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Major relapse of giant cell arteritis with jaw claudication — SCE Rheumatology MCQ

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ModerateGiant Cell ArteritisMajor relapse of giant cell arteritis with jaw claudicationSCE Rheumatology

A 73-year-old woman has biopsy-confirmed giant cell arteritis diagnosed 8 months ago. Her initial cranial symptoms resolved with prednisolone 60 mg daily, which has been tapered to 7.5 mg daily. She was asymptomatic when taking 10 mg daily. Over the past 48 hours, she has developed recurrent right temporal headache and pain with fatigue of the jaw muscles after chewing, resolving within several minutes of rest. She has no visual disturbance or limb claudication. Visual acuity, pupillary responses and fundoscopy are normal. CRP is 4 mg/L and ESR is 18 mm/hour. There are no clinical features of infection or another explanation for her symptoms. Which is the most appropriate immediate glucocorticoid strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Increase oral prednisolone to 40–60 mg daily

Explanation lettering: B = shown as A · C = shown as B · E = shown as C · A = shown as D · D = shown as E

New jaw claudication represents cranial ischaemia and therefore classifies this presentation as a major GCA relapse, despite the absence of visual symptoms. Major relapse requires reinstitution or escalation of glucocorticoids to the dose used for induction of new-onset disease: oral prednisolone 40–60 mg daily when there is no acute visual ischaemia. Normal inflammatory markers do not exclude relapse; both ESR and CRP were normal in 21% of relapses in a prospective cohort. A is appropriate for a minor relapse, where glucocorticoids are increased at least to the previous effective dose, but is inadequate for new ischaemic symptoms. C is also below the recommended induction range and should not be selected merely as an intermediate escalation. D would be considered for acute visual loss or amaurosis fugax; jaw claudication without ocular involvement does not by itself mandate intravenous pulses. E incorrectly allows reassuring laboratory results to override a characteristic clinical relapse and risks progression to irreversible cranial ischaemia. Following immediate glucocorticoid escalation, the patient requires urgent specialist reassessment and consideration of adjunctive glucocorticoid-sparing treatment because the disease has relapsed during tapering.

Reference: 2018 update of the EULAR recommendations for the management of large vessel vasculitis (January 2020) — https://ard.bmj.com/content/79/1/19 Disease Relapses among Patients with Giant Cell Arteritis: A Prospective, Longitudinal Cohort Study (July 2015) — https://pubmed.ncbi.nlm.nih.gov/25877501/ Blog: diagnosis and treatment of giant cell arteritis (23 January 2020) — https://www.rheumatology.org.uk/news/details/articleid/217