Bear in mind that approximately a quarter of patients present without headache. Just to make life even more complicated, they seem to be more likely to develop visual loss. Non-headache presenting symptoms include:
- Jaw claudication
- Visual loss (yup, it can be the first presentation)
- Non-specific systemic symptoms – low-grade fever, weight loss.
And 4% have a normal ESR.
Window of opportunity for biopsy after starting steroids is about two weeks. Prednisolone can actually be started at 40 mg od in patients with no ischaemic symptoms (visual loss or jaw claudication), but should be 60 mg in patients with jaw claudication and, of course, immediate admission for IV steroids in patients with visual symptoms (3 day course).
For oral pred, the starter dose is continued until both symptoms and inflammatory markers resolve, then reduced by 10 mg every fortnight until it gets to 20 mg, 2.5 mg every fortnight until 10 mg, and 1 mg every 4 – 8 weeks thereafter. Inflammatory markers are measured weekly at first but then tapered to monthly and then three-monthly. However, it is sometimes possible to get relapses without inflammatory markers rising.
As well as bisphosphonates, consider low-dose aspirin if no CIs.
A rare complication is vasculitis of the aortic arch and its branches – this may manifest as upper limb claudication, absent pulses, or a widened mediastinum on chest X-ray, any of which should prompt urgent specialist referral.
(BJGP June 2012)