Here are links to the executive summary of this guideline: British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis: executive summary [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Rheumatology, Volume 59, Issue 3, March 2020, Pages 487–494, https://doi.org/10.1093/rheumatology/kez664
Today I review, link to and excerpt from the resource below.
Note to myself: The resource below is an outstanding guideline. However, the executive summary, above, is much better for a rapid review.
Here are the links to British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis [Full-Text HTML] [Full-Text PDF]. Rheumatology, Volume 59, Issue 3, March 2020, Pages e1–e23, https://doi.org/10.1093/rheumatology/kez672
All that follows is from the above resource.
Introduction
Background
GCA is a large vessel vasculitis affecting older people, with the highest incidence among persons 70–79 years of age [1]. Due to forecasted demographic changes, it has been estimated that between 2014 and 2050, >3 million people will have been diagnosed with GCA in Europe, North America and Oceania [2].
In GCA there is inflammation within the walls of medium and large-sized arteries, with associated intimal hyperplasia [3]. The ischaemia to end organs results in characteristic clinical features such as jaw or limb claudication [4]. Visual loss or stroke may occur in GCA, attributed to vascular occlusion; most GCA-associated visual loss occurs prior to glucocorticoid treatment or shortly after treatment initiation, underlining the importance of immediate treatment if the disease is strongly suspected [5, 6]. The reported proportion of patients with visual loss in GCA varies depending on the GCA case-finding method and method of ascertainment of visual loss; for example, in a UK study recruiting from a rheumatology setting, 17% of 271 patients with GCA reported irreversible visual loss and 1% had stroke [7]. Headache, scalp tenderness, jaw claudication, visual loss and stroke are all classified as cranial manifestations of GCA [4]. In addition, inflammation of the aorta and/or its proximal branches is common in GCA; this is often called large vessel vasculitis outside the head and neck (LV-GCA) and may be asymptomatic or produce non-specific systemic symptoms, such as fever or weight loss. Vascular imaging in GCA demonstrates large vessel involvement, usually with some degree of aortitis, in up to 83% of cases [8]. This large vessel inflammation may lead to later development of vascular stenosis, aneurysm or dilatation, dissection or rupture [9]. A subset of patients with LV-GCA presents with symptoms of a systemic inflammatory syndrome, which can have features of PMR without the classic cranial clinical features of GCA [4]. The true prevalence of this is unknown, as vascular imaging is not routinely performed in PMR at presentation.
Need for the guideline
As GCA is considered a medical emergency, it is treated at the point of diagnosis by clinicians in primary and secondary care who have a wide variety of clinical backgrounds. It is therefore necessary to provide clear guidance about current best practice and the underlying evidence including areas of uncertainty.
Recent years have seen new evidence emerge regarding the diagnosis and treatment of GCA. For this reason, a major revision to the 2010 British Society for Rheumatology (BSR) guideline for the management of GCA [10] was required. We also broadened the remit of the previous guideline to include diagnostic imaging for GCA.
Objectives of the guideline
The objective is to provide guidance for clinicians in the diagnosis and treatment of GCA. The guideline is supported by evidence wherever some evidence exists and by expert consensus where current evidence alone cannot provide a definite answer. The patient population covered by the guideline includes those patients in whom GCA is suspected sufficiently strongly that a decision to initiate glucocorticoid treatment is made. The guideline is not limited to GCA-related temporal (cranial) arteritis but also includes patients presenting with LV-GCA and limited forms of GCA with or without an association with PMR.
The evidence search was restricted to adult humans with GCA or suspected GCA, not limited by ethnicity, age or sex; however, since GCA is extremely rare in patients <50 years of age [1], generalizability below this age limit cannot be assured.
Areas the guideline does not cover
Takayasu arteritis and other forms of vasculitis (e.g. secondary large vessel vasculitis) are not covered by this guideline. The treatment of uncomplicated PMR is outside the scope of this guideline; readers are referred to the most recent BSR and ACR/EULAR guidance on the management of PMR [11, 12]. Guidance regarding immunizations and prophylaxis of glucocorticoid-induced osteoporosis is available elsewhere [13, 14].
