Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Giant Cell Arteritis

Giant cell arteritis (GCA) is a systemic inflammatory vasculitis mainly affecting people over 50 years [S9]. It is a medical emergency because of the risk of sudden, irreversible loss of sight and, more rarely, stroke [S4] [S9]. Immediate high-dose glucocorticoids are the first-line treatment, and glucocorticoid-sparing agents reduce relapse and steroid exposure [S1] [S2].

Key points - Start high-dose glucocorticoids immediately in active GCA; EULAR reports 40-60 mg/day prednisone-equivalent for induction [S2]. - Confirm the diagnosis by imaging or histology [S2]; EULAR now recommends ultrasound as the first-line imaging test, including the axillary arteries [S8]. - No single symptom or test confirms or excludes GCA; jaw claudication, temporal artery abnormalities, platelets above 400 × 10³/µL and very high ESR raise the likelihood [S5]. - Relapse occurs in almost half of patients, mainly in the first two years [S7]. - Tocilizumab (RCT) and upadacitinib 15 mg (RCT) improve sustained remission with a shorter steroid taper [S1] [S11].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Any visual symptom in a patient over 50 with headache or jaw claudication: GCA threatens sudden irreversible sight loss [S4] [S9].
• Jaw claudication (positive likelihood ratio 4.90) and limb claudication (6.01) [S5].
• Temporal artery thickening, loss of pulse or tenderness (positive likelihood ratios 4.70, 3.25 and 3.14) [S5].
• Large vessel involvement, which predicts relapse [S7].

Recognise it

• In a meta-analysis of 68 studies (14,037 patients with suspected GCA), features that increased the probability of GCA included ESR above 100 mm/h (positive LR 3.11) and platelet count above 400 × 10³/µL (3.75) [S5].
• Features whose absence lowered the probability: ESR above 40 mm/h (negative LR 0.18), CRP of 2.5 mg/dL or more (0.38) and age over 70 years (0.48) [S5].
• Combinations of features help direct further tests such as vascular imaging or biopsy [S5].
• Headache is a cardinal symptom of cranial GCA [S4].

Confirm it

• Ultrasound is the first-line imaging test in suspected GCA; FDG-PET or MRI of cranial and extracranial arteries are alternatives [S8]. This is guideline advice based on evidence and expert opinion [S8].
• Temporal artery biopsy: pooled sensitivity 77.3% in 32 studies (3092 patients), with high heterogeneity, so a negative biopsy does not exclude GCA [S3].
• Ultrasound vs biopsy: a Cochrane review (2024) found very low-certainty evidence; ultrasound appears moderately sensitive when specificity is good, and no conclusion could be drawn on whether it can replace biopsy [S9].
• Fast-track pathways and advanced imaging help reduce diagnostic delay in Europe [S4].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / no specialist)

1. Suspect GCA in anyone over 50 with headache [S4], jaw claudication, scalp or temporal tenderness, or visual symptoms [S5] [S9].
2. Send ESR, CRP and platelet count if available [S5], but do not wait for results before arranging urgent treatment and referral [S2].
3. Glucocorticoids should be started immediately in active GCA [S2]. If a clinician can prescribe, start as per local protocol; EULAR reports 40-60 mg/day prednisone-equivalent (as reported in [S2]).

Tier B (general eye clinic)

1. Document visual function and start glucocorticoids immediately in active GCA [S2]; sight loss can be sudden and irreversible [S4].
2. Arrange ultrasound or temporal artery biopsy without delaying treatment [S2] [S8]. Biopsy was positive in only 77% of confirmed cases [S3].
3. Co-manage with rheumatology or internal medicine for long-term steroid tapering [S6] [S10].

Tier C (specialist centre)

1. Glucocorticoid-sparing therapy: - Tocilizumab (GiACTA, 251 patients): sustained remission at 52 weeks in 56% (weekly) and 53% (every other week) vs 14% and 18% with placebo plus 26- or 52-week prednisone tapers; cumulative prednisone 1862 mg vs 3296 to 3818 mg [S1]. Dose as reported in [S1]: 162 mg subcutaneously. Industry-funded. - Upadacitinib (SELECT-GCA, 428 patients): sustained remission 46.4% with 15 mg daily vs 29.0% with placebo; 7.5 mg was not superior; no major adverse cardiovascular events [S11]. Industry-funded. - Methotrexate may be used as an alternative to tocilizumab [S2] [S10].
2. Who should get tocilizumab: EULAR advises it in refractory or relapsing disease or high risk of glucocorticoid adverse effects [S2]. The French group (2025) recommends it at diagnosis after a major cardiovascular event, fracture with osteoporosis, psychiatric event with steroids, complicated diabetes, or previous steroid use over 6 months, for at least 12 months [S10]. The ACR guideline supports glucocorticoid-sparing agents [S6].
3. Antiplatelet or anticoagulant therapy is no longer routinely recommended unless indicated for other reasons [S2].
4. Relapse monitoring: cumulative relapse rates were 32% at 1 year, 44% at 2 years and 47% at 5 years; female sex and large vessel involvement predicted relapse [S7]. Imaging can help assess suspected relapse when inflammatory markers are unreliable [S8].

Low-resource note: where ultrasound, biopsy or biologics are unavailable, immediate glucocorticoids remain the first-line treatment [S2] [S4], and methotrexate is an alternative glucocorticoid-sparing agent [S2].

Refer when

Pitfalls

• Delaying glucocorticoids while waiting for biopsy or imaging [S2].
• Excluding GCA on a negative biopsy [S3].
• Relying on one symptom or test [S5].
• Tapering too fast without a plan for relapse, which affects almost half of patients [S7].

Evidence notes

• Conflict: EULAR recommends ultrasound first-line [S8], while the Cochrane review found very low-certainty evidence and could not conclude whether ultrasound can replace biopsy [S9]. Biopsy sensitivity estimates also vary widely [S3].
• The ACR guideline has only 2 strong recommendations; the rest are conditional because of low-quality evidence [S6].
• The tocilizumab and upadacitinib trials were industry-funded and compared against placebo with steroid tapers [S1] [S11].
• Not covered by these sources: intravenous methylprednisolone for visual loss, bone and gastric protection, the size of the visual-loss risk, and data from low- and middle-income countries.

Related articles

• Non-Arteritic Anterior Ischaemic Optic Neuropathy
• Central Retinal Artery Occlusion: An Ocular Stroke
• Sudden painless vision loss: triage

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.