Call the same day by telephone if GCA is suspected and steroids commenced as per the flow chart below.

Rheumatology will organise urgent review in clinic and temporal artery ultrasound as needed. This will minimise the patient's time on steroids before scanning.

Additional Information/Further Reading

¹For the vast majority of patients the above steroid starting doses should suffice, for those at extremes of BMI (e.g. >100kg or <50kg), a weight based dosing of 0.7mg/kg in place of 60mg prednisolone and 0.5mg/kg in place of 40mg prednisolone can be employed.
²Rheumatology on call is from 9am-5pm weekdays. Out of hours, or in the event we are unable to answer immediately voicemails can be left to give details to call back but responsibility to discuss remains with the referrer.
There have been no confirmed cases to date of GCA in patients with PTPS<9
Almost all GCA patients with cranial disease are over 60
GCA is very rare in non-white patients
GCA is extremely unlikely if CRP <5

Patient Pathway

Once referred to rheumatology we will aim to urgently assess in clinic and perform Temporal Artery Ultrasound (TAUS). If no evidence of GCA is found, then we will discharge back to primary care. If clinical assessment and TAUS are inconclusive we will then request Temporal Artery Biopsy (TAB), to further assess. Please contact rheumatology same or next working day 9am-5pm when GCA is suspected as TAUS findings can swiftly normalise after 3 days of steroids. Patients should be advised that TAUS will mean needing to access their axillary area, and we will also need to use ultrasonic gel on the side of the head above the hairline, so patients may wish to consider their choice of clothing and need to wash hair after the appointment.

If GCA is diagnosed/not ruled out then we will normally follow the steroid reduction regime as detailed below and consider if long term bone protection is necessary. In cases who relapse during prednisolone reduction, particularly if >10mg prednisolone, we will consider adding steroid sparing agents such as methotrexate or leflunomide to augment the next attempt at steroid dose reduction. In severe cases a biologic agent called ‘Tocilizumab’ is sometimes used (pending regional approval.)

Steroid Reduction

In patients with significant steroid toxicity a faster steroid reduction regime and earlier use of steroid sparing agents may be required.

Relapse

If headache or PMR symptoms recur on dose reduction, then return to previously effective dose of prednisolone and inform rheumatology.

If ischaemic symptoms develop (either new or recurrent) then commence high dose prednisolone and manage as per a new case.

Patient information

Versus Arthritis, GCA patient information.

https://www.versusarthritis.org/about-arthritis/conditions/giant-cell-arteritis-gca/

References

Mackie S, Dejaco S, Appenzeller Set al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis, Rheumatology, Volume 59, Issue 3, March 2020, Pages e1–e23, https://doi.org/10.1093/rheumatology/kez672

Sebastian A, Tomelleri A, Kayani A, et al. Probability-based algorithm using ultrasound and additional tests for suspected GCA in a fast-track clinic. RMD Open. 2020 Sep;6(3):e001297. doi: 10.1136/rmdopen-2020-001297

Quick V, Hughes M, Mothojakan N, Fishman D. P180 External validation of the Southend GCA Probability Score (GCAPS) as a screening tool for referrals with possible GCA, Rheumatology, Volume 59, Issue Supplement_2, April 2020, keaa111.175, https://doi.org/10.1093/rheumatology/keaa111.175

Contributors:

Dr Laura McArthur, GPST3

Dr Mark Hughes, Consultant Rheumatologist, RCHT

Dr Bridgitte Wesson, GP & Kernow RMS Rheumatology guideline lead

Guidelines reviewed: January 2024

Next review due: January 2025