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rheum.gca.chronic.v1PRODUCTION
rheum.gca.chronic.v1

Giant cell arteritis (GCA / temporal arteritis)

rheumatologyacutechronicadultgeriatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult GCA (cranial + large-vessel phenotypes per ACR 2021). PMR-only without cranial / vascular features routed separately

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scope confirmed

Patient inputs (12)

GCA essentially restricted to age ≥50 (ACR 2021 classification criterion); rare under 60

Strongest LR+ for GCA among presenting features (Smetana JAMA 2002 meta-analysis)

Often >50 mm/h (ACR 2021); trend on therapy

More sensitive than ESR (BSR 2020); key trend marker — CRP suppressed by tocilizumab independent of disease (GiACTA Stone 2017)

Normocytic anemia + thrombocytosis common (BSR 2020)

Gold standard — perform within 14 days of starting steroids (ACR 2021); segmental skip lesions → 1-2 cm sample (BSR 2020)

Visual loss is irreversible — STAT high-dose steroids before biopsy (ACR 2021 / EULAR 2023 strong recommendation)

Large-vessel GCA (PET-CT / MRA / CTA aorta) — up to 50% have aortic involvement (ACR 2021 / EULAR 2018)

PMR present in 40-50% of GCA (BSR 2020); informs treatment + prognosis

Mild AST/ALK-P elevation common (BSR 2020); baseline for steroid + tocilizumab hepatotoxicity monitoring

Halo sign on color Doppler / MRI vessel-wall enhancement; EULAR 2018/2023 fast-track imaging path

Steroid-induced diabetes baseline (ACR 2017 GIO guideline)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningvisual_loss_or_amaurosis_fugax (ACR 2024)
    Transient or persistent monocular / binocular visual loss in suspected GCA [ACR 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningstroke_like_symptoms
    Hemiplegia, vertebral ischemia features, or new TIA in patient with cranial GCA features [ACR 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaortic_aneurysm_or_dissection
    Thoracic aortic aneurysm/dilation or dissection in GCA patient [ACR 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretocilizumab_specific_complication
    GI perforation, severe infection, or hepatotoxicity on TCZ [ACR 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepjp_pneumonia_on_steroids
    Hypoxia + bilateral infiltrates in patient on prednisone ≥20 mg ≥4 weeks [ACR 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterelapse_during_taper
    Recurrent symptoms or rising ESR/CRP during steroid taper [ACR 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

GCA — induction steroid + tocilizumab steroid-sparing (2022 ACR + 2023 EULAR)
axis: gca_steroid_and_steroid_sparing
Selected axis "GCA — induction steroid + tocilizumab steroid-sparing (2022 ACR + 2023 EULAR)" by default fallback (first axis)
  • prednisone
    first line
    corticosteroid
    40-60 mg PO daily (1 mg/kg) • PO • daily
    triggers: suspected_GCA_no_visual_symptoms
    2022 ACR / 2023 EULAR strong — induction; do not delay for biopsy
    rxcui 8640
  • methylprednisolone
    rescue
    corticosteroid
    500-1000 mg IV daily × 3 days then prednisone 60 mg • IV → PO • daily × 3 d then PO
    triggers: amaurosis_fugax, persistent_visual_loss, CRAO
    IV pulse for visual / neurologic involvement (ACR 2024)
    rxcui 6902
  • tocilizumab
    add on
    IL_6_inhibitor
    162 mg SC weekly (or q2 weeks initially) • SC • weekly
    triggers: relapse_on_taper, high_steroid_burden_predicted, GiACTA_eligible
    GiACTA NEJM 2017 — Class I steroid-sparing; CRP unreliable on TCZ (rely on symptoms)
    rxcui 612865
  • methotrexate
    second line
    anti_metabolite
    10-25 mg PO/SC weekly • PO/SC • weekly
    triggers: tocilizumab_unavailable, tocilizumab_intolerant
    EULAR 2023 alternative steroid-sparer; modest effect
    rxcui 6851
  • aspirin
    add on
    antiplatelet
    81 mg PO daily • PO • daily
    triggers: no_bleeding_contraindication
    EULAR 2023 — possible reduction in ophthalmic / cerebrovascular events
    rxcui 1191
  • pantoprazole
    add on
    PPI
    40 mg PO daily • PO • daily
    triggers: high_dose_steroid
    GI prophylaxis during high-dose steroid (BSR 2020)
    rxcui 40790
  • alendronate
    add on
    bisphosphonate
    70 mg PO weekly • PO • weekly
    triggers: glucocorticoid_>=5mg_>=3months
    ACR 2017 GIO — bone protection during chronic steroid
    rxcui 46041

outpatient playbook — drug actions (5)

