Suspected GCA or PMR
Patient >50 years with suggestive symptoms
All Pathways
RheumatologyManagement
Giant Cell Arteritis & PMR Management (EULAR 2023)
Giant Cell Arteritis & PMR Management (EULAR 2023): Suspected GCA or PMR → Clinical Assessment → ⚠️ URGENT: Visual Symptoms? → GCA Initial Treatment → T...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Clinical Assessment
Evaluate for GCA vs PMR vs overlap
- GCA: New headache, scalp tenderness, jaw claudication, visual symptoms
- PMR: Bilateral shoulder/hip girdle pain and stiffness
- Elevated ESR and/or CRP in both
- ~40-60% of GCA patients have PMR features
- ~15-20% of PMR patients develop GCA
03Warning ⚠️ URGENT: Visual Symptoms?
Vision loss, diplopia, amaurosis fugax
- IMMEDIATE high-dose GC to prevent permanent vision loss
- Do NOT delay treatment for diagnostics
- IV methylprednisolone 1g/day x3 days often recommended
- Urgent ophthalmology consultation
- Irreversible blindness can occur within hours
04Action GCA Initial Treatment
High-dose glucocorticoids
- Prednisone 40-60 mg/day (or 1 mg/kg, max 60mg)
- Visual symptoms: Consider IV methylpred 500-1000mg x3 days first
- Start BEFORE biopsy/imaging (do not delay)
- Add tocilizumab early to facilitate GC taper
- Aspirin 75-100mg/day for CV protection (controversial)
05Action Tocilizumab for GCA
GC-sparing biologic (Strong recommendation)
- Tocilizumab 162mg SC weekly OR every 2 weeks (FDA approved)
- Add early (at diagnosis or first relapse)
- Allows faster GC taper and lower cumulative GC exposure
- Continue for ≥12-18 months minimum
- Monitor: infections, lipids, LFTs, GI perforation risk
06Action GCA Glucocorticoid Taper
With tocilizumab allows faster taper
- Without tocilizumab: Taper over 12-18+ months
- With tocilizumab: May taper to 0 within 6-12 months
- Example: Reduce by 10mg every 2 weeks until 20mg, then slower
- Below 10mg: reduce by 1-2.5mg every 2-4 weeks
- Monitor symptoms and inflammatory markers (CRP less reliable on TCZ)
07Decision Treatment Target: Remission?
Absence of symptoms + normalized inflammatory markers
- Clinical remission: no symptoms of active vasculitis/PMR
- Laboratory remission: normal ESR/CRP
- Imaging remission (GCA): resolution of arterial inflammation
- Monitor for relapse during and after GC taper
08Outcome GCA/PMR Controlled
Remission achieved, GC tapered, monitoring continues
09Action Relapse Management
Common during GC taper
- Minor relapse: return to pre-relapse dose, slower taper
- Major relapse (GCA cranial symptoms): treat as new diagnosis
- PMR relapse: increase to last effective dose
- If frequent relapses: add tocilizumab (GCA) or MTX (PMR)
- Reconsider diagnosis if multiple relapses on treatment
- Path rejoins step 08Shared downstream outcome
10Warning Specialist Referral
Refractory disease, large vessel complications, atypical features
11Decision GCA or PMR?
Distinguish based on clinical features and imaging
12Action GCA Diagnosis
Confirm with imaging (preferred) or biopsy
- Ultrasound FIRST-LINE imaging (halo sign)
- Cranial + axillary arteries standard
- Alternative: MRI, FDG-PET, CTA
- Temporal artery biopsy if imaging negative/unavailable
- Do NOT delay treatment for biopsy
- Path rejoins step 04Shared downstream outcome
13Action PMR Diagnosis
Clinical diagnosis, consider imaging if atypical
- Bilateral shoulder pain with morning stiffness >45 min
- Elevated inflammatory markers (ESR/CRP)
- Consider ultrasound to assess for bursitis/synovitis
- Exclude other causes: RA, inflammatory myopathy, malignancy
14Action PMR Initial Treatment
Moderate-dose glucocorticoids
- Prednisone 12.5-25 mg/day initially
- Dramatic response within days (diagnostic clue)
- Lower end if mild, higher if severe or GCA overlap suspected
- If no response: reconsider diagnosis
- Assess for GCA features at each visit
15Action PMR Glucocorticoid Taper
Gradual reduction over 12-18 months
- Once controlled: reduce by 2.5mg every 2-4 weeks to 10mg
- Below 10mg: reduce by 1-2.5mg every 4-8 weeks
- Minimum treatment duration: 12-18 months
- Many patients need low-dose GC for 2-3 years
- Monitor for relapse (symptoms + inflammatory markers)
- Path rejoins step 07Shared downstream outcome
Guideline Source
EULAR Treat-to-Target Recommendations in Giant Cell Arteritis and Polymyalgia Rheumatica
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Visual symptoms require emergent ophthalmology evaluation
- Large vessel GCA may need vascular surgery input
- Pediatric disease (rare) not addressed
- Overlap with other vasculitides may require specialist input
- Does not address Takayasu arteritis
Contraindicated Populations
pediatric
Applicable Regions
EUUSAU
AU: ARA endorses EULAR recommendations
EU: EULAR 2023 is primary guidance
US: ACR 2021 also available; tocilizumab FDA-approved for GCA
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Giant Cell Arteritis & PMR Management (EULAR 2023)?
The Giant Cell Arteritis & PMR Management (EULAR 2023) is a management clinical algorithm for Rheumatology. It provides a structured decision tree to guide clinical decision-making, based on EULAR Treat-to-Target Recommendations in Giant Cell Arteritis and Polymyalgia Rheumatica.
What guideline is the Giant Cell Arteritis & PMR Management (EULAR 2023) based on?
This algorithm is based on EULAR Treat-to-Target Recommendations in Giant Cell Arteritis and Polymyalgia Rheumatica (DOI: 10.1136/ard-2022-223429).
What are the limitations of the Giant Cell Arteritis & PMR Management (EULAR 2023)?
Known limitations include: Visual symptoms require emergent ophthalmology evaluation; Large vessel GCA may need vascular surgery input; Pediatric disease (rare) not addressed; Overlap with other vasculitides may require specialist input; Does not address Takayasu arteritis. Individual patient factors may require deviation from these recommendations.
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