rheumatology and musculoskeletal
Treating giant cell arteritis
Giant cell arteritis remains a clinical emergency , which can lead to irreversible sight loss . New ‘ Fast Track Pathways ’, diagnostics and treatments are improving the standard of care and outcomes
Fiona Coath MBChB MRCP Faidra Laskou MBBS MRCP Bhaskar Dasgupta MBBS MD FRCP Rheumatology Department , Southend University Hospital , UK
Giant cell arteritis ( GCA ) remains a rheumatology emergency . Critical ischaemia of the temporal arteries can lead to anterior ischaemic optic neuropathy and irreversible sight loss . This is a significant cause of morbidity among these patients , not least due to subsequent loss of independence and depression . If the symptoms of GCA are recognised promptly and treated appropriately , then the incidence of this catastrophic event could be reduced . There is increasing evidence regarding the efficacy and positive outcomes of ‘ Fast Track Pathways ’. This is a process whereby patients are offered rapid access to specialist clinical assessment , with the goal of providing a secure diagnosis in as many patients as possible . Glucocorticoid therapy can then be continued or importantly stopped if inappropriate .
14 HHE 2018 | hospitalhealthcare . com
Evidence from current services of this type has shown significant reduction in morbidity . For example , at Southend Hospital , the incidence of sight loss has been reduced from 37 % to 9 %. 1 Similar results have been replicated in other centres .
Presentation and classification In clinical practice , it is clear there are subgroups within GCA . Recognition of these subgroups is important to determine additional investigations and management . It is no longer sufficient to label this simply as a ‘ headache ’ disease . Some patients may have isolated cranial GCA , presenting with headaches and ischaemic symptoms such as jaw or tongue claudication and uniocular visual disturbance . However many are found to have more extensive large vessel involvement , termed large vessel giant cell arteritis ( LV-GCA ). With the advent of improved imaging techniques , the estimated prevalence of this group is greater than previously recognised ; 12 – 37 % depending on the modality used . 2 A clinical suspicion of LV-GCA can be prompted by patients presenting with more predominant constitutional symptoms , including unintentional weight loss , and night sweats and fevers , or in patients who have already developed symptoms of vascular compromise such as limb claudication secondary to stenotic disease . In reality , there is a significant degree of symptom overlap between cranial GCA , LV-GCA and polymyalgia rheumatica ( PMR ), and it may be more accurate to think of them as a spectrum of disease rather than discrete conditions . 3
Another clinically significant method of classification is ‘ response to treatment ’. Figure 1 divides patients into four groups : remission ; relapse ; refractory disease ; and adverse effects or intolerance . 4 It is these latter three groups , outlined in the red box , for which there is currently an unmet need for effective disease modifying and glucocorticoid-sparing treatment . Observational cohort studies report flares in 34 – 62 % of GCA patients , with only 15 – 20 % achieving sustained remission with GC alone . 3
Investigations Advances in vascular ultrasound ( US ) have transformed the management of GCA in recent years . EULAR now recommends it as the first-line investigation in acute GCA if there is appropriate equipment and expertise available . 5 Vascular US forms a significant part of ‘ Fast Track Pathway ’ clinics , as it potentially offers a ‘ one-stop shop ’