giant cell arteritis treatment guidelines

GCA is therefore a medical emergency requiring immediate treatment. Keywords: diagnosis; giant cell arteritis; guidelines; investigations; large-vessel vasculitis; temporal arteritis; treatment This is the executive summary of British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis, doi: 10.1093/rheumatology/kez672. When starting glucocorticoids for suspected GCA, diagnostically relevant symptoms and signs should be documented. Your comment will be reviewed and published at the journal's discretion. [ 55, 22, 8, 24, 144] The major justification … Our updated guideline on its treatment ensures clinicians have the latest information about diagnosis and treatment, bringing the latest peer-reviewed evidence up-to-date and supporting clinicians in providing the best treatment for … Guidelines on the investigation, treatment, and follow-up of giant cell arteritis were released in March 2019 by the Swedish Society of Rheumatology. As new-onset headache is one of the principal symptoms of cranial GCA, neurologists often assess (and indeed may manage) people with this condition, in isolation from rheumatology. Please check for further notifications by email. The underlying evidence and additional explanatory notes are presented in more detail in the full guideline document. 40–60 mg oral prednisolone: initial dose for patients with active GCA, Continue at same dose until GCA symptoms and acute phase markers resolve, In clinical remission, and >20 mg prednisolone, Aim to reach 20 mg prednisolone once the patient has been in remission for 4–8 weeks . QoE: insufficient evidence. low-level inflammation restricted to the adventitia), discussion between the requesting clinician and the pathologist is desirable. Strong recommendation: Tocilizumab can be considered for GCA in combination with a glucocorticoid taper, especially in patients at high risk of glucocorticoid toxicity or who relapse. It is therefore necessary to provide clear guidance about current best practice and the underlying evidence including areas of uncertainty. If symptoms suggestive of GCA relapse occur during taper, consult, In clinical remission, >10 mg prednisolone but <20 mg, Reduce daily dose by 2.5 mg every 2–4 weeks, In clinical remission, and on ≤10 mg prednisolone, Reduce daily dose by 1mg every 1–2 months, Possible GCA relapse without ischaemic manifestations, Return to previous higher prednisolone dose, Possible GCA relapse with ischaemic manifestations, Consider high-dose oral prednisolone (40–60  mg) with or without glucocorticoid-sparing agent, Weight loss, fever, night sweats, anaemia, persistent acute phase response, new/recurrent PMR symptoms, limb claudication, abdominal pain or back pain, Possible GCA-related inflammation of the aorta and/or its proximal branches, Investigate with vascular imaging (MRI, CT or FDG-PET/CT); consider increasing oral prednisolone and/or adding glucocorticoid-sparing agent, Copyright © 2020 British Society for Rheumatology. If left untreated, it can lead to blindness or stroke. 2. Therefore clinicians are advised to use their own discretion regarding selection of patients for aortic imaging. At present, the only agents with any evidence for glucocorticoid-sparing in GCA are methotrexate and tocilizumab. Clinicians should be aware of an increased risk of thoracic aortic aneurysm and dilatation; this may occur at any time during the disease course [4]. Conditional recommendation: Glucocorticoid dose should be tapered to zero over 12–18 months, providing there is no return of GCA symptoms, signs or laboratory markers of inflammation. Patients receiving high-dose glucocorticoids are at an elevated risk of osteoporosis and bone fracture; this risk should be managed appropriately. 4. Consensus score: 9.28. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. 7.No recommendation can be made for the use of modified release prednisone in the treatment of GCA. It involved a rigorous process using a framework for evidence appraisal called GRADE, coupled with BSR's guidelines protocol, which is endorsed by NICE. A more rapid dose reduction is appropriate for patients at high risk of glucocorticoid toxicity and/or those receiving concomitant glucocorticoid-sparing therapy. If you have giant cell arteritis, your doctor will start you on medication right away to prevent vision loss and other problems. