SCOPE: Urgent diagnostic workup, empiric glucocorticoid treatment, and long-term management of giant cell arteritis. Covers cranial GCA (visual, neurologic), large-vessel GCA, overlap with polymyalgia rheumatica (PMR), vision-threatening presentations, steroid-sparing therapy, and disease monitoring. For isolated PMR without GCA features, GCA workup should still be considered. For other vasculitides (CNS vasculitis, PAN), use separate templates.
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
Elevated in GCA; potential biomarker for monitoring (especially on tocilizumab where ESR/CRP are suppressed)
Elevated
-
ROUTINE
ROUTINE
-
Vitamin D 25-OH (CPT 82306)
Baseline before long-term steroids (bone health)
>30 ng/mL; supplement if deficient
-
ROUTINE
ROUTINE
-
DEXA scan baseline referral (CPT 77080)
Bone density before anticipated chronic steroid use
T-score >-2.5
-
-
ROUTINE
-
Complement C3, C4 (CPT 86160+86162)
Complement-mediated vasculitis screen
Normal
-
ROUTINE
ROUTINE
-
Note: Normal ESR does NOT exclude GCA -- approximately 4-10% of biopsy-proven GCA has normal ESR. Always obtain BOTH ESR and CRP. A normal ESR with normal CRP has very high negative predictive value but still does not fully exclude GCA if clinical suspicion is high.
1000 mg :: IV :: daily x 3 days :: 1000 mg IV daily for 3 days (some protocols use 500 mg-1000 mg); infuse over 1-2 hours; then transition to oral prednisone 1 mg/kg/day
Active untreated infection; uncontrolled diabetes; psychosis from steroids
Glucose q6h (target <180); BP; mood; electrolytes; GI prophylaxis
STAT
STAT
-
STAT
Aspirin (low-dose)
PO
Antiplatelet therapy to reduce ischemic complications (visual loss, stroke) in GCA
81 mg daily :: PO :: daily :: 81 mg PO daily
Active GI bleeding; aspirin allergy; concurrent anticoagulation (relative)
GI symptoms; bleeding signs
STAT
STAT
ROUTINE
STAT
Omeprazole (GI prophylaxis)
PO/IV
GI protection during high-dose steroids + aspirin
40 mg daily :: PO :: daily :: 40 mg PO/IV daily while on steroids
PPI allergy
None routine
STAT
STAT
ROUTINE
STAT
Note: VISUAL SYMPTOMS ARE A MEDICAL EMERGENCY. Start IV methylprednisolone IMMEDIATELY -- do NOT wait for biopsy, lab results, or imaging. Vision loss in GCA is often irreversible if untreated. The goal is to prevent vision loss in the fellow eye (bilateral involvement occurs in ~25-50% within days without treatment). If the patient can take oral medications and has no vision-threatening symptoms, oral prednisone can be started directly.
3B. Standard Oral Glucocorticoid Treatment (Non-Vision-Threatening)¶
Treatment
Route
Indication
Dosing
Contraindications
Monitoring
ED
HOSP
OPD
ICU
Prednisone (initial high-dose)
PO
GCA without visual symptoms; after IV pulse for vision-threatening GCA
1 mg/kg :: PO :: daily :: 1 mg/kg/day PO (max 60 mg); take in morning with food; maintain initial dose 2-4 weeks until symptoms resolve and ESR/CRP normalize
Active untreated infection; poorly controlled diabetes
Glucose; BP; weight; mood; bone density; cataracts; adrenal function
STAT
STAT
ROUTINE
STAT
Prednisone (taper phase 1: 40 mg → 20 mg)
PO
After 2-4 weeks at initial dose with symptom resolution
40 mg :: PO :: daily :: Reduce by 5-10 mg every 2 weeks from 40 mg to 20 mg; monitor symptoms and ESR/CRP at each step
Same as above
ESR/CRP at each taper step; symptom recurrence
-
ROUTINE
ROUTINE
-
Prednisone (taper phase 2: 20 mg → 10 mg)
PO
Continued improvement; normal inflammatory markers
20 mg :: PO :: daily :: Reduce by 2.5 mg every 2-4 weeks from 20 mg to 10 mg; slower taper reduces relapse risk
Same as above
ESR/CRP; symptoms; adrenal function assessment
-
-
ROUTINE
-
Prednisone (taper phase 3: 10 mg → off)
PO
Near-remission; on steroid-sparing agent if available
10 mg :: PO :: daily :: Reduce by 1 mg every month from 10 mg to off; total steroid duration typically 12-24 months; some patients require low-dose indefinitely
Adrenal insufficiency risk on discontinuation
Morning cortisol if dose <7.5 mg; ACTH stimulation test before complete discontinuation; ESR/CRP
-
-
ROUTINE
-
Calcium + Vitamin D (bone protection)
PO
All patients on chronic steroids
1000 mg Ca + 2000 IU Vit D :: PO :: daily :: Calcium 1000-1200 mg/day + Vitamin D 2000-4000 IU/day (target 25-OH >30 ng/mL)
Hypercalcemia; kidney stones
25-OH Vitamin D level; calcium; DEXA at baseline and annually
-
ROUTINE
ROUTINE
-
Alendronate (bisphosphonate for osteoporosis prevention)
PO
Steroids anticipated >3 months; T-score ≤-1.0
70 mg weekly :: PO :: weekly :: 70 mg PO weekly; take on empty stomach with 8 oz water; remain upright 30 min
Esophageal disorders; CrCl <35; hypocalcemia
DEXA q1-2 years; dental health (osteonecrosis of jaw); esophageal symptoms
-
-
ROUTINE
-
Note: Typical steroid taper duration is 12-24 months. Relapse rate on taper is ~50%. Most relapses occur when prednisone dose is below 10-15 mg or within 1 year of discontinuation. Monitor ESR/CRP at each taper step -- rising markers may herald relapse. Cumulative steroid toxicity is the major long-term concern (osteoporosis, diabetes, cataracts, infections, weight gain, skin fragility).
