23 January 2020
We've published an updated guideline on the treatment of giant cell arteritis (GCA), a condition diagnosed in around 2,500 people in the UK every year. It’s a serious, autoimmune condition in which blood vessels become inflamed and can restrict blood flow. We spoke to guideline co-lead, Dr Sarah Mackie, about what's changed and how the guideline improves care for patients across the UK.
GCA affects the blood supply to the scalp, jaw muscles or the back of the eye and is treated with high-dose glucocorticoids (steroids). If left untreated, it can lead to blindness or stroke. Fortunately, in most cases GCA is caught in time, but it's thought that up to one in five patients may experience a degree of permanent loss of vision from the disease. This means early diagnosis and prompt treatment is essential.
Our updated guideline aims to ensure clinicians have the latest information about the diagnosis and treatment of the condition. It brings the latest peer-reviewed evidence up-to-date and supports clinicians in providing the best treatment for people with GCA.
Dr Sarah Mackie, Associate Clinical Professor in Vascular Rheumatology at the University of Leeds, co-led the development of the guideline, working with over 35 national and international experts in the field, including rheumatologists, GPs, ophthalmologists and patients. It involved a rigorous process using a framework for evidence appraisal called GRADE, coupled with BSR's guidelines protocol, which is endorsed by NICE.
Dr Mackie says: “The way patients with suspected GCA have been assessed and treated is variable across the UK. Giant cell arteritis is time-critical; a delay in starting high-dose steroid treatment can cause blindness, but this same treatment can cause serious side-effects, so this is not a matter to be taken lightly. We recommend all patients are referred to a specialist who can see them promptly – on the same working day if possible and in all cases within three working days.”
There have been major developments in the treatment of giant cell arteritis since the last guideline was produced in 2010, particularly with imaging and biologic therapy.
Dr Mackie continues: “This guideline provides a coherent statement of what is the latest best practice. It also means that care can be standardised for all patients.”
The two major new areas of evidence are:
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Diagnostic imaging: The guideline recommends a sequence of tests, including if possible, the use of vascular ultrasound before a temporal artery biopsy for a faster, accurate diagnosis. It can often be useful to do both an ultrasound and a temporal artery biopsy; the guidelines explain when to do this. Ultrasound for diagnosis for GCA is quite a new test and not all hospitals have access to this yet.
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Biologic therapy: Since the previous guidelines, the drug tocilizumab has been licensed for GCA, prescribed alongside steroids for patients who have relapsed, as well as for the small minority who do not respond to initial steroid treatment. Trials suggest adding tocilizumab can reduce the risk of further relapse and so lessen patients’ overall exposure to steroids.
The guideline reviews this latest evidence. The guideline also includes practical information for clinicians including what symptoms to check, what tests to do, steroid dosing and care pathways. Charities such as PMRGCA UK, which was involved in the development of the updated guideline, welcomes this development.
Humphrey Hodgson, Chair of Trustees for PMRGCA UK, says it's vital the guideline is rolled out across the UK: “These new guidelines have the power, if implemented fully, to transform the diagnosis and treatment of giant cell arteritis. Too often our charity learns of cases of people losing all or some of their sight needlessly because diagnosis was delayed, or the wrong treatment given. People with GCA have the right to fast-track treatment to save their sight just as fast-track treatment has transformed outcomes for those who have strokes.”
Dr Mackie concludes: “These guidelines help clinicians who are trying to improve their local service for patients with suspected GCA. The standardised approach to care outlined in the guidelines supports clinicians in conversations with their managers about developing business cases for investment in this area. By talking about the guideline and using it, we'll help raise the profile of this condition and drive forward best practice.”