Suspected Giant Cell Arteritis

GCA is a chronic vasculitis of large vessels, predominantly affecting cranial arteries. However, it is a systemic illness and vascular involvement might be widespread. Mean age of onset is about 70; it is very rare before 50 years of age.

Scope

Referral and diagnostic protocol for suspected GCA.

Out of Scope

Any other acute Rheumatology condition.

Assessment

Signs and Symptoms

  • Aged over 50
  • New headache (usually unilateral, temporal but can be diffuse or bilateral)
  • Scalp pain (diffuse or localised, typically pain on brushing the hair)
  • Temporal artery abnormalities (tender, thickened or beaded with reduced or absent pulsation)
  • Jaw and tongue claudication
    • Claudication is defined by ischaemic masseter pain on chewing
    • Pain on jaw opening only is more suggestive of TMJ pathology
  • Visual symptoms, e.g. Transient or permanent reduction in visual acuity, ischaemic optic neuropathy or diplopia
  • Unexplained fever
  • Weight loss, loss of appetite or tiredness; often generally unwell
  • Symptoms of polymyalgia rheumatica
  • Limb claudication
  • Raised CRP, plasma viscosity or ESR greater than 50
  • Normocytic anaemia, thrombocytosis

History and Examination

  • Full history including systems review.
  • Full examination, in particular temporal arteries, and scalp palpation, BP in both arms, peripheral pulses including listening for bruits and cranial nerve examination including fundoscopy.

Malignancy and infection must be excluded if prominent systemic symptoms such as weight loss or fevers.

Red Flags

Malignancy and infection must be excluded if prominent systemic symptoms such as weight loss or fevers

Investigations

Investigations in primary care should not delay referral if GCA is suspected clinically.

  • inflammatory markers should be performed before patient commences steroid treatment
  • CRP, Plasma viscosity, FBC, U&E, LFTs,
  • Urine dipstick – systemic vasculitis can cause glomerulonephritis/renal vasculitis and proteinuria

Management

1. Steroid Therapy

  • Do not delay treatment awaiting results – initiate steroid therapy if there is a high index of clinical suspicion:
    • Uncomplicated GCA
      • without jaw claudication or visual symptoms: prednisolone 40mg daily;
    • Complicated GCA
      • with jaw claudication or visual symptoms: prednisolone 60mg daily.

2. Please ensure additional prescription of the following if diagnosis confirmed:

Patient Information

  • Inform patient of working diagnosis
  • Explain importance of diagnosis and treatment;
    • 1 in 20 lose vision in 1 eye
    • 1 in 40 have a stroke of some sort.
  • Discuss risks from steroids including the dangers of sudden cessation. Please provide the patient with a steroid card.
  • Long term nature of follow up and steroid treatment. Most patients are on a steroid for couple of years, about half experience a relapse requiring an increase in steroid dose.
Long-term Condition Self-Management Programme

GPs and patients can refer to Improving Lives Plymouth for patient support with any long-term physical or low level mental health condition. The service helps people to better manage their condition and to achieve a better quality of life.

Referral

Referral Criteria

  • If GCA is suspected, please initiate therapy & request initial investigation as above
  • Urgent referral should be requested as below:

Referral Instructions

  • Please call the Derriford Hospital Switchboard on 01752 202082 and ask to speak urgently with the with the on call consultant Rheumatologist or Registrar (0900 to 1700 Mon - Fri)

Please also refer to the rheumatology service via DRSS using the urgent suspected giant cell arteritis pathway.

  • Where there is ocular involvement, please contact the Royal Eye Infirmary A&E to arrange referral for same day Ophthalmology review in Eye Casualty and simultaneously refer to rheumatology using the above process.

Patient Information

  • Inform patient of working diagnosis
  • Explain importance of diagnosis and treatment;
    • 1 in 20 lose vision in 1 eye
    • 1 in 40 have a stroke of some sort.
  • Discuss risks from steroids including the dangers of sudden cessation. Please provide the patient with a steroid card.
  • Long term nature of follow up and steroid treatment. Most patients are on a steroid for couple of years, about half experience a relapse requiring an increase in steroid dose.

Refer to Long Term Conditions Self-Management Programme

Supporting Information

Patient Information

Improving Lives Plymouth - Long Term Conditions Self-Management Programme

Evidence

Adapted from 2010 BSR/BHPR guidelines for the management of giant cell arteritis

Pathway Group

Plymouth Hospitals Trust

Consultant Rheumatologists:

Dr Robertson, Dr King, Dr Moore, Dr Perry, Dr Viner, Dr Savanovic-Abel

Consultant Ophthalmologists:

Prof Habib, Mr Thaller, Mr Cudrnak

Care of Elderly department

Maxillo-facial department

Publication date: January 2018
Updated: October 2018

 

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