Reduce methotrexate side effects (stomatitis, cytopenias)
1 mg daily :: PO :: daily :: 1 mg PO daily (skip day of MTX)
None significant
None routine
-
-
ROUTINE
-
Leflunomide
PO
Alternative steroid-sparing if MTX intolerant (limited evidence)
10-20 mg daily :: PO :: daily :: 10-20 mg PO daily
Pregnancy (Category X); hepatic disease
CBC; LFTs monthly x 6 months, then q1-3 months; BP; diarrhea
-
-
EXT
-
Note: Tocilizumab (GiACTA trial, 2017) is the only FDA-approved steroid-sparing agent for GCA. It significantly reduces relapse rate and allows faster steroid taper. IMPORTANT: Tocilizumab suppresses ESR and CRP, making these markers unreliable for disease monitoring -- use clinical assessment and IL-6 levels instead. Methotrexate has mixed trial data (3 RCTs with conflicting results) but is commonly used as a cheaper alternative. Consider steroid-sparing therapy for all GCA patients to reduce cumulative steroid toxicity.
Return to ED IMMEDIATELY for any new or worsening vision changes (blurred vision, double vision, vision loss, shadows) -- this is a vision-threatening emergency requiring immediate treatment
Y
Y
Y
Report new headache, jaw pain while chewing, scalp tenderness, or limb claudication as these may indicate disease relapse
-
Y
Y
Do NOT stop prednisone abruptly -- sudden discontinuation can cause adrenal crisis and disease flare
-
Y
Y
Take prednisone in the morning with food to minimize insomnia and GI upset
-
Y
Y
Monitor blood glucose as directed; report persistent readings >200 mg/dL
-
Y
Y
Report signs of infection (fever >100.4F, cough, dysuria) promptly as steroids increase infection risk
-
Y
Y
Attend all follow-up appointments for blood work (ESR/CRP monitoring guides treatment)
-
Y
Y
Do NOT miss tocilizumab injections if prescribed; medication adherence prevents relapse
-
Y
Y
Weight-bearing exercise 30 minutes daily to maintain bone density and muscle strength on steroids
-
Y
Y
Annual ophthalmology exam for steroid-induced cataract and glaucoma screening
No visual symptoms or stable/improving vision; oral steroids initiated; able to tolerate oral medication; outpatient biopsy arranged; follow-up with rheumatology/ophthalmology within 1 week; patient educated on visual warning signs
Admit to floor
Acute vision loss or amaurosis fugax requiring IV methylprednisolone; new stroke symptoms; unable to tolerate oral steroids; significant steroid complications (severe hyperglycemia, psychosis); diagnostic uncertainty requiring expedited workup
Admit to ICU
Acute stroke with neurologic emergency; aortic dissection from aortitis; severe steroid complications requiring ICU monitoring; rare: severe systemic vasculitis with multiorgan involvement
Transfer to higher level of care
Neuro-ophthalmology or temporal artery biopsy not available; stroke requiring neurointerventional capability not available at current facility
Outpatient follow-up
All patients: rheumatology within 1-2 weeks; ophthalmology/neuro-ophthalmology within 1-2 weeks; PCP within 2-4 weeks (steroid monitoring); labs (ESR/CRP) at 1 week, then q2 weeks during initial taper
Readmission criteria
New visual symptoms (any); disease flare with headache/jaw claudication and rising ESR/CRP; severe steroid complications (psychosis, GI bleeding, severe hyperglycemia, infection)
Suspected GCA with ANY visual symptom
↓
STAT ophthalmology exam + STAT ESR/CRP
↓
START IV methylprednisolone 1000 mg IMMEDIATELY (do NOT wait for labs or biopsy)
↓
Temporal artery ultrasound within 24h
↓
Temporal artery biopsy within 1-2 weeks (remains positive on steroids)
↓
After 3 days IV steroids → oral prednisone 1 mg/kg/day
↓
Monitor visual acuity daily until stable
v1.1 (January 30, 2026)
- Standardized structured dosing format across all treatment sections (3A, 3B, 3C, 3D)
- Fixed prednisone taper phases to use starting dose of each phase in standard_dose field
- Added frequency field to all medications (methylprednisolone, prednisone, calcium/vitamin D, tocilizumab, methotrexate, acetaminophen, TMP-SMX)