An Audit of the Diagnosis and Management of Giant Cell Arteritis: Evolving Pathways of Care
Stephen McDonald, Khemerin Eng, Philip Gardiner
Altnagelvin hospital, Londonderry (Western Health and Social Care Trust)
Giant Cell Arteritis (GCA) can present in many different ways and can lead to permanent blindness in up to 20% of cases. Fast track clinics are being introduced to reduce the risk of complications.
To examine existing pathways of care in the presentation and management of GCA in a busy general hospital and to audit our adherence to the 2010 BSR/BHPR guidelines for management of GCA.
Retrospective review of the records of 31 patients with a provisional diagnosis of GCA selected consecutively. Information on diagnosis and management was retrieved.
There was no delay in diagnosis in 27 of 31 patients, four of whom had a final diagnosis that was not GCA. In 4 cases diagnosis was delayed for more than 48h (3days, 18d, 17d, and one atypical case took 90d to come to rheumatology attention). For the 27 who had a final diagnosis of GCA, 25 had fulfilled at least 3 of the 5 ACR diagnostic criteria.
The initial clinical and ESR response to steroid was documented in all cases except one in whom the therapy had been initiated in primary care. A Temporal artery biopsy (TAB) was performed in 19 cases, ultrasound in 7. One patient with a visibly thickened temporal artery (and a normal ESR) had a negative initial biopsy but a repeat biopsy on the other side was positive. 8/19 biopsies were under 1cm in length.
The initial referral pathways were quite varied, with some patients being admitted or referred directly through the emergency department. A high proportion were seen and managed on the day ward over the first few months before transferring to the outpatient clinics. The starting dose of steroid was in keeping with BSR guidelines in all patients. After 6 months, 22 out of 28 had reduced the steroid dose below 10mg/day. Of the three recommended adjunct therapies, 19 were prescribed all three drugs, 10 were not on Aspirin and one was only on a PPI.
Three patients suffered loss of vision before presentation to hospital. In one elderly patient the visual loss resolved but unfortunately that patient later died from TB. In two cases of visual loss the diagnosis was delayed. Four other cases had symptoms of transient visual disturbance. In spite of bisphosphonate prophylaxis, two patients had a vertebral fracture, and one had a fractured neck of femur.
The pathway of care for GCA patients has improved but not everyone was aware of it and delays in diagnosis still occurred. The major challenges are to increase awareness of the fast track referral system among GPs and Opticians and to reduce the delay in performing TAB. A fast track pathway of care for GCA is being widely circulated.