eMedicine Specialties > Dermatology > Diseases of the Vessels

Temporal (Giant Cell) Arteritis: Treatment & Medication

Author: John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center
Coauthor(s): Victor J Marks, MD, Associate, Department of Dermatology, Section Chief, Dermatologic Surgery, Geisinger Health System; Hyland Cronin, MD, Resident, Dermatology Department, Geisinger Health System, Danville, Pennsylvania
Contributor Information and Disclosures

Updated: May 29, 2009

Treatment

Medical Care

  • Medical care for temporal arteritis (TA) is supportive and symptom specific.

Consultations

  • Consultation with an ophthalmologist is critical for all patients suspected of having temporal arteritis in order to prevent any permanent visual deficit.
  • Rheumatologists often treat these patients, although referral is not essential.

Medication

Since 1950, the use of systemic corticosteroids has revolutionized the treatment of temporal arteritis, as well as a legion of other inflammatory diseases. Supportive care was the primary treatment before steroid therapy. Now, patients with temporal arteritis respond quickly and often completely to systemic steroids.

Despite corticosteroids serving as the mainstay of therapy, no consensus exists regarding a standard initial dose, maintenance dosing, or alternate-day schedules. Authorities do agree that the initiation of steroid therapy should not be delayed because TABx can still confirm the diagnosis and serious sequelae can be avoided.

An initial dose of 40-60 mg/d of prednisone (or equivalent) as a single or divided dose is generally found to be adequate in the vast majority of the cases. It is usually given for 2-4 weeks until all reversible signs and symptoms have resolved and levels of acute-phase reactants are back to normal. The dose is then gradually reduced every 1-2 weeks by a maximum of 10% of the total daily dose. Most patients are treated for 1-2 years, but some with a prolonged or relapsing course may require low doses of glucocorticoids (GCs) for several years. Clinical flares usually occur when the prednisone is reduced to 5-10 mg/d.

Higher-dose pulse GC therapy has been advocated by some for patients with recent or pending visual disturbances, but an observational study and a randomized controlled trial failed to demonstrate superiority of pulse therapy over oral GC therapy in preventing ischemic complications. The benefit conferred by GCs needs to be balanced against the common and well-recognized complications related to long-term GC use. In a population-based study of 120 patients with temporal arteritis, 86% of patients had adverse events, including bone fractures, avascular necrosis of the hip, diabetes mellitus, infections, GI bleeding, and cataracts. Adverse events were related to the age of patients and a high cumulative dose of GCs. Therefore, randomized controlled trials need to be performed to define the minimal effective starting GC dosage.

Furthermore, much of the total morbidity of temporal arteritis is not related to the disease itself, but to the impact of long-term GC therapy in a population of elderly patients. Therefore, most treatment studies in which other drugs have been added to GCs have been aimed at early reduction of steroids while maintaining the suppression of temporal arteritis for the duration of time the disease evolves through its natural course to become inactive. Only methotrexate (MTX), azathioprine, and the TNF-blockers infliximab and etanercept have been tested in randomized controlled trials.

A formal meta-analysis has suggested that adjunctive MTX treatment in dosages of 7.5-15 mg/wk for temporal arteritis reduced the risk of a first relapse by 35% and of a second relapse by 51%. In addition, MTX reduced the cumulative exposure to GCs. However, the superiority of the treatment effect of MTX over placebo fully appeared only after a latency period of 24-36 weeks, and no between-group difference was noted in the occurrence of adverse events.

The benefit observed in the azathioprine-treated patients appeared to be unimpressive and of late onset.

Another randomized controlled trial showed that adding infliximab to GCs provided no measurable benefit in the management of newly diagnosed temporal arteritis.

Finally, a double-blind, placebo-controlled trial was performed to test the hypothesis that TNF inhibition with etanercept could reduce GC exposure in patients with refractory temporal arteritis requiring a stable dose of prednisone of 10 mg/d for maintaining clinical remission and with at least one GC-related adverse effect. The results showed that patients in the etanercept group were more successful in discontinuing prednisone therapy and they required a significantly lower cumulative prednisone dose. By contrast, no difference was noted in the number and type of adverse events. Thus, at least for the time being, anti-TNF therapy can be considered in patients with longstanding GC-resistant temporal arteritis who are at risk of GC-related adverse events. A larger trial with longer follow-up is needed to determine if TNF blockers are able to reduce the cumulative GC dosage and decrease GC-associated morbidity. Until more data are available, GCs remain the drug of choice.3,16

Other possible therapeutic drug options include cyclophosphamide, cyclosporine, dapsone, toclizumab (humanized monoclonal anti-interleukin 6 receptor antibody), rituximab (anti-CD20 monoclonal antibody), and abatacept (recombinant fusion protein that modulates CD28-mediated T cell co-stimulation).3 Generally, none is routinely recommended.

