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==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Pharmacologic medical therapies for temporal arteritis is  high-dose corticosteroid therapy. [53, 22, 8, 136, 137]  
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*Damage may be irreversible if treatment is delayed beyond 48 hours.
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*should be started on oral prednisone 40-60 mg/day, with a temporal artery biopsy performed within 1 week. [104] Prednisone doses of 80-100 mg/day have been suggested for patients with visual or neurologic symptoms of GCA. [138] Follow-up care within 72 hours after starting therapy should be arranged.
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
===Disease Name===


* '''1 Stage 1 - Name of stage'''
*patients with acute visual changes from GCA can be started on intravenous (IV) methylprednisolone at a dose of 1,000 mg daily for 3 days. Limited data suggest that initial high-dose IV corticosteroid treatment (eg, methylprednisolone, 15 mg/kg of ideal body weight/day) may reduce remission rates. [139, 140]  
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. ''''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
*use of low-dose aspirin (81 mg) in patients with GCA for prevention of visual loss and stroke. [141]
** 2.1 '''Specific Organ system involved 1 '''
 
**: '''Note (1):'''
British guidelines recommend the following schedule for tapering of standard-regimen corticosteroids [53] :
**: '''Note (2)''':
 
**: '''Note (3):'''
Continue prednisolone, 40-60 mg (not <0.75 mg/kg) for 4 weeks (or until symptoms and laboratory abnormalities resolve), then
*** 2.1.1 '''Adult'''
Reduce dose by 10 mg every 2 weeks to 20 mg, then
**** Parenteral regimen
Reduce dose by 2.5 mg every 2-4 weeks to 10 mg, then
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
Reduce dose by 1 mg every 1-2 months, provided no relapse occurs
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
 
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
The guidelines recommend that patients on steroid therapy receive prophylactic treatment with the following medications [53] :
**** Oral regimen
 
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
Low-dose aspirin, 81 mg per day – To decrease cranial ischemic complications
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
Proton pump inhibitor – For gastrointestinal protection
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
Bisphosphonate, calcium, and vitamin D – For bone protection
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
It may be reasonable to maintain the patient on treatment for 2 years to lessen the chances for relapses. Even then, relapses have been reported. [142]  
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
 
*** 2.1.2 '''Pediatric'''
Long-term corticosteroid therapy has frequent and potentially serious consequences, including diabetes mellitus, vertebral compression fractures, steroid myopathy, steroid psychosis, and immunosuppression-related infections. [143]
**** Parenteral regimen
 
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
US Food and Drug Administration (FDA) expanded the indications for use of tocilizumab for use in GCA. Tocilizumab had previously been approved for use in rheumatoid arthritis. [146]
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
 
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
Improvement of systemic symptoms (eg, headache, lethargy) typically occurs within 72 hours of initiation of therapy. The elevation in erythrocyte sedimentation rate (ESR) and ischemic manifestations (eg, temporal headache, jaw claudication) diminish in several days.
**** Oral regimen
 
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
High-dose steroid therapy should be maintained only long enough for symptoms to resolve. Steroids should then be tapered slowly to the lowest dose required to suppress symptoms.
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days


==Medical Therapy==
==Medical Therapy==

Revision as of 19:36, 8 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2]

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

  • Pharmacologic medical therapies for temporal arteritis is high-dose corticosteroid therapy. [53, 22, 8, 136, 137]
  • Damage may be irreversible if treatment is delayed beyond 48 hours.
  • should be started on oral prednisone 40-60 mg/day, with a temporal artery biopsy performed within 1 week. [104] Prednisone doses of 80-100 mg/day have been suggested for patients with visual or neurologic symptoms of GCA. [138] Follow-up care within 72 hours after starting therapy should be arranged.
  • patients with acute visual changes from GCA can be started on intravenous (IV) methylprednisolone at a dose of 1,000 mg daily for 3 days. Limited data suggest that initial high-dose IV corticosteroid treatment (eg, methylprednisolone, 15 mg/kg of ideal body weight/day) may reduce remission rates. [139, 140]
  • use of low-dose aspirin (81 mg) in patients with GCA for prevention of visual loss and stroke. [141]

British guidelines recommend the following schedule for tapering of standard-regimen corticosteroids [53] :

Continue prednisolone, 40-60 mg (not <0.75 mg/kg) for 4 weeks (or until symptoms and laboratory abnormalities resolve), then Reduce dose by 10 mg every 2 weeks to 20 mg, then Reduce dose by 2.5 mg every 2-4 weeks to 10 mg, then Reduce dose by 1 mg every 1-2 months, provided no relapse occurs

The guidelines recommend that patients on steroid therapy receive prophylactic treatment with the following medications [53] :

Low-dose aspirin, 81 mg per day – To decrease cranial ischemic complications Proton pump inhibitor – For gastrointestinal protection Bisphosphonate, calcium, and vitamin D – For bone protection

It may be reasonable to maintain the patient on treatment for 2 years to lessen the chances for relapses. Even then, relapses have been reported. [142]

Long-term corticosteroid therapy has frequent and potentially serious consequences, including diabetes mellitus, vertebral compression fractures, steroid myopathy, steroid psychosis, and immunosuppression-related infections. [143]

US Food and Drug Administration (FDA) expanded the indications for use of tocilizumab for use in GCA. Tocilizumab had previously been approved for use in rheumatoid arthritis. [146]

Improvement of systemic symptoms (eg, headache, lethargy) typically occurs within 72 hours of initiation of therapy. The elevation in erythrocyte sedimentation rate (ESR) and ischemic manifestations (eg, temporal headache, jaw claudication) diminish in several days.

High-dose steroid therapy should be maintained only long enough for symptoms to resolve. Steroids should then be tapered slowly to the lowest dose required to suppress symptoms.

Medical Therapy

Pharmacotherapy

Acute Pharmacotherapies

Prompt treatment with steroids is a medical emergency to reduce the risk of blindness.

Corticosteroids must be started as soon as the diagnosis is suspected (even before the diagnosis is confirmed by biopsy). Steroids do not prevent the diagnosis later being confirmed by biopsy, although certain changes in the histology may be observed towards the end of the first week of treatment and are more difficult to identify after a couple of months.[1]

A 3 day course of pulse steroids with 250 mg of IV solumedrol BID is critical in reducing the risk of permanent visual loss. If there is progression of visual loss on steroids, IV heparin can be administered to reduce the risk of thrombotic occlusion.

Treatment should not be deferred while waiting on the results of a temporal artery biopsy.

References

  1. ↑ Font RL, Prabhakaran VC (2007). "Histological parameters helpful in recognising steroid-treated temporal arteritis: an analysis of 35 cases". The British journal of ophthalmology. 91 (2): 204–9. doi:10.1136/bjo.2006.101725. PMID 16987903.

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