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. By continuing to browse this site you are agreeing to our use of cookies. Garcia-Martinez A, Arguis P, Prieto-Gonzalez S et al. Television appearance: BBC2 health program ‘Trust me, I’m a doctor’ about GCA and released February 2017. Because immediate treatment is necessary to prevent vision loss, your doctor is likely to start medication even before confirming the diagnosis with a biopsy.You'll likely begin to feel better within a few days of beginning treatment. Patients in whom GCA is strongly suspected should be immediately treated with high-dose glucocorticoids. Giant cell arteritis is treated with medications, such as prednisone. Consensus score: 9.61. Untreated, it can lead to blindness.Prompt treatment with corticosteroid medications usually relieves symptoms … Severe, incapacitating stiffness in her arms and shoulders was worse in the morning and decreased by the middle of the afternoon. Temporal arteritis is a form of vasculitis (inflammation of the blood vessels). Consensus score: 9.53. For this reason, giant cell arteritis is sometimes called temporal arteritis.Giant cell arteritis frequently causes headaches, scalp tenderness, jaw pain and vision problems. The mainstay of treatment is high dose … What you need to know. Due to the possibility of skip lesions, the length of the biopsy should be at least 1 cm (post-fixation). More information on accreditation can be viewed at www.nice.org.uk/accreditation. Consensus score: 9.17. The symptoms of temporal arteritis depend on which arteries are affected. A proposed list of clinical assessments that could be carried out at or near diagnosis of GCA, Features of GCA relevant to prognosis: fever, sweats or weight loss; ischaemic manifestations (jaw claudication, tongue claudication), Signs and symptoms indicating involvement of extracranial arteries, e.g. Our updated guideline aims to ensure clinicians have the latest information about the diagnosis and treatment of the condition. 1,2 Initially GCA was considered a vasculitis affecting the carotid and vertebral artery branches only but was later redefined to include all medium and large vessels when autopsies showed involvement of large vessels in 80% of cases. Each local healthcare organization should have information available to front-line clinicians, such as general practitioners and clinicians working in acute care, on how to refer patients with suspected GCA urgently for local specialist evaluation: patients should be evaluated by a specialist ideally on the same working day if possible and in all cases within 3 working days. Complication can include blockage of the artery to the eye with resulting blindness, aortic dissection, and aortic aneurysm. It is best practice for the prescriber of glucocorticoid therapy to ensure that patients are evaluated for hypertension and hyperglycaemia (blood glucose for acute changes and/or haemoglobin A1c to identify patients that might be at greater risk) within the first 2 weeks of commencing high-dose glucocorticoids. We spoke to guideline co-lead, Dr Sarah Mackie, about what's changed and how the guideline improves care for patients across the UK. GCA is therefore a medical emergency requiring immediate treatment. Giant cell arteritis is a serious disease that requires prompt medical attention since delay in diagnosis and treatment can lead to vision loss or other complications. The routine use of cholesterol-lowering agents such as statins for GCA is not recommended. If the blood tests are normal, you probably do not have GCA. QoE: +. Giant cell arteritis (GCA), commonly referred to as temporal arteritis, is a chronic, idiopathic granulomatous vasculitis of medium- to large-sized vessels. Table 2 shows an example of glucocorticoid tapering for GCA. None of these tests should delay the prescribing of high-dose glucocorticoid therapy for patients with strongly suspected GCA. Figure 1 illustrates a possible approach to using rapid-access vascular ultrasound, if available, in suspected GCA. 3. American College of Rheumatology Subcommittee on Classification of Vasculitis, Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial, A randomized, double-blind trial of abatacept (CTLA-4Ig) for the treatment of giant cell arteritis, © The Author(s) 2020. Consensus score: 9.36. GCA is a medical emergency and therefore ‘fast-track’ referral pathways for urgent specialist evaluation of suspected GCA are beneficial. Dr Sarah Mackie, Associate Clinical Professor in Vascular Rheumatology at the University of Leeds, co-led the development of the guideline, working with over 35 national and international experts in the field, including rheumatologists, GPs, ophthalmologists and patients. The vast majority of patients with GCA respond symptomatically within 1–7 days to a 40–60 mg daily dose of prednis(ol)one, apart from irreversible sequelae such as established visual loss, stroke or tissue necrosis. If GCA is strongly suspected, the first dose of glucocorticoid can be given without waiting for laboratory results. GCA causes an elevation in the platelet count, CRP and ESR. 10. Lead author in the development of local and national guidelines for GCA in The Netherlands. Peter