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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Giant-cell arteritis

Rheumatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Impending or established visual ischaemia

Transient visual loss, diplopia or new permanent visual impairment in suspected giant-cell arteritis signals threatened ophthalmic circulation and risk to the fellow eye.

Action: Give immediate high-dose glucocorticoid, arrange same-day ophthalmology and rheumatology or acute medical assessment, and obtain temporal-artery ultrasound or biopsy without allowing testing to delay treatment.

Synopsis

Recognise cranial, ocular and large-vessel giant-cell arteritis promptly, give glucocorticoid before diagnostic delay causes blindness, secure ultrasound or biopsy evidence, and reduce relapse and steroid toxicity through structured specialist care.

  • Suspect GCA in anyone over fifty with new headache, scalp tenderness, jaw or tongue claudication, visual symptoms, abnormal temporal artery, PMR symptoms or unexplained inflammatory illness.
  • Ask every suspected patient explicitly about transient visual loss, diplopia and permanent change; visual symptoms move care to an immediate same-day pathway.
  • Give prednisolone 40–60 mg orally immediately for strongly suspected uncomplicated cranial GCA; do not wait for ESR, CRP, ultrasound or biopsy.
  • For acute or intermittent visual loss, give intravenous methylprednisolone 500 mg–1 g daily for up to three days under same-day specialist care, or oral prednisolone 60–100 mg if IV treatment would cause delay.
  • Obtain FBC, CRP, ESR, renal, liver, glucose and bone-risk baseline, but normal inflammatory markers do not safely override a convincing ischaemic phenotype.
  • Temporal and axillary artery ultrasound is the preferred rapid first diagnostic test in an experienced pathway; temporal-artery biopsy remains valuable when imaging is unavailable, discordant or diagnostic certainty remains important.
  • Ultrasound and biopsy sensitivity decline after glucocorticoid, so arrange within days, ideally within one week, without withholding treatment.
  • Use PET-CT, CTA or MRA for suspected extracranial large-vessel disease, unexplained systemic features or discordant cranial tests; each modality answers a different inflammation and anatomy question.
  • Taper glucocorticoid only after symptoms and markers respond, usually over at least one year; relapse requires reassessment for infection and confirmation of active vascular disease.
  • Consider tocilizumab with a planned steroid taper for relapsing, refractory or high-toxicity-risk disease under NICE and specialist criteria; IL-6 blockade suppresses CRP, so clinical monitoring changes.

Key red flags

Amaurosis fugax, diplopia, colour or field loss and new visual impairment require immediate treatment and same-day ophthalmic assessment.

Jaw or tongue claudication, tongue infarction, scalp necrosis or an abnormal temporal artery indicates high cranial-ischaemic risk.

Stroke, limb claudication, pulse asymmetry, aortic pain or a new regurgitant murmur suggests large-vessel ischaemia or aortic complication.

Fever, weight loss or high inflammatory markers can reflect infection or malignancy; investigate alternatives while protecting vision when GCA is credible.

Normal ESR or CRP is uncommon but does not exclude a convincing visual or cranial presentation.

Visual ischaemia

Amaurosis fugax, diplopia, field or colour loss and sudden permanent visual change requires immediate glucocorticoid and ophthalmic care.

Investigation priorities

01
Immediate visual and vascular examinationFirst step

Identify threatened sight, cranial arterial abnormality and large-vessel asymmetry before treatment or transfer.

Management branches

Immediate first-line treatmentProtect sight before confirmation

Clinical suspicion of GCA is strong, with no current visual symptom.

  1. Draw baseline bloods and assess visual, neurological and vascular status without delaying the first glucocorticoid dose.
  2. Start prednisolone 40–60 mg orally once daily and arrange fast-track rheumatology review and ultrasound within days.
  3. Use biopsy or extracranial imaging when ultrasound is negative or discordant and probability remains clinically important.

Key medicines

Prednisolone for uncomplicated GCAStart 40–60 mg orally once daily immediately, maintain until symptoms and inflammatory markers resolve, then taper over at least twelve months using the specialist schedule.Do not delay for testing. Check infection, glucose, pressure, mood, eyes and bone, provide gastric and Pneumocystis protection when total risk indicates, and never stop prolonged therapy abruptly.
Intravenous methylprednisolone for visual ischaemiaGive 500 mg–1 g intravenously once daily for up to three consecutive days, followed by high-dose oral prednisolone under same-day specialist care.Monitor rhythm, pressure, glucose, electrolytes, psychiatric and infection effects. If IV treatment would delay care, give oral prednisolone 60–100 mg immediately.
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Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • BSR 2020 giant cell arteritis guidelineUK emergency treatment, ultrasound, biopsy, imaging, taper and monitoring guidance.
  • NICE TA518 tocilizumab for GCANHS access for relapsing or refractory GCA.
  • NHS temporal arteritis informationUK symptoms, visual emergency and treatment advice.
  • Actemra UK product informationGCA dose, screening and laboratory safety.
  • NICE CG146 fragility-fracture risk assessmentGlucocorticoid-related fracture-risk assessment using FRAX, QFracture and selective DXA.
  • NOGG 2024 osteoporosis guidelineGlucocorticoid-induced osteoporosis thresholds and first-line antiresorptive bone protection.
  • Alendronic acid UK product informationWeekly administration, licensed indication and oesophageal, renal and dental safety.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom