Login
Search

Search
Search

Giant Cell Arteritis (GCA)

NICE CKS Giant cell arteritis. Last revised: Jul 2024. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis. Published: Jan 2020.

Background Information

Suspect GCA if >50 y/o with at least one of the following:
  • Headache (usually temporal but may be more generalised, occipital or parietal) - most common symptoms
  • Temporal artery abnormality
    • Tenderness / thickening / nodularity (present up to 30%)
    • Red overlying skin
    • Reduced / absent pulsation

Other suggestive features:
  • Visual disturbances - loss of vision / diplopia / change to colour vision
  • Scalp tenderness
  • Intermittent jaw claudication
  • Neurological features
    • Mononeuropathy / polyneuropathy
    • Upper cranial nerve palsies
    • TIA / stroke (less common)
  • Systemic features - fatigue, fever, anorexia, weight loss, depression
  • PMRPolymyalgia rheumatica features seen in ~40% (e.g. proximal muscle pain, stiffness, and tenderness)
 
 

None of the GCA sign or symptom is pathognomic, they are all very non-specific.

Guidelines

Refer suspected GCA cases to specialist (ASAP but within 3 days):
  • Do not delay referral while ordering and waiting for results in primary care
 

Bloods to be taken before or immediately after starting steroids
  • FBC, CRP, ESR

Diagnostic tests:
  • Initial: temporal artery ultrasound
    • Halo sign (hypoechoic thickening around vessels) - suggests vessel wall inflammation
 
  • Definitive: temporal artery biopsy (always needed to confirm diagnosis)
    • -ve biopsy does nto exclude diagnosis if there is strong clinical suspicion and supporitve Ix
    • Segmetnal skin lesions make sensitivity lower

Other investigations to exclude alternative diagnoses or identify increased risk of glucorticoid-related adverse effects:
  • Baseline U&E, HbA1c, calcium, LFT
  • Screen tests for risk of serious infection (e.g. urine dipstick, chest X-ray, latent tuberculosis screening)
  • Screening test for osteoporosis risk (e.g. TSH, vitamin D, bone density test, DEXA)
  • If ESR is elevated out of proportion to CRP → serum protein electrophoresis and urine Bence-Jones protein / serum free light chains

1st line: oral prednisolone 40-60 mg per day
  • Most patients respond clinically within 1 week
  • Failure to respond should prompt re-evaluation of diagnosis

 

Steroids can be started without awaiting laboratory results, if GCA is strongly suspected clinically.

Urgent same day referral to ophthalmology

  • 1st line: IV methylprednisolone 0.5-1g up to 3 consecutive days before commencing oral prednisolone
  • Alternative: oral prednisolone 60-100mg per day

Maintain the initial steroid dose until symptoms and inflammatory markers (CRP, ESR) resolves
  • Once in remisison, steroid dose should be tapered to zero over 12–18 months, providing there is no return of GCA symptoms, signs or laboratory markers of inflammation
  • Some patients may require low doses of corticosteroids for several further years

For those at high risk of steroid toxicity or relapse while tapering, consider adding the following with the steroid tapering:
  • Methotrexate, or
  • Tocilizumab (strong recommendation)

References

Author: Adams Lau
Reviewer:
Last edited: 23/07/25