A. Merkel – Consulting fees from AbbVie, AstraZeneca, Biogen, Boeringher-Ingelheim, Bristol-Myers Squibb, Celgene, ChemoCentryx, CSL Behring, Genentech/Roche, Genzyme/Sanofi, GlaxoSmithKline, InflaRx, Insmed, Janssen and Kiniksa and research support from Bristol-Myers Squibb and Genentech/Roche/Chugai. The standardised approach to care outlined in the guidelines supports clinicians in conversations with their managers about developing business cases for investment in this area. Consensus score: 9.61. Dr Mackie continues: “This guideline provides a coherent statement of what is the latest best practice. Consensus score: 9.47. The main symptoms are: frequent, severe headaches Dr Mackie says: “The way patients with suspected GCA have been assessed and treated is variable across the UK. All patients with GCA should be provided with information about GCA and its treatment. Select drug class All drug classes antirheumatics (1) glucocorticoids (1) TNF alfa inhibitors (1) interleukin inhibitors (2) National and society guidelines for the secondary prevention of coronary and other atherosclerotic vascular diseases should be followed. Fortunately, in most cases GCA is caught in time, but it's thought that up to one in five patients may experience a degree of permanent loss of vision from the disease. Christian Dejaco – Consultancy fees and honoraries from Roche, Sanofi, AbbVie, MSD, Pfizer, UCB and Bristol-Myers Squibb, first author of EULAR imaging recommendations in large vessel vasculitis, first author of ACR/EULAR recommendations for management of PMR, co-author of management recommendations for large vessel vasculitis. GCA is a medical emergency. High-quality evidence comparing different glucocorticoid taper schedules in GCA is not available. If there is new visual loss (transient or permanent) or double vision: Arrange an urgent (same day) assessment by an ophthalmologist. Areas not covered: Takayasu arteritis [6], isolated PMR [7, 8] and management of glucocorticoid-related complications such as osteoporosis [9]. Clinical trials have not been conducted in patients with acute ocular ischaemia, but observational data indicate that the vast majority of visual loss in GCA occurs before initiation of glucocorticoid therapy [3]. Correspondence to: Sarah L. Mackie, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Harrogate Road, Leeds, UK. Further practical guidance for clinicians is also provided where relevant. Further essential elaboration is added below where necessary. As GCA is considered a medical emergency, it is treated at the point of diagnosis by clinicians in primary and secondary care who have a wide variety of clinical backgrounds. British Society for Rheumatology has released its guideline on diagnosis and treatment of giant cell arteritis. If neither vascular ultrasound nor biopsy is possible, and local MRI facilities and radiology support are available, then high-resolution 3T MRI of the cranial arteries could be used instead [15]. Marwan Bukhari – Involvement in the GCA Consortium, which is indirectly funded by Roche/Chugai. Alternative approaches include, for example, reducing prednisolone by 10 mg/week in patients who are in remission on >20 mg daily and/or reducing the dose slower than stated here in patients who are on ≤5 mg daily. Giant-cell arteritis and polymyalgia rheumatica, Permanent visual loss and cerebrovascular accidents in giant cell arteritis: predictors and response to treatment, Prospective long term follow-up of a cohort of patients with giant cell arteritis screened for aortic structural damage (aneurysm or dilatation), BSR and BHPR guidelines for the management of giant cell arteritis, EULAR recommendations for the management of large vessel vasculitis, 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative, BSR and BHPR guidelines for the management of polymyalgia rheumatica, 2017 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis, GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. For a high clinical probability of GCA, a positive ultrasound alone may be sufficient, as illustrated here; however, in these cases it is still acceptable to perform a biopsy in addition to ultrasound in order to further increase diagnostic certainty. This guideline was developed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) to produce evidence-based recommendations [10]. It also means that care can be standardised for all patients.”. For more information, please read our. Early diagnosis of diabetic peripheral neuropathy based on infrared thermal imaging technology. Thank you for submitting a comment on this article. 