Giant Cell Arteritis – GCA

GCA is a is a vasculitis generally seen in the over 50’s and associated with polymyalgia rheumatic (PMR). However, unlike a lot of rheumatology, GCA is far from a benign condition that can be passed back to the GP’s, it can lead to some significant problems

  • Sudden irreversible visual loss
  • Development of thoracic aortic aneurysm

Diagnostic Criteria

Patients with ≥3 of the following SHOULD be treated and referred (Sens 93.5%, Spec 91.2%)

  • >50 years old
  • New onset headache
  • Temporal artery abnormality (thickened, beaded, reduced/absent piece, tender)
  • ESR >50 mm/hr
  • Abnormal biopsy (this won’t happen in ED)

But remember you are looking for specific temporal artery tenderness (not a vague general tenderness)

High Risk Criteria

Visual

  • NEW blurred vision (no other cause found)
  • NEW binocular diplopia (i.e. only wen both eyes open)
  • NEW pain in or around eye

Non-Visual

  • Jaw claudication  – Not TMJ dysfunction (see below)
  • Tongue claudication
  • Scalp necrosis  – consider if Herpes zoster(Shingles) affecting V1 dermatome

Investigations

  • Bloods: CRP, ESR, FBC, LFT, Electrolyte, Glucose, HBA1c
  • CXR
  • Weight

Management

High Risk Features (ANY)

Medication

  • Methylprednisolone 1g IV (500mg if <50kg)

Admit

  • Ophthalmology (if ANY visual features)
  • Medicine (if NO visual features)

Referrals

  • Rheumatology (in hours only – speciality team can do this next day)
  • Ophthalmology – for urgent review (if admitted to medicine)

Low Risk (NO High Risk features)

Medication

  • Prednisolone Oral 0.75mg/kg (min 40mg – max 60mg) OD PO
  • Adcal D3 One tablet OD
  • Lanzoprazole 30mg OD
  • (Consider) Aspirin 75mg OD

Give 2 weeks and tell patient they need to keep taking until seen in Rheumatology clinic

Referrals

  • Rheumatology –  Fax letter to rheumatology secretary (“Clinic letter” can be written and printed from EPR)
  • Vascular – Fax the Vascular Referral Form to vascular surgery secretaries

GCA vs. TMJ dysfunction

PDF: Full guide

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