Diagnosis and management of giant cell arteritis and polymyalgia rheumatica: challenges, controversies and practical tips

Abstract

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are inflammatory rheumatic diseases that may present to a variety of disciplines and specialities. The mainstay of treatment is glucocorticoids (steroids); together PMR and GCA now represent one of the most common reasons for medium-to-high dose, long-term glucocorticoid treatment in primary care. However, adverse effects of glucocorticoids are common in these patients. Management of both diseases involves balancing the symptoms and risks of the disease against the adverse effects and risks of glucocorticoids. The crucial first step in management is to make a firm, well-documented diagnosis, since once glucocorticoids are started they can mask the symptoms of a number of other diseases. Diagnosis however can be challenging and there are still substantial gaps in the evidence for treatment.

Diagnosis of polymyalgia rheumatica usually means a favourable outcome for your patient

“…PMR symptoms can dominate over the clinical picture of GCA. Small CSs doses used for PMR do not suppress concomitant GCA (although this is more generally accepted than proved opinion) 21 that may progress to cause blindness.…”

“…However, PMR pivotal manifestations may be less specific: fewer or raised C-reactive protein (CRP) of unknown origin, general weakness, weight loss, depressive reaction, decompensation of chronic diseases (e.g. chronic heart failure) due to increased metabolism 1 21 .…”

Giant cell arteritis

“…La distinción entre ACG y PMR es fundamental, debido a que la ACG puede llevar a una ceguera irreversible y requiere dosis mayores de corticoides. Aproximadamente el 10% de los pacientes que inicialmente se presentan como PMR, tendrán vasculitis en la biopsia de la arteria temporal, requiriendo una revisión de su diagnóstico pero desafortunadamente el tratamiento estándar para la PMR con dosis bajas de corticoides no tiene efecto profiláctico para evitar el compromiso ocular en la ACG 20 .…”

“…El examen clínico incluye la palpación de las arteriastemporales, auscultación de otras arterias, incluyendo las arterias subclavia y axilar, ymedición de la presión arterial bilateral con el fin de detectar cualquier estenosis vascular [16][17][18][19][20][21] . la lámina elástica interna es fragmentada y la luz disminuye por el edema intimal.…”

Giant Cell Arteritis– Who to Refer to?

“…A vital step in the management of GCA is to make a firm, well-documented diagnosis, as once systemic corticosteroids are started they can mask symptoms of other diseases (16). There is no single investigation or symptom that is positive in all patients with GCA.…”