Giant Cell Arteritis (GCA), also known as temporal arteritis, is the most common form of systemic vasculitis in adults over 50. Characterized by inflammation of large and medium-sized arteries, especially the cranial branches of the carotid artery, GCA demands rapid diagnosis and prompt treatment to prevent irreversible complications like vision loss. With evolving diagnostic tools and targeted therapies, GCA management is shifting from broad immunosuppression to more individualized and durable strategies.

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What is Giant Cell Arteritis?
GCA is a chronic granulomatous vasculitis that primarily affects the aorta and its branches. The immune system, particularly T cells and macrophages, targets arterial walls, leading to inflammation, wall thickening, and luminal narrowing.

Key clinical features include:
* New-onset temporal headache
* Scalp tenderness
* Jaw claudication
* Visual disturbances or sudden vision loss
* Constitutional symptoms: fever, weight loss, fatigue
* Polymyalgia rheumatica (PMR) co-occurrence in up to 50% of cases

Without timely intervention, ischemic complications such as anterior ischemic optic neuropathy (AION) can cause permanent blindness.

Diagnosing GCA: From Clinical Suspicion to Imaging
Early recognition is essential due to the high risk of vision loss. Diagnosis is based on:
* Elevated ESR and CRP
* Temporal artery biopsy (TAB): gold standard showing granulomatous inflammation with giant cells
* Ultrasound (“halo sign”) of temporal arteries
* MRI or PET-CT: to assess large-vessel involvement beyond the cranial arteries

New imaging modalities are helping identify extracranial GCA, which may present with less obvious symptoms, often leading to delayed diagnosis.

Glucocorticoids: Still the First Line
High-dose glucocorticoids are the cornerstone of initial GCA treatment. Immediate therapy is crucial, especially when visual symptoms are present.
* Prednisone (40–60 mg/day) is typically started immediately
* Intravenous methylprednisolone is reserved for acute vision loss

While effective in rapidly controlling inflammation, long-term corticosteroid use carries risks:
* Osteoporosis
* Diabetes mellitus
* Hypertension
* Infections
The goal is to taper steroids safely while maintaining disease control.

Tocilizumab: Targeting the IL-6 Pathway
Introducing Tocilizumab, an anti–IL–6 receptor monoclonal antibody, has transformed the GCA treatment landscape. Approved for GCA by the FDA and EMA, tocilizumab offers:
* Glucocorticoid-sparing benefit
* Sustained remission in relapsing/refractory cases
* Improved quality of life and reduced steroid complications

It is administered weekly or biweekly subcutaneously and is especially useful in patients with frequent flares or steroid toxicity.

Other Immunomodulators Under Investigation
Several steroid-sparing agents are being explored, including:
* Methotrexate: modest benefit in reducing relapse risk
* JAK inhibitors (e.g., upadacitinib): early trial data shows potential
* Abatacept: T-cell co-stimulation modulator studied in GCA flares

These emerging therapies aim to redefine long-term management, particularly in cases with large-vessel involvement or those who cannot tolerate steroids or tocilizumab.

Monitoring and Long-Term Management
Chronic management involves balancing inflammation control with side effect reduction. Regular monitoring includes:
* ESR/CRP trends (may be normal on IL-6 therapy)
* Imaging follow-up in large-vessel GCA
* Monitoring bone health, glucose, and infection risk
Preventing complications like aneurysm formation, particularly of the thoracic aorta, is vital in long-term care.

Addressing Challenges in Diagnosis and Access
Delayed recognition, especially in atypical or extracranial cases, remains a concern. Increasing awareness among primary care and emergency physicians is critical.

Barriers to care include:
* Limited access to advanced imaging
* High cost of biologics
* Inconsistent referral pathways
Cross-specialty collaboration between rheumatologists, ophthalmologists, and radiologists is essential to improving outcomes.

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Conclusion: Giant Cell Arteritis in the Age of Targeted Therapy
GCA is transitioning from a corticosteroid-reliant emergency to a manageable chronic vasculitis with precision immunotherapy. With early diagnosis, targeted agents like tocilizumab, and advancing imaging, patients with GCA now have better prospects for long-term remission, reduced toxicity, and vision preservation. Ongoing clinical trials and biomarker development will continue to guide a more personalized, evidence-based approach to GCA.

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