## Giant Cell Arteritis (Temporal Arteritis) — First-Line Therapy ### Clinical Context This patient presents with classic features of giant cell arteritis (GCA): age >50, headache, jaw claudication, visual symptoms, elevated ESR, and confirmatory temporal artery biopsy showing granulomatous inflammation. ### Drug of Choice: Corticosteroids (Prednisolone) **Key Point:** Corticosteroids are the gold standard and ONLY first-line therapy for GCA. High-dose prednisolone must be initiated immediately to prevent irreversible vision loss. **High-Yield:** - **Initial dose:** Prednisolone 40–60 mg daily (or equivalent methylprednisolone IV 500–1000 mg daily if vision-threatening symptoms) - **Rationale:** Rapid anti-inflammatory effect prevents arteritic anterior ischemic optic neuropathy (AAION) and stroke - **Duration:** Gradual taper over 12–24 months based on clinical response and ESR normalization ### Steroid-Sparing Agents (Adjunctive, Not First-Line) | Agent | Role | Timing | |-------|------|--------| | Methotrexate | Steroid-sparing agent | Added after 2–4 weeks if high steroid requirement | | Azathioprine | Second-line steroid-sparer | Reserved for steroid intolerance | | Tocilizumab (IL-6 inhibitor) | Emerging steroid-sparer | Recent evidence; not first-line | **Clinical Pearl:** Vision loss in GCA is a medical emergency. Corticosteroids must be started BEFORE biopsy results if clinical suspicion is high (biopsy can be done within 1–2 weeks without delaying treatment). **Warning:** Delaying corticosteroids while awaiting biopsy or using immunosuppressants alone risks permanent blindness — this is a common exam trap.
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