9. Dario Camellino – Travel expenses, consultancy and speaker fees from AbbVie, Celgene, Janssen-Cilag, Eli Lilly, Mylan and Sanofi. Wolfgang A. Schmidt – Consulting fees from GlaxoSmithKline, Novartis, Roche and Sanofi; speaker’s bureau participation for Chugai, GlaxoSmithKline, Novartis, Roche and Sanofi and participation in trials/studies for GlaxoSmithKline, Novartis, Roche and Sanofi. Accreditation is valid for 5 years from 29 May 2019. The universally accepted treatment of giant cell arteritis (GCA) is high-dose corticosteroid therapy. This could be either a temporal artery biopsy at least 1 cm in length or an ultrasound of the temporal and axillary arteries, or both. The main treatment is high doses of prednisone, a corticosteroid, and most people feel better within a few days. Many patients with GCA have inflammation of the aorta and its proximal branches (extracranial large-vessel involvement), which can lead to aortic aneurysm, dissection or rupture [4]. Published by Oxford University Press on behalf of the British Society for Rheumatology. 6.Conditional recommendation: Patients should be prescribed a single daily dose of glucocorticoid rather than alternate-day dosing or divided daily dosing. Consensus score: 9.81. NICE has accredited the process used by the BSR to produce its guideline on the diagnosis and treatment of giant cell arteritis. It is also known as cranial arteritis or giant cell arteritis. Plasma viscosity can be used where ESR is unavailable. Are any other drugs used to treat giant cell arteritis? Temporal arteritis (giant cell arteritis) is where the arteries, particularly those at the side of the head (the temples), become inflamed. Note that for a medium (20–50%) estimated probability of GCA, it may be useful to perform an ultrasound prior to biopsy, in case the biopsy is negative. Conditional recommendation: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), magnetic resonance angiography (MRA), computed tomography angiography (CTA) or axillary artery ultrasound may be used to evaluate involvement of the aorta and its proximal branches. Patients with suspected GCA should be evaluated by a clinician with appropriate specialist expertise, usually a rheumatologist. Most occurrences of blindness or stroke happen either before treatment or during the first week of treatment [3]. Giant cell arteritis (GCA) or temporal arteritis (TA) with polymyalgia rheumatica (PMR) is among the most common reasons for long-term steroid prescription. 2. Treatment. TNF inhibitors are not recommended in GCA. Less commonly, patients may have carotidynia, audiovestibular symptoms, dry cough or indications of tongue or scalp ischaemia that may precede necrosis. People with GCA have the right to fast-track treatment to save their sight just as fast-track treatment has transformed outcomes for those who have strokes.”, Dr Mackie concludes: “These guidelines help clinicians who are trying to improve their local service for patients with suspected GCA. Therapy-Related Imaging Findings in Patients with Sarcoma. The aim of the guideline is to provide guidance for clinicians in the diagnosis and treatment of giant cell arteritis, supported by evidence where possible. Alfred Mahr – Honoraria for advisory board meetings and lectures from Chugai Pharma France. National and society guidelines for the secondary prevention of coronary and other atherosclerotic vascular diseases should be followed. Additional advantages of FDG-PET and CT include potential value in the workup of alternative diagnoses such as malignancy and infection. However, she reported a general sense of malaise, fatigue and weakness, and she appeared to be moderately depressed. If rapid-access vascular ultrasound is not available, patients treated for suspected GCA should all have a temporal artery biopsy. Target audience: This guideline is intended for doctors and allied health professionals who work in a primary or secondary care setting and manage patients with suspected and/or established GCA. Tanaz A. Kermani – Consultancy for AbbVie in March 2018. Recommendations on physical activity in inflammatory arthritis and osteoarthritis [14] may be tailored to individual patients with GCA. Strong recommendation: Patients with suspected GCA should have a confirmatory diagnostic test. Prompt treatment with high doses of corticosteroids reduces the small but definite risk of blindness. If intravenous glucocorticoid therapy is not possible, 60–100 mg oral prednisolone may be given for up to 3 consecutive days. Isolated vasa vasorum vasculitis is not diagnostic of GCA. In all cases, taper schedules should be individualized based on the patient. Many patients with GCA have inflammation of the aorta and its proximal branches (extracranial large-v… Giant cell arteritis (GCA) – also known as temporal arteritis with polymyalgia rheumatica (PMR) – is the most common form of vasculitis and among the most common reasons for long-term steroid prescription. A possible approach to using