## Giant Cell Arteritis (Temporal Arteritis) — First-Line Therapy ### Clinical Context This patient has classic giant cell arteritis (GCA) with: - Age >50 years - Temporal headache and jaw claudication - Visual symptoms (risk of blindness) - Elevated ESR - Positive temporal artery biopsy (granulomatous inflammation with giant cells) ### Drug of Choice: Corticosteroids (Prednisolone) **Key Point:** High-dose corticosteroids are the gold standard first-line therapy for GCA and must be initiated immediately to prevent irreversible vision loss. ### Dosing Regimen | Phase | Dose | Duration | Rationale | |-------|------|----------|----------| | Induction | 40–60 mg/day prednisolone | 4 weeks | Rapid control of inflammation; prevent arteritic complications | | Taper | Gradual reduction by 5–10 mg every 2–4 weeks | Months to years | Minimize steroid side effects while maintaining remission | | Maintenance | 5–15 mg/day | Long-term (1–2 years) | Sustain disease control | **Clinical Pearl:** Vision loss in GCA is often irreversible. Corticosteroids must be started BEFORE biopsy confirmation if clinical suspicion is high — do not delay treatment awaiting biopsy results. ### Adjunctive Therapy **High-Yield:** Methotrexate or azathioprine may be added in steroid-dependent cases (requiring >15 mg/day prednisolone to maintain remission) to allow steroid-sparing effect, but they are NOT first-line monotherapy. ### Why Not Other Options? - **Methotrexate:** Slower onset (weeks); used as adjunct in steroid-dependent disease, not as monotherapy - **Azathioprine:** Steroid-sparing agent for maintenance; no role in acute phase - **Infliximab:** TNF-α inhibitors are experimental; not standard first-line; reserved for refractory cases **Mnemonic:** **GCA = Corticosteroids Always** — immediate high-dose steroids are non-negotiable to prevent blindness. [cite:Harrison 21e Ch 319]
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