Can rheumatologists diagnose and manage Giant Cell Arteritis better than nonrheumatologists? The Maltese Experience

Abstract

OBJECTIVES: Giant Cell Arteritis (GCA) remains a challenge both in terms of diagnosis and management as patients may present to several different specialists. The objectives were to determine incidence of biopsy-proven GCA in Malta and to compare the management between rheumatologists and nonrheumatologists. METHODS: This was a retrospective observational population study of patients with suspected GCA who underwent a temporal artery biopsy (TAB) between 2012 and 2015. Data collected consisted of demographics, presenting symptoms, TAB histology reports, treatment and outcome. The British Society for Rheumatology (BSR) 2010 guidelines were used as standard of care. RESULTS: 136 patients underwent a TAB for suspected GCA of which 26 were positive. The incidence of biopsy-proven GCA in Malta was 3.82 per 100,000 patient years in the over 50 population. There were 63 patients who were treated as GCA. Only 43.3% of confirmed cases had rheumatology input. TABs requested by rheumatologists were twice more likely to be positive compared to requests by non-rheumatologists (30.5% vs. 14.1%).The majority of patients were started on a Prednisolone dose between 40-60mg. Rheumatologists maintained patients on high doses for at least 1 month in 54% of cases as opposed to 20% under non-rheumatologists. Monitoring was more regular for cases followed up by rheumatologists (40% vs. 21%). CONCLUSIONS: Malta has a low incidence of biopsy proven GCA. Although rheumatologists are more likely to adhere to the recommended guidelines, improvement is needed. Rheumatologists should take the lead to minimise variation and optimise management of GCA.

Temporal Artery Biopsy Debate: Positive TAB Result Prolongs Steroid Use in Giant Cell Arteritis

“…However, only 12% of rheumatologist referrals in our study resulted in a positive TAB. While other studies have shown rheumatologists to have a higher positivity rate when requesting TAB compared with nonrheumatologists, 22 this was not the case in our study.…”

Necessity of Temporal Artery Biopsy for Giant Cell Arteritis: A Systematic Review

“…This could be due to differing referral patterns of GCA patients at different centers. Cefai et al 27 found that 31% of TABs requested by rheumatologists were positive, whereas only 14% of TABs requested by other physicians were positive. A center where rheumatologists are the predominant referring physician could have a higher positivity percentage, as this specialty is historically more accurate at requesting TABs that go on to be positive.…”

Mediterranean Journal of Rheumatology September 2017 Highlights

“…In a commentary, Cefai at al. 6 asked the question whether rheumatologists or non-rheumatologists in Malta fare better in diagnosing and managing giant cell arteritis. They showed that temporal artery biopsy (TAB) requested by rheumatologists was more likely to be positive than TAB requested by non-rheumatologists, but the percentage was low (30% vs 14%).…”