  1. 1. prednisone induction
    40-60 mg PO daily (1 mg/kg) • PO • daily
    trigger: Suspected GCA without visual symptoms (ACR 2024)
    2022 ACR / 2023 EULAR; do NOT delay for biopsy
  2. 2. tocilizumab
    162 mg SC weekly • SC • weekly
    trigger: Relapse on taper, predicted high cumulative steroid burden, comorbidity intolerant of steroids (ACR 2024)
    GiACTA Class I — steroid-sparing
  3. 3. aspirin 81 mg
    81 mg PO daily • PO • daily
    trigger: No bleeding contraindication (ACR 2024)
    EULAR 2023 — possible thromboprotection
  4. 4. PPI + bisphosphonate
    Pantoprazole 40 mg daily; alendronate 70 mg weekly • PO • daily / weekly
    trigger: Starting chronic steroid (ACR 2024)
    Bone protection (ACR 2017 GIO) + GI protection
  5. 5. PJP prophylaxis
    TMP-SMX SS daily • PO • daily
    trigger: Prednisone ≥20 mg ≥4 weeks (ACR 2024)
    PJP risk during high-dose steroid (BSR 2020)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New-onset headache in patient ≥50 (ACR 2021 classification criterion); Jaw claudication (highest LR+ for GCA — ACR 2021); Amaurosis fugax / acute visual loss (ACR 2021 / EULAR 2023 — IV pulse indication).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Giant cell arteritis (GCA / temporal arteritis)** (rheum.gca.chronic.v1).
Phenotype framing: CRAO non-arteritic AION, migraine, tension headache, sinusitis, infection, malignancy, ANCA vasculitis, Takayasu (younger — ACR 2021), atherosclerotic disease
Scope: Adult GCA (cranial + large-vessel phenotypes per ACR 2021). PMR-only without cranial / vascular features routed separately

No severity triggers fired against current inputs.

Plan

Regimen axis: **GCA — induction steroid + tocilizumab steroid-sparing (2022 ACR + 2023 EULAR)**.
1. prednisone 40-60 mg PO daily (1 mg/kg) PO daily (corticosteroid, first line) — 2022 ACR / 2023 EULAR strong — induction; do not delay for biopsy
2. methylprednisolone 500-1000 mg IV daily × 3 days then prednisone 60 mg IV → PO daily × 3 d then PO (corticosteroid, rescue) — IV pulse for visual / neurologic involvement (ACR 2024)
3. tocilizumab 162 mg SC weekly (or q2 weeks initially) SC weekly (IL_6_inhibitor, add on) — GiACTA NEJM 2017 — Class I steroid-sparing; CRP unreliable on TCZ (rely on symptoms)
4. methotrexate 10-25 mg PO/SC weekly PO/SC weekly (anti_metabolite, second line) — EULAR 2023 alternative steroid-sparer; modest effect
5. aspirin 81 mg PO daily PO daily (antiplatelet, add on) — EULAR 2023 — possible reduction in ophthalmic / cerebrovascular events
6. pantoprazole 40 mg PO daily PO daily (PPI, add on) — GI prophylaxis during high-dose steroid (BSR 2020)
7. alendronate 70 mg PO weekly PO weekly (bisphosphonate, add on) — ACR 2017 GIO — bone protection during chronic steroid

Setting playbook (outpatient) — Confirm GCA, induce remission with steroids, add tocilizumab for steroid-sparing, slow taper over 18-24 months, monitor for relapse and large-vessel involvement (ACR 2024)
8. prednisone induction 40-60 mg PO daily (1 mg/kg) PO daily — Suspected GCA without visual symptoms (ACR 2024) (2022 ACR / 2023 EULAR; do NOT delay for biopsy)
9. tocilizumab 162 mg SC weekly SC weekly — Relapse on taper, predicted high cumulative steroid burden, comorbidity intolerant of steroids (ACR 2024) (GiACTA Class I — steroid-sparing)
10. aspirin 81 mg 81 mg PO daily PO daily — No bleeding contraindication (ACR 2024) (EULAR 2023 — possible thromboprotection)
11. PPI + bisphosphonate Pantoprazole 40 mg daily; alendronate 70 mg weekly PO daily / weekly — Starting chronic steroid (ACR 2024) (Bone protection (ACR 2017 GIO) + GI protection)
12. PJP prophylaxis TMP-SMX SS daily PO daily — Prednisone ≥20 mg ≥4 weeks (ACR 2024) (PJP risk during high-dose steroid (BSR 2020))