Several clinical trials are either actively recruiting or are active but not yet recruiting. For a complete list, see these List Results from ClinicalTrials.gov.

Corticosteroids

Anti-inflammatory action is effective in the treatment of granulomatous vasculitis.


Prednisone (Deltasone, Orasone, Sterapred)

Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN leukocyte activity.
Oral therapy is standard choice for outpatient management, but intravenous and intramuscular alternatives may be options for unique situations.

Adult

1 mg/kg/d PO or 80-100 mg/d PO for first mo; as clinical and laboratory parameters improve, taper and titrate dose

Pediatric

4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve

Ketoconazole, erythromycin, clarithromycin, estrogens, and birth control pills increase levels
Aminoglutethimide, phenytoin, phenobarbital, rifampin, cholestyramine, and ephedrine decrease steroid levels
Potassium-depleting diuretics (potentiate potassium loss and digitalis toxicity) and cyclosporine increase levels
Isoniazid, insulin (resistance is induced), and salicylates decrease levels
Monitor anticoagulant therapy and theophylline levels

Absolute: Systemic fungal infection; herpes simplex keratitis; hypersensitivity.
Relative: Hypertension, active tuberculosis, congestive heart failure, prior psychosis, positive PPD test, glaucoma, severe depression, diabetes, active peptic ulcer disease, cataracts, osteoporosis, recent bowel anastomosis, pregnancy.

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation of GCs may cause adrenal crisis; because of vision complications and potentially life-threatening nature of temporal arteritis, steroid treatment is rarely withheld; well-known adverse effects of systemic steroids are managed prophylactically and systematically depending on the patient
Caution in hypertension, CHF, severe depression or prior psychosis, active peptic ulcer disease, recent bowel anastomosis, active tuberculosis, positive PPD test, diabetes mellitus, osteoporosis, glaucoma, cataracts, and pregnancy; elderly patients are particularly susceptible to many adverse effects, including hyperglycemia, fluid retention, hypertension, hyperlipidemia, benign intracranial pressure, hypokalemia, enhanced neuromuscular blockade, GI bleeding, myopathy, psychosis, osteoporosis, and drug interactions
Patients requiring long-term treatment benefit from increased exercise and calcium and vitamin D supplementation; qod dosing; diets low in calories, fat, and sodium and high in protein, potassium, and calcium; avoid alcohol, coffee, and nicotine; hormonal supplementation for menopausal women


Prednisolone (AK-Pred, Delta-Cortef, Articulose-50, Econopred)

Decreases inflammation by suppressing migration of PMN leukocytes and reducing capillary permeability.

Adult

5-60 mg/d PO/IV/IM

Pediatric

0.1-2 mg/kg PO/IV/IM qd or divided tid/qid

Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis


Methylprednisolone (Solu-Medrol, Depo-Medrol)

Decreases inflammation by suppressing migration of PMN leukocytes and reversing increased capillary permeability.

Adult

2-60 mg PO qd or divided bid/qid followed by gradual reduction to lowest level that maintains clinical response

Pediatric

0.5-1.7 mg/kg/d or 5-25 mg/m2/d PO/IV/IM divided q6-12h

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of GC use

More on Temporal (Giant Cell) Arteritis

Overview: Temporal (Giant Cell) Arteritis
Differential Diagnoses & Workup: Temporal (Giant Cell) Arteritis
Treatment & Medication: Temporal (Giant Cell) Arteritis
Follow-up: Temporal (Giant Cell) Arteritis
References
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References

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Further Reading

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Keywords

temporal arteritis, giant cell arteritis, arteritis temporalis, arteritis cranialis, Horton disease, Horton's disease, granulomatous arteritis, arteritis of the aged, cranial arteritis, systemic vasculitis, TA, giant cell arteritis, temporal arteritis

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Contributor Information and Disclosures

Author

John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center
John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

Coauthor(s)

Victor J Marks, MD, Associate, Department of Dermatology, Section Chief, Dermatologic Surgery, Geisinger Health System
Victor J Marks, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physicians, American Medical Association, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Hyland Cronin, MD, Resident, Dermatology Department, Geisinger Health System, Danville, Pennsylvania
Disclosure: Nothing to disclose.

Medical Editor

Russell Hall, MD, Chief, Professor, Department of Internal Medicine, Division of Dermatology, Duke University
Russell Hall, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Federation for Medical Research, American Society for Clinical Investigation, and Society for Investigative Dermatology
Disclosure: Genetech Grant/research funds Principle Investigator; Centecor  Grant/research funds Principle Investigator

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Julia R Nunley, MD, Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center
Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, and Women's Dermatologic Society
Disclosure: Johnson and Johnson stock holder dividends; Amgen stock holder dividends; Forest Lab, Inc stock holder dividends; Galaxo Smith Klein stock holder dividends; Covidien stock holder dividends; Novartis Grant/research funds Consulting; Biolex  sub-investigator

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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