Oral and intravenous steroids in giant cell arteritis

Corticosteroid Usage in Giant Cell Arteritis

Giant cell arteritis (GCA) is a condition that can cause irreversible visual loss if untreated. While corticosteroids remain the mainstay of treatment to prevent visual loss, the type, dose, route, and duration of corticosteroid treatment of GCA remain controversial. Our study surveyed neuro-ophthalmologists to determine commonly prescribed dosages of corticosteroids for the treatment of GCA with or without visual loss. For patients with acute visual loss, 52% would use intravenous (IV), 46% would use IV or oral and 2% would use oral corticosteroids. Seventy-three per cent would use 500 to 1000 mg IV methylprednisolone in this group. For patients with GCA without acute visual loss, 67% would use the oral route, 30% would use IV or oral, and 3% indicated they would use IV route of treatment. Seventy-five per cent would use 1.0 to 1.5 mg/kg oral prednisone in this group. Our results suggest a majority but not a complete consensus for route and dose of corticosteroid treatment in GCA and confirm conventional recommendations for high dose IV corticosteroids for GCA with visual loss and lower dose oral regimens for GCA without visual loss.

Giant cell arteritis: an updated review

Giant cell arteritis (GCA) is the most common primary vasculitis of adults. The incidence of this disease is practically nil in the population under the age of 50 years, then rises dramatically with each passing decade. The median age of onset of the disease is about 75 years. As the ageing population expands, it is increasingly important for ophthalmologists to be familiar with GCA and its various manifestations, ophthalmic and non-ophthalmic. A heightened awareness of this condition can avoid delays in diagnosis and treatment. It is well known that prompt initiation of steroids remains the most effective means for preventing potentially devastating ischaemic complications. This review summarizes the current concepts regarding the immunopathogenetic pathways that lead to arteritis and the major phenotypic subtypes of GCA with emphasis on large vessel vasculitis, novel modalities for disease detection and investigative trials using alternative, non-steroid therapies.

Giant cell arteritis presenting with scalp necrosis--the timing of temporal artery biopsy?

Scalp necrosis in patients presenting with clinical features suggestive of giant cell arteritis is rare. The immediate concern is that temporal artery biopsy might further compromise scalp circulation. We report a case of extensive scalp necrosis caused by giant cell arteritis. Temporal artery biopsy performed after 14 days was not associated with any significant damage and still provided florid evidence of the disease. Rapid and complete scalp healing was achieved with aggressive treatment.

Novel therapeutic strategies for large vessel vasculitis

Giant cell arteritis and Takayasu's arteritis are systemic vasculitides that cause inflammation of large arteries and their branches. Both have similar histology, but differ in their age of onset. Corticosteroids have been the mainstay of treatment for the past 50 years but are limited by the potential toxicity that may occur in almost 60% of patients. This limitation has lead to the investigation of alternative agents for the treatment of these diseases.

Giant cell arteritis

Giant cell arteritis (GCA) is an immune-mediated vasculitis, affecting medium- to large-sized arteries, in individuals over the age of 50 years. Visual loss is a frequent complication of GCA, and once it occurs it tends to be both permanent and profound. Although major advances have been made in recent years in genetics, molecular biology and the description of the vessel wall morphology, the aetiology and pathogenesis of GCA are still incompletely understood. Over the years there has been much debate over whether polymyalgia rheumatica and GCA are separate or linked entities. Recent investigations support that polymyalgia rheumatica and GCA are two different expressions of the same underlying vasculitic disorder. A single cause or aetiological agent has not as yet been identified. Except for the histopathology of the arterial wall, there are no laboratory findings specific for GCA, and no particular signs or symptoms specific for the diagnosis. GCA typically causes vasculitis of the extracranial branches of the aorta and spares intracranial vessels. Transmural inflammation of the arteries induces luminal occlusion through intimal hyperplasia. Clinical symptoms reflect end-organ ischaemia. Branches of the external and internal carotid arteries are particularly susceptible. Corticosteroids remain the only proven treatment for GCA, the regimen initially involving high doses followed by a slow taper. However, early detection and treatment with high-dose corticosteroids is effective in preventing visual deterioration in most patients.

Neuro-Ophthalmic Emergencies for the Neurologist

A variety of acute neurologic disorders present with visual signs and symptoms. In this review the authors focus on those disorders in which the clinical outcome is dependent on timely and accurate diagnosis. The first section deals with acute visual loss, specifically optic neuritis, ischemic optic neuropathy (ION), retinal artery occlusion, and homonymous hemianopia. The authors include a discussion of those clinical features that are helpful in distinguishing between inflammatory and ischemic optic nerve disease and between arteritic and nonarteritic ION. The second section concerns disc edema with an emphasis on the prevention of visual loss in patients with increased intracranial pressure. The third section deals with abnormal ocular motility, and includes orbital inflammatory disease, carotid-cavernous fistulas, painful ophthalmoplegia, conjugate gaze palsies, and neuromuscular junction disorders. The final section concerns pupillary abnormalities, with a particular emphasis on the dilated pupil and on carotid artery dissection. Throughout there are specific guidelines for the management of these disorders, and areas are highlighted in which there is ongoing controversy.