Non-pharmacologic actions:
- Vaccinate before TCZ — zoster recombinant, pneumococcal, flu, COVID (ACR 2021 / EULAR 2023)
- Bone health — calcium 1200 mg, vitamin D 800-1000 IU (ACR 2017 GIO)
- Glucose monitoring (BSR 2020)
- Fall prevention (ACR 2024)
- Eye exam baseline + during taper if steroid >5 mg (BSR 2020)

AVOID / contraindication checks:
- Tocilizumab screen TB HBV and perforation risk (ACR 2024)
- Tocilizumab CRP blunted rely on clinical (ACR 2024)
- Methotrexate LFT CBC monitoring and contraception (ACR 2024)
- Steroid glucose bone mood cataract monitoring (ACR 2024)
- Bisphosphonate not first 3 months of pregnancy (ACR 2024)

Monitoring

Regimen monitoring:
- symptoms + ESR CRP at 2-4 weeks then monthly during taper (ACR 2024)
- glucose weekly during high dose steroid (ACR 2024)
- DEXA baseline then annual (ACR 2024)
- TCZ LFT and lipids q4-8 weeks first 6 months (ACR 2024)
- aortic imaging q1-2 years for LV GCA (ACR 2024)
- taper to <=5mg by 12 months when feasible (ACR 2024)

Setting (outpatient) monitoring:
- Symptoms + ESR/CRP at 2-4 weeks then monthly during taper (ACR 2024)
- Glucose weekly during high-dose steroid (ACR 2024)
- DEXA annually (ACR 2024)
- TCZ: LFT + lipids q4-8 weeks first 6 months (ACR 2024)
- Aortic surveillance imaging q1-2 years if LV-GCA (ACR 2024)
- Taper goal: ≤5 mg by 12 months when feasible (ACR 2024)

Follow-up plan: Slow steroid taper to ≤5 mg by 12 months when feasible (BSR 2020 / EULAR 2023); aortic surveillance imaging q1-2 years if LV-GCA (EULAR 2018); relapse education + return-precaution counseling
- Close-out criterion: long-term management plan documented

Monitoring phase: Symptom + ESR/CRP at 2-4 weeks, then monthly during taper (BSR 2020). Watch for tocilizumab-blunted CRP — rely on symptoms + ESR (GiACTA Stone 2017). DEXA at baseline + annually (ACR 2017 GIO). Glucose monitoring weekly during high-dose steroids

Disposition

Current setting: outpatient — Confirm GCA, induce remission with steroids, add tocilizumab for steroid-sparing, slow taper over 18-24 months, monitor for relapse and large-vessel involvement (ACR 2024)

Disposition criteria:
- Continue outpatient unless visual / neurologic emergency (ACR 2024)

Escalation triggers (move to higher acuity):
- New visual loss / amaurosis fugax → ED for IV pulse methylpred (ACR 2021 strong)
- Stroke-like symptoms → ED + stroke pathway (ACR 2021 / EULAR 2018)
- Severe relapse despite TCZ → rheumatology + consider CYC / rituximab off-label (EULAR 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Transient or persistent monocular / binocular visual loss in suspected GCA [ACR 2021]
- [LIFE_THREATENING] Hemiplegia, vertebral ischemia features, or new TIA in patient with cranial GCA features [ACR 2021]
- [SEVERE] Thoracic aortic aneurysm/dilation or dissection in GCA patient [ACR 2021]

Citations

- 2022 ACR/Vasculitis Foundation GCA + 2023 EULAR Recommendations + GiACTA (Stone NEJM 2017) [PMID:34235871](https://pubmed.ncbi.nlm.nih.gov/34235871/)
- Cited evidence (PMID 34235884) [PMID:34235884](https://pubmed.ncbi.nlm.nih.gov/34235884/)
- Cited evidence (PMID 28745999) [PMID:28745999](https://pubmed.ncbi.nlm.nih.gov/28745999/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2022 ACR/Vasculitis Foundation GCA + 2023 EULAR Recommendations + GiACTA (Stone NEJM 2017) — PMID:34235871
  • Cited evidence (PMID 34235884) — PMID:34235884
  • Cited evidence (PMID 28745999) — PMID:28745999