1. L Alvarez 2018 Adjuncts to Steroid Treatment
Choroidal ischemia/ perfusion delay behind transient or other visual loss without infarcted disc in GCA
Arteritic disc : acute pale swelling with (usually if temporal disc involved) very poor vision
(+++ suggestive)
Suspected Giant Cell Arteritis (GCA) presenting to the BMEC Accident and Emergency
Suspect
Acute ocular ARTERIAL ischemic signs ( ischemic optic neuropathy, retinal ischemia, amaurosis fugax/ transient visual loss) new onset non explained visual disturbance or diplopia in patient > 50. (* note GCA is very rare in non-caucasians, but not impossible).
Typical Systemic Symptoms? (can be absent [20%])
Scalp pain or tenderness
Jaw claudication
Limb claudication
Hip/shoulder girdle pain and stiffness
Lethargy, malaise, fever, weight loss,
Supportive Examination?
Thickened, tender or non-pulsatile TAs
Cranial nerve / compatible visual signs/ symptom
Peripheral pulses – inequality/absence/bruits
High Acute Phase Response?
Urgent FBC, U&E, LFT, ESR, CRP, Glu, INR, (HbA1c)
Pre-test probability : GCA still suspected?
High suspicion :
Raised inflammatory markers
+ systemic signs, compatible or patognomonic ocular presentation (arteritic AION)
High suspicion
Low suspicion
Intermediate suspicion
Raised inflammatory markers, absent or few systemic symptoms, compatible / possible ocular presentation
Consider alternative cause
eg if amaurosis fugax = TIA? Embolic source  urgent referral stroke pathway
No visual symptoms (eg GP referral with very suggestive systemic symptoms), raised inflammatory markers
Impending (acute visual symptoms) or established visual loss
Consider risk/benefit of high dose steroids and probability of pre-test diagnosis before commencing steroids
Consider urgent admission (if visual loss/ visual symptoms) for IV steroids
Organise TAB
Medical assessment/ Fill out referral leaflet
Urgent referral to neuro-ophthalmology
Commence FIRST dose of steroids (oral MG OD)
Organise TAB/ Doppler TA
Medical assessment/ Fill out referral leaflet
Urgent referral to rheumatology
Admit and commence FIRST dose of steroids STAT * and organise temporal artery biopsy (TAB)
Medical assessment/ Fill out referral leaflet
Start AAS if no contraindication
Referral to rheumatology/ neuro-ophthalmology
STEROIDS and High suspicion GCA
* Some evidence supports IV versus oral steroids in GCA with acute visual loss, in GCA but if delays are expected/ unavoidable for intravenous administration, start oral stat in the Accident and Emergency department.
Assess risk/ benefit of oral versus IV (oral may be preferable in CKD/ electrolite imbalance/ cardiac failure/ diabetes)
In high suspicion GCA, first dose of steroids must not be delayed. Chest X ray should be organised acutely on starting steroids but never delaying first dose.
Dose of intravenous steroids : 15 mg/kg BW Methylprednisolone (up to 1g per day) for 3 days when acute visual loss / impending visual loss. Alternative: 60 mg oral prednisolone
Steroids for treatment of GCA are maintained (always under rheumatology guidance) 40mg or 60mg for 4 weeks - or longer until symptoms resolved- then reduce dose by 10mg every 2 weeks until 20mg, then reduce dose by 2.5mg every 2 weeks until 10mg, then reduce dose by 0.5-1mg every 2 months
Adjuncts to Steroid Treatment
Prednisolone oral tablets – non-enteric coated – dose as per pathway
Aspirin 75mg OD to prevent (further) neuro-ophthalmic complications
Proton pump inhibitor (PPI) or H2 antagonist for gastroprotection
Calcium and vitamin D supplement and Bisphosphonate (if no contraindication – consider renal function, previous peptic ulcer disease etc.)
Medical assessment
Always document full medical history : cardiac or renal failure, diabetes, other systemic comorbidities?
If present : medical review by medical team (rheumatology) as inpatient, consider adjusting dose of steroids

2. Sandwell and West Birmingham NHS Trust
Suspected Giant Cell Arteritis (GCA) Care Pathway - Referral form – draft 1
Surname: Forename: Location of Patient:
Eye casualty
Date of Birth: Ward
GP practice
Hospital (RXK) or NHS no:
Patient Tel.number:
Symptoms: (circle yes / no) Investigations:
Scalp pain or tenderness yes / no ESR (mm/h)
Jaw claudication yes / no
Visual loss or blurring, diplopia yes / no CRP (mg/L)
Hip/shoulder girdle pain or stiffness yes / no
Lethargy, malaise, anorexia, weight loss yes / no GFR ml/min
Fever yes / no
Limb claudication yes / no Plts x109/L
Signs: (circle as appropriate)
INR………………………………………
Temporal artery / branches tender No – R – L – Both
Temporal artery / branches thickened No – R – L – Both
Temporal pulses absent No – R – L – Both
Description of visual symptoms and signs Amaurosis fugax / Ischemic optic neuropathy/ Other (specify ) R – L – Both ……………………………………………………………………………………………………………………………………………………………
Comorbidities: (circle) Diabetes Osteoporosis CKD Ischaemic heart disease
other (please state)
Drug Treatment (circle) Aspirin Warfarin/Rivaroxaban/Clexane etc. Bisphosphonate
PPI or H2 antagonist Calcium/vitamin D
other (please state)
ACTION BY REFERRER:
Dose of Prednisolone commenced? Date: ...../...../.....
TA Ultrasound (US skull on iCM) scheduled? yes/no Date: ...../...../.....
Print Name: Contact tel./bleep
Signature: Date: ...../...../.....
FAX REFERRAL TO (City) OR (Sandwell)
PLEASE CALL (City) OR (Sandwell) TO CONFIRM RECEIPT
Contact Rheumatology SpR at City / Sandwell Hospital or Consultant on-call via Switch if queries