Immediate Management of Vision Loss in Giant Cell Arteritis (GCA)

Initial Assessment and Treatment

The American College of Rheumatology conditionally recommends immediate treatment with intravenous (IV) pulse glucocorticoids (methylprednisolone 0.25-1g/day for 3 days) for patients with suspected GCA and threatened vision loss, over high-dose oral glucocorticoids 1, 2, 3
Visual loss occurs in 15-35% of patients with GCA, primarily before initiation of therapy, according to the American College of Rheumatology 4
If one eye is affected, the risk for losing vision in the second eye is as high as 50% without treatment, as reported by the American College of Rheumatology 4

The European League Against Rheumatism recommends administering IV pulse methylprednisolone 250-1000 mg/day for 3 days for patients with GCA and visual symptoms 2, 5
The American College of Rheumatology advises not to delay oral glucocorticoid treatment while arranging for IV therapy, and to start oral prednisone immediately if IV administration will be delayed 2, 5

The American College of Rheumatology recommends transitioning to high-dose oral prednisone (1 mg/kg/day, up to 60-80 mg daily) after IV pulse therapy 3
The American College of Rheumatology suggests considering adding tocilizumab as a glucocorticoid-sparing agent for patients with GCA 3, 6

The American College of Rheumatology recommends arranging for temporal artery biopsy as soon as possible, ideally within 2 weeks of starting glucocorticoids, and considering noninvasive vascular imaging to evaluate large vessel involvement 1, 3, 7

The American College of Rheumatology advises not to delay treatment while awaiting biopsy results, as vision loss can be permanent, and notes that visual recovery is uncommon in patients who have already lost vision from GCA 1, 3, 4
The American College of Rheumatology recommends aggressive treatment with IV pulse glucocorticoids for patients with GCA and cranial ischemia, despite conflicting results in studies 1, 3

The European League Against Rheumatism recommends tapering prednisone to 15-20 mg/day within 2-3 months and to ≤5 mg/day after 1 year 5
The American College of Rheumatology advises that tapering should be guided by clinical symptoms and normalization of inflammatory markers 4, 5