Temporal Arteritis

Key points

• Large-vessel vasculitis overlapping with PMR; histology shows 'skip lesions'.
• Typically > 60 years, rapid onset (< 1 month): headache (85%) · jaw claudication (65%) · visual disturbance (anterior ischaemic optic neuropathy) · tender palpable temporal artery; ~50% have PMR features.
• ESR > 50 mm/hr (but < 30 in 10%); CK and EMG normal; temporal artery biopsy may show skip lesions.
• Treatment (BSR 2020): start a glucocorticoid IMMEDIATELY on clinical suspicion — do not wait for biopsy · without ischaemic visual manifestations the standard initial dose is prednisolone 40–60 mg daily · a dramatic response is expected within days, otherwise reconsider the diagnosis.
• Acute or intermittent visual loss: IV methylprednisolone 500 mg–1 g daily for up to 3 consecutive days may be given before starting oral prednisolone — but if IV is not immediately possible this must not delay the oral dose · SAME-DAY ophthalmology review; visual damage is often irreversible.
• Temporal artery biopsy should still be obtained (ideally within 2 weeks of starting steroids) but must NOT delay treatment · temporal artery ultrasound (the 'halo sign') is increasingly used as an early test.
• Taper the glucocorticoid to zero over about 12–18 months if symptoms, signs and inflammatory markers stay settled · consider methotrexate or tocilizumab as a steroid-sparing agent where there is relapse or high glucocorticoid-toxicity risk · give bone protection and consider gastroprotection.

Decision points in this pathway

• Visual symptoms present?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.