A 75-year-old woman comes to the physician for follow-up after she was started on prednisone 60 mg daily a week ago for suspected giant cell arteritis. She had headaches, blurred vision, fatigue, dry cough, and jaw pain with chewing. She had a normal complete blood count, comprehensive metabolic panel, and chest x-ray, but the erythrocyte sedimentation rate was 88 mm/hr. A biopsy of the right temporal artery was obtained due to tenderness over that area.
The patient had rapid relief on prednisone with resolution of headaches and significant improvement of her systemic symptoms. The biopsy report shows no evidence of giant cell arteritis, only atherosclerosis.
Which of the following is the best course of action?

Question

A 75-year-old woman comes to the physician for follow-up after she was started on prednisone 60 mg daily a week ago for suspected giant cell arteritis.  She had headaches, blurred vision, fatigue, dry cough, and jaw pain with chewing.  She had a normal complete blood count, comprehensive metabolic panel, and chest x-ray, but the erythrocyte sedimentation rate was 88 mm/hr.  A biopsy of the right temporal artery was obtained due to tenderness over that area.
The patient had rapid relief on prednisone with resolution of headaches and significant improvement of her systemic symptoms.  The biopsy report shows no evidence of giant cell arteritis, only atherosclerosis.
Which of the following is the best course of action?

Quizplus · Accepted Answer

11ec193a_9938_b285_853d_31db88ff6e80_MD0002_00 Giant cell arteritis (GCA) (temporal arteritis) is diagnosed based on clinical risk estimation. Typical features include age >50, headache and tenderness over the temporal artery, erythrocyte sedimentation rate >50 mm/hr, and often polymyalgia rheumatica (achy muscular pain over the shoulder and hip areas). Elderly patients can present with atypical symptoms such as cough, hoarseness, and malaise. This patient's age, symptoms, physical examination findings, and elevated erythrocyte sedimentation rate significantly increase the probability of GCA, and she was appropriately started on prednisone. An additional characteristic of GCA is rapid symptomatic response to glucocorticoid therapy. Biopsy of the temporal artery is the gold standard for the diagnosis of GCA. However, negative biopsy results are common and occur in up to 40% of patients. If the clinical suspicion is very high, as in this patient, a contralateral biopsy should be considered if the first biopsy is negative. However, in practice, the second biopsy is often not pursued and the patient is treated for GCA regardless of the biopsy results if the clinical suspicion remains high and no alternate diagnoses are found. (Choice A) Methotrexate may be used as a steroid-sparing agent, but there is no evidence for the use of hydroxychloroquine in GCA. (Choices B, C, and E) After achieving initial remission of GCA with high-dose glucocorticoids, steroid treatment is slowly tapered over several months. Some patients will require a longer course of treatment, as much as 1-2 years or longer. Premature discontinuation is associated with a high risk of relapse of GCA. For this reason, it is inappropriate to discontinue prednisone immediately or rapidly taper over 2 weeks based on the negative biopsy result when there is high probability of GCA. Addition of aspirin to the steroid regimen is recommended to reduce the risk of long-term vascular complications in GCA (eg, transient ischemic attack, stroke), but steroids should be continued. Educational objective: If the clinical suspicion is high for giant cell arteritis (GCA) but temporal artery biopsy is negative, a contralateral biopsy should be considered. In a patient with typical features of GCA, treatment should be continued despite a negative biopsy unless a more likely diagnosis has been found. Addition of aspirin to the steroid regimen is recommended to reduce the risk of long-term vascular complications in GCA (eg, transient ischemic attack, stroke). __________ References: Adjunctive methotrexate for treatment of giant cell arteritis: an individual patient data meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/17665429) Clinicopathologic correlations in giant cell arteritis: a retrospective study of 107 cases. (http://www.ncbi.nlm.nih.gov/pubmed/19500846) The diagnosis and treatment of giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/23795218)

A 75-Year-Old Woman Comes to the Physician for Follow-Up After