Giant cell arteritis in polymyalgia rheumatica — SCE Geriatric Medicine MCQ

Correct answer: C — Start high-dose glucocorticoid treatment urgently and arrange same-day specialist assessment

This patient has clinical features highly suspicious for giant cell arteritis (GCA) superimposed on polymyalgia rheumatica: new headache, scalp tenderness, and jaw claudication in an older woman with markedly elevated inflammatory markers (ESR 88, CRP 74). GCA is a medical emergency because of the risk of ischaemic visual loss; preserved vision today does not exclude this risk—approximately one in five untreated patients develop blindness. UK guidance (NHS regional rheumatology pathways, British Society for Rheumatology) mandates immediate initiation of high-dose prednisolone (40–60 mg daily) without waiting for diagnostic confirmation by ultrasound or biopsy, as investigations must not delay treatment when GCA is strongly suspected. Current prednisolone dose (7.5 mg) is appropriate for PMR maintenance but entirely inadequate for GCA. Urgent specialist assessment (same-day rheumatology referral) is required to confirm diagnosis, evaluate for large-vessel involvement, and plan steroid-sparing strategies (e.g., tocilizumab if relapsing disease or high steroid risk—relevant given her age and comorbidities). Option E delays essential treatment. Option B provides insufficient glucocorticoid dose and further delay. Option D uses monotherapy without high-dose glucocorticoids and delays the standard-of-care emergency treatment. Option A falsely reassures based on preserved vision, which is not protective against GCA-related vascular events.

Reference: NHS Highland Right Decisions: Giant Cell Arteritis Guidelines; British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis (2020); https://www.rightdecisions.scot.nhs.uk/tam-treatments-and-medicines-nhs-highland/adult-therapeutic-guidelines/rheumatology/giant-cell-arteritis-gca-guidelines/