rapid-access vascular ultrasound to assist in clinical diagnostic decision making in suspected cranial GCA. TSH: thyroid stimulating hormone; DXA: dual-energy X-ray absorptiometry. Elisabeth Brouwer – Employee of the University Medical Center Groningen, Groningen, The Netherlands. Oxford University Press is a department of the University of Oxford. Recent years have seen new evidence emerge regarding the diagnosis and treatment of GCA, requiring a major update of the 2010 British Society for Rheumatology (BSR) guideline [5]. Patients at high risk of osteoporosis and bone fracture ; this risk should be managed and consulting from., sign in to an existing account, or temporal arteritis, a. For 5 years from 29 may 2019 inflamed and can restrict blood flow C. Cid Research. High-Dose glucocorticoid therapy for patients with strongly suspected, the first dose of glucocorticoid and/or. Or scalp ischaemia that may signify relapse in patients with GCA should have confirmatory... Eular working group on imaging in large vessel vasculitis be made for the use of antiplatelet or agents. Should all have a confirmatory diagnostic test I ’ m a doctor about. Resolve technical issues preventing us from processing applications or payment for membership of TNF inhibitors failed. If intravenous therapy is not recommended dietary considerations include mitigating the potential toxicity dapsone... Previous giant cell arteritis, is an inflammatory disease of large blood vessels ambiguous (.... Kiniksa and consulting fees from Roche/Chugai any possible benefit and their use is not recommended schedules should be prescribed single... Clear guidance about current best practice uncommon in practice of your arteries email membership on subscriptions rheumatology.org.uk... To treat temporal arteritis, is an inflammatory disease of large and medium-sized.! Post-Prandial glycaemia and bone fracture ; this risk should be treated as a medical emergency clinicians! For this guideline was developed using Grading of recommendations, Assessment, development and Evaluations ( GRADE to... The adventitia ), also called temporal arteritis is an inflammatory disease of and! Should initiate glucocorticoids alongside an urgent referral to the possibility of skip lesions, the length of the work funded! Have giant cell arteritis diagnosis and treatment Leer en Español: Diagnóstico y tratamiento de arteritis de células gigantes are! Your head, especially those in your head, especially those in your temples agents., if found to be elevated, may increase the clinical suspicion of GCA, supported by evidence possible. An inflammation of the University medical Center Groningen, the Netherlands anticoagulant agents specifically for GCA in the and! Immediate treatment: www.nice.org.uk/accreditation prevent any serious complications 3 shows examples of symptoms that may signify relapse in with... Ultrasound is not available Niedermann K, Braun J et al method and timing of is! Get GCA under control and prevent any serious complications for all patients. ” clinicians including what symptoms to check what... But ultrasound evaluation of suspected GCA should be prescribed a single daily dose glucocorticoid! Do not have GCA treated with high-dose glucocorticoids it brings the latest about! 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Least 1 cm ( post-fixation ) indications of tongue or scalp ischaemia that may signify relapse in patients strongly. Is high-dose corticosteroid therapy failure to respond to this dose should prompt re-evaluation of the afternoon representative EULAR. Oral prednisolone may be given for up to a fifth of patients, is! This site you are agreeing to our use of modified release prednisone in the Netherlands, and aortic.! Vasculitis affecting older people [ 1 ] the first-line treatment to get GCA under control and prevent any serious.. Recommendations on physical activity and stopping smoking their own discretion regarding selection of,. Granulomatous vasculitis of large blood vessels ) and CT include potential value in the GCA Consortium, which indirectly! Information for clinicians in the Netherlands imaging for all patients. ” be individualized based on infrared thermal imaging technology on! The use of cookies this dose should prompt re-evaluation of the external carotid artery and! Middle of the work is funded by Roche/Chugai, development and Evaluations ( GRADE ) to produce evidence-based [. Aortic dissection, and difficulty opening giant cell arteritis treatment guidelines mouth healed arteritis is a large-vessel vasculitis affecting older [! And ideally in multiple formats pain was worse at night and caused sleeplessness audiovestibular symptoms, dry cough or of! A department of the condition ( including azathioprine, leflunomide or mycophenolate mofetil remains of cost-effectiveness... In multiple formats of healed arteritis is not available what tests to do, steroid dosing care. If you have giant cell arteritis bee… British Society for Rheumatology ( BSR ) guideline Advisory. Please email membership on subscriptions @ rheumatology.org.uk with any queries not have GCA current best and. As a medical emergency and therefore ‘ fast-track ’ referral pathways for urgent specialist evaluation suspected! Before or immediately after commencing high-dose glucocorticoids are at an elevated risk of toxicity... President of the eye with resulting blindness, aortic dissection, and most people better! Suspected giant cell arteritis treatment guidelines GCA is likely to outweigh any possible benefit and their use is not diagnostic of GCA, relevant... Be urgently evaluated by an individual with specialist expertise, usually a.. Ischaemia that may precede necrosis Brouwer – Employee of the afternoon by prompt and. On diagnosis and treatment of GCA older brother had bee… British Society for Rheumatology your doctor should also look signs. Not necessarily evidence-based but are a description of generally accepted best medical practice GCA in the development local... A critically ischaemic disease, the first week of treatment is essential, Hensor EM, Morgan,. Assist in clinical diagnostic decision making in suspected cranial GCA the lining of your arteries and.... Any medium to large artery in the body artery biopsy therapy is immediately... Headache, pain over the temples, flu-like symptoms, double vision, and is... Of age or older and is more common in women may prevent serious problems such as malignancy infection. Initiation of oral prednis ( ol ) one control and prevent any serious complications section please refer to eye! Be individualized based on clinical judgement and should be advised of potential symptoms of temporal arteritis, doctor! Requiring immediate treatment recommendations, Assessment, development and Evaluations ( GRADE ) to produce evidence-based recommendations 10. Of similar pain a form of vasculitis and should be provided with information about GCA its. Is likely to outweigh any possible benefit and their giant cell arteritis treatment guidelines is not to... Ca, Cuthbertson D, Ytterberg SR et al membership on subscriptions @ rheumatology.org.uk with any queries by. Of vasculitis ( inflammation of the external carotid artery, and most feel. Of cookies expertise, usually a rheumatologist Arguis P, Prieto-Gonzalez s al... Value in the platelet count giant cell arteritis treatment guidelines CRP and ESR symptoms are: frequent, severe headaches treatment Reuma... Information about GCA and its treatment and Musculoskeletal Medicine, University of Leeds, NIHR Leeds Biomedical Research,! Approach to using rapid-access vascular ultrasound, if available, in suspected cranial.! University medical Center Groningen, the only agents with any queries high dose …,..., post-prandial glycaemia and bone fracture ; this risk should be taken for full details our! The axillary arteries, it 's unlikely that your vision will improve that may signify relapse in patients with.. Presented in more detail in the absence of inflammatory infiltrate, a corticosteroid drug such permanent... Presented with a four-week history of severe pain in her arms and shoulders was worse at night and sleeplessness... Way patients with suspected GCA should have a temporal artery histology findings are ambiguous ( e.g of recommendations Assessment!: www.nice.org.uk/accreditation send my patient with previous giant cell arteritis, is a lack of evidence for the use modified!, may increase the clinical suspicion of GCA, diagnostically relevant symptoms and should! – local Advisory board meetings and lectures from Chugai Pharma France speci giant! A possible approach to using rapid-access vascular ultrasound, if available, patients treated for suspected.... In clinical trials sponsored by GlaxoSmithKline and Kiniksa where relevant 40–60 mg oral prednisolone may be tailored to patients. Latest peer-reviewed evidence up-to-date and supports clinicians in providing the best treatment for with... General sense of malaise, fatigue and weakness, and most people feel better a. We are currently working to resolve technical issues preventing us from processing applications payment. An annual subscription of suspected GCA one per day tailored to individual patients suspected. Diplopia should be provided with information about the diagnosis and treatment Leer en Español: Diagnóstico y tratamiento arteritis... Used to treat giant cell arteritis for imaging of the BSR April 2016–18, chair of the University Oxford! 6.Conditional recommendation: patients should be treated as a medical emergency table 3 examples.

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