Giant Cell Arteritis (GCA) Referral

NHSL Referral Pathways
NHS Lanarkshire

Fast Track Giant Cell Arteritis Referral Pathway and GCA Probability Score

Giant Cell Arteritis (GCA) or Temporal Arteritis (TA) is a form of Large Vessel Vasculitis (inflammation of the blood vessels) which affects mainly elderly population (usually above 65 years of age). The complications include permanent loss of vision, stroke and other complications related to arterial occlusion.

Treatment with high doses of steroids usually leads to resolution of symptoms within 24 hours (this is not specific effect and does not confirm the diagnosis). In uncertain cases the use of steroids before confirmation of GCA delays diagnosis and poses risk of prolonged, unnecessary treatment.

Patients with suspected GCA should be therefore seen in the specialist clinic as soon as possible, best within 24 - 48 hours from first presentation. Please call the rheumatology on 01698 366088 to make sure that the appointment will be arranged on time.

History

  • Sub-acute/acute onset
  • New type of headache
  • Scalp tenderness – on brushing/combing hair, resting head on the pillow
  • Jaw or tongue claudication – pain occurring while chewing
  • Unilateral blurring, double vision, visual loss
  • Limb claudication
  • Systemic upset - weight loss, night sweats, fever
  • Shoulder +/- pelvic girdle muscles pain and stiffness – difficulty turning in bed and rising arms

Examination

  • Temporal artery – tenderness, thickening, beading, reduced or absent pulsation
  • Scalp tenderness
  • Peripheral pulses upper extremities – diminished or lack
  • Auscultation of subclavian, axillary, brachial arteries – bruits
  • Blood pressure on both arms – discrepancy of more than 20mmHg in systolic pressure
  • Visual acuity, eye movements, visual fields

Helpful Investigations

  • ESR and CRP – raised
  • Full blood count – low Hb, raised PLT
  • U&E, LFT, ALP
  • Fundoscopy – pale, swollen optic disc with haemorrhages (anterior ischaemic optic neuritis)

Primary Care Management

  • If high risk of GCA (or GCA Probability Score above 12) – prednisolone 40mg daily plus omeprazole.
  • If tongue claudication and/or new visual symptoms (partial/complete visual loss, amaurosis fugax, diplopia) – prednisolone 60mg daily plus omeprazole.
  • Refer to rheumatology urgently – call 01698 366088.
  • Refer to ophthalmology urgently (all with new visual symptoms) – call 01355 585387.

Who to Refer

  • Patients of 50 years of age and older
  • Acute/sub-acute onset of headache and scalp tenderness
  • Other symptoms of GCA (as above).
  • Raised ESR/CRP (if typical presentation do not delay the referral by waiting for test results).
  • Or GCA Probability Score ≥ 10

Who Not to Refer

  • Patients under 50 year of age
  • Chronic headache/neck/shoulder pain
  • Normal ESR and CRP
  • Alternative diagnosis more likely, e.g.
  • Migraine
  • Infection including sinusitis
  • Herpes zoster
  • Temporo-mandibular joint disease
  • Ear disease
  • Trigeminal neuralgia
  • Cervical spine disease
  • TIA
  • Intracranial pathology
  • Malignancy
  • Pain on mouth opening but not aggravated by chewing
  • Bilateral blurred vision of known cause (glaucoma, cataract, uncontrolled diabetes) and corrected with glasses
  • Or GCA Probability Score < 10
  • GCA is rare in non-Caucasians

Call rheumatology on-call if unsure.

For More Information

Mackie S.L., Dejaco C., Appenzeller S., Camellino D., Duftner C., Gonzalez-Chiappe S., Mahr A., Mukhtyar C., Reynolds G., de Souza A.W.S., Brouwer E., Bukhari M., Buttgereit F., Byrne D., Cid M.C., Cimmino M., Direskeneli H., Gilbert K., Kermani T.A., Khan A., Lanyon P., Luqmani R., Mallen C., Mason J.C., Matteson E.L., Merkel P.A., Mollan S., Neill L., Sullivan E.O., Sandovici M., Schmidt W.A., Watts R., Whitlock M., Yacyshyn E., Ytterberg S., Dasgupta B. (2020) British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis. Rheumatology, 59(3), pp. e1-e23. DOI: https://doi-org.knowledge.idm.oclc.org/10.1093/rheumatology/kez672.

Editorial Information

Last reviewed: 01/12/2021

Next review date: 01/12/2024

Author(s): Dr Anna Ciechomska.

Co-Author(s): Rheumatology team: Dr Robin Munro, Dr Karen Donaldson, Dr Elizabeth Murphy, Dr James Dale, Dr Sanjiv Nandwani, Dr Georgiana Young, Dr May Chee, Mr Nico Groenendijk, GP representatives: Dr Tyra Smith, Dr Mark Russell, Dr Linda Findlay, Dr Paul Deehan, Dr Lucy Munro, Medical directorate: Dr Mehrdad Malekian.

Approved By: Dr Karen Donaldson

Reviewer name(s): Dr Anna Ciechomska.

Document